One of my biggest challenges is introducing the Paleo diet to patients who are initially very reluctant to listen. I’m sure all of you have this problem whether it’s to your friends or family members who are curious about all this “caveman” business. Several of my twitter friends asked if I could post about how I approach this problem with my patients, so I’ll give it a try. I will attempt to write it as a dialogue between me (E) and a patient (P). Along the way I may stop and fill in with some additional info. I certainly do not review this entire thing with every single patient, but I hit the high points and address the most pressing questions they may have.
Most of the time the question of diet and weight loss comes up in this fashion…
P: I swear I’m doing everything right doc, and I just can’t lose any weight. I’m very frustrated and I really don’t think that I am eating very much. What can I do?
E: Ok, so what you are doing is not working. Let’s start with you taking me through a typical day in your diet. Take yesterday for example, what did you eat?
P: Ok, I eat oatmeal every morning because it is good for my cholesterol. Most days I also eat a yogurt, and maybe a piece of fruit. For lunch I normally eat a sandwich like tuna salad or chicken salad…with low fat mayo and whole grain bread. Baked Lays or something on the side, all low fat stuff or I won’t eat it. For dinner I may eat a little more, but I figure I haven’t eaten much all day so I allow myself to eat a bit more. I’ll typically eat chicken or fish, usually broiled, and some vegetables on the side. My husband loves cornbread, so we eat a lot of that as well. I’ll usually eat a little desert, like a little chocolate or a few cookies; just a little something sweet ya know to kill my sweet tooth. That’s really it.
E: So no snacking during the day?
P: Well yeah, I snack on things here or there. Come to think of it, I probably eat more junk snacking than anything else. Just little stuff though; a few chips here, a couple of M&Ms there, not enough to really matter though I think.
E: Ok, that’s what you eat, what do you drink all day?
P: Well, I hate water, and I can’t stand Diet Coke. I do force myself to drink water as much as I can, but I just HAVE to have at least a coke every day. I just can’t do without it. Maybe some days I’ll drink two, but that’s not the norm for me.
E: What size cokes? Are we talking a can, or a bigger soda like from Sonic or something?
P: Oh I just love Sonic Ice, so I go there almost every day. So yeah, it’s usually a large coke from Sonic or McDonalds when I’m swinging through there to get the kids something after school.
E: So how long have you been eating this way trying to lose weight?
P: I’ve been doing this for years. I may lose a little weight here or there, but I can’t seem to make any real ground? I swear I just don’t see where I eat that much food.
E: So what you are saying is what you are doing isn’t working right?
Ok, this is a good time for a note. When you are talking to patients, or even friends who are questioning the Paleo diet, you want to get a good foothold on what their current “diet” is, and whether it is working or not. Most people do not inquire about lifestyles or diets if they are totally content with how things are going for them. Ask them questions, establish patterns and identify weaknesses. Most importantly, make them admit that what they are doing, although they feel it is “right”, is not working!
E: Ok, I’m going to tell you how I eat. I spent years also trying to figure out what the best way to get off weight and keep it off, and this is what I feel is your best bet. I’ll make it easy by just saying what I do eat. I eat meat, vegetables, fruits in moderation, eggs, any nut except for a peanut, and healthy oils like olive oil, coconut oil, or avocado oil. Anything else is off limits.
P: So how do you make a sandwich?
E: I don’t.
P: What do you eat for breakfast? I mean I need to eat oatmeal for my cholesterol don’t I? And calcium, where do I get my calcium for my bones? Wait a minute (desperate opening of mouth)…what about cheese?
E: No cheese, no dairy of any kind. I eat whatever I want for breakfast as long as it is on the list I just gave you. It’s not hard it’s just different.
P: There is no way I could do that. I can’t live without a lot of things on that list. I mean what do you drink? Don’t say water, I told you I hate water.
E: I drink water.
P: (Blank stare of disbelief as if I didn’t hear her water comment) That sounds crazy.
E: Well them I’m crazy I guess because I’ve been eating this way for quite a while and it has done wonders for how I feel and for my health overall. I sleep better than I ever have, I’m hardly ever hungry, I don’t fight the cravings for food I used to, my stomach isn’t upset all the time, and I’ve lost weight without tons of effort and have no trouble keeping it off. Isn’t that what you are looking for?
P: Yes, but I can’t eat that way. I’ve tried Atkins before and I just can’t take it for too long. You basically eat Atkins right?
E: No, not at all. I eat based on what is called the Paleo diet, or the Caveman diet. The key is that it’s not a diet at all, it’s a change in the way you do things. You have to be willing to change permanently; it’s a lifestyle cha…
P: Yeah, yeah, I know, a lifestyle change and all that. But why, why can’t you eat dairy? Milk is good for you, everyone knows that! And oatmeal, I mean come on, oatmeal is so healthy!
E: I disagree. We can look at each individual area of foods you need to avoid and discuss why if you would like, but I can simplify it in one word: insulin. Insulin’s job is to make sure that your blood sugar stays controlled in a very tight range. When you eat a diet based primarily on carbohydrates it causes your global insulin levels to be higher than they should be because your body is working overtime to keep your sugar tightly controlled. This increased insulin causes two things; it makes you hungry, and it stores sugar as fat. So the more carbohydrates you eat, the more insulin your pancreas produces. All the while this insulin is making you hungrier and fatter. As a consequence of accumulating more fat your body also starts to require more and more insulin to control blood sugar, and eventually your body stops listening…you become resistant to your own insulin. At that point you develop Type 2, or insulin resistant diabetes. This is how your current diet is leading to your downfall. Understand?
P: Well, sort of. But I don’t eat donuts or potatoes or anything, I just don’t see where I eat that many carbs?
E: You told me you eat bread for sandwiches, yogurt, oatmeal, chocolate, cookies, and soda. All those are carb based right? It sounds like to me you eat primarily carbs on a daily basis, am I wrong?
P: But I eat whole wheat bread and pasta, and low fat yogurt or skim milk for dairy!
E: Pasta, you never said anything about pasta?
P: Oh, pasta is a major weakness. I love pasta so much, and I was so proud of myself for finally getting used to the whole wheat stuff.
E: To your body bread is bread, and pasta is pasta no matter the type of wheat…they are carbs. And milk, ever notice that a cup of skim milk has around 100 calories, and a cup of whole milk has a little over 140 calories?
P: Oh, I don’t drink whole milk or skim milk, I drink 2%!
E: Focus, you’re missing the point here. Like I was saying, you would figure if they take all that high calorie fat out of milk it should really drop the calories right? Fat does have twice as many calories as carbs or protein after all. But, it only drop it 40 calories or so per cup! The reason is that when food manufacturers take fat out of food, they add in carbohydrates to make the food taste ok. So by avoiding the fat, you are contributing to the insulin train we discussed earlier. What I’m trying to tell you is that fat is not your enemy, as long as it is the right kind of fat. Carbs on the other hand are for the most part universally bad, unless it is in fruit and you want to eat that in moderation as I said earlier. After all, a carb is a carb.
P: You are killing me here doc.
E: Sorry, but you asked!
P: Ok, so I kind of get the milk thing. So why can’t I just change to whole milk?
E: Good question! The answer is that milk is not just made of fat, it also contains sugars and proteins. It’s these sugars and proteins that cause an increase in your insulin levels when you drink it. Importantly, this increase in insulin that is seen when milk raises your blood sugar is essentially the same for any milk: Whole, 2%, or skim. So milk may be a source of calcium, but it comes with significant baggage.
P: So that’s it, all these foods increase my blood sugar and my insulin levels, so I can’t eat them. Guess it sort of makes sense.
E: Yes, and no. Dairy products can also teach us about the other main reason the Paleo diet eliminates what it does. It’s called inflammation.
P: Inflammation? Like a bug bite or something?
E: Yeah, exactly. This can get complicated, but I’ll try to make it as easy as I can. Milk proteins lead to chronic inflammation in your GI tract that change the way we absorb many foods. To expand the list, other foods like wheat, legumes, and even soy to some extent cause this inflammation. Think of your GI tract like an impenetrable wall. That wall was designed to keep everything out of your bloodstream that is not supposed to get in there. When you eat these pro-inflammatory foods, that smooth impenetrable wall becomes leaky and more like swiss cheese. All sorts of proteins that are not supposed to enter the blood stream do so, and your body sees them as foreign. Just like ant venom is foreign and your body builds an inflammatory response to it on your skin, your body will build an inflammatory response to say for example gluten in wheat products. This chronic inflammation is felt to increase your risk of heart disease and stroke in particular over time. Like I said, this can get complicated and I can give you some good information to read up on it. Big picture is, you have to eliminate foods that will lead to chronic inflammation in your arteries.
P: But you are eliminating all these foods that I hear all the time are healthy? How can I eat that much fat and stay healthy? Isn’t eating fat the worst thing for your heart?
E: Like I said, it depends on the type of fat. You know that fish oil you take? I presume you take it because you read or heard that Omega-3 fats are good for you right? Well, that’s right indeed. Omega-3 fats are known to be much less atherogenic than Omega-6 fats…in other words, they don’t cause heart attacks or strokes. So eating this way will help shift your diet from one primarily composed of Omega-6 fats to one mainly of Omega-3 fats. Also, it will change the size of your cholesterol molecules. Omega-6 fats lead to LDL, or bad cholesterol, molecules that are small and dense. These small and dense molecules can easily lodge themselves into the “swiss cheese” like walls of your arteries at the moment. When they lodge into the walls they form plaque, and that plaque leads to blockage, and that blockage leads to heart attacks and strokes. If you can shift your diet to Omega-3 fats your LDL becomes what we call large and fluffy. These large molecules pass smoothly along your artery walls and are not stored as plaque. In other words, even if your cholesterol is a little high, it won’t be the dangerous kind. Is this all coming together for you?
P: Yeah, I guess. I just don’t understand why the government doesn’t talk about all this if it is true? I mean look at the food pyramid. My kid brought one home the other day from school and it’s build on whole grains! I don’t understand that at all if what you are saying is true.
E: Well….that’s a hard one. We could talk for hours on this one, but I’ll just tell you this. The government and multiple medical associations bought into the fat = heart disease theory long ago. They have spent decades trying to get people to eat less fat and more carbs. In fact, they have succeeded. As a nation we eat less fat today than we did 40 years ago. But just look around and answer this question: Is it working?! In the 1960’s the government took the data from one study that appeared to correlate rate of heart attacks with national dietary fat intake. The study was terribly flawed and most of the data was not reported, but it was taken as law. When the government decided to push the low fat diet as a cure for heart disease the obesity rate in America was just under 10%, and now it’s nearing 30%. 20% more obesity in 40 years or so, you tell me if it’s working. My simple answer is that the government is wrong, and they are too deep into their beliefs to change their ways. We’ve already agreed their plan hasn’t worked for you yet right?
P: Yeah, you’re right.
E: I’m always right.
P: Thanks for the confidence doc. Here’s the deal though, I can’t do this. You like to cook and stuff, and it sounds expensive. There is no way I can so it.
E: What if you gave me 30 days? Just 30 days to change your life. You can go home today and kind of try it a bit, eat a few less sandwiches, and say you give it a shot. But why not do it super strict for 30 days. Get everything out of your system and see how you feel. I’ll see you in 30 days and we’ll evaluate how you feel and if you think it’s worth continuing. I’ll warn you though, I haven’t had one person who did the 30 days right who wanted to go back to eating the way they used to eat. Go 30 days strict, and then I’ll ask for 90% compliance from here on out. You can do anything for 30 days right?
P: I guess, but I’m not sure it’s worth it anyway.
E: Do you think I hate chocolate chip cookies? Or wedding cake? Or Chimichangas? Or fresh baked cinnamon rolls? Absolutely not! I love each and every one of them! Almost everyone that follows a Paleo lifestyle loves these things. So ask yourself this question. If we all love those foods, why did we keep eating Paleo after 30 days? It’s simple, cause it works and we feel better. In fact, I never want to feel the way I used to feel before I changed my diet. I’m pretty sure you won’t want to go back either. Only one way to find out though…
P: Well doc, I’m going to reluctantly agree to give this a try. I love many of the foods you have explained I can’t eat, but I’m so sick and tired of feeling like this I’m willing to give anything a try I guess.
E: You know what the best thing for me about this lifestyle change for me has been? I am no longer in any way controlled by food. You are controlled by food right now, you said yourself you cannot “live” without a coke every day. Think about it, that soda controls your life! I don’t worry about food as much anymore because I’m not as hungry and I don’t crave things as much. Don’t get me wrong, I love food more than ever; just in a different way. You have the power to change your life so much, all you have to do is give me 30 days.
P: All right doc, you win. Let’s do it.
Now before you ask, no, I don’t have 45 minutes with every patient! I made this conversation as complete as I can for educational purposes. I challenge most patients to get a book on Paleo and educated themselves as much as possible about the dos, don’ts, and whys of the lifestyle. If people put the effort to learn why they should do things a certain way, they are more likely to stick to it long term. All you can do is start the educational process for people whether it be clients, friends, or family. Always challenge them to learn more about Paleo before they just dismiss it as a “fad” diet sure to play out. Memorize some numbers on our nation’s rates of obesity, diabetes, childhood diabetes, cancer, and other medical conditions tied closely to what we eat. Above all else, challenge them to tell you that what they believe to be true is actually working. If they insist that it is, they may be drinking too much of the Kool-Aid to ever see the light. Don’t worry about that though, like I said all you can do is try.
I really hope this will help some of you talk to other people about Paleo, why you changed to it, and why they should as well. It’s not easy since everyone has been exposed since birth to the vastly superior health qualities of milk and whole wheat among others. Debunk them one point at a time, know your science, and point them to more detailed sources to complete the picture.
Fight the good fight everyone! We must keep spreading the word about Paleo and science will continue to fall in our favor. If you know of someone who may benefit from reading this, please direct them here, RT my tweet about it, or whatever! Together we can change history, one loaf of whole wheat bread at a time 😉
June 5, 2012 at 12:12 am
Love it! I’ve had that conversation with dozens, err, hundreds of patients, and while the approach gets more refined, the intense hope that they will actually jump into a Paleo lifestyle is enough to motivate me to have redundant, illogical conversations with hundreds, err, thousands more people. Keep up the great work!
June 8, 2012 at 6:29 pm
Aw Man! I was with you until you said Chimichangas.
June 8, 2012 at 6:34 pm
Btw, thanks for the explanation of Inflamation. I learned from reading about statins on about.com that it is now believed that “inflamation” is more linked to heart attacks and strokes, but I didn’t know what it really was.
July 27, 2012 at 12:39 pm
That’s an excellent back and forth. I’ve been wondering how to “convert” friends and family. However, the one problem I’m having is trying to raise an infant on paleo. Any suggestions or guidelines? The pediatrician of course recommends a lot of whole grain foods (I’ve resisted for the most part) and whole milk. My son is 14 months old now and enjoys his meat and veggies immensely, but is hooked on milk. He has battled constipation for the last 7 monts or so and has some serious snoring issues (not quite to the sleep apnea stage but close). Would coconut milk be an acceptable replacement for whole milk? Just trying to make sense of everything and be able to convince my conventional wisdom wife. Thanks!
David J. Garza
July 27, 2012 at 12:43 pm
Wow… great post. Until I tried a Paleo-based lifestyle, I said most of those things (except I was “healthier” because I didn’t drink soda). Anyways… I appreciate the explanations here.
February 20, 2013 at 4:53 pm
I LOVE this post! I have been saying VERBATIM to patients many of the things you mention here. I am so happy the Hartwigs wrote ‘It Starts With Food” because now I feel like I don’t have ot explain everything myself- I just tell patients to buy the book. I noticed you wrote a more recent blog that you partnered with Whole9 and have some materials. Would love to hear feedback on this as I am considerign this myself. Any chance you are keeping stats in your practice?