Integrating Plant-based Nutrition into the Medical System with Michelle McMacken: PYP 221

Michelle McMacken, MD, is a leader in the field of plant-based lifestyle medicine. She's an assistant professor at New York University's School of Medicine, and the director of a medical weight-loss clinic at Bellevue Medical Center.

She's also responsible for teaching doctors-in-training at Bellevue, where she gets to introduce the next generation of medical professionals to the wonderful world of lifestyle medicine.

Bellevue serves a very diverse patient population, including people who live in homeless shelters, who speak very little English, and who have multiple other obstacles to the “Whole Foods” lifestyle.

And yet she works with them, and with the other healthcare professionals who work with them, to improve their health outcomes and happiness by replacing junk food and animal products with life-supporting plant foods.

In our conversation, we talked about Dr McMacken's unlikely journey, the state of healthcare today, and how she and many others are shifting the paradigm from disease management to disease prevention and reversal through lifestyle habits.

We covered:

  • Dr. McMacken's winding path to medicine as a career
  • the healing power of story and narrative
  • the Lifestyle Medicine conference that changed her life
  • the counseling gap in medicine – the missing link in changing patient behavior and outcomes
  • the power of Motivational Interviewing
  • the magic 6-word teaser question that engaged patients in real conversations about health habits
  • case study: reversing type 2 diabetes
  • starting patients with the familiar
  • the power of a stepwise approach
  • how to get doctors to add lifestyle medicine to their toolkit
  • forming coalitions by not harping on the fine points
  • dispelling the ketogenic myth
  • and much more…

Enjoy, add your voice to the conversation via the comment box below, and please share – that's how we spread our message and spread our roots.

Links

Dr McMacken's NYU professional page

Dr McMacken on Instagram

Dr McMacken on Twitter

American College of Lifestyle Medicine

Free video course on Motivational Interviewing

Transcript

Download the transcript in PDF format here. (Thanks to Kelly Michiya for transcribing the episode!)

Read the full transcript here

HOWARD: Doctor Michelle McMacken, welcome to the Plant Yourself Podcast!
DR. MCMACKEN: Thank you! It’s great to be talking with you.
HOWARD: So, we wanted to talk about two things that you’re known for and have spent a lot of time thinking about, which is how to talk to patients about adopting healthier lifestyles and how to talk to doctors and other medical professionals to teach them about it. But let’s start with your story because you’re a doctor, a board certified internal medicine specialist?
DR. MCMACKEN: Yes.
HOWARD: And you do a whole bunch of other things including medically supervised weight loss. But you have an unusual path to the MD degree. Can you start by telling us about that?
DR. MCMACKEN: Sure. So, I am a lover of books and literature, and I found myself in college really being drawn to study English even though I come from… both of my parents are scientists and there was a lot of science in my home growing up… I just really loved the English literature angle, and that’s what I studied in undergrad. I think I took a couple of science classes in college to meet requirements, but essentially didn’t really do much in that area. When I finished college with my English degree, I was so excited to get out into the world and get a job, and I realized, what am I gonna… what am I actually gonna do [laughs] with this education that I have, and I ended up almost randomly getting a job at the Centers for Disease Control and Prevention down in Atlanta. That job was as a writer/editor, so my job was to edit manuscripts and look over health education materials from the angle of editing and writing, and within just a few months of working there, I really fell in love with the content. I was working in the tuberculosis division there and really just became excited about the work that my epidemiology colleagues were doing and physicians and another public health specialist there were doing going out there on outbreaks, and it’s started… this sort of twinkle in the back of my mind, you know, I started thinking, is this something I might wanna do and sort of mulling it over, and over the three and a half years that I worked there I came to the realization that it was something that I thought I might really like.
So, I ended up deciding to approach it from getting a medical degree angle and I ended up, you know, deciding to quit my job and sell my car and move back in with my parents for a year just to take a post-bach program because I really had never taken science classes. Obviously, to enroll in medial school, I had to do some basic requirements. So, I found myself in my mid-20s living at home for a year and taking basic biology and physics and organic chemistry and chemistry, and then another surprise happened, which was that I LOVED science, and I LOVED studying it. I got so excited about it, and I thought, well, this is not expected at all. But I kind of got through that, and I ended up working for the year that I was applying to medical school working at the New York City Department of Health as a health educator and applied to medical schools and got into Columbia and enrolled as an “older” student in my late 20’s. And I found myself in medical school pretty early on realizing that even though I had gone there because I wanted to do public health, I’d really fallen in love with the one-on-one interaction with patients and the communication piece and what it brought to me personally to be able to have the privilege of taking care of people and working through their health and helping them make decisions. That’s what I ended up really falling in love with, so after medical school, I decided to train in internal medicine, which is a field that focuses on adult medicine but really integrates all the different organ systems including mental health and sort of everything it takes to be a primary care doctor and look at the whole person, and that kind of led me to my current career path.
HOWARD: Wow, it’s so interesting how every piece of candy you opened was delicious.
DR. MCMACKEN: [laughs] I love that analogy!
HOWARD: And led you to the next one. What was it about epidemiology or clinical work you were doing with TB and with other things at the CDC that got you excited?
DR. MCMACKEN: I think it was really just the analytics of looking at what causes disease outbreaks and the fact that you’re always being… uh, you’re always resisting making assumptions. In the field of epidemiology, it’s easy to say, oh, I think this is the reality, but then when you start getting more data, you have to keep taking steps back and seeing how it all fits into a framework, and that really appealed to me.
HOWARD: Hmmm. It must have been… did it feel different from your literature stuff or were there ways of interpreting and reading literature that felt useful like you had… your background in humanities was actually giving you tools to apply here?
DR. MCMACKEN: That’s a great question. I think when I was in the thick of all of my training, it was a little bit hard for me to see the bigger picture on how my humanities background directly informed my understanding of public health or epidemiology or clinical medicine. But now that I’m out and a little less sleep deprived [laughs] and really sort of flourishing in my practice with patients, I can see that my interest in the story and narrative has really come full circle with my interest in hearing people talk about their stories and where they come from and understanding themes that run through their lives, if that makes sense.
HOWARD: Yeah, so there’s a form of therapy called story therapy, right?
DR. MCMACKEN: That’s right.
HOWARD: When you start to understand the patient’s story of themselves, you then can see the places where an intervention is possible.
DR. MCMACKEN: That’s right.
HOWARD: That’s where you can change the arc a little bit.
DR. MCMACKEN: That’s right.
HOWARD: You know, I had a similar experience. I’m a humanities guy. I did go to Temple University for health studies and public health, and I kind of struggled with a lot of the data stuff, not that it was hard, but it felt so dry. And it was only when I could make stories of it… something would happen when I looked at a spreadsheet or when I looked at a table in a study, and all of a sudden, the numbers would shift. It would turn into like, here’s the story of the study whether it was window bars in New York or cases of diabetes. It is sort of resolving into human beings, into the real world.
DR. MCMACKEN: That’s right, and I think, I mean it’s the same thing when I give a talk, for example, on nutrition. You can share tons of data, but until you pair it with a narrative of a patient’s success story or a patient’s experience, it doesn’t feel as real to people. You know, the data are important, and you need those too, but those two things sort of complement each other. I think that’s really a powerful way of presenting information to people.
HOWARD: Mmm. And it’s one of the weaknesses of our plant-based, evidence-based movement is that the other side has better stories even though we have better data.
DR. MCMACKEN: [laughs] Yeah. Maybe. We definitely have some great stories, and when we share them, they’re incredibly powerful, but you know, the quick bait too is the other aspect of this.
HOWARD: Right. All of a sudden, whatever we wanna hear has some fake scientific validity backing it up.
DR. MCMACKEN: Right. Exactly.
HOWARD: So, you started working one on one, and you fell in love with that dynamic, and I think I’ve read in the piece you wrote for the Plantrician Project that you had already been a vegetarian for many years, but you were practicing the very traditional, standard pills-and-procedures medicine. First of all, what led you to vegetarianism and when was that?
DR. MCMACKEN: Sure. So, I became a vegetarian, or I should say, technically a pescatarian very early on when I was around 13 because I was really turned off by chicken in particular, and red meat just didn’t appeal to me, so I felt like it was a natural thing to do to not eat those foods since it wasn’t appealing. And as I… over the years I realized that the part of why it wasn’t appealing to me was understanding what had to happen to an animal for it to become food for me, and once I made that connection, I realized it wasn’t completely consistent for me to eat fish, so I let go of fish as well in my early 20’s, and I went a long time as what you’d call a lacto-ovo-vegetarian until actually ten years ago this summer when I then became aware of or actually I let myself hear information about what happens to animals… cows and chicken and egg-laying hens and so forth, and once I sort of took that in, I think for me it was very hard to turn back in terms of where my values were aligned, and I didn’t want to support those industries once I learned what it entailed.
So, I made the decision to go completely vegan. At that time, this was around 2007, and at that time, obviously social media and even the Internet wasn’t what it is today, and I don’t think I… a lot of the key books that we all… and information that we all rely on now on the health benefits of plant-base diets had not been published or were not very mainstream, so I don’t think I fully appreciated from the health perspective, you know, ironically as a physician that this could be an astonishingly healthy way of eating. That coupled with the fact that I’m very well trained in pharmacology and very well trained in how to prescribe medication and refer people to procedures. Those two things together led me to well, this is a very personal choice. I’m gonna keep living according to my values and making choices according to my values in terms of my food, but at work, I am going to prescribe medications because that’s what I know how to do.
HOWARD: Gotcha.
DR. MCMACKEN: And that’s what I did for ten years.
HOWARD: So, you were eating vegan. Was it whole food plant-based, you know, doing it for your health or was it just eliminating the animal products but still having processed foods and things like that?
DR. MCMACKEN: Yeah, I think back then and certainly in the beginning, I was eating more processed foods and just trying to make myself around the world as a new vegan, and there were not the kind of options, even in terms of availability of say, plant milks or other things in the grocery stores that are now. So, I was kind of finding my way through that world, and it wasn’t until a few years after that I really sort of started to read more about the health benefits and start emphasizing more of the whole foods plant-based approach.
HOWARD: Did you notice any health benefits or performance benefits or subjective feelings of feeling better at each stage, you know, when you gave up fish or when you gave up dairy and eggs?
DR. MCMACKEN: I’ve always been… to be honest, my health has always been very good, so I never really struggled with major health problems fortunately, and for me it was more… it felt really good to know that I had made a decision on the basis of my values and was not contributing to something I didn’t agree with rather than necessarily huge astounding health benefits right off the bat. I will say that transitioning more to a whole foods plant-based approach certainly has come with some health benefits in terms of energy level and just feeling better overall. For someone who started out fairly healthy to begin with, I definitely notice I feel better when I eat that way.
HOWARD: Gotcha. Where were you in your career? What were you doing when the whole food plant-based protocol started leaking into your practice?
DR. MCMACKEN: Yeah, I was about ten years into my practice, and I had this very, very life-changing experience where I went to a medical conference called the American College of Lifestyle Medicine, and I went there with a colleague of mine who’s very likeminded, and at the time, I’m embarrassed to say, I didn’t even know what the term “lifestyle medicine” was. Yeah. I got to this confidence, and I heard Dr. Esselstyn speak and Dr. Ornish speak and Dr. Bernard speak and others who really… you know, it’s hard to hear people like that talk about their experience and their data without having a huge impact on you, and I remember being at that conference and literally at the end of the conference day coming back to my hotel room and feeling like I couldn’t even sleep. I was so hyped up about this new information and what I was learning and realizing that all of this time in my practice I had been missing a HUGE opportunity to help my patients get to the root cause of their chronic conditions, the things that I spent day in and day out… I’m treating diabetes, treating prediabetes, high cholesterol, high blood pressure, heart disease... people are afraid of getting cancer because it runs in their family, and the list goes on and on and on, and I’m focusing on pharmacotherapy, and I’m focusing on screening tests, but I’m not focusing on lifestyle… and that was a really humbling realization.
HOWARD: What made you go to the conference in the first place? What did you think it was going to be about?
DR. MCMACKEN: I can only think that I had some subconscious… uh maybe the same way I made the decision to, you know, I made the decision to drop everything I was doing and go to med school at an older age than other people to take these turns in my life. I can’t think of what exactly. I just remember having this… you know, I had a little bit of extra money in my budget for continuing medical education and something made me google lifestyle, and it came up almost like somebody whispering in my ear, so I’m just glad I did it.
HOWARD: Do you think the part of the gap in your understanding of lifestyle was around the mantra in mainstream medicine that we can’t get people to change their lifestyles, they just won’t do it, so the best we can do is hope for their compliance with the pill or impose our will upon them with the procedure, they’re gonna be sedated and they won’t be able to get out of it? Were you looking for proof that lifestyle could make a big difference or just ways in which you can get them to improve a little bit?
DR. MCMACKEN: I think that for my vantage point, the issue is that nothing in my medical training was framed as ‘lifestyle works,’ and the paradigm doesn’t exist at all. So, you don’t really understand the power that changes in lifestyle are gonna have, and beyond that of course you’re not taught specifically what are the lifestyle changes that people can do, and you’re not taught how you counsel patients on those, what is the evidence based for it and how to actually reach people and help them change behavior. You’re taught a little bit about motivational interviewing or behavioral change in the context of things like quitting smoking or other unhealthy behaviors, but you’re not taught about nutrition in a meaningful way, and you’re not taught about sleep or stress management, things that are extremely relevant. So for me, I just don’t think I had any sense that this was something that worked at all. It just wasn’t on my radar. I will say that a part of my work in addition to being a primary care physician and practicing internal medicine was I also, as you mentioned, have been directing a medical weight management program, and that program has for a very long time focused on lifestyle changes, but up until I had this epiphany, my focus was on traditional lifestyle management of excess bodyweight, which is count your calories, measure your portions, things that I now sort of look at and think that doesn’t really work well with my philosophy, and I don’t find that to be very useful.
HOWARD: So, you came back from the conference and you were so excited you couldn’t sleep. I know a lot of doctors who have seen Forks Over Knives or you know, somehow been exposed to this and changed their own lifestyle and improved their own health, and yet they have no clue how to change their practice, how to reach patients differently, how to make money at it so they end up doing it Wednesday nights and Saturday mornings for free. Like what did you do when you came back and all of a sudden you had this new mandate from these giants of lifestyle medicine you hadn’t known existed to start bringing this into your own work?
DR. MCMACKEN: Yeah, I really fumbled at the beginning. I do remember very specifically that Monday morning after the conference one of my patients on my schedule was a woman who is from West Africa and I remember talking to her… she’d been my patient for a year by that point… I remember talking to her for the very first time ever about her diet, the first time EVER. She has high cholesterol, high blood pressure, type 2 diabetes, and she had recently had another cardiac stent placed for coronary artery disease, and I had never talked to her about her diet. So, I knew that I had to start somewhere, and I knew that I didn’t have a lot of the training, but I was really committed to just giving it a try, so I just started fumbling my way through it. I really… because I work in a hospital where the patient population is extraordinarily diverse and I’m frequently using interpreter phones, speaking Spanish, which I do speak, but many many other languages, speaking across culture and different socioeconomic statuses… I really had to get creative, and so I kind of fumbled my way through, but pretty quickly I started seeing, even with my very crude, untrained approach, seeing a lot of benefits.
For one thing, my patients almost universally really liked talking about it, and it brought us closer in a way that you know, the patients that I’d known for a long time I learned more about them from talking about what they ate than I had from prescribing medications or just very superficial understanding of their home life. So that was the first thing that really helped my relationships with people, and I think that the second thing was that it quickly… just very minimal simple advice, people took it to heart and started making their own changes and within a few months, I started… we both started reaping the benefits by their having made those changes, so I started to see people whose blood sugar got a lot better with these simple dietary changes, for whom I could actually start discontinuing or lowering doses of medications in just a very short time, so that gave me more impetus to keep going, and it was very rewarding very very quickly.
HOWARD: Wow. So, how did you do it? I mean, that’s like supposedly the hardest nut to crack to talk to your patients about lifestyle because they’d nod and say “yes yes” and then they’d go home and eat the same foods they always ate and hang out with the same people they always hung out with and they’d talk to themselves and explain well, they can always take the pill. What did you do in your untrained, crude way that was having an actual impact?
DR. MCMACKEN: Yeah, I think that the first step for me is usually assessing a person’s interest in talking about it. That’s the basic principle of motivational interviewing where you kind of get permission to talk to someone about something that they may or may not have interest in, but that first step is very powerful because prior to that I had just assumed that most people weren’t gonna change and or weren’t just interested at all. So, just even asking that question at the beginning of a visit and saying, “Hey, you know, you’re taking these 12 medications and you have these conditions. Would it be okay if we talked for a few minutes about how you can get a little healthier by making some changes to the way you eat or other aspects of lifestyle?” And I would say that about 75% of my patients are interested in hearing more, so for those who are, we can go to the next step.
HOWARD: That’s so interesting because it’s such a simple thing to start with. My experience with clinicians it’s rare that I hear it from them. So, being hyper-respectful and saying “May I have your permission to discuss these things with you?” It’s typically more rushed and here’s what you’ve gotta do. Have you studied motivational interviewing at that point, or did it sort of come naturally to you?
DR. MCMACKEN: Well, I had definitely studied motivational interviewing as part of my work with the weight management program, and again because the communication and connection part of being a physician is what I find so rewarding, I think I naturally enjoy that dynamic. But the word “permission” is interesting because even though I’m framing it as if I’m asking for permission, it’s really just an introduction. It’s really a way of saying, hey, it’s a teaser. It’s a way of saying, hey, there are things you can do to improve your health that don’t involve a pill or procedure. Do you want to hear more? And when you frame it that way, a lot of people admit that they do and are amazed that no physician has mentioned it to them before.
HOWARD: Huh, it’s almost… I’m coming back to your background in literature, and it’s almost like a little bit of a cliffhanger, right? The last line of a chapter, like do you wanna know more? Like all you have to do to get someone interested is to say, “Hey, I wanna tell you something. Oh, never mind.”
DR. MCMACKEN: Wait until your next visit or appointment. Yeah.
HOWARD: I’m hearing your literary chops, you know, coming to the fore here.
DR. MCMACKEN: [laughs] That’s funny. So, most people do wanna hear more, and of course, I have my eye on the clock. I mean, I have a regular busy practice, and it’s not a practice where I have the ability to spend the amount of time that I wanna spend with every patient. I’m subject to many of the same time constraints that regular, most primary care doctors are. But for those who wanna hear more, then I take it to the next step, and we spaced it out over multiple visits usually, but with the first visit sort of laying a broad framework of foods that support health and foods that detract from health.
HOWARD: Mmm.
DR. MCMACKEN: For the patients who tell me, no, I really don’t wanna hear about changes in food or change in my lifestyle, then for me that’s… they haven’t given me permission or they don’t want to read past the cliffhanger, and I tell them, that’s ok. But I’m actually gonna bring it up at the next appointment, and I keep bringing it up because you never know when they might be ready to talk about it.
HOWARD: Mmm hmm, so you’re working with a diverse patient population and that’s at Bellevue?
DR. MCMACKEN: Yes.
HOWARD: Okay, so who are some of the patient case studies that we, the listeners, might be surprised to hear about? Maybe a couple of… you know, back to stories. A couple of stories of people who made big changes that you might have thought, oh they’re not gonna do it?
DR. MCMACKEN: Yeah, I have many, and they’re really fun to talk about. I would say one of my most favorite stories is a gentleman who, he’s in his mid-40s and he’s originally from Mexico, and he came to me about eight years ago as a patient with really, very poorly controlled type 2 diabetes and very uninterested in taking medications. But at that time, I was really not equipped or motivated or in the know to talk to him about lifestyle changes, so he went on for a very long time with very high blood sugars, and about a year ago we sat down and I said, you know, you’re at a point where your blood sugar is so high that you are sort of at a fork in the road where we can either talk about a dramatic lifestyle change to try to get things under control or you can start taking insulin, but one way or the other I don’t think it’s a good idea to stay in the state you’re in. Even though I had brought it up a few times over the past few years, this was the time he was ready to do it and ready to hear about it, so I seized on that opportunity. One of the things I’m really passionate about is type 2 diabetes and prediabetes because I would say that aside from cholesterol lowering, that’s the area where I see DRAMATIC improvements by switching one’s diet.
So, for him and most of my patients with any kind of insulin resistance, type 2 diabetes, prediabetes, I like to talk through, first what do you think are the foods that contribute to your having diabetes? And most patients will right off the bat tell me sugar or bread or rice. I love doing that because I’d love to understand where people are starting from and normalize why they think that, and I tell them I used to think that too and there’s some truth to that in certain situations, but you’re forgetting about a whole category of foods that is also contributing to your diabetes, so we talk about where the evidence lies and processed meats and red meats and how those contribute to insulin resistance, and with this patient and all patients, I usually draw, you know for diabetes, I draw a picture of what’s really going on at the level of the cell. And this sounds a little crazy, I know, but it really, really works because until you understand that the problem is not blood sugar. Blood sugar is only a symptom. Until you understand that eating a banana and the sugar going up is not the banana’s fault. I call the banana the innocent victim. Until you understand that, you’re not gonna understand what I’m explaining to you about how to change your diet.
So, I do it all the time. I’ve found it to be very effective even among my patients who have an elementary school education. They get it, and I talk through the foods that are evidenced based for increasing insulin resistance, namely processed meats, red meats, to some degree all animal protein, and certainly sugar-sweetened beverages. And I talk about foods that actually help your body heal and help your insulin function better, and those are the whole grains, the fruits, the vegetables, and the beans. And we take it from there. Of course, woven into all of this is I take a dietary history. I usually do a quick 24-hour recall. Even though it’s not 100% accurate of what a person always eats, it at least gives me a snapshot, and that’s efficient. And I talk through what are the foods that you like that are in the categories of healthy foods, where can we start from in terms of the foods you already like that promote health? So that I’m not introducing “strange” foods that a person is not accustomed to that they don’t know how to prepare. I start with what the person already knows and likes and what’s reasonable to add to their life and we just keep building from there.
HOWARD: So, you’re not asking them to make a giant, all-in-once changes?
DR. MCMACKEN: Well, it really depends on the person. I would say that the vast majority of people are making stepwise changes, but this particular patient that I’m bringing up, he knew that he was at a really crucial point and his sugar was so high, and he, for whatever reason, was just really motivated at that point, so for him, I said I can see that you really wanna try this, why don’t you try a whole food plant-based diet for three weeks? And let’s see what it does to your blood sugar and how you feel and other parameters, and he wanted to give it a try, so if a person is ready to do that, great! I give them the tools and I talk about how to do that, and we create sort of a menu that would work for them for the next three weeks or so. I use a variety of resources, and then we follow up. In his case, he went all out, and he went completely whole food plant-based and within four months, he had almost completely reversed his diabetes.
HOWARD: Hmmm. Did he enjoy the food?
DR. MCMACKEN: He’s still doing that. He loves the food. He’s super happy.
HOWARD: Wow. So, he was from Mexico…
DR. MCMACKEN: Yes.
HOWARD: … so he would’ve had a fondness for certain traditional foods, you know, taco, maybe chili, lots of cheese on stuff. How did you help him navigate, you know, going from his traditional diet maybe to the one that could be seen as sort of northeastern elitist hippie quinoa and kale?
DR. MCMACKEN: I’ve found it surprisingly easy to talk to people about simple foods that are culturally relevant to them that are based in plants, and maybe that’s one of the advantages of taking care of a patient population that… for whom either immigrated to the United States fairly recently or who are still eating traditional diets. Um, while no one has come from a fully plant-based diet traditionally, plant foods in their traditional diet are prominent, so it’s just a matter of giving those foods sort of the microphone and magnifying those foods and really crowding out the unhealthy ones, and that’s really what he did. There’s, you know, foods that he… there is a lot of misunderstandings around… particularly when it comes to diabetes, foods that they “cannot” eat, so a lot of my patients are DELIGHTED when I tell them, if you like sweet potatoes, fantastic, eat sweet potatoes! They have been denying themselves fruits. They have been denying themselves foods like corn that they have been told they shouldn’t eat because they have diabetes or are at risk for diabetes, so it’s actually a message that is, in my experience, very well received, and people are excited about.
HOWARD: Hmmm. So, one difficulty is helping people to get started. It sounds like you have sort of a protocol for easing them into whatever level to identify those foods they already like and they can build on them stepwise. Do you help patients with the issue of cravings or willpower? Do they say, yeah, doc, I wanna do it, and they come back and they’re shamefaced, and they admit that they haven’t been doing it at all because of hotdogs at the stadium or dinner at the auntie’s house, or the pretzel wagon, whatever it is. Like they wanna do it, but they behaviorally don’t seem to know how to make the habit change stick?
DR. MCMACKEN: Yeah, sure. There’s definitely that, and my approach… there are people for whom eating some of these foods that tends to trigger addictive, you know, where people sort of can’t… they have these cravings, they just can’t get off the cycle. There are people for whom they are capable of doing that every once in a while and are still doing generally okay and there are other people for whom it works much better to just eliminate those foods completely from the diet. People need a lot of help too with just the basic strategizing around how do I get away from those foods – they’re such a key part of my life. I use the concept that, you know, there are certain foods where if I had them in my house, I know I would be tempted to eat them, so my strategy is to not always rely on willpower because that decays [laughs] throughout the day and throughout time but to change your environment. So, helping people negotiate ways to change their environment is a big part of it, and working with family members, and you can imagine there’s all kinds of scenarios that make it hard for people to change their environment, so that’s what I try to do, and it’s not perfect. I’m still… I’ve a lot to learn, and there’s a lot of really tough situations, but in general, I’ve been real pleased with how much movement people have had along the spectrum of moving towards a healthier diet.
HOWARD: Hmmm. So, you work in a lot of… looks like collaborative settings. How do your colleagues feel about you in this lifestyle stuff and this plant stuff? Do you get pushback or are they curious?
DR. MCMACKEN: I’m fortunate, I think, because my colleagues have been very receptive. Part of it may just be that I started this relatively late in my time of working in this institution, so I already had networks and friendships, and it’s not like I came cold with this new idea and meeting with everyone for the first time, so I already had trust built up. But early on after I started seeing all these changes in my patients even through my very rudimentary counseling, I realized I needed more training myself. So, along with a colleague, I applied for and got a grant to study evidence-based nutrition and develop a curriculum for my colleagues. That was a two-year grant in which I pretty much delved into the nutrition literature and science and sort of started to catch up everything I had missed throughout my training, and that experience developing a curriculum to teach my faculty… we started with our faculty colleagues so the folks who are teaching doctors in training and medical students… that actually was very well received. When you show people the science behind all the evidence that is there, I have to say, as I said before, when you pair that with specific examples, vignettes of patients who’ve gotten healthier, I think it really resonated with people. They were excited about it. They appropriately brought up concerns about how am I gonna do this in the time that I have, and that’s something we are all trying to figure out, but as far as conceptually, they all were pretty much on board, and in fact some of them after hearing the nutrition curriculum actually decided to move towards more of a plant-based diet themselves, which was really cool to see. So, it’s been well received.
HOWARD: So, it seems like we travel in different circles.
DR. MCMACKEN: [laughs]
HOWARD: You know, I worked on Proteinaholic with Dr. Garth Davis, and he is always getting into fights with people in the medical community and the medical weight loss community and the bariatric community and endocrinology, people who are promoting from their own perspective a science-based, evidence-based view of the low-carb lifestyle, and it’s kind of everywhere that he turns, and I’m seeing a lot of it, too. You know, what’s your take? Are people, your colleagues, are they just smarter or…
DR. MCMACKEN: Extra awesome? [laughs]
HOWARD: Yeah, is there anything… for ordinary people like, you know, we like Colin Campbell, Neal Barnard, Garth Davis, we like them better, but honestly, most of us don’t know if they’re right, you know because we are not scientists? So, it’s always good to hear from someone who doesn’t have a plant-based background being convinced by this. Do you have to kind of discuss the so-called evidence for the benefits of low-carb versus plant-based with your colleagues?
DR. MCMACKEN: I’ve definitely come up against that, and when I’ve spoken outside of the immediate group where I work, I’ve felt more of that, and it’s certainly frustrating. But I think the bigger picture for me, my first message… my overarching message is always… I’m so glad we’re talking about food at all and that we’re talking about lifestyle at all as physicians, and that’s a unifying point, and then my second point is we can debate the nuances of, you know, little nuances where the evidence isn’t clear, but it is very hard to refute the data. If you look at the landscape of where nutrition science lies, it’s very hard to refute that diets based in whole plant foods are helpful. It’s hard to refute that. When you look at each individual part of plant-based diets, so whole grains, fruits, vegetables, legumes, nuts and seeds, you know, the evidence is overwhelming for each of those individual food groups and when you put them together, the evidence is very strong as well.
Yet, where we spend as Americans, where we spend most of our time eating is in the food categories for which there is actually evidence of harm: processed meats, added sugars, refined grains, or there is evidence of neutrality or harm: chicken, poultry, dairy, eggs, and so forth. So, I just try to unify people around, you know, let’s focus on how we can get people to eat more of the foods we know promote health and let’s talk in terms of foods instead of nutrients because people don’t, when you say carb, that could be food that could be very helpful or food that’s not helpful, so let’s talk in terms of specific foods and let’s unify around the fact that we should be getting people to eat these healthful foods and stop arguing about macronutrient ratios and things that are not going to be productive in terms of how we council our patients.
HOWARD: Mmm. So, in you work with doctors teaching them the nutrition curriculum, do you get a lot of resistance just based on the fact that they are eating a certain way, like when you went to the ACLM confidence, you were already a vegan, so you didn’t necessarily have any cognitive dissonance…
DR. MCMACKEN: Right.
HOWARD: … or a bias against this, like I’m feeling this right now. I’m reading this book called Grit by Angela Duckworth, and I took a little quiz at the beginning and it turns out I’m not very gritty…
DR. MCMACKEN: [laughs]
HOWARD: … and so I’m really resisting all her argument, you know like I’m listening to it as I run and arguing with it, and I can just feel I’m no better than anybody else, I don’t want this to be true because it’s challenging my beliefs about myself. Do you find that it’s harder for doctors to hear when they themselves are eating a pretty crappy diet?
DR. MCMACKEN: I definitely think… first of all, we have strong evidence that physicians who practice healthier lifestyles are more likely to counsel on healthier lifestyles, right? Now, when I give a talk on nutrition to doctors or medical students, I usually start by acknowledging that potential discomfort right off the bat, and somewhere in the beginning of my talk I mention that at some point in the next hour you may start to feel uncomfortable, and that’s because you may be sitting here eating… you know, you may be eating a white bagel with cream cheese, as you are hearing me talk about how certain foods like refined grains might be harmful. So, I say, listen, we’re all on some kind of a journey, and I’m certainly not a perfect eater, and it’s okay to feel that discomfort. What I’m gonna ask you to do for the next hour is to make it a productive discomfort, which is a term I heard once from somebody I thought was great, you know, take that discomfort and harness it to some kind of productivity, even if you yourself realize that you’re not maybe ready to change or you like those foods, at least acknowledge the bias that you have and just try to look at the science that I’m going to present to you with an open mind, and again when you couple that with examples of how patients can… how their lives can literally be transformed in certain cases, I think it’s a message that appeals to people. You know, do I have people who walk out from the lecture and say, you know, I don’t believe it, I don’t buy it? Of course. But the vast majority of people have been pretty eager to hear about it, particularly when you frame it in terms of your direct experience with patients.
HOWARD: It feels like it’s kinda hard to argue with you. You’re doing sort of Taiichi or jujitsu.
DR. MCMACKEN: [laughs]
HOWARD: You’re not interested in sort of pushing back. Is that your nature or is it something that you cultivated because you’re much less… you know, I’ve read your writings in Forks Over Knives and Plantrician, and your writing is sort of uniformly positive and inviting and kind of gee-whiz, this is so cool, and it tends not to be confrontational. I’m thinking you don’t tend to raise people’s hackles the way a lot of us do. I’m wondering, is that a strategy or does it come naturally or both?
DR. MCMACKEN: Yeah, no, I think I can get into a pretty mean argument if I want to…
HOWARD: [laughs]
DR. MCMACKEN: [laughs] But in terms of how I present this information, I feel it’s not an understatement to say this experience of helping my patients get to the root cause of their disease and making these changes in their diet and lifestyle, it’s not an understatement to say that that has literally changed my life. Of course, it’s changed my patients’ lives, but from the most selfish perspective, I feel so opportunistic about it. Perhaps that radiates. I don’t know. If someone wants to meet out back in the alley and argue about a ketogenic diet, I’m more than happy to do so, and it will be fun, and it will be academic, and it will be interesting. But when it comes to nutrition science, I think it’s important to recognize that it all converges around the same basic concepts, and I don’t wanna get into an argument with someone about whether they can include a little bit of dairy or a little bit of egg in their diet. I don’t wanna get into that argument. Do I think it’s great to follow a 100% whole food plant-based diet or a whole food vegan’s diet? Of course! There are so many incredible reasons. But I don’t wanna argue the fine points. I wanna argue how we can get people to shift towards a healthier eating pattern.
HOWARD: Hmmm… I had a question, and it just slipped my mind.
DR. MCMACKEN: [laughs]
HOWARD: I might edit this out, or I might leave it in, so people would know that I was frazzled as the rest of us. Um, huh…
DR. MCMACKEN: Yeah, I mean…
HOWARD: Darn it.
DR. MCMACKEN: Should I tell some more patient stories, or?
HOWARD: Yeah, why don’t you ask the question that I should’ve asked had I been paying attention.
DR. MCMACKEN: [laughs] No, I mean, I think that a little bit goes a long way in my experience in doling out some of the counseling over time and helping people build on it. It’s been very useful. So, for example, for a long time, my patients used to ask me, can you just give me a list of foods that I can eat, and I really resisted that, and I thought, oh, that’s ridiculous, that’s so concrete. Why would I just give you a list of foods you can eat? After about a year, I thought, you know what, fine, I’ll make a list of foods that you can eat, and it will be a list of whole plant foods, and I’ll put it in English and Spanish, and I’ll put pictures on it, and that has actually turned out to be a two-page handout, front and back, and everyone in our practice has been using it – the doctors in training, medical students, and faculty – because all it is is just a simple list of whole plant foods. The way people use it is they give it to their patient. If there is time, they have the patient go through it and check off the foods on the list that they already happen to like, and you can strategize, well, what’s a meal you can make with these foods or what are two different meals or a dinner you can make with these foods, and then you start building from there. What can you start using these foods to crowd out some of the unhealthy foods in your diet? I’ve seen the doctors in training use it by… they give it to the patient while they are going to present the situation and the case to their supervisor, and then by the time they get back to the room, the patient has filled up the whole page, and it’s something that they can quickly talk about and bring up at the next visit as well. So, it’s actually been very useful.
HOWARD: So, someone that gets that checklist, a list of foods with pictures on it, they can go to the supermarket, the local store, and find those foods. But then how do they know what to do with them?
DR. MCMACKEN: Right. So, for people who already have, who already like to cook or for whom they are making most of their meals at home, usually it’s just a matter of making substitutions and getting them to start thinking about foods that can substitute, say legumes instead of chicken, or using avocado instead of cheese, or something like that. For people who don’t like to cook… obviously, I take care of people who live in housing situations where sometimes they don’t even have a kitchen or they’re living in a shelter, or they’re relying on getting food from the street. That’s obviously a very different situation and potentially infinitely more challenging. But even there, there is a little workaround. Is the person gonna be able to adopt a completely whole foods plant-based diet by eating on the street? Probably not, but are they gonna be able to make shifts? Yes, and I’ve seen them do that as well. Uh, sometimes, I always joke that sometimes the root on nutrition counseling is… when you have people just increase their fruit in their diet and fill up on that, it can actually crowd out a lot of the snack foods that people eat and fill them up so that they can get to the next meal in a state where they can actually make a healthier choice. So, those are just some of the little tricks I’ve used.
HOWARD: Gotcha. So, I remember what I was gonna ask you when I blanked, which is picking up on something you said in passing, which is there’s these foods that Americans eat, these categories with the evidence of harm. But there are others you said, there is evidence of harm or neutrality. You mentioned chicken and dairy.
DR. MCMACKEN: Right.
HOWARD: I know for a lot of people in the plant-based community, thems fighting words, right?
DR. MCMACKEN: Right.
HOWARD: The thought that the scientific evidence against chicken and dairy is not so airtight as to be overwhelming, but you see it differently?
DR. MCMACKEN: Well, listen, here’s what someone is gonna say to that, someone who is not in the plant-based community. They’re gonna take, they’re gonna look at the study like the… there was a big study published recently through the… I think it was half a million people looking at red and processed meat, and a variety of different… mortality from a variety of different diseases. And that study, if you just read the abstract, what you learn from that is that red and processed meats are bad for you, which is no surprise, and that eating poultry is associated with a 25% reduction in the overall death rate. So, a person who’s just reading the abstract and just thinking superficially about a study like that is gonna come away with the thinking, okay, so chicken is good for me, right? That’s what an average person would think. I would think when they read that.
HOWARD: Right.
DR. MCMACKEN: So, what I try to explain when I give nutrition talks is that these foods that I call… I call them the, you know, the yellow box foods. I divide foods into green, yellow, and red boxes, and so these yellow box foods which are really the poultry, eggs, dairy and to some degree fish, these foods can actually look pretty good if you compare them to really bad foods. But it doesn’t mean that they’re necessarily healthier for you than eating the whole plant foods. In fact, almost all of us would argue that there is great science showing that they are not. And I usually point to studies showing that, you know, there was a big study last year looking at animal versus plant protein and mortality and across the board, substituting just three percent of your calories for plant protein instead of animal protein carried a mortality benefit, even all the way to poultry and fish. So, people need to understand that a lot of these studies are relative. It’s the same thing that we get into when we look at saturated fat studies, so does chicken look neutral or helpful in certain studies? Maybe if you’re comparing it to hotdogs, but what if you compare it to beans, I don’t think it will look so healthful anymore, and that’s kind of how I portray it.
HOWARD: Where do you see your work and the work of other allies in the community going over the next five, ten years? I’m asking sort of a longer arc because I’m thinking about the fight over smoking cigarettes that took like 70 years to really go from initial research to public awareness and medical acceptance of the fact to things like trans fats. Do you see a tipping point or are the food industry influences still so powerful that we’re still at the infancy?
DR. MCMACKEN: Well, I see things changing pretty quickly, and it seems like every third day, there’s a new, really cool study coming out about something related to plant-based diets, and I see… of course I’m coming at it from a vantage point of… I see this adding to a framework that overall supports eating plant-based diets and that is an overall healthy eating pattern, but I do think that the information is getting out there. I’m concerned about some of the rise… the parallel rise in the sort of ketogenic diets, Paleo, you know, this very low-carb phenomenon, which is either very high in fat and or high in protein, typically animal proteins. I do see that there’s still a lot of confusion out there, and one can make an argument that some of the confusion is growing. You and I have talked about this over email threads with others, but we’re at a point where I’m not sure what the answer is to how to get people to understand what is actually based in science. You can find the studies to show that there is benefit to some random thing, but that is just a blip in the overall landscape of where nutrition science lies. How do we get people to understand that? I don’t know that I have the answer, but I think that’s where we need to move and we also need to… it’s really imperative that more people in the health community, more physicians especially are aware not just of how powerful food choices can be but can very quickly start to dispel some of these myths around and lack of understanding around carbohydrates, for example, and insulin resistance and saturated fat not causing heart disease and all these things that spread among health professionals just the same way they spread among non-medical folks probably because there is lack of training in the medical community .
HOWARD: Hmm…
DR. MCMACKEN: So, I don’t have a single answer, but I have provided some concerns.
HOWARD: Right. I think you need to write a book. You have to put in all the science but give it like a literally twist so people have to keep turning the page.
DR. MCMACKEN: That’s a WONDERFUL idea!
HOWARD: Do you have a book in you? Is it something you’ve been thinking about?
DR. MCMACKEN: Yes. It’s definitely something I’ve been thinking about. It’s a little intimidating to think about writing a book, and I will probably have to cut back on other stuff I’m doing, but it’s certainly on the bucket list.
HOWARD: Yeah, just start with like sleep and personal time…
DR. MCMACKEN: [laughs]
HOWARD: … and see how that goes. Then you can figure out if you need to cut back on your professional responsibilities too.
DR. MCMACKEN: That’s sage advice. Thank you.
HOWARD: [laughs] Well, Michelle McMacken. This has been so much fun talking to you and hearing your story, and I’m so glad that you’re out there doing the things the way you do with the people you’re doing them with and not only spreading the word but also sort of bringing back to us best practices in communication and influence.
DR. MCMACKEN: Thank you so much. Likewise. It’s really an honor to be on the podcast.
HOWARD: Thank you so much, and I hope we’ll talk again soon.
DR. MCMACKEN: Sounds good. Take care.

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