When fasting is more than going without food

If you are like most people, then you’ve heard the buzz recently on fasting but don’t quite understand the process.  If fasting is nothing more than not eating food, you could be left wondering why anyone would think this concept is a good idea or why it has developed a large, trendy following.  However, the science of fasting is starting to come to light and the health benefits are being elucidated.  It seems like this ancient ritual has hit a modern day stride.

Fasting has been part of my religious tradition for millennia, but, I admit, I have rarely practiced it.  As an evangelical Christian of the reformed tradition, I have always viewed fasting as one of those extra things you could do but it wasn’t required for salvific faith.  So over the years I would engage in types of fasting such as abstinence from particular foods during the Lenten season but never with a mindset that it might be beneficial for my physical body or that it would be very easy.  In fact, it was supposed to be hard.  I viewed it as solely an act of self-denial that was meant to sharpen my appreciation and understanding of Christ’s self-denial and sacrifice.  For me, giving up food was always a challenge.

This article from Science does a good job a describing the four basic types of fasting methods that are commonly researched.  In my practice, I typically only utilize two of them for myself and my patients.  I encourage time restricted feeding (TRF or sometimes called time restricted eating, TRE) for virtually all of my patients from day one.  As patients progress or if they have more metabolic challenges to overcome like diabetes, I will layer on intermittent fasting (IF) to their therapy plan.  Of note, the last two patients I’ve had who reversed their diabetes utilized both TRE and IF regularly.

The other two types of fasting are not as well utilized in my practice for separate reasons.  Calorie restriction has long been the cornerstone of weight loss therapies however we also have a long history of poor success with these programs.  It turns out that humans have a really hard time not eating enough food indefinitely.  Go figure.  These programs often fail because our lack of willpower to deny ourselves something we need to survive for an indeterminate time.  That is why fasting on an intermittent basis works.  We can deny ourselves for shorter periods of times, even a few days in a row, without the same psychological stress of long term food denial.  So, while calorie restriction has its scientific success stories, from a practical standpoint, I don’t find it useful in my practice.

The fasting-mimicking diet is a fascinating plan which I have yet to incorporate in large scale to my practice.  The 5 day time frame of very little food intake is a big step for many patients.  The results are impressive in animal models and the regenerative powers of such a program are hard to ignore.  I hope as our experience in fasting grows that I’ll be able to incorporate this into the appropriate patient’s therapeutic strategy.

Now, let’s go back to the two types of fasting protocols I regularly prescribe.  Time restricted eating is a very simple program where patients develop a diurnal pattern of eating for a set number of hours followed by abstinence of all food and drink save water for the remainder of there 24 hour cycle.  In several observational studies on eating schedules it has been found that many people eat some type of food every few hours from the time they get up to right before they go to bed.  That accounts for up to 16 hrs out of every 24 that we’re ingesting something.  The 7-8 hour window of bedtime and sleep is the only time they don’t consume food.

F3.largeWith TRE that 7-8 hour window of fasting is stretched so that the minimum fasting time to be considered TRE is about 12 hours.  Biologically, many unique activities begin to occur after 12 hours of fasting that don’t occur while we are in the fed state.  As the duration of fasting grows, the cellular changes continue to expand such that after 13-14 hours of fasting several thousand fasting-only cellular activities are occurring.  If we never reach this threshold, then we can never see the effects.

For most all of my patients, I recommend TRE of about 12 hours as a basic step.  It’s not too hard either.  Most patients have to decide not to eat again after dinner by avoiding their bedtime snack.  Breakfast may need to be pushed back to sometime other than upon awakening in the morning.  Otherwise, many patients don’t require much adaptation.  This type of fasting doesn’t require much in the way of nutrient change either.  Therefore, as patients learn to change their nutrition some simple changes in timing can be incorporated too.

As patients progress in our dietary education program and adopt our whole food, low carbohydrate, high fat approach I encourage them to incorporate intermittent fasting (IF) into their weekly schedule.  By the way, the graphic above lists the low carb, high fat (LCHF) approach as ‘obesogenic’.  This is blatantly wrong on several levels but I won’t address it in this post.  Not coincidentally, as this nutrition program takes root in a person’s daily life, their body begins to normalize hormonal production of insulin, grehlin, and leptin.  These regulatory hormones help us shed or store weight and strongly influence the hunger sensation.  Normalization allows for weight loss which prompts reduced hunger.   Consider this, if stored weight in a fat cell is being released into the blood stream and your body is now tuned to utilize that for fuel, wouldn’t the need for finding food to ingest lessen?  It does, dramatically.

As patients adopt and adapt to the whole food, LCHF plan, they naturally adopt varying degrees of TRE and IF.  They often forget to eat.  They get busy working on something and without the hunger drive to kick in they opt to work through the day instead of stopping for lunch.  It’s not that their mechanisms are broken, it’s just that their fuel tanks are so much bigger now.  They don’t run out nearly as easily.

As this progresses, I encourage my patients to find one 24 hour stretch of time that they can fast.  Often the best time to do this is the roughly 24 hours that begins after a dinner meal and ends prior to the next meal.  By skipping after dinner eating and snacks, we can wake up with 10-12 hours of fasting already out of the way.  We’re well into the cellular machinery that makes fasting easier.  Continuing this until the dinner meal will be less challenging than you think.F4.large

I’ve talked a lot about the types of fasting I use in my practice and touched slightly on how to initiate them.  However, there are many factors involved which I obviously can’t cover in a blog post.  Please don’t take this as specific medical advice for you in your situation as many other factors need to be considered.  If you’re on medications that are influenced by fasting, you’ll need advice on how to adjust them.  If one fails to appropriately adjust their insulin, for instance, it could be disastrous or even deadly for someone attempting to fast.

If you’re interested in adding fasting to your dietary regimen, then give me a call.  As a DPC patient you already have my phone number and email so feel free to contact me anytime.  The DPC dietician, Carly Slagle, and I will guide you through a program that makes sense and allows you to hit your health goals.  If you aren’t a member of our DPC program, then consider signing up.  It’s hard to imagine just how healthy you can be until you start to see the progress that so quickly occurs with good nutrition.

Fever Phobia – Science-Based Medicine

Should you be afraid of your child having a fever? It depends, but probably not.
— Read on sciencebasedmedicine.org/fever-phobia/

Millennials moving away from primary care doctors | Fox News

Alternatives to the traditional fee for service primary care are on the rise. Direct Primary Care programs are part of the shift away from spending your day in a waiting room for a 10 minute visit. Fellow DPC physician, Jeffrey Gold, MD, is featured in this article as an example of simple, affordable care that focuses on the patient and not their insurance requirements.

Many young Americans are opting to get their healthcare from urgent care centers and retail health clinics.
— Read on www.foxnews.com/health/millennials-moving-away-from-primary-care-doctors.amp

“The Free Market Won’t Work for Specialists…” Except It Is.

Here’s a pediatric endocrinologist in Texas who has opened up a clinic that operates outside of insurance like Trinity Direct Primary Care.

Check out their program and encourage your local specialists to consider doing the same.


Pre-existing is non-existent with Trinity Direct Primary Care

Trinity Direct Primary Care takes care of you. Pre-existing conditions are not a hinderance to care for us. Providing healthcare is our mission so we don’t charge more for patients with diabetes or hypertension. We don’t charge more if you smoke or have a family history of major illnesses. We just take care of you. Simple as that. Come see the difference. Call 244-1800 to sign up today.

Article: Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring from JACC: Journal of the American College of Cardiology

Here’s a very interesting study that showed a clear stratification of the benefit of statins in over 13,000 patients who had not previously had any cardiovascular disease.  The average age of patients followed was 50 years and they were followed for a mean duration of 9.4 years.  Patients with a calcium score of 0 showed no benefit.  For reference, the calcium score indicates the amount of atherosclerosis in the coronary arteries where lower numbers indicate less calcification and therefore less damage.  Zero is the perfect score and most desirable result.  As the CAC scoring increased, representing more calcification and pre-existing damage, the benefit of statin use in primary prevention increased.  Remarkably, this was irrespective of lipid levels.  In the highest risk quartile the number needed to treat (NNT) to show benefit was only 12.  That is, of 12 patients taking a statin one of them will see benefit in preventing a major cardiovascular event like a heart attack or stroke over the roughly 10 years of measurement.  That’s pretty good.  For the low risk, non-zero group scoring 0-100 the NNT was 100.  One hundred patients would need to take a statin for roughly 10 years to see one patient avoid a major event.  That’s not very good.

If you’re not sure of your cardiovascular risk or want to know your calcium score, set up an appointment with your Trinity DPC physician and we’ll sort it out with you and help you decide the best course of action for your own good health.  Call us at 244-1800 or 980-8551 to schedule your visit.

statins and CAC

Impact of Statins on Cardiovascular Outcomes Following Coronary Artery Calcium Scoring | JACC: Journal of the American College of Cardiology
— Read on www.onlinejacc.org/content/early/2018/10/31/j.jacc.2018.09.051

Trinity Direct Primary Care featured in Farragut Press

Trinity DPC Dr. McColl, Kristen, and LainyA few weeks ago I was interviewed by Michelle Hollenhead of the Farragut Press about our practice, Trinity Direct Primary Care.  It was a fun time and a privilege to have our story told.  Her article was published in this week’s edition that was delivered yesterday.

Trinity Medical operates from membership fees, not insurance

Take a minute to check out the story and pass it along to someone you know.  As the Direct Primary Care movement is exploding across the country many metropolitan communities are seeing the benefits of lower cost, better access primary care for individuals, families, and corporations.  Trinity is leading the free market healthcare revolution right here in East Tennessee.  Anyone interested in learning more can contact our office at 244-1800, check out our website at trinitydpc.com, or email me directly at mbmccoll@trinitymedical.net

-Dr. McColl

The consultation

Have you ever seen the Norman Rockwell era oil paintings of physicians at work?  One in particular has always intrigued me. It shows an older male physician at a desk with his patient across from him in conversation.  It’s an image of the true consultation. One where the patient and physician spend a significant amount of time talking about and thinking through the patient’s complaint. I was always baffled by that painting because it was so far from modern medical practice as to be laughable. That is, until I started my DPC practice.

The Country Doctor - Felix Schlesinger

When I completed residency and finished eight grueling years of medical training, I assumed private practice would offer me more control over my daily schedule and workload.  I was completely wrong.  I entered private practice and immediately realized it is akin to drinking from a fire hydrant. The pace is dizzying and unsustainable. Every second of every working day is spent pushing faster because more and more is expected of you.  There is little time for truly thoughtful discussion with your patient and even less time to research a nuanced answer.  I found that whenever I let one of my patient’s down it was by failing to deliver on researching some topic outside of the exam room.  I found that there just was never any extra time for research.  Trinity as a practice fought against this fast paced trend by attempting to schedule more time with each patient and buffering work days with unscheduled, uninterruptible non-clinical days.  By community comparison, we are slow and spend too many days not seeing patients.  But these were the only safeguards I had at trying to maintain a high level of medical care for my patients who needed complex answers to their complex problems.

During the heat of each day, clinical questions would come rapid fire and pausing to think through a harder situation only allows everyone to assume you’re ‘not doing anything’ and are therefore free to help them with their question. Since 99.9% of my job involves nothing other than firing off a few trillion neurons, if you ever see me standing around looking off into the distance then I’m likely working my hardest.

After nearly 10 years in practice I figured the days of a Normal Rockwell era physician thoughtfully discussing the case with his patient were gone.  Thankfully, I’ve seen that turn around since being a DPC physician.

This week for instance, one morning while reviewing my new lab reports I found an unusual and dangerous result on one of my patients. The implications were significant but the therapeutic next steps were not clear. So, without another patient pressing on the schedule, I fired up my modern online medical resources and then sought counsel from some trusted physician sources who have expert knowledge in the area. In the following hour I digested all I found on this disorder, developed a protocol for helping future patients discover their risk, and formulated a treatment plan based on the best medical evidence.  I grew as a physician.  I have more understanding into this poorly known disorder than I did last week.

After my time of study I called my patient and spent another 15-20 minutes talking about the result and explaining what we need to do next.  We discussed the implications it has on their family. As I care for many of their family members I was able to step back and look comprehensively as to how it affects everyone’s health. With permission from my patient, I contacted another family member who the result would also directly impact.  We had another thoughtful discussion and developed a plan of action.

It’s in these moments that I realize the art of continually learning and honing my craft as a physician was being pushed to the wayside by the modern business approach.  I understand now what it means to work with your patient and not simply be present in the exam room with them.  Most all of us went into medical training with the hopes that we would spend our hours with our patients and not on their paperwork.  Don’t get me wrong, there are many exceptional physicians working in the standard medical business model, but most assuredly, they are a dying breed.    I, however, have found a place of deep professional satisfaction in being able to care for the whole of my patient, to grow along with their needs, to develop intricate, nuanced therapeutic plans, to provide comprehensive, family wide care, and to walk with them over the years as we face these challenges together.  Direct Primary Care allows me to be the physician I always knew I was meant to be.

Podcast: Medicine in Canada: Promises and Realities

Does the safety and stability of a single-payer system free doctors from business concerns so they can concentrate on patient care?  Our guest is Dr. Shawn Whatley who runs a primary care practice in Ontario, Canada.  He is past-president of the Ontario Medical Association and the author of “No More Lethal Waits.”
— Read on accadandkoka.com/episode40/

A reasonable defense of direct primary care | Medical Economics

A rational approach to the criticisms of direct primary care.
— Read on www.medicaleconomics.com/business/reasonable-defense-direct-primary-care