Wednesday, November 14, 2012

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


  1. Tammy and I are going to do the Carb Night Solution (Keeping as Bulletproof as possible)

  2. Sounds like a game plan, lots of white rice and sweet potato's are in your future ;-)

  3. Dr. Patel, very informative insights into this. You are a great if not the greatest "family physician" I know. The reason is because of how far the medical community has distanced itself from the recent research on nutrition and exercise. I hope that you are a fan of Dr. Robert H. Lustig, the Sugar Guy; Sugar: the Bitter Truth, and Skinny on Obesity episodes on you tube.

    I started my weight loss journey when I hit the 330 lbs mark in November of 2010. By March of 2011, I was at 280. When I visited my doctor "family physician/internist" earlier in 2011, I did a general physical and some lab work. He noticed that I lost a lot of weight, but instead of asking me what I was doing, or at least encouraging me to stay the course, he suggested that I cut calories a little and exercise more.

    Now, out of respect, I said OK. But, deep inside, I was thinking WHAT, YOU should ask me what I was doing so I can help You (he is overweight from the look, clinically he is in the obese category), oh well what an irony.

    I think you should present something in the AAFP annual conference about your current observation and the need to change the dietary recommendations. I think you have a really good shot at this. I know that the information is out there but how many Family Physicians do you think give similar recommendations to what you give your patients?

    Keep those articles coming !!

  4. Thanks for the props! Great job on the weight loss!

    Yes I remember seeing Dr. Lustig's presentation when it first hit youtube. We actually use the skinny on obesity series when we are educating our first responders on insulin resistance.

    We are looking at accumulating data that we can hopefully publish over the next 1-2 years.

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  6. Hi Dr Patel,
    This question is not directly related to the post but I figured I'd ask anyways. Is there any online resource that talks about low carbohydrate diet for Indians (south asian)? Basically, my Dad just had bypass surgery which was brought on due to years of uncontrolled diabetes. Their current dietitian is allowing foods that I would consider very high in carbs (semolina). He is still on oral medications for diabetes. His fasting blood sugar is around 100 and post meal can be as high as 170. I understand that you might not have the answer. Just struggling to convince them to give up some high carb traditional foods.

    1. I would start with Dr. Bernstein's Diabetes Solution:

  7. This comment has been removed by the author.

  8. Perhaps?:

    "I tend to think that the view that cholesterol increases with stress because cholesterol is used by the body to cope with stress is the closest to the truth."

    "The simplest answer is that the most important causal factor of cardiovascular disease aka the development of plaques (thickenings) in the arteries, is stress . . . ."

  9. Just heard you on Kiefer's newest Body IO FM pod cast and wanted to share my n=1 with you. I also responded to keto with a high LDL-P and saw that my thyroid function went down:

  10. Thanks for this article, I'll definitely consider the information. Right now I'm looking for family medicine in Pueblo. We decided to look into it recently.
    John Bond |

  11. Dealing with a scale can be stressful. I have always felt it was more taunting me then helping me. Though it is nice to see when the numbers go down, but that doesn't happen as much as I would like it to.

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