Meal Journal - Sunday

For breakfast, my favorite, sausage and eggs . . . over easy.  

For lunch, a nice lettuce wedge salad with blue cheese dressing left over from yesterday's dinner. . .

A handful of roasted almonds was all I had time for at dinner. 

What's For Breakfast?

Many of my patient's ask me what I eat regularly.  I thought that I would document my meals for a few weeks to give you ideas and include recipes when pertinent.  Here was this mornings breakfast . . . and, Oh, was it tasty!

Said Hippocrates . . .

"Let food be your medicine, and let medicine be your food."

Melanoma

Definition: Vegetarian

The Skinny About Sweeteners

I am often asked about which sweeteners are safe and which ones can be effectively used to assist with weight loss and maintenance.  It has been long in coming, but I finally put it all together in my article "The Skinny About Sweeteners". You can find it at The Arizona Bariatric Institute website under Recommended Links.

Integrated Blog with Website!

After struggling for a few weeks, I figured out how to integrate my blog into my bariatric website.  Just a little reading about "iframes" solved the question and there it is.

The website is a work in progress.  My hope is to help people successfully lose weight and give people an edge up on the dietary treatment of obesity.

Let me know what you think.  I would love to make it a user friendly place for answers.

Patient Survey on EHR Issues

Is Your Diet Soda Making You Fat?

Is your diet pop causing you to gain weight?  It is very possible. There have been a number of small studies linking some of the artificial sweeteners to weight gain. The most recent of these studies was completed by Ganesh Halade, Ph.D., Gabriel Fernandes, Ph.D., the senior author and professor of rheumatology and clinical immunology, and Sharon P. Fowler, M.P.H., in the Division of Clinical Epidemiology. They studied the relationship between oral exposure to aspartame (NutraSweet) and fasting glucose and insulin levels in 40 diabetes-prone mice. Aspartame is an artificial sweetener widely used in diet sodas and other products. 
After three months, the mice that were fed aspartame with a high fat diet had a notable increase in glucose levels but a decrease in insulin levels compared to those mice fed only a diet high in fat.  These results imply that the aspartame stimulates a decline in pancreatic beta-cell function, the cells responsible for production of insulin.   This may explain the sudden rise in diabetes we have seen over the last 40 years.  Heavy intake of aspartame in humans potentially leads to diabetes.  Increased glucose levels leads to increased need fro insulin and if the aspartame is suppressing the beta-cell function, this will cause overload of the pancreas, increased obesity, and eventually progression to diabetes. 
Other studies commented on in the recent conference of the American Diabetes Association have shown that the use of diet soda in general increases thirst and sensation of hunger that stimulates overeating.
So, what can you and I do about it? Well, for starters.  Don't order that diet pop with your meal.  Second, increase your water intake.  Most of us don't drink enough water anyway.  You should be drinking at least eight 8oz glasses of water per day.  Third, be careful with other low carbohydrate foods that are sweetened with aspartame (NutraSweet).  Stay tuned for more information on sweeteners.  Upcoming blog posts will contain the good, bad and ugly on specific sweeteners. 
Until then, stay healthy!
Click here to register for Dr. Nally's free online weight loss mini-course.

Age & Weight Gain

I was recently asked why it gets harder to lose weight as you get older.  There are a number of reasons. 

Why the Slowing of the Metabolism ?

First, it is commonly known in the medical community that your metabolism slows by about 5% every ten years after age 30.  This occurs due to intracellular slowing of the mitochondria, the little powerhouses in each cell within your body.  This leads to a significant decrease in the overall fuel you burn on a daily basis and leads to a decreased need for fuel intake over time.  Interestingly, we frequently seem to increase our food intake over time and the sizes of our meals has become larger and larger over the past century.

With Aging We Burn Fewer Calories Each Day -

Second, the average person burns approximately 100 calories less per day for every ten years of age past thirty.  That’s 36,500 calories less each year than in previous years when you and I were younger. The average American gains 1-3% of his or her body weight each year. 

Shifting of Hormones -

Third, there is a hormone shift that occurs with aging as well.  In men, and in some degree in women, testosterone commonly decreases.  This lowering of testosterone leads to decreased stimulus for muscle mass and muscle gain.  We see some natural wasting of muscle tissue as we age.  The muscles are where most of the fuel is burned in the body and it is one of the main locations fat can be metabolized and burned as fuel.  The less muscle you have, the less fat you burn.   

Women also experience a decline in estrogen over time and recent studies show that a decrease in estrogen leads to an increase in retention of abdominal fat.  

Decreased Activity -

Fourth, as we age, we frequently become less active.  This can occur due to the decrease in muscle mass, decrease in bone density and increased fragility of the bones, increased pain due to arthritis and other medical conditions that are age related that make activity a little more difficult.  This overall decrease in activity and lead to weight gain.

How Do I Avoid This?

This is the age old question asked throughout the centuries and the answer to which many have sought for the fountain of youth.  However, what we do know about slowing the slowing is this. 

• Exercise increases the number of mitochondria in our muscles cells.  A healthy well balanced diet will provide the body with adequate protein, amino acids, omega 3 & 6 fatty acids and the essential vitamins and minerals necessary to keep the metabolism operating at its best. 
• A diet low in simple sugars and carbohydrates has been show to decrease free radicals and oxidative stress at the cellular level.  
• Getting adequate sleep is another key.  Sleep gives the body time to repair and restore damaged tissues.  Following up with your doctor to check hormone levels may be needed.  These hormones can often be modified by dietary changes or can be supplemented through medications. 
• Drink adequate water.  Many people’s metabolisms are slowed for the simple reason that they are frequently dehydrated.  Your urine should be the color of tap water. If its any darker, you’re probably not drinking enough water.
• Eat frequent smaller meals 5-6 times per day.  Eating a small meal every 3-4 hours helps your body not to feel like it is starving and it will be less likely to store fat. 

Age will affect us all in the end, but we can age gracefully and slow the process if we apply the simple principles listed above. 

Diet High in Saturated Fat Improves Heart Failure

Impaired contractile function of the heart is a hallmark of heart failure. A recent study published in the American Journal of Physiology revealed that a diet high in saturated fat actually improved the contractile effect of the heart muscle. This may be related to the effect of ketone as the primary source of fuel in place of glucose. Read more about this here.

Ketogenic Diet Reduces Diabetic Neuropathy

Very impressive kidney results were found in both Type I and Type II diabetic mice placed on a low carbohydrate ketogenic causing diet in just 8 weeks. The nephropathy (passage of protein through the kidneys) was completely reversed in all the mice. This is the first in what I suspect will be a series of articles showing that ketogenic diets have significant effect on reversal of age related and diabetic tissue damage.  See the article here.

Never Give Up!

Failure should not mean defeat.  Remember all good things require effort and patience and time. . .

Message From The Future . . .

I wish I could do this for many of my patients.  Thanks, Ryan.

Look, Dad, My Thumb Turned Green!

For many years I was under the impression that I had a black thumb.  My father was an avid gardener and never failed to have a lush beautiful garden in his back yard.  He states that he learned his gardening from his grandmother.  He often tried to pass those skills on to me in my youth, but try as I might, I had not been able to grow much in the garden other than weeds until just recently.

I have been following my own very low carbohydrate diet for the last 18 months.  While discussing this lifestyle with my wife one evening, she commented to me about the significant amount of leafy greens that our family eats.  She noted a significant chunk of change goes to Sprouts grocery store every week because of the changes in our family's diet.  After talking about it, she located a book a few family members had previously mentioned on gardening and picked it up.

The book is "Square Foot Gardening" by Mel Bartholomew.  We read it together.   (I recommend reading something regularly with your wife and family. We either read or listen to an audio book as often as possible. It really is refreshing.)  Mel Bartholomew does a wonderful job. He makes the process of gardening simple.  For someone with limited time and limited space, this is an amazing approach to gardening.
I found myself standing in my yard looking over what is beginning to look like one of my father's gardens.  He passed away a few years ago, but I felt as though he was standing there with his arm around me saying, "Well done, Adam. Well done."

Thanks, Mel.

Senate Nixes 1099 ACA Health Requirement . . .

April 5, 2011 — Following the lead of the House, the Senate today voted 87 to 12 to eliminate an onerous tax-reporting duty in the new healthcare reform law.

The repeal measure now goes to President Barack Obama, who has signaled that he will sign it . . .

Read the full report here on Medscape.

Bill Cosby's Take On Liberty

Bill Cosby has a great way of"distilling" things . . .              I  HAVE DECIDED TO BECOME A WRITE-IN CANDIDATE FOR PRESIDENT IN THE YEAR 2012...   HERE IS MY PLATFORM:  (1). Any use of the phrase:'Press 1 for English'  is immediately BANNED!!!.    English  is  the official language;   speak it or wait outside of our borders until you can.  (2). We will immediately go into a two year isolationist  attitude in order to straighten out the greedy big business posture in this country. America will allow NO imports,  and we'll do no exports.     We will begin using Wal-Mart 's policy,   'If  we  ain't got it, you don't need it.' We'll make and sell it here!  (3). When imports are allowed, there will be a 100% import tax on it coming in here.  (4). All retired military personnel will be required to man one of the many observation towers located on the southern border of the United States  (six month tour).They will be under strict orders not to fire on SOUTH BOUND aliens.  (5). Social Security will immediately return to its original state.   If you didn't put nuttin in, you AIN'T getting nuttin out.  Neither the President nor any other politician will be able to touch it.  (6). Welfare. -- Checks will be handed out on Fridays, at the end of the 40 hour school week, AFTER the successful completion of a urinalysis test for drugs, and passing grades.  (7). Professional Athletes -- Steroids?  The FIRST time you check positive you're banned from sports ... for life.  (8). Crime -- We will adopt the Turkish method,  i.e.,  the first time you steal,  you lose your right hand.  There is no more 'life sentences'.  If convicted of murder, you will be put to death by the same method you chose for the victim you killed: gun, knife, strangulation,  etc.  (9). One export of ours will be allowed: wheat; because the world needs to eat.  However, a bushel of wheat will be the EXACT price of a barrel of oil.  (10).  All foreign aid, using American taxpayer money, will immediately cease and the saved money will help to pay off the national debt and, ultimately, lower taxes.  When disasters occur around the world, we'll ask The American People if they want to donate to a disaster fund, and each citizen can make the decision as to whether, or not, it's a worthy cause.  (11). The Pledge of Allegiance will  be said EVERY day at school and  every day in CONGRESS.  (12). The National Anthem  will be played at all appropriate ceremonies,  sporting events,  outings, etc.  My apology is offered if I've stepped on anyone's toes .... nevertheless......  GOD  BLESS AMERICA ! Sincerely,  Bill Cosby

The Infamous Stool Sample

Toward the end of a very rough day in the office, one of my patients tells me, "Doc, I have just one more complaint. . . ."  When a patient phrases it like that I have learned to brace myself, 'cause it's usually chest pain, or something major they saved for the last minute. Today, however, this patient says, "I brought you a stool sample thinking you were going to need it."  

Now, when a patient brings you a stool sample and reaches into their pocket to pull it out, you really begin to worry. He tells me he has been having trouble with his stools and thought he would bring me this sample to examine.  He wanted a diagnosis right there on the spot. . . 

So, I ask you, what's your diagnosis?

Medical News: Marijuana Use Precedes Psychosis - in Psychiatry, General Psychiatry from MedPage Today

A recent German study reports that users of marijuana have twice the risk of developing subsequent psychosis than those who have never used marijuana. The study was completed over an 8.5 year period with close to 2,000 participants ages 14-24. Risk for psychosis increased to 20% of those using marijuana. Read a summary of the study here.

Source reference:
Kuepper R, et al "Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10-year follow-up cohort study" BMJ 2011; DOI: 10.1136/bmj.d738.

6 Tips to Prepare Your Child For Vaccinations

See this great article about preparing your child for vaccinations at Dr. Wendy Sue Swanson's blog (Seattle Mama Doc). I agree with all of her points.

What makes fructose fattening? Some answers found in the brain

Recent MRI data in research reported in Science Daily finds that fructose has an opposite effect on the brain than glucose. It appears that fructose stimulates weight gaining hormones in the brain and can have an addictive effect stimulating increased appetite and fat storage. The research is published in the online edition of the journal Diabetes, Obesity and Metabolism and will appear in the March print edition. You can read the full article here.

May The Force Be With You

Yes, I too remember trying to exercise my powers of the force at this age.  May the force be with you . . .

Through The Eyes of My Dog

Ok, yes. I am a dog lover. I have three of them. I am amazed at how they never fail to greet me at the door when I come home and they never fail to greet me in the morning.

If only everyone saw things like my dogs do . . .

Three Reasons Obamacare Is Bad For the Nation

Former white collar undercover FBI agent, Representative Michael Grimm explains why Obamacare will hurt our nation and why it should be repealed.

Colon Cleansing? Yea, Right.

I had a few patients ask about an article I read published on the Men's Health blog today: "Ashton Kutcher's Plan to Survive the Apocalypse." I had to laugh. It's quite entertaining to read about his plans to thwart the apocalypse with colon cleansing. 
I'm not quite sure how cleansing your colon will protect you from the apocalypse, at least the the apocalypse I envision and have read about in the Bible's Book of Revelations.  Either way, there's only one problem with colon cleansing including the Master Cleanse diet. Colon cleansing is a sham.  Yes, a sham. 
The body was designed to clean itself and to heal itself, especially the colon and liver. There is a constant turnover of colon cells and liver cells each week and each month.  There is no need to plug yourself full of "detoxifiers" or use a combination of  "fresh lemon juice, rich maple syrup, and cayenne pepper into pure water" (Master Cleanse recipe) acting as a laxative to cleans your colon.  A simple fast for 18-24 hours does the same trick.  The only reason to clean yourself out in this way would be to prepare for a colonoscopy where the gastroenterologist needs to see a colon that is "spic and span" clean.  Now, if you are just worried that at the time of the apocalypse you'll need clean underwear and you think you would just feel fresher with a clean colon, then be my guest, more power to ya!
So what do you need for the end of the world?
Well, for starters, studies show that many of us are not really ready for an emergency including the worlds demise. But here are a few things to think about having ready just in case the need arises:
Water. You'll need at least a 3 day supply for each person in an emergency and enough to last up to 2 weeks if you're at home. 
Food.  Fresh lemon juice and maple syrup will only last you a week before the diarrhea is so bad you would wish you died from the apocalypse.  So I would suggest at least a 3 day supply for evacuation and at least a 3 month supply for your home. 
First Aid Kit. Hey, I'm a doctor, and you're reading my medical blog, so the first things I think about are food and band-aids. 
Medications for 7 days. Having a 7 day supply of medications on hand is essential, especially for those with significant heart or lung diseases. 
Personal Hygiene Items. Placing all of these items in an emergency 3 day pack or bag that can be easily grabbed on your way out the door is a very good idea.
Emergency Blankets. You never know where a good blanket could come in handy in an emergency.
Batteries.  These are self explanatory.
Extra Cash.  In an emergency, the last place you want to be is at the bank (cause everyone else will be there too).   So it is a good idea to have a little stash of cash available for emergencies. 
Flashlight. Self explanatory.
Radio (battery powered or handcrank). 
Hopefully, you are already prepared.  If not, you should consider the above list along with any other items you think may be handy.  Regardless of what Ashton Kurcher or Demi Moore says,  the colon cleanse really won't do you much good at the worlds end. 

Super Jump

Crossing the street can be a challenge. Remember to look both ways! A friend and neighbor of mine got a new camera and video editing software.  He is quite the filmaker.  Here is a short that my kids love.  Enjoy. Thanks Ryan.

Three Things

Most days, I feel like I am a contestant on that continuously running game show "The Price Is Right".  I go from room to room, often wondering what is behind Door #1 - surprised at what I find behind Door #3 - occasionally wishing I never when into Door #2.

This can be really exciting. (Not as exciting as a carotid endarterectomy or a colonoscopy, I'll admit, but hey, this is outpatient medicine.) There is always something interesting behind the next door.
It can also be fatiguing.  This morning brought two cases of valley fever, three cases of depression, four episodes of constipation, two cases of shingles, and four upper respiratory infections. That was just part of my morning. Oh, there was a nice external plump hemorrhoid and a really ugly looking wart for kicks. (No, I didn't kick them, but it sounded nice, didn't it?)  Don't get me wrong, I really enjoy what I do.  It is rewarding, but I have found over the last 10 years that I have to work faster and faster and see an increasing number of people with increasingly complex medical problems to cover the overhead.  This is the fatiguing part.
I'm sure I'm not alone in my feelings. Many people I see in the office are working harder in their fields for less and many are without work, looking for a job.  There seems to be a general feeling of worry and fatigue among many that I see.
In looking for relief to my fatigue, I came across a few thoughts.  The first was that of John White. "There are three kinds of people in the world: those that can't stand Picasso, those that can't stand Raphael, and those who've never heard of either of them."
That didn't help.
The second was a comment made by Albert Einstein. "He who marches joyfully to the music rank and file has already earned my contempt.  He has been given a large brain by mistake, since for him the spinal cord would suffice."

Really? Now, I just feel bad.
But, I was reminded of "three things" at the New Year that seemed to lighten the load. The Holidays were wonderful at my house.  I hope they were at yours.  Not that great gifts were showered, or that the Christmas fudge was better than ever this year, or that I got exactly what I wanted for Christmas, but that my understanding of a person's basic needs was enlightened.
A drugstore psychiatrist was once heard stating that a healthy psyche really only needs three things:
1. Someone to Love
2. Something Important to Do
3. Something Pleasant to Look Forward to
The holidays were refreshing, as I had a chance to spend time with those that I love, my wife and children, and to think about extended family and friends that are close to my heart.  Taking a little time each day to think about or do something simple with those you love is energizing.  I was involved in a serious auto accident recently and for a brief time during that ordeal I was not sure how much longer I would spend upon this earth. It drove home the point to me that this life is short and we really have no idea what tomorrow holds for us. I have found that this just takes a little focus. In the words of Albert Einstein, "Any man that can drive safely while kissing a pretty girl is simply not giving the kiss the attention it deserves."  I have committed myself to focusing a little time each day on making sure that I can express my love in meaningful ways.
Each of us needs a task.  That task needs to be important in some way.  I have had many patients over the years arrive at retirement and within a few short month, looking forward to enjoying the "easy life," become depressed, irritable, and reclusive because they are no longer contributing in a productive way to something meaningful.  We need to feel like we are making a difference. We need to feel like we are making a contribution in some way.  This keeps us healthy and it keeps us strong.  It keeps us engaged. Find something in your day that is meaningful to those around you or your community, and make it a priority to contribute your skills and energies to improve this world because you were here today. To put it in the words of one of our generations great thinkers, "Strive not to be a success, but rather to be of value."

Lastly, we each need something enjoyable to look forward to.  King Solomon of the biblical Old Testament states that "where there is no vision, the people perish" (Proverbs 29:18). How much happier a person is when they have something pleasant to work toward or to look forward to.  Our day to day lives often involve a great deal of repetition.  This can bring monotony and boredom. Looking forward to even a simple change of pace each week can be invigorating and rejuvenating.  I have found that spending an hour or two each week working on a hobby, reading a good book, taking my wife on a date, taking my child for an ice cream, or taking a trip to someplace interesting can be welcome activities you look forward too all week. These need be expensive, yet can be refreshing and renewing for your outlook on the week Commit yourself to planning a simple activity this week you look forward experiencing.

Your Parking Ability as a Determinant for Medical Career Choice?

One of the most fascinating and questionably relevant studies this author has ever read was recently published.  A covert observational study was conducted by R. Scott McCain et al., published last week in the British Medical Journal showing some very interesting findings.  103 medical practioners were covertly observed as they entered the parking area of a British Hospital over a three day period.  Their speed to enter the parking garage, exit their car, and walk to the facility were each measured. The study looked specifically at the approach to the entrance where a key swipe was necessary, total time to park and then exit the car, and the speed with which they walked to from the car to the facility.
The results are most interesting in that surgeons appeared to be the quickest, followed by anesthseologists, radiologists, then general medical practitioners.  Sex of the physician did not seem to play a role, however, as the males and females physicians did not differ in their specialty.

Unique and consistent behavior has been identified among specialties by this study.  Suggestion is made by the author that this could be a good and inexpensive aptitude test for medical specialty selection.  This is, however, the first study of its kind, and further evaluation should be conducted as the researcher himself was a surgeon.