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!

Measles is spreading. 41,000 cases and counting.

Measles cases skyrocket in Europe, killing dozens

Aug 20, 2018 11:26 AM EDT



A child receives the MMR vaccine against measles, mumps and rubella in Lyon, France.  BSIP/UIG via Getty Images

The World Health Organization says the number of measles cases in Europe jumped sharply during the first six months of 2018. At least 37 people have died.

The U.N. agency’s European office said Monday more than 41,000 measles cases were reported in the region during the first half of the year. That’s more than in any 12-month period so far this decade.

The previous highest annual total was 23,927 cases in 2017. A year earlier, only 5,273 cases were reported.

“We are seeing a dramatic increase in infections and extended outbreaks,” Dr. Zsuzsanna Jakab, WHO regional director for Europe, said in a statement. “We call on all countries to immediately implement broad, context-appropriate measures to stop further spread of this disease. Good health for all starts with immunization.

Measles was virtually eliminated in the U.S. after the vaccine became widely available in the 1960s, but outbreaks have flared in recent years — often sparked by a case picked up overseas. The illness is highly contagious and can spread rapidly among people who didn’t get the MMR vaccine, which protects against measles, mumps and rubella. Babies too young for the vaccine are especially at risk.

Symptoms of measles may include rash, high fever, cough, runny nose, and red, watery eyes. In rare cases, complications can be life-threatening.

The World Health Organization said half the cases in Europe so far this year — about 23,000 — occurred in Ukraine. France, Georgia, Greece, Italy, Russia and Serbia also had more than 1,000 infections each.

The agency called for better surveillance and increased immunization rates to prevent the disease from becoming endemic.

© 2018 CBS Interactive Inc. All Rights Reserved. This material may not be published, broadcast, rewritten, or redistributed. The Associated Press contributed to this report.