Assessment of Respiratory Distress by the Roth Score – Chorin – 2016 – Clinical Cardiology – Wiley Online Library

Maximal counting number <10 or counting time <7 seconds identified patients with a room‐air pulse oximetry <95% with sensitivity of 91% and 83%, respectively. Maximal counting number <7 or counting time <5 seconds identified patients with a room‐air pulse oximetry <90% with sensitivity of 87% and 82%, respectively.
— Read on

Old school medicine at work. Cool study.

‘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.”

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

Maybe saturated fat doesn’t cause heart disease

Several recently published meta-analyses of observational studies and randomised controlled trials (RCTs) have found that total saturated fat is not associated with non-communicable diseases including coronary heart disease, cardiovascular disease, and all cause mortality

A recent report published in the British Medical Journal calls into question the validity of associating saturated fat intake with cardiovascular disease. Maybe the tide is changing.


Cough, cough, fever. Welcome to RSV.

This time of year we start to see lots of kids and some adults with pretty nasty respiratory infections.  One of the worst is caused by Respiratory Syncytical Virus (RSV).

Infants are usually the most at risk for complications of RSV

Here are several quality resources for understanding RSV and managing symptoms.

CDC RSV information page RSV information pagec

Is RSV contagious?

Yes. RSV spreads just like a common-cold virus―from one person to another. It enters the body through the nose or eyes or, usually from:

  • Direct person-to-person contact withsaliva, mucus, or nasal discharge.
  • Unclean hands (RSV can survive 30 minutes or more on unwashed hands).
  • Unclean objects or surfaces (RSV can survive up to 6 hours on surfaces, toys, keyboards, door knobs, etc).

Symptoms can appear 2 to 8 days after contact with RSV. According to the Centers for Disease Control and Prevention (CDC), people infected with RSV are usually contagious for 3 to 8 days. However, some infants and people with weakened immune systems can be contagious for as long as four weeks―even if they are not showing symptoms.

Keep in mind, children and adults can get RSV multiple times–even during a single season. Often, however, repeat infections are less severe than the first one.

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

Low Testosterone? Separating medical advice from marketing with Dr. Andrew Smith

“Hey Doc, do you think I have low T?”  It’s a question that comes up quite a lot these days.  Whereas 10 or 15 years ago, testosterone (T) was an occasional level to be checked, it is now a frequent part of a blood workup.  This may be partly due to marketing.  But, at the same time, low T is rather common, affecting perhaps 20% of men or more.  That estimate keeps changing, partly because what is considered a normal T level keeps being changed as well.

Clinical low T is diagnosed when a low blood of testosterone is coupled with some of the signs or symptoms of low T.  So, what are these signs and symptoms?  They can include anemia, muscle wasting, reduced bone density, increased belly fat, sexual dysfunction, reduced sense of vitality, depressed mood, decreased motivation, increased irritability, difficulty concentrating, and/or hot flushes. Of course the problem is that these symptoms can have many other causes as well.  Still, they are troublesome enough that a T level is worth checking if someone has some of them.

It is probably not a good idea to simply screen all men for low T and treat everyone whose number is low.  Why?  If someone isn’t having any of the symptoms of low T, it isn’t generally recommended that they be treated with T replacement.  T replacement can occasionally have side effects.   For example, if you have the beginnings of prostate cancer, T may stimulate it to grow more rapidly, though it doesn’t seem to increase the incidence of prostate cancer.  T can also worsen benign enlargement of the prostate leading to increased difficulty with urination.  Fluid retention and an increase in red blood cell count can also occur and thereby increase blood pressure, heart failure, heart attack and stroke in those who are prone.  The numbers here don’t seem to be large, and there are some definite benefits to T replacement, but the point is that only those who will truly benefit should be treated with T replacement.

Perhaps surprisingly, sperm production can also be reduced by T replacement, thus impairing fertility.  Sometimes the sperm count doesn’t readily return to normal after T replacement is stopped.  So, for young men who may wish to have more children in the future, rather than directly giving T, there are other prescriptions such as clomiphene that can stimulate the body’s own T production without impairing the sperm count.

All those precautions being noted, if you have some of the symptoms of low T which we have listed, it makes sense to check a T level.  If indeed your levels are low, and you have symptoms that correlate, it is certainly reasonable to consider a trial of testosterone replacement.

What are your choices for replacement?  Testosterone is not absorbed well when swallowed.  So, T can be given by injections, patches, gels and dissolvable oral pellets given by prescription.  Levels can then be rechecked to ensure that adequate replacement has been given.  The other key is to see whether the symptoms of low testosterone have actually improved substantially with replacement.  T replacement is only continued if it actually helps your symptoms and doesn’t give troublesome side effects.  Usually a 2-3 month trial is long enough for a man to know how much difference T replacement makes in how he feels.  We have many men in our practice who find that T replacement has greatly improved their sense of well-being and who have no interest in going back to being without it.

This whole issue of when low testosterone is really pathologic, when it should be replaced, and for how long, is still an evolving story but more and more practical answers are being hammered out. So, if you’ve got the symptoms, get it checked, and then think it through with your doctor and decide whether to treat your low T and how.

 Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835.  He participates with some commercial insurance plans but also contracts with patients through Trinity DPC for those without insurance, belong to a cost sharing program, or are on Medicare.


There’s Another Type of ‘Bad’ Cholesterol, and Doctors Don’t Usually Test for It [unless you’re a patient at Trinity DPC where we test for it all the time and then it’s only $28]

Here’s what you need to know about the other “bad” cholesterol.
— Read on

We test for Lp(a) and a host of other biomarkers concerning cholesterol disorders, inflammation and atherosclerosis in the arteries. Generally these tests are about 60-90% off retail pricing. Come check it out sometime.

The molecular changes caused by sleep loss, and how that leads to weight gain

A number of observational studies have suggested that sleep loss or disrupted circadian rhythms are associated with obesity, diabetes and other dysfunctional metabolic conditions. A study is now offering evidence that helps explain how tissue-level molecular changes are brought on by sleep loss.
— Read on

There are so many ways that sleep is good for you. That’s why I believe it is one of the three pillars of good health. Come see what we can do to help you get better sleep. It’s not all about sleeping pills either!