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Despite
a growing consensus that cardiovascular disease is a
"food-borne" illness, many physicians are
ill-prepared to advise patients on what they should eat to
best protect them from heart attack or stroke.
One
provocative new study found that a Mediterranean-style diet
was so effective at warding off heart attacks, stroke and
death that scientists stopped it early. They wanted to let
subjects in the control group and the public start to reap the
benefits.
Yet the
number of hours devoted to nutrition education in medical
schools is decreasing, leaving doctors unequipped to deal with
common patient concerns about diet, studies have found.
Even as
rates of obesity and Type 2 diabetes soar, researchers report
that doctors are spending less time than ever talking to
patients about nutrition because they lack time, training and
optimism that patients can make lifestyle changes. Insurance
is also more likely to cover procedures than behavioral
counseling.
"Ask
50 cardiologists and they’ll say, ‘Of course I know about
the Mediterranean diet,’" said Dr. Dean Ornish,
president and founder of the nonprofit Preventive Medicine
Research Institute. "But if you ask, ‘Do you teach it?’
they say, ‘No, who has the time?’ This is real-world
medicine. We need to do it better."
"There’s
tremendous ignorance about nutrition among physicians,"
added Dr. William Davis, a preventive cardiologist in
Milwaukee. "It has never been part of the culture."
Cardiovascular
disease, which kills 600,000 Americans a year — more than
all types of cancer and AIDS combined — is linked to high
blood cholesterol. Though cholesterol-lowering statin drugs
are popular treatments, levels in the body also can be lowered
through diet.
Meanwhile,
lifestyle changes have been shown to work better than
medication in preventing obesity and Type 2 diabetes, both
risk factors for heart disease.
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Procedures
involving stents and angioplasty can save lives when patients
are in the middle of a heart attack or having unstable
symptoms, but patients also often undergo them in more stable
situations in which they have not been proved to prevent a
heart attack or extend life.
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Research
suggests that physicians don’t feel comfortable, confident
or adequately prepared to give nutrition advice, said Kelly
Adams, a research associate in the department of nutrition at
the University of North Carolina.
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One
survey published in 2003, for example, found that 96 percent
of internists and 84 percent of the cardiologists who
responded did not know that a low-fat diet, in general, would
increase triglycerides in the blood. High triglycerides
increase the risk of heart disease.
"This
can lead to well-meaning but misguided information being given
to patients," Adams said.
Some
heart specialists say the question is whether physicians
should be the ones supplying the information on diet and
nutrition, even if they are well-educated.
"The
patients we see are in sensory overload — a new diagnosis,
an evaluation of lifestyle, new medicines, perhaps recent
procedures and then diet issues," said Dr. Clyde Yancy,
chief of cardiology at Northwestern University’s Feinberg
School of Medicine.
What
patients need most is coaching and support that can help them
make lasting behavioral changes, but that’s no easy task,
Yancy said. "We (physicians) may lead the team, but it
does take a village and requires having access to good
information and an expert dietitian," he said.
A 1985
landmark report on nutrition in medical schools by the
National Academy of Sciences found that on average, future
physicians received 21 hours of nutrition instruction over
four years. Medical students need at least 25 hours to be
adequately prepared to help patients, the report concluded.
Since
then, professional groups, federal agencies, scientific
journals and even a congressional mandate have called for
improved nutritional training among doctors.
Yet more
than two decades later, nutrition education in U.S. medical
schools remains inadequate, according to a 2010 study led by
Adams and her UNC colleagues and published in the journal
Academic Medicine.
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On
average, doctors receive 19 hours of total nutrition education
in medical school; in 2004 the average was 22.3 hours,
according to the study, conducted as part of the Nutrition in
Medicine project at UNC. In 2009, 27 percent of the schools
met the minimum standard of nutrition training, compared with
38 percent in 2004.
Ben
Kester, 25, who is finishing his second year at the
Northwestern medical school, said nutrition has been mixed
into some of his classes; in a recent cardiology unit, the
class talked about using statin drugs in combination with diet
as the first line of treatment, he said.
Learning
about nutrition is important, he agreed, but it can also fall
by the wayside amid other demands. Medical school can be so
stressful that, often, "our own eating habits are the
first thing to go," he said.
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Nutrition
education is also slighted during fellowship training, the
period after medical school when doctors specialize, said
integrative preventive cardiologist Stephen Devries, executive
director of the Gaples Institute for Integrative Cardiology in
Deerfield, Ill., which advocates for nutrition and lifestyle
interventions.
In the
32-page cardiology accreditation guidelines, "nutrition
isn’t mentioned once," said Devries, who is gathering
support to lobby the Accreditation Council of Graduate Medical
Education to mandate nutrition education as part of all
physician training programs.
Today’s
primary care physicians spend less time than previous
generations of doctors talking to patients about what they
eat, according to a study published last year in the journal
Medical Care.
Among
the obstacles? "Many physicians are overweight themselves
and may feel uncomfortable talking about healthy diet and
physical activity when they themselves struggle with similar
issues," said lead author Jennifer Kraschnewski, an
assistant professor of medicine and public health sciences at
the Penn State College of Medicine.
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Though
several diets can benefit heart health, a systematic review
ranked the Mediterranean diet as the most likely model to
provide protection against heart disease. The Lyon Diet Heart
Study previously showed that it could reduce the risk of a
second heart attack by up to 70 percent.
The
traditional Mediterranean-style diet is characterized by high
intake of olive oil, fruits, nuts, vegetables and cereals,
moderate amounts of fish and poultry and low doses of dairy
products, red and processed meat, and sweets. Consuming wine
at meals in moderation, exercise and relaxing with friends are
also considered important elements.
The
heart-healthy mechanism is still a mystery, but evidence
suggests the diet is anti-inflammatory and helps improve the
function of endothelial cells, which pump out nitric oxide.
"Nitric
oxide keeps cells within our blood vessels flowing smoothly,
prevents inflammation from developing in the walls of the
arteries, keeps us from getting stiff vessels and has a role
in keeping us from developing blockages or plaque," said
Dr. Caldwell B. Esselstyn Jr., author of "Prevent and
Reverse Heart Disease."
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"Certain
foods compromise and injure the endothelial cells’ capacity
to make nitric oxide," Esselstyn said. "As we are
constantly getting less and less nitric oxide, we are less
able to prevent coronary artery disease."
Animal
products, processed foods and sugar compromise the cells the
most, said Esselstyn, who also, controversially, tells his
patients to avoid oil.
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For the
recent study on the Mediterranean-style diet, published last
month in the New England Journal of Medicine, researchers in
Spain randomly divided patients who were already at high risk
for heart disease into three groups. One was given a low-fat
diet and advice on how to follow it.
The
other two groups were placed on a Mediterranean diet, with one
using at least four tablespoons of extra-virgin olive oil per
day for cooking and dressing food. The third group was told to
eat an ounce, or a generous handful, of a combination of
walnuts, almonds and hazelnuts per day.
The
volunteers in both Mediterranean diet groups had a
"substantial reduction in the risk of major
cardiovascular events among high-risk persons," the
researchers concluded.
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Yancy
stressed that the results went beyond added olive oil, nuts or
even regular wine consumption. "They were greatly
influenced by diet coaching and constant reinforcement that
kept patients on board with the chosen diet," he said.
"It’s the entire diet program. That’s where the real
gains reside."
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For
Jessie Chavez, 39, a software engineer for Google, heart
disease loomed in his future. His father had three heart
attacks — the third was fatal — and Chavez, who worked
long hours at the computer and neglected his diet, had high
cholesterol.
Initially
his doctor put him on a statin drug. But when he asked if
there was anything more he could do, "she said, ‘Well,
of course you can look into diet,’ but I felt like she didn’t
see it as something viable," Chavez said.
Chavez
went to see Devries, who incorporated a Mediterranean-style
diet and exercise into his heart health program. Chavez, 5
feet 10 inches tall, dropped his weight from 196 to 156 and is
now off nearly all medication because his cholesterol is back
to normal. Once physically unfit, he’s now able to run 10
miles.
"As
an engineer, I always think, ‘Where’s the proof?’"
said Chavez, of Berwyn, Ill. "To actually have a
cardiologist tell you, ‘Here are a few studies, this is what
it shows and this is the impact’ gives you more options. I
liked knowing it wasn’t part of a fad, but science."
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MEDITERRANEAN
DIET: A SAMPLE MENU
A day’s
worth of heart-healthy foods
A
Mediterranean-style diet emphasizes foods traditionally
consumed in countries bordering the Mediterranean Sea. Here is
a sample day’s menu provided by Dr. Stephen Devries,
executive director of the Gaples Institute in Deerfield, Ill.,
which promotes the value of nutrition and natural strategies
in medical care.
Breakfast:
Yogurt
parfait: Layer fat-free plain Greek yogurt with blueberries or
strawberries. One teaspoon honey optional.
Or: 100
percent whole-wheat English muffin topped with one tablespoon
almond butter and a cup of blueberries or strawberries.
Water
(best option) or a ½-cup juice. One cup coffee or green tea.
Midmorning
snack:
Apple,
orange or pear.
Lunch:
Spinach
and kale salad with a wide variety of colored vegetables,
dressed with balsamic vinaigrette, and topped with either
walnuts and feta cheese or chicken breast.
Small
slice of 100 percent whole-grain bread or pita.
Sparkling
water with slice of lemon or lime.
Mid-afternoon
snack
Handful
of almonds, green tea.
Dinner:
Grilled
wild salmon, ¼-cup of quinoa with rosemary and pine nuts,
grilled cauliflower/broccoli/carrots drizzled with olive oil.
Spinach
and kale side salad with vegetables and balsamic vinaigrette.
One
glass of wine if desired. Sparkling water with slice of lemon
or lime.
Sliced
fresh fruit.
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