For most people, a diet rich in fruits and vegetables, whole grains, and plant-based protein is healthy and nutritious. However, if you are one of the millions of people who live with chronic kidney disease (CKD), a plant-based diet may be hazardous to your health.

High potassium and chronic kidney disease

Plant-based diets are high in nutrients such as potassium. Potassium-rich foods are generally considered healthy due to their alkalinity as well as a high micronutrient, fiber, and phytochemical content that benefits the body.

However, if you are living with chronic kidney disease (CKD), watching your intake of nutrients, such as potassium, can be important. This is because high levels of potassium in the body, a condition known as hyperkalemia, can potentially be fatal for people with CKD.

Hyperkalemia can result in abnormal heart rhythms and even sudden death. With more than three million people in the United States living with hyperkalemia, this is a serious concern. Further, those with conditions such as CKD or heart failure are at the highest risk for hyperkalemia.

The benefits of plant-based diets

Growing evidence supports the health benefits of plant-based diets, such as the Dietary Approaches to Stop Hypertension (DASH) diet. These diets are high in fiber, low in saturated fat, and contain sources of potassium, magnesium, and calcium. They also have low levels of sodium for preventing heart disease and hypertension.

In contrast to meat-based diets, which are high in full-fat dairy foods and higher in sulfur-containing amino acids, plant-based diets are lower in these amino acids. These lower amounts of amino acids in plant-based diets have been associated with reductions in cardiovascular disease and CKD.

The risk of plant-based diets in chronic kidney disease

Kidneys serve to filter extra water and wastes out of the body. If the kidneys are damaged, they cannot filter wastes the way they should. This may cause potassium to build-up in the body and eventually lead to hyperkalemia.

Since plant-based diets are rich in potassium, they can be risky for people with CKD and therefore they are usually advised to avoid them. As a result, they may be deprived of the health benefits associated with consumption of plant-based diets. Further, their alternative diet may lack essential vitamins and minerals normally found in potassium-rich food sources.

Newer research, however, suggests that individuals with CKD can benefit from plant-based diets. And, there are now treatment options for people who are at risk of high potassium, such as potassium binders, which may allow for the consumption of plant-based diets while maintaining the balance of potassium in the body. These binders stick to potassium to increase its excretion from the body, helping to keep potassium levels low.

Why tailor plant-based diets to meet the needs of CKD Patients

In the general population, increased consumption of fruits and vegetables has been shown to reduce the risk for the following conditions:

• Cardiovascular disease
• Alzheimer’s Disease
• Cancer
• Diabetes
• Cataracts

Tailoring a plant-based diet to meet the needs of CKD patients would allow them to benefit from the improved nutritional profile of their diet. A reduction in cardiovascular disease, in particular, is important for CKD patients as it is the leading cause of death.8

Insulin and potassium

What has been underappreciated is that meat is also a source of potassium. Plant-based foods are typically higher in carbohydrates. Ingestion of carbohydrates, amongst other things, stimulates insulin release. Further, it is well known that potassium homeostasis is facilitated by insulin. Therefore, it is possible that foods that contain carbohydrates and stimulate insulin release, might not cause the same overall rise in potassium as foods that are low in carbohydrates, such as meats.

Given the disconnect between the restrictions of the CKD diet and what is recommended for a heart-healthy diet, it may be reasonable to try to tailor a plant-based to the specific needs of CKD patients.

This could be phased in by working with physicians and dietitians to begin to encourage the consumption of more fruits and vegetables. This would, of course, require frequent monitoring of potassium and other tests, such as sodium and phosphate and kidney function tests.

The bottom line

If you have CKD and are concerned about high potassium as a result of a plant-based diet, talk to your physician and dietitian about your options.

You may be able to increase your consumption of fruits and vegetables with frequent evaluations but without any change in your medications. On the other hand, your doctor may recommend water pills or potassium binders to help rid the body of any excess potassium that occurs as a result of your change in diet.

Adding more fruits and vegetables to your diet may provide you with the known benefits of a more plant-based diet. And, for sure, the added variety of a liberalized diet can make meals more enjoyable.

The post Plant-based Diets Can Be Risky If You Have Kidney Disease appeared first on The Doctor Weighs In.

Although their intervention reduces carbohydrate and sugar intake dramatically and it does lower blood glucose. The problem is that it does not address the core issue in Type 2 diabetes.

The definition of Type 2 diabetes

Type 2 diabetes is defined by a blood glucose of 126 or higher or a hemoglobin A1c of 6.5 or higher. If you introduce sugar and carbohydrate restriction and cause weight loss, the glucose and hemoglobin A1c levels will fall below those numbers and so, by that definition, diabetes is “cured.” The patient no longer meets the criteria for a diabetes diagnosis.

But this premise ignores fundamental and important realities. High glucose levels cause changes in gene expression that persist after the glucose returns to normal causing atherosclerosis and other complications. This well-known phenomenon is called metabolic memory.

Metabolic memory

Metabolic memory is a critical concept that points to the broader reality of people living with Type 2 diabetes. The high glucose levels found in people with the condition are only one part of the complex molecular biology that causes diabetic complications.

The cardiovascular complications of diabetes begin in the fetus and even in the lifestyle choices of prior generations. Overfeeding or underfeeding in the parental generation can produce infants that are too small or too large based on inappropriate activation or inactivation of genes (epigenetics). That inappropriate switching on or off is persistent and many genes are involved causing hypertension, diabetes, and cardiovascular complications in adults.

Patients may themselves switch these genes on or off later in life by gaining weight or smoking. These genes cause diabetes by killing insulin-producing cells in the pancreas and increasing insulin resistance leading to high glucose which further increases oxidative particles and switches on additional genes that cause diabetic complications.

These genes remain switched on even when the glucose is lowered. Therefore, it is very important to continue to take medications that interfere very specifically with the signaling that these genes generate.

Metformin

Promoting the message that cardiometabolic medication should be stopped when the glucose falls below the diabetic level is not in keeping with the latest science and contrary to diabetic guidelines.

The American Diabetes Association (ADA) guidelines recommend metformin use even in prediabetic patients who have a BMI of 35 or greater, have a history of gestational diabetes, or an increasing fasting glucose or hemoglobin A1c. That is because metformin reduces progression to diabetes by about 31%.

Roughly half of prediabetic patients will progress to diabetes despite weight loss. Even patients in the later stages of prediabetes may have lost 70-80% of their insulin-producing function.

These prediabetic patients should not stop metformin when they have lost weight and their glucose improves. There is a tendency for diabetes to reappear with age. Certainly, metformin should not be stopped in patients who already have diabetes regardless of their glucose level.

How metformin works

Metformin reduces diabetic complications by interfering with signaling that has nothing to do with blood glucose levels. It inhibits the same master metabolic switch as the active ingredient in the drug-eluting coronary artery stent.

The increased risk of major cardiovascular events does not disappear with diet and weight loss, however, metformin directly reduces that risk. Type 2 diabetics lose about 10 years of life. If they are on metformin, they live a bit longer than normal people. Metformin is safe and costs only about $4 a month. It is dangerous to recommend “stopping diabetic medications once the glucose is controlled by lifestyle interventions.”

Controlling glucose

Controlling glucose levels has beneficial effects on microvascular events like retinopathy, neuropathy, and kidney damage but it does not reduce the problems that cause most serious cardiovascular complications, death, disability, and costs. Most diabetics die of cardiovascular disease.

Lowering the glucose with lifestyle or any medication approved for the purpose does NOT reduce cardiovascular events. In fact, aggressive glucose lowering with medication and lifestyle caused more people to die.

This is especially important because cardiovascular event incidence and other complications can be dramatically mitigated with a comprehensive solution that brings to bear lifestyle management and medications that interfere with the molecular biology that causes cardiometabolic complications.

Lowering the glucose by any means below the diabetic level, stopping the medication, and expecting complications to fall makes sense, but that idea is not supported by the evidence.

Drugs that block epigenetic signaling

Take a look at the diagram below. Type 2 diabetes occurs mostly in patients with extra abdominal fat caused by poor diet. Increased nutrition and fat switches genes on/off that increase angiotensin II, aldosterone, HMG CoA Reductase, and mTOR activity.

Angiotensin receptor blockers (ARBs), spironolactone, statins, and metformin interfere directly with the molecular signaling cascades that these genes activate. Blocking angiotensin II with an ARB, aldosterone with spironolactone, HMG CoA reductase with a statin, and mTOR with metformin dramatically reduces cardiovascular events in multiple settings. The genes involved are switched on before diabetes develops.

In fact, these elements contribute to diabetes development. Increased mTOR activity directly increases insulin resistance. Blocking mTOR with metformin reduces progression to diabetes.

Elevated aldosterone levels make a strong contribution to metabolic syndrome development. Blocking angiotensin II reduces progression to diabetes.

Blocking HMG Co A reductase with a statin actually increases the incidence of diabetes but has a powerful impact on cardiovascular events and other outcomes. Even that can likely be explained by a hard look at the molecular biology. Blocking HMG CoA reductase with a statin does lower LDL cholesterol but it also reduces Coenzyme Q10 production. Coenzyme Q10 is a powerful antioxidant and it is important for mitochondrial function. Impaired mitochondrial function may be important in the modestly increased risk of diabetes in patients who take statins.

Type 2 Diabetes Treatment

The best treatment for type 2 diabetes is not a matter of either lifestyle or medication. Effective treatment requires best practice implementation of lifestyle measures along with medications that interfere with the molecular biology causing disease. For most patients, medical treatment will include metformin, statins, and angiotensin receptor blockers.

It is important to move beyond a medical system focused on risk factors and organ systems.

There is a very complex interplay in the molecular biology that causes hypertension, diabetes, high cholesterol, and related complications. Reversing diabetes with weight loss and dietary interventions makes perfect sense but improving cardiovascular outcomes and reducing costs to the fullest extent requires a more comprehensive solution. We can treat chronic disease with precision medicine and molecular biology now.

The post Is There Really a Way to Reverse Diabetes? appeared first on The Doctor Weighs In.

Here are five possible reasons why patients ignore their doctors’ advice on weight loss and fitness.

1. Fear of failure and hopelessness

Most patients with eating and weight concerns are not new to the concept of diets and exercise. In fact, providers may not know that their patients have gained and lost 50, 75, or more than 100 pounds several times in their lives.¹ These patients have been there and done that, and it hasn’t turned out as well as everyone had hoped.

For most of them, the deprivation they felt while dieting was stupefying, and the restraint they had to muster daily was insufferable until they finally ran out of self-control and self-discipline and gave into eating normal portions, sweets and treats, and foods that they enjoyed.^2,3 While providers are trying to psych them on starting a new health regimen, they’re recalling the last time they let their gym membership lapse and the closet full of smaller-sized clothes they fear they’ll never squeeze into again.

2. Depression

Many patients with eating and weight concerns have neurotransmitter imbalances causing depression and anxiety.⁴ Maybe they started out with the happy genes, but more likely not. Even if they did, the weight stigma and fat prejudice that runs rampant in society, not only through the media but from surgeons to secretaries in medical offices, would have demoralized them and shattered their self-esteem.

Patients who misuse food when they have the blues or the blahs may not even know that they’re depressed. Those who have social anxiety may not realize that eating is their way of coping when out to dinner with friends or attending a work party. They don’t want to hurt their bodies. They only want to feel the way that others appear to feel—relaxed and normal—when they’re around people.

Related content: How to Help Your Partner Make Healthy Lifestyle Changes

3. Lack of life skills to attain and maintain health goals

Most of us weren’t raised with a full complement of the life skills needed to maintain a healthy lifestyle. For example:

• effective self-care,
• healthy relationships,
• work and play balance,
• emotional management,
• goal achievement,
• problem-solving, and
• self-regulation.

Moreover, we don’t all start out on an equal playing field. Sadly, dysfunctional families too often produce children who are lacking in life skills and end up with a diminished quality of life in adulthood.

Expecting these patients to make healthy choices when they’ve never been taught how to delay gratification or tolerate frustration is a waste of time.

Hoping that they’ll call a friend when they’re upset rather than down a pint of Häagen-Dazs is misplaced optimism if they were raised in an insular family that mistrusted outsiders. Encouraging them to take a walk to unwind is wishful thinking if they feel they must be productive 24/7. We need effective life skills if we’re going to effectively take care of mind and body.

4. Mixed feelings about the weight loss advice

It may seem like a no-brainer to medical professionals that everyone would want to lose weight and be attractive. This is not always the case. Sexual abuse survivors often feel less vulnerable and safer with more meat on their bones. People who are more sexually active when they’re thinner sometimes fear that weight loss will compromise their marital fidelity.

Patients who’ve suffered emotional and physical abuse may insist that they want to date. However, they are afraid of relationships because of what has happened when they’ve let their guard down in the past. In other cases, holding onto excess weight may be a badge of suffering, a way to signify that life hasn’t been good to them. These are serious psychological dilemmas that won’t go away without clinical attention.

5. Rebellion – but not just against weight loss advice

One of the most common reasons for not following medical advice is unconscious rebellion. This is a characteristic of people who are confused about care versus control.⁵ If they had parents who were domineering, critical, and demanding (and parental dependence was encouraged), they, while wanting to follow providers’ advice, would resent being told what to do. They dislike being pressured, even to do what’s good for them. Further, they will avoid doing it out of misplaced spite.

Rebellion is a complex dynamic which most patients and providers are unaware of. Even though professionals try to care for them, these patients only feel and fear that they’re being controlled. No wonder what doctors say seems to go in one ear and out the other. It’s easy to see why this dynamic may seem like self-sabotage, but it’s much more unconscious and complicated.

The bottom line on why patients ignore doctors’ weight loss advice

Doctors and healthcare providers need not feel that without a graduate degree in psychology they can’t possibly do right by their patients who have eating and weight concerns. They do need to recognize that patients are not intentionally trying to remain unhealthy and hurt their bodies. And they must offer empathy and compassion for their minimal and inconsistent efforts.

If doctors are able to do these things, they will find themselves on the right track. In addition, providers would also benefit from encouraging patients to get support from eating disorders therapists so that no one has to wrestle with eating and weight concerns by themselves.

The post 5 Reasons Why Patients Ignore Doctors’ Weight Loss Advice appeared first on The Doctor Weighs In.

The latest story was published in the Journal of Pediatrics, from Columbia University. What the researchers found is that childhood weight gain has a negative impact on the liver health in children as young as eight years of age. Larger waist circumference at age 3 raises the likelihood that by age 8, these young children will have early indicators of non-alcohol fatty liver disease (NAFLD).

This excess fat in the liver triggers inflammation in the liver, which in select patients, puts them at increased risk for advanced liver disease and cirrhosis (scarring of the liver). For those of us that are intimate with this topic and clinical scenario, this is an eye-opening report for parents, who need to seriously look at their children’s nutrition, what they are being fed, and the exposure to processed foods that are the norm in today’s culture.

Eating yourself sick

With over 25 years of experience in liver disease, I have written a book addressing these very concerns. Eating Yourself Sick: How To Stop Obesity, Fatty Liver, And Diabetes From Killing You And Your Family is the culmination of my years in practice, sharing my experience and suggestions on how to control this looming public health disaster.

According to the World Health Organization, obesity has more than doubled worldwide since 1980. In 2014, more than 1.9 billion adults were overweight, including 600 million considered to be obese. Those overweight comprised 39 percent of the adult population, one-third of all people age eighteen and over.

Some forty-two million children age four and under were also overweight or obese.3 Since 1980, the rates of obesity have tripled in youth, ages two to nineteen, while the numbers of obese six- to eleven-year-olds has doubled, and obese teenagers quadrupled from 5 to 20 percent. There are significant racial and ethnic inequalities in those numbers. Latinos and blacks, for example, become obese earlier, faster, and more frequently than whites and Asian.

Once thought of as a problem only affecting high-income countries, today obesity is on the rise in low- and middle-income areas of the world. In fact, the World Health Organization (WHO) reports that, worldwide, overweight and obesity now accounts for more deaths than underweight.

In addition to the current Journal of Pediatrics article, a recent New England Journal of Medicine article found childhood obesity to be a strong indicator of obesity at age thirty-five. Obese two-year-olds have a better than 50 percent chance of being obese at thirty-five, showing the powerful predictive value of obesity at a young age.

The discussion about obesity, as a result, needs to start even sooner, and is not just a problem of those adults over fifty years old. Research data further supports the revelation that because of obesity and fatty liver being seen in children, this generation of children will not live as long as their parents, a result of life-shortening complications of type-2 diabetes, liver disease, heart disease, and kidney disease.

Now, it’s true that the liver is capable of regenerating itself. In the very early stages of scarring, there is the potential to reverse some of the damage. But when it is subjected to a destructive, ongoing, vicious cycle of damage-regeneration-damage-regeneration, it begins to develop irreversible scar tissue. Ultimately, that leads to the develop­ment of cirrhosis.

Once cirrhosis has reached more advanced stages, there’s very little that can be done short of a transplant. Without a transplant, death is forthcoming.

Who is at risk for NAFLD?

NAFLD is more common in obese people, and as many as 7% of normal-weight people also have NAFLD. High-calorie diets that include consumption of excess saturated fats, refined carbohydrates, and high-fructose and sugar-sweetened foods and beverages have been associated with NAFLD.

Even without a current diagnosis of fatty liver, you may still fit into a high-risk category for fatty liver. Again, fatty liver is the liver mani­festation of metabolic syndrome. The other characters of metabolic syndrome — obesity, diabetes or insulin resistance, high cholesterol — increase the risk for fatty liver.

In studies of obese patients undergoing bariatric surgery, 90 percent have NAFLD, and around 5 to 8 percent of them already have cirrhosis. Type-2 diabetes also increases the prob­ability of having fatty liver. Studies have shown that 70 percent of people with type-2 diabetes who have gone in for an ultrasound were found to have fatty liver. And half of the people with high triglycerides and low HDL (bad cholesterol) are found to have fatty liver.

Since metabolic syndrome is an early warning of liver disease, the symptoms may not come from the liver itself but from one of the other characters: obesity, diabetes, or heart disease. If you have any of those comorbidities, those other metabolic syndrome characters, then you are at a higher risk for the development of more scar tissue and cirrhosis, which means you’re at risk for liver cancer, liver failure, and maybe, even the need for a liver transplant.

The silent killer

It has become popular with the lay public to refer to liver disease as the silent killer. While I have never truly liked this characterization, probably because not every liver issue will kill you, it does have some credence because all too many patients I have cared for over the past twenty-five years arrive too late to benefit from an early diagnosis and intervention.

But liver disease is called the silent killer because it often doesn’t reveal any real outward signs of problems until it’s too late. Unlike the gallblad­der, pancreas, and other abdominal organs, fatty liver really doesn’t cause pain or abdominal distress. It’s easy for people to ignore it and have a false sense of security that they’re well.

The first sign of a problem is often fatigue, something most people just tolerate by moping along. They make up excuses such as stress, a bad marriage, shift work, or other possible causes. But at age thirty, forty, or fifty, it’s not normal to be “just tolerating” fatigue. If you’re obese, fatigue may be a sign of sleep apnea. It may be related to acid reflux (GERD), which is causing an unrecognized disturbance in your sleeping pattern. Fatigue can also be an early symptom of diabetes, hormonal imbalances, anemia, or a yet-to-be-diagnosed cardiovascular disease or malignancy.

People also have a tendency to tolerate gradual weight gain. Obesity doesn’t usually happen as a fifty-pound gain over six months. It’s gradual, a pound or two every month adding up over several years. With so many extra pounds added on, people tend to overlook another symptom of liver problems: swelling of the legs and feet. Often, they’ll just chalk it up to being on their feet too long.

With cirrhosis, healthy, functioning, metabolically active liver cells are replaced with scar tissue, which, essentially, doesn’t work. Because of the scar tissue in the liver, circulation in the liver is altered and a condition known as portal hypertension develops. Complications of portal hypertension include ascites, which is a buildup of fluid in the abdomen.

By the time people come to me, many have advanced scarring and fibrosis. Once someone comes to me with fatty liver or a further progression of liver disease, we have a far more detailed conversation to put their situation into perspective.

When we are able to intervene earlier, when we identify that a patient is on the road to having metabolic syndrome by being overweight and having prediabetes or high blood pressure, we don’t fall back on the punch line, “Eat more fruits and vegetables.”

My staff and I know that simply snapping out some recommendations is an unrealistic way of turning things around. Instead, we guide patients through a detailed assessment that looks at eating patterns, snacking, family structure, barriers to exercise, barriers to eating right, and more. We ask questions such as,

• Who is living at home with you?
• Do you have little children?
• Do you work shift work?
• Are you a caretaker for someone with special needs?
• How do the dynamics of your life positively or negatively impact your ability to shop, cook, eat, and prepare food?
• What are the obstacles to going to the gym or going for a thirty-minute bike ride, four days a week?

For many people, turning around a lifestyle begins by learning what healthy food looks like.

The obesity epidemic is taking no prisoners.

Now, we need to be especially concerned about our children. Do you share my concern and outrage? You should.

The post Did You Know that Obesity Can Damage Your Liver? appeared first on The Doctor Weighs In.

The keto, or ketogenic, diet is growing in popularity. It focuses on eating almost no carbs. Instead, you replace your daily calories with fat and protein to encourage your body to enter a state called ketosis, where it starts to burn fat for energy.

While this sounds like the ideal weight loss plan, it can be challenging to understand or even to know where to start. What do you need to know about the keto diet before you decide to try it out?

1. It’s not something you can do casually

The keto diet requires a change in your mindset. The entire basis of keto is that you maintain perpetually low carb levels so that your body has no choice but to burn fat for energy. This, in turn, can help you lose weight as your body turns to your internal fat stores to keep you moving. It’s called a diet, but it’s more of a lifestyle change.

Your body converts carbohydrates into glycogen which is stored in your muscles. This is why athletes will eat a ton of carbs before running a marathon or playing a football game. The glycogen stores serve to fuel them during their match.

Without that extra glycogen from carbohydrates, your body still needs a source of energy — especially if you’re active or moving around a lot. Athletes are used to eating more than 200 grams of carbohydrates a day, but that’s many times the amount you’ll want to eat on the keto diet.

2. The basis of the keto diet

How do you get started with the keto diet?

The keto diet is a high-fat, low-carb, moderate-protein plan. You need to take your regular carbohydrate intake — which for most Americans is between 200 and 300 grams a day — and reduce that to 20–50 grams a day. To do that, you need to learn how to calculate your macros.

Macros are the three primary nutrition groups you’ll want to pay attention to — fats, carbs, and protein. Carbohydrates are the only macronutrient that isn’t necessary for survival. There are no essential carbs, which means you can reduce them dramatically while still maintaining a healthy diet.

Ideally, on the keto diet, you want to get between 60–75% of your calories from fat, 15–30% from protein and only 5–10% from carbs.

Tracking your macros can be difficult at first. You need to learn how to read labels to figure out what has a lot of carbs and what is suitable for your diet. You also need to learn how to calculate your net carbs. You can’t just count all the carbs you eat during the day. Instead, you take note of the total number of grams of digestible carbs that you eat. Then, you subtract the number of grams of indigestible fiber you consume. The result is your net carbs.

All that’s left to do now is choose the right foods to help push your body toward ketosis.

3. Choosing the right foods

How do you reduce your regular carb intake while still enjoying the foods you love? Start paying attention to the carbs in everyday meals. Things like natural fats — butter, various oils — and meats have no carbs per 100 grams. Many kinds of cheese also have zero carbs — be sure to check the label. Eggs usually have one carb per 100 grams, and vegetables that are above ground have anywhere from one to five carbs.

On the other side of the spectrum, you’ll want to avoid things that have too many carbs. Pasta, bread and most sweets are anathemas on the keto diet. You can eat an entire day’s worth of carbohydrates in a single protein bar.

So what do you want to eat? Eggs are an excellent option for the keto diet. Each egg contains 13 percent of your daily recommended protein intake, based on a 2,000-calorie diet, in addition to 5 grams of fat and tons of vitamins and minerals. In addition, lean proteins like chicken, turkey and red meats are low-carb options that can help you meet both your fat and protein macros for the day.

Don’t neglect your vegetables and fruits. Veggies that grow above ground have very few carbs per serving. Further, they are chock full of healthy fiber that helps reduce your daily net carb intake.

4. It’s not for everyone

While the keto diet can be a great way to lose weight, it’s not for everyone. Doctors don’t recommend this extremely low-carb diet for pregnant women or breastfeeding mothers.

Although many people with Type 2 diabetes become more sensitive to insulin on a ketogenic diet, particularly when they lose weight. Furthermore, diabetics on medications that lower blood glucose by increasing insulin levels (e.g, insulin, sulfonylureas, glinides) must monitor their sugars closely while on this diet because of the increase in insulin sensitivity.

A study of the keto diet in mice found that this high-fat, low-carbohydrate diet could raise the risk for Type 2 diabetes in otherwise healthy individuals. It doesn’t allow the body to use insulin properly, which can, in turn, lead to insulin resistance. This adds one more note of caution related to keto diets and diabetes.

Make sure you talk to your doctor before you make any major changes to your diet to make sure you’re healthy enough for this kind of lifestyle change. The goal is to get healthier, not make yourself sick trying to lose weight.

Take it slow and enjoy the results

Don’t try to cut your daily carb intake down to 5% in one shot. The most important thing you need to know when starting with the keto diet is to take it slow. Take time lowering your carbs until you reach your desired macros.

Don’t get discouraged — you will feel like crap as you work toward ketosis. They call it the “keto flu.” It’s the result of your body making the shift from burning glycogens to burning fat.

If you can keep your body in ketosis, it can be a fantastic tool to help you lose weight. Just be sure to talk to your doctor before making any major changes to your diet. If done properly, the keto lifestyle can be the health boost you need.

The post What You Need to Know About the Keto Diet appeared first on The Doctor Weighs In.

A widely held belief is that we absolutely need carbohydrates for successful workout recovery. The reasoning behind this is that carbohydrates help replenish glycogen. They also spike insulin which supports muscle protein synthesis. If that is the case, does that mean that low carb diets like the keto diet are detrimental to workout success?

Why carbohydrates are recommended?

After a tough workout, your glycogen stores become depleted. In case you are not familiar: glycogen is carbohydrate stored in muscle tissue. It fuels much of your workouts.

Traditional sports nutrition advice says we need to replenish that lost glycogen as soon as possible. Failing to do so is bound to slow down your recovery.

More specifically, taking carbohydrates within a couple of hours after vigorous training is believed to:

• Replenish muscle glycogen
• Spike insulin which is an important anabolic hormone
• Increase water content within muscle tissue
• Lower levels of cortisol, a catabolic hormone

However, many of these claims are now being questioned. And some are really not all important for the average person.

If you’re someone who works out three times a week, for example, there’s no need for you to speed up the rate at which your muscle glycogen gets replenished. As long as you’re eating some carbohydrates, your glycogen stores will get back to normal within two days.

Besides that, studies have found that protein, especially the amino acid leucine, spike insulin just as much as carbohydrates. Studies also found that taking carbs together with protein was no more effective than a placebo when it comes to workout recovery.

The keto diet and workout recovery

The ketogenic (keto) diet is controversial in regard to sports nutrition. Because carbs are considered essential for performance and post-workout recovery, a diet deficient in carbs seems like a recipe for disaster. But the human body is complex and able to adapt to things we think impossible.

So, what does the science say about keto diets
and workout recovery?

Dr. Jeff Volek, a renowned low-carb researcher led a study that was published in a 2016 issue of Metabolism. The study revealed that 10 ultra-endurance athletes who had been following a keto diet for at least 6 months showed a higher fat oxidation rate and a lower carbohydrate oxidation rate during exercise. They also showed similar muscle glycogen levels at rest as the control group.

The study also found that glycogen levels recovered at the same rate in the keto group as well as the control group. This was despite the fact that the keto group consumed a diet containing 5% carbohydrates while the control group diet had 50% carbohydrates.

This study concluded that endurance athletes could maintain normal muscle glycogen content, utilization, and recovery after long-term adaptation to a ketogenic diet.

This study shows that adapting to a low-carb diet like keto makes the body use fat for energy during workouts while sparing muscle glycogen. With less glycogen lost, you need fewer carbs to recover. However, it takes several months to truly adapt to low-carb diets, so performance and recovery may suffer in the meantime. This has been confirmed by short-term studies.

Another thing to keep in mind is that ketosis, which is the primary goal of the ketogenic diet, is not the end goal of this diet. Instead, it is keto-adaptation (after long-term ketosis) that matters, especially for athletic types.

Some limitations of the keto diet

There is a caveat to using keto for workouts. Researchers agree that workouts that heavily rely on anaerobic metabolisms, like strength training, will not work on a fat-fueled diet. That’s because ketones and fat cannot be metabolized anaerobically.

But this may apply only to athletes. Common folk may actually do quite well on a low-carb diet where strength training and other anaerobic-heavy workouts are concerned.

A study published in Nutrition & Metabolism found that the keto diet combined with resistance training reduces body fat without affecting muscle mass in untrained overweight women. So, there was no major impairment.

Central Fatigue

Another problem with the keto diet when it comes to workout recovery is how it affects central fatigue, meaning feelings of tiredness caused by changes in brain chemicals.

There’s evidence that when you’re burning more fat, the brain takes up more tryptophan — a precursor to the production of the feel-good neurotransmitter serotonin, which makes you feel tired.

Eating too much protein on this diet, which isn’t uncommon in people who regularly exercise, can also lead to elevated ammonia production during workouts. Ammonia alters energy metabolism in the brain and also communication between nerve cells, all of which leads to feelings of fatigue.

However, most of this evidence is based on short-term research, and longer studies on keto-adapted subjects are needed to check if keto truly does make you feel tired after workouts.

What else you need to consider

A major benefit of the keto diet is that it enhances fat burning. Most people follow this diet for this very reason. Even athletes may use it to shed pounds before major events.

What’s best about keto is that it is proven to burn fat while sparing muscle — something not found with most other weight-loss programs. The keto diet also does not affect resting metabolic rate (RMR) even after it leads to major weight loss.

And while you can definitely use this diet to burn fat, there are things you need to consider if you’re someone who’s an athlete or very active:

1. Increasing sodium intake

Another pioneering expert in keto sports nutrition, Dr. Stephen Phinney, recommends consuming more sodium on a keto diet. Between 3,000 and 5,000 mg of this important electrolyte is necessary to maintain normal metabolism and hydration levels, especially if you’re athletic. Besides sodium, Dr. Phinney recommends consuming 3,000 to 4,000 mg of potassium and 300–500mg of magnesium.

2. Carb cycling

The cyclical ketogenic diet (CKD) involves cycling between the standard keto diet and a high-carb diet. Usually, dieters will eat low-carb for 5–6 days of the week and do a carb refeed on days 6 and/or 7.

On carb-refeed days, you will be temporarily kicked out of ketosis. This helps restore muscle glycogen to greater levels than you could achieve by maintaining ketosis. This approach seems to work better for athletes than standard keto.

3. Targeting carb intake

Another option is to target your carbohydrate intake around your workouts. This is called the targeted ketogenic (TKD). This nutritional approach was developed to help athletic types fuel their workouts and improve post-exercise recovery.

If you’re someone who takes part in vigorous anaerobic activity, this method may be best for you.

Related Article: A Healthy Lifestyle is Important in How Diet Works

Conclusion

Post-workout recovery is an essential aspect of all types of training. Resting is one part of the process, proper nutrition is another.

Usually, you will hear that carbohydrates are essential for proper workout recovery. And, that low-carb diets like keto cannot help with this process. However, this is simply not true.

The keto diet does not impair post-workout recovery in most cases. But it isn’t perfect, and whether you should consider it for your exercise regime boils down to personal choice. The reason? We don’t know everything about sports nutrition.

The post How the Keto Diet Impacts Workout Recovery appeared first on The Doctor Weighs In.

My healthcare provider, Kaiser Permanente, once sent me a glossy brochure extolling the virtues of a plant-based diet. My own diet is already rich in fruits and veggies and I rarely eat meat except for the occasional social barbecue.

So, I promptly relegated the brochure to the recycling basket. I didn’t think about the topic again until some friends asked me to take a critical look at it.

Primum non-nocere

“ First, do no harm,” thus spake Hippocrates 2500 years ago, and every budding physician declaims on graduation day. And in this respect, the plant-based diet shines: Nobody has died from eating it-if you exclude patients with food hypersensitivities (peanuts, tomatoes) or celiac disease -and adverse reactions are practically nil.

No wonder that even in the difficult and contentious field of nutrition science, a wide consensus has formed. The plant-based diet is “good for you”. But lack of “bad” doesn’t mean “good”. To qualify for this designation, the scientific bar is much higher.

Forks over knives

As part of my research, I watched the documentary “Forks Over Knives.” What does a documentary have to do with a serious inquiry into a scientific field of research you might ask? I wondered myself.

The documentary presents the work of nutrition scientist T. Colin Campbell and cardiologist Dr. Caldwell B. Esselstyn Jr. They proposed that most of our major health issues can be prevented and even reversed, including heart disease, cancer, and diabetes. How? By following a diet of vegetables, fruits, and whole grains.

Their work was rich in assumptions, correlations, clinical observations, and anecdotes. That’s because at the time they did their work was all there was. However, this approach falls far short of today’s scientific standards.

Finally, a randomized controlled study

Then along came Dean Ornish, MD, and his collaborators. They carried out a randomized, controlled trial which is the gold standard in research.

They found that a predominantly (but not exclusively) plant-based diet combined with lifestyle changes, such as stress reduction, can reverse the progression of even severe coronary heart disease. Episodes of chest pain decreased by 91% after only a few weeks. After five years, there were 2.5 times fewer cardiac events. Blood flow to the heart improved by over 300%.

But, that’s not the end of the story.

Let’s look at the study design

There is always a ‘but’ to spoil the fun. A deeper dive into the study design showed that the experimental group was put on a plant-based diet. But, they also

• ceased smoking,
• got stress reduction training, and
• followed a moderate exercise regimen.

And the control group? They continued in their old “bad” ways:

• eating red meat,
• high-fat,
• high protein,
• smoking (although Ornish states that only one subject was a smoker at baseline), and
• not exercising.

So, what was responsible for the spectacular results? The plant-based diet? The exercise? Or smoking cessation? Stress reduction? Or a combination of these factors?

There are statistical methods to account for such confounding factors but it requires a very large number of participants to increase their validity. There were not enough people in this study to do that.

Another strengthened the conclusions

That being said, a later study strengthened the conclusions of the early studies that plant proteins were superior to animal proteins in terms of health.

Song et al.’s large (131,342 participants) prospective cohort study of U.S. nurses and other health care professionals was published in 2016. It described the association between animal protein intake and cardiovascular, cancer, and all-cause mortality.

The major conclusion of this study was that higher intake of animal protein (including processed red meat, unprocessed red meat, dairy, poultry, and eggs) was associated with higher mortality. Whereas, a high intake of plant protein was associated with lower mortality.

Are all plant-based diets created equal?

Before going any further, let’s pause for a minute to explore whether all plant-based proteins created equal. We can answer with an (almost) rhetorical question: Are mashed potatoes equal to broccoli in their effect on cardiac health?

In a prospective series of 209,298 participants, Satija and colleagues examined the relationship between cardiovascular disease and healthful and unhealthful plant-based diets.

They used food intake surveys to index dietary patterns into graded plant-based diet indices. The index of the overall study population was called the plant-based diet index or PDI. The other two indices were the healthful (hPDI) and the unhealthful plant-based diets(uPDI).

They found that higher adherence to PDI was independently associated with a lower incidence of cardiovascular disease (hazard ratio 0.92) compared to the diet of the general population which has a hazard ratio of 1.0.

But when they looked at the ‘healthful’ group (hPDI), the hazard ratio dropped even more to an impressive 0.75. But the ‘unhealthful’ group (uPDI) had an alarming increase in the hazard ratio to 1.32.

These results are unequivocal. Good fruits and veggies showed -0.25% drop in the risk of heart disease, however, bad ones showed a 32% rise in risk.

Does age make a difference?

What about the effect of age? Gerontologists have published many observational studies showing that slightly plump people over the age of 65 actually enjoy a longer (and happier?) life. How do you account for that?

In a study published in Cell Metabolism, Valter Longo and Morgan Levine at the University of Southern California in Los Angeles focused on data from 6381 adults over 50 years old. They had all been interviewed once about their diet as part of NHANES, a national survey of health and nutrition.

Longo’s team used death records to conclude that those under 65 whose self-reported diets they classified as high-protein (at least 20% of calories came from protein) were at much higher risk of illness and death than a group who took in 10% or fewer of their calories from protein. The high-protein eaters were more than four times as likely to die from cancer over the 18 years after they were surveyed and 75% more likely to die of any cause.

But, (again the pesky ‘but’) in the over-65 crowd, those who ate lots of protein survived longer, on average, than those who ate less. Longo speculates that elderly individuals may be less likely to absorb the protein they take in, so need more of it.

Do you need to go completely vegetarian?

So do you need to go completely vegan or vegetarian to mitigate the risks of cardiovascular disease, stroke, and cancer? The answer to that is no. A more varied and equally healthful alternative is the Mediterranean diet that includes a moderate intake of protein from animal sources, such as certain fish and chicken. The intake of dairy products, red meat, processed meats is infrequent.

An excellent study in the New England Journal of Medicine showed that among persons at high cardiovascular risk, a Mediterranean diet (supplemented with either extra-virgin olive oil or with nuts) reduced the incidence of major cardiovascular events. The hazard ratio was 0.69 for oil supplemented diet and 0.72 for the nuts supplemented diet. These are slightly superior to 0.75 hazard ratio of a strict vegetarian diet.

So what’s the bottom line

As I said at the beginning, plant-based diets are good for you but there is no reason to be a fanatic about it. In fact, five years ago, Ornish put former President Bill Clinton on a diet that included salmon once a week. Further, he featured a slab of salmon filet on the cover of one of his books, The Spectrum: A Scientifically Proven Program to Feel Better, Live Longer, Lose Weight, and Gain Health

So, dear reader, my bottom line is this:

Follow a good diet, be it vegan, vegetarian, or Mediterranean; exercise, and mellow out. Most importantly, don’t smoke. And you’ll be OK.

The post Plant-based Diet: Facts & Fiction appeared first on The Doctor Weighs In.

Before you can decide whether this is a good choice for you, you need to know the facts. Though bariatric surgery is safe and generally successful in achieving weight loss, to be a good candidate, you must be prepared to deal with both physical and emotional issues.

Seven years ago, I had a gastric bypass and went from being barely able to function to living a magnificent life as an authentic and productive person. (I tell my story in more depth at Medium and in my book Recovering My Life: A Personal Bariatric Story.)

To be clear, I speak as a clinician (I am a licensed Marriage and Family Therapist) and as someone who has been through weight-loss surgery and the difficult process of recovery. I am not a nutritionist or medical practitioner.

But my experience and research have taught me that successful bariatric surgery requires preparation, long-term recovery, and lifelong changes in your relationships with your body, food, and the people in your life.

What is bariatric surgery?

Bariatric surgery is not a cosmetic procedure. We may hope to look better after losing weight, but the best reasons for undergoing this major surgery are to extend and improve our lives.

The most common procedures are lap band, with a success rate of 47%; gastric sleeve, with a success rate of 80%; and gastric bypass, which has an 85% success rate. These procedures support weight loss while requiring lifestyle changes.

There’s a common misconception that most patients who have bariatric (weight-loss) surgery regain their weight. The truth is, most bariatric surgery patients maintain successful weight loss long-term.

Patients who undergo bariatric surgery and follow all treatment guidelines can expect to lose weight and improve the quality of their lives. More than 85% of patients lose and maintain 50% of their initial weight loss.

Physical and emotional issues

If you’re thinking about bariatric surgery, it’s important to get all the information you need — including the physical and emotional ups and downs.

Though bariatric surgery is safe and less life-threatening than obesity, it is major surgery. You will have to deal with physical pain, medication, possible complications, and all the to-be-expected problems associated with surgery. More, you will face dietary restrictions, some of which are ongoing, like not drinking with meals.

Perhaps the greater challenge is dealing with the mental and emotional issues. For years, you have used food as a means of coping.

Changing that complicated relationship goes far beyond getting back to “normal” after surgery. The new normal will be a novel approach to an understanding of food, your body, and other people.

The challenge of preparing for surgery

Persuading and advocating

You must be absolutely sure that this is the best path for you because you’ll have to convince others: your family, your doctors, and your insurance carrier.

To be considered for the surgery, your doctor must recommend it. Then, you must provide at least six months of records showing your weight and your attempts to lose the weight. Once you have the doctors on board, your medical insurance provider must authorize payment.

Advocating for yourself means educating yourself, planning, and learning how to speak up for yourself.

Planning and building support

Once you’ve been approved, you need to build a support system. One of the most important decisions you’ll make is choosing your team. The family members, friends, acquaintances, and professionals on your team must respect and support your decision.

You’ll need to make plans for an extended recovery. Beyond help with childcare, household chores, and transportation during and after hospitalization, you will need help adjusting to the changes in your life and the emotions that accompany those changes.

Your surgeon is likely to require you to follow a weight-loss regimen for about six months before surgery to ensure you are committed and as healthy as possible before surgery.

You’ll need to deal with fears and frustrations. Support from a therapist or support group and family is as important now as it will be later.

The challenge of recovery

Recovery from the surgery itself is just the beginning.

Physical recovery

Your doctors will advise you about the physical challenges that may follow bariatric surgery: constipation, dumping syndrome (nausea, vomiting, and weakness caused by eating high sugar meals, sodas, and fruit juices), possible infection of the wound, and possible leaks in the new connections.

Physical changes may include body aches or fatigue (vitamin or mineral deficiency may be the cause). You may feel cold. Dry or sagging skin, hair loss or thinning, and the inability to process certain vitamins (B12 and D) and minerals (iron, folate, calcium) may cause problems.

Medications

Managing your pain medication is another challenge. The early stage of recovery can last from one to six weeks. You will need to taper off from prescription pain meds. Don’t go cold turkey!

Follow your doctor’s advice on medication. Stopping without medical approval can cause serious complications, even hospitalization.

Be aware that bariatric patients should not take NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen. NSAIDs are not safe for people who have undergone bariatric surgery. Even one use can cause “marginal ulcers”, that is, sores or holes in the stomach pouch. If it is necessary to take an NSAID, take it with a proton pump inhibitor (PPI) medication, such as Prilosec or Nexium.

Emotional side effects

Medical advice may not give you the information you need about the emotional side effects of your surgery. You may lose your appetite, or you may feel hungry. You’ll be on a liquid diet at first, and that can be stressful.

You may experience “food grief”. Food has a special meaning for people who suffer from morbid obesity, and “mourning for lost foods is a natural step in the re-birth process after weight loss surgery.”

Emotional issues like self-doubt and mood swings may arise. Weight loss will be dramatic at first, but there may be setbacks — reaching a plateau or regaining some weight.

It may take time to get used to your new body. Keep your expectations realistic. Focus on the improvement in your health.

Ask for help. Take time for self-care. Keep friends who support you close. Avoid the ones who don’t. Use your support system.

Other risks

Alcohol use

Some patients who have undergone weight-loss surgery struggle with alcohol and substance abuse. One explanation is “addiction swapping”. No longer able to use food as an addiction, the patient may be drawn to alcohol or other substances as substitutes.

Also, weight-loss surgery is known to change alcohol sensitivity because the alcohol goes through the stomach and into the small intestine more quickly. You feel even small amounts more rapidly.

Eating disorders

Ironically, you may be at risk of developing an eating disorder after bariatric surgery. Having trouble eating because you don’t have an appetite may lead to “the type of disordered eating that can turn into bulimia or anorexia.”

After surgery, eating too quickly or not chewing thoroughly can cause vomiting. Another unhealthy habit is chewing and spitting out food, which can lead to an eating disorder.

Learning new eating habits

Eating out may be a challenge after bariatric surgery. Avoid high-calorie drinks, like lattes and sodas. Select meals with a balance of protein, fiber, and healthy fats. Don’t be afraid to create your own dish, ask for a half portion, or take leftovers.

New eating habits to acquire:

• Chew every bite thoroughly
• Eat slowly
• Eat six small meals instead of three big ones
• Stop eating when you feel full
• Drink lots of water (8 cups per day)

Be prepared for change

Bariatric surgery, even when successful, mandates changes in many areas of life. Many of these, like better health, more energy, and better self-esteem, are positive.

But even though your body may be in better health, emotional challenges may remain.

• Missing food and the rituals that surround it, missing old habits, the stress of the surgery, and postoperative complications may trigger depression in some patients.
• Anxiety after surgery is not uncommon.
• Patients may find themselves focusing on one body part or experiencing Body Dysmorphic Disorder (obsessing about appearance).
• Health problems like regaining weight, the weight loss plateau, and complications from the surgery may arise.
• Hypoglycemia (low blood sugar), nutritional deficiencies, and dehydration may cause uncomfortable symptoms and require treatment or changes in diet.

It’s up to you to manage the physical and emotional challenges. With the help of your medical team and your support group, you can weather these storms and live the magnificent, productive life you are meant to live.

Ongoing recovery

Successful bariatric surgery means making lifelong changes to your lifestyle. Taking on the physical and emotional work to make these changes requires total commitment to your health. Are you ready to meet these challenges? Then you’re ready for bariatric surgery.

The post What You Should Know Before Undergoing Bariatric Surgery appeared first on The Doctor Weighs In.

Rice immediately contacted Ghezzi’s primary care doctor—also at Dartmouth Health Connect—who called Ghezzi that day. The phone conversation was long and unhurried. During the call, the doctor decided to change Ghezzi’s prescription, and she made an appointment to meet with Ghezzi, her health coach, and the behavioral health specialist as a team the next month. Ghezzi recalled,

“I felt like the wagons had surrounded me in protection,”

The benefits of a team-based-model of care

A same-day call back from a doctor? A long phone conversation? An appointment with three health professionals in the room at the same time? If this doesn’t sound like a typical interaction with the healthcare system, it’s because Dartmouth Health Connect is not a typical clinic. Its team-based model of care strikes a stark contrast to the solo doctor-does-all, 7-minute visit model that most patients know (but few love).

By design, team-based practices, also called patient-centered medical homes, have the potential to redistribute provider workload, change the way healthcare providers get paid, and—in the best cases—put patients at the center of it all. Providers have many reasons to love the model of care, but what do patients think?

What do patients think about team-based care?

Research shows that patients want four things in a medical practice:

1. Whole-person care
2. Coordination and communication among providers and between providers and patients
3. Patient support and empowerment
4. Ready access

If a healthcare model by any name delivers those benefits, patients are likely to take to it. Christine Bechtel, Co-Chair of the Center for Patients, Families, and Consumers at the Patient-Centered Primary Care Collaborative said,

“Patients love the concept, but if it’s not operationalized, if the practice isn’t visibly operating as a team, they won’t embrace it.”

Bechtel co-authored the aforementioned research published in 2010 in Health Affairs.

What is team-based care?

The idea behind team-based care is that doctors can not—and should not—do it all. They can’t see all the patients, solve all the problems, and complete all the associated administrative tasks in a day’s work. Even if they could do it all, they’re not always the best one for the job. Consider these examples:

• Doctors diagnose but pharmacists unravel complex medication regimens to discover which one is causing the unpleasant side effects.
• Dietitians help patients come up with a meal plan to achieve a healthy weight or manage their diabetes.
• Behavioral health specialists address the mental and emotional issues that may prevent us from achieving optimum health.

Sure, doctors can refer patients to these and other specialists, but patients don’t always follow through. And when they do, the referring doctor may never know what happened during the visit.

Variations on a theme

Team-based care can bring multiple healthcare providers together under one roof, or it can include a care coordinator who quarterbacks care that happens in multiple settings. Team members can free up their teammates to do what they do best, whether it’s to diagnose, manage medications, or optimize a diet.

Amy Gibson, RN, who is the chief operating officer of the Patient-Centered Primary Care Collaborative (PCPCC) said,

“It’s not about a doctor just writing a prescription and telling you what to do. It’s about bringing [providers] together as partners who can provide expertise. At any given point in time, it may be the behavioral health specialist or some other team member besides the physician who needs to be leading that team.”

Placing patients with the most appropriate healthcare provider, rather than the doctor every time, can also increase access to all providers for all patients. That’s why some team-based models may offer same-day appointments, email and telephone access to providers, and longer appointments. Team-based models may also allow for innovative payment structures. For example, payers might reimburse practices a flat monthly fee per patient rather than a fee for each service provided.

When it doesn’t work

Simply declaring a practice to be “team-based” is not enough to convince patients. Bechtel selected her current primary care provider because it was a team-based clinic. She has been a patient there for several years now.

But every time she goes, she says she feels like a new patient that no one knows. She fills out paperwork for the receptionist, who asks her why she is there. She then sees the medical assistant (MA), who takes her vitals and asks her why she’s there. The MA then leaves her with a doctor, physician assistant (PA), or nurse practitioner, who again asks her why she is there. Bechtel says,

“Where is the team part of this? I’ve just been asked why I’m here three times. It’s so obvious to patients when they’re not operating as a team.”

For patients, a team-based model like this one just seems to place more barriers between their doctors and themselves. As Bechtel explains,

“Oftentimes, what patients observe, unfortunately, is that they can’t get to their doctor because it’s ‘team-based.’ They ask, ‘Well, what does that mean?’ And the practice tells you it means that all providers can access the medical record and read each other’s notes. But that’s not a team.”

Shared access to an electronic medical record may streamline the workflow for providers, but it’s not necessarily a visible improvement in the patient’s experience.

Patients need to understand what ‘team-based’ really means

Even the best-intentioned team-based clinics may not get full buy-in from patients if patients don’t know what team-based care is. Patients need to be fully oriented as to what the new model offers, what issues it addresses, and how patients can make the most of it. As Bechtel said,

“If no one ever explains to patients what a team-based approach is, that you might sometimes see a different person, but that person is always going to know what’s happening with you and has full access to your doctor and your records…If no one ever says that, the patient experience isn’t going to be good.”

When it works

Team-based care that works puts the patient at the center and addresses the patient’s needs and concerns ahead of those of the provider or payer. According to Amy Gibson, the COO of the PCPCC mentioned above,

“We haven’t done such a good job of knowing and engaging our customer in health care, and we’re trying to make that happen through the patient-centered medical home.”

Whether patients like Ghezzi can cite precisely the four things that research says patients want, the way she describes her experience reflects these values. Her physician teamed up with the behavioral health specialist to address her complaints as a whole person. The providers communicated with each other prior to contacting her and then engaged her in a conversation with them during a group appointment. The quick call-back demonstrated their support for her and her ready access to them. Ghezzi says,

“Everyone is working together, recognizing that none of these things are separate from each other. Emotional and physical are interconnected And you feel, by the kind of care they give, that it’s all being worked on as a whole.”

Is a rose a rose?

Many medical practices can call their model team-based but that doesn’t predict what the patient’s experience will be. At the same time, whether or not patients even know the name of the model, they will know whether their healthcare providers are working together as a team with the patient at the center.

“If you build it will they come?” Bechtel asks in the title of her 2010 Health Affairs article on team-based care. The answer, she says, is “if you build it with them, they will already be there.”

The post What Do Patients Think About Team-Based Care? appeared first on The Doctor Weighs In.

While the Avengers team is fictitious, it serves as an inspiration. It shows how individuals from different backgrounds with various skill sets can come together to fight for a common cause.

We believe that Avengers-like teamwork and collaboration is needed to reach the audacious goal of Your Autoimmunity Connection to

reimagine research, diagnosis, and care for all autoimmune diseases.

Collaboration is key in autoimmune disease

For years, we and other patient advocates have called for coordinated care between disciplines involved in autoimmune disease. Now, with the incidence and prevalence of autoimmunity on the rise, the most effective way to treat patients is through a broad collaboration. One that includes

• research and clinical immunologists 
• rheumatologists
• dermatologists
• neurologists
• cardiologists
• psychiatrists, and
• others

Collaboration and the Interdisciplinary Autoimmune Summit

I (BF) recently attended the Interdisciplinary Autoimmune Summit 2019 that was held in Chicago, April 5-7. The theme of many of the presentations was interdisciplinary collaboration.

It was extremely heartening to hear a renowned academic, Leonard Calabrese, DO, echoing this call to action. Dr. Calabrese is the Cleveland Clinic Lerner College of Medicine professor and RJ Fasenmyer Chair of the Department of Immunology. He stated that 

“we are very subspecialized and we tend to live in silos…Collaboration is important across disciplines in both the basic sciences and clinical practice.”

Interdisciplinary collaboration is essential not only on the clinical side but also in the field of drug development. Tens of years and hundreds of thousands of dollars are invested into research before a drug is discovered, developed, approved, and on the market.

Along the way, pharmaceutical researchers and clinicians often gain a new understanding of molecular pathways or underlying mechanisms of a certain disease. Some of this knowledge may provide insights into other diseases. Interdisciplinary collaboration facilitates this process.

Related content: Understanding Systemic Sclerosis (Scleroderma)

Advances in clinical and basic immunology

To start off the conference, Dr. Calabrese presented an overview of recent advances in clinical and basic immunology. He drilled down on four different areas as shown below:

1. Inflammation 

Interleukin-1 is the first of what is now a family of 11 chemical messengers (cytokines) that regulate inflammatory processes. It was discovered through studies that explored possible connections between fever and other types of inflammation in animals and humans.

IL-1 occurs in two forms called alpha and beta. It is a powerful pro-inflammatory cytokine. Over decades of study, IL-1 has emerged as a target for drug intervention. The hope was that reducing IL-1 could inhibit processes leading to cardiovascular and other diseases.

–C-Reactive Protein 

C-Reactive Protein (CRP) is a biomarker of inflammation. It is produced by the liver in the presence of any inflammation, including infection and autoimmune diseases such as Rheumatoid Arthritis.

Measures of CRP in the blood are used as a proxy for blocking IL-1, however, the correlation with clinical benefit has been unclear.

Recent research theorized that blocking IL-1 via canakinumab (a monoclonal antibody biological) could reduce cardiovascular events and mortality. However, when tested in the CANTOS trial, this approach fell short of producing significant results.

Regardless, the scientific community did not turn their backs on the IL-1 target. Instead, they looked at inhibition of the IL-1 pathway in various metabolic syndromes. For example, they tested whether IL-1 inhibition could reduce progression from prediabetes to diabetes?  Unfortunately, research trials found no statistically significant protection from progression to diabetes.

–Can IL-1 inhibition be applied in cancer therapies?

Research has found that Rheumatoid Arthritis patients have a higher incidence of comorbid lung cancer. Inhibition of IL-1 (as measured by CRP) in Rheumatoid Arthritis patients might mitigate symptoms of arthritis as well as minimize cancer risk. However, clinical trial results are still inconclusive. Calabrese described this as a “cup half empty, cup half full” situation.

Although the definitive benefit of IL-1 inhibition and development or progression of various diseases has yet to be proven, future research may yet demonstrate a link with inflammation or possible associations with inflammatory pathways.

2. Telomeres and aging

Attached to the ends of each of our chromosomes (as well as in other mammals) are long strands of repetitive nucleotide sequences called telomeres. They protect the chromosome from deteriorating during replication.

Telomeres grow shorter as we age. Genetics play a significant role in telomere shortening as do environmental exposures and individual lifestyle behaviors.

Telomere length offers an easy-to-test, but very general, view of biological (vs chronological) age.

–The mTOR pathway

Another molecular pathway that scientists have been analyzing for a better understanding of aging is the mTOR pathway, a  molecular complex encoded by the mTOR gene.

The mTOR pathway is involved in regulating many critical cell pathways, including:

• • • energy sensing,
    • cell division, 
    • cell trafficking, and 
    • other metabolic pathways.

Inhibiting mTOR in the appropriate way may increase longevity.

Within the mTOR pathway, there is a pivotal switch that leads to two downstream pathways, mTOR1 and mTOR2.

Inhibition of the mTOR1 complex and increasing mTOR2 results in longer life in mice.  While this sounds like an easy fix to lengthen human lifespan, finding a biologic to accomplish this has proven to be much more difficult.

In the search for the perfect molecule that would effectively inhibit mTOR1 and not mTOR2, researchers discovered that mTOR pathway inhibition also

• • • enhances immune function
    • reduces infection in the elderly
    • improves response to influenza vaccine.

3. The never-ending microbiome

The microbiome is perhaps the latest gold mine of research endeavors. Omics studies and technological advances now allow for better characterization of bacterial strains/species that inhabit our gut. 

Fecal transplant is the best-known therapy involving the gut microbiome. In the world of autoimmune diseases, it has been shown to improve symptoms in Inflammatory Bowel Disease (IBD) patients.

Now, researchers have begun to look into how fecal transplants may help fight infections and cancer. Researchers managed to isolate 11 bacterial strains that enhanced cancer checkpoint inhibitor (CPI) therapy in two tumor models in mice.

Further research on the microbiome has produced other noteworthy findings, demonstrating that the human microbiome may be relevant in most, if not all, fields of medicine.

This year’s surprising research findings include:

• The womb is not sterile!
• The vascular microbiome is different for those with inflammation in their vessels.
• Probiotics may be specialized for each individual. Our current thinking: taking probiotics along with antibiotics may not be universally effective depending on which species different people repopulate their microbiomes with.
• The immune response may be related to the microbiome and might explain why checkpoint inhibitors work for some folks and not others.

4. What’s Up With JAK?

The Janus Kinases (JAKs) are a family of intracellular tyrosine kinases. They provide transmission signals from cytokines, interferons, and many hormones receptors to the nucleus. 

These signals result in the synthesis of many biologically active compounds and changing cell metabolism and function. With this ability to transmit cytokine-related signals, JAKs play a key role in proper function of innate and adaptive immune systems as well as an important role in such pathophysiological processes as hematopoiesis, immune cells development, and many others.

Until recently, JAK inhibitors were known to have safety issues. In fact, one of us (BF) worked at SGX Pharmaceuticals which created an early JAK inhibitor that failed preclinical safety trials.

Yet, as shown below, this year “JAK Inhibitors are Coming of Age”  New indications include ankylosing spondylitis, lupus, psoriatic arthritis, and others autoimmune diseases. The drug is available in both oral and topical formulations.

The Science of Wellness: The Brain-Body Connection

Another topic explored at the conference was the role of mental health providers, psychiatrists in particular, in the management of autoimmune disease. We know that mental disorders are generally approached and treated independently from the rest of the body. Speaker Saundra Jain MA, PsyD, LPC  jokes,

“psychiatry takes care of the neck up, and everyone else takes care of the neck down.”

However, with recent research that shows mental disorders, such as depression and anxiety, may play a role in inflammation (and maybe vice versa), Jain and her colleague Andrew Laster, MD, FACR discussed the importance of including mental wellness into disease treatment plans.

Explaining the Brain-Body Link

Understanding the brain-body link in autoimmune disease requires a general understanding of psychoneuroimmunology (PNI). PNI is a convergence of disciplines including

• behavioral science
• neurosciences
• endocrinology
• immunology

More specifically, the field looks at three systems: nervous, endocrine and immune.

In short, the systems are all bidirectional and are able to communicate with each other through neurotransmitters, hormones, and cytokines. As a result, the presence of psychosocial stressors affecting one system causes a domino effect on all the systems.

–The blood-brain barrier

It was once thought that the blood-brain barrier (BBB)— a border that separates the circulating blood from the brain and cerebral spinal fluid (CSF) in the central nervous system, was mostly, as the name implies impenetrable to chemicals.

A new understanding of the BBB, however, is that it is a highly selective semi-permeable barrier, allowing only smaller molecules, such as cytokines, access to the brain. 

Proinflammatory cytokines are produced by activated macrophages in response to psychosocial stressors. They can then pass through the BBB and activate microglia within the brain.

These microscopic interactions may seem inconsequential. However, research conducted on study participants with major depression found that additional psychosocial stress can induce inflammatory responses through increased levels of IL-6 (cytokines).

Of note, patients with Rheumatoid Arthritis had a significantly higher baseline and stress-induced levels of proinflammatory cytokines compared to healthy controls.

From these findings, Jain and Laster concluded that psychiatrists and other mental health providers, ought to be included in the conversation of interdisciplinary healing teams and mental wellness practices incorporated in treatment plans.

Five wellness-enhancing behaviors

Jain and Laster recommended these five wellness-enhancing behaviors and practices:

1. Exercise:

Obesity itself is an inflammatory state. However, whether you are obese or not, exercise has been found to alter IL-6 cytokines from their proinflammatory trans-bonded state to their anti-inflammatory cis-bonded state. While some people may choose to hit the gym or go for a five-mile run,  those that want to start out at a lower intensity can find more exercise options here.

2. Sleep:

Sleep deprivation has been shown to increase cytokine production in monocytes and macrophages. Sufficient, restorative sleep has numerous additional benefits on top of cytokine reduction.

3. Nutrition:

While there are many foods that are anti-inflammatory, Dr. Jain discusses the Mediterranean diet as having anti-inflammatory results, lowering levels of CRP, IL-6 and other inflammatory proteins. If dietary restrictions are a concern, perhaps look into other diets that also reduce inflammation.

Related Content:  New Medical Nutrition Therapy for Patients with Malabsorption

4. Mindfulness:

Mindfulness has been shown to downregulate inflammatory genes. Not to mention, long-term meditation practices may reduce stress reactivity and have therapeutic benefits in chronic inflammatory conditions characterized by neurogenic inflammation.

5. Social Connectedness:

Do friends really matter? Jain references research studies that found people who had more friends and more social network ties also had lower levels of inflammation, fibrinogen, and albumin.

While the above-mentioned wellness behaviors and practices are great, there are many other methods that can also be incorporated in daily life. Practicing good, well-informed oral care is another good way to enhance wellness practices.

Medical homes and IBD

By creating and coordinating a multidisciplinary team of specialists, nurses, dieticians, social workers and psychiatrists, a so-called medical home can provide the “one stop shopping’ that inflammatory bowel disease (IBD) patients need.   

The idea of a medical home is something that we have been dreaming of ever since 2014, resonating with our findings from our Stanford Medicine X workshop. It puts the patient at the center of care, using home visits, coordinated scheduling, management of pharmaceuticals, even telemedicine and digital tools, to more smoothly coordinate care, prevent emergency visits, improve patient outcomes and satisfaction, all while lowering cost of care to the system. Sounds visionary, doesn’t it?

I was excited to meet Dr. Miguel Regueiro, MD and learn about his pioneering work aiming to incorporate the concept of a medical home for IBD patients.

“For the treatment of IBD patients, we need better communication and collaboration between primary care and the GI docs.”

In addition to using the team approach to support patient care, (above) there are new digital tools, such as remote monitoring and telemedicine, that can act as supportive devices for patients to reach their care team between appointments. (below)

The good news is that not only did IBD patients benefit from this holistic care redesign, but they also experienced cost savings associated with implementing this approach.

The medical home in IBD is currently being applied at the Cleveland Clinic, UPMC, Allegheny Health Network, and UCLA.  We can’t wait until next year’s meeting where we hope to hear about the progress of other medical homes in other autoimmune diseases.

Conclusion

Collaboration is needed throughout the entire autoimmune disease management process. This applies to research, diagnosis, treatment, and care management.

Overall, the 2019 Interdisciplinary Autoimmune Summit was an excellent update and overview of the valuable potential of collaboration to reimagine research, diagnosis, and care for autoimmune patients.

The post Why Collaboration is So Important in Autoimmune Disease appeared first on The Doctor Weighs In.