The importance of critical reading.

A review of The 80/10/10 Diet, by Dr Douglas N. Graham

Firstly, if you’re after a thorough review, you won’t find it here, because I didn’t finish the book. I didn’t finish the book because I was, perhaps naively, outraged by what I found when I started reading it critically.

I think there’s merit in Dr Graham’s work, but I was also disturbed by what I found when I scratched the surface.

I read the first few chapters, raised my eyebrows incredulously more than once, made a mental note to check up on this and that and, when my mental notepad filled up, put the book down and started to do some looking.

First up, I find it a bit objectionable that Dr Graham is, as far as I can tell, a chiropractor, not a nutritionist.  He has a ‘background’ in sports science and nutrition, but his qualifications are as a chiropractor and a “professional hygenist” (which, as far as I can ascertain, means an alternative-holistic kind of health practitioner). Judging by his website he’s also had a lot of hands-on experience in his fields of interest. But he’s a chiropractor.

I don’t have anything against chiropractors (and no, some of my best friends aren’t chiropractors… I’ve never had any dealings with one nor any need to as yet), but I know that if I was looking for nutritional advice, I’d go to a nutritionist, not a chiropractor.

This isn’t really a big deal of course, and if I’d done the hard yards to become a doctor (in anything) and I was writing a book (about anything), I’d probably slap “Dr” on the cover as well. But if it was a book on nutrition, I think I’d be careful to state up front that my ‘doctorhood’ isn’t due to being a highly qualified nutritionist. I only noticed that Dr Graham is a chiropractor by reading the small print in the Trademark Statement on the publisher’s page.

I’m not saying that someone can’t know their stuff just because they don’t have a degree in that stuff. I don’t have a degree in anything, but people are happy enough with my work to keep coming back and paying me for more work. Mind you, I charge a lot less because I’m not qualified, among other reasons.

However, this point – the Dr bit – particularly rankled for me when I read the broadside Dr Graham fired on the mainstream medical profession, which is my next point.

On page 9 of the book (2008 edn), in a stand-out emphasised block (very similar to below), he quotes, beginning with a bold heading:

Your Doctor Cannot Help Here….

“…In a medical journal article entitled ‘Bizarre and Unusual Diets,’ the authors warn that the Atkins Diet had such questionable safety that it should ‘only be followed under medical supervision.’ But what do doctors know about nutrition? Even though the United States Congress mandated that nutrition become an integrated component of medical education, as of 2004, less than half of all U.S. medical schools have a single mandatory course in nutrition. That explains the results of a study published in the American Journal of Clinical Nutrition that pitted doctors against patients head to head in a test of basic nutrition knowledge. The patients won.”

I’ve found that a good rule of thumb is to test the most extreme statements of a text one is reading. This was one of those, which I’d noted for follow up in my mental notepad. To Dr Graham’s credit, the quotation is footnoted, which at least enabled me to check the veracity of the comments. But in this case that seems to be about all the credit that’s due.

I followed the footnote, and it turns out that he’s quoting from an e-book.  I found that e-book online, searched through it to find that quote, and followed that reference in turn, which was to an article in the American Journal of Clinical Nutrition 58(1997):319.

Now, it was quite difficult to find this particular article, since issue 58 of that journal in 1997 does not exist; it was well in to the mid-60s by 1997.  No author was cited either, which added to the difficulty. Alarm bells were ringing by this point…  Some more online searching turned up another website which gleefully states “A study, for example, in the American Journal of Clinical Nutrition pitted doctors against patients head-to-head in a test of nutrition knowledge. More than half the patients scored higher than the physicians!”  This quotation also cites the same non-existent issue 58 of 1997 (right down to the same page number, 319).  Perhaps the author of the e-book used this site as his source.

This second website did at least cite the author (footnote 70 in that last link), and by using the article name and author name I eventually found what I can only assume is the original source article. It was in issue 58, but was published in 1993 (and did start on page 319). Either this is it, or it was published in a non-existent issue, or it’s somewhere else altogether. My money bets that this is it: it’s called “Nutrition knowledge and practices of physicians in a family practice residency program: the effect of an education program provided by a physician nutrition specialist”.

Firstly, this run-around suggests to me that Dr Graham didn’t bother to check his sources. If he did, he would’ve had the same difficulty locating the non-existent issue 58 for 1997.

Secondly, the statement that this study “pitted doctors against patients” is a bit of an exaggeration. The study’s chief aim was, as the title suggests, to evaluate the impact (for both physicians and patients) of providing  specialised nutrition education as an intervention. The study did compare the basic practical nutritional knowledge of doctors and patients, but this was a relatively minor focus of the study – the comparison was more to establish whether the specialist training improved the situation.

Thirdly, the notion that “the patients won” is a massive exaggeration. The study did conclude that “Patients may rely on physicians to provide them with nutrition information, and physicians should be more knowledgeable about nutrition than their patients, but these results suggest that this is not necessarily true” (p. 323 in the link above). But when you look at the figures, you’d have to say “yeah, not necessarily true, but most likely is…”

Before intervention, patients were more knowledgeable than were physicians on 30% of the questions (p. 322). 52% of the patients scored higher than the physician with the lowest score (p. 322). Only 7% of patients scored better than the average score of the doctors (p. 322). Consider also that the questions that were asked of both doctors and patients were practical nutrition questions, “(eg, which foods have more fat or sodium)” (p. 321), rather than clinical questions (which doctors were asked, but patients weren’t).

So it seems (and, in a way, I hope) that Dr Graham never actually looked at this study before citing it. That could be forgivable if it was a minor piece of information. But instead he’s plonked this “patients won” claim in stand-out formatting in the middle of a page that questions whether “there is value in looking to the medical profession for nutritional advice” and which concludes, in his words, that “doctors have nothing to offer…” (p. 6)

The apparent willingness to debunk the entire mainstream medical establishment on the strength of the exaggerated interpretation of an apparently mis-referenced study, is really “a bit rich” when you read Dr Graham’s preface, in which he states “the research for this book often left me studying for several days in order to write just one or two sentences.” (p. xii)

I like to think that I have an open mind, so much so that I’m aware that I do need to be mindful of a saying I heard somewhere: that if you maintain an open mind it tends to get filled full of junk (but, of course, it was put with much more wit than that). I’m also not necessarily a slave to the biomedical approach to health – the approach that generally assumes there’s a single corresponding cause for each and every every ailment that is best addressed by (often chemical) intervention. I don’t trust everything that comes out of a medical specialist’s mouth, just because it came out of a medical specialist’s mouth, and I consider other options. But at the same time, I recognise that western medicine does have good things to offer; I just had a skin cancer cut out by a plastic surgeon because, after doing some reading, that seemed to me to be the best option (others included two topical creams – one a mainstream pharmaceutical, another an alternative treatment).

So I wasn’t necessarily pro- or anti- with regard to this book when I started. My problem with a book like this is that if it becomes clear that I have to track down every footnote to make sure that what’s being said is legitimate, I may as well just go and do the research myself. Which is why I never finished the book.