Interview with Kenneth Shafer, MD
Kenneth Shafer, MD
Cardiologist at Cleveland Clinic Foundation’s Family Health Center in Wooster, OH
Q: Dr. Shafer, tell us a little about your training and practice.
A: I’m a non-invasive Cardiologist and practice at the Cleveland Clinic Foundation’s Family Health Center in Wooster, OH. I received my undergraduate training at the College of Wooster, where I was trained to think critically, keep my eye on the big picture, integrate information and be suspicious of authoritative statements. I made it a point to spend my final year in college sampling as many humanities courses as possible, while preparing my undergraduate thesis in Inorganic Chemistry. I then headed to St. Louis University for medical training, an institution with an emphasis on community based health. This is where I learned to be practical and pragmatic—again, keeping my eye on the long view.
After practicing for a short time in St. Louis, I moved in 1986 to West Plains, MO, a town of about 10,000 in the heart of the Ozarks, where I established a full service Cardiology practice. In 2002, I returned to Wooster, OH where I now practice along with two other cardiologists. My practice had been very conventional and focused primarily on evidence based treatment with drugs, procedures and devices until seven years ago—when a paradigm-shift was sparked.
Q: What happened to cause this shift?
A: I was given a copy of “The China Study.” Reading this book has been the “Ah-hah!” moment for many physicians. About the same time, I had the privilege to hear both Colin Campbell, PhD and Caldwell Esselstyn, MD speak at a colloquium in Wooster. This was the first time I really started thinking about food as medicine and realized that much of what I had been taught about nutrition was suspect. It was also the time I began to embrace the concept of whole food, plant-based nutrition.
Q: What was your training in nutrition?
A: Like virtually all physicians, my training in medical school was very limited, consisting mostly of discussion about diseases of deficiency (e.g. scurvy) and virtually nothing about diseases of consumption. Most of the continuing education training I have received has been similarly narrow-focused and incomplete. Our understanding of the effect of food on health has been very slow to develop over the years, and there is little reliable information to give patients or to guide the physician. We are also trained, often quite authoritatively, that changes in diet are too difficult for patients and are unsustainable.
Getting back to the events of seven years ago, I began looking more critically at what changes might take place in the health of my patients if changes in nutrition could lead to improvement in chronic disease. I also made myself aware of the cost of healthcare and what we are getting for our money. Let me tell you a few very disturbing things I learned:
- We in the US pay more per capita for health care than any other country in the world. In fact, we spend almost twice as much as the next highest spender.
- Despite that expense (which currently consumes 17% of our economy), there are over 50 countries in the world with a longer life expectancy. Clearly we are not achieving at least one of the desired outcomes.
- It is estimated that 80% of the healthcare budget is for treatment of chronic disease, much of which is life style related and, presumably, largely preventable.
- Diseases of the heart and circulation consume a large part of the healthcare budget, and the cost is expected to increase consistently over the next several decades. We simply will not be able to pay for the treatments we are developing and recommending to an increasing population of patients.
- Dietary guidelines have changed little over the past several decades, and the understanding of nutrition has advanced at a snail’s pace, compared to other areas of medical science. Yet, prevention, treatment, and even reversal of chronic disease—often directly tied to what we’re eating—has the largest potential to drive down the cost of care, not to mention what the additional dollars that are freed up would do for education, infrastructure, etc.
- Despite the anemic guidelines and recommendations we give our patients, adherence is abominable. Less than 10% of adults are getting currently recommended amounts of fiber, fruits and vegetables. The data are even worse for children.
- The information we give is contradicted by claims of miraculous weight loss in the popular press and by our own reversals in advice about the value and/or dangers of things like supplements, cholesterol, saturated fat, and carbohydrates.
Q: What can we tell patients that will be persuasive and lead to lifestyle change?
A: First, we have to be honest when we talk about nutrition and emphasize that there is much we don’t know for certain. We can’t be absolute and dogmatic, because patients have access to lots of information which is conflicting, so they’re often confused and skeptical. However, there is growing agreement among many experts, coming at this from different points of view, that a diet which is based on plant protein and consists of whole, minimally processed foods is the one most supportive of health and freedom from chronic disease. We can mention that most of the leading disease societies and several leading medical centers (including the Cleveland Clinic) embrace such an approach. We may couch this in different terms, such as Mediterranean Diet, vegan diet, WFPD diet, etc., but there is an opportunity to stress the commonalities of these nutritional approaches.
I think that we also need to keep in mind that there is a large body of evidence concerning the benefits of medication and procedures in the prevention of adverse events like death and MI, and it is incumbent on us to use lifestyle change as adjuncts to published best practice standards and not as substitutes for them. One of the biggest challenges I face is to encourage significant lifestyle changes while maintaining evidence based practices. There is certainly much to be gained from both approaches and they should be complementary.
Q: How have you integrated this approach into your practice? How do you engage patients?
A: First, let me say that patient engagement is critical. It has been surprising to me to discover how much compliance benefits from helping patients see how much control they have. Too much of our medical system is based on treatment options which are poorly explained, inadequately understood, and given without full discussion of alternatives.
Training of patients to make changes in nutrition is very challenging. I admit that I have yet to find the most efficacious way of doing it. I have tried, among other things, incorporating it in the 15 minute office visit (definitely not recommended!), conducting shared medical appointments, giving cooking classes in the evening, stressing nutrition education in the context of conventional cardiac rehab programs, and working with community groups. The big obstacles are time, social support and continuity. Unless you address all three, you cannot be successful. I am very excited about the potential of the Plantrician Project’s CulinaryRx program and what is likely to follow. We are experiencing a growing, vibrant grass roots movement toward WFPB nutrition. We now need a sound, continuing support program that has the endorsement of major organizations. That will make it much easier for the average physician to engage patients and make meaningful, chronic nutritional change.
Q: How have you personally been effected by your “Ah-hah!” moment?
A: I like a challenge, and hearing that change is “impossible” for most people but potentially so valuable for those at highest risk (the patients in Dr. Esselstyn’s study, for example), I chose to adopt a diet that was strictly plant based with a minimum of processed food and added oil. My anecdotal experience (and I recognize it as such) has been that I have never felt better and that many chronic, non-debilitating but irritating bodily malfunctions have improved. My LDL cholesterol fell by 50% (equivalent to the effect of high dose statins) and my weight has never been as stable or my energy level as good. My experience is not unique.
Research has shown that other lifestyle habits also affect health. Throughout my life, I have had variable success with adherence to exercise programs and meditation (I learned TM in college), relaxation and vacation time has been challenging and personal relationships have occasionally been a source of stress more than of comfort. Eating, however, has been a consistent need and practice, and this is the main reason to think that “nutrition trumps all” and has the most potential for change in health.
The more important personal changes I have noticed, however, are in the way I think about food choices and their effect on global health issues like animal rights, climate change, water conservation, social justice and economic inequality. That has been the biggest surprise for me, and it has rekindled a lot of the mindset I had during my senior year of college, when I last took time to think about the big questions.
Q: What advice would you give to other physicians and healthcare professionals?
A: First — don’t buy the argument that patients can’t or won’t make changes. In fact, many suffer from a lack of engagement in general and welcome the empowerment that comes when their physician says “this is what you can do to improve the quality of your life, and here is what I am going to do to help you make and sustain those changes.” We will soon have better tools to effectively and efficiently support patients as they make these changes—resources like Plantrician’s Culinay Rx and WFPB Quick Start Guide.
Second — remain intellectually discriminating and don’t forget to consider what makes sense. When you hear that the only way to know whether something works is to do a randomized, controlled, blinded trial (although that is the best way to evaluate treatments which are expensive, potentially harmful and/or of minimally incremental value), remember that there are other ways to acquire knowledge. When you are told that guidelines should be applied to whole populations, ask whether it is reasonable that 50% of adults need statins to maintain good health.
Finally — look for partnerships. None of us can do this alone. We are dependent on our colleagues, mentors, allied professionals, teachers, and industry partners. We will soon be riding the crest of the growing wave and will have the tools we need to help patients make radical changes in their health.