Blog

Walmart adds primary care services, right next to automotive

What can’t you get at Walmart?

Apparently nothing. The retail giant has begun opening retail medical clinics in major metropolitan areas with the expectation that more Americans are going to need access to primary care services.

The retailers see 10,000 baby boomers aging into Medicare coverage each day

Walmart’s First Healthcare Super Center Opens

To their credit they do offer a more transparent pricing scheme for services with an asterisk disclaimer stating that the final price of services is dependent on what services are rendered. Certainly the list of labs prices I’ve seen offers standard labs at 4-5x their wholesale price. These are labs we offer free in our practice, by the way.

Additionally, they limit their services to patients older than 18 months of age. That’s pretty typical of retail clinics. I’m sorry/not-sorry for my sarcasm, but retail clinics want to help but only if it’s easy. They aren’t there to actually develop a long term relationship with a patient who needs care over the various seasons of their life. Retail clinics are the definition of vending machine medicine.

Given what I’ve personally experienced trying to get routine medications filled at Walmart, I’m not excited about the prospect of my mother having to get her Medicare annual wellness exams done there. For the sake of all those patients who need a skilled physician to walk with them through the difficult moments of their lives, I hope my pessimism is proven wrong.

‘All natural, 100% fruit juice with no added sugar’ will still kill you.

As a kid, I grew up drinking orange juice from time to time. I always found it one of the most refreshing drinks when I was really thirsty. As I learned more about carbohydrates and their impact on my body, I came to realize that the fast acting nature of a fruit juice drink could be harmful. Now to be fair from the onset, I teach my patients an appropriately low enough carb, whole food nutritional plan that, if followed from an early age, might include naturally occurring fruit like an orange. I’m not anti-fruit or even anti-carb as it is a complex question to answer. I even spent about 30 minutes one afternoon in the middle of Food City answering my then 9 year old daughter’s simple question “Is orange juice healthy?” That being said, I spent so many years of my life eating Poptarts and Crunch Berries that I must be more deliberate about my choices now as a consequence. What is the perfect human diet? That may be different than the diet a particular patient may need to correct the metabolic damage done. The principles remain the same but the details might be different.

In my case, I’ve written before that during my four years of medical residency I was on call every 3rd or 4th night spending about 36 hours straight in the hospital. Making a meager salary, I depended on the meal stipend of $9 per 36 hour shift to get me through those long stints. One wilted, slightly too warm salad was $8.50 and only available at lunch time. However, a package of frosted brown sugar and cinnamon Poptarts was $0.85 all night long. I ‘needed’ the emotional reward anyway. It was easy to justify.

8 ounces of all natural deliciousness?

This morning I decided to try orange juice again since I’m wearing my Freestyle Libre continuous glucose monitor. In a fasted state, I had 8 ounces of all natural, 100% fruit juice with no added sugar orange juice. Pulp free, of course, because I’m not a sociopath. So, is orange juice healthy?

As bad as pancakes

You can see from my monitor report how well controlled my glucose was overnight while fasted. The slight waver noted just before 6am is due to the catecholamine surge that occurs when the alarm clock goes off and I get out of bed. My peak of 160 mg/dL took 31 minutes to occur on the meter which means it was even faster in my blood stream. I might as well be mainlining a glucose solution. This is like going to the beach at noon in the summer time and putting on tan amplifier oil.

The beauty of the CGM is that it automatically tracks the progress of my body sorting and dealing with the excess sugar. It took about 1.5 hours for my system to normalize. During the time of my sugar high I was meeting with some friends for breakfast and I had a hard time concentrating on the topic at hand. Literally, my brain was so foggy that I struggled to remember facts that should have been immediately present on my mind. It was frustrating to say the least. Even now as I write this over 3 hours later I’m still not as clear as I was yesterday when I was still in nutritional ketosis.

Back to normal? Only by the number

So what’s your story? What foods have you had that impacted your glucose numbers? Are there foods you have enjoyed by tradition, culture, or habit that you now realize shouldn’t be a part of your diet? What’s been the impact? I’d love to hear your stories and the lessons you’ve learned. And, if you don’t yet have a CGM, ask your doctor for one. Don’t take ‘no’ for an answer. If they tell you that you don’t qualify for one politely tell them “Well, I have $35 in my pocket and I’m a responsible human interested in my own health, so, yes, I do qualify.”

Mealtime patterns

Posted below are two reports generated from the Freestyle Libre LibreView website. They show the average relative change in my blood glucose with each meal of the day. The first report was during the high carb, standard American diet experiment in July. The second report is from the nutritional ketosis diet I just blogged about and am still following. I think it is readily apparent the differences. In the high carb diet I would jump 20-30 mg/dL every time I ate and I averaged 30-80 gms of carbs per meal at least. With nutritional ketosis the glucose changed less than 10 mg/dL with each meal and I only averaged 6gms of carbs per meal.

Nutritional Ketosis and Intermittent Fasting

Over the last week I’ve documented my progress into nutritional ketosis through a ketogenic diet. Yesterday, I added intermittent fasting to that process. Here are the results.

As most of you know, I have advocated for low carb high fat nutrition to reverse metabolic disease since I began practicing it myself in 1999. My understanding of this powerful tool has grown both with my personal experience of it and with the growing body of literature helping to explain the nuances we should all understand. Over the last three years intermittent fasting (IF) has come into it’s own in large part due to the influence of Jason Fung, MD author of The Obesity Code and The Diabetes Code, both books I highly recommend to my patients. I have adopted IF as a personal routine over the last year and have found it extraordinarily powerful at improving my health and well-being.

There are many different ways to undertake fasting ranging from time restricted eating (TRE) to prolonged fasts. TRE is simply not eating for about 12 hours in every 24 hour cycle such as not eating after dinner until breakfast the next day roughly 12 hours apart (8pm to 8am). Most studies don’t consider this true fasting as many of the genes and benefits of fasting are not measurable until one reaches 14-16 hours of fasting.

Intermittent fasting therefore is usually anything lasting 16 hours or longer with the remaining hours used as an opportunity to feed. A 16:8 protocol is nothing after dinner at 8pm until noon the next day. A 20:4 protocol is nothing between 8pm and 4pm the next day. I recommend many of my patients undertake a 24 hour fast weekly or every fourth day depending on the goal. Again, I stress, please don’t undertake this without talking to me first as many times patients need their medications reduced or altered to avoid being over treated during the fasted state.

Yesterday I undertook a 24 hour fast which ended up lasting 27 hours due to the timing of my dinner meals on Monday and Tuesday. Monday night I ate a quick meal of roasted chicken, blueberries, and macadamia nuts then went to exercise around 5:30pm. I didn’t eat again until Tuesday night at 8:30pm. Tuesday’s dinner of 1/2 of chicken, an avocado, and cheese was 5 net carbs.

Throughout the day I followed my glucose levels on my Libre and my blood ketone levels on my KetoMojo meter. As you can see from the Libre readings below, my glucose levels were exceedingly stable and slowly declined throughout the day to a nadir of about 69 mg/dL right before dinner. My meal didn’t budge that number at all.

The ketone readings steadily climbed to some very nice levels throughout the day and have stayed higher than last week even after I’ve eaten several times today. Starting out the day at 1.0 mmol/L they climbed to 1.7 mmol/L by lunch time, 2.7 mmol/L by the end of work, and 3.1 mmol/L by the time I broke the fast at dinner.

Beneficial ketone zones after an overnight fast should be around 0.5 mmol/L or higher. They are are optimal around 1.5-2 mmol/L while eating a long term ketogenic diet. After a prolonged fast they can be around 3-5 mmol/L.

When I fast I tend to feel better and better as the day progresses. The initial hours can be challenging but as the ketones develop the desire for food all but fades to zero and hunger is non-existent. I really enjoy that freedom. The clarity of thought and presence of mind that comes in this state is one of the main benefits I desire from fasting. It brings me back to it again and again and I find myself looking forward to the next day of fasting.

If you’re interested in learning how to use nutritional ketosis, intermittent fasting, or a continuous glucose monitor for its health benefits give me a call. We’ll walk through the process together to ensure your success and safety.

Nutritional Ketosis, Days 5 & 6

I didn’t get a chance to update the daily posts yesterday as the start of school, high school sports practice, and school supply shopping made for a long day. Regardless, the data hasn’t changed much. I had about 29 net carbs Sunday and 22 net carbs Monday.

This produced very stable blood sugar results as shown below.

The spike on August 4th around noon was due to some heavy outdoor work I was cutting down another storm blown tree. The following trend down into the red zone (again not dangerous) was a recovery period. To a degree this is repeated on August 5th at 6pm where I worked out hiking the Hardin Valley hill. During exercise my glucose climbed and then right afterwards it dipped again. That’s an interesting phenomenon that I’m going to have to study more. It happens more often with outdoor exercise than indoor exercise. Maybe the body heat, sweat, and evaporation have something to do with it. This is a good reminder that not all causes of glucose elevation are to be avoided or are harmful. As the body works it wants to fuel the cells and will send glucose out to do that.

My last meal of the day was at 5:30pm yesterday which was some roasted chicken, blueberries, and macadamia nuts. Then I started my 24 hour fast. I’ve tried to incorporate a 24 hour fast into my weekly routine starting Monday after dinner until Tuesday dinner. For various reasons this is the day I’m least likely to eat with my family so giving up a meal doesn’t usually impact our time together. As I write this I just finished up today’s only meal so the fast ended up lasting about 27 hours. I have to say I feel focused and calm more than normal and I have the ketones to prove it. I’ll tell you more about that tomorrow.

So after one week of ketogenic nutrition with daily net carb intake averaging 19.6 gms per day this morning’s ketone level was a solid 1.0 mmol/L. I hope that one week journey into nutritional ketosis show just how straightforward it can be and how it can be implemented in a very busy life.

Tomorrow I’ll share with you my ketone levels throughout a day of fasting. Stay tuned.

154 people can’t be wrong

Low carb nutrition prompted a 20 lb weight loss along with a reduction in blood pressure even after they had a 20% reduction in medication in these 154 diabetic and insulin resistant individuals that was sustained over two years on average.

https://www.mdpi.com/1660-4601/16/15/2680/htm

Abstract

: Hypertension is the second biggest known global risk factor for disease after poor diet; perhaps lifestyle interventions are underutilized? In a previous small pilot study, it was found that a low carbohydrate diet was associated with significant improvements in blood pressure, weight, ‘deprescribing’ of medications and lipid profiles. We were interested to investigate if these results would be replicated in a larger study based in ‘real world’ GP practice. 154 patients with type 2 diabetes or impaired glucose tolerance were recruited into an observational cohort study in primary care. The effects of a low carbohydrate diet sustained for an average of two years (interquartile range 10–32 months) on cardiovascular risk factors were examined. Results demonstrate significant and substantial reductions in blood pressure (mean reduction of systolic BP 10.9 mmHg (interquartile range 0–22 mmHg) (p < 0.0001), mean reduction in diastolic BP 6.3 mmHg (interquartile range 0–12.8 mmHg) (p < 0.0001) and mean weight reduction of 9.5 Kg (interquartile range 5–13 Kg) (p < 0.0001) together with marked improvement in lipid profiles. This occurred despite a 20% reduction in anti-hypertensive medications. This novel and potentially highly effective dietary modification, done very cheaply alongside routine care, offers hope that should be tested in a large prospective trial.

Nutritional Ketosis, Day 5

Saturday was day 5 of my journey journaling nutritional ketosis for my patients. It was a pretty busy day where I staffed Trinity’s walk-in clinic and then had lots of home chores to get to before school starts next week for the kids.

Breakfast was three eggs fried in ghee and a half dozen chicken sausages from Jones Farms that I’ve been meaning to try. I found these breakfast sausages at Costco a while ago and they looked like a pretty good option for a fast low carb breakfast. They tasted fair but not outstanding, too herby for me. So, they’ll probably stay on the grocery list for when I need something quick to get out the door but, despite the name, I won’t be jonesing for them. Breakfast yielded a net carb of 1.1gms.

During medical school and residency after a long night of call in the hospital, some of the best attendings would show up at morning rounds with a nice treat like bagels or donuts. In that tradition, I’m very appreciative of the team at Trinity and the exceptional fellow clinicians with whom I work that do most of the heavy lifting during our Saturday clinics. As such, I bring fruit, yogurt, and lower carb granola as a treat for everyone. While working I ate a Fage 2% plain yogurt and a 1/4 cup of blueberries. I’ve shown before that too many blueberries, which I love, can elevate my glucose so I had to resist the temptation to eat all of them. This time around there wasn’t much of a bump in my readings. The net carbs for the yogurt and berries was about 9 gms. Again, that’s if the carbs in plain, unsweetened yogurt need to be fully counted. The process of making yogurt uses up some of the sugars in milk.

I didn’t finish up work until mid afternoon so didn’t get to eat lunch until after 3pm. My ketone levels were solid at 0.9 mmol/L though. Same as post overnight fasting. That’s a really good mid day number for me.

For lunch I finished off the brisket along with an avocado and 2 oz of macadamia nuts. Net carbs were 7 gms. After lunch I went to work out at VitalSigns with my daughter. Interestingly, after an hour of cardio and strength work, my ketones actually went down a little to 0.7 mmol/L.

Dinner was a ribeye. Seriously, just 8 ounces of a deliciously marinaded ribeye. Net carbs were under 1 gm. It was a very satisfying meal.

The day’s total net carbs were right at 20 gms with a robust amount of fat and protein too. My glucose readings for the day were static under 100 mg/dL the whole time. This day produced an overnight fasted ketone level of 0.7 mmol/L.Tomorrow, when I write the entry about today’s journey (how timey-wimey), I’ll share with you what caused my glucose to bump over 100mg/dL and why I’m not worried about it.

Fasting, Irradiation, and Cancer

I wanted to share this week’s email from Peter Attia, MD. It’s a fascinating read about the protective benefits of extreme fasting in mice when they were subjected to a lethal dose of radiation. As he notes in his writing, what happens in mice cannot be directly translated to humans. We’re different species but it helps us develop theories and experiments (that don’t involve lethal radiation) that might prove benefit in humans.

Greetings –

I recently came across an interesting study pertaining to fasting (in mice). The rodents were randomized to ad libitum (i.e., without restriction) feeding or ad libitum feeding followed by 24 hours of fasting prior to the, ahem, “intervention.” Said mice collectively had the privilege of getting blasted with total abdominal radiation at a mega-dose of 11.5 Gy (a unit of ionizing radiation dose) in a single fraction. To get some sense of context here, a CT scan of the abdomen and the pelvis exposes an individual to a relatively high radiation dose, clocking in at approximately 20 milligrays, or mGy (0.020 Gy). This means that for the mice in this study, the absorbed dose of radiation was about the equivalent of 575 abdominal CT scans in one shot.

The average American living at sea level absorbs about 3-5 mGy of radiation annually. So the dose used in the study is almost 3000 times the radiation a person is typically exposed to (and absorbs) over the course of a year.

It therefore might not come as a shock that the non-fasting mice all died within a week from radiation-induced toxicity, akin to humans who have been exposed to staggering doses of radiation (e.g., Hiroshima, Nagasaki, Chernobyl). However, all of the mice that fasted for 24 hours prior to the radiation insult were alive after one month. And while all of the mice, in both groups, showed signs of radiation toxicity, the fasted mice were back to their baseline activity levels 8 days later. The fasting also appeared to protect intestinal stem cells: intestinal epithelial cells in the fasting mice were regenerating by day 10 post-radiation.

The purpose of the study was to find out if fasting could protect the intestines from high-dose radiation, which could allow for higher doses of radiation treatment in killing pancreatic tumor cells. (When patients undergo abdominal radiation the intestines are, due to their rapid turnover of cells that make up the lining, very sensitive to the dose of radiation, and patients are often debilitated by colitis-like symptoms.) Not only did the investigators demonstrate that fasting improved survival and intestinal cell regeneration, they also found that fasting improved the survival of mice with pancreatic tumors also subjected to lethal doses of abdominal radiation. The investigators also noted that the protection conferred by fasting applied only to the normal tissues, whereas the pancreatic tumors were not radioprotected, and actually may have been more vulnerable as a result of the 24-hour fast.

This is not the first time that fasting and/or dietary restriction has been shown to improve the tolerability of toxic cancer therapies (e.g., chemotherapy, radiation therapy). A 2019 review points to several studies in which forms of fasting protects normal cells in mice from the damage induced by chemotherapy and other toxic drugs while differentially making cancer cells more vulnerable.

Of course, what’s true in mice living in laboratory conditions may not be true in men and women living in the real world. I’m doubtful that the study above swung the door wide open for an IRB to approve a clinical trial in humans that includes a lethal dose of radiation. However, fasting is an entirely different story. There already have been a number of feasibility studies in cancer patients showing it is well-tolerated and efficacious.

It’s also worth reiterating (as I try to do every time I make a comment about fasting rodents) that the 24-hour fast in the study above resulted in a 20% loss of body weight. Not a typo. This is about the equivalent of an individual starting a fast this evening weighing 180 lb and dropping 36 lb by the next night. For context, each quarter when I fast for about 7 days, my weight typical goes from about 178 lb to 172 lb or so. (I covered this issue in a little more detail in a previous email.) A 7-day fast is almost universally fatal in mice. In other words, fasting is riskier in mice and generally better tolerated in humans. On the other side of the coin, there is still the question of whether the dose makes the antidote. If a mouse fasts for 24 hours and loses 20% of its body weight, it’s probably not an unreasonable assumption that an equivalent fast for a human is closer to 3 or 4 weeks. (Although, given such dramatic differences, it’s really difficult to say with any confidence if there is a truly equivalent dose of fasting between mice and humans.) Given that the mice in the study received a lethal dose of radiation and survived beyond expectations, could less fasting have sufficed if a more clinically appropriate radiation was given?

That said, given the mounting evidence that fasting appears to be safe and may be beneficial, I would love to see more clinical trials in cancer patients looking at its potential effects, especially given that humans might not need a fraction of the protection the mice needed to survive this study, even under all but the most extreme circumstances.

– Peter

Trump’s New Executive Order: Unleashing HSAs For Direct Primary Care

You might have missed this big news because the media .08/04/2019 8:11:46AM EST.
— Read on townhall.com/columnists/chadsavage/2019/08/03/trumps-new-executive-order-unleashing-hsas-for-direct-primary-care-n2551034

Nutritional Ketosis Day 4

Friday August 2nd was the fourth day of my journey documenting how to achieve nutritional ketosis. So far my dietary intake of net carbs have been 10 gms, 17.6 gms, and 22.5 gms. Yesterday, I had 17.2 gms of net carbs. I’m averaging 16.8 gms of net carbs per day. Not bad, I think.

Breakfast was three eggs, bacon, sausage and cheese with black coffee. Lunch was beef brisket, an avocado, and a tomato with a spoonful of Purely Pecans sea salt pecan butter with unsweet tea. This stuff is very good and is often what I eat with apple slices. At 1.5 net carbs per tablespoon and 12 gms of fat it’s a great low sugar, whole food snack. Breakfast was 5 gms of net carbs and lunch was only 7 gms of net carbs.

I also need to give a shout out to one of my awesome patients who brought me some of the best tomatoes I’ve ever tasted. He came in this week for a routine follow up and we celebrated a reduction of his fasting blood sugar back to normal and a reduction of his fasting insulin by over 50%! Truly unbelievably good work. I’m so proud of you and happy birthday today!

Dinner was a naked hamburger patty topped with cheddar cheese, sauteed mushrooms, diced tomatoes on a bed of baby spinach leaves. Adding another spoonful of pecan butter made the total meal only 5 net carbs.

Again, my glucose readings remained pretty flat all day. This produced a ketone reading of 0.9 mmol/L this morning after fasting overnight. (I forgot to snap a picture of it before leaving the house this morning, whoops).

I’m pleased with this progress. I’ve been able to eat well and feel satisfied while producing a mild nutritional ketosis. My energy level is good and sleep is too. Both are things that I find deepen in their quality when I eat really well.

You may have noticed the dip in my blood glucose around 4-5 am noted in red on the graph above. I don’t have a definitive explanation of that. It could be associated to changes to cortisol and growth hormone levels that usually happen around that time each morning.

I remember that night as being a particularly dream filled night too. While we sleep our metabolic rate isn’t very much lower than when we are awake and REM sleep, where dreams happen, produces brainwave activity similar to doing those same actions while being awake. The brain consumes a large amount of the body’s energy needs at around 16% so it’s possible that my particularly intense dream consumed more glucose than a typical night. It’s also possible that my night time mental activity had nothing to do with my glucose as REM sleep is always dream filled, we just don’t usually remember it as such. Regardless, the dip, I believe, is inconsequential to my overall progress and health. The CGMs don’t measure lows as well as they measure highs and I always take numbers less than 60 gm/dL with a grain of salt.