My low-carb program within my medical clinic is set up to last for six months. It starts with a medical evaluation with each of the potential 12 participants of a cohort, followed by a four-hour class with the entire cohort, and then 7 one-hour follow-ups in groups of four.
At the end of the program, the participants can have a one-on-one session with me if they want. We take a look at how their labs (cholesterol, glycaemia, inflammation markers, etc.) vastly improved, and I show them a graph of their plummeting weight.
When I set up my program, I knew 6 months was unlikely to be long enough for every patient to achieve their health or weight goals. Reversing diabetes in someone who’s been living with this condition for decades usually takes more (sometimes A LOT more) than six months. Same for reversing obesity, in most cases.
However, my goal was to make low carb their new way of eating forever, their new lifestyle. I had figured that six months was long enough to truly understand the physiology behind insulin resistance and hyperinsulinemia, get through the adaptation phase, learn to navigate this way of eating, make mistakes, have a few setbacks, and become knowledgeable and efficient at eating low carb or keto in a way that works for each individual.I had envisioned a six-month journey that takes participants from novice sailors to seasoned captains who are able to continue sailing with steady hands on their ship’s wheel, towards their final destination.
And then my first few cohorts completed their 6-month program. All of them had achieved good, often even great results, and it was incredibly inspiring! THIS was the medicine I had signed up for when I first got into med school.
A few months down the road, though, a wonderful colleague of mine had an appointment with one of her patients, for an unrelated medical reason. This patient had finished her low-carb program with my team a while back. She had regained every pound.
About a week later, I had a follow up appointment with one of my patients who had also participated in the program and had completed it some months ago. She is diabetic, and while she was in the program, we had managed to eliminate most of her drugs and get her blood-sugar levels and HbA1c under control. Her weight was currently stable, but her HbA1c and fasting blood sugar had gone back up, and were the worst we’d seen since 2012.
That was a double hit. I was extremely disappointed. I felt responsible. I felt like it was MY failure.
I pour so much unpaid time and energy into my low-carb program that my real salary, in the end, is the success my patients have. It compensates for all the times when I practice a standard medicine and have to prescribe pills for most health issues.
Was this all useless?
Call me naïve, in particular if you are an experienced health care professional, but that wasn’t part of my vision… I couldn’t comprehend that a competent captain knowing his ship and his route would choose to sail away from his desired destination.
Reasons why people get off the rails
I’ve been reflecting on this for a long time now.
Here are my conclusions thus far:
First, any patient who gets proper counseling and coaching by a healthcare professional to try low carb for health reasons has been given an opportunity to make a much more informed decision. Which is already a lot more than being offered the usual dichotomy of standard of care: take drugs or don’t take drugs.
Every single time I diagnose a new type 2 diabetes in a patient of mine, I tell them “This is caused by lifestyle habits, and it can be reversed with a change in your diet. It doesn’t have to be chronic and progressive. Or we can choose to treat you with medication. And, of course, you have the choice to refuse any kind of treatment. What do you think?”
In my mind, this is a more informed choice than “You have diabetes. I am going to start you on Metformin.”, which was my old way.
Second, some people, for all kinds of reasons, have a hard time sailing on their own. They lack the confidence, or the willpower, or they lose faith, or they have too much going on in their personal lives to be able to put themselves or their diet first. It might be temporary, or it might be a lifelong battle for them. It might involve eating disorders or self-esteem issues. It might involve all sorts of things that I do not know about. We do have a psychologist on our team, but we cannot offer much beyond a one-hour initial evaluation for those who request it.
Third, failures are unavoidable. They will happen. Not every time, not with everyone, but they will happen. It’s a fact of life.Fourth, apparent failures can be just setbacks. Relapses. It’s not an all-or-nothing situation. My captains know how to sail, and so they might choose at some point to steer back into a direction that makes them healthier. Smokers often make several attempts at quitting before they finally succeed for good. Should a doctor stop counseling on quitting smoking just because patients might have relapses? Obviously, no. Is counseling a waste of time if some patients never succeed? No. You cannot predict who will succeed in the end. You cannot predict the impact your counseling might have on patients, even when you think you don’t see any tangible results.
Fifth, even though I should not take this personal, it doesn’t mean that there is nothing that I can do about it. So, we sat down with our team and decided to offer extra follow-ups for those who feel they need them. We also decided to allow our “graduated” patients to stay in our closed Facebook group for an undetermined amount of time, so that they could keep on feeling part of a low-carb community, and have the opportunity to ask their questions or share their problems with our group. Support is so incredibly important.
Sixth, I needed to face and focus on the facts: so far, for every failure, there is at least a dozen of successes. Hard to say for sure what is our real rate of success. Success is hard to define to begin with. But in my mind, I tick a success box under the name of a patient when I hear them say: “I feel so much better, this is now my way of eating for good. This is my new normal diet.”
And I have had numerous follow-ups with such patients, who are sailing away towards their health goals, with steady hands on their ship’s wheel.
So, not offering low carb as a therapeutic option to patients just because they might not sustain it in the long term is not a valid reason.
Offer it to patients. Give them the opportunity to decide whether they want to make food their medicine. Allow them to make a more informed consent about their health issues. Help them start navigating their own ship. Expect a few setbacks or failures, and a lot of successes and lives changed forever.
Isn’t this the medicine you also signed up for some years ago?