It has been around a year now since I changed to a Paleo lifestyle in my own life, and I thought it would be interesting to look back on my practice and see how I think I have changed in how I approach three common problems: Hypertension or High Blood Pressure, High Cholesterol, and Diabetes. I can’t stress to everyone how fundamentally different a “Paleo” way of thinking is compared with what I was taught in school. Most physicians are simply not exposed to information other than the status quo, and whose fault that it is a long story…so, let’s just look at me!
High Blood Pressure: Statistically, this is the number one problem that I treat in my office on a day to day basis. 95% or so of hypertension (HTN) is of an unknown cause, and is known as “Essential HTN.” Even over the 8 years I have been out of training our approach to HTN has changed. We are much more aggressive from the start in treating people’s blood pressure because the more we study the problem, the more it is linked with medical badness in the form of strokes, heart attacks, and kidney failure (among others). There used to be something called “Pre-Hypertension,” which is now simply known as Stage I HTN. There are lots of conspiracy theories on the internet about Statin medicines for cholesterol and the evils that they bring. Notice this though, you DON’T see much bad press for high blood pressure treatment. The simple answer for this is that HTN kills, and treating it helps prevent death. It’s very clear cut, our medication options are affective and affordable, and the standard of care is to be aggressive with medical treatment.
Another interesting thing about HTN is that it does not traditionally respond tremendously to weight loss. Although you can see modest decreases in blood pressure with the shedding of pounds, it’s not often as effective as people wish it would be. Don’t get me wrong, it helps, but shedding 15-20 pounds rarely leads to the elimination of HTN medications for the grand majority of people.
The one side of Paleo that does certainly help HTN is the decreased sodium intake which accompanies the elimination of processed foods from one’s diet. What this does is help control a patient’s BP with LESS medicine in many cases. I used to tell patients that HTN is like a train rolling down the tracks…it’s always rolling, even ever so slowly, and we would have to increase their meds over time to keep up. I suspect that lowering sodium intake over time MAY help shut the train down. As I said, the train will likely still be there, just more under control. Ultimately if I can control blood pressure and keep it from getting worse I will be happy.
So how has Paleo changed my treatment of HTN? I recommend Paleo to all as an overall way to best improve their health, but I don’t expect people to be able to stop their BP meds, particularly if they are on multiple meds with difficult to control blood pressure. I emphasize Paleo to limit lifetime drug burden and keep things controlled with hopefully less medicine. I never partially treat high blood pressure with “watchful waiting.” Take home: don’t mess with your blood pressure! If it’s high, see your doctor and control it one way or the other.
Cholesterol: This is a condition that has certainly changed when it comes to the way that I approach patients. I have always been very aggressive as a doctor overall, and I was typically aggressive in getting a patient’s cholesterol down. Don’t get me wrong, I still am! I just may approach it a little differently. I’ll concentrate on one particular patient type.
In generally healthy patient’s with high cholesterol, but without a known history of cardiovascular disease or strong family history of CV disease, I am definitely less quick to prescribe a statin. I have an honest discussion with the patient and explain that we need to decide whether or not to treat their high cholesterol. I am increasingly ordering a more sophisticated cholesterol profile known as a VAP cholesterol to help make that determination, along with assessing how serious the patient is in changing his/her diet to create a generally healthier cholesterol environment in their bloodstream. What I’m interested in is lowering the bad cholesterol in their body, and also changing the characteristics of that cholesterol from a more dangerous small/dense cholesterol to a less dangerous large/fluffy cholesterol. If we can do that with a Paleo lifestyle, awesome! This is ALWAYS my first choice. If patients are unwilling to do that, the next step is cholesterol meds. The newer statins have indeed shown the ability to shift particle size in the right direction, but I feel it is no where near as powerful as the shift we can see with a strong Paleo lifestyle. This is my BELIEF, and it is my hope that over time we will have the data to support that.
I treat people, and some people are more willing and able to approach medical problems with lifestyle changes, while some are simply “give me a pill” type of people. I encourage, but I do not judge. I’m honest and realistic with all my patients, and I just want to try to help everyone that I can. I explain my position, and allow them to take a position they are comfortable with…after all, I am treating THEIR health, not mine!
The use of statins in patients with known heart disease is a very complex topic fraught with questions, controversy, and medico-legal issues I’m not up for entertaining. It would be easy, but foolish to preach on this subject. If you have known heart disease I’ll simply tell you: educate yourself, consult a physician you are comfortable with, and come up with a plan together you are each comfortable with.
Diabetes: This is the condition I probably have been most affected by when it comes to my approach to patients and the Paleo lifestyle. I have had many diabetics commit to a Paleo lifestyle, and the results have been remarkable. I am currently working on a prospective study looking at the effectiveness of going Paleo on diabetics over a three month period (but more on that later!).
For me, treating diabetes has always been the most difficult of the big three because of how much a patient’s habits ultimately decide the “success” of my treatment regimen. Blood pressure high?…I can bring it down no problem! Cholesterol up?…just take this medicine and you’ll look great on paper in 6 weeks! Diabetes on the other hand is no where near as simple. Patient’s can quite easily overwhelm their pancreas’ ability to produce insulin, a medicine’s ability to assist their pancreas, or both!, by simply eating the wrong things. I became quite frustrated as traditional “diabetic” diets seemed useless at improving LONGTERM control of a patient’s disease process.
My Paleo journey began as a personal one. I did it to feel better, get fitter, and live longer. The more I researched the science behind it, the more it was obvious to me that it should be a tremendous treatment for diabetes. It may not eliminate the treatment of the disease with pills or shots, but it could be a great baseline on which to manage everyone. Again, there is no argument that elevated blood sugars are bad for you, and must be corrected at all costs. I see Paleo as an alternative for patients to keep their blood sugars lower with LESS medicine! In the end, only one thing matters…get those sugars down. Paleo adds another weapon in the arsenal.
Again, with my diabetics I sit down and explain why I feel Paleo will benefit them. I do this in detail, and utilize some simple handouts I’ve written up as to how making the right food choices can truly help control blood sugar. I then discuss the experiences my other patients have had after adapting their lifestyle. I make it perfectly clear that in my opinion, their best chance for long term sugar control and limiting the meds they will need to use is to adapt an 85-90% Paleolithic lifestyle. If I can get them to bite, I hand them a flash drive with my clinic’s Nutrition Guide we obtained from our friends at Whole 9 Life. This is all they need to be successful right in the palm of their hand. Do all patient’s follow through? Absolutely not. But, it’s a crack in the armor. Eventually we will have the discussion again, and the next time they may be more willing to give Paleo a more serious try. As always…one patient at a time.
I’ll admit, it really bums me out when people won’t give it a try. I practically beg for patient’s to try it for 30 days because I know they won’t go back. Literally, I have not had one patient who went 30 days go back to eating non-Paleo. 100% success rate for my patients…not too shabby.
There are many applications of the Paleo diet to chronic disease, but my passion at the moment has to do with it’s application in the diabetic population. From the hormonal standpoint it strikes at the core of the disease, and offers AMAZING potential for REAL change in people’s lives. I have so many plans…and so little time…
My personal journey in the Paleo lifestyle is far from over, as is my re-orientation as a PaleolithicMD. I would have never thought a year ago that I would have changed my personal health and diet so much, or that my views on the treatment of these three diseases would have changed so much. I certainly would not have guessed I would be moderating this blog in an effort to spread the word that Paleo is a valid addition to the traditional fight against chronic disease. Basically it shows that you can indeed teach an old dog new tricks! So, let’s see what the next year will bring!
August 9, 2012 at 9:19 am
Paleo and CrossFit are why I am not becoming a doctor. I almost enrolled in medical school before finally deciding that the majority of things that doctors treat can be prevented and reversed with the ‘right’ diet and exercise program.
Personally, I don’t really want to deal with the “give me a pill” kind of people. As a trainer and educator, I LOVE working with people who are committed to working on themselves!
August 9, 2012 at 10:17 am
Great article! Instead of statins, do you ever use slow-release niacin (with carnitine to protect the liver)? Niacin therapy shifts particle size, lowers Lp(a), and increases HDL-2.
Also, do you ever refer your patients to a paleo dietitian for one-on-one support?
August 9, 2012 at 12:21 pm
Most patients will not take Niacin due to the flushing, no matter how slow release it is.
And, we don’t hardly have dieticians where I practice, much less a Paleo one 😉 I’m the closest thing I have to that!
August 10, 2012 at 12:06 am
I do consulting via phone or video chat. 🙂
August 9, 2012 at 11:35 am
See Dr Briffa’s blog on high blood pressure http://bit.ly/MTKlue
August 9, 2012 at 11:59 am
This article is nice, but to make such broad statements with a grand total of ONE reference is not a good idea, and I would caution against taking such unilateral advice as fact. Not treating high blood pressure is a very bad idea, and will lead to an extensive list of problems which no one wants to deal with, and which are preventable. Dr. Briffa does not care for patients…he just writes about how he thinks you should. I will stick to my experience and treat HTN aggressively in my patients. You and your doctor can plan what is best for you!
September 16, 2012 at 6:17 pm
did you actually read what briffa wrote? true, there could be more references but he was basically making a comment on the results of a particular meta-analysis of 147 trials. he wasn’t saying that people with high blood pressure shouldn’t be treated, he was simply expressing skepticism about the value of anti-hypertensive medication. to state that he doesn’t care for patients and that he just tells others how they should do it means you only gave his site a very cursory look–he states clearly that he is a practicing physician.
can’t speak for others, but when i’m a patient, i appreciate docs that pay attention to the details. you don’t have agree with everything he writes, but a closer look might allow you to see that you and he are probably on the same side.
August 9, 2012 at 12:38 pm
Then look at Dr Kendrick’s post http://bit.ly/HNBAhD
August 9, 2012 at 2:05 pm
I’ll try to end this issue, none of these articles are going to change the way I take care of my patients. I see hundreds of patients a week, and I review the pertinent medical literature often. I feel strongly about treating HTN aggressively due to my experience and personal interpretation of the medical literature. It is very easy to pick and choose articles that make us feel better, but when you are dealing with real patients, real fathers, real grandmothers…just real people, the game changes. There is a general belief among some that doctors only care about money and pushing drugs; and I disagree wholeheartedly. I’m proud of what I do, I’m proud of my profession, and we collectively do a great deal of good. The American Health Care System, although it has it’s flaws, is far and away the best health care system in the world. My patients come to me for a reason, to get taken care of. That’s what I do…and what I’ll continue to do.
August 13, 2012 at 2:48 pm
do you find better success with type 1 or type 2 diabetics? i get frustrated that most people just say diabetes and not specify which type. they are a little different. thanks!
August 13, 2012 at 9:55 pm
Honestly I’ve had pretty good success with both Type I and Type II diabetics, but most of my patients have been Type II. As the Type I patients are normally diagnosed early in life, they usually associate themselves with an endocrinologist who cares for their disease. Type two diabetics are more my domain and thus where I have most of my experience.
That said, I can think of three Type I patients on insulin pumps who have done extremely well on Paleo. If you think of it strictly from a physiological standpoint, both conditions line up nicely to react positively to turning off the carb train.
Thanks for the feedback, and I will be sure to try to remember to specify which variety of diabetes my patients have when I post about them 🙂
August 14, 2012 at 7:12 am
thanks! i really appreciate that. i was diagnosed 2 years ago with type 1.5, and, it’s been, interesting. i do seem to respond to a reduction in carbs, but i also respond to exercise too. i don’t do well on keto though. no energy at all. 80-100g carbs a day seems to do me well for the exercise i like to do. lchf has not beent the best for me, i gained 30 lbs this past year. now, i have to lose that plus the 15 i was originally trying to lose. oh, and i ended up on meal time insulin even though i was doing lchf. one night after the brazilian steak house, my sugars were up to 311. they were ramping up all week, but, yeah, that happened.
August 14, 2012 at 11:11 am
Have you ever tried a complete elimination diet like the Whole 30 for 30 days strictly?
August 14, 2012 at 11:15 am
yes, and that is when i started getting fat and losing control.
August 25, 2012 at 10:42 am
Overall, I agree with everything that you said. Have you ever used the NMR Lipoprofile analysis? I have used both the VAP and NMR in my practice and because the NMR is a true representation (no calculations) have come to trust its reliability more. Just my opinion. Thanks for your blogging.
August 4, 2013 at 8:42 am
My 13 year old son started the paleo diet the day his was discharged from hospital with type 1 (against the advise of his diabetes educator and dietician) His BG’s are always normal if he eats my cooking and his HbA1C is 5.5. His doctor says he has the best numbers of any of his patients and his educator can’t figure out why his basal rate of insulin is more than his boluses (he is on a pump) I have done my own research about true nutrition and physiology (even though I did physiology at uni many years ago, I believe there are now new discoveries about how the body works) I was told the usual dietary crap , “healthy wholegrains (but no sugar – huh??) low fat, use margarine, eat high carb food in every meal, etc.etc. I allow treats on special occasions so he can still enjoy social occasions. I find it very easy to control his BGs. Also, I have learned to bolus a small amount for protein, but each person would need to experiment with this – I add an extra 5grams of carbohydrate for an average serve of protein into the bolus amount. Sometimes we are not strictly paleo, but always low carbohydrate. It is easy to adhere to and eating this way becomes a way of life, and the benefits of losing weight and being able to fast for a day are an added bonus.
One other point I would like to add is that a type 1 diabetic who produces little or no insulin should not be eating “low glycemic carbohydrates” either. Regardless of the glycemic index, any carbohydrate will cause a fast rise in BG, and wheat products are probably the worst.