Thursday, August 28, 2014

What's the Deal With Gluten?

By Caroline Shannon-Karasik

These days, it’s hard to pick up a newspaper, turn on the television or surf the Web without seeing a mention of two little words: gluten-free.  But the truth is, while there is more information out there than ever, the wealth of knowledge has also caused a bit of misconception about the lifestyle, how it affects certain people and what the difference is between healthy gluten-free food and gluten-free junk food. 

Well, guess what? I am a gluten-free gal who has celiac disease, so I say now is as good a time as ever to suss out the details, right?  According to the National Foundation for Celiac Awareness (NFCA), an estimated 1 in 133 Americans has celiac disease, yet 83% remain either undiagnosed or misdiagnosed. And, as you might have guessed, the only treatment is a strict, lifelong gluten-free diet.

Why Is Gluten the Bad Guy?

Here's the short of it: When people with celiac disease eat foods containing wheat, rye, barley, triticale and/or contaminated oats (i.e. gluten!), their immune systems cop an attitude and create a toxic reaction that causes damage to their small intestines, making them feel like crap. Talk abut a host of symptoms that come hand-in-hand with celiac disease –– digestive discomfort, diarrhea and vomiting, chronic fatigue, nutritional deficiencies, migraines, reproductive health issues and anxiety are just a few. 

What’s more, mild to severe symptoms resulting from gluten intolerance and sensitivity are plaguing people left and right. According to the NFCA, research estimates that 18 million Americans have non-celiac gluten sensitivity. That’s six times the number of Americans who have celiac disease. Unlike celiac diseases, non-celiac gluten sensitivity does not result in an autoimmune response, but many of the symptoms, including digestive discomfort, bloating and cramping, migraine headaches, and fatigue, are similar. 

"The prevalence of gluten intolerance and celiac disease diagnosis is certainly remarkable and has clearly caught the attention of the medical community by surprise," says Jennifer Fugo, certified health coach and author of The Savvy Gluten-Free Shopper: How to Eat Healthy Without Breaking the Bank. "They've spent a massive amount of time generally believing that an immune reaction to gluten was of little interest and problem for those of us complaining of various issues that don't quite make sense when viewed separately."

Gluten on the Rise

So, why now? Why the increase in diagnoses? Experts say there are two main reasons pointing to the increased awareness of gluten and the nasty spell it has cast on many: 

Today's "wheat" isn't exactly wheat. Kiss that idyllic vision of farmers harvesting their grains goodbye. The truth is, very little of our grain production is done in a wholesome manner. These days, we're chowing down on refined grains that have been modified to suit the business that agriculture has become.
We like to eat ... a lot. Take the fact that glutenous grains have been hocus-pocused and match it with the fact that the overconsumption of food is an ever-expanding problem, and you've delivered quite the double-whammy to your guts. "What might be an occasional issue in the past for those sensitive has now become a monster storm of inflammation that rolls through the body at every bite, [causing] repeated damage to the body," Fugo said.

Gluten-Free Game Plan

So what are you to do? If you suspect gluten may be a creeper that lurks in your gut, then it’s time to pay a visit to your doctor for testing. And listen up: Don't stop eating gluten before you have a blood test –– it may provide a negative result. If the blood test proves you're a dead ringer for celiac disease or gluten intolerance, then the doctor may order a small bowel biopsy. Don't worry –– after the hell your intestines have been through, a teeny biopsy is a walk in the park.

Left untreated, celiac disease can lead to even more health problems, including Type 1 diabetes, infertility, certain types of intestinal cancer and osteoporosis. So guess what that means? This isn’t something you want to mess around with, mmmk?

Need More Help?

The National Foundation for Celiac Awareness and Celiac Disease Foundation offer loads of information, including a symptoms checklist, recipe ideas, shopping tips and information on the latest research.

Do you have questions about celiac disease or a gluten intolerance? Visit my Website for recipes, shopping lists, and more, or send me an email at


Pad Thai Veggie Noodles
gluten-free and vegan

  • 4 cups spiralized zucchini and/or yellow squash
  • 1/4 cup gluten-free soy sauce or tamari
  • 2 Tablespoons toasted sesame oil
  • 1/4 cup pure maple syrup
  • 2 Tablespoons natural chunky peanut butter
  • 1 Tablespoon arrowroot or tapioca starch
  • 1-2 garlic cloves, minced
  • juice of 1/2 a lime


(1) Peel zucchini and/or squash. Prepare spiralized pasta using a spiral vegetable slicer, like the Paderno World Cuisine model, and place in a large bowl. Set aside. (No spiralizer? Use your vegetable peeler to make quick “pasta” by simply continuing to peel the zucchini or squash, creating ribbon-like noodles!)

(2) In a small saucepan, combine soy sauce, sesame oil, maple syrup, peanut butter, arrowroot starch, garlic and lime, whisking consistently over medium-low heat. Continue whisking throughout cooking process, until sauce begins to thicken. Remove from heat and pour over veggie pasta, stirring to combine. Top with desired toppings and serve!

Caroline Shannon-Karasik is the author of The Gluten-Free Revolution, a certified health coach and author of the popular gluten-free blog Sincerely Caroline. Her writing and recipe development have been featured in several publications, including, VegNews, Kiwi, and REDBOOK magazines. She has been a long distance runner for more than 15 years and certified Pilates instructor for more than a decade. Caroline lives with her husband Dan and four adopted cats in Pittsburgh, Pennsylvania. 

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Thursday, August 14, 2014

"You're American, I presume?"

[originally posted at my old tumblr blog in 2011]
I just returned from a short trip to the Dominican Republic.  I initially thought that the DR was an oversized Cancun, but this trip changed my mind.  My sister - who is currently living there - was my tour guide.  The highlight of the trip was Cabarete.
The majority of the non-locals at the beach aren’t travelers from what I could gather.  They were living/working in the small beach town, and I left the DR inspired as a result of the mostly Europeans’ outlook on life.  
I’m currently finishing my second year of med school, so I brought my USMLE Step 1 prep book with me to the island, and I opened it up on my lap as soon as my butt hit the lounge chair.  A Dutch man approached me, took my book from my hands, and closed it at the foot of the chair.  
Him: “You’re studying medicine, correct?”
Me: “Yeah…how did you know?”
Him: “I was just watching you walk from the restaurant to your chair, and your behavior reminded me of a doctor.  You’re American, I presume?”
Me: “Yeah.  Why?”
Him: “Americans work too much.  I suggest you just relax and enjoy your vacation.”
My book remained closed for the rest of the day.  I played frisbee with a kid on the beach. I shared some jokes with my sister.  Admired the dozens of kite surfers.  Tasted the salt water. Got a sun burn.  Spoke with some locals.  Bought a mango from a Haitian lady.  Soaked up the smell of the sand.
We spend so much time worrying about our happiness in the future that we forget all about enjoying the present.  In med school, the majority of our time that isn’t spent sleeping is spent with our heads in the books.  We complain of the misery, madness, and frustration that comes with the demands of our program, yet we trudge on because we crave a future in which we enjoy financial stability, a dream career, and the respect and admiration carried by physicians.  Yet there are far too many variables at play to guarantee that all of this hard work will bring us happiness in the future.  
On the other hand, we have complete control over our present.  The variables are laid out on the table in clear view.  You can dwell on the negative or focus on the positive.  In the future, your career-driven focus will hopefully pay off.  But it’s not a guarantee.  Taking time to visit friends, write letters, kiss your significant other, savor your dessert, indulge a runner’s high, smile like a unicorn while plunging face first into the waves off the North coast of the Dominican Republic: In the present, there are various devices which can guarantee you happiness.  
When you’re on your death bed, you won’t dwell on the test score or the career status that were part of an indeterminable future.  Rather, you’ll reflect on those little guarantees that you indulged in throughout your ever-changing present.
Reform Yourself.  Tomorrow could end today.

Nathan Riley, MD, is [now] a Resident OB/Gyn at Kaiser Permanente in Los Angeles.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at You can also connect with him on Google+. 

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Monday, July 7, 2014

Here and Now: The Silver Lining of Your Present

In two weeks, I will be moving to Los Angeles to begin a four-year residency program in obstetrics and gynecology.  To celebrate the move, I have been trying to catch up with as many of my Pittsburgh friends as possible.  Recently, on the way back from dinner with some family friends, I was riding with my mother down the highway, and we hit a patch of traffic.

As she cursed out the other drivers, it occurred to me how futile her efforts were.  She angrily encouraged the driver – yours truly - to straddle the dotted line so that the other drivers – in an equally frustrating situation – couldn’t creep up in front of us.  She had been at work for ten hours prior to our meal, so she was understandably grumpy about the traffic, but I couldn’t help thinking to myself, “What’s the point?  How does allowing a car or two in front of us change her situation?”  My mother only began to calm down when the traffic started to move, though I tried repeatedly to remind her that chilling out and singing along to the radio with me wasn’t the worst way to cap off our evening.

We have all experienced that feeling of dread that comes with the anticipation of sitting in traffic, especially at ten o’clock at night.  My mother complained that now she wouldn’t “be able to get to bed on time!”  That she had “so many things that she wanted to get done for work before she went to bed!”  But what she hadn’t considered was the silver lining.  This was one of the final evenings that she would be spending with me, her only son, to whom she had reiterated on numerous occasions how sad she had been that I was leaving to the West coast for four years.  Had she just taken a moment to readjust her perspective, she would have seen the silver lining: thirty extra minutes of uninterrupted time with her son. 

Our population always seems so eager to be somewhere.  When we finally arrive to wherever it is that we were so eager to get, we quickly become bored with our surroundings and turn to our smart phones to entertain us until something exciting happens.  When we do achieve excitement, we feel compelled to take a selfie to show how great our lives are for that brief moment.  But after the moment has passed, we are simply waiting for something else to happen.

In general, we have forgotten how to live in the present.  Although this concept has become a clichĂ© popularized in Internet memes, maybe there’s something to it?

This concept of being present is rooted in many Eastern philosophies.  For instance, in Buddhism, suffering is attributed to our efforts to control that over which we have no control. Buddhists thus believe that by ridding ourselves of desire – sex, money, power, fame, etc. – we can rid our lives of suffering. After all, you can’t control your past (what’s done is done), and you certainly can’t expect to manipulate your future.  What you do have full control over is your present.  That is, at this moment, you have 100% control over your comfort and happiness, but many individuals are so consumed by what’s on the horizon that they forget to enjoy the present. 

In January, 2010, I set out to complete an Ironman distance triathlon, which consists of a 2.4-mile swim, 112 mile bike ride, and then a full marathon.  After nine months of training, I stood at the finish line with my supporters for only a few minutes before heading to the transition area to gather my things for the ride home.  In hindsight, I can say that it wasn’t as climaticcat as I had hoped it would be, but what exactly had I been expecting?   I was there to become an Ironman, wasn’t I?  In the excitement of finishing the race, I failed to spend just a few extra minutes to look around at my surroundings, to take in the smells, to acknowledge the perfect machine into which I had crafted my body.  All I could think about was getting home for school the next day.  Does this sound familiar? 

Eckhardt Tolle, author of “The Power of Now: A Guide to Spiritual Enlightenment”, refers to the ego in describing this pathology of the mind.  The ego is concerned only with how it came to be (the past) and where it is heading (the future).  In our society, we live by a credo that one must preoccupy themselves with investment for the future, and, in order to accomplish this, we must learn from the past.  But what about the present? 

This illness leads to car accidents due to irresponsible drivers texting or answering emails while speeding down the highway.  It drags a father away to answer a business call the moment before his son gets his first RBI in little league.  It encourages bad habits like eating in front of the TV instead of mindfully enjoying every bite of a freshly tossed salad.  It’s the driving force behind this strange concept that accumulating more material “stuff” like electronics and fancy cars is going to make us happier.  It’s a societal pathology, and it’s likely responsible for the low-grade anxiety that pervades many households and work places.

The good news?  You have all of the tools to fix it.  Extreme athletes experience this on a regular basis.  Rock climbers, for example, are intensely aware of the position of every part of the body at every moment while they are clinging to a wall one-hundred feet in the air. Climbers aren’t thinking about bills, the stock market, financial investments, or other tribulations of life when they are hanging off a rocky cliff side.  As a result, adrenaline junkies experience a “rush” that results from escaping the present, even for a brief moment.

It feels good to live in the moment, but you don’t need an extreme sport to enjoy the present.  Think back to a time when you were focused on the present.  When did you last find yourself thinking, “Wow…life is wonderful”?  This used to be our normal state back in childhood, before our egos had fully formed.  As a child, our minds and senses were wide open, but somewhere along the line, in the hustle and bustle of adult life, we forgot altogether how wonderful it is to be present.

This past weekend, my fiancĂ©e and I went on a hike in Ohiopyle, PA.  There’s an outlook there that has always dazzled my senses.  Dangling your legs over the ledge, you can see for miles.  You can hear nothing but the sound of the rapids on the river far below.  Stare at the dirt around your feet, and you’ll see hundreds of organisms shuffling around in the dust.  The sunlight at four o’clock was still bright overhead, illuminating the leaves that created a natural canopy overhead.  I had left my iPhone back at the car, so there were no distractions from the feel of my lady’s hand in mine.  Laying back with my head rested on my hands, I had one of those rare moments.  I thought to myself, “This is why I work so hard; this is what life is all about.  This moment is perfect.”

If you are cognizant of the way that you allow anxiety and impatience to rise up within you, it’s possible to spend more of your time in the present, but this is entirely dependent on you.  Are you willing to forego your busy mind once in a while?  The stuff of the past may have been grand.  Likewise, your anticipations for the future might change your life for the better.  But you have no control over those things.  What you can control is this very moment.

Where to start?  The Zen master Rinzai would advise you to ask yourself, “What, at this moment, is lacking?”  Turn off your computer and go hug somebody you love.  Show them that you appreciate them.  Stop and smell the flowers.  Realize that there’s no better time than now to make happiness a reality, because you never know what the future holds.

Nathan Riley, MD, is a Resident OB/Gyn at Kaiser Permanente in Los Angeles.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at You can also connect with him on Google+. 

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Tuesday, June 10, 2014

The Biggest, Baddest Disease Facing Medicine Today? Human Behavior

Two college students walk into a bar.  It is about five o'clock in the afternoon and one says to the other, I bet I can drink more beer than you.

The second student smiles and says, Why dont we see who can drink the most before midnight, and the loser pays for both tabs?

The first student exclaims, Oh! Im definitely going to win! They each open their tabs and order a beer.  The first student eagerly gulps his drink and immediately orders another.  The second student slowly sips his drink, enjoying its taste and refreshing coolness.  Before long, two hours have passed and the first student slurs to his friend, “Mmm already drank five annnn I bet-ya din’t even finish yur seggond!"  The second student smiles and again sips his beer.

As the night approaches midnight, the second student decides to locate his friend whos been lost to the growing crowd at the bar.  He finds him alone, slumped in a booth near the back of the bar.  He tries to rouse him, but his friend is hopelessly unconscious and snoring. He throws his friends arm over his shoulder, makes his way to the bar, and discovers that, overall, he had more to drink than his slumbering friend.  In fact, the last beer on his friends tab was only at 8PM!  He generously pays both of their tabs before helping his friend home.

Despite being a somewhat silly anecdote, an analogy can be drawn between this series of events and societal perspectives on health.  We bite off more than we can chew, we misunderstand how our bodies operate, and we often limit our own foresight of consequence. The same attribute that limited the first student’s ability to win his prospective contest can be easily seen in modern medicine.  In fact, as a budding Emergency Medicine physician, I was once asked, “What is the most difficult disease to treat?”  After having finished only a few months in various Emergency Departments, I contemplated the immense array of disease and illness that plagues humanity before realizing an appropriate answer: human behavior.

We are complex beings, products of not only our personal environments and experiences, but also the experimental result of millions of years of evolutionary trial and error.  Our genetic constructs, though, being 99% similar to each other (and 50% similar to bananas), still create the enormous level of diversity we see in our species.  It is unfortunate that this same genetic construct can incur the wrath of nature: cancer, diabetes, nearsightedness, baldness, and so worth.  It is with this sentiment that individuals identifying genetics or molecular biologys role in human illness stand to carry a sense of truth.  However, it is with this same sentiment that these individuals begin to unknowingly accept certain defeat.Human behavior is as diverse as our individual genetic constructs, but, strangely enough, just as homogenous as well.  We often overlook the simple aspects of our behaviors that are strikingly similar in favor of identifying our unique traits, but I ask you this: When you are hungry, what is your first instinct?  When you are tired, what do you want to do?  Time and time again, “repeat business” presents to emergency rooms, doomed to a seemingly endless cycle of disease relapse and medical treatment, all the while ignoring the role of behavior in the cycle’s perpetuation.  These patients would gladly like to break the cycle, for, as it currently proceeds, they self-identify feelings of misery, pain, guilt, and hopelessness on a daily basis. Yet, after being discharged from the hospital, their illness having been “tuned-up”, they relapse right back into the same cycle!  It is not difficult to see that both themselves and the healthcare system have failed them, for while patients of certain disease types are often victims of themselves, they are victims nonetheless.

What makes breaking this cycle so difficult?  What prevents people from identifying perpetuators in their lives and striving to amend them?  In many cases, lack of knowledge may play a role.  Simply overhearing conversations at the supermarket underscores this hypothesis, No, dont buy those cookies, theyre unhealthy, but make sure you grab a box of Count Chocula because it has a ton of vitamins.  Some people simply do not know the difference between healthy and unhealthy.  How could they?  It is entirely unreasonable to assume that every person has a basic level of understanding of health, whether it be diet, exercise, or disease management.

Another commonly observed barrier is the amount of effort needed to enact change. Improvements do not come easy, nor do they occupy a single facet of lifestyle.  Changing only a single aspect of an afflicted patient’s life is much like changing only one tire on your car.  While an isolated improvement has been made, the overall function of the car has not been drastically improved.  Unfortunately, it is difficult to sustain prolonged improvements in patients suffering from a disease cycle, since, cumulatively, it may take more effort than that person has ever had to expend.  Four tires cost far more than just one, do they not?

Just as importantly, patients may not understand or identify potential improvements and abandon their efforts with feelings that the changes are simply not worth it.  Imagine if I asked you to walk into your basement every morning to ensure that a light bulb in a far-off corner was turned off.  I tell you that it would save you money on your electric bill while also giving you a tiny bit of exercise each morning.  After a few days, you may abandon the task, deeming the idea to be unworthy of the necessary effort.  However, if everyone with a basement were to do this, the energy demand of society as a whole could drastically decrease.  Patients often view the effort it would take to change their lifestyle from the perspective of the person walking up and down the stairs every morning: an unfamiliar and potentially irritating task that offers minimally observable rewards.  

A physician's view of a patient's efforts, on the other hand, reflects the comprehensive advantage that society would experience as a whole: a very simple and relatively easy task with enormous benefits.  The human body is that society, your own society, a gross aggregate of varying cells, tissues, and organs, each dedicated to a specific function while working together towards a common goal.  Through this lens, it is now much easier to see how comprehensive care can suffer from even the smallest infractions.  You see, sins of omission stand to cause just as much damage as the sins we actively commit.

There are an innumerable number of additional barriers that preserve the cycle of disease in patients lives.  Perhaps the person has already admitted defeat and is relegated to the bare minimum until (morbidly) they die.  Or maybe they are financially limited from enacting positive change.  In fact, resource availability could serve as its own dissertation for disease cycles.   Above all, though, the most pervasive attribute of all of these barriers is the role human behavior plays in perpetuating them.  We all have unique life experiences, environments, and perspectives, yet we are all governed by the same inescapable biological laws that mandate the best way we should live our lives so as to maximize life.  I certainly do not claim to know how to begin to improve this system, but I am compelled to recognize the importance of individual considerations in disease perpetuations.

My last analogy takes place in the kitchen sink. The only way a sink remains empty is if the drain can move water faster than the faucet can provide it.  It is your goal to keep the water flowing down the drain as quickly as possible.  All we need is for it to drain just 51% faster than the faucet can provide water, and the sink will never overflow. To bring this full circle, at patient's behavior is at least half of the battle against human disease.  If you do 51% of the work, you can get off of this endless disease cycle that I see so often in the ER.

Vedant Desai, MD, is a resident ER physician at Allegheny General Hospital in Pittsburgh, PA. You can reach him at

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Wednesday, June 4, 2014

Why I Put Butter In My Coffee

I get a lot of questions regarding my coffee habits.  Most people think that the NutriBullet cannister I'm often seen carrying is filled with a strange milkshake, but when I describe the contents (coffee + butter + coconut oil), the normal response is "Yuck!"  Over the next few paragraphs, I hope to convince you to try it for yourself.  Here are five reasons to switch up your coffee recipe:

1.  It tastes great.

First and foremost, this coffee recipe - known as "Bulletproof Coffee" in many circles - is delicious.  Here's how you make it. Put a few cups of brewed coffee into a blender (I'm a proponent of minimizing caffeine, so I use decaf).  Add a few tablespoons of high-quality butter, such as Kerrygold.  Last, drop in a few tablespoons of unrefined coconut oil.  Blend it for twenty seconds, and it will foam up into the most delicious latte you've ever tasted.

2.  It will help you lose weight.

Drinking a fatty beverage on your way to work has several positive benefits (listed below).  The first one is that it may enhance weight loss.  Fat keeps you satiated far longer than carbohydrate-rich foods
as it's more slowly digested in the gut, and it doesn't cause the massive spike in insulin that you see with sugar consumption.  If insulin levels are chronically elevated, your body tissues may become resistant to it, which is an early step towards diabetes and weight gain.  Weight loss is effective only when this metabolic derangement is corrected, meaning re-sensitizing your tissues to insulin through physical exercise and carbohydrate restriction.  The weight loss effect is further increased with the incorporation of coconut oil.  This low-carb recipe not only helps to improve the activity of insulin, but it also has been shown to maintain muscle mass through growth hormone release and ketosis (more on this later).  Just remember that a fatty, low-carb beverage is only useful in short bouts.  If you are too strict with your carbohydrate deprivation, you are asking a lot of your adrenals to maintain blood sugar, which can lead to all sorts of trouble.

3.  It's good for the brain.

Fasting has numerous benefits, most of which are imparted by ketones.  When you fast, your tissues are starved of sugar, so you begin to break down fat.  Fatty acids are converted to ketones, which are an alternative fuel source for many tissues in the body, namely the brain and heart.  Instead of starving yourself, though, it's better to train your body to preferentially use fatty acids for fuel as opposed to sugar by avoiding breads, pastas, and sweets.  The process of inducing ketone formation through diet and lifestyle is called ketogenesis (or simply ketosis).  Butter and coconut oil are comprised of short- and medium-chain triglycerides (SCTs and MCTs, respectively).  These fatty acids are special in that when you ingest them they are sent straight to the liver to be converted to ketones.

Ketone bodies are formed from excess acetyl-CoA
There are many benefits to ketogenesis.  We already mentioned weight loss.  Another benefit is that it supports your brain.  Ketones are neuroprotective, and it has been shown beneficial in mice recovering from cerebral ischemia and other brain injuries.  It has also been used with positive results in managing certain types of seizures.  It's suggested that these benefits are conferred by enhanced release of neurotrophic factors, which are important for the maintenance of your cognitive abilities and motor skills.  Even though you may not suffer from any neurological disorders, occasionally pushing your body into ketosis could keep your mind sharp for years to come.

4.  It keeps your gut healthy.

Butter, especially grass-fed butter like Kerrygold, is one of the richest sources of a SCT called butyrate.  Butyrate helps to maintain the integrity of the lining of the colon, keeping your gut bacteria healthy and reducing your risk of colon cancer.  Also, the addition of quality coconut oil provides lauric acid, a special MCT that has anti-parasitic and anti-fungal properties that regulates pathogenic microorganisms in the gut.

5.  It might improve your lipid profile

We associate high cholesterol with heart disease, but this isn't entirely correct.  Cholesterol isn't the problem.  The lipoproteins (HDL, LDL, VLDL, etc.) that carry cholesterol are those blood components that we should actually be concerned with: size, type, and quantity.
Furthermore, these lipoproteins are only dangerous when they become oxidized.   The cholesterol results reported by your doctor will vary depending on your diet and lifestyle. When you eat coconut oil and saturated fatty acids like those found in butter, your blood triglyceride levels will decrease, your HDL will increase, and the most easily oxidized forms of LDL will decrease, all of which are beneficial to your arteries and mortality.


Remember, there are no silver bullets for your health.  There's a difference between your new chugging a gallon of your new coffee a gallon at a time seven days per week and occasionally whipping up a mug when your breakfast time is cut short.  If nothing else, this recipe is a delicious alternative to loading up your coffee with skim milk and sugar.  At its best, your health could seriously benefit.  Give it a shot, and let us know how it affects your blood work, waistline, and energy levels.

Nathan Riley, MD, writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at You can also connect with him on Google+. 

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Wednesday, May 21, 2014

The Why of Weight Loss

"I want to lose weight!"

This is the most popular goal reported by our health coaching clients.  It's an easy assumption that - for societal or health reasons - most of the health conscious public wants first and foremost to lose weight.  We hear this request on a daily basis, so we've become very good at helping people achieve this goal.  

But have you ever asked yourself: "Why do I want to lose weight?"

The majority of people who want to lose weight answer this question with any or all of the following:
  • "I want to feel more confident."
  • "I want to look good naked."
  • "I want to fit better in my clothes"
  • "My doctor told me to do it."
  • "I want to be able to stop obsessing about my weight and to stop thinking about food all day."
  • "I just want to lose weight and be happier."
The surface level reasons for wanting to lose weight are all valid, but, if we dig a little deeper with our clients, it always comes down to the desire for more happiness and fulfillment in life. We often mistake the desire to lose weight with the expectation that it will provide a deeper level of fulfillment.  

Our next question to a weight loss client is: "What are your goals?"  Normally, the response is an arbitrary numerical value that they have been married to for years: 

"I need to lose 20 pounds." or "I want to be more toned."

Regardless of your number, it's important to consider why 20 pounds will make a difference to you.  Would you be happier if you weighed less?  Would your relationships become more cohesive if you weighted less?  Would you have more free time if you decreased that number on the scale?

The point of this exercise is to consider your personal rationale behind your health goals.  Many people do in fact report improved happiness initially after losing weight, but a few months later they often find themselves back to square one: still unhappy and still looking for answers.  The same has been said - and studied - about money.  We all think that a larger paycheck will lead to happiness: "Once I hit six figures, I will be care-free!"  But this is simply not true, and it applies in the same way to weight loss.  

Losing weight may be a source of renewed confidence at the beach.  You might be able to shop at stores that cater to thinner people.  Your doctor might be extremely happy with your progress.  But improved body composition is not the end of the line.  Take a moment to truly consider why you want to weigh less.  Ask yourself: "If I could wave a magic wand and magically hit my goal body weight, which aspects of my life would change?"  Think hard about this.  What new opportunities become available to you?  What would you think about all day if not about losing weight?  What would you do with all the time you'd free up if you weren't  wasting time obsessing over your weight? 

Answering this question will get you to the root of what is really missing from your life.  You will feel more confident when you achieve your ideal body image.  You will have more energy and a better, more stable mood after you lose weight.  Looking past that, though, you may realize that working on the book you've had on hold for two years and laughing more and spending more time with friends instead will bring you to a much deeper level of happiness.  The best part about this is that these are all things that you can start working on while you're trying to lose weight.

Instead of obsessing over the weight loss goal by starving yourself and working your butt off at the gym, consider the other aspects of your life that need improvement.  The weight will drop if you clean up your diet and lifestyle, but it will stay off if you've taken care of the other things, many of which have nothing to do with the scale and everything to do with your relationships and personal life.  After all, is your goal truly to weigh less?  Or is your goal to find comfort in your skin, spend more quality time with loved ones, and to live more

Nathan Riley, MD, writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at  You can also connect with him on Google+. 

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Wednesday, April 23, 2014

Health Coaches - Bridging the Primary Care Gap

As I set foot into medical residency in July, one of my biggest concerns is the amount of time that I'll have to discuss diet, exercise, sleep, and stress with my patients.  My frustrations in medical school were the driving motivator to establish Sweat and Butter.  A physician is neither trained nor incentivized to promote lifestyle change in their patients.  Health coaches, on the other hand, have the training that the healthcare system currently lacks in preventing the nation's most expensive diseases.  Normally, I write lengthy pieces focusing on the science behind lifestyle change, but this time around I'm going to keep my post short and sweet. 

When Sweat and Butter speaks to groups of health care professionals (e.g. physicians, nurses, nurse practitioners, and physician assistants), the idea of a "quick fix" is the first thing that we feel compelled to dispel.  If you have ever tried to lose weight yourself, you know that it's more complicated than following a simple "eat this, not that" list.  Physicians and patients alike continue to exhibit silver bullet syndrome in their search for easy solutions to complicated, ingrained problems. 

The tendency to seek a quick fix is a big problem.  The willingness of health care professionals to treat symptoms pharmaceutically without simultaneously treating the underlying causes for their unhealthy lifestyle is a Gordian knot.  In many rheumatology clinics, for example, patients would prefer to continue to take strong, expensive medications for their joint pain and skin flare-ups as opposed to transition to a gluten-free diet in an effort to curb their symptoms. On the other hand, some conversation with patients around the barriers that they experience regarding cutting bread and pasta out of their diets might make this a less daunting task.  Pharmaceutical companies and health insurers have catered to an increasingly impatient population of sick people who have now come to expect a quick solution to their multi-faceted problems.  This is a positive feedback cycle with no end in sight, and, as the cost of treating obesity-related disease eclipses $200 billion annually in the coming years, we need to reassess our approach.

Sweat and Butter's approach to helping clients lose weight has several advantages over the typical support provided in an outpatient clinical setting.  

First of all, health care professionals don't have sufficient time with patients to fully elucidate a particular patient's obstacles to developing lasting, healthy habits.  On the other hand, our health coaches spend sixty minutes on average during their first session with a client. During this session, which we call a "health history", we direct our questions to unveil the client's fears and their preconceptions about what it means to live a healthy lifestyle.  We get to know every detail of the client's life as it pertains to their lifestyle goals. In the clinic, you simply don't have the time required to understand these barriers.  

Second, you can't bill insurers for the effort required to build deep relationships with patients. Currently, a few major health insurers cover health coaching, but the programs are usually insufficient.  At Sweat and Butter, several of our clients have come to us skeptical of health coaching because the coaching service provided through their health insurer was less than adequate.  It isn't the advice that is lacking; it's the approach.  An occasional, impersonal phone call isn't going to build trust or keep patients accountable.  Our coaches meet with clients in person or on an internet service like Skype every two weeks, enabling us to gradually develop a trusting relationship.  It is important to recognize relationship-building as an important aspect of behavioral change for your patients.  Once we have proven that personal health coaching is a potential means of reversing preventable disease, health insurers may improve compensation.  

Third, in the short time allotted to counseling patients, health care professionals are probably giving incomplete advice.  In preparing his presentation for the 2014 PaleoFX conference, a friend asked me to browse my entire medical school curriculum to gauge the amount of training that I had received on counseling patients in lifestyle change.  My search revealed a paltry three lectures, and they were outdated, focusing on BMR and "calories in, calories out" as opposed to the science behind behavioral change.  When health care professionals do manage to squeeze in some advice in the outpatient setting, it's hasty and generalized.  For various reasons, patients have begun to tune physicians and other health professionals out. Furthermore, because it is reserved as an after-thought in the outpatient setting, weight loss and dietary advice is met with defensiveness.  Is it any surprise that your patients return six or twelve months later without having lost weight or without having made any lasting changes to their diet?  It shouldn't be.  If an engineer fails to complete a task with a specific type of valve, for instance, the failure doesn't trigger her to think, "Oh!  Maybe I should just use two of these valves."  She is more likely thinking, "I guess that won't work.  Time to try something new."   Likewise, in an effort to motivate patients to change their lifestyle, you are using an approach that has failed time and time again.  Instead of continuing to blame your patients for their failure to practice a healthy lifestyle, let's change things up.

As health care professionals, it's time to admit that you need help in the area of lifestyle modification.  As medical school curricula attempt to accommodate the rapidly expanding field of medicine, the study of behavioral change is being crowded out.  Health coaches are a special breed that can connect with your patients in ways for which you have neither the time nor training.  At Sweat and Butter, we are collecting testimonials and data that lasting lifestyle modification is possible for even the most difficult patients.  

The advice that we provide our clients is similar to the advice that you are hopefully providing in your office, but getting patients to change their ways will likely require much more than that. Your patients need to be heard, and you need to respect the complicated nature of behavioral change.  Some of the obstacles that we reveal in our clients have nothing to do with diet and exercise.  In our practice, we work with clients on five factors: sleep, stress, movement, diet, and relationships.  Some clients seek weight loss; others are chronically stressed out and sick because of it.  Regardless of their goals, they need help in prioritizing their lifestyle to feel better.  

A cookie-cutter approach isn't going to work.  Health coaching is a resource that needs to be tapped into as a bridge between patients and their primary care clinicians.  At Sweat and Butter, we have an approach that has been proven through experience to meet your patients' needs between office visits.  We help to foster lasting, healthy habits by challenging clients to make small, realistic adjustments, one baby step at a time, which allows for sufficient reflection on successes and failures.  This is the missing piece in your efforts to motivate patients to live a healthier lifestyle.  If we collaborate, you will gain time, insurers will save money, and your patients may achieve lasting well-being.   

Nathan Riley is a 2014 MD candidate at Temple University School of Medicine.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at  You can also connect with him on Google+. 

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