The Physical

“I don’t have time for this. I have other patients to see.” Said my doctor, clearly indicating that I had used up all my allocated time for my yearly physical – or had finally pushed enough of his buttons. One or the other. It was awfully late and I thought I was his last patient. Perhaps it was true that he had other patients to see, or maybe it would have been more truthful for him to say: “I’ve had enough of arguing with you. I’m hungry and tired and want to go home and see my wife and kids.”

Either way I wasn’t offended. I am an exasperating patient. I am exasperating human in general, always questioning the obvious, asking questions that generate cow-stares or mild shock from those within earshot, or saying what I believe to be the unvarnished truth when it might be more prudent to just shut the fuck up.

In this particular instance of exasperating another human being, it was because my doctor, assessing my spectacular weight gain of 40 pounds since my last visit and a crappy total cholesterol count in the 260s, wanted to put me on statins – cholesterol-lowering drugs.

He showed me a worksheet from the American Heart Association that, when my crappy blood work numbers were plugged in, said I had a 14% chance of a heart attack in the next 5 years. He had done his homework probably because he knew I was a hard sell. We had the ‘statin talk’ last year when I was about 207 pounds and my total cholesterol was only a little elevated. I told him ‘no’ then.

And 40 pounds heavier and with really shitty blood work – the worst ever, I told him ‘no’ again.

I told him: “I have to be honest with you: I’m not a big fan of statins. They have not been shown to reduce all-cause mortality in patients like me and they also have a curious side effect, little discussed, of increasing the risk of violent death and suicide.”

My doc is a chill guy. I like him, though we don’t agree on a lot of things. I’ve mentioned this to people and they say: “Why don’t you change doctors?”

“Why? I’m not looking for somebody to always agree with me.” He’s smart and has a good 15 years of experience as a clinician. I also think he cares. He took the time to prep for me coming in by running that American Heart Association risk assessment. I think that counts as ‘going the extra mile’. He genuinely thought that he had the evidence to convince me – a seemingly rational and  medically knowledgeable layperson – to comply with his recommendation.

And I exasperated him by still saying ‘no’.

So I suppose I like him because, with nearly every relationship I have, there is a certain aspect to it where the other person has to put up with me.

People in their professional roles sometime turn into caricatures – and I suppose doctors are probably more guilty of this than most professions. In a line of business where on any given day your job might be to tell a seemingly young and healthy parent who came in with what they thought to be some minor ill that they need to ‘get their affairs in order’ because they are going to die soon, I can’t judge them harshly for perhaps putting up a wall of sorts between their patients and themselves.

But I am fascinated with these walls we put up as part of our daily interactions – and I love to break through them. Being exasperating frequently causes people’s walls to unexpectedly crumble – and what’s behind them is usually interesting.

So when I mentioned the statin research showing no benefit in all-cause mortality for patients without active cardiac vascular disease – and the crack about the increased risk of suicide and violent death, my doc’s usual chill turned less chill. He seemed slightly taken aback by the all-cause mortality, violent death and suicide bit and said with reserved force: “I challenge you to produce the evidence on these.”

I could easily find these mentioned in respected journals like the Oxford University Press, Pubmed, and the Lancet sitting in my car on my smart phone before leaving the parking lot of his office. I’ll be printing out whatever isn’t paywalled before my next visit.

Here’s one link: http://www.thennt.com/nnt/statins-for-heart-disease-prevention-without-prior-heart-disease/

It says – and backs it up with a boatload of legitimate citations – that after 5 years of statin use in patients without known cardiac vascular disease:

  • None were helped (life saved)
  • 1 in 104 were helped (preventing heart attack)
  • 1 in 154 were helped (preventing stroke)
  • 1 in 50 were harmed (develop diabetes)
  • 1 in 10 were harmed (muscle damage)

Here’s another: http://qjmed.oxfordjournals.org/content/97/4/229 – you might have heard of Oxford, it is the world’s second oldest university, having been around since 1167. 16 Nobel prizes in medicine were awarded to alumni. It’s not a citation from some jackass with a blog and an axe to grind.

The study was small and warrants further investigation, surely, but a few people put on statins got really grumpy afterward. The link notes:

Manifestations of severe irritability included homicidal impulses, threats to others, road rage, generation of fear in family members, and damage to property.

Now – don’t get me wrong – statins have their place. In people with CVD it is a lifesaver (http://www.thennt.com/nnt/statins-for-heart-disease-prevention-with-known-heart-disease/). However, I come from a family with no predisposition toward heart disease even though my father’s side of my family ate and drank with abandon and all had potbellies and ruddy faces from all the beer they drank. A good part of my heredity ate whatever the hell they wanted and lived well past 80 – with 80 being the point where the dodginess from the family predisposition toward Alzheimer’s began to take full effect.

I don’t have known heart disease, nor do I have diabetes though my brother, sister, father, and mother all had it – with my siblings getting it way before the age I currently am. I don’t have a family history of CVD. I see nothing in my medical history nor my heredity that makes me a good candidate for statins and have to put up with the potential to develop diabetes, the potential for muscle damage, or the potential for negative psychological effects.

Before the ‘statin talk’ I had already parried with him on diet. As I sat in my underwear, an unpleasant sight except perhaps to a clinician who has trained themselves to be detached and doesn’t really give a shit as a protection mechanism from going insane, he mentioned in what in retrospect was carefully chosen language that “I was a much larger patient” than when he last saw me – and he hoped I had a plan.

“Yeah. My plan is to go on a low carb diet.” I said.

“Do you mean below 100 grams of carbs or below 50 grams?” He asked.

“Oh, I want to do a ketogenic diet. I’ve been on one on and off for a decade and I find it works quite well for me. It even seems to make me calmer.”

“What is recommended is a calorie-restricted diets with legumes, whole grains, and lean meat, along with vigorous exercise most days of the week.”

“Well, a ketogenic diet has worked for me in the past.”

His tone changed. He was going into his ‘learned clinician schtick’. It became more patronizing. “Well you know, a ketogenic diet puts your body into a mode similar to starving. You body can’t live without glucose. What is most important is that a diet be sustainable – and a low carb diet isn’t sustainable.”

OK – a decade of sustained weight loss shows it isn’t ‘sustainable’ – he’s right – I gained weight after a decade. Got it.

I did counter on the glucose thing, though: “Um…but your body can create the glucose it needs from a moderate protein diet and converts the protein into glucose through gluconeogenesis – right?”

He didn’t say anything for a bit – frankly, I don’t recall a direct response at all. Perhaps he had busied himself with the next part of the examination – the part that included the snap of a latex glove and ‘bend over’.

Given the asymmetry of the situation – he fully clothed and I in my skivvies – I wasn’t about to tell him that my lack of exercise is almost a badge of honor for me. I follow the advice of a quote I once read: ‘Whenever I get the urge to exercise, I lie down until the feeling passes.’ I have a sneaking suspicion that the relentless advocation of ‘exercise for everyone’ is not so much for the health of individuals but rather the health of the economy: every gym membership, every Thighmaster, every pair of running shoes raises the GDP – and so do the attendant sports injuries: muscle pulls and torn ligaments provide physical therapists gainful employment; injections of steroids provide income to doctors as well as relief to the patients who have exercised their way to worn out joints, and finally the people who thrive on a steady stream of former exercise enthusiasts who, instead of choosing the next pair of running shoes to buy, now have a choice between a hip replacement or a walker and constant pain.

I also feel that above a given weight, it is smart to start losing weight without the exercise (it can be done – I did it) – and with an increasingly lighter body comes more energy and the freedom of movement that can make you *want* to exercise.

And I haven’t even begun with my feelings about what constitutes ‘healthy eating’. If my differences with the standard accepted notions on exercise were a flaming match head, my differences on nutrition from most people were a nuclear bomb.

As I left I mentioned he should check out the book ‘The Big Fat Suprise‘ – a masterfully written work that clearly explains just how we ended up vilifying fat as a nutrient because of bad science, big egos, and politics. He just snorted. It was only a:

  • A New York Times bestseller
  • Named one of The Economist’s Books of the Year 2014
  • Named one of The Wall Street Journal’s Top Ten Best Nonfiction Books of 2014
  • Kirkus Reviews Best Nonfiction Books of 2014
  • Forbes’s Most Memorable Healthcare Book of 2014
  • Named a Best Food Book of 2014 by Mother Jones
  • Named one of Library Journal’s Best Books of 2014

Kinda what I expected. 

For those of you unfamiliar with my backstory, in 2003 I lost 80 pounds on a low carb diet. Unlike most people who would have reveled in their success, bought new clothes and left it at that, I needed to know why. How could I eat like I did and lose weight? I had only read the Atkins book, and learned about ketosis: a chemical transformation to your body that allows you to run your body on ketones – the product of burning fat – instead of glucose – which comes from sugars and starches and is what the vast majority of human beings run on these days. In fact, running your body on ketones is so rare that one way of measuring your ketones to track your progress – urine strips – are actually manufactured for people with severe diabetes to manage a severe side effect called ‘ketoacidosis’.

Being slightly obsessive – or maybe a tad more than ‘slight’ – I spent the next 10 years reading books, research, blogs, and articles and all aspects of diet nutrition, the history of diets and dieting, how diet has changed over the centuries, the psychology and sociology of food and eating, as well as a myriad of odd little detours into admittedly wacky material produced by people with dubious credibility as well as my own hare-brained ideas.

All that obsession spilled out into a blog on low carb which I started on a whim and then wrote and published over 500 articles over 7 years. I sort of abandoned writing on low carb and shuttered the blog at the end of 2014 for reasons not entirely clear to me. Perhaps I had grown tired of it all. Perhaps I had said all that I had to say on the subject.

Perhaps I was just paying lip-service to my low carb lifestyle and writing about it – as I gained weight – seemed disingenuous.

Perhaps I needed to regain enough weight to give a shit again.

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REPOST: Low Carb Crockpot Beef and Daikon Radish

Daikon Radish, for those of you unfamiliar with this vegetable
Daikon Radish, for those of you unfamiliar with this vegetable

04/16/15 Update – I just made this again except simpler: just the meat, fire-roasted tomatoes, daikon, an onion and Worcestershire sauce. It came out great and I thought I’d unearth it from the 2013 archives for those of you who haven’t seen this one. 

This kitchen experiment was prompted by a recipe my wife made with short ribs and daikon radish. You often find this mild radish in Japanese cuisine, julienned into fine threads and served raw with sushi. I had never considered cooking radishes, but I thought I I was eating potatoes when I tried my wife’s dish.

This gave me the idea of a beef ‘stew’ of some sort so it was time to perform an experiment and potentially waste $20 worth of food. Of course, being a hot an muggy day, I was inspired to make it a crockpot recipe (I wonder about me.)

Using just the daikon and the stew meat as the main ingredients and a large can of fire-roasted tomatoes in a supporting role, I threw in whatever else I found lying about the fridge, low carb, and reaching it’s golden years in terms of edible lifespan.

  • 2 pound stew meat
  • 3 tablespoons olive oil
  • 5 shakes tabasco sauce
  • 1 large can fire-roasted chopped tomatoes
  • 10 shakes Worcestershire sauce
  • 1/2 sweet onion
  • 2 green onions
  • 1 green bell pepper
  • 2 daikon radishes, each as long as a forearm, diced into chunks about the size of a thumb
  • salt
  • pepper
  • oregano

I used the fire-roasted tomatoes in particular to save a step: browning the meat beforehand. I think this step is to introduce the flavor notes from the browning and does not change anything else about the result. I spared myself the extra time spent but getting those flavor notes from the tomatoes.

I placed the beef at the bottom, then added can of tomatoes then the cut veggies.

You will note that I did NOT use beef stock nor add water. The hope was that the liquid from the tomatoes and the juices from the meat and veggies would be enough. Crock pots are tricky in that they need enough liquid to transfer the heat to the solid pieces of food – and crock pots are s-l-o-w so you don’t know for 8 hours if you’ve created a delight or a disaster when experimenting.

I crossed my fingers and set the crock pot on low for 8 hours.

After 6 hours I had a small bowl.

The stuff was great. 6 hours proved to be enough.

The combination of vegetables made for a flavorful broth, the meat was tender, the fire-roasted tomatoes added nice flavor notes and the Worcestershire sauce and tabasco added some complexity that didn’t overwhelm the dish or make it too spicy. The chunks of daikon reminiscent of potato in texture and played their part nicely. Imagine a vegetable soup with meat and potatoes.

I didn’t know what I was going to get when I started this, but these are all fine ingredients that tasted great together.

The feedback I got was it might have used a little more salt, and in retrospect I would dice the daikon a little smaller next time – I found myself breaking the daikon into smaller pieces.

Given the temperature, eating hot soup was somewhat bone-headed as it put me in a sweat, but regardless, I think I have another interesting crockpot recipe to add to my repertoire for the colder months when this would fit the bill after coming in from the cold on a winter day.

I have one of those large oval crockpots. I’m guesstimating that we have 8 servings here. If that’s the case, here’s the nutrition info:

Calories: 333
Net Carbs: 8 grams
Total fat: 20 grams
Protein: 26.5

Who Is This Guy?

IMG_2452

After a newfound commitment to begin again, and off to a great start in week one, things slowly drifted back to the habits that helped get me fat again and the passionate indifference returned.

I’m now back to pretty much where I started.

Iv’e spent some time reading some of my old posts – which I typically forget moments after writing and have to ask: who IS this guy? He seems more eloquent than I. He seems more curious, more committed, and more energetic.

He *is* younger than me – and thinner. I don’t think that time spent on the right-hand side of the big five-zero has been kind to him. He can’t claim any bad luck – actually the Universe has been quite generous to him in comparison to many of his age. Yes – there have been the sort of things one starts to expect as the car passes the 50,000 mile mark. Parts start to wear.

My eyesight isn’t what it once was and while wearing readers for almost a decade, it seems I need them now more than ever. I also have Uveitis in one eye – a condition that makes the vision quite blurry in that eye – and is treated with an injection – INTO THE EYEBALL.

Did that make you cringe? It really isn’t as awful procedure as you’d imagine, but it does make your eye blood red for a while.

And the 12-year-old in me get a kick by seeing the faces of the people who ask why my eye looks like that and I tell them it’s because I got an injection in it.

An appendix got removed. It’s wasn’t a big deal except that it was a milestone of sorts: my first surgery. Yet more proof that the Universe has been kind: how many people get cut open for a myriad of reasons well before the half-century mark?

Still – despite my good fortune in many aspects of my life, something seems changed. I’m different than the guy who wrote all these posts.

First, I’ve become somewhat tired of the science aspect of a lot of nutrition. Perhaps it’s that I know enough – or at least I think I do.

I think that it was the Buddha that tried to teach his students that his teachings didn’t need to be worshipped, made sacred, or endlessly studied but were only a tool meant to be used to accomplish a goal and discarded. He described it as a boat to cross a deep river. Even though it was valuable to make the crossing, once the river was crossed there was no need to carry the damn boat all over creation – it could be left on the shore while the journey continued unburdened by it.

In Zen Buddhism there is a state where an adherent is said to ‘stink of Zen’. It means they are going overboard. The tool has become more important than its purpose. The study has become more important than its application.

Zen has little tolerance for righteousness or for excessive knowledge. It’s about the practice.

Perhaps I know enough and it’s time to get my nose out of the books and practice more.

Second, which might be the bigger problem, is that I’ve become bored with low carb eating – and this extends from the fact that I’ve become tired of low carb cooking. As my enjoyment of cooking has waned, low carb eating by necessity becomes less varied, and perhaps this is what is derailing me.

Third, perhaps the gain in weight, combined with age, and combined with the fact I no longer drink 3 pots of coffee a day, contribute to a lack of energy. I used to happily get up at 4am, drink a pot of coffee, write blog posts, maintain a little notebook of goals and to-dos, then leave for work, put in my time while putting away another 2 pots of coffee, and come home and cook and do other chores. Now I get up between 5 and 6, have a cup of coffee while staring into space, then go to work where I have maybe 3 or 4 cups.

The decline in coffee drinking was not intentional – not something I wanted to necessarily do – it just happened. Perhaps being a caffeinated speed-freak was good for me, but it’s not me anymore.

Fourth, perhaps my long-documented love of sloth – and the ability to lose weight without it – has to come to an end. I don’t know where I read it, but the case was made that, while this nonsense of burning calories talked about as if it is a financial transaction: “If I run for 30 minutes I will burn 200 calories” is a simplistic explanation, wrong, and yet enshrined as a myth so strong that every treadmill purports to tell the user down to the calorie just how much they’ve ‘burned’, it was said that there is *something* more subtle going on with exercise and weight. It isn’t well understood – but there’s a connection.

I can buy that.

After years of reading all sorts of research on these topics, I’m more comfortable with the people who know that ‘I dunno’ is not an admission of stupidity but one of honesty.

A good friend is moving and giving away their treadmill. I’m going to try to get it. Maybe it will jumpstart some better habits.

Maybe my repeated failures shows I’m not ready for a full-blown low carb diet just yet. I’ve done a hard-core program before with great result – and I can do it now, too – for about a week. Then I crumple like a cheap suit.

Maybe I’m not ready for a diet just yet, but instead in need of a ‘pre-diet rehabilitation’. Maybe I should start small, make small wins where I can, and proceed slowly in the direction of the headwinds of the right direction than to think I’m going to do it in a dash.

After thinking this, I bought a salad – just vegetables – and bought that home. My wife asked if this was the start of a new beginning. I told her: “I’m not being that ambitious. I’m just thinking that ‘maybe a salad now and than wouldn’t kill me'”.

Her birthday is soon and I’m thinking of giving her a gift: I abstain from alcohol until I’m under 200 pounds.

The dynamics are different here: promising yourself is one thing – but promising the spouse you love? That’s another.

The occasional salad and the abstention from alcohol are not going to result in an almost 60 pound weight loss – but they might not hurt.

I have a quote on the recent change in dietary guidelines that has announced that all the dietary cholesterol we were supposed to be worried about? Nah – they were wrong. “It isn’t a nutrient of concern.” Apologies to all those egg lovers frightened into avoiding a food they loved by science that has now been dismissed.

One section really struck me of the article on the topic in the Washington Post (emphasis mine):

“These reversals in the field do make us wonder and scratch our heads,” said David Allison, a public health professor at the University of Alabama at Birmingham. “But in science, change is normal and expected.”

When our view of the cosmos shifted from Ptolemy to Copernicus to Newton and Einstein, Allison said, “the reaction was not to say, ‘Oh my gosh, something is wrong with physics!’ We say, ‘Oh my gosh, isn’t this cool?’ ”

Allison said the problem in nutrition stems from the arrogance that sometimes accompanies dietary advice. A little humility could go a long way.

“Where nutrition has some trouble,” he said, “is all the confidence and vitriol and moralism that goes along with our recommendations.”

Perhaps professor Allison’s admonition to his colleagues might apply to those of us trying to lose weight as well. More humility, less moralism, less hubris about progress  – those resolutions the emptily echo because you know you and know it ain’t gonna play out like that. Patience and tolerance for ourselves while gradually moving toward a better way of eating – without worrying about the scale as much as how we feel might do a world of good before taking the plunge into a more serious diet.

For me that means trying to score me a treadmill and maybe replacing a few meals a week with a salad.