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By Michelle Levine, OMS IV Rocky Vista University College of Osteopathic Medicine, Colorado, Class of 2019 If you’ve struggled with your weight, as so many of us have either intermittently or continuously in our lives, I hope you already know that you’re not alone. That your self worth does not rest in your physical appearance. You also probably know many or all of the various types of diets suggested in our culture to lose weight and be healthier, and have likely tried many of these diets in hopes of more energy, fewer necessitated medications, and maybe even a bit of the prestige that accompanies a slim physique in our modern society. In struggling with obesity, it is not only our bodies that are affected but disproportionately our minds and our spirits as well. The Obesity Code by Dr. Jason Fung translates his experiences as a physician treating obesity into terms that are easily understood, relatable, and backed by various scientific studies. His perspective on obesity will offer validation of your prior dieting efforts as well as explanations for why diets fail despite continued compliance. He explores how we arrived at such overwhelming rates of obesity as a culture as well as the role of each of the macronutrients in our diet. He also offers steps that you can take to reduce your weight and improve your overall health, focusing mainly on the type and timing of food consumption but also acknowledging the roles of exercise, sleep, and meditation in creating a balanced picture of health. Dr. Fung presents a hormonal theory of obesity that integrates our bodies’ tendency to self-regulate with the effect that eating has on insulin levels. He suggests a diet that minimizes blood insulin levels and fights insulin resistance with short periods of fasting. The diet he recommends reflects a healthy balance of whole unprocessed foods. His theories about obesity are well supported in scientific literature, although his interventions have not yet been accepted as superior to other diets and further research in this area is needed. In my own personal experience since reading the book, I have done a fast of about 30 hours and found it to be achievable with the right mindset and not disruptive to my normal activities. I have done more frequent and shorter fasting intervals of ~16 hours and found this to help decrease cravings and allow me to make healthier food choices. Although I will need much more time to fully evaluate the effects of these practices on my own body, the relationship between insulin and the body’s homeostatic mechanisms to control weight fits well into my greater understanding of physiology. Join the Conversation!What are your thoughts on The Obesity Code? Leave a comment below, and join us in January 10th 2019 for a live book group discussion at our office in Denver. Click for more details.
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 There are SO many fad diets out there that it is hard to keep up. Since I get asked a lot about what is currently popular, let’s focus on the diets that were most common to try last year according to the survey by a survey by the International Food Information Council Foundation. If you have questions about others, just ask! Intermittent Fasting The basics: Intermittent fasting describes a pattern of eating, incorporating periods of low to no caloric intake, but not necessarily what to eat. The ideas and interpretations vary, from limiting your food intake to certain hours of the day (e.g. 8am-6pm), to certain days of the week (e.g. fasting on Saturdays), to certain longer periods of time (e.g. fasting for consecutive days during the year). One of the theories behind intermittent fasting has to do with our insulin response. When we eat, food gets broken down into building blocks. Carbohydrates are broken down into glucose, which, when it enters the bloodstream, then triggers insulin to be released. Insulin is responsible for getting that glucose out of the bloodstream and into brain and muscle cells (for energy), liver cells (for storage as glycogen) and fat cells (for storage as fat). Too much insulin can cause cells to be less responsive to it, leaving glucose in the bloodstream to wreak havoc, a condition called insulin resistance. When we don’t eat, we don’t release insulin and therefore, we don’t put as much into storage and instead, force our bodies to take energy out of storage, thereby causing weight loss and reversing insulin resistance. Intermittent fasting can often be done in conjunction with a specific eating plan, like the Paleolithic diet or “Paleo.” Why try it? The main reason people try this eating pattern is to lose weight. Fasting can affect different hormone levels in the body (besides insulin) that lead to weight loss. Fasting and cutting down on snacking in general can improve insulin resistance as reviewed above. A 2017 review in the Annual Review of Nutrition cited limited data suggesting that intermittent fasting can offer protection from heart disease and cancer as well as some neurodegenerative diseases (like dementia). Think twice: This is not a silver bullet. More robust studies are necessary to confirm that those benefits are real and significant. Fasting is a physical stress on the body and can trigger cortisol response which may cause fluctuating energy levels and interrupt sleep. It can result in low blood sugar, fatigue and delayed cognition (brain fog). Fasting may not be safe in pregnancy or in patients with certain health conditions like diabetes. Learn more about intermittent fasting with us!We are reading The Obesity Code by Jason Fung MD for our book club this month. Pick up a copy and join in the conversation! Email us if you are reading along! Paleolithic Diet or “Paleo”The basics: The Paleo diet consists of eating foods that can be hunted and gathered, like our “caveman” ancestors. This means cutting out things like grains, dairy, legumes, processed foods, processed sugar. This generally results in a diet that is high in lean protein, high in fiber and low in carbs. One hypothesis behind this choice in nutrients is that our bodies are not genetically equipped to process a diet created by farming practices because this change happened more quickly than our bodies were able to adapt. Why try it? Paleo is considered a healthy diet as it generally contains lot of veggies, fruit and nuts. By cutting out processed and high sugar foods, weight loss is inevitable, other health benefits of Paleo may include improved insulin resistance, blood pressure and cholesterol cholesterol parameters (as suggested by this review in the American Journal of Clinical Nutrition). Think twice: Whole grains, legumes and dairy can also be part of a healthy diet and contain other vitamins and nutrients (and in the case of dairy, calcium) that are important for good cellular growth and function. Getting grass-fed meat/wild game can be cost-prohibitive for some. And, as in intermittent fasting, there are no long term studies to prove the health benefits are significant and outweigh potential risks. In fact, the Australian Family Physician published a good summary of study results on the Paleo diet and there just isn’t enough good data. Besides, do we actually know if cavemen were healthier because of this diet? Low-carb The basics: A low-carb diet limits the amount of carbohydrates you consume and instead promotes higher protein and fat intake. The idea is based on the fundamental fact that your body prefers glucose as its energy source. When you consume carbs, they get broken down to glucose, so your body is happy. Any extra glucose gets stored as fat. But, if you cut down on carb intake and eat fat, you are forcing your body to breakdown fat to create ketone bodies, which your body uses as a substitute for the glucose. This state is called ketosis. There are many variations of this diet based on the amount of carbs that are recommended. The quintessential low-carb diet is the Atkins diet, which allows 5-15% of carbs. In recent years, the Ketogenic, or Keto, diet has made a comeback and this diet allows from <5% to 10%. The focus with the Keto diet is heavily leaning toward fat. The South Beach diet can be considered a modified low carb diet--though it does not restrict carb intake, it shifts the focus to healthier (lower glycemic index) carbs, lean protein and healthy fats. It also promotes eating 6-7 times per day. Why try it? Again, many people choose this type of diet to lose weight. Weight loss is achievable on this diet. Low-carb diets may also improve your blood sugar and insulin response. As of yet, there is no evidence to show there are any heart health benefits from following a low-carb diet. Think twice: Low-carb diets, especially severe/strict low-carb diets can result in vitamin or mineral deficiencies since they limit nutrients found in whole grains, fruits and vegetables. Ketosis can have side effects as well, including gastrointestinal disturbances, nausea, bad breath, headache, mental and physical fatigue, kidney stones, and dehydration. The classic ketogenic diet was initially developed as an intentionally extreme diet (used to treat seizures in children) and required physician supervision in the hospital during initiation because of the risk of complications. Intentionally putting yourself in ketosis may not be safe during pregnancy and while breastfeeding. MediterraneanThe basics: Inspired by eating habits of the Greeks, Southern Italians and Spaniards, this diet encourages intake of plant based foods (fruits/veggies, whole grains, legumes, nuts), choosing fish and poultry in moderation, limiting red meat, replacing butter with healthy fats like olive oil. It does allow for red wine in moderation and also encourages regular exercise as part of the plan. The specific diet may look slightly different from region to region, but follows those general guidelines. Why try it? The Mediterranean diet is one of the most well studied diets over the past decade. Consistent data point to the heart health benefits of the Mediterranean diet. Meta-analyses (read: statistical gymnastics on data from multiple studies) such as this one from the journal Nutrients have also shown an association between following the Mediterranean diet with lower risk of coronary artery disease, diabetes, cancer and dementia. Think twice: The Mediterranean diet can be difficult for people who have food intolerances, like gluten or dairy, though substitutions can be made easily. In general, there are not many drawbacks to this well-rounded lifestyle plan. Vegetarian/VeganThe basics: Vegetarianism is a diet that excludes all meat, but may (or may not) animal products such as milk/dairy, eggs, honey. There are many variations on being vegetarian, such as lacto-vegetarianism (vegetarian diet but includes dairy), pescatarianism (vegetarian diet but includes fish). Veganism is also a type of vegetarian diet which excludes all meat and animal related products. Why try it? People choose a vegetarian diet for a variety of reasons, from animal welfare to religion to sustainability and carbon footprint. Diets that emphasize consumption of veggies, fruits, legumes, whole grains, seeds and nuts are naturally low in saturated fats and higher in fiber and vitamins and minerals. Some studies, such as this suggest longevity, heart health, lower risk for diabetes as benefits of a vegetarian diet, but I did not find many randomized controlled trials (the gold standard) evaluating these benefits. Think twice: A healthy vegetarian diet takes planning. Vegetarian sources of iron, calcium, zinc and in particular are not as well absorbed as meat sources of those same nutrients. B12 is only found naturally in animal products, but can be fortified in some vegetarian products. Vegans in particular need ensure adequate calcium, Vitamin D and omega-3 intake. It is also particularly easy to consume higher amounts of processed foods (calling yourself a vegan with a diet of orange soda, potato chips and veggie burgers isn’t necessarily healthier). If you try vegetarianism is important not to simply avoid meat, but to diversify the plant protein sources in your diet by doing things like eating more beans and lentils. Weight loss plan such as Weight WatchersThe basics: Weight Watchers is a popular weight loss program, having survived many diet trends, and has created a name for itself around the world (30 countries?!). Weight watchers encourages healthy eating and regular exercise to lose weight by creating a calorie deficit. The program has simplified nutrition label reading using a system of “SmartPoints,” which assigns points to a food based on calories, saturated fat, sugar, and protein. Why try it? The program does not restrict any particular food and can be easily adapted to any food preferences or diet. Weight Watchers has online tools, coaches and brick-and-mortar studios to allow for more accountability, guidance and flexibility. A systematic review in 2015 showed that participants lost 2.6% more weight than the control group at 1 year. Over the long term, new habits are created and can lead to successful weight loss and maintenance of goal weight. Think twice: This program is focused on weight loss and may only be accessible to people who can afford the $45/month. It also doesn’t distinguish between good and bad calories, so theoretically, you can allocate all of your points to “treats” and eat lots of zero point foods to balance. DASH DietThe basics: The DASH Diet was initially developed by the National Heart, Lung and Blood Institute as Dietary Approaches to Stop Hypertension, but is now being promoted to help with weight loss. It encourages intake of fruits, veggies, low fat/nonfat dairy, whole grains, lean meats/fish/poultry, nuts and beans. Sweets, sugar-sweetened beverages, and foods high in saturated fats are limited on this diet. To lower blood pressure, the sodium limit is at 2300mg/day or for even more lowering, 1500mg/day, encourage intake of potassium, magnesium and calcium instead. Why try it? Multiple NHLBI studies (DASH trial, OmniHeart and Premier) have demonstrated lower blood pressure and LDL cholesterol in patients who follow this diet. The DASH diet website suggests it is the American version of the Mediterranean diet. This diet does not restrict any food categories and encourages high intake of fiber and heart healthy fats. Per the 2010 Dietary Guidelines by the USDA, The DASH diet was promoted as a type of diet that followed the Guidelines. Aside from the blood pressure lowering benefits, you may find weight loss, improved heart health, and lowered risk of diabetes and stroke as additional effects of following this plan. Think twice: Low-fat/nonfat dairy can also mean added sugar and lower protein levels for some, this isn’t better. However, as it is relatively well balanced and can be modified for a variety of tastes and food restrictions, many people could adapt this as part of a sustainable lifestyle plan. Whew! Can you believe this was only a fraction of the fad diet plans that are out there?! If you have questions about other specific eating plans or want to review if any of these might be right for you, schedule an appointment and let’s talk! Dr Lisa Nguyen Sources include links above as well as Wikipedia and The Mayo Clinic. Other useful resources: Current USDA Dietary Guidelines Harvard TH Chan School of Public Health - The Nutrition Source
 Open House for Open Enrollment: Why Add Direct Primary Care to a High Deductible Plan?Thursday November 1 from 5:15-6:30 PM. RSVP so we can save you some hors d'oeuvres! This time last year, I decided to do the math to see how much our clients can save when they switch to direct primary care. We know that many people choose to see us because they like the that we offer traditional primary care for the whole family combined with a holistic approach. However, at the end of the day healthcare dollars drive many decisions and we want to be sure that we generate not only value, but savings. I compared this year to last, which was fun at first but not much has changed. Unfortunately what is being offered on the insurance exchange has even higher premiums than last year. I performed a search on the Colorado exchange, Connect for Health Colorado. Using a family of four here’s what I found:  Combining a high deductible plan and Direct Osteopathic Primary Care, a typical family of four ends up saving an average of $849 per month on premiums compared to having a low deductible plan. That is a 44% savings! But high deductible plans make people nervous. That is where direct primary care comes in. For our members, the deductible is reserved for a “collision” with the healthcare industry - a true emergency or surgery. A typical family of four ends up saving an average of $849 per month with DOPC plus a High-Deductible Insurance Plan. Our clients don’t need to save money for an unnecessary urgent care or an emergency room visit. Because patients can always get a hold of us when something comes up and many urgent visits can be handled quickly when care is at your fingertips. That way, health care dollars can go further and be applied to prevention and proactive health habits. Your health insurance becomes more like your car insurance - there to cover you when you need it. Direct primary care acts like your oil changes and gas - you don’t expect your insurance to cover this low cost maintenance but you do it because it keeps your car healthy for longer.  When it comes to health care costs, we all know that this isn’t just about your premiums. It's about all of the hidden costs of care that direct primary care eliminates. Co-insurance, co-pays, bewildering bills that come months after care, unanticipated. This past year we have seen healthcare bills brought to us that are appalling. More and more, we see the value of circumventing insurance for the little things because our patients benefit. Save your insurance for high cost care, that is what it is designed to cover. Our in-office pharmacy beats Walmart and Walgreens on generic medications. Then we come to prescription drug costs. Some of our current members do not even know that we can beat Walmart and Walgreens on generic medications through our in office pharmacy. So let’s say that your family of 4 joins direct Osteopathic Primary care and one of your family members is fatigued, gets a lab panel with a discount. The other moves their prescription for lisinopril over to our in house pharmacy. Now look at the money saved!  How Much could a Family of Four Save with DOPC?
This doesn't even include the cost savings we provide by including all office visits in the membership fee and not charging extra for procedures or urgent visits! At the end of the day our office uses the direct primary care model because we love establishing and building relationships with families. It is also nice to know that our clients can save money too. We hope you can join us and bring your loved ones! Open House for Open Enrollment: Why Add Direct Primary Care to a High Deductible Plan?We know you probably have questions about how all of this is possible. Open Enrollment starts November 1st for the Colorado Health Exchange. Join us for an open discussion, questions and answers about adding direct primary care for your family this year.
Thursday November 1 from 5:15-6:30 PM. RSVP so we can save you some hors d'oeuvres!  One of the most frustrating things in family medicine is when a patient comes to me with a host of symptoms, I order testing, and everything comes back normal. It’s NOT in your head, I swear! For some people, the more obvious stomach ache or change in bowel habits gives a clue to food being the culprit, but for others, it’s a change in behavior, headaches, or mood changes. Other times it can be breathing problems, joint pain, rash, weakness or just not feeling well. These latter symptoms don’t always lead people to look at their diet.
Just about everyone has heard of the saying, “You are what you eat.” And nowadays, research is clarifying a fascinating connection between your gut and your mind. I often turn people to elimination diets to help parse out the relationship between their symptoms and food. Of course, we can do food allergy testing, but these test results don’t always add up to real-life symptoms: One can test positive for egg allergy, for example, but has eaten eggs all of their life without problems. This can be because the test is looking for a true allergy (immune reaction) and what the person is experiencing is actually an intolerance (difficulty digesting). Even then, sometimes the problematic agent is not something we can easily test for. People can be affected by food additives or coloring too. Elimination diets, while there are many, are generally made up of 2 phases: elimination and reintroduction. They are pretty straightforward, but do require commitment and planning. The majority of elimination diets, are about 6-8 weeks long for both phases.
Some popular elimination diets include the Whole30 (cutting out inflammatory foods), Conscious Cleanse (changing the way you pair foods), low FODMAP diet (FODMAPs are short-chain carbohydrates that some people cannot digest), and the Feingold Diet (removing food additives and coloring). Gastroenterologists found that the Six Food Elimination diet helped reverse Eosinophilic Esophagitis, a condition of the immune system that masquerades as gastroesophageal reflux but is really allergy related. Depending on your current diet and your symptoms, one may be better for you than another and you may need to try more than one type of elimination diet (avoiding histamine provoking foods and food additives, for example). My general approach in working up symptoms through diet is to start with an elimination diet as a way to collect more information. Keeping a diary/journal is very important during an elimination diet, I recommend it during the elimination phase as well, starting with an inventory of symptoms before you eliminate anything. Be sure to be slow and methodical about the reintroduction phase. It’s best to work with your doctor or a nutritionist especially during this phase so you can maximize learning from the sneaky delayed reactions that happen with some food groups. At Direct Osteopathic, we also add in supportive supplements, hoping to reverse reactions by rebalancing and healing the microbiome. This fosters resilience in your gut so that minor food reactions don't cause significant symptoms, which allows people to maintain a more balanced diet. Getting back into the driver's seat with food that makes you sick is very empowering. Many elimination diets are too restrictive to continue on an on-going basis (unless, of course you are affected by ALL of the foods you cut out!). Ultimately, eliminating what causes problems and keeping in what doesn’t is more sustainable and, frankly, more enjoyable. You are what you eat, but you can’t let what you eat control who you are! Have you thought about doing an elimination diet? Need some guidance? Schedule your visit or consultation with us, we can dive right into it with you. Dr Lisa
In case you missed it watch our video to find out:
 Welcome Fall!
It is officially here and I am overjoyed! I am among many who enjoy Fall. Like others, I love taking in the briskness each morning, sweater weather, cozying up to a warm drink, a sense of getting to slow down a bit, and of course, FOOD! Besides all the chilis and soups and stews that you can make, there's football, Halloween, Thanksgiving, Hanukkah, Christmas and MORE football! This always seems to be a double edged sword for people: on the one hand, it is such a social time, family and friends, so many excuses to get together. On the other hand, there is SO MUCH FOOD! And with that, we are faced with so many temptations to pull away from our healthy habits. The International Food Information Council Foundation found that 36% of Americans have tried a specific eating plan in the past year. Interestingly, this past year the fad diet of choice was intermittent fasting (stay tuned, we are going to dive into that). Nowadays, it's not just for weight loss. Countless people are realizing that some foods are making them sick. Or they just don't feel well and want to explore whether food is the culprit. Others have been diagnosed with a condition that forces their diet to change forever more. As we approach the season of celebration, being on a diet becomes more than just discipline, it is exponentially more stressful. You'd think I was crazy then, when I decided to do the Whole30 a couple of years ago, in October. The Whole30 is an easy to follow diet that is essentially an elimination diet with a paleo focus. But it was hard for me. We were ramping up for cold and flu season and all I could think about was food. Planning food. Cooking food. The next time I could eat food. But by the end of it, I felt better: my face was clearer, I had more energy, I didn't get "hangry", I hadn't realized that I was perpetually bloated until I wasn't anymore. And then Thanksgiving and the rest of the holiday season came and habits returned. The benefits were short-lived, but the experience was eye-opening. I know that I would feel better repeating the Whole30, when I muster up the focus and determination again. Starting this Fall, we are launching an educational series, with a new topic each quarter. As we continue to learn, you can too! Our first topic, in light of the nature of this season, will be on Nutrition. In family medicine, I get a variety of patients, from those who are dealing with health problems such as diabetes, thyroid problems, or IBS to those who just want to lose some weight and I often get asked, “What diet should I be on?” This is a difficult question to answer and in fact, I don’t often have a "one size fits all" answer! Each person is so different and the health problems they have are so varied, there is never just one answer, let alone an easy one, to that question. However, this fall, we will review the most popular eating plans so that you can understand what's out there and decide if any of them are right for you. If you want a more detailed, personalized plan you can always see me for a consult, I love guiding people through this process.What if you just want to lose weight?? We'll talk about that too, from factors that impact weight to all the different options, including medications and surgery. As your healthcare providers, we strive to stay up to date and are constantly learning. Our goal is to build a platform to facilitate information sharing and exchange so that you can make informed decisions about your health as you head into the extravagance of the holiday season. Join us as we all continue our journey towards wellness. Dr Lisa Nguyen
October brings the beginning of holiday foods and habits. Listen to this video for mindful tips on:
School is starting up again, and while it’s an exciting time it can also mean extra stress for students and their parents! Helping adults and kids calm the mind at bedtime is key to good, restorative sleep. Try this technique of progressive muscle relaxation. It’s good for all ages!
My kids are getting ready for school this week, as many are. This year they will be in 1st grade and pre-kindergarten. I am struck by the courage they have inside as they face this transition. Shopping among the back to school isle at Target today, I noted that every mom was heads down reading off their phones to check off the list of supplies requested for another year. Much has changed since you bought a trapper keeper, a pencil holder and a ream of three-hole punched paper and considered yourself prepared. My daughter is convinced her new teacher is “her favorite” and is counting the days to see her friends again. My son is still not in complete realization that he will be changing schools. He makes the transition to the elementary school setting this year and big days are ahead.
A few new clothes ease the transition between our summer vacation and brave new world. I can see and feel the excitement in them, laced with the nervousness that we all have during times of change. I observed some of the same this past week in the first Osteopathic manipulation lab I taught at Rocky Vista. The new first year medical students are getting to know each other, asking the usual, “Where did you go to undergrad?” Everyone is settling in. Nervous. Anticipating. Change abounding. Facing these transitions truly does require courage. Courage, “the ability to do something that frightens one” according to Google, or per Merriam Webster “mental or moral strength to venture, persevere and withstand danger, fear or difficulty.” Is courage mental and emotional? Is our ability to flex with change endogenous – natural and inborn? Do we learn to cope with change from our environment – how we observe those around us that teach by modeling? It is the age old question: Nature or Nurture? I am certain, it is a bit of both. Our neurotransmitters strongly influence how we respond to the stressors around us. In testing neurotransmitters over the past few years, a newer approach to holistic mental health, I see there are subtle, but real variations. Some have more of our calming neurotransmitters – serotonin, gaba. Too little of these players can cause a tendency toward depression or anxiety. Others have an excess in the excitatory neurotransmitters – glutamine, dopamine, norepinephrine and epinephrine. Too much of team excitatory puts your body always on edge, like fight or flight – ready to jump at any moment. Of course, there are many things that impact neurotransmitters from your parents to their parents, and their parents, etc. Traumas or joys of early childhood impact brain chemistry. Drugs, alcohol and even smoking can change things from a moment to moment basis, and even long term. And some of neurotransmitter balance is simply, “how you are.” Luckily, there are the things you can do to control how you feed into this system. Eating a diet high in health proteins and amino acids increasing the building blocks available for your nervous system. Sleeping adequately and with good quality has tremendous impact on your brain. Even breathing shifts our mental and emotional state. Meditation and exercise impact your mind. Being aware of “cognitive distortions” can help you figure out how to work with the neurotransmitter make up that you have at this moment, with this stress and in this situation. That is a skill that takes practice, but it can become stronger that even the genes you were given. Learning, modeling and teaching coping skills is essential if you are a parent. If you are a parent to no one other than yourself, understanding how you cope with stress remains and important. I often ask patients, “How do you cope with stress? What are your healthy and your unhealthy coping skills?” We all know that we have both. In times of stress and transition, how can you parent yourself to get outside and move your body instead of go home and distance the worries with wine or chocolate? Now there is a time and place for everything, so don’t give me a reputation for being that doctor that recommends against wine and chocolate. We all need anti-oxidants after all! We can learn from our children. We can watch them as they approach the new year with nervous excitement and calm courage. We can talk about healthy ways of working with being anxious to start new things, meet new people and push ourselves. We can acknowledge the bravery we see. We can remind our each other that it is normal to go into school with a belly of butterflies and a mind full of mixed emotions. This goes for moms and dads too! Here’s a few tips for all of us as we transition from the fun of summer to the discipline, structure and routine of fall.
Cheers to another school year. And to fall, the arrival of cool weather, the change of leaves and, of course, football… Dr Brie |
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