Why Go Paleo?

I never expected to become a doctor. I did well at school, and my successes led me down various paths, none of which suited me. I made the decision not to accept a law school admission with the dubious rationale, “If I died on the last day of law school, I would have lived my last three years full of regret.” Although many people would say the same of medical school, my experience was quite the opposite. From the beginning of premed (squeezed into 15 months with other post-BA students at UC Berkeley) to the last day of my training (UC San Francisco School of Medicine and subsequent Family Practice Residency), I enjoyed the process. I am no masochist and moaned as much as anyone, but I loved the subject matter and the company. I spent my days and nights with committed and passionate people engaged in becoming the best physicians possible.

But the practice of medicine has not always been so satisfying, and I understand why physician burnout is such a serious problem. Most physicians who leave their practice leave medicine altogether, find greater satisfaction elsewhere, and often earn more money. My frustration with medicine stemmed from disillusionment: I missed the camaraderie of medical training, and I was disappointed in my practice. I had hoped to develop great skills at preventive medicine: to help people adopt healthy lifestyles and to avoid pharmaceuticals as much as possible. I remember one pharmacology professor who told our class, “All these drugs have side effects. Use them as a last resort.” If I had realized how rare that sentiment was, I would have asked for his autograph.

I can claim full flower-child status: from offering flowers into the rifles of National Guard troops in Berkeley, to months spent living on communes in the Pacific Northwest, to working as the medical director of a farmworker clinic. I was late to learn yoga, but relied instead on backpacking to find calm in the midst of a hurried medical life. I had great faith in wholesome food, suitable exercise, and a connection to nature as reservoirs of health. They worked for me. They just didn’t work so well with many of my patients.

When I advise a patient on lifestyle interventions for medical problems, I prioritize what is most likely to help. A smoker needs to stop smoking, that’s an easy first priority. A sedentary depressive will benefit as much from walking with a therapist as from talking with one. Stress reduction has a proven track record, whether it’s walking with friends, getting a dog, or learning to meditate. But the elephant in the room for lifestyle interventions has always been diet: What do I tell my patients to eat? I knew in my heart that eating right was the most important health practice. Food is our way of interacting with the world, of ingesting the world. What to eat, how to eat, and how well it nourishes us have been uncomfortable mysteries in my mind.

Conventional medical wisdom advises us to eat a diet based on whole grains, adding in lots of fruits and vegetables (considered equivalent), dairy, and protein in the form of fish and chicken. Red meat is a delicacy right up there with dessert: not too often. Fat is a no-no, and its elimination should surely lead one to a slim figure, normal blood pressure, and a long life. This approach actually works for some when taken to an extreme. Dean Ornish, MD, a clinical professor of medicine at UC San Francisco, has reversed heart disease with an extremely low fat, vegan diet and multiple lifestyle interventions including walking, yoga, and meditation. Medicare covers enrollment in Dr. Ornish’s program as a medical treatment.

So it seemed logical to cut fat, and I dutifully advised my high-cholesterol and overweight patients to drink skim milk and skimp on the butter. But as logical as it was, fat reduction never actually helped my patients lower their body fat or blood cholesterol. Despite my advice (or perhaps because of it!) my patients didn’t lose fat. I was just about to hang up the nutritional part of my shingle when my world changed.

A Bread and Butter Awakening

I remember sneaking pats of butter as a child, and I still loved it. But I had come to believe butter was bad for all of us, so I was shocked when I gave my seven-year-old a buttered slice of whole-grain bread and she returned to the kitchen having using the bread as a spoon, not a food item. She had no interest in the bread. She just wanted more butter. The image stuck in my head because at some level I trusted my daughter’s instincts, and also because I was beginning to believe the conventional medical wisdom was wrong.

Over time, three influential voices emerged to change my understanding of diet and health, a change that brought me back to the committed and passionate exploration that made me love my medical training. After so many years of practicing medicine, I felt like I was coming home.

The first voice was Weston Price, DDS, a dentist who founded what would become the research section of the American Dental Association. Dr. Price traveled the world studying the diets and nutrition of various cultures and published Nutrition and Physical Degeneration in 1939. He argued that aspects of the modern Western diet (particularly flour, sugar, and modern processed vegetable fats) cause nutritional deficiencies that are a cause of many dental issues and health problems. In 1999 the Weston A. Price Foundation began promoting the lessons gleaned from Dr. Price’s global travels, and I started to pay attention.

The next voice was the Harvard-educated science writer Gary Taubes, an investigative journalist who has made a name by uncovering bad science. In 2008, he published Good Calories, Bad Calories, challenging the conventional understanding of obesity and weight loss and shifting the focus from the excess calories in fat to the hormonal effects of carbohydrates.

The third voice was Robb Wolf, who published The Paleo Solution in 2010, suggesting that applying evolutionary principles can help us regain the health that so many modern Americans have largely lost. Wolf is neither a doctor nor a scientist. Instead, Wolf suffers from celiac disease, and the catalyst for his exploration was the simple fact that a conventional diet was killing him.

Thanks to these three men, my medical world has become filled with intelligent, passionate people looking for new answers about optimizing health, and being the best they can be. These three pioneers have had a large share of both adulation and attack. Here’s the bread and butter of their argument.

First the Butter

Dr. Price discovered that a nutritional cofactor in butter benefits the immune system, as well as bone and dental health. He didn’t identify the cofactor, but we now know it to be vitamin K2, the vitamin thought responsible for directing the calcium in your bloodstream to where you want it, rather than to the lining of your blood vessels.

Then Taubes traced the physiological consequences of consuming butter across populations, what is famously known as the “French Paradox” because the French consume more butter and cream than we do and yet have far less heart disease.

Finally, Wolf demonstrates one of the misunderstood principles of Paleo by eating butter. Paleo principles suggest eliminating all dairy for four to six weeks, as a modern food with which our species did not evolve. But he also believes you should resume eating foods that you tolerate. So if butter works for you, you’ll know it and you can eat it.

Now the Bread

Price reported that traditional societies ate grains that had sprouted and were often fermented (sourdough). Such grains were both digestible and non-allergenic—and quite different from the grains used in our typical foods today.

Next, Taubes charted the great increase in carbohydrate consumption that preceded the obesity and disease epidemics of the Pima Indians, who transitioned from a hunter-gatherer lifestyle to “civilization” in our federal reservation system. In other words, Taubes found that it wasn’t butter that made the Pima fat and diabetic, but modern wheat products.

Finally came Wolf’s descriptions of the effects of modern wheat, which are not suitable for polite print. Celiac disease is rare and serious and would cause anyone to loathe wheat, but research in the world of Paleo, notably conducted by Alessio Fasano, MD, a gastroenterologist and Chair of Pediatrics at Harvard Medical School, has elucidated the mechanism by which wheat is toxic for many people—not just celiac sufferers.

Personally, I loved whole-grain bread. It had always been one of the top three foods I’d want to have on a desert island, and I didn’t believe it caused me any ill effects. So I dragged my feet about doing a six-week Paleo trial. After all, I wasn’t sick.

Or was I? Let’s just say that my first six weeks without grains made the air around me consistently more fragrant, my abdomen mysteriously silent, my belts all notched a little tighter, and I didn’t even miss the bread! After that, I dove into the Paleo world—and gradually brought my patients with me.

And it is with my patients that I have seen the most benefit in the reversal of medical problems. Prescriptions and outsized clothes were discarded, digestion and fibromyalgia pains improved, allergies and headaches resolved. The response is not 100 percent, nor is the compliance: It is not easy to change a lifestyle that might seem to depend on morning buttered toast and fruit. Nevertheless, I have no doubt that it works.

Paleo is Not a Diet

The point of studying the Paleo lifestyle is to figure out what made our ancestors strong enough to survive for two and a half million years without agriculture (not to mention without refrigeration, central heating, and doctors). What have we gained since then? What have we lost?

What now seems clear is that the advent of agriculture 10,000 years ago increased our food security but decreased our food diversity and nutrient density. We created cultures that nourish our minds, but there is evidence that we grew shorter on average and developed more cavities in our teeth. Farm life enabled women to have more children, but childbirth became more hazardous because maternal bone structures became smaller. Overall, these tradeoffs worked to our advantage—but these are tradeoffs we no longer have to make, if we choose not to.

So my Paleo prescription suggests that for six weeks you look back to your roots before the advent of agriculture—and see how that works for the modern you. Like your ancestors, you should know where your food comes from, which ideally means farmers’ markets. For that period you eliminate grains, legumes (including peanuts), and dairy from your diet. (Butter is an exception, since there is so little dairy protein in butter.) One thing I can guarantee is that you will feel different at the end of six weeks. Pay attention to the changes, and reintroduce foods one at a time, noting their effects. Maybe you’ll never reintroduce gluten, especially if you have digestive, autoimmune, or skin problems. Maybe you will.

Before you start grumbling that life sounds not worth living, consider what you will be encouraged to eat:

Meats from animals raised on pasture, with a superior nutritional content and less environmental hazard than conventionally raised animals.

Vegetables, lots of vegetables, of all different kinds.

Fruit, yes, but think of fruit as dessert, not as a staple like vegetables.

And yes, butter, tea, coffee, avocado, even dark chocolate is fine.

Alcohol is okay too, with clear non-grain alcohols or wines preferred. Beer, sadly, is made from grains and is off the list.

If you worry about the health hazards attributed to red meat and fat, the Paleo diet has been tested against both a standard diabetic regime and the Mediterranean diet, and Paleo prevailed in improving the markers for diabetes and cardiovascular health, as well as weight and well-being. I suggest you test this for yourself before and after your six-week trial.

The Paleo Lifestyle

The Paleo exercise prescription is fairly simple: move around a lot, sprint occasionally and lift heavy things. That daily five-mile run or two-mile swim is not necessary, and for many people not helpful, so long as you build movement into your lifestyle. Efficient exercise paired with a grain-free and perhaps dairy-free diet balances body composition, strength, agility, and aerobic conditioning for modern people just as it did for preagricultural people.

The Paleo sleep prescription also works in the bedroom. Have you ever noticed how well you sleep when you’re camping, and you go to bed and get up with the sun? There is evidence that abundant evening light (particularly that light emanating from computer or tablet screens) fools our brain into thinking it is morning and therefore turning off its usual nighttime melatonin production. Sleep in the dark and wake without an alarm as often as possible.

In the end, what I love most about Paleo is the feeling of belonging to a giant, heterogeneous, and very intentionally living tribe. Every Paleo blogger has some familiarity with the current medical literature, and every Paleo physician has charted his or her own lipids and has experimented with finding the Paleo exercise program they will most enjoy. People I barely know tell me what wonderful changes Paleo living has made in
their lives, and patients I’ve struggled with for years tell me they now have
their lives back.

I think we all share a deep respect for the incredible complexity that is health and disease, and we are all pioneers and scientists, looking for our own individual truths amid a sea of conflicting data. We’re opinionated and passionate, but I think we all agree on the most basic Paleo prescription: the need to choose your food wisely, to stop, to laugh, to take a nap, and to play.

Didn’t all Paleolithic people die before they turned 30?

Although the average age of death for our ancestors was 25 years of age, for those who survived childbirth and childhood (60 to 70 percent of people), mortality overall can be traced in a U-shaped curve. If you survived to 15, you could expect a reasonable life span. Mortality rates started to increase at 40, reaching significance for most from 60 to 75. Those who lived past the age of 60 died without the ravages of tooth decay (more important than you may think!), heart disease, cancer, or arthritis. Most deaths occurred due to injury and infection.

I Respect the Vegan Position, BUT...

It seems increasingly clear that ecosystems work better with natural (or at least well-designed) predator/prey systems rather than by leaving either one out of the equation. For example, reintroducing wolves into Yellowstone Park in 1995 dramatically improved the health of not just the other animals but the vegetation and even the rivers (watch “How Wolves Change Rivers” on YouTube). At the other end of the spectrum, reintroducing buffalo, cattle, and goats onto land not suitable for farming has been shown to help sequester carbon in the soil, encourage plant growth, and allow for better water retention. That scenario is being used to restore the prairies of Africa and parts of this country as well. Of course, natural predators of buffalo and goats include human beings. So the question becomes: do we improve the overall health of the world by no longer being predators or by becoming more conscientious predators? I think the health data support the latter.

As a physician I am ethically bound to warn vegans that they will jeopardize their own health unless they supplement wisely. The same goes for vegetarians, who have to be very careful about zinc and B12 and the fat-soluble vitamins. The need for supplements concerns me because at every age people have considered themselves wiser than their bodies—and often wiser than the earth. Fortunately, the human body and the earth have proven amazingly resilient, so we can make a range of suboptimal decisions and still get by. That said, I believe the Paleo ideal has proven to be healthiest for the body and, by extension, for the planet. Keep in mind that Paleo includes insects, which for the billions of humans are necessary for survival.

Personally, I think vegan ethical arguments are well intentioned but don’t hold up in practice. I might kill one cow a year to eat beef while countless small rodents are killed in the raising of row crops. Ironically, fewer sentient beings are killed when we choose to eat larger animals than when we rely on crops. We need to treat our “prey” animals better, but that’s a different discussion.

The New York Times held a contest to answer the question, “Why eat meat?” that was judged by vegans. My favorite answer: If we destroy this planet and move to Mars, the cows will be left behind unless we take them to raise for food.

Paleo vs. MS

Perhaps the most exciting Paleo intervention to gain public attention has been the work of Dr. Terry Wahls, who reversed her own progressive (and therefore considered irreversible) multiple sclerosis. She is hosting her second set of clinical trials in which MS patients follow her protocol, which includes a Paleo diet (valuable to point out that Paleo in general is suitable for omnivores or vegetarians, although Dr. Wahls recommends the omnivore path), as well as specified stress reduction and exercise. For more information on the interventions she recommends, see The Wahls Protocol by Terry Wahls, MD.

A Paleo Day

6:30 Wake with the first light of dawn and slowly get up, move around, and maybe have a nice cup of hot water with lemon juice.

7:30 Breakfast of bacon (or smoked salmon), sautéed greens, and lightly fried eggs. Tea or coffee with cream or blended with butter.

8:30 Spend some time outside to help pattern sleep habits. On days at the computer, set a timer so every hour you remind yourself to get up, stretch, or walk about for 5 minutes. Drink water to satisfy your thirst, especially if you had a caffeinated morning beverage.

1:00 Lunch is leftover dinner: ideally meat, a non-starchy vegetable, and a salad. If your morning exercise was vigorous, a starchy vegetable is great. Butter, salad dressing, avocadoes all encouraged.

1:30 If you crave a snack during the afternoon, an ounce of dark chocolate (75% or higher) or some nuts will get you to dinner. Remember that water.

6:30 Dinner is protein, starchy vegetables, and leafy greens, cooked or raw. If you find yourself at a restaurant, order lightly grilled meat or fish and ask that extra vegetables be substituted for pasta.

7:30 All screens off and soon start winding down for bed, turning down the houselights, stretch, read, and hang out with your loved ones.

9:30 Good night!

Final Tip: Paleo people enjoyed greater nutrient diversity and a healthier gut than we have. Do your part by enjoying a wide variety of foods, include all colors in your plate’s palate, and eat your nutritious food to satiety, saving treats for that small space remaining after you’re truly satisfied.

Your Six-Week Trial

Prepare yourself: mentally and in your kitchen. Get rid of forbidden foods and stock up on allowed favorites. Start keeping a journal about your mental clarity, emotional state, and sleep quality.

Pick a date and measure yourself. I suggest waist circumference rather than weight. You also may want to check your blood lipids.

For six weeks, do your very best to avoid grains, legumes, and dairy. Plan ahead for social occasions: warn everyone or eat first.

Review your journal and remeasure yourself. Any changes?

Books of interest

Nutrition and Physical Degeneration, by Weston A. Price, DDS

Good Calories, Bad Calories and its more readable sequel, Why We Get Fat, both by award-winning science writer Gary Taubes

The Big Fat Surprise, by Nina Teicholz, on the base-less evolution of our fear of dietary fat.

The Paleo Solution, by Robb Wolf

The Paleo Cure, by Chris Kresser; details on how to individualize an ancestral approach for your own health situation.