Today I attended, along with a lot of others, the much awaited debate about the Paleo diet in Trendo 2017(The Annual Endocine Conference). The hall was jam packed and both the speakers did a fantastic job. This is an issue that I have been ruminating for quite a while now.I had been skeptical about the Paleo diet – the scientific aspect of it. It was a knee jerk reaction. Knee jerk reactions are rarely right – so I decided to do what every doctor has been taught : look at the evidence.
I started the search at a familiar place – PubMed. As expected, there weren’t many studies. . There were studies of short duration, some of which showed great effect and others didn’t. Even the pattern was familiar, just like the place where I started. In fact I couldn’t find a single trial from India. I guess we are content to ask questions and want others to come up with answers.
However, the absence of evidence is not evidence of absence of effect.
Like all searches, I was left with more questions than answers. What exactly is Paleo diet? How far back in human history do we go? Should we just emulate the caveman’s diet or his whole life style? Somehow, drinking butter tea in plush AC rooms alone without working hard like the cave man seemed counter intuitive.
It was at this stage, that I stumbled onto a Facebook group called Arokiyam Nalvazhvu(Healthy Life in Tamil). I can hear the evidence based snobs scoffing . After all , a social network isn’t a traditional place to find answers to one of the fundamental questions of science – how and what should we eat? The group had over 3.5 lakh members, almost all of whom are either taking Paleo diet or planning to. [Talk of big data :-). This would be brilliant data mining project, for those who love to work with unstructure data]. Now this diet isn’t a standardized intervention, these were mostly prescribed by hobbyists who had no background in medicine. I saw some doctors as members of the group too. I decided to become a lurker.
Here’s how the group works:
Members post the pre and post images of themselves and their blood test reports. Several admins are there who approve the post and given them a unique id. The member has to take the requisite blood tests and post in the same thread. Within a couple of days, a paleo diet chart is given. It has its own menu and can be expensive, but if the member requests there are cheaper options as well. After 100 days, the member posts his lab tests/photos or both.The remarkable thing is the dedication of the admins. I have never seen patient empowerment on such a grand scale. Those who follow the diet religiously and lose weight, in turn become evangelists of Paleo and welcome new comers and start mentoring. It is a virtuous cycle. The best part is all of this is done absolutely free of cost.
Interestingly, Paleo has spawned several entrepreneurs as well. The people are home delivering Paleo ingredients. There are even a few Paleo diet hotels around. The members and admins actively go out and raise awareness.
I must say that the photos of people weighing over 150 kgs and becoming 90 kg after paleo are far more impressive than p values <0.05. Of course, this is not to say that statistics is unimportant – quite the contrary. It is to emphasize that just because the data is not available in nice and easy spreadsheets or published in some top tier journal, doesn’t mean there is no data.
In the most unexpected of places, I did learn a few things that aren’t readily understood about Paleo diet. These are not the attributes of the diet itself. They are the extras- the sidekicks. Just like in the best of tales, the sidekicks save the day, even when the hero is down and out.
- Paleo diet is like a religion. It’s more a way a life than a diet. Just like religion acts as a vehicle to take good ideas and principles to the masses, the Paleo brand helps in bringing common sense and not so common sense dietary principles to the masses. Just like religion, there are high priests,evangelists and followers. Just like religion, there is a strong sense of belonging – for which people give their love and labor for free. Just like religion, it has spawned a parallel economy, where members enrich themselves and others through innovative business models.
- Just like religion, Paleo has its own issues. Since there’s no universal agreement on even what constitutes Paleo diet ( you can be pretty sure that the cave man didn’t take butter tea!), there are often conflicting views on some topics. These conflicts are resolved not through research, but personal experience of the admins and volunteers. However unlike religions, the group and the shared culture, ultimately puts the power in the hands of the people.
- Paleo diet groups are like corporations – they work with a clear hierarchy. They use data to continuously refine the advice and through rapid iteration understand what works and what doesn’t.Unlike corporations, they don’t operate for profit and don’t chase the bottom line.
- Paleo diet groups are like cooperative societies. Through the sheer strength of numbers, they are able to bargain with the labs and vendors and reduce the prices.
- Paleo diet groups are like schools – where the pupils are educated on a radically new diet and the pitfalls to watch out for. The advice may not always be in sync with what the medical community believes, but there can be no denying that it has worked in the short term for many people. The long term health effects of ketosis are largely unknown.
In short, the Paleo diet clearly goes beyond the boundaries of a diet – it’s more of a subaltern lifestyle. Some would even call it a social revolution – for it is of the people,by the people and for the people. There in lies its strength. It’s not an edifice built on multicenter clinical trials – but a belief system that has surprisingly worked for many people and continues to do so. Evidence is accumulating that it is effective in many lifestyle diseases. Even as the neo converts to the EBM decry the lack of evidence, we cannot forget that evidence often takes time. Seeing is believing ,but the reverse is true too – you need to believe in something strongly enough to see the results. For instance, if Gandhiji had asked for evidence that ahimsa can wrest political power from a powerful empire before embarking on the struggle, he would have come up with a nought – after all, there was no historical precedent- and we might have remained under imperial rule!
Our diet is very dear to us – which explain why we have a strong bias towards the status quo. When I see a morbidly obese man becoming fit in the short, without going under the surgeon’s scalpel, I know that’s special. It’s life changing. The biggest impact this search had on me was that now I find it impossibly hard to recommend bariatric surgery to anyone before a paleo trial – I cannot unsee the photos after all !
Of course, the jury is still out on the science of Paleo diet. However I am convinced that even good principles and ideas,like religion, require good packaging and branding. The social component of the Paleo groups is incredibly hard to replicate. We just can’t peddle good advice to people and expect it to catch on like wildfire. In that sense, Paleo might have already transcended the outer limits of conventional medicine.
I still remain a lurker in the group. I eat normal diet. I love statistics. However, when people quote meta analyses and p values, merely to buttress their belief system and show no effort to search for the truth, I chuckle inside. It takes a bit of humility and guts to say we don’t know. May be deep down, we don’t want to know.
May be we don’t want to look beyond evidence. When we do dare to look, the view is breathtaking.