The field of medicine, with its aura of mystique and importance, holds a great attraction. It is well known that many more people aspire to enter medicine than there are spaces in medical schools, only a few amongst them find the place. And among these aspirants, I found this opportunity to get into medical school in 1996.
Our medical education curriculum was guided by principles articulated by Abraham Flexner and William Osler in the early 20th century .The result was the establishment of two key components or pillars of medical education, namely, the basic or foundational sciences and the clinical sciences .As medical students our training initiated by a ritual as gory as it was awe-inducing: the cadaver dissection, the mystical phenomenons of homeostasis in physiology and the great metabolism and genetics lectures in biochemistry. Thanks to our most revered and great teacher of our time ,Professor Tafazul sahib, who intrigued me to fall in love with those cycles of metabolism and how beautifully they integrate for us to be functional at a cellular level.
As time went on, my thick text-books and the classical teachings taught me that fat in the diet is the principal nemesis for cardiac and related diseases , and any other form of calorie was considered acceptable. The dangers of fat haunted me — I embarked on a regimen that restricted fatty foods and once back home from hostel on weekends , I would intensify my crackdown on fatty and oily recipes. I quickly enlisted in the war on fat, and would avoid butter-slathered Lavasa (a thin, large, unleavened flat bread, white in colour, made of finely- milled wheat flour - maida ), pakoras, parathas in breakfast, Gustaba, Rista (minced meat varieties amalgamated with fat ) ,Tabak maaz and other staples of our traditional cuisine in ceremonies and get-together parties .I recall experiencing something like withdrawal, daydreaming about past feasts as my stomach grumbled.
Throughout my training from medical school through undergraduate to postgraduate in medicine, I had received very little relevant training in nutrition, lifestyle, or effective behavior change strategies. I learnt to perform and interpret a dizzying array of technologically-based diagnostic tests and interventions, but I had not been given the tools to address the root causes of my patients' illnesses and distress. Remarkably, I faced my patients every day with only a subset of the full complement of necessary information and approaches to improve their health and answer the wary questions regarding diet and demonised fats and cholesterol .
In most wars, the enemy stays the enemy. But I never knew that in this war against obesity , our allies and demons will keep swapping places. In 2014 after qualifying the national level competition , I joined my Doctorate in cardiology at one of the most reputed institutions of Delhi. I got an opportunity to work under stalwarts of cardiology who have been all AIIMS alumni’s top notch faculty .This reshaped my concepts about cardiac disease process holistically .
Attending bedside rounds and patients in OPD with Dr Rajiv Bajaj ,my thesis guide and good teacher, has been a thrilling and thought provoking experience .His dietary advice to the cardiac patients “Ghee, Makhan and Araam” —challenging the orthodoxy of restricting dietary fat, has intrigued me to rethink my previous concepts about fat and cholesterol .
As a research scholar we cannot sit in an ivory tower, we need to invest time to understand the facts when we know the research and guidelines are cherry-picked under the influence of industrial giants . If we analyse and scrutinise the unbiased and uninfluenced data beyond epistemic corruption, it is not impossible to foresee that the vilification of fat might be an error.
Energy from food comes to us in three forms: fat, carbohydrate, and protein. Since the proportion of energy we get from protein tends to stay stable, whatever our diet, a low-fat diet effectively means a high-carbohydrate diet. Obsessed with the ‘low-fat’ ideology, we unknowingly increased our consumption of refined sugar as a result. The most versatile and palatable carbohydrate is sugar, which John Yudkin had already circled in red. In 1974, the UK medical journal, the Lancet, sounded a warning about the possible consequences of recommending reductions in dietary fat: “The cure should not be worse than the disease.”
Let’s not characterise “Fat ‘simply as inert blubber” —it is a verifiable endocrine organ with wide influence on our bodies. It is a vehicle by which our cells receive certain essential nutrients, like Vitamins A, D, E, and K. The myelin sheaths around our nerves are eighty percent lipids, which means fat is actually required to think. Studies by Jeffrey Friedman, a molecular geneticist at New York City's Rockefeller University, have shown that the hormone leptin travels from fat cells to the hypothalamus, a part of the brain which is involved in regulating appetite. Through leptin, fat could talk. It could tell the brain to stop eating.
My culinary enemies shifted — now from fats to carbohydrates/sugars .I understood that it is mainly Carbohydrates that are the real danger—not only just processed foods containing refined sugars like sucrose and fructose but also easily digestible starches from grains and vegetables. Sugary drinks under different fancy names are lavished on dastarkhwan after full Trami of wazwan , candy, baked goods and sweetened dairy and many such related items are the main sources of added sugar. But even savory foods, like breads, tomato sauce, and protein bars, can have sugar, making it all too easy to end up with a surplus of the sweet stuff. To complicate it further, added sugars can be hard to spot on nutrition labels since they can be listed under a number of names, such as corn syrup, agave nectar, palm sugar, cane juice, or sucrose. No matter what it’s called, sugar is sugar, and in excess, it can negatively affect our body in many ways.
The surplus of the sweet stuff that we consume , be it the crystalline variety that we put in our coffee or high-fructose corn syrup—it is the fundamental cause for metabolic disturbances particularly a condition known as insulin resistance. This sweet main ingredient of our diet has a uniquely powerful role in causing obesity and diabetes—and thus increases our risk of developing the major chronic illnesses, such as heart disease, associated with these conditions.
Insulin, the hormone secreted by pancreas ,orchestrates the body’s use of fuels—proteins, carbohydrates and fats, and whether we store them or burn them. That key function apparently goes awry when we consume too much sugar and our cells resist the hormone. The cell stops listening to the insulin knocking at the door. This is insulin resistance. The cell starts refusing to take glucose from the blood, glucose builds up in the bloodstream, causing the pancreas to make even more insulin, which tells the cells to hold onto your fat. It’s a feedback loop that causes obesity and culminates in Type 2 diabetes. The link between obesity and Type 2 diabetes is one of such interdependence that the term “diabesity” has been coined. There is belief that a wide range of seemingly unrelated diseases— beyond diabetes and heart diseases —stroke, and Alzheimer’s are in fact linked, and that dietary sugar is the cause of them all, as well as of other disorders that associate with these illnesses, among them polycystic ovary syndrome (PCOS), rheumatoid arthritis, gout, varicose veins, asthma, and inflammatory bowel disease. But the majestic food industry has systematically tried to obstruct scientific research that exposes the dangers of sugar, just as tobacco companies tried to hide the risks of smoking.
Other than the famous PREDIMED Spanish primary prevention study (Mediterranean diet ) ,our most nutritional studies are observational; they rely on so-called food diaries, in which subjects record what they remember about their daily intake. Such diaries are notoriously inexact. This study further rekindled my anti-sugar belief that has gained considerable popularity due to its beneficial effects on health—lower incidence of stroke, coronary heart disease, and some types of cancer (although at the time, the basic elements of this diet model are based on ancient civilizations evolving around the Mediterranean). In fact, in the “Mediterranean diet,” the main components are olive and olive oil, wheat, grapes, and usually vegetables in all forms of salads, has similarities with the Plato's diet concept of the 5th century .To add further to anti-sugar credo argument are the proponents of ‘The Atkins diet ‘and, more recently, the ‘Paleo diet’ that have popularized the idea that we can get slim eating high-protein, high-cholesterol foods with lowest carbohydrate content.
Science is an accretion of provisional certainties. Till date we have no evidence based research that is genuinely promising—several groups have now identified genes that predispose some people to obesity, and are studying how targeted diets and exercise can attenuate these effects—but the more one pays attention to the latest news from the labs the harder it becomes to separate signal from noise. Amid the constant back-and-forth of various hypotheses, orthodoxies, and fads, it’s more important to pay attention to the gradual advances, such as our understanding of calories and vitamins or the consensus among the different studies. What this means for most of us is that common sense should prevail. Eat and exercise in moderation, as the philosopher Ibn Khaldun said: “Hunger does not kill, an overfilled stomach does.”Let’s go back to nature: maintain unprocessed / minimally processed diet consisting of balanced amounts of protein, fat, and carbohydrates; make sure you get plenty of fruit and vegetables. And enjoy an occasional piece of Kandhi Kulcha and Harissa!
The author is Consultant Cardiologist at GMC Anantnag