Happy New Year!

Hope the holidays treated you well and you are full with family, fun, and food! I know I am. When we started our quarter, we knew it was going to be a hard one. With high stress, lots going on, colds and flus and short days to top it all, we often seek comfort in the most familiar ways: tasty food, warm drinks and cozy blankets. 

This is probably why one of the top New Year’s resolutions are some variation of be healthier, eat healthier, exercise more, cut back on (insert less than good thing we are consuming to excess). Inc. reported that 5 of their top 10 resolutions were the above, with 71% wanting to diet or eat healthier. 

You probably already know this, but the stats are against you achieving your resolution. Why? Well, most likely because it’s far more complicated than the simple statement that makes up the resolution. Take healthy eating and weight loss, for example: after having read my blog on the different diets, you may have chosen to pick one and start it in the New Year. Did you also know that there are other factors that contribute to your dietary needs and weight control than just which diet you are on? Read on!

Stress

This seems like a no-brainer. When we are stressed, we don’t make the best food decisions (we can even make really bad ones). We forego our plans to exercise and we indulge instead. Most people are this way. Did you also know that when we are stressed, our body releases cortisol and this makes us GAIN weight? It does! Cortisol is responsible for regulating our metabolism, helps to regulate our blood sugar, regulates salt and water balance, our heart rate, blood pressure, our sleep, and our memory. When we are stressed, these functions alter then return to normal balance afterwards.

But when we are chronically stressed, we may see things such as poor digestion, increased blood sugar (even diabetes), increased blood pressure, poor sleep and memory, poor immune function (getting sick often), hair loss, slowed metabolism, low energy. How is this going to make it any easier to eat better and lose weight?!

Sleep

While sleep is not something that comes to people’s mind with nutrition or weight loss, it is so important! The average adult needs between 7-9 hours of sleep per night. If you get less once in a while, it’s what Dr. Brie likes to call NABD (not a big deal). But many people get less than 7 hours on a regular basis. When we don’t get enough sleep, our body doesn’t sense hunger/satiety normally. We tend be more hungry and crave high calorie, high fat and high carb foods. Not to mention, poor sleep also impairs our decision making and we are not able to resist cravings/temptations very well.

Poor sleep can slow your metabolism--your body is trying to conserve energy for increased waking hours. Being sleep deprived is also a condition of stress, and you know what that means? You got it, increased cortisol levels, which we just talked about. You’re also more tired and less likely to do physical activity.

Physical activity

While it would be easy to say,” Work out more and you’ll lose the weight,” it’s actually not that easy. Yes, physical activity will cause a deficit in calories. But often times, when you are working out, your body needs fuel to be able to sustain the activity and then repair itself afterwards. Some people eat more when they work out for this reason. It is important to eat enough calories when you are working out so your body does not become stressed (read: releases cortisol). It is important to note that exercise alone will not result in significant weight loss, but ongoing exercise can help tremendously with weight loss maintenance (see one of many studies).

Not only that, exercise helps to increase heart, bone and muscle health (your doctors will thank you), it helps manage stress and keeps you happier (bye bye, excess cortisol), and it will help you sleep better (regulate that hunger!).

Your social life

Humans are social beings and Coloradans especially love to celebrate everything that makes this state so fun to live in: the grand outdoors and our craft beer, all booze, really. (Anyone read this article in 5280?) Even if you don’t ski, mountain bike, rock climb, etc, social gatherings are yet another time where your healthy eating plans can fall by the wayside. Call it peer pressure, call it indulging, call it what you want. It’s harder to resist the beer or bar food when you’re with a group of friends. Seeing, smelling and being able to reach out to the french fries or wings or whatever is temptation waiting to win. Alcohol also can impair judgement, make you hungrier and adds calories!

Your job

Besides work adding the obvious stress, your work situation may make it difficult for you to stay on your bandwagon. On the go all the time? This makes it easier to want to pick up fast food or skip a meal. No lunch hour? You may be more prone to snacking throughout the day or bingeing when you do eat. Traveling? Less chance for a home cooked meal or meal planning. We won’t even talk about catered lunches/lunches out and office snacks or candy/cookie jars that park themselves at the end of everyone’s desk for convenience.

Your gut bacteria

Say what?! Yep, if you didn’t know it already, your gut bacteria may be playing a part in keeping your weight the way that it is. This Scientific American article is one of many that summarize current research on this association specifically. We know that the bacteria in our gut help digest things we can’t, making more calories available to us. They also can affect hormone production, altering the signals that tell us we are full or hungry. The bacteria can affect inflammation in our gut, calming it or increasing it by releasing certain chemicals based on our diets, thereby causing us to gain weight. No, there isn’t a probiotic for weight loss yet, but having a good diversity of bacteria and eating a variety of prebiotics (foods that feed our gut bacteria, usually high-fiber foods) is a good place to start.

Your medications and your health conditions

Yet another example of why it may be more elusive than you think to maintain a healthy diet and/or weight. Certain health conditions limit what you can eat and you may only be able to choose what you can eat rather than what you should eat. Take those who are doing a FODMAP elimination diet, for example, foods like asparagus, apples and some seafood are considered healthy, but are high in FODMAPs and thus need to be limited.

Certain medications can cause weight gain too, like medications for seizures and insulin, and it would not be easy to “avoid” these medications in some individuals.

It is important to remember that while it may seem easy to modify one or several of these factors, the reality is that eating healthy and maintaining a healthy weight are not easy things to do. Because, as I always like to say, “If they were, I’d be out of a job!” This doesn’t mean you don’t try to modify one or several of the factors mentioned above, it means that you modify what you can and don’t beat yourself up over the rest of it. Just keep at it, one step at a time. Healthy eating and maintaining a healthy weight should be lifelong goals, not just a resolution for this year.  And really, if getting better sleep, having less stress, being more active and having a healthy social life are things you can fold into your lifestyle and actually enjoy (who wouldn’t??), you’ll get full bragging rights on those successes, whether or not you lose weight—I promise.

Dr Lisa

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.

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.

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!

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.

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?

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.

The 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.

The 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.

The 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.

The 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

• Find out how phones activate the pleasure center in your brain and cause dopamine release, very much like a slot machine habit or addiction!
• Learns ways to set limits with technology so you can be in control
• Use mindfulness to figure out how to have healthy technology habits

Articles to consider, read and share:

• http://sitn.hms.harvard.edu/flash/2018/dopamine-smartphones-battle-time/
• http://www.tristanharris.com/2016/01/distracted-in-2016-welcome-to-mindfulness-bootcamp-for-your-iphone/
• http://humanetech.com/take-control/

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:

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.

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! 

In case you missed it watch our video to find out: 

• Why we are focusing on nutrition this fall
• What we have done to prepare ourselves and nutrition focused family doctors
• Upcoming events 
• Details about our new book club!

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: 

• How to bring your awareness into habits by "urge surfing" 
• Bringing in your full mindful awareness while eating to savor delicious foods (and eat less of them because you pause to actually appreciate them) 
• Why it is important to slow down and let your "rest and digest" nervous system do its job

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!