Courtesy of a Quick Google Images Search or Two…
Well Hurricane Issac came our way and thankfully we were spared any significant weather. Many folks south of us are still struggling, and I ask for everyone to pray for their safety and a quick resolution to the chaos that has come into their lives. On top of the hurricane, much has been going on…where to begin…
Several months ago two of my friends and I decided to try something new. All three of us follow a Paleo lifestyle, participate in CrossFit (each on very different levels as William is part owner of our local gym and one of the it’s trainers, and Sam has been attending CrossFit for much longer than I) and have a passion for helping others. William Albritton is an engineer by trade, but spends all of his spare time as a CrossFit trainer and health coach. Sam Bledsoe is somewhat of a rarity as I’m almost certain he is the only Paleo Bariatric Surgeon in the country! He identified a group of his successful weight loss surgery (WLS) patients who had stopped losing weight after surgery, or plateaued. He and William devised a plan to put them in an 8 week program based on strict Paleolithic nutrition and consistent application of CrossFit…lucky for me they asked me to join in the fun! In total, there were 6 lucky participants.
Looking back at our first meeting it was pretty comical. They really did not know what they were getting into, and we had to completely define the term “paleo” to them. We set about explaining to them what and why we eat the way we do, and in the process I think I may have broken a few hearts. Who knew what a stronghold someone’s oatmeal could be! Regardless, they are all people of integrity, and they committed to our program by trusting our judgement.
So lets just look at this for a moment. How much more difficult of a challenge could we ask for? Here are 6 individuals who have fought their weight their whole lives, and who have lifelong food relationships that often were unhealthy. When you have WLS a certain amount of weight loss is almost automatic, but the last of the loss is much harder. Here is the thing though, each of these individuals was working hard through traditional weight loss regimens. Low calorie, low fat, exercise at the gym when you can, walk when you can’t get to the gym…it just was not working. There is a misconception that overweight individuals are inherently lazy, and this group of people blow that mold out of the water. They were all trying, they were just trying the wrong things. One of our group members had already lost 120 pounds since surgery, but had only lost 5 pounds in the 6 months or so before our challenge. Bottom line is that they did not necessarily “get” what we were telling them, but they were willing to try something new.
So began the process, some form of exercise 5-6 times a week, half of them being CrossFit WODs, and the other days much more light walks or runs. All along we held them accountable to following a Paleo regimen by turning in weekly food logs and helping them sort through the best choices to make. Each had their own issues at the start, but they all worked hard to get through the beginning, and quickly began to thrive. Their group workouts became a source of encouragement and our consistent interaction with them kept their eyes open at all times. Slowly the magic started to happen, but they did not know exactly how much magic. Why? We strictly prohibited them from weighing themselves over the 8 weeks. It was time to worry about health, not weight!
The results of our 8 weeks was amazing, and I’ll let two things do the talking. First is a chart of the results.
The numbers in the first row are where each person started, the middle row is their end measurements, and the bottom row is the difference between the start and finish of the 8 weeks. You are reading right, each person averaged around 20 INCHES of loss over the program. Now THAT is results!
Please notice that even though overall weight loss was not earth shattering for all, the number of inches lost and overall improvement in body “tone” was awesome. We did not have one unhappy participant!
Second I’ll let everyone read an essay that one of our participants wrote at the end of the program. He is an amazing gentleman whose transformation following WLS and our program is nothing short of remarkable. Here is what he had to say…
At the end of our journey we had a little get together at my home where we were all able to talk and share about the program, and we enjoyed some amazing Paleo food (including a healthy dose of @FitPaleoMom’s Chocolate Chip Cookies). It was so inspirational to hear everyone’s stories about the struggles over the years, and the positive light that our program was able to put on their circumstances. All six participants have officially joined CrossFit, and the road ahead will be nothing but success for them. As a physician is it easy to get discouraged in the day to day grind of taking care of people. I can honestly say at the end of the 8 weeks we owed, and gave, a heartfelt thanks to each participant for giving their all, and reminding us how much of a difference we all can make. It was one of the most enjoyable journeys in both my personal and professional life.
So what do we do from here? We have decided to spread the wealth and open our program to all comers in our area. [www.Genesis-Experience.com] We want to keep attracting people who would never consider coming to the gym and helping them revolutionize their lives. People looking to “forge elite fitness” will find the gym, we need to go out and FIND everyday people who stand to benefit so much from a dramatic lifestyle change. As a physician this is what really excites me, changing lives that have been abandoned and failed by the “system”. If 6 WLS patients can see these changes, anyone can!
Hope all are well…
I’m sure many of you have seen that two new “Diet” pills were recently approved by the FDA. Once I saw this, I braced myself for the inevitable flood of people coming to my office asking to be prescribed the latest quick fix; and as expected, I was not disappointed. I’ve had at least 10 people over the last month ask for one of the new pills, and I thought this would be a great topic to discuss in this setting. I’ve mentioned in prior posts that in my 15 years of training and private practice I have prescribed diet pills a grand total of ZERO times. So, will these new medicines change my habits? Lets look and see what we got.
Qsymia is a combination of phentermine and topiramate and has been approved by the FDA for “chronic weight management in adults who are obese, or overweight with at least one weight-related medical condition such as high blood pressure, Type II Diabetes, or High Cholesterol”. [I would vote that these conditions, although they are “weight” related, should be more properly described as “nutrition” related…but I digress] That is a quote from the product web page, and lets keep the information coming from the same source, the producers of Qsymia:
-The effect of Qsymia on cardiovascular morbidity and mortality has not been established. [emphasis added]
-The safety and effectiveness of Qsymia in combination with other products intended for weight loss…has not been established.
-Qsymia can harm your unborn baby.
-Qsymia can increase your heart rate at rest.
-Qsymia increases the risk of suicidal thoughts or behavior.
-Qsymia may affect how you think and is associated with difficulty with attention and concentration, memory, and word-finding. Therefore, use caution when operating hazardous machinery, including automobiles [emphasis added]
-The most common side effects seen in Qsymia clinical studies were tingling in the hands and feet, dizziness, change in taste, trouble sleeping, constipation, and dry mouth.
Because Qsymia contains phentermine (a pharmacologic cousin to amphetamine) it is classified as a federally controlled substance, indicating it can be abused or lead to drug dependence. It’s basic mechanism of action is to reduce hunger and increase the release of serotonin and dopamine in the brain. It’s important to note that topiramate, also known commercially as Topamax is a seizure and migraine medicine that just so happens to make people feel full.
The other drug recently approved is called Belviq (lorcaserin hydrochloride) and is approved for essentially the same indications as Qsymia. Again, let’s look at the package insert for some indications and cautions:
-The safety and efficacy of coadministration with other products for weight loss have not been established
-The effect of Belviq on cardiovascular morbidity and mortality has not been established [emphasis added]
-Warnings and Precautions were listed for:
1) Serotonin Syndrome or Neuroleptic Malignant Syndrome – which means this drug should be VERY cautiously given with traditional antidepressants
2) Valvular Heart Disease
3) Cognitive Impairment
4) Psychiatric euphoria and dissociation
5) Monitor for depression or suicidal thoughts
Most common adverse reactions (greater than 5%) in non-diabetic patients are headache, dizziness, fatigue, nausea, dry mouth, and constipation, and in diabetic patients are hypoglycemia, headache, back pain, cough, and fatigue.
Belviq’s mechanism of action is that it stimulates brain receptors for serotonin, a neurotransmitter that initiates feelings of fullness. Basically, both of these drugs try to trick your brain into thinking that you are full.
So, will I prescribe any of these medicines for my patients? Well you guessed it, the answer is no! The reason is simple, SAFETY. We may all remember Fen Phen, a diet pill from some years back that was taken off the market due to causing serious valvular heart disease resulting in congestive heart failure. I remember vividly being called to the ER soon after I moved back to Louisiana to admit a young lady with heart failure. I remember thinking it odd that a 32 year old female would be in severe heart failure, but the mystery was revealed once I got to the ER and spoke to her. Turns out she had taken Fen Phen for TWO WEEKS in an effort to lose a few pounds and fit in a dress for a friend’s wedding. She developed severe Mitral Valvular Heart Disease and resultant heart failure. She had a valve replacement, but it never worked well and she had severe chronic congestive heart failure as a result. The look on her face telling me the story said it all…”I was an idiot, looked for a quick fix, and look at me now.” I really felt bad for her.
A year ago both of these drugs came up for FDA approval and they were denied…why? They were not felt to be safe from the cardiovascular standpoint, and both seemed to have significant teratogenic effects. It is simply not known if these drugs can potentially cause the same valvular heart disease that Fen Phen caused. Now look, I’m not at all saying they will, but information from the MANUFACTURERS themselves clearly state that the risks are unknown. Also not, the Phen is Fen Phen…yep, it’s short for phentermine. The FDA stated that the medicines were given approval essentially because doctors needed “something” to combat the worsening obesity epidemic. I see it as a basic act of desperation from the FDA, and truthfully I understand their viewpoint on this. Do I agree with it? No, but I understand where they are coming from. Regardless, this physician won’t be writing out scripts for these meds any time soon.
Now that I got this out of the way, let me make one simple point for anyone out there considering asking their doctor for one of these pills. There is the misconception out there amongst many people that diet pills are an answer. Some great conspiracy is holding back doctors from prescribing these meds and we should all be thinner and get to eat more of the things we want without consequences. Well, let me ask you a few questions…
-If these pills worked, would there be ONE FAT DOCTOR IN THE WORLD? I may not be able to prescribe these meds for myself, but I certainly have 50 buddies on speed dial that could. Think about it!
-Let’s take it a step farther, would there be any fat people in the world at all, especially those with money? Ever seen a fat rich person? Sure! There are plenty around. Would there be ONE FAT RICH PERSON in the world if it was as easy as finding the right pill?
If you make a statement about your plan to lose weight, and the word “diet” is somewhere in the sentence, just give up because you are going to fail. By definition a diet is something you are either “on” or “off”. You will likely lose weight while on it, and gain it back when you get off it. So essentially all “diets” will result in a yo-yo affect to your weight.
One other thing, the FDA has approved these medicines as “an addition to a reduced-calorie diet and exercise program.” They are not designed to simply remove the weight without requiring any effort from the patient. What does that mean? If you simply take the pills and do not change any of your already bad habits…you will fail again in improving your health longterm through significant weight loss.
There are certain things in life that are easy, and some that are hard. There are also differences in how difficult or hard those same things are for some to achieve versus others. Take a look at this well demonstrated problem in America…
Obesity is a very complex problem and it’s rise in America is multi-factorial: lack of exercise, reliance on cheap food built on the backbone of highly processed carbohydrates, poverty, lack of nutritional education, reliance on “quick-fixes” as a society, government subsidies on corn and soy, the gradual extinction of cooking at home combined with increasing numbers of families chronically obtaining dinner through the car window, lack of sleep, an abundance of stress (and cortisol) in our lives!, manipulation of the food supply to promote weight gain, etc. I could go on and on. So, REALLY, does ANYONE think a little pill can even put a dent in any of this?
How do we fix obesity? Well, it’s not easy, but we must get at the root cause if we are to get anywhere. My motto is Real Food…Real Health. In the end, the beginning of the end of obesity must itself begin with a transition back to eating Real Food as a society. I’ve seen it around the web and twitter as JERF (Just Eat Real Food). This must start on an individual level, with individual families deciding that enough junk is enough. My family has made that choice, so can yours!
Know anyone thinking about asking their doctor for one of these new pills? Invite them to read this post, and then ask them to join you on a journey to Real Health by emphasizing Real Food in their life again. Need more information? Browse around my blog for ways to change your life. Are you a reader, check out It Starts with Food by my friends Dallas and Melissa Hartwig. Don’t know where to start? Easy…JERF!
This weekend the Ancestral Health Society had its annual symposium in Boston, MA. Unfortunately for me I was home (on call none the less!) and was forced to follow the proceedings via the Twitterverse. I also recently posted about how my change to the Paleo lifestyle has affected the way I approach three common chronic diseases: Hypertension, High Cholesterol, and Diabetes. Several comments I read from the AHS and that I received on my blog post have got me thinking, and I need to get a few things off my chest.
First of all, I must confess to everyone that although I run a blog site called PaleolithicMD, I am still a common variety Internist in the South of our great nation. I absolutely push Paleolithic nutrition to everyone in my practice, but it does not in any way stop me from prescribing medicines to my patients on a daily basis. I am forced to ride the fine line between strict Ancestral Medicine and Modern Day Medicine. Some may say that is a negative, I even had one comment from someone who chose not to apply to medical school because he could not deal with people who simply want a pill to fix everything. I find that unfortunate, but respect the opinion none the less.
I had several responses particularly to my stance on aggressive treatment of hypertension. Several kind readers directed to me to articles stating that the treatment of chronic hypertension with medical intervention to prevent disease is weakly supported. What concerns me is the “blanket” nature of people’s opinions about high blood pressure. I, like most practicing physicians in America and around the world routinely review the latest scientific journals pertaining to our field of specialty. We are true life long learners, one of the aspects of my job that I most enjoy. That said, arterial hypertension is a systemic disorder, with wide ranging system consequences. Chronic untreated Hypertension is/will (among others):
-The most common major risk factor for premature cardiovascular disease 1
-Directly lead to Left Ventricular Enlargement and consequently chronic systolic Congestive Heart Failure and increased incidence of ventricular arrythmias 2
-The most common and important risk factor for ischemic stroke, the incidence of which has been shown to be markedly reduced with effective BP control 3
-The most common risk factor for the development of intracerebral hemorrhage 4
-Major risk factor for chronic and end-stage renal disease 5
It is cool and sexy to take a universal stand against all medicine, it must ALL be bad for you. Not only that, EVERYTHING can be cured by changing one’s diet right! Take this tweet for instance…
Disease can be prevented, treated and cured by food. Amazing results from research & studies being presented at #AHS12. Totally blown away!
What a far ranging statement! Most common “Paleo” folk live in and out of gyms, hang out with their fit friends, and search far and wide for the cleanest restaurants to eat at. We (I include myself in this crowd) source the best farm raised protein and organically grown produce…we live in this perfect little sustainable world! I live in this world, but I also live in a very different world; one where I take care of very sick individuals. How am I to care for critically ill patients without medicine to give them, or surgery to fix things? This leads me to my two favorite quotes from today on twitter, both from Dr. Wahls.
“Superior doctors prevent disease. Mediocre doctors treat impending disease. Inferior doctors treat actual disease.”
“The doctor of the future will give no medicine. You guys are the doctors of the future. I salute you.”
Let’s talk about each of them in turn. The first quote is, how can I put it, an incredibly arrogant and asinine thing to say! What Dr. Wahls is doing is playing to her crowd. She figures she is in front of a group of AHS attendees who WANT to hear something like this. Why not make a ridiculous statement and get a few oohs and aahs (I wasn’t there, so I admit some speculation here!) Her statement takes a very far reaching stance that is dependent on one important thing…that ALL DISEASE is completely preventable by proper nutrition or following the right “Protocol.” Make no mistake, her story is remarkable and inspirational, but it is not grounds to advocate that all disease is preventable, and that the only “superior” doctors are those who prevent disease. I guess the ER physician who initiates the life saving care of a motorcycle victim, or the radiologist who diagnoses his injuries, or the trauma surgeon who saves his life from a ruptured spleen, or the orthopedic surgeon who repairs his broken bones, or the nephrologist who temporarily supports his kidney function through hemodialysis, or the critical care specialist who keeps him alive in the ICU until his body starts to heal itself, or the Internist who takes over his care once out of the ICU and methodically advances his care, or the Physical Medicine & Rehabilitation physician who expertly crafts his rehab program…I guess none of these doctors are “superior”…in fact, they are surely “inferior.” One can read a statement like this by Dr. Wahls and feel all nice and tingly because WE can do this, WE can fight disease through Ancestral Health alone, WHO needs inferior doctors!!! I can just hear William Wallace himself yelling “But they can’t…take away… our BACON!!!” What if that motorcycle victim is your dad, or husband, or son…what about those inferior doctors now? Is all disease preventable by eating more bacon and coconut? I won’t answer that, you can do that on your own… You may take this as simply a doctor being defensive, but that is not the case. Thousands of doctors will be away from their families tonight on call caring for your loved ones with a great deal of compassion and heart. I refuse to accept a fellow physician downgrading the status of 99% of her fellow physicians simply to get a rise out of a crowd or to advance her personal agenda. Say what you will, so will I.
So what about the “doctor of the future” comment? Amazing, talk about playing up to the crowd again with another far fetched statement. I guess the future will have no doctors nor need any doctors. All everyone will have to do is read a book on how to eat and live, and we’ll all live to be 120 years old. Seriously, who will need a doctor? Again, this is a “cool” statement to make, but it’s just ridiculous in my opinion. You may agree with her, or just hope she is right, but I can assure you she is 110% wrong. What will a doctor without medicine do for a broken bone, or a gunshot wound, or a pneumonia, or an appendicitis, or a cataract causing blindness, or a skin cancer caused by SUN exposure, or a congenital heart defect, or an abscessed tooth, or a kidney stone, or a… I hope you get my point. The thought that the only thing doctors in the future will do is prescribe you their nutritional “protocol” is terribly short sighted and misleading.
Let me explain to everyone where I live, I live in REALITY! One of the main reasons I started my blog was to stress that there is a real and valid place for both Paleolithic Nutrition AND Modern Medicine in each and every person’s life. INCLUSION rather than EXCLUSION. I agree with each of you who is saying things like “but wait, if everyone ate Paleo we wouldn’t have as much heart disease, or diabetes, or high blood pressure, or autoimmune disease, or osteoporosis, or whatever…” You know what, I think you are absolutely right, but I also believe strongly that Paleolithic Nutrition is not going to be taking the world by storm any time soon. My job as a doctor is multi-faceted.
-My primary role is to catch people early, before chronic diseases set in, and get them to buy into the idea that their actions, particularly through what they eat, can and will significantly affect their health both short and long-term. As I like to say, Real Food…Real Health.
-My secondary role is to treat those who have not followed the right lifestyle and consequently have developed any number of chronic diseases. The most exciting ones are those who are willing to re-adapt their lives and change the habits that got them in trouble in the first place. The use of medication in these patients is necessary and frequent, but is also often diminished if they can adapt to following a strict Paleo lifestyle.
-My final role is to treat those who will simply not listen to what they are doing wrong, and want to live life the way that they please. I have said it many times that I believe strongly in NOT JUDGING people in any aspect of life (no, I’m not perfect in this). What am I to do if someone is unwilling to adapt their diet? Fire them as a patient? Refuse them treatments that HAVE been proven in studies to help them live longer lives? If I run a Paleo-Only medical practice I will do two bad things: go broke, and miss out on the amazing relationships and interactions that I have with most of my patients. You see, just because someone will not give up their carbohydrates despite their terrible blood sugars does not mean that they are not a wonderful person, or that they don’t get benefit from seeing me. Likewise, just because a physician will not abandon all modern practices and preach only a Paleo lifestyle as the treatment for chronic disease does not make him or her “inferior.”
So many people advocate for social tolerance all the while berating the many American’s who for whatever reason, cannot adapt to the lifestyle we find so helpful to us. Or for that matter, look down upon the majority of doctors who simply “push pills” to the benefit of them and the all powerful and evil drug companies. What about the grandma with pneumonia, or the grandpa with a broken hip, or the mother of two whose husband left her and tried to kill herself, or the 17 year old college student with meningitis…what do I do, hang an IV of bacon fat or pureed beef liver and hope for the best?
This is not us against them, or “superior” vs “inferior” doctors, this is simply the story of humanity played out for all to see. I’ll say it again, be INCLUSIVE and not EXCLUSIVE. I absolutely love my job; I enjoy finally breaking through to the diabetic who agrees to give Paleo a try just as much as I enjoy laughing with the 86 year old who knew he was having a stroke because his cigarette kept falling out of the right side of his mouth. I admitted this gentleman to the hospital, worked him up, put him on Aspirin, and sent him home…where he picked right back up smoking. I can get mad at him, or just understand my role in his life. What did he do about all this? He laughed! The German’s didn’t kill him on the beaches at Normandy, and he’s not too concerned about what the cigarettes are doing to him at this point.
There is nothing inherently bad about you if you can’t fellow a 100% Paleo diet, nor is there anything particularly special about you simply because you can. I see you as an amazing human being with as much to offer me as I have to offer you. Guess all this makes me and Inferior doctor…and I’m very proud of my work and the influence I have on people’s lives.
Thank you. I came here tonight… and I didn’t know what to expect. I’ve seen a lot of people hating me… and I didn’t know… what to feel about that, so… I guess I didn’t like you much either. During this fight… I seen a lot of changing: the way you felt about me… and the way I felt about you. In here… there were two guys… killing each other. But I guess that’s better than million. What I’m trying to say is… if I can change… and you can change… everybody can change! -Rocky Balboa
PS – Also, check out this like-minded quote from Dr. Emily Deans at her blog Evolutionary Psychiatry.
1 Established risk factors and coronary artery disease: the Framingham Study, Am J Hypertension. 1994;7(7 Pt 2):7S.
2 Prognostic implications of left ventricular hypertrophy. Vakili BA, Okin PM, Devereux RB Am Heart J. 2001;141(3):334.
3 Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhäger WH, Bulpitt CJ, de Leeuw PW, Dollery CT, Fletcher AE, Forette F, Leonetti G, Nachev C, O’Brien ET, Rosenfeld J, Rodicio JL, Tuomilehto J, Zanchetti A Lancet. 1997;350(9080):757.
4Risk factors for cerebral hemorrhage in the era of well-controlled hypertension. Melbourne Risk Factor Study (MERFS) Group. Thrift AG, McNeil JJ, Forbes A, Donnan GA Stroke. 1996;27(11):2020.
5Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Hsu CY, McCulloch CE, Darbinian J, Go AS, Iribarren C Arch Intern Med. 2005;165(8):923.
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!
Many people ask me what I think the future of Paleo is? Will it ever by mainstream and recommended by doctors, government, and society alike? In many ways Paleolithic Nutrition is at it’s infancy in the scientific world and although it is the oldest “diet” in human history, it’s concepts are foreign to most people around us. In order for Paleo to have any chance to become more accepted, we will have to overcome several barriers…let’s see what I think they are.
Cost – There is a great deal of debate about how expensive eating Paleo really is. Some say it is extremely cost prohibitive while others insist that’s just a misperception. What do I think? I think the answer lies somewhere in the middle.
When people say that eating Paleo is no more expensive than eating the typical carb based diet most American’s eat these days, I would have to disagree. If you look at food at the grocery store as a whole, it is often cheaper to feed your family with processed foods than with fresh foods. Put it this way, IF you don’t care in the least about the health of the food you put on your families table, and you don’t really care what it is you eat anyway, you can find cheaper ways to feed your family with unhealthy food. If your family is hungry, and you have very little money, it is very hard to beat 4 packs of Ramen noodles at 15 cents each. Unless you really are extremely poor, I caution anyone from making assumptions that Paleo is “easy” to accomplish.
Next is the significant price difference between regular and organic produce, or bulk raised vs grass fed/free range meats. A whole chicken at my local Kroger costs 4-5 Dollars, while a whole organic bird costs $15. Now look, I agree with most of you that the organic bird has too many benefits to discuss as far as quality and lack of questionable processing practices, but many folks JUST DON’T HAVE THE MONEY! I am very up front with my patients and tell them that they simply have to buy what they can afford, as well as source what they can depending on their geographic location.
The bottom line is that you have to try much harder to eat a Paleo lifestyle on a budget. Can it be done, of coarse it can! But in our world of both parents working long hours, more and more meals being eaten outside of the home, and ever raising prices of food on the grocery store floors, the idea that cost does not present a significant barrier to more widespread adoption of the Paleo diet is foolish at best.
Social Environment – I touched on this just a bit above, but the way our society approaches food and free time is a major factor. The days of learning to cook from your parents, who learned to cook from their parents is becoming a lost art. Convenience is what drives the food industry and most families feel forced to take advantage of that convenience on a nearly daily basis. Late hours at work, ball practice that never ends, homework that takes up more time than it should…there are so many factors that force families to put the quality of the food they eat on the back burner.
I am saddened by the way most people choose their food. When is the last time you saw someone pull up to a car lot and ask for “the crappiest thing on the lot, I don’t care what it looks like, smells like, came from, how old it is, or how long it will last; I just need it to get me through the day.” Most take much more care in picking their cell phones than in picking their dinners. Sad as this is, it is reality. I wish I could change it, but the scale of the changes society would have to undertake to change this are so monumental, I don’t see it every happening. That train has simply left the station, and it does not have a reverse.
Overcoming these social forces is amazingly difficult, especially with the food industry catering at every turn to keep them going. Take an onion for example; you can now buy an onion, pay a bit more for a peeled onion, pay a bit more for sliced onions off the salad bar, pay a bit more for a container of (who knows how old) diced onions, or forget the whole darn thing and just buy something called “onion juice”. Buy a whole chicken for $4, four thighs for $6, or 4 boneless skinless thighs for $8! Imagine, having to butcher your own chicken!!! The nerve… With this type of social and retail environment, can you ever see Paleo hitting the mainstream?
Logistics – Have you ever had this thought? I can go down to my local grocery store and find so many items it is unreal. Take a simple red delicious apple. I would be willing to say that basically every grocery store in America has red delicious apples in it. Let’s say every store has a modest 10 apples, and a quick google search yielded that there are around 250,000 grocery stores in the US. So at any given point, I think it’s reasonable to assume that there are conservatively 2.5 Million red delicious apples on the shelves across America. Does that not just amaze you? How many trees does it take to produce that many apples? How many varieties of apples does your grocery store have? Realize we have these apples ALL YEAR LONG. What I’m trying to emphasize is that it takes an insane amount of food to feed Americans on even a daily basis. How many cans of corn stand on grocery shelves? Loaves of bread? Gallons of milk? Every day we have to feed approximately 310,000,000 people in America! Seriously, just stop a minute and appreciate the infrastructure that can accomplish this monumental task.
So, I have a question for you. Let’s say a third of the American population suddenly decided to go Paleo. I would first join you in saying Hooray!, I can’t believe so many others are going to experience the benefits of this lifestyle. So to my question… do we have enough food? I can’t say that I know the answer, but I would think a pretty good educated guess would be absolutely not. Let’s say Americans took it a step farther and decided they would only eat organic and pastured animals and produce, what then? Do we have the land to produce enough beef in a responsible fashion for the masses to consume? Again, I don’t know (although I’m comfortable saying I don’t think so by a long shot), but I can see where this could be a very real problem. There is a reason that cows are pumped full of antibiotics and steroids, and their health is sacrificed in the name of growth…we need the food!! Never given this much thought? Sit down for a few minutes, discuss with your Paleo friends…can America logistically be a primarily Paleo society?
Politics – Oh how I hate the word…Politics. I really don’t care what side of the aisle you are on, your party of choice has likely failed miserably over the years when it comes to nutrition in America. (Please, don’t leave me a comment and preach about why it’s all red’s fault, or blue’s fault…there are no clean hands in Washington. Believing otherwise shows nothing but blind faith.) Why is that so? One word…Lobbyists. Take for example last week when the USDA released a statement supporting “Meatless Mondays” as a way to enhance the sustainability of our food industry. Now personally the idea of a meatless any-day is depressing, but I guess I can see where the USDA was coming from. Problem is, they hacked off a lot of people! Beef people, pork people, chicken people… hell, probably even the Veal people were upset! ONE DAY later the USDA retracted their statement, and said they did not support the practice of Meatless Mondays. Amazing, truly amazing.
I don’t care what side of the issue you are on, I think we can all agree that it is sad that a government agency can be influenced so swiftly by big business. Don’t like it, I think you are gonna have to sort of get over it…welcome to America.
For Paleo to go mainstream, the government along with it’s health advisory committees, the American Heart Association, the American Medical Association (of which I am a proud NON-Member), the American Diabetes Association, etc…etc, would have to completely reverse their stance on fat, carbohydrates, obesity, and heart disease. In order to do that they would have to do something they will never do…ADMIT THEY ARE WRONG! Even if they had the intestinal fortitude to admit their beliefs have been wrong for decades, they would then have to convince a few other people that it is important to change their views and recommendations. Who you ask? I can think of the Dairy Industry, the Corn Industry, the Potato Industry, the Sugar Industry, the Fast Food Industry, the Peanut Industry, the Pharmaceutical Industry, the Beef Industry (yes, they would have to address how our modern livestock rearing practices adversely affect the quality and danger of the fats inside our animals), the Poultry Industry…I’m getting bored now, you get the picture. The entire food industry would have to change in order for Paleo to go mainstream. What do you think? That gonna happen anytime soon?
Nobody wants to hear it, but politics and money are at the core of how our country work. It should be no surprise then that politics and money have an un-alterable effect on the food that we eat.
So, Will Paleo Ever Go Mainstream? – In a word, no. I don’t see a time where the Paleo lifestyle is commonplace in American society. Call me negative if you want, but I see it as more realistic. Cost, social pressures, logistics, and politics; each contribute greatly to the low likelihood that Paleo takes America by storm.
I guess that means we just go on our merry way and live with this reality? Also in a word, NO! The Paleo community must band together and be as inclusive and understanding as possible so that anyone with an inclination to join us is able. Don’t look down on those who can’t afford grassfed meat, and instead applaud them for doing all THEY can do improve their health. Support your local farmer’s market, CSA, or grass fed farm if you are able. If you can’t afford their products, spread the word to someone who might be able to. Can’t afford a quarter of a cow, find a family or two to split the cost with. Grow a garden. Find ways to sustain YOURSELF in an environment of mass sustainability.
I’ll never likely get a chance to lobby in front of congress as to why the Paleo lifestyle should be moved to the forefront of our country’s war on the worsening epidemics of obesity, heart disease, strokes, or cancer. I will on the other hand have the chance, likely as soon as tomorrow, to talk to a single patient about why changing their nutritional habits could very well save their life. Don’t get caught up ruminating with anger about the injustices of our political system, while as a consequence missing the chance to make the world a better place one person at a time. Don’t get caught up in going mainstream, instead relish the opportunity to go UP-stream against the forces that hold back the Paleo lifestyle. The war may very well be un-winnable, but the little battles are where the real satisfaction must lay.
Agree? Disagree? Let me and everyone else know what you think!
The recurring series “Overcoming Medical Dogma” is a collaborative effort between The Paleo Mom Sarah Ballantyne, PhD, scientist turned stay-at-home-mom, and Paleolithic MD Dr. Ernie Garcia, MD, Internal Medicine and Sleep Medicine specialist. The goal of these co-written posts is to go beyond the typical physician-patient interaction where the patient describes symptoms, the physician diagnoses and prescribes medication and/or dispenses diet and lifestyle advice. In each post, we will discuss a common medical condition, the typical treatments that your doctor may recommend, and what you should know about these conditions that your doctor may not tell you. We will reference relevant research and present our recommendations for addressing this condition. Lastly, we will address the benefits of pharmaceuticals (prescription and OTC) as well as home/natural remedies which may help.
What is Eczema? Eczema is a general term used to describe a collection of skin conditions (the most common being atopic dermatitis) in which the skin is inflamed and irritated. The inflammation in these skin conditions is in the epidermis, or outer layer of the skin, and this is the main distinction between eczema and other skin conditions. The presentation varies and can include any of the following symptoms: redness, skin edema (swelling), itching, dryness, crusting, flaking, blistering, cracking, oozing, or bleeding. It can affect any area of the body and areas can range in size from quite small to very large. Eczema affects about 10% to 20% of infants and about 3% of adults and children in the U.S.
It was once thought that eczema was a primary immune system disorder, where an overactive immune system, led by a type of white blood cell called T-Cells, responded to environmental factors by initiating an inflammatory response. This idea made sense because not only would inflammation produce the red, irritated skin characteristic of eczema, but this dysfunctional immune response also provided an explanation for the observed incidence of atopic dermatitis in conjunction with asthma, hay fever, and other allergies. However, the most up-to-date research does not support this explanation.
The most current research points to a different origin of eczema. It is now thought that eczema results from structural defects in the epidermis resulting in “impaired barrier function”. Essentially, abnormalities in the skin make it more permeable to toxins and antigens, which then causes an exaggerated immune response 1. You could think of this as “leaky skin”, where the skin no longer is able to fulfil its primary role as the first line of defence between the body and the outside world. Once the barrier function of the skin is disrupted, various substances (like toxins, allergens, antigens; basically anything that the immune system views as a foreign invader) can “leak” in from the outside and this is what activates the immune response. This model is supported by recent isolation of specific mutations in the gene for filaggrin, a structural protein in the epithelial cells of the skin. This defective gene (and perhaps other similar gene mutations) may lead to a dysfunctional epidermal barrier and is likely the primary cause of eczema.
What is your doctor likely to tell you about it? Your doctor will likely tell you that the exact cause of eczema is unknown, but it’s thought to be linked to an overactive response by the body’s immune system to an irritant. He or she may not be aware of the newest research on eczema, but that will not affect decisions on treatment. It’s fairly common and not life threatening.
What is your doctor likely to prescribe? Treatment of any skin condition should always start with proper care of your skin. In the case of eczema, you should avoid triggers such as heat, perspiration, and low humidity, and keep the skin well hydrated at all times. The standard pharmaceutical treatment is the application of topical corticosteroid creams, which can be purchased in your local pharmacy or prescribed in stronger strengths by your doctor. If allergies are suspected, a daily antihistamine such as loratidine (Claritin) may be suggested. In severe cases, your doctor may prescribe an oral corticosteroid, such as prednisone.
Now if you have your thinking hats on (and we’re sure you do), you are asking “If eczema is no longer considered a primary immune disorder, why is the standard of treatment aimed at stopping inflammation and controlling the immune response?” The answer is that the symptoms of eczema are indeed caused by an immune response, but it is a response from environmental triggers entering the body through “leaky” skin as opposed to an immune system run wild and attacking itself.
What should you know that your doctor may not tell you? As discussed above, the most current belief is that those with eczema carry a genetic predisposition to “disrupted epidermal barrier function” 1. This could be thought of as “leaky skin” and is a very analogous to a “leaky gut”. In fact, because of the similar roles of the skin and the gut to act as a barrier, it is no surprise that eczema is also associated with increased intestinal permeability 2, i.e., a leaky gut. It is still unknown whether a leaky gut contributes to the development of eczema, however.
Eczema is also often seen in conjunction with a multitude of autoimmune diseases. For example, eczema occurs about three times more frequently in celiac disease patients and about two times more frequently in relatives of celiac patients, potentially indicating a genetic link between the two conditions. For this reason, gluten sensitivity is suspected as a possible root cause for eczema, but that is still unconfirmed. Anecdotally, many people find that their eczema goes away when they adopt a gluten-free diet. Other people find elimination of additional foods, such as eggs, are required to see improvement. There also appears to be a strong link between eczema and immune hypersensitivity 3. For example, more than 50% of children with atopic dermatitis go on to develop asthma and allergies. This may be related to the association with increased intestinal permeability or may reflect an as yet unknown common causal mechanism (such as a gene mutation or environmental factors).
Although progress had been made toward understanding this complex condition and how it relates to other health issues, the cause of eczema remains unknown. We are certain the coming years will bring more information and we will try to update everyone as it is available.
A Comprehensive Approach to Treatment: We believe that a paleo diet is an excellent initial approach to dealing with eczema. This is because a paleo diet reduces inflammation and heals the gut. Including glycine-rich foods like homemade bone broth and organ meat can help speed the healing of both the gut and the skin (glycine is an essential component of connective tissue and the extracellular matrix that acts as a scaffold for cells). Sun exposure and eating vitamin D-rich foods such as fish and organ meat can be very helpful in speeding healing (you might also consider a Vitamin D3 supplement, but check with your doctor first). Consuming plenty of oily cold-water fish (at least three times per week) as well as eating grass-fed and pastured meat will also help because the high omega-3 content of these foods (and low omega-6 content) could help resolve inflammation.
Anecdotally, most people report alleviation of their symptoms with adoption of a paleo diet. In extreme cases, or in individuals who do not see alleviation of their symptoms with out-of-the-box paleo, it may be worth trying a more restricted implementation of the paleo diet, such as the Autoimmune Protocol, a paleo version of the GAPS diet, or even something as simple as completing the Whole 30 Challenge from Whole 9 Life.
Over the counter topical corticosteroid creams may still provide some alleviation of symptoms (most notably the itching) and might be required initially. Other moisturizers which may help heal the skin faster and relieve itching include extra virgin coconut oil and lotions containing calamine, aloe vera, arnica montana, Vitamin D and/or Vitamin E. Diane Sanfilippo provides herbal supplement recommendations in her new book Practical Paleo (herbal supplement recommendations are generally beyond both of our backgrounds and we recommend that you consult with someone with specific training in these supplements such as a Naturopathic Physician). If your attempts to control symptoms with diet and supplements alone do not produce adequate relief, we suggest visiting your doctor for advice on more specific pharmaceutical intervention in the form of stronger topical steroids or short courses of oral steroids in extreme cases.
1 Elias PM and Steinhoff M “Outside-to-Inside” (and Now Back to “Outside”) Pathogenic Mechanisms in Atopic Dermatitis. J Invest Dermatol. 2008 May; 128(5): 1067–1070.
2 Pike MG et. al. Increased intestinal permeability in atopic eczema. J Invest Dermatol. 1986 Feb;86(2):101-4.
3 Boguniewicz M. Atopic dermatitis: beyond the itch that rashes. Immunol Allergy Clin North Am. 2005 May;25(2):333-51.