"Nothing was ever real food..." - Nutrition Medicine (Part I)

In our inaugural episode of the nutrition series, Nate, Justin and our patient, Tina,  tackle nutrition myths and what it means to eat for joy. Pretty ambitious... did they bite off more than they can chew?? Listen to find out. 

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Tina's Story
3. Chapter 2: Eating for Joy
4. Chapter 3: Busting Nutrition Myths
5. Conclusion

=== Learning Points ===

1. Eating behavior is deeply rooted in personal experience. 
2. Healthy eating can be a joyous experience, a message that is often lost in mass media and cultural myths. 
3. Instead of focusing on individual components of food such as macronutrient profiles, carbohydrates, or fats, focus more on what a particular food offers as a whole.  
4. Robust literature is available to guide physicians in counseling patients on their nutrition choices (more on this to come in future episodes). 

=== Our Expert(s) ===

Dr. Justin Charles is a graduate of the Yale Primary Care Internal Medicine Residency Program. His clinical interests are in Lifestyle Medicine, the use of evidence-based lifestyle interventions to not only prevent, but treat and reverse chronic disease from a root cause perspective. He has received training in Plant-Based Nutrition through the T. Colin Campbell Center for Nutrition Studies and eCornell, as well as Dr. John McDougall's Starch Solution Certification Course. 

=== References ===

1. Ros E. The PREDIMED study. Endocrinol Diabetes Nutr. 2017 Feb;64(2):63-66. English, Spanish. doi: 10.1016/j.endinu.2016.11.003. Epub 2017 Feb 1. PMID: 28440779.
2. Le LT, Sabaté J. Beyond meatless, the health effects of vegan diets: findings from the Adventist cohorts. Nutrients. 2014 May 27;6(6):2131-47. doi: 10.3390/nu6062131. PMID: 24871675; PMCID: PMC4073139.

=== Recommended Reading ===

1. Zhang B, Zhai FY, Du SF, Popkin BM. The China Health and Nutrition Survey, 1989-2011. Obes Rev 2014; 15(suppl 1):2–7.
2. Campbell TC, Parpia B, Chen J. Diet, lifestyle, and the etiology of coronary artery disease: the Cornell China Study 
3. Davey GK, Spencer EA, Appleby PN, et al. EPIC–Oxford: lifestyle characteristics and nutrient intakes in a cohort of 33,883 meat-eaters and 31,546 non meat-eaters in the UK.
4. Wilkins JT, Karmali KN, Huffman MD, et al. Data resource profile: the cardiovascular disease lifetime risk pooling project. Alles B, Baudry J, Mejean C, et al.

=== About Us ===
The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts for furthering the medical education of residents and clinicians in early stages of their careers. Building on the work of other medical education podcasts, Primary Care Pearls includes contributions from patients themselves, who have the autonomy to share their own experiences of how their primary care physician directly impacted the quality of their care.

Hosts: Nate Wood
Producers: Nate Wood, Helen Cai, August Alloco,
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: TrackTribe, The Tide, Patrick Patrikios, Asher Fulero, Windows of Ken, Joel Cummins

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Intro

[00:00:29] Nate: Um, chocolate. Hi everyone. Welcome to primary care pearls. A podcast made by learners for learners, and most importantly led by our patient stories. Today. We are very excited to talk about food 

[00:00:47] Justin: Nutrition is the leading global risk factor for death in the world causes about 11 million deaths globally. And that's independent of high blood pressure. That's independent of diabetes. That's independent of high cholesterol. It's even more than smoking and that's a lot. These are patient lives that are in the mix that are people that are unhappy, that are unhealthy, that are taking a ton of medications that don't feel well that are searching to us as their primary care doctors for answers.

And we don't always have them. And not that nutrition is the only thing that's important, but it really has the power to help prevent, help, treat help, even reverse a lot of chronic diseases while also not making people live longer. And just having it feel like they're living longer actually to add joy to their lives as well.

[00:01:41] Nate: during our discussion. We'll be joined by Tina Weston, a patient struggling with. 

[00:01:47] Tina: this is Tina Western. food is exciting. And food is just like, you're having a good time So the food equates a good time. 

[00:01:55] Justin: Right. And if it stops being fun, then what's the point.

[00:01:58] Tina: Right. 

[00:01:59] Nate: We'll learn more about her personal motivations for changing her nutrition plan and the emotional struggles she's faced while doing so we'll also be joined by a resident expert and a good friend of mine from the Yale school of mass.

[00:02:13] Justin: I'm Justin Charles. I'm one of the residents in the Yale primary care program, really passionate, interested about nutrition and lifestyle medicine, and excited to talk to Tina today about nutrition and her journey.

[00:02:28] Nate: you know, one of my favorite things about you and one of the reasons I'm so happy that we're happy, that we're able to have you here on, on the podcast is that you are able to understand this stuff at the level of a physician at the biochemical level, knowing the different names of the compounds, what foods to present in, and the negative impacts that they have on the body.

But you're able to, I think, convey that in such a. No nonsense, easy way to patients, So I think that's why we're so lucky to have you here today

This discussion will be the first part of a four-pa rt series that we'll explore eating habits, the psychological underpinnings of eating behavior and strategies for the primary care provider to address them. My name's Nate wood. And I'll be your host for this. We hope that through this discussion, you'll develop confidence about what we in the scientific community know about healthy eating, and that you'll also be inspired to understand your patients' backgrounds before engaging with them about changing their diet.

Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you or a loved one is suffering from anything discussed in today's episode, please be sure to discuss it with a medical. Okay. With that, let's get started.

Chapter 1: Tina's Story 

[00:03:53] Justin: one thing that really underpins a lot of this discussion is how people's early life and other experiences impact how people eat and their eating behaviors. There is a lot going on beneath the surface related to issues of control, issues of trauma, issues of feeling loved that go into why people eat a certain way or don't eat certain things. 

And it's really crucial to develop an understanding of that as we're going to help people make changes. It's not just about telling people what to do. It's about understanding their story. 

I think Tina mentioned something about this, um, which really stuck with me

Tell me about your. Relationship with food, food.

I feel like plays a lot of different roles in our life and there's the nutrition part. There's the taste part. There's the comfort part. And I just want to hear more from you where that fits in with everything. 

[00:04:49] Tina: I don't like the way I liked the way it tastes. I don't like the way it affects me physically and visually, because we're always our own worst critic.

And what I see myself, like, it's just disgusting and I want to lose weight. I try to follow your advice, but it's hard because everything is just like, I'm an emotional eater. I'm eating because somebody else is eating. I'm eating because of my job, I'm eating because I remember what something else tasted like before.

So I want to try it again. It's kind of like drugs.

[00:05:26] Justin: Yeah, it's a food can really have a pull on us and affect us in a whole spectrum of ways. And a lot of that I think starts from how we eat and how food affects us when we're growing up, what was eating and healthy, eating or not healthy eating like for you.

And your childhood? 

[00:05:46] Tina: Well, in my childhood, we grew up extremely poor. So everything was just like, you ate what you ate. Now, I get to make my own decisions as far as food is concerned. So I eat whatever I want to eat when I want to eat it. 

[00:05:59] Justin: So things were, it was a little more of a scarcity state and get ready can then, and now that you're in a better position, you can 

[00:06:06] Tina: eat whatever.

[00:06:07] Justin: Right. And then 

[00:06:08] Tina: making up a little less time. 

[00:06:09] Justin: There's, there's a certain power in that sense of control, right? 

[00:06:13] Tina: Yes. 

[00:06:14] Justin: Things feel out of control in our world. And so we control the things we can and then other parts of our life feel more out of control too.

[00:06:22] Tina: Yes. 

[00:06:23] Justin: What's it been like in terms of your diet journey? I hate the word diet, but you're a nutrition journey. 

[00:06:32] Tina: Okay. Um, I think the thing, the two things that work the best for me, they did work. It's just, I got happy with the results and I stopped. Number one was the low carb stuff, the kettle, but I didn't like the way it affected me in Mimi. Like I had headaches constantly.

I felt terrible, but I liked the way I looked. So I was like, who? Here's how I look. I want to feel better. Right. So I started eating what I wanted to eat. Then 

when you told me about the plant-based diet stuff that worked well, I tell my daughter, me some chicken, and then I felt like I eat that chicken. I might as well keep eating.

[00:07:08] Justin: Right. 

[00:07:09] Tina: So I never went back fully on that.

[00:07:11] Justin: Got it. So it's, it's been kind of a roller coaster? 

[00:07:14] Tina: Yes. 

[00:07:16] Justin: Yeah. I feel like that happens a lot where we're on track with something and then one little thing, and then we just veered entirely off before we talked. What was your view of eating healthy? 

[00:07:32] Tina: I wanted to do it. My thing is this. When the doctor tells you to do something, to try to do it. So I try to follow you, you know, to the letter. But then, like I said, I messed up and. Being at your doctor, you would know more about it than me. If I had to put my feelings aside and try to incorporate your views and everything.

[00:07:52] Justin: And before you learned about my views, but what was your view on what's healthy? What's unhealthy. How did you think about making healthy choices from a conceptual standpoint? 

[00:08:03] Tina: Well, my conception of nutrition was things that were good for you full of vitamins and nutrition and things of that nature. But what I wanted to have with sweets, because mostly my diet consists of cakes, cookies, sugary stuff, right?

No real food. Nothing's real food. You get full off of a soda and a bag of potato chips and some rings, right? So nothing was really ever food. It was always sweets and junk. Right. 

[00:08:29] Justin: And, and it's always that battle between. And a lot of cases, what tastes good and what I know I should be eating. And I found that it's, it can be really helpful when those two things aren't at odds anymore

[00:08:45] Nate: Now, I know we're only just a couple minutes into this episode, but already I feel like we've learned so much and are so blessed by Tina's story. She is motivated to change. She really takes into consideration what her doctor recommends and has such good insight into some of the influencers on her. You know, she mentioned that she eats kind of what's easily available around her. She discusses some of her previous experiences with food insecurity and how that impacts her diet even today and what she thinks she needs to eat in order to lose weight.

And then Justin mentioned a couple of other possible factors. He mentioned, you know, some things just taste good. And other times we're eating because it makes us feel like we're in control. So already we're learning about all these different facets of what eating means and all of these potential environmental influences that can impact how we eat on a day-to-day basis.

But I'm really excited for what comes next, which is one of everyone's most favorite things about food. 

Chapter 2: Eating for Joy

[00:09:47] Justin: A lot of people think, oh, well, I'm going to watch what I'm eating. And that means that food no longer as this pleasurable thing. It's this bland soggy boiled spinach that tastes bitter and sulfury, and there goes this whole joyous part of my life. 

[00:10:04] Tina: food is exciting.

And food is just like, you're having a good time lately. I've been going out with my sister would go out to Chili's or somewhere, and we're having a good time. Like my boyfriend we'd go out to eat and we're relaxing and we're eating. So the food equates a good time. 

[00:10:20] Justin: Right. And if it stops being fun, then what's the point.

[00:10:24] Tina: Right. 

[00:10:24] Justin: food should be a joyful experience. There's a difference between using it as a self-soothing and wanting your food to taste good and be colorful and make you happy and feel full. And that you're not starving yourself. And there's this dichotomy that people think that either food can be healthy or food can be tasting. and it can really be both.

 Do you think there could be any way? This is a leading question. I know that. Eating healthy or eating healthier could still have the fun and the joy, even if it's not a, life's an open buffet and I can eat whenever I want. 

Well, I don't know any place that you could go to an eat healthy food and have a good time.

[00:11:08] Nate: you know, I remember my grandma growing up, she would say, oh, this tastes good. So it must not be healthy for me. And that was something that she had just realized, uh, as gospel, the more food that she ate, the longer she'd been on earth, if it tasted good, it wasn't good for her. 

[00:11:22] Justin: now not everyone needs to be a professionally trained chef, like you to be able to cook a really healthy meal. There is a lot of push for culinary medicine and for patients to be able to get in the kitchen, even with limited skills, even with limited supplies, even with not the highest quality, most exp ensive ingredients, and still be able to put flavors together in a way that makes something tasty, no added experience required. 

[00:11:49] Nate: And I think Tina actually really nicely exemplified why this is so important

[00:11:54] Justin: there can be a lot of natural flavors in foods that that can taste really good, especially when we know how to combine ingredients right way. What's your, uh, relationship in with, with cooking? 

[00:12:06] Tina: Almost?

Nobody cooks at the house really. Like my daughter she'll cook some stuff with this. Everything is fried. Everything is fry. Um, did I eat at work and I eat out on the street. So it was easier to go to fast food restaurants because they cook the food for you. And that's the thing about fast food is it's fast and it's there and you don't have to do anything. I'm just making it. It's not an excuse on test to say it. That's the why I mess up all the time, because I get to the point where I don't make it as good as the other people make it. 

when you told me about the plant-based diet stuff that worked well, I tell my daughter, me some chicken, and then I felt like I eat that chicken. I might as well keep eating.

You know what I mean? 

[00:12:50] Justin: You said your mom used to cook for you back in the day. 

Oh, what was that like, 

[00:12:54] Tina: she couldn't cook that I know better with food tastes like she can't go, she could cook, she didn't use seasoning. She didn't use any of that stuff. She would just like salt and pepper was the seasoning. And then she would cook the food just as basic and bland, but it was all, you know?

Yeah. So then once you start going over to your friend's house and their mothers could cook, then that's what you want. You don't want that stuff. 

Have you made any, have you eaten anything healthy before that you thought was really. And what made it so good.

 I love watermelon. I could eat order belt, like a whole watermelon. So yeah, something like that.

Like I keep throwing the summertime. I can't keep buying them because all he eat them, nobody's getting them just me.

[00:13:35] Nate: I love that. She says that because I think it's not just her, that has this issue. Right? So many people do not know how to cook and we don't realize that that can be such a big barrier to people improving their health. You know, she even mentioned something healthy that she likes to eat. Right. And what. Fresh fresh fruit, watermelon, right? That requires no cooking. It requires you to cut it up and that is it. And so that's, that's a red flag. I think when we're talking with patients, another one is like, if you ask them to name some of their healthiest foods that they enjoy eating and they can only name salads, right?

These are things that do not require cooking. You just throw them together in a bowl. And then before, you know, it, you end up at the end of your rope. Like she said, I had gone through all the flavorful things. I knew how to make. And the, you know, that's in that moment, she felt weak and, and looked at chicken, right?

Because that was something that was cooked and different, which is so not what she had been eating previously.

eating food that tastes good and eating food that is good for you do not have to be mutually exclusive. this is so attainable and it's my life passion, you know, to empower people, to enjoy food in a healthy way.

Chapter 3: Evidence-Based Medicine and Debunking Nutrition Myths

[00:14:44] Nate: what are the key components of healthy eating? 

[00:14:48] Justin: I think the most important thing is to look at food quality. We too often break down into macronutrients or including this and not including that. And carbs are bad. Fat is bad. Protein is good. Butter is back and all of these different things, instead of really looking at what are healthful components of food, what are healthful components of food and which foods have more helpful components and the least amount of unhelpful components and design a diet around that.

[00:15:19] Nate: And that I think is the key message here. That a lot of times we view good nutrition or a good, healthy diet as a long laundry list of things that we cannot eat. But when we think about it in this other way, when we flip it on its head and say, actually, let's focus on the things that give our body some benefit in some way, what things are health promoting.

And we instead focus on that. It becomes less about. The laundry list of things that we should stay away from and more about eating good nutritious foods that nourish our body. And I think that frame shift for so many people I know for myself, um, has been and can be really, really powerful.

[00:16:01] Justin: You look at things like fiber, which 95% of Americans are deficient in more than any other vitamin or mineral. So we want food that has fiber. We want food that has enough vitamins and nutrients. We want food that has phytochemicals and antioxidants and anti-inflammatory compounds. We want food that's low in calorie density, meaning per given weight of food, there's a lower amount of calories, so we can consume more of it and not necessarily get too many calories.

And we want low amounts of things that are more harmful, lower amounts of saturated, fat, lower amounts of things like preservatives and nitrates and nitrites that have been linked to cancer, lower amounts of heme, iron, TMAO, new five GC, other harmful components that raise cholesterol, raise inflammation, caused heart disease. And when you boil that down, it comes to eating foods that are minimally processed and eating mostly plant-based foods. And that's where the whole food plant-based diet comes into being. It's not to cut out fat or cut out protein or cut out this it's, which foods are more health promoting vegetables, fruits, whole grains, legumes, avocados, nuts, and seeds, which foods are generally more health harming. the animal products, the meat, the poultry, the fish, although that's a little debatable, uh, the eggs, the dairy, and the processed foods, the brownies and cookies and chips and crackers and pretzels and white rice and white breads and added oils and TV dinners. And it leads to a pretty common sense way of eating. 

[00:17:43] Nate: So just to briefly summarize those things that we can eat that are health promoting, that the preponderance of evidence really has told us across generations, across many different types of studies across decades of research that we've really learned are healthy for us are things that grow in the ground. Right. Vegetables nuts, seeds, legumes, whole grains. And then as we focus on eating more and more of those things, we can kind of allow the less health promoting aspects of our diet things like many animal products and ultra processed quote unquote foods that are high in added oil sugar, all of that stuff, we can kind of just let it be crowded out as we focus on eating those healthier foods.

But of course, as data minded practitioners, we're all very much interested in truly what the research does say. What is the evidence behind this type of diet? So next, I'm going to ask Justin some questions along the way.

you keep touching on this point, that nutrition is so complicated. I think we would be simple minded to think that it's ever going to be easy to study. It's such a complex issue and requires complex research methods, I think, to study it effectively.

[00:18:54] Justin: Yeah, exactly. And I think when we try to boil it down to one specific variable, we really miss the boat. A lot of the early studies looking at vitamins and antioxidants did exactly that. They, like I mentioned, with the orange before he said, oh, vitamin C, when people eat oranges, they get healthy. Let's extract the vitamin C from the oranges, put them into pills, give them to people and they'll get healthier. And they didn't.

So a lot of the times, even though we're, well-intentioned of trying to simplify this and trying to apply this reductionist view, which is really helpful in a lot of areas, it just misses the boat when it comes to nutrition and it still boils down to eating foods in their natural state tends to lead to better outcomes.

[00:19:37] Nate: so how much do we really know? And, you know, thinking about this phrase, evidence-based nutrition, a lot of people would push back on that and say, oh, that's a misnomer or that's oxymoronic, but you knowing the state of the literature, I'm curious what your thoughts are on what we know for sure and what is still up for debate.

[00:19:55] Justin: we live in a world where science is not a static thing. Everything is changing, but that being said, we have decades, if not centuries of research of general nutritional principles, you have some critics that say, well, anything observational there could be biases and it's not good methodology.

And we should just throw it out altogether. And it's important to keep an eye on what those biases are. But for one, not all nutrition research is observational. Look at the PREDIMED study looking at the Mediterranean diet, which is a mostly plant-based minimally processed diet, over 6,000 people in a very well done randomized control trial published in new England journal of medicine within the last decade, we have randomized control trials and meta analysis and systematic reviews that are high quality published in peer reviewed leading journals that discuss nutrition that a lot of people would say, that's the gold standard. So the idea that all nutrition research is observationalist is a myth.

Secondly, observational research can still be really useful when paired with the general preponderance of the evidence. If we have one study that said, cherries are good for you. And then a lot of other, you know, you can make one study, say anything depending on how you design it.

But when we look back at large scale epidemiologic studies like Adventist health study, like the China study, all of these studies that are done that show more predominantly plant-based diets, lead to longevity reduced the risk of chronic disease in large populations.

So, if you look at any one of these things in isolation, I agree it's not enough, but when you look at decades and decades of literature with randomized control trials, with observational studies, with proposed mechanisms, you really get a much more clear picture than a lot of people want you to think.

nutrition's also very different than trialing a drug. When we say we have this one drug, that is the only variable that we are going to change it is do you get lisinopril or do you not get less than a, And that lends itself to a double-blinded placebo randomized controlled trial and the gold standard, but we're trying to change someone's diet. That can't just be one thing it's so complicated. What goes into nutrition, even looking at the difference in vitamin C between our oranges and how bioavailable that vitamin C is and how much magnesium is also with that vitamin C and how different people process it.

We could either spend a hundred thousand years trying to reverse engineer an orange, or we could say Hmm, maybe the orange is just healthy enough. And we don't need to know every single reason why some people might say that's unscientific. I say, it's just not being insane. And at a certain point, we need to say, this is good enough it has low harms. And as we continue to find more and more mounting evidence, we do have a preponderance of evidence inline with a more minimally processed and plant-based diet.

Outro

[00:22:55] Nate: I love that. And if you're anything like me, it's left you wanting to know more, right?

We want to know more studies, more evidence giving me more of that research. But remember, this is only episode one of four in our nutrition series. So there will be plenty of time for that in future episodes. You'll just have to come back to hear more. 

Here are some takeaways that I took from today's episode, and I hope you will. 

Number one. And I think this is one that we often miss or overlook or sometimes are just too busy to really attend to. And that is getting to know our patients' backgrounds is a very important prerequisite for understanding the role nutrition plays in their lives.

Number two, my favorite eating healthy can be a joyous experience. So if any of us personally has not yet embraced this truth, please now is the time as we learn more and more about nutrition and how to achieve a healthy diet, or maybe at least a healthier diet in our own lives, we can then help our patients realize this for themselves.

And number three, to provide everyone with a little bit of reassurance. There is indeed robust literature available to help guide us as providers on how to counsel our patients about healthy eating and most of the evidence, it seems really does support eating a minimally processed diet that's high in plants, like the whole food plant-based diet that Justin introduced.

Be sure to tune in next time, wherever you listen to your podcasts to catch part two in our four-part series where we'll introduce some of the various diets. Tina has tried in the past, including that ubiquitous keto diet that we're all familiar with by now, in addition to taking a deeper dive into the whole food plant.

As much as I love food and could spend all day talking about it. That does conclude our episode for today. We hope you enjoyed and were able to learn something as well. This episode was made possible by contributions from our patient, Tina and Dr. Justin Charles, who served as our patient interviewer and expert, and also provided peer review for this.

Special, thanks to our producers. Madison Swallow, August Allocco Helen sigh and Dr. Joshua Onyango as well as our faculty advisor, Dr. Katie Gielissen be sure to follow us @PC pearls on Instagram, where you can expect to get sneak, peeks, additional learning content and the most up-to-date details on show release times.

Thanks again for joining us today. Farewell from all of us at the primary care pearls podcast. We'll catch you in the next one.