On Being Metabolically and Psychologically Flexible

As a doctor that focuses on the early detection of diabetes and heart attack risk, I see risk where a lot of other doctors might not. It comes back to that “ounce of prevention pound of cure” thing. It amazes me to see how many patients come through my door that have been in a state of insulin resistance for such a long time without knowing it and more importantly without an action plan. See this study and this one if you don’t believe me.

Patients need to have something tangible they can leave my office to change their lives (and get inspired). Unfortunately there is no “one size fits all” solution. We can talk about metabolic flexibility in regards of how the body uses energy; well how about diet flexibility for patients.

I offer an array of options for patients, like Robb Wolf"s Paleo Solution, Steven Gundry's Diet Evolution, or Dave Asprey's Bulletproof Diet.  (can you tell I was an Anthropology-Zoology major in undergrad?)

Those struggling with their weight have to be in it for the long haul or else it is just a set up for failure, both metabolically and psychologically. This is something I see over and over again in the low calorie, “Weight Watchers” mentality. Short term weight loss with long term rebound weight gain.

For my patients with “metabolic risk”, a lower carbohydrate approach is the starting point. Some are more eager than others to get on their way. For those patients that want to grab the bull by the horns, my go to is Kiefer’s plan/book: The Carb Nite Solution (CNS).  It is the plan I recommend to most of my diabetics who are looking for a way to improve how they feel and get off that wheelbarrow full of medicine they are on. 

One of the reasons I like the plan is that it offers flexibility for patients. Knowing they can have one Carb Nite (CN) a week, makes it easier for them to plan for that work party, family get together, or special event.  I believe also that psychologically, there is not that constant denial of food you get with most standard low calorie plans, not to mention it adds a little fun to making lifestyle changes.

I would like to share 2 patient stories, both are women (I have their permission) who have struggled with diabetes for the last 7-10 years. One is on oral medications and the other is on oral medication plus insulin. They both had hemoglobin A1C’s that were elevated (8.3 and 10.1 respectively) and have always struggled with there weight. Both went on CNS and have now successfully have lost weight (15 lbs and 20 lbs respectively) and have lowered their hemoglobin A1C at or under 7.0. That is as good as or better than any multimillion dollar drug.  Their cost: about $20 investing in a book.

They are both a work in progress, but these changes have had a big impact, both metabolically and psychologically for both women. Both patients had improvement in markers of inflammation (i.e. hs-CRP, PLAC2). They also now exude a bit of confidence in moving forward instead of previous desperation.

I have had many other patient success stories, but these two stick out the most to me because it made such a large impact on both of their lives.

There is a lot of “psychology” that goes along with making changes, you know that little voice in your head that you have that constant dialogue with (common, it’s not just me). So the following is what I talk to my patients about:

1.      Throw your scale away, you don’t need it, really.

2.      Relax, do not stress, especially when you fall off the wagon (yes it is going to happen), just get back on. High cortisol is bad, ummmkay (in the voice from the teacher on South Park)

3.      Go with the flow and do not over analyze things. Enjoy the foods that you get to eat on ultra low carb days (ie bacon) and on carb nites (ie cherry turnovers ;-) ).

4.      If the CNS is not right for you, than be flexible and modify the program (ie initially start with lesser carb restriction)

5.      Have a short and long term goal. Reward yourself for every short-term goal you meet.

6.      Be prepared. Have your food options planned out ahead of time and have a back up “emergency” plan in place.

7.      Don’t be afraid of eating fat

8.      Did I say relax?

9.      Manage your expectations. The weight did not come on in 1 month and it will not all come off in 1 month.

10.  Eat real food. Avoid or limit shakes and smoothies (or at least only keep them to post resistance training time only)

11.  You are in it for the long haul. If it is something that you do not think you can do, then stop and let’s find something that will.

12.  When in doubt, rub some bacon on it.

If you want to learn more about Kiefer, check out his website at www.athlete.io

Does LDL-P Matter?

(Note: Please consult with your healthcare provider for any personal health issues)

Now that I have your attention, the question above is certainly rhetorical and one could easily substitute ApoB or Non-HDL cholesterol, so I am not singling out LDL-P (or picking on NMR technology). 

It has been a several weeks since AHS 2012 occurred and unfortunately I was unable to attend. From the twittersphere, I read about some good presentations including Peter Attia’s discussion on cholesterol (if you have not checked out The Eating Academy, you really should).

I fell down the low carb rabbit hole several years ago and have never felt better, both physically and mentally. As that rabbit hole goes deeper (read: greater carb restriction), there have been some inherent “problems”. There are numerous reports of low carbers having their cholesterol go thru the roof when they restrict their carbs (for definition let’s say less than 50 grams a day). Food quality is good, exercise is good, they feel good, but their lipids look horrible.

I would like to share my story, my n=1 case. I started a lower carb Paleolithic diet over 2 years ago after I had read Steven Gundry’s Diet Evolution (also see books by Cordain, DeVany, Wolf, Taubes, among others). I have progressed in my personal views and have progressed to where currently I eat a form of a cyclic ketogenic diet (CarbNiteSolution (CNS) by Kiefer). There are many reasons, but I am a fat kid at heart and it allows me some flexibility with my “re-feeds”.

Last fall I had a NMR LipoProfile done which showed a LDL-P of 2700 (less than 1000 is optimal). For a physician who focuses on heart attack prevention, this was quite horrifying. What should I do? My initial thought was to slug down 20 mg of Crestor daily. The only thing was that I was losing weight (more precisely, fat via body composition testing) and I felt better than ever. My energy was amazing. So I continued and eventually started Kiefer’s protocol described in CNS earlier this year. There was one problem, my LDL-P was not changing and as of this writing the last value was over 3000.

Well, as I do with my patients, I always want to know if a patient has disease or not. That really is the question, not how high is the cholesterol. I know from my practice that risk factor assessment means very little without actually knowing if disease exists.  Using standard risk assessment tools can miss people who really are at risk (3). By looking at risk assessment models  (like Framingham Risk Score) we can over- or under-estimate risk greatly. My workhorse disease detection is Carotid Intima Media Thickness (CIMT). This test simply put, measures the “lining” of the carotid artery via ultrasound. The thicker the lining is, the greater the risk. It is also a way to assess for plaque (atherosclerosis) of the artery. Having plaque means you have atherosclerosis. I believe it is a significantly better way of looking at risk because we are looking for the actual pathology (1,2).

I had my CIMT done in 2006 on the Standard American “heart healthy diet” eating low fat, higher carb. You know those espoused by the ADA and AHA. My lipids were “normal” at this time. My thickness was 0.6 mm (about the 50^th percentile). I also had two small “road bumps “ (minimal plaques) at my left carotid bulb both measuring 1.2 mm. I was not happy. I also had similar findings on a study in 1/2010.

Flash-forward to June 2012, about 4 months into CNS, my CIMT showed a thickness of 0.445 mm (13^th percentile) and I had the vascular age of a 16 year old! And oh by the way, the “road bumps” were gone. All the while carrying an LDL-P of over 2500 consistently for over a year. I have also had a CT Coronary Calcium score that was zero.

Epidemiology tells us that high LDL-P is associated with greater CVD risk (4,5). Where is mine?

Lets address the high LDL-P issue on low carb diets first. Unfortunately, I do not have the complete answer. The literature does not reveal much. The work of Paul Jaminet/Chris Masterjohn proves interesting (6). To sum, high cholesterol on a low carb diet could be due to:

            1. Thyroid dysfunction (my TSH, T4, T3, rT3 were normal)

            2. Micronutrient deficiency (none noted via testing)

            3. Toxin/Infectious exposure (no periodontal disease or other sources of infection)

            4. Active weight loss (check, but does not explain why others with active weight loss have better/normal lipids)

Let’s take a 50000 ft. view. My hypothesis is that insulin signaling is playing a huge role. We know that the root cause of atherosclerosis in 80% of people is due to insulin resistance (7).  Insulin is an anabolic hormone (ask bodybuilders). Unfortunately it is not very discriminatory. Meaning: subcutaneous areas, the liver and the arteries can be storage depots for fat in the setting of insulin resistance. I see insulin resistance as “loading the gun” for initial heart attack risk/event.

Inflammation is the second part. If insulin resistance loads the gun, then inflammation pulls the trigger. Inflammation has a role in the development and progression of atherosclerosis AND in the rupture/destabilization of plaques (8). In addition, to complicate matters, the majority of plaque rupture/erosions do not cause events.

So what does one due to mitigate all of this disease? Well, that would be to minimize the effects of insulin. That can be done by a carbohydrate-restricted diet. In the largest extreme that would be a ketogenic diet.

What does a ketogenic diet do? Well simply put, it minimizes the effect of insulin from the dietary component. This mitigation can be a reason for fat efflux (ala LPL and HSL activity).  Could one also hypothesize that fat is being effluxed not only from the subcutaneous tissue, but also the liver, hence a potential treatment of nonalcoholic hepatitis (NASH)? By this same thought process, could this be a mechanism to efflux “fat” out of arteries, which may be one mechanism of action which may account for disease in patients with high HDL-C cholesterol in the presence of insulin resistance?

Although not widely studied, Ketogenic diets (which remove agents of Neolithic disease) can minimize inflammation. I have seen this clinically in my practice and in myself. My hs-CRP is not detectable (all my other markers of inflammation are normal as well, Lp-PLA2 and Myeloperoxidase). Inflammation IS the key component to events (ie plaque rupture) as stated above.

So if LDL-P is high but inflammation is very low and there is no insulin resistance, does it matter? This, of course, does not preclude the possibility of atherosclerosis to progress in the setting of insulin resistance and no/low inflammation (think the 78 yr old that needs a stent but never had the event).  So if one is eating low carb, one would think these metabolic issues should take care of themselves.

I definitely think in the Standard American Diet (SAD), high LDL-P is a huge problem. Primarily due to the significant insulin resistance associated with the discordance of LDL-C to LDL-P in the setting of inflammation. It is a recipe for disaster. It also represents nearly 80% of patients coming thru my door.  Yes, 80%, it is that high! (9,10)

I propose diet DOES matter (shocking, I know). In particular, those that minimize carbohydrate exposure and thus insulin signaling; will have difficulty developing atherosclerosis, inflammation and thus events and potentially reverse it. What are the diets that do this? A ketogenic diet,  low carb/LC Paleo diet AND as much as it pains me to say, the plant based diet.

This is a very complex issue and one that warrants further investigation and for now most of my answers are “it depends”. But we must always remember to treat the patient/disease and not the number.

References:

1.     http://www.ncbi.nlm.nih.gov/pubmed?term=CAFES-CAVE%20study

2.     http://ht.ly/dQAo9

3.     http://www.ncbi.nlm.nih.gov/pubmed/22399535

4.     www.ncbi.nlm.nih.gov/pubmed/21392724

5.     http://www.ncbi.nlm.nih.gov/pubmed/16765964

6.     http://perfecthealthdiet.com/category/biomarkers/hdlldlcholesterol/

7.     http://www.ncbi.nlm.nih.gov/pubmed/10466661

8.     http://www.ncbi.nlm.nih.gov/pubmed?term=Arbab-Zadeh%20A%20et%20al.%20Circulation%203%2F6%2F2012%3B125%3A1147-1156

9.     http://www.ncbi.nlm.nih.gov/pubmed/21788628

10. http://www.ncbi.nlm.nih.gov/pubmed/20007945

Eating a Dangerously Bulletproof meal

As many people close to me know, I have struggled with my weight over the last decade. I have come a long way, losing over 85 lbs in my quest to be a healthier Dad and doctor. Lead by example. In my journey over the last year I have become a fan of several bloggers. Two of my favorites are Dave Asprey’s Bulletproofexec and John Kiefer’s Dangerously Hardcore.

I find it amazing when an internet geek and a physicist/bodybuilder can come to common ideas based on differing reasons. Anyways, I have coined a term I would like to take dibs on: “Dangerously Bulletproof”. Basically a mash of both mechanism’s to improve function, both physically and mentally. One of my office staff suggested I use the term “Pateleo” (Patel and Paleo), which I like, but Dangerously Bulletproof just sounds sexier. I plan to write more on this in a future blog posts. Today, I thought I would offer up a “Dangerously Bulletproof” meal. I know it’s not very original and I am sure @nomnompaleo probably has this on her site somewhere (i just have not had time to look over there), but as for now I claim it.

Pasta and spaghetti dinners with garlic bread are something I tend  to miss, so here is a substitute I find satisfying: Pateleo “Spaghetti”

Ingredients:
4-6 oz grassfed beef
4 slices bacon (good source like from US Wellness Meats)
1 oz shredded spinach
1-2 oz asparagus, chopped
½ cup Lower carb tomato sauce (I used Tomato Basil Pasta Sauce from Monte Bene Farm Fresh)

1.    Place Bacon in fry pan and cook until crispy but not burnt, at the same time place beef in sauce pan or skillet and brown.
2.    While bacon/beef are cooking, shred spinach and chop up asparagus in 1/2 to 3/4  inch pieces
3.    Once bacon is cooked, set aside and add the veggies to the left over bacon grease and cook until spinach wilts slightly. Pour this on a plate and this will be your “spaghetti”.
4.    Mix the sauce with the ground beef and pour on top of the veggies.
5.    Add bacon to the side, and this will be your substitute for garlic bread. A nice salty alternative, besides bacon makes it better!.
6.    Enjoy with a bottle of San Pellegrino!

“Vital Signs”: Total Calories 459; Fat grams 32; Total Carbs 14grams;Dietary Fiber 6 grams; Total “usable” Carbs 8 grams; Total Protein 30.  62%of cals from Fat, 25% cals from protein, and 12% cals from carbs
If you want more fiber, add a tbsp of chia seeds over the top.

Weight loss, Fat Loss, and Voodoo

It has been awhile since my last post. When I started this blog, it was my intention to post monthly. But such are things with life.  I post today after my workout. But before I get to that, let me tell a little story.

Over the last 2 ½ years I have changed my diet. I was changed forever after reading Dr. Gundry’s Diet Evolution. Since then I have read many other books/blogs. Those include The Paleo Diet, Good Calories Bad Calories, The Perfect Health Diet, Bulletproofexec, and The 4 Hour Body among others. I have also been collecting journal articles reading about as much of the research that I can.  

The main thing I surmised is that it is key to keep insulin levels even (mostly by controlling carbohydrate intake in both quantity AND quality), adequate fiber intake when eating carbohydrates to buffer the insulin response, and fat can be your friend and has been wrongly demonized.   

Back to my “story”. The problem recently has been that I had reached a plateau in my weight loss efforts. In addition I just got back from vacation and was about 5 lbs above the baseline I had been over the previous six months. So what did I do? Like every other person does, I hit the gym.  So for two months I did cardio 4-5 x a week with some weights, mixed in with some hot yoga. But results were not forthcoming and I was getting frustrated. I had actually gained 2 pounds (not sure if this was fat or muscle or both).

 Then my gym started a 90 day challenge. So I thought to myself, what the heck, I know it was pretty much a scam to get me to by more services (which of course I did), but I thought that a challenge is what I needed. Recommit! I hooked up with a trainer, 2 x a week. He asked what my main goal was, and I obviously pointed to my gut and said “I want to get rid of this”.  He said not a problem, but you are not going to like me very much. What ensued was a brutal high intensity workout 2 days a week with cardio/spinnning or hot yoga on off days. 90 days later I was down about 5 lbs and had lost about 2% body fat. Not quite the results I was looking for, but it was a start. I thought my nutrition was good, but I know it was not perfect.  About 1 month ago, I had come across a blog called the Whole9. On their site, they mentioned something called the Whole30 challenge. Basically you eat whole, unprocessed foods for 30 days, including no alcohol and processed carbohydrates.  Again, I was up for the challenge.  Re-recommit! Well, my 30 days are almost up and I must say I have been impressed.  After 3 weeks I had lost 9 lbs and decreased body fat by about 3-5%, all with only working out 2-3 x a week (very little cardio).

Here are my observations.  They are specific for me and are not intended to be extrapolated to other individuals (see #9).

1. I must stay under 100 grams of carbohydrates in order to continue my weight loss.  On days I go over 100 grams I either stay even or gain weight, no matter my calorie count!

2. During the 30 days I did not actively “count” calories (although I did log them along with wearing my Fitbit).  My daily calorie intake ranged from 1400-2500 calories a day.

3. Eggs are my friend.

4. I LOVE the grass fed beef I purchased locally (I went in on 1/3 of a cow). 

5. I need to eat this way for the rest of my life, not just 30 days, Duh!

6. Post prandial blood glucose never went above 125 at the 1 hour mark or 2 hour mark.

7. Counting calories is imperfect because food labels are imperfect. 

8. If I “carb crave” in the evening then I have not eaten enough fat during the day.

9. Self-quantification is important. Collect data about your body then make changes from the data you obtain. The definition of insanity is doing the same thing over and over again and expecting different results. Weigh daily, check blood sugar and blood pressure regularly, track activity (Fitbit or Bodybugg), track your sleep (Fitbit or Zeo Sleep Coach).

I am most interested in my lipid, metabolic, and inflammatory markers. My hs-CRP, Lp-PLA2 and MPO were already low, but several markers of insulin resistance (IR) were elevated. I performed a baseline in April and will have them re-drawn next week. I will post results.

Nutrition, weight loss, and muscle gain are a complex machinery and it is even trickier in the setting of IR. About 70% of patients I treat have some form of IR, along with some form of lipoprotein abnormality. IR is really the source of most people’s issues that I treat. Until this is addressed, pathology (cardiovascular disease) will continue to ensue.  I see this in patients day in and day out. I firmly believe carbohydrate restriction is a major piece of the puzzle and continue to recommend this for my patients with IR.

In the meantime, I will continue my low carb, moderate fat ways as it is working for me as it has for countless others.

Use of Artificial Sweeteners Increases Body Fat

There has been conflicting stories about the use of artificial sweeteners, especially diet sodas. A recent article suggest drinking diet soda does not increase the risk of diabetes (http://tinyurl.com/43j3dck). Well here is some research to suggest that artificial sweeteners can actually increase body fat, which can be a risk factor for Type 2 Diabetes and the Insulin Resistant Syndrome. This is from the Colgan Institute (http://colganinstitute.com/index.php?main_page). So maybe think twice before you decide to guzzle down that next diet soda.


The main sugar substitutes are saccarin (Sweet'N Low), aspartame (Equal,NutraSweet), sucralose (Splenda, Altern) and acesulfame potassium.  Sorbital and maltitol are used in "no sugar " ice cream and candy. Erythritol is the most recent, xylitol, cyclamate, and stevia are common. Despite their minimal to zero calories, they all make you put on body fat.
They pile on the pudge for simple physiological reasons.  Sweet tastes in the mouth, and in the gut, induce an appetitive response by the brain, and an insulin response by the pancreas.(1-3)   Because the artificial sweeteners are much sweeter than sugar, the  response is larger than if you use sugar. Insulin is a prime storage hormone.  The extra insulin will store as fat all the extra calories you eat because of the appetitive response induced but not satisfied by the chemical sweetener.  Studies show definitively that both rats and people fed artificial sweeteners, put on more weight than if they used the equivalent amount of sugar.(1-3) 
The artificial sweetener industry does not like being told that they are contributing to the rampant adult-onset diabetes and obesity in the US and Canada.  And their ads claim the opposite.  But if you examine the science, you will never use an artificial sweetener again.
  
1. Yang Q.Gain weight by "going diet?" Artificial sweeteners and the neurobiology of sugar cravings: Neuroscience 2010. Yale J Biol Med. 2010 Jun;83(2):101-8.
2. Brown RJ, de Banate MA, Rother KI.Artificial sweeteners: a systematic review of metabolic effects in youth. Int J Pediatr Obes. 2010 Aug;5(4):305-12.
3. Margolskee,R, et al. T1R3 and gustducin in gut sense sugars to regulate expression of Na+-glucose cotransporter 1 PNAS 2007 104: 15075-15080

Yeaaa! We're number one again!!!

Unfortunately, this number 1 ranking is something that we should not be proud about. Congratulations to the US for being the fattest nation in the world. Latest statistics show that our average body mass index is over 28 (25-29.9 is overweight and over 30 is obese).

I am always amazed at the charts on obesity on the CDC website over the last 20 years (http://www.cdc.gov/obesity/data/trends.html#State) . It is shocking.

This article has charts from the World Health Organization:

http://www.dailymail.co.uk/news/article-1353761/U-S-home-fattest-men-women-Western-World.html

Yet, the "Food-Industrial Complex", continues to dupe the masses with fancy marketing and deceptive food labels.

I just saw this ad on the TV yesterday regarding high fructose corn syrup:

http://www.youtube.com/watch?v=EEbRxTOyGf0

Well, if you have 1 1/2 hour to kill, I HIGHLY recommend spending the time watching this presentation "Sugar: The Bitter Truth" by Robert H. Lustig MD. He is a Endocrinologist at UCSF. I think he does an elegant job of talking about sugar in the diet and particularly fructose.

Sorry to be a downer on Super Bowl Sunday, but as I tell my patients, "it is, what it is".

Metabolic Syndrome and Cognitive Function

Bordeaux, France - People with the metabolic syndrome were significantly more likely than others to experience a decline in cognitive function, independent of previous cardiovascular disease, depression, or APOE genotype, in a study of generally healthy adults aged 65 and older who were followed for four years [1]. In particular, hypertriglyceridemia and low HDL-cholesterol levels were associated with declines in global cognitive function, and diabetes was associated with deteriorating memory.

"Our study sheds new light on how metabolic syndrome and the individual factors of the disease may affect cognitive health," first author Dr Christelle Raffaitin (French National Institute of Health Research, Bordeaux, France) noted in a statement on the study from the American Academy of Neurology. The report was published online February 2, 2011 in Neurology.

"Our results suggest that management of metabolic syndrome may help slow down age-related memory loss or delay the onset of dementia." to read more click the link

http://www.theheart.org/article/1181423.do

My comments:

The data keeps coming in how detrimental the metabolic syndrome and insulin resistant cholesterol pattern is in terms of risk for disease beyond the heart. I feel it is very important to look for insulin resistance. The key is identifying it early and educating my patients of the risk to their health. This way a plan of action can be formulated.

Those markers of insulin resistance can include acanthosis nigricans on physical exam (unfortunately commonly seen in my practice in adults as well as in teens!), abnormal lab values like elevated uric acid, GGT, high TG/HDL ratio, elevated blood glucose, low testosterone, low vitamin D.

A word on blood glucose. I feel it is very important to make use of the 2 hour glucose tolerance test (fasting, 1 hour and 2 hour post 70 gram carbohydrate challenge). Based on this article in Diabetes care last March (http://care.diabetesjournals.org/content/33/3/557.full), a lot of information can be obtained and education points for patients. The scary realization from the study is that if the 1 hour blood glucose is over 150 mg/dl, you have a 13 times increased risk of becoming diabetic in the next 8 years (even with normal fasting and 2 hour blood glucose)! Worse yet, the risk starts to increase with the 1 hour sugar staring at 120 mg/dl!

So be on the look out and be vigilant, you never know when insulin resistance can rear it's ugly head. Unfortunately, these days it is more common than not.