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.

#awesome
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 nathan@sweatandbutter.com. 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 vedant.g.desai@gmail.com.





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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.


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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 nathan@sweatandbutter.com. 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 nathan@sweatandbutter.com.  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 nathan@sweatandbutter.com.  You can also connect with him on Google+. 




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Wednesday, April 9, 2014

A Mud Race: Your New Goal For the Summer

My legs were feeling stiff from the mud that was caking on my skin, making it uncomfortable to bend at the knee as I ran.  I knew what whatever lied ahead was going to test my strength, but I was determined to press on.  While on the trail I was able to assess my condition, and I realized that my bruised legs would be horrifyingly black and blue for days to come and the scratches that I had accrued were starting to sting.

I laughed a little under my breath as I jogged on: "Why I am doing this to myself?" I was surprised that my response was an instant and resounding, "Because it's not often that we get to play like this!"  It's true!  No matter how crazy some of the obstacles were throughout the Tough Mudder, I was loving life at every step.  Being outdoors, challenging myself mentally and physically, surrounded by friends and helpful strangers was a breath of fresh air.

I have never been an athletic person and even less of a competitive opponent.  My first Tough Mudder was an intimidating venture, because I thought that I was going to be the weakest link in the team, and I feared the embarrassment of failure.  It is important to physically prepare for these events so that you minimize the risk of injury.  At that time, I  maintained a relatively relaxed workout routine, though I by no means trained diligently for the race.  From the beginning I was supported by friends that assured me that it was going to be a day dedicated to team work and fun.  
Turkey leg, no manners and no cares

If you have ever considered the challenge of an obstacle course race, I highly recommend it! There are people of all different shapes and sizes that take the challenge, and the entire day is loaded with a palpable positive energy.  I was pleasantly surprised to realize that no matter what physical condition you may be in there are obstacles that can hit everyone's strengths and weaknesses.

I found it endearing when I came across a large beast of a man who was hesitant to start one of the obstacles.  The burly guy was nervous about crawling through an underground tunnel that was pitch black once you were inside.  I coaxed him in by telling him that I would follow closely behind him for support.  We both made it out on the other side and he gave me huge bear hug because I had helped him through his fear of confined spaces.  Thankfully we kept bumping into one another at other obstacles, and he was able to hoist me over huge walls that I could not do on my own.

I have a few of these under my belt now.  Without fail, I cry at the end of each race.  To be honest, I'm not exactly sure why I get so emotionally overwhelmed, but I do know that the entire day of activities exhausts me.  After a good 20 seconds of emotional release, happiness overrides and hunger proceeds!  It is important to fuel up after such rigorous activity, and let me tell you that the first meal after the event is a glorious, well-earned experience.  

My favorite parts of these kinds of events are as follows:

"Let's get weird"
* The only one you are competing with is yourself! - The challenges are fun and unique to test your abilities.  If you are unable or unwilling to do one of the obstacles you are free to walk around and skip it.  I loved feeling free  to laugh at myself during my failed attempts, and I relished  the feeling of success when I completed an obstacle.  I finally completed the monkey bars on my 3rd Tough Mudder, and I couldn't have been happier.  High-fives never felt so good! 

* You get to move your body like a kid again - I never realized how liberating it was to run, jump, crawl, swim, reach and stretch!  I was brought back to the feeling of recess where everyone just let loose and had fun.  I definitely had to push myself to complete the race, but I enjoyed the opportunity to move my body in ways that I do not do on a daily basis. 

* Camaraderie - The whole day is full of those connections that Sweat and Butter tells you to seek out. We explain the importance of being present and mindful with yourself and others. They are not necessarily life-changing interactions but having a the same goal as everyone else, people cheering you on and even simply acknowledging the people around you makes for a special environment.  

* The challenge - I cannot tell you enough how much self doubt I discovered during these events.  Knowing that I had all day to complete the course gave me some solace, but I had to counsel myself just to keep going. The course allowed me to take physical obstacles head on even when I knew that failure was almost a guarantee.  It was clear to me that, whether obstacles were physical or mental. overcoming that self doubt requires a first big step.  I have been able to translate that experience into many life experiences such as avoiding a big project that needs to be done at work where the pressure was too daunting to even get started.  This fueled many ah-ha moments for me throughout the day.  I enjoyed proving myself wrong over and over again by saying, "See you can do it!" 

If you have been curious about doing one of these events I suggest that you leave your reservations at the door and sign up!  Get a group of friends together and make it a bonding day for everyone.  You can dress up around a specific theme or just go in with the ultimate goal of pushing yourself past your comfort zone.  If you have been needing some extra encouragement, having a goal like an obstacle race is also a great motivator to get active and stay healthy throughout the process before the big day.

Curious? Get pumped!

**Disclosure: I am not writing on behalf of or for the Tough Mudder or any other obstacle races.  All opinions are my own, and these are personal stories of my experience with races. 


Stephanie Telep is a co-owner and health coach at Sweat and Butter.  She received her training at the Institute for Integrative Nutrition and holds a bachelor’s degree in Psychology from Duquesne University.  She hopes to help others make necessary changes in their lives while fostering a positive and healthy attitude.  She can be reached at stephanie@sweatandbutter.com.





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Wednesday, March 26, 2014

A Story About Inflammation: Oils and Your Health

Here at the Sweat and Butter Journal, I write on topics about which I'm asked most commonly by our health coaching clients and workshop attendees, and oils top the list.  Understanding the nature of oils as they pertain to human health requires an understanding of "inflammation", a buzz word that can take on a wide range of meaning.  For our purposes, I will review the dangers of inflammation when it persists in the body as well as how selection of cooking oils/fats can exacerbate it.  

This article is rather dense.  If you are the type who found yourself spacing out in science class, here are the take home points:
  • The primary problem with oil consumption in our nation is that we consume too much omega-6-rich fat and too little omega-3-rich fat.  Both types of fatty acids are important to your health, but neither should be consumed in great abundance.  The idea ratio of omega-6-to-omega-3 is 2:1, but the actual ratio in the typical Western diet is 20:1.  This ratio promotes low-grade, chronic inflammation.
  • Seed and vegetable oils such as canola, safflower, and sunflower are rich in omega-6 fatty acids.  Wild-caught fish, walnuts, seaweed, and grass-fed beef are rich in omega-3 fatty acids.
  • Extra virgin olive oil will easily burn even under low heat, thus becoming oxidized and potentially damaging to your health.  It's best to drizzle olive oil on food that is already cooked.  Keep your olive oil refrigerated in an air-tight container.
  • Cook with unrefined coconut oil, palm oil, or butter or lard produced from grass-fed animals.
  • It's better to eat fish a few times per week than to supplement with high doses of fish oil.  If you don't eat fish, I recommend supplementing with a fermented cod liver oil/butter oil blend.  Keep this oil in the fridge and in an air-tight container.
Let's start with a little cell biology and biochemistry...
Image credit: http://www.biologycorner.com
This story begins at the level of the cell.  Each cell in your body is comprised of phospholipids.  The structure of a phospholipid permits a bilayer of these compounds to arrange themselves such that the internal environment of the cell remains tightly regulated.  
If you look closely at this image, you will see the fatty acyl ("acid") tails of the phospholipids labeled at the bottom right corner.  Here is an enlarged schematic of the structure of phospholipids: 
Image credit: http://textbookofbacteriology.net

These fatty acid tails (blue squiggly lines in the image to the left) help the cell membrane to keep certain things in and other things out.  As I mentioned before, the phospholipid bilayer is the gatekeeper.  Because your body tissues are regularly under physical stress, it's important that your cells are compressible and flexible.  A fragile cell will easily break open, which renders it useless. Fatty acid chains stack neatly together allowing phospholipids to sit very closely together in order to fully enclose the cell, but this neat stacking also tends to make the cell membrane rigid.  A rigid cell membrane is fragile, so this is not favorable.  Fortunately low-density lipoprotein (LDL) is constantly delivering cholesterol to the cell membranes of every tissue in your body, wedging it between the otherwise perfectly arranged phospholipids.  Though it may seem counter-intuitive, cholesterol helps promote fluidity in the cell membrane phospholipid bilayer, and this is important for the health of your cells.  

Image credit: http://www.lakemaryphysicians.com

Phospholipids are clearly important, but the nature of their structure can also lead to problems.  Their fatty acid chains are polyunsaturated fatty acids (PUFAs).  This type off fatty acid is great for use in the phospholipid bilayer because, as I've already mentioned, they can stack neatly beside one another, but this structure is also easily oxidized.   Oxidation is a chemical reaction whereby the multiple double bonds of PUFAs are broken and rearranged when exposed to oxygen, and these rearranged bonds are at an increased risk of forming free radicals.  
Image credit: http://www.bubblews.com

Free radicals aren't necessarily a big problem in small doses, because our cell membranes are equipped with special enzymes and antioxidants such as Vitamin E to repair damaged ("rearranged") fatty acid chains.  If they aren't repaired, free radicals will greedily steal electrons from nearby structures - i.e. DNA, organelles, other phospholipids, proteins, etc. - in order to stabilize themselves, but this theft is damaging.


OK.  Now, you're probably thinking, how do cooking oils fit into this picture?  Moving on.


Not All Cooking Oils Are Made the Same
The next chapter in this story will be a little more useful in the kitchen.  Every cooking oil that you see in the grocery store has a slightly different fatty acid profile.  The two major types of fatty acids that we must cover are omega-3 and omega-6 PUFAs. 

All of the omega-3s are derived from alpha-linoleic acid (ALA), whereas the omega-6s are derived from linoleic acid.  Several enzymes are required to convert these precursors to the the various omega-3s, such as EPA and DHA, and omega-6s.  The details of these conversions from precursors to useful fatty acids are found in the image below:
Image credit: http://clarecorp.com 
(Isn't it interestingthat the same enzymes are used in both pathways?!  This means that whichever 
pathway is supplied with more precursors will procede preferentially over the other.  Neat.)



Omega-3s are generally said to be "anti-inflammatory" and omega-6s are generally regarded as "pro-inflammatory".  The reason for this takes us back into the biology of the cell membrane.  As you can see in the image above, EPA and DHA are intermediates in the omega-3 synthesis pathway.  Both of these compounds are readily converted into anti-inflammatory substances.  On the other side of the image, arachidonic acid (AA) is an intermediate in the omega-6 synthesis pathway.  AA is readily converted into pro-inflammatory compounds.  The balance between EPA/DHA versus AA production is the fundamental root of inflammation in the body.  If you are producing AA at a higher rate than EPA/DHA, you are inflamed.  But what does it mean to be inflamed?  We'll get to that a little bit later.  For now, just understand that it's no bueno.  

Image credit: http://www.pureencapsulations.com
Until we can talk about inflammation, there are still a few important things to discuss about cooking oils.  Depending on its source, an oil will contain different proportions of PUFAs.  When you eat omega-6 PUFAs, they are incorporated into the phospholipids that comprise the cell membranes.  As you may have already guessed, if you are consuming more omega-6 PUFAs in your diet, you'll be producing more pro-inflammatory compounds via a higher proportion of AA versus EPA/DHA, as your omega-6-rich diet will provide a steady supply of precursors to feed the omega-6 synthesis pathway shown in the image above.  When the cell membrane is injured due to free radical damage or trauma, AA is produced and converted into the pro-inflammatory compounds mentioned before, namely LTC4PGI2PGE2, and PGF2.  
Below you'll find a list of common cooking substances and their relative proportions of anti-inflammatory omega-3s and omega-6s.  A low-inflammatory diet will have a relatively low proportion of omega-6s. Unfortunately, vegetable oils have been produced cheaply and abundantly since the 1960s, which marked the beginning of the demonization of saturated fats.  These oils - canola oil, safflower oil, sunflower oil, soybean oil, and corn oil, as seen in the chart below - are rich in linoleic acid (blue).  If you read the labels of most processed foods, you'll see that one or more of these oils have been slipped into the product.  Likewise, restaurants use these oils in the majority of their meals because they are so cheap.  This has meant bad news for consumers of the Western diet.  As I mentioned before, both omega-6s and omega-3s are important for the construction of healthy cell membranes, but the ideal relative proportion is 2:1, omega-6-to-omega3.  For the reasons noted, the typical Western dieter is likely consuming a ratio closer to 14:1 or 20:1! This means a greater opportunity for the production of AA and thus pro-inflammatory compounds. 

Image credit: http://www.susanallport.com
  

I recommend that you minimize use of omega-6-rich oils at the top of the list in favor of butter, ghee, lard, palm oil, and coconut oil

Before we shift the discussion to the dangers of inflammation, I want to make a few comments about extra virgin olive oil (EVOO).  This oil has been touted as a superfood for years, as it is consumed in high quantities by healthy populations that live in the vicinity of the Mediterranean Sea.  On the chart above, you'll see that olive oil is comparable to safflower oil in fatty acid composition, but extra virgin olive oil tends to be lower in omega-6s than more refined varieties.  Having said this, the omega-6 content of EVOO is still higher than the healthier options I mentioned before such as butter or coconut oil, so use it sparingly. Furthermore, EVOO burns easily even at low temperatures, which expedites the oxidation process.  As you'll recall from our discussion at the beginning of this article, oxidation is our enemy because it leads to free radical production in the phospholipids of our cell membranes. This free radical formation can trigger the conversion of phospholipid fatty acid tails to AA, which, as you know, easily converts to pro-inflammatory compounds.


The Final Chapter: Inflammation
It's time to come full circle.  We know that a diet rich in omega-6s may lead to inflammation, but what exactly is inflammation?

When we hear the word inflammation, we normally think of sore joints .  After running a marathon, your knees or hips may be sore and inflamed for weeks.  This is an example of acute inflammation, which occurs in response to injury.  It's easy to know that your knees are inflamed because they hurt and this may limit your mobility.  On the other hand, chronic inflammation is probably far less noticeable, which is why it's routinely referred to as "low-grade" inflammation.  This is dangerous because, unlike in response to acute inflammation, we don't always address chronic inflammation since it can often burn in the background without producing any dramatic symptoms.  After all, if you aren't experiencing any severe pain at the moment, how will you know you need to change your ways?  A little stress once in a while can set into motion cellular mechanisms that will make you stronger through a process called "hormesis", but a relentless bombardment of stressors can be destructive.  Chronic inflammation can persist for years, and serious disease processes are normally well under way before you change your ways through lifestyle modification. 

The pro-inflammatory compounds produced from AA in response to free radicals or other damaging trauma to a cell membrane set into motion physiologic mechanisms that help to repair the damage.  Evolution at its finest!  Prostaglandins and prostacyclins work to dilate blood vessels, allowing blood carrying immune cells to rush to the site of injury.  Leukotrienes raise a red flag to mark the site of injury in order to direct the immune cells that are brought to the site by the increase in blood flow.  These immune cells, namely neutrophils, go to work on the damaged tissue at the site of injury.  If they hang around for along enough, they also start to eat away at healthy tissue, disrupting the physiologic processes that keep us healthy, which is why chronic inflammation has been linked to so many chronic diseases, including cancer, heart disease, diabetes, obesity, and Alzheimer's dementia.  

To mitigate the inflammatory effects of an omega6-rich diet, you must aim to restore your omega-6-to-omega-3 ratio to 2:1.  First of all, reduce your omega-6 consumption by cutting out vegetable oils altogether.  Cooking with butter, lard, palm oil, and coconut oil tastes better and is better for you.  Likewise, you should increase your consumption of anti-inflammatory, omega-3-rich foods like fatty fish, walnuts, and seaweed.  Certain fish are richer in omega-3s than others.  Check out the graphic below.

Image credit: http://paleozonenutrition.com


Image credit: http://www.crossfitinvictus.com
Please keep in mind that PUFAs are naturally produced in chloroplasts in the leaves of plants! Fish that feed on algae (or fish that feed on fish that feed on algae) are rich in omega-3s because they feast on wild marine plant-life.  Farmed fish, on the other hand, are fattened up with soy products, which are rich in omega-6s. Take care to purchase wild-caught fish. Likewise, cows that spend their lives grazing on healthy, lush grass as nature intended will provide you with a healthier fatty acid composition when compared to cows that are marbled up at a feedlot.  Vegetarians and vegans argue that they can consume sufficient omega-3s on their diets.  Of course you can obtain a lot of ALA by eating flax seeds and other leafy plants, but our bodies aren't great at converting ALA to EPA and, in particular, DHA.  Our herbivorous critter friends help us out by munching plants rich in ALA, converting it into EPA and DHA, then stashing it away in their meaty flesh to the benefit of predators - us.
Modern feedlot
Image credit: http://blackboxfw.com

One note about fish oil supplementation.  Fish oil is often touted for its anti-inflammatory effects, but all PUFAs - both omega-3s and omega-6s - are at risk of oxidation and thus free radical formation, so consuming large quantities of even "healthy" omega-3-laden fish oil predisposes you to harm. Of all the fats you consume in a day, it's best to keep your PUFA consumption to around 1-3% of your daily caloric intake.  If you absolutely won't eat fish, taking just 1000mg (1g) of fish oil daily is sufficient to reap the benefits (although the clinical evidence on the beneficence of fish oil supplementation is a mixed bag).  It's thought that Vitamin E will prevent the oxidation of this high-dose PUFA supplementation, though this is also debatable.  Better yet, I recommend fermented cod liver oil/butter oil in capsule or liquid form.  This formulation provides ample Vitamin D, Vitamin K, Vitamin E, and Vitamin A in addition to sufficient omega-3s.  Keep your fish oil refrigerated in an air-tight container, as oxygen exposure increases the likelihood of oxidation. 

I hope this article helps you to understand the importance of selecting healthy, nourishing oils and fats for use in the kitchen.  This guide is incomplete in a lot of ways, but I didn't want to burden you with too many details.  I'll leave that to the guys getting their hands dirty in the lab. I'm only the messenger, and, as the messenger, I would be happy to answer any questions you have about the information presented here or to start a discussion if you want to delve even deeper.  


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 nathan@sweatandbutter.com.  You can also connect with him on Google+. 




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