The Case Against Dairy

Disclaimer

I realize that I live just 25 miles from Wisconsin, the “Dairy State”, and that attitudes in this part of the country are solidly Midwestern, but the number of people who refuse to believe that dairy is not only unnecessary for good health, but is also detrimental to good health is a little staggering. So, let me begin with an open and honest disclaimer. I have no financial ties to any pro- or anti- dairy group. I stand to derive no financial benefit from this post (unless you click on one of the dopey ads). I do have a BS in Chemistry, an MD, 17 years of clinical practice experience in medicine and a certificate in plant based nutrition from Cornell. So you can choose to ignore what I tell you, but please admit that you’re doing so because you prefer to believe what you’ve been told by people who stand to gain financially from what you “know” and who trust you won’t be bold enough to change your habits because of new information.

OK, with that out of the way, I want to split this up thusly:

  1. What is milk?
  2. Why you think dairy is good for you.
  3. The Case Against Dairy
What is milk?

Milk is a liquid that contains macronutrients (protein, sugars, fats) and micronutrients that is made by the mammary glands of all mammals to feed their infant offspring. It is, quite literally, a growth formula that is species specific (i.e. human milk has a different composition than goat milk) and is designed to nurture the young until the digestive tract has developed enough to transition to food appropriate to the species. The particulars of human, cow, and goats milk are presented in the following table, derived from the USDA’s own food analysis tables1.

Human vs Animal MilkThe USDA and most dairy types express the amount of protein, fat, and carbohydrate as grams, but most clinical types of people (i.e. physicians (as if) and nutritionists) talk about protein, fat, and carbohydrate as percent of total calories. In the lower half of the table I’ve converted the numbers above into percent of total calories. I realize that the numbers don’t add up to 100%, so I’m just leaving them there because the raw data came right from USDA. If the number of calories for human milk was, for example, 175 per cup, then the numbers below would be 100%.

It should be obvious right away is that human milk has more carbohydrate and much less protein than cow or goat milk. Remembering that milk is a growth formula for the time of life when the individual will grow the fastest, it’s remarkable that human milk is about 6% protein, which should suggest that this is the amount of protein that is necessary for sustained growth and health. Interestingly, 112 years ago, a nutritionist at Yale University named Russel Henry Chittenden published the results of his research on the amount of protein necessary for adult humans. Challenging the status quo of 116 grams of protein suggested by Carl Von Voit, Chittenden found that active adult men (Yale student athletes and men in the Army Corps of Engineers) did perfectly well on 40 grams of protein a day2. Given an average diet of 2400 calories for these active men, Chittenden’s 40 grams of protein translates to protein as about 6.5% of total calories, almost identical to the protein content in human breast milk. Unfortunately, Chittenden’s work, although of great interest at the time, has largely been lost to posterity.

Why you think dairy is good for you.

When asked, most people say that cow’s milk is “good for you” because it is high in protein and has calcium to “make your bones strong”. Let’s look at those two things.

Cow milk does have a lot of protein. As our table shows, protein is 20% of the total calories. I’m going to keep this short and not get bogged down in the numbers, but it turns out that 20% of calories as protein is not good for your health, particularly if the proteins come from animal sources. Animal proteins are usually labeled as “high quality” because the protein sequences are very similar to our own and our bodies can use them more efficiently than plant proteins. This oversupply of efficiently used proteins does promote growth in the human body, but it’s not well regulated. And there are unintended (and unwanted) consequences including (but not limited to) cancer initiation, promotion, and progression. Cow milk protein is approximately 80% casein, which has been identified as a powerful carcinogen.

Cow milk has calcium. Yes, this is true also, but it must be said that cows have certainly not cornered the market on calcium. There are, in fact, much safer sources of calcium that don’t mix calcium with excess protein, saturated fat, and carcinogens. And where, do you suppose, cows get all their calcium? It’s not like they’re out in the field taking calcium supplements. No, cows get their calcium from the same place that you should, from their greens.

Furthermore, this study3 from the American Journal of Clinical Nutrition concluded “neither milk nor a high-calcium diet appears to reduce risk (of osteoporosis)”. In fact, as this map from the International Osteoporosis Foundation shows, high dairy consumption areas like the US and New Zealand have significantly higher osteoporosis risk than low dairy areas like Brazil, China, India and Indonesia.Osteoporosis

The Case Against Dairy
  1. Lactose Intolerance: affects approximately 95 percent of Asian-Americans, 74 percent of Native Americans, 70 percent of African-Americans, 53 percent of Mexican-Americans, and 15 percent of Caucasians.4 Doesn’t it seem odd that with this striking degree of lactose intolerance among non-Caucasians that the USDA mandates milk consumption in school age children?
  2. Growth Hormones: I know that there has been some lip service to decreasing the amount of bovine growth hormone given to cows to increase their milk production, but we’re talking about big agriculture doing the right thing when it could adversely effect profits? When has that ever worked? And that’s just the growth hormones that are synthetically given to the cow. What about all of the growth hormones that occur naturally in cow’s milk because the milk was designed to act as a growth food for the baby calf? Most worrisome is high levels of insulin like growth factor 1 (IGF-1) that is present in cow’s milk and is linked to a number of human cancers.
  3. Bacterial contamination and antibiotics: I admit I got a little squeamish on this one, so be warned. According to the USDA5 guidelines, “the legal maximum BTSCC for Grade A milk shipments is 750,000 cells/ml”. That sentence needs a little background and if I get this wrong, I hope one of my dairy farming knowledgeable friends will correct me (gently). But as I understand it, when the milk is removed from the cows it is placed (on the dairy farm) in the blending tank (where the milk from all of the cows is blended). This is then tested periodically for contamination. Somatic Cell Counts are the number of “somatic cells” present in the sample. According to the Agriculture and Horticulture Development Board (in Britain) “The Somatic Cell Count (SCC) is a main indicator of milk quality. The majority of somatic cells are leukocytes (white blood cells).” White blood cells are also the primary component of pus and are present in increasing amounts in dairy cows because of an infection of the mammary glands (mastitis). And just so we’re clear, because there are 237 mL in a cup of milk, that means that Grade A milk in the U.S. can contain 177,750,000 white blood cells. If that isn’t enough to make you put down your glass, I don’t know what is. Of course, to treat that mastitis in the cow you have to give the cow antibiotics. The CDC has recently warned about the impending doom caused by resistant organisms, but the truth is that 80% of all antibiotics are used on our farm animals. The CDC has even put out this little infographic. ar-infographic-508c
  4. Type I Diabetes: Cow’s milk proteins are clearly linked to the development of Type I diabetes mellitus. Among other convincing evidence, the American Academy of Pediatrics observed up to a 30 percent reduction in the incidence of type 1 diabetes in infants who avoid exposure to cow’s milk protein for at least the first three months of their lives.6
  5. Environmental risks: The contamination from cattle and dairy production is potentially catastrophic. Arable farmland and forests are cleared to support more cows. The nitrogen rich effluent of farms growing grain to support the cows as well as the manure cause coastal water algae blooms and oceanic “dead zones”. The methane from cow belches and flatulence is a major green house gas contributor. The Chatham House think tank from the UK came to these key findings:

    1. Public awareness of the link between diet and climate change is very low. There is a considerable awareness gap around the links between livestock, diet and climate change. While awareness-raising alone will not be sufficient to effect dietary change, it will be crucial to ensuring the efficacy of the range of government policy interventions required.
    2. Governments must lead. Our research found a general belief across cultures and continents that it is the role of government to spearhead efforts to address unsustainable consumption of meat. Governments overestimate the risk of public backlash and their inaction signals to publics that the issue is unimportant or undeserving of concern.
    3. The issue is complex but the message must be simple. Publics respond best to simple messages. Efforts must be made to develop meaningful, accessible and impactful messaging around the need for dietary change. The overall message remains clear: globally we should eat less meat.
    4. Trusted sources are key to raising awareness. Unless disseminated and supported by trusted sources, new information that encourages shifts in meat-eating habits is likely to be met with resistance. Trust in governments varies considerably between countries, but experts are consistently seen as the most reliable source of information within a country.
    5. – See more at: https://www.chathamhouse.org/publication/changing-climate-changing-diets#sthash.ew3vLdLu.dpuf
  6. Greenhouse-gas-emissions
The Bottom Line (or, in Reddit speak, tl:dr)

There is no compelling reason to consume dairy from a nutritional or health perspective and a wealth of high quality data to strongly suggest eliminating it from the diet. It has too much protein, saturated fat, and a number of very potentially deleterious effects. Dairy can provide calcium, but this is readily available from many sources.

References:
  1. USDA. (n.d.). USDA National Nutrient Database. Retrieved 03 11, 2016, from https://ndb.nal.usda.gov/
  2. Chittenden, R. H. (1904). Physiological economy in nutrition, with special reference to the minimal proteid requirement of the healthy man: An experimental Study. New York, NY, USA: F.A. Stokes & Co.
  3. Feskanich, D., Willett, W., & Colditz, G., Calcium, vitamin D, milk consumption and hip fractures: a prospective study among postmenopausal women, Am J Clin Nutr 2003;77:504-11.
  4. Bertron P, Barnard ND, Mills M. Racial bias in federal nutrition policy, part I: the public health implications of variations in lactase persistence. J Natl Med Assoc. 1999;91:151–157.
  5. USDA. (2013, July). APHIS (Animal Plant Health Inspection Service). Retrieved March 11, 2016, from https://www.aphis.usda.gov/animal_health/nahms/dairy/downloads/dairy_monitoring/BTSCC_2012infosheet.pdf
  6. Eidelman AI, Schanler RJ. Policy statement: breastfeeding and the use of human milk. From the American Academy of Pediatrics. Pediatrics. 2012;129:827–841.

 

Letting go. A post about running

I’m taking a departure today to write about running. Should be back to plant based ranting and government/agribusiness misdeeds next week.

As some of you know, I’m in Mesa, Arizona today for the Phoenix Marathon and Half-marathon. And I was sitting in my hotel room this morning at 4:15 pondering the nature of letting go and just how difficult that can be. But for a more full understanding, I’m going to have to take you back to last October.

On October 18 I ran the Des Moines (Iowa) Half-marathon with Kathy Lindstrom. Neither of us was expecting much besides a finish. Kathy was still recovering from a terrible hamstring injury incurred during a Ragnar and I had had my training interrupted by the vagaries of life (work. Selling the house, moving, etc.). But we both made it to Des Moines that day and queued up at the start line.  As it turns out, I did pretty well, coming in at 2:04:57 (my PR for a half is (1:54:59). Despite the erratic training, I got it together and ran a decent course. Buoyed by this, I set out to find my next run with the expectation that I might be able to best my PR. (In my heart of hearts I know I have a 1:45 in me!) and behold, I found it in the form of the Phoenix Marathon. February 27 in Phoenix, away from the cold of the Twin Cities and, best of all, a long, slow, gentle downhill course. Perfect!

So I dusted off my Runner’s Connect sub-2 hour half-marathon training plan, my calendar, and set to work. I mapped out all of the runs right up to race day with all of the optimism that any distance runner has months away from the start line and in the comfort of their computer chair. Registration for the race completed, hotel and flight booked, I was ready to start training. And, for the first 6 weeks or so things went very well. The weather was turning toward winter, but I was still running outside most of the time. I had done a few treadmill runs when it was dark, raining, or snowing and they had left me with a vague ache in the left foot near the 4th MTP joint (where the toe joins to the foot bones), but it was not something that would keep me from getting my miles in. Then, on Christmas Eve day I did an 11 mile run on an indoor track (Eagan YMCA) and almost immediately after I quit running I had a very sharp, severe pain in that left foot. I knew that it was either some serious inflammation of the joint capsule (cleverly called capsulitis) or a stress fracture. Either way, I was shut down on running until it at least didn’t hurt to walk. I didn’t know that it would be almost 5 weeks.

Determined not to give up on the half-marathon, I decided to use the elliptical trainer and stationary cycles plus treadmill walking to keep my cardio conditioning up. I spent a good bit of time on the elliptical in particular, going up to 2 hours to mimic long runs. But it wasn’t until January 19 that I tentatively stepped on the treadmill and did first mile. Miraculously, no pain. I did 2 miles 2 days later, 5k two days after that and on January 24 a 10k. I was back, and just 5 weeks before the run.

I was able to log well over 100 miles between January 19 and today, with the longest run a 12 miler on the 15th. With the way that weekends get busy and since I have free time, I’ve found a lot of pleasure in long running on Monday around mid-day. I knew that I wasn’t going to PR in Phoenix. No one takes 5 weeks out of the middle of a training schedule and PRs, but I hoped to make a decent show of it and secretly hoped I’d best Des Moines. I set out on Monday, the 22nd, just 5 days ahead of the race, on my last longer run with a nice taper planned for the week.

The weather was nice, about 38 degrees (F) and there was no snow or ice on the sidewalks. My 9 miles went very well, averaging about 9:35 per mile. When I reached 9 I stopped, about 2 blocks from home. On my second step after stopping I knew something was very wrong. I had this sudden, terrible tightness in my right hip and butt and pain shooting down my right leg when I tried to extend my foot. I hobbled home and grabbed the ibuprofen, took a shower to try to loosen up, but to no avail.

I contacted my massage therapist and she worked me in for 30 minutes on Tuesday afternoon. No serious inflammation, she reported, but a lot of muscle tightness. I was stretching twice a day and feeling like it was going to release at any time, but the thought of Kathy’s rehab from her hamstring tear was lurking in the back of my mind. On Wednesday I couldn’t  take the inactivity, so I went out for a nice long leisurely walk. To my surprise and pleasure, the tightness almost completely disappeared and I was feeling very good about Saturday.

Thursday morning I got up to the worst tightness yet and a return of the sciatica. Rest, ibuprofen, gentle stretching, none of it made any difference. I began to understand and try to come to grips with the idea that I might not run on Saturday. Suffice to say, I was not happy. After struggling to make a comeback from  foot pain, this just seemed needlessly cruel.

And then it was travel day. Getting down to Phoenix, getting the race packet and getting around all involved  a fair bit of walking. And the hip wasn’t terrible. It was stiff and sore, but no sciatica at all! I began to hope again and made plans to run in the morning, knowing that I’d have to make a hard call in the morning.

Which brings me back to 4:15 this morning, sitting in a hotel room in Mesa trying to let go of the dream of running this race. I knew the moment the alarm went off that I wasn’t running. The stiffness was back with a vengeance. No sciatica, thankfully, but I got up went through my stretches feeling just how tight that hip was. Just two more days, I thought. In two more days I’ll be good to go. It’s not a major muscle tear, it’s just a spasm, like I thought on Monday when it first hit. In two days it will be gone and I could do this 13 miles without a care. But. There’s always that but. But it’s not gone now. Can I do the 13? Yes, I think I can. If I do the 13, will I set it off? Yes, I think I will. If I set it off, will I run again anytime soon? Will I be able to walk to the plane tomorrow? Will I be able to get around at all over the next week? These were all good questions and the sort of thing that haunts you at 4:15 in Mesa. If I was 25 I would have gone outa d run, I’m sure of it. But in not 25, I’m 53 and healing is not so quick and automatic as it used to be. And, I’d like to think, I’m a bit wiser. If I feel better on Monday, I’ll head out and do 13.1. If not, perhaps on Tuesday, or whenever this pain goes away. But until then, well, I let it go and went back to bed and slept well, knowing I’d made the right, but difficult, decision.

So what’s holding YOU back?

I had an interesting discussion with one of my kids last night. This is the son that is most definitely not a plant based eater. He said that it was going to take a lot more than health benefits to get a lot of people to consider changing their diet from standard American diet (SAD) to a whole food plant based (WFPB) diet. He thought that things like cost and convenience were very important. As I’ve already posted on Twitter and Facebook this morning, an epidemiological study in Spain reports that those who spend more on their food generally have a healthier diet and weight. But this is not new information. A 2012 article in the American Journal of Preventive Medicine described “Obesogenic Neighborhoods” and make a clear link between zip code and obesity that was at least as prevalent as genetics. In follow up work, a 2015 article in the same journal was the kind of study that doctors and researchers love. The researchers looked at people who moved into poorer socioeconomic neighborhoods and found that people gained weight after doing so.

But I digress. Rather than cover the science, I thought today I would share more personal information. Here’s why I follow a WFPB diet.

  1. Health. No secret here, WFPB diet is the healthiest diet we know. While there may be some who “feel” that other diets have health benefits, there is little scientific data to support long term health for any pattern of eating other than WFPB. This is particularly true for those who suffer the “diseases of affluence” like cancer, obesity, hypertension, diabetes, vascular disease and all of the non-disease symptoms that are diet related (like abdominal pain and constipation).
  2. The Planet. There are not a lot of ways individuals can actually make a difference, but this is one. If you won’t do it for yourself, do it for your planet. If you are such a brainwashed dolt as to believe that Climate Change isn’t real, well, go somewhere else and put your head back in the sand. Don’t worry, it will all be fine, just like Fox News said it would be (or, open your eyes and your mind and do a little research, it’s not hard to find). Everyone else knows that emissions from cars is bad for the environment. It turns out, cows are worse. The impact of methane emissions from livestock is worse than the impact of car emissions. A couple of “factoids” taken from The Purple Carrot website:
    • each burger you don’t eat saves the impact equivalent of 320 miles of driving
    • If everyone in the USA ate not meat or cheese for one day a week for a year (52 times a year) we would save the impact of 91 billion miles of driving
    • Eating WFPB for four days a week is the carbon-savings equivalent of three months with no car for a family of four
    • It takes 1,811 more gallons of water to produce a pound of beef vs. a pound of vegetables.
  3. Because I’m mad about being deceived. Yes, this the “let’s stick it to the man” part of me that is likely a product of being raised in the 1960’s. But this has seen a huge resurgence with millennials in response to “Big Tobacco” and it’s pretty clear that “Big Food” doesn’t want to go the way of Tobacco. The Physicians Committee for Responsible Medicine (PCRM) has been at the forefront of trying to hold the government and “Big Food” responsible. They successfully sued the USDA and in October of 2000, the court ruled that the USDA violated federal law by withholding documents and hiding financial conflicts of interest. In 2011 PCRM again sued the USDA over the 2010 dietary guidelines and “food pyramid” the did not give good guidance to Americans on diet choices. In response, the USDA switched to the “Healthy Plate” model that they still use. PCRM has also petitioned the FTC, USDA, and national dairy organization to stop false and misleading ads about the health benefits of milk consumption, which led directly to a cessation of that promotion. Apparently the Center for Consumer Freedom objects to all of this activity by PCRM and led to this “report“. However, the Center for Consumer Freedom is “The Center for Consumer Freedom (CCF), formerly the Guest Choice Network, is an American non-profit entity founded by Richard Berman that lobbies on behalf of the fast food, meat, alcohol and tobacco industries.” This whole nutrition thing stinks of greed and profit through purposeful deception and ignorance. I’m grateful that I have the time, energy and education and interest to pursue this and I truly understand that most of you do not. All the more reason why it should not be so difficult to get the truth.

So, that’s it. It’s why I am a WFPB eater. How about you?

 

 

 

Why Does My Belly Ache?

Gluten’s Bad Rap, FODMAPs, and Plant Based Eating

Let’s get this part out of the way first. There is a disease called celiac sprue, often known as just celiac, where people have an intense immune response (allergic reaction) to gluten. Gluten is a plant based protein found in barley, rye, and wheat. There is no doubt that this condition exists and that the consequences can be devastating.

There is no evidence that non-celiac gluten sensitivity exists. I thought about writing that sentence again, because it seems worth repeating and it flies in the face of conventional wisdom, where the entire country seems to be on a gluten restriction program. But non-celiac gluten sensitivity is a made up condition. It’s a cure without a disease. It’s a way to profit from ignorance where sales of gluten free products is expected to reach $15 billion this year. Yes, $15 billion. Not because it’s better for you, but because you don’t know better. Let’s explore.

A 22 year old otherwise very healthy young man came to see me because of intermittent abdominal pain. It seemed to occur predominantly after eating and was characterized by a diffuse abdominal ache, with  cramping, bloating, belching, and occasional urgent diarrhea. Many will recognize these symptoms because they either share them or know someone who does. This is classic functional abdominal pain, which also goes by the irritable bowel syndrome (IBS) label. There is no anatomic abnormality that has been identified with this syndrome. If you do an upper GI endoscopy it is normal. If you biopsy the small intestine there is no sign of celiac disease. If you do a colonoscopy, it will be normal. If you do a capsule endoscopy and look at all of the small intestine, it will look normal too. Lab tests: normal. X-ray tests: normal. Ultrasounds: normal. Normal, normal, normal. But there are very real symptoms and so people often begin to think they are crazy or that it’s all in their head. Physicians are not much better and usually of no help at all. How can they be when there is nothing to treat? There are, of course, pills to give (never forget that all drugs are poison, I learned that my first day of Pharmacology in medical school and it’s the most true thing I learned in 4 years), but they rarely help. Out of desperation, many try a gluten free diet and sometimes it helps. And suddenly, they have self-diagnosed as gluten sensitive.

The AboutIBS website estimates that 10–15% of all Americans have IBS. True? Who knows. I, and most physicians, would probably say it’s about right. I have seen an amazing number of patients with vague abdominal pain and no other findings and I’m sure they are just the tip of the iceberg, so to speak. The problem is so common that it attracts a fair amount of research and publications. An in 2011, in the American Journal of Gastroenterology, Dr. Peter Gibson from Australia published a paper that pointed a finger squarely at gluten as the culprit for a lot of people. It was a good paper and, most important, a double-randomized placebo controlled trial, almost the holy grail of medical studies. And the gluten free boom was born. Don’t get me wrong. This has been a great time for the poor people with real celiac sprue. The widespread availability of gluten free goods is a godsend for them and I’m happy they have better access to foods. But, as any physician will tell you, the number of patients with gut aches have not decreased, despite the boom market in gluten free products.

What industry fails to mention and went almost completely unreported, was Dr. Gibson is a pretty good scientist. He wasn’t completely satisfied with his results and he went back to the drawing board and designed a new study. A particularly elegant study where people who identified themselves as having non-celiac gluten sensitivity were divided into 3 groups and fed three different diets, high gluten, low gluten and gluten free. They didn’t know which diet they were eating and they kept journals of their symptoms. Then, two weeks later, they rotated diets. Two weeks later, they rotated again, until each group had eaten each diet. Then the results were tabulated. Anyone want to guess the results?

No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates.

That’s the title of Dr. Gibson’s 2013 article in Gastroenterology. And I’m pretty sure you never heard of this paper at all. Because, if you had and you believed, as Dr. Gibson does, that gluten is not the issue, well, what happens to that $15 BILLION market for gluten free goods?

As the title above suggests, Dr. Gibson has hit on a better explanation for functional abdominal pain and it’s called FODMAPS. FODMAP stands for fermentable, oligo-, di-, monosaccharides, and polyols and with a name like that, even FODMAP seems easy. I have no doubt that for many people following a low FODMAP diet will ease some of their complaints. If you are interested and want to know more, Dr. Gibson’s own site is probably the best resource and includes explanations, video, diet recommendations and even phone apps to help people feel better. But I have two problems with the whole FODMAP thing.

First, the idea is classic reductionist western medical thinking. Briefly, this is the idea that if we keep reducing the whole gut to it’s individual parts and components, we’ll eventually find something that causes this functional gut disorder. This kind of thinking works with bacterial disease because, if you look hard enough, you can often find something that causes a wide range of symptoms. Think of Borrelia burgdorferi,  the forgotten cause of Lyme’s disease. The problem with this sort of thinking, however, is that the gut is a system and it requires a systems thinking approach. For instance, the Monash University site (where Dr. Gibson practices and does reasearch) has a list of high and low FODMAP foods. You’ll notice that there are a lot of fruits and vegetables that are not recommended on a low FODMAP diet. But a Google search of “low FODMAP cookies” yields 284,000 results, which would lead one to conclude that cookies are OK, but I should avoid asparagus, artichokes, onions, leeks, legumes, celery and sweet corn as well as apples, pears, mango, watermelon, nectarines, peaches and plums. Madness.

My second issue, which is really an extension of the first, is that functional gut problems and IBS are basically non-existent in people who follow a plant based diet. Unfortunately, there is little research here, but numerous anecdotal reports of people with symptoms becoming symptom free when adopting a vegan or plant-based diet. So, perhaps, there is more to it than the FODMAPs. Maybe, just maybe, it’s the whole package. It’s the fiber, the complex carbohydrates, the phytochemicals and the nutrients that work together, naturally and in concert, to make the gut function better.

So, what happened to my 22 year old patient? Well, time for truth, it wasn’t a patient. It was my son Andrew. And he’s now a plant based eater and only has pain when he eats cheese. Go figure.

Let’s Talk About Constipation

As a practicing General Surgeon in a rural community, my practice also involved a good bit of upper GI endoscopy and colonoscopy. As such, I have spent many years talking with patients about their GI complaints and one of the most common, by far, is constipation. In light of my current efforts to promote a plant based diet, I thought it might be time to have a few words about this common problem. It’s also an interesting study in where the medical practice in the US has gone so wrong.

I refer the interested readers to a new article, published in the Journal of the American Medical Association (JAMA) on January 12, 2016 entitled “Constipation, Advances in Diagnosis and Treatment“. The article was written by Arnold Wald, MD from the University of Wisconsin’s Gastroenterology Division. Dr. Wald was recommended as a “Best Doctor in America” for 2011, 2013, 2014 and 2015 (no mention of what happened in 2012). I’m not here to pick on Dr. Wald, who I’m sure is very learned and an excellent physician. I am here to pick on his article.

As background, you have to understand the role that JAMA plays in American medicine. There are basically two journals that most primary care doctors read. One is JAMA and the other is The New England Journal of Medicine. After that, it’s hit or miss depending upon the specialty and interest of the physician (i.e. Family Practice, Internal Medicine, Peds, etc.). So having a review article in JAMA, which is likely to have wide readership among primary care physicians, is a big deal. And, equally important, it’s a big deal to get the information right so these busy primary care docs know what to do when a patient presents complaining of constipation. In the section of the article headed Clinical Presentation and Assessment Dr. Wald is informing his readers what he recommends they do to assess patients with constipation. He says: “The clinical evaluation should include the duration of symptoms, frequency and consistency of stools, presence of excessive straining, feeling of incomplete evacuation, or use of manual maneuvers during defecation. Clinical evaluation should also focus on excluding organic causes and medications (box) and identifying the presence of “alarm” symptoms that suggest further workup is required for colon cancer (such as sudden change in bowel habits, blood mixed in the stool, unexpected weight loss, or a strong family history of colon cancer).” The (box) notation then goes on to a graphic that illustrates the other “common” causes of constipation that the clinician should consider. It includes: Mechanical, Neurologic Disease, Metabolic Disturbances, Medications (Partial List), and Miscellaneous causes.

OK, I know that most of you are not physicians, but I’m hoping, at this point, you don’t need to be to spot the huge gap here. What did our esteemed colleague Dr. Wald miss? Well, how about diet? How in the world can you expect to work up constipation if you don’t ask about the diet? According to Journal of Academy of Nutrition and Dietetics article in May 2012 the average fiber intake for someone living in the US was 15 grams. 15 grams! Even the lame guidelines recommend a minimum of 25 grams. As a plant based eater, my daily intake varies between 45 and 100 grams and I can assure you that it makes a serious impact on colon function.

Bottom line (so to speak): if you’re a physician, ask patients what they eat. If they have any GI problems (and so many do) think about recommending a plant based diet. The naturally occurring high fiber is excellent for IBS, constipation, diverticular disease and hemorrhoids. And if you are interested in taking an active role in your own health, consider being more plant based to get you back to “normal”.

Add-on bonus! The second most important thing that Dr. Wald forgot to advise physicians to ask is what position do you assume for defecation (i.e. going #2, pooping, etc.). There has been some very good research done on the effect of position on ease of passing stool. The bottom line here is it is super important to get your hips flexed (i.e. get your feet off the floor). A commercial Squatty Potty  will do the trick. If that’s too difficult or inconvenient, Doctors Takano and Sands from the colorectal division of the Cleveland Clinic recommend “The Thinker” position. Food for thought?the-thinker-by-rodin-1233081-639x852