Saturday, July 14, 2018

Tasty Racks, Juicy Thighs, Smoking Butts

100 day commitment is fulfilled today. I was successful in terms of eating macronutrient ratio to goal with caloric limit in mind, with the exception of 5 days total, and that includes an intern year graduation extravaganza and vacation with friends and family. Below are the numbers:


It should be noted that no extra exercise from what I would do at baseline was conducted during this time. This is comforting, as I know as soon as I engage in consisted exercise, with a blend of cardiovascular and hypertrophic weight training the body re-composition process will only hasten. 

In some ways I am disappointed that I "only" lost 28.6 pounds. On a day where I was coming off of a 3 day fast and had not had nearly enough water, I maxed out at nearly 35 pounds lost. That was a couple of weeks ago. That day I was uncomfortable with how dehydrated I was and am certain that I was down 5 or 6 pounds just from volume depletion. And last week had me in Oregon, celebrating and seeing old friends and family and eating, always eating! If not over on my carbohydrate intake, I was definitely way over on my caloric intake on most of those days. Even on a ketogenic way of eating, the 2nd law of thermodynamics rules all -- and when I take a step back and realize how I would have eaten in those settings prior to this project, I am proud of myself and realize that a couple of days of wonton celebration and revelry will not undo 97 days of consciously deployed self-discipline, and all while finishing out intern year of residency. 

This diet is restrictive, but if you're willing to eat meat -- a lot of meat, and cheese and green leafy, and cruciferous vegetables to exclusion you will be just fine. This is the food I naturally am drawn to -- I yearn not for pastries and pies but pork butt and pastrami. And with this the negative aspects of this end. I don't mean to diminish the sacrifice that will come, and the obsessiveness that develops from fear of clandestine carb ingestion -- checking labels, asking coffee shops if you can scan the barcode of the almond milk container. Requesting bunless burgers. Please hold the hashbrowns and may I have a side of bacon with my meat-lovers omelette? Going to Red Robin, against all better instincts because they have "bottomless" broccoli with a burger -- a bunless burger of course. All these are bad enough, but the worst of the diet stems from having to explain yourself to others. As a doctor I may be able to get away with criticism, at least to my face, relative to others who find themselves trying to defend how their high fat diet will not push the inevitable myocardial infarctions into high gear. Fighting against a whole generations indoctrination concerning the evils of dietary fat and cholesterol is so disheartening -- from corruption and greed comes deception and the unwitting betrayal of a populace medical sciences is sworn to protect. From this comes distrust of the faces of medical sciences -- physicians. And here we are, with a nation, and now world that has let the industrialization of agriculture and processed food-like products become so prominent that eating whole foods, whether it be meat, vegetable or fruit is for the more fortunate of our society and stretching a budget to include these fresh items is often unrealistic. We are a nation that has armed forces facing difficulties finding recruits who are physically fit enough to serve. This should be seen as a national security liability and a nationalized healthcare safety net system which includes cost effective preventative medicine should be funded by the pentagon. Our society has a lot of easily prevented chronic medical issues, and the pennywise pound foolishness of our leaders will cost us in the long run.  

I count myself as being among the fortunate who are able to afford whole foods and eating poorly is a matter of poor choice, not financially mandated and for that, I'm very thankful. Last year when we moved to Long Beach I bought a "Red Egg" which is a knock-off Green Egg. My version is about $400 cheaper, and as long as I don't leave it in the rain it will last forever. It has been dormant in the garage since last summer and the last effort to smoke some ribs went awry. I thought I could wing it and just figure it out as I went. They were burnt. Badly. Last week I was at a cousin's house, and her husband smoked some ribs on a traditional smoker and from that, the inspiration to finally properly smoke ribs in the red egg sprung. A meal to celebrate. 


Found myself at Costco yesterday, having to get passport photos for well, not only passport but my medical license as well. I picked up these pork ribs there. I put together the rub myself, large components include smoked paprika, kosher salt, black pepper, garlic powder, Lawry's salt, some random other things. No overt sugar added, notice, and the only carbohydrate stems from the small amount of sugar in the small amount of Lawry's Seasoning that I added. I may get some sugar-free, low carb barbecue sauce when it comes to eating these things. 

Yesterday I watched a bunch of YouTube videos about how to smoke ribs in the Egg, regardless of color. Heat control is a big thing, along with varying opinions about foil wrapping, mustard as mortar, apple juice vs water, water pan vs dry smoke. All very helpful, but what I learned most is that it seems to be only big-bellied white dudes with Southern Accents make Egg smoker videos. On a sidenote, I think that one of my last big biases, one that insidiously creeps its way into my thinking, is that I automatically assume someone with a thick Southern Accent is less intelligent than average. I know it is not always true and honestly, I don't run in to many with these accents on the West Coast anyway, but I am aware of this and hope to be less critical in the future. Anyway, all the videos were helpful. 





The average calorie per day is interesting to me, as seen above. 1702 per day. That is a fairly low number for me, as a larger person, with a higher than average lean body mass to maintain and it is no wonder that I lost weight. But there is more behind this number in that I began to employ fasting on a regular basis, especially the last half of the 100 days. Forcing one's body to use stored fat as a fuel lends itself to fasting quite naturally. This is what I found. Many days I would just not eat because I was not hungry, and through this process I feel like I have an increased capacity to listen to my body and take the clues and surmise what was needed. I made it a habit to fast 2 days per week, at least. Many days were eating one meal a day, or not eating until dinner. Even for me, trying to take in 1700 calories in one meal is a challenge, and this process, regardless of hormonal benefits, lends itself to decreased overall caloric intake. As the weeks of fasting continued, it turned into a period I really looked forward to and I began to read about fasting research and was quite pleased that many benefits are derived from fasting. I may continue to incorporate elements of fasting for the rest of my life. Eating to engender ketogenic metabolic processes and water fasting provides a state in which lean body mass is preserved; anecdotally, I can corroborate this with vigor as I feel as if my muscles are getting bigger -- most likely not the case, but is due to the adipose tissue melting away. Perhaps I would feel the same way if I was simply following a "CICO" (calories in calories out) manner, but most likely I would have lost more lean muscle mass operating under that edict. 

I'm continuing this project for now, and with intern year behind me and only a handful of brutal months and call shifts left before this whole thing is over, I'll be working my way back into the gym. 

Near the beginning of this 100 day commitment it became obvious that I didn't want to write about the process on here, or even talk about it. I don't fancy myself being one of those people who interject my personal behavior at every opportunity. I try not to be. Now that things have calmed down, and our household is humming along with keto friendly foods it seems like a perfectly normal thing to eat like this and while I'm sure I'll have more posts concerning my ongoing experiment with regaining my health while I still can, I hope to get back to other more interesting and less inwardly focused blog posts. 

The ribs turned out well. Next time I will take care to spray them down with at least some water through the process. I think that I took them off the grill perhaps 30 minutes too early. Some of the smaller, thinner end pieces were burning. I should have just pulled those pieces off and let the larger, thicker sections simmer in the smoke just a bit longer. The rub was super simple and just perfect for these ribs. I never did get any sauce and these really don't need any. The dog is very happy and she'll continue to have bones for the next few weeks as a treat. 


Sunday, July 1, 2018

Save us Jack Ramsay!

In 1976, when the NBA season started, the Portland Trail Blazers were not considered contenders at all. The team won the championship, and with a player like Bill Walton on the roster, the future was bright. Then Mr Walton had foot issues. Injuries sidelined him and he was never the same player again.

In 1984 Sam Bowie was drafted by the Portland Trail Blazers. Famously, he was drafted at position two, one selection prior to the GOAT, Michael Jordan. Sam Bowie soon had a fractured femur, and never developed into a franchise cornerstone. 


The draft of 2007 the 'Zers selected Greg Oden, ahead of Kevin Durant. Greg Oden showed us enough flashes of brilliance to know what we missed out on. He had leg injuries too, of various kinds. 


Three of the most impactful decisions the Portland franchise have made concerning drafting players resulted, ultimately, much too short of success secondary to lower leg injuries. It feels like the franchise has been snakebit, but each decision can be defended by being the right one with the information available at that time. 

For the sake of discussion, lets suppose that the Trail Blazers somehow get the number one pick next year, and while I have no idea what kind of draft class next year is shaping up to be, let us also say that their is a dominant big man who pundits predict will be a literal game-changer in his career, just like all the previous big-men that the franchise had put faith in. Perhaps there is another smaller player, a wing or a guard who is undeniably talented -- what should they do? 

It is painful to have past choices analyzed; decisions made put into question. And this is exactly what medicine is -- a constant process of evaluation of decisions made. At this point in my career I still have an external observer and evaluator, with the ultimate goal being a proficient and effective process of self-evaluation and recognition when different courses of action are indicated. The field of medicine requires this, yes, because aspirations are for continued harm reduction through past experience. Well, I would argue that all fields should require this, and furthermore, all of our lives, in some way, at least, have this as a underlying, ongoing if not at times, subconscious process.

Death of Ego
As mentioned above, the painful aspect of this is related to our insecurity. I believe everyone has, either hidden away or not, an aspect of self-doubt. A physician can be full of experience and the wisdom that stems from a competent analyzation and course corrections and this, in conjunction with a diligent and attentive habit of knowing evidence based medicine publications and still wonder if the right decision was made. This is normal, in my opinion. 

In medical school there is a story often told about horses and zebras and hearing their respective hoofbeats. When hearing hoofbeats, knowing which is more common and expected is important to keep in mind. If I am in California, and not in the Zebra area of the San Diego zoo, for example, I should expect the sound of hoofbeats to belong to the horse, not a zebra. While this seems exceedingly obvious, one must know that medical education, especially when standardized tests are a way too common tool of assessment, that knowing diseases that represent zebras are most frequently tested topics. Part of this is that knowing a disease process, the etiology, the symptoms, diagnostic tools and management of a pathology is often indicative of valuable testable topics in that physiology, anatomy and their consequence in the health of a given human. I work with medical students on a regular basis and see the process of moving from lecture hall to hospital on a regular basis. Differential diagnoses provided by students, either in discussion or associated with a new admission in the ED have a higher 'zebra-to-horse' ratio than my own. At this point in my career as a resident physician, I know the type of hoofbeats and what they are associated with quite well. Through this process of forming a wide, but appropriate differential when working a new patient up the clinician can build their experience and acumen as a diagnostician and become better with every new patient encounter. 


Remember this: woe to those who never consider a zebra's presence

Something that may seem like a slam-dunk community acquired pneumonia can be a pulmonary embolism. I've already seen it happen multiple times. Granted, a PE should not be a zebra, no matter if you live in zebra-land or horse-land. 

Did the Blazer's decisions through the decades represent someone who is suspecting zebras in the land of horses? I don't know. And the comparison that contrasts the draft decisions of an NBA franchise with the decisions that comprise medical management breaks down fairly quickly in that there is no going back on a draft decision; even if the player is traded you can never undo the decision to draft a player. In medicine, we frequently order tests to ascertain the likelihood of certain maladies and we do this at the same time. The real question though, and where the analogy serves us well, is the question of whether we will allow our psyches and egos the luxury of seeing every decision made as independent of the last. What I mean is that, while it may seem that a curse has been placed on the careers of big-men associated with the Blazers I maintain that this is ridiculous and don't ascribe to the superstitions of willingly ignorant humanity. Each decision to draft Bill Walton, Sam Bowie, and then Greg Oden is defendable. Overwhelming evidence exists to support drafting Sam Bowie versus Michale Jordan and Oden before Durant -- and yes, evidence compiled since the draft day now proves them to be the absolute wrong choice, but this is only significant in the eyes of a fool. 

Likewise, a physician who defends his or her decision making process through documentation while it occurs should be immune from the disease of hindsight. Unfortunately, one cannot rely on the absence of fools in high places, can one?




Saturday, May 19, 2018

"I'm Sorry That I Got Fat, I Will Slim Down" - Wesley Willis


The spring in Portland shows glimpses of itself many times over before fully revealing it's gloom shattering nature. Days of 43 degrees and a kind of ethereal drizzle drone on and on. It was a night like this one. Wet, cold and just perfect was the kind of day that saw me see Wesley Willis perform live. EJ's was a rock club off of Sandy Boulevard, which occupied a building having been relegated to the inglorious task of housing a pawn shop. Sandy takes a diagonal approach as it passes over Burnside, the north-south dividing line, due northeast. It used to be a deer trail connecting the Columbia and Willamette rivers, which meet and mix on their journey to the mighty Pacific. In the year 2000 it was a mixed use major thoroughfare, off of which, in a quirky brick gilded building, yours truly was about to witness one of the greatest performances of his life.

Wesley Willis, may God rest his soul, was a man I'd never heard of before I sauntered into EJ's that cold and rainy night. Occasionally I indulge myself and ponder the various ways I can divide and organize the various phases and, at times, significant differences between these phases I look back and think that this was a "pre-9/11" night. I lived in a relatively care-free and hopeful future, on that was built on 8 years of consistent economic boom under the Clinton administration (oh the good old days when Christians and Republicans saw a clandestine blow-job as an impeachable offence -- oh, and the lying thing, too) and did not understand the looming storm that was to come in the wake of 9/11. Perhaps I think this because this was one of first nights out with what was to be a long-time girlfriend and group of friends I had many good years with. 

Back to Double-Dub. He had a callous on his forehead that lore said was due to him headbutting a line-up of fans after his show. And indeed, I stood in line and when it was my turn he said something and headbutted me. It was a night of significant revelry and celebratory partakings and I can't honestly say I remember what he said but it was kind of like a laying-on-of-the-hands, of sorts.

Early in the set we heard his ode to the Double Arches with this tune:


Later he followed this up with "I'm Sorry That I Got Fat," which is at the top of the post. Other insightful, popular songs include:

"Cut The Mullet"


"Suck a Camel's Poody Hole"


And of course, "My Mother Smokes Crack Rocks"


Out of all of these beloved classics, the one that continue to speak to me and help guide me is the confession of remorse concerning one's body habitus. And in my ongoing efforts to get "un-fat" this song is a component of my war chest that serves as my motivation ammunition. My initial commitment was 100 days to a strict way of eating. I set a ridiculous goal of losing 50lbs in 100 days. Aiming to burn one half of a pound of fat per day. That is, essentially, a 1750 caloric deficit, per day, as 1 lb of fat has 3500 calories. Well, I'm 38.4% of the way to that goal and this is the 44th day. That is correct, nearly 20 lbs down in just over 6 weeks.

I've found a successful way, a sustainable plan that has provided much more than just turning me into a fat burning blast furnace -- my mind continues to be functioning at a level that surprises me as I round the last corner of intern year. My sleep is higher quality, and I am naturally waking up before my alarm clock slaps me in the fact before 5 am. I occasionally have hunger pangs, but in general I can fast an entire day with very little hunger and even better, my energy is amazing on those days.

But I've already said too much. I've found that talking about accomplishments prematurely, even in the setting of good progress is unsettling; 55 days to go for my first preordained milestone. No more posts for the next 55 days concerning this topic. '

Saturday, April 28, 2018

Eastbound Powell Blvd at SE 92nd Stopped at Traffic Light in Lane #1

Must have been twelve years old, thirteen at most. It was before I started skateboarding.

The majority of my childhood had annual highlights, one of them being having my cousin and his family travel from Edmonton, Alberta -- The "Wild Rose" Province of Canada. Generally they would travel down for Christmas and then again in July, where our extended family had a beach outing. And this year was no different, my Canuck Cousin was staying with me and after an exciting night out on the town, with some older Cousins (I think) we stopped at McDonalds. I think it was McDonalds, we were being driven home. My cousin was in the driver's side back seat, I was in the passenger side backseat. Someone was in the middle. I don't remember who. For some reason I had picked up some nutritional pamphlets. For some reason, while in the backseat of the car, travelling due east on Powell Blvd (AKA State Highway 26) in the left land, somewhere between 60th and 92nd street, I was holding the pamphlets up to the window and pointing to them, trying to get the attention of a car in the right lane.

I got their attention. At the intersection of 92nd and Powell the light was red and our car, and the car of unknown people were stopped. We were next to each other. The driver exited his vehicle and came to my window -- he looked angry. My window was rolled all the way up; however, the window that my cousin controlled was rolled either partially or fully down. The angry man proceeded to the other side of the car and was yelling, with vulgarities. He may have requesting information as to why we (I) were holding papers up to the window and attempting to gain their attention. None of us had a good answer, including me, but especially the other passengers in the car who knew nothing of what had transpired for the previous 30 or so blocks. I'm not sure if my cousin responded to the inquiries or had much to say regarding the insults and such; but I do remember the angry man striking my cousin in the head. Was it open handed or closed fist? I'm not sure. It was a glancing blow, it did no permanent damage but it was scary.

This was before the days of cell phones and easily accessible cameras. My cousin took it all in stride; in general I think Canadians are a well adjusted, strong people. He is no exception.

We drove home with no other incidents.

At that time of my life, and as I see other young people, there is an element of "randomness equals funny" and, I think I had that going on. While occupying my "armchair psychologist" role, I see this as a mechanism of maturation, in that being "random" is a way to garner attention, and in some ways the person thinks it lends an air of mystery to themselves. In my childhood and even into my teen years I spent most of my time with people older than myself, some of this was because my parents were the Youth Group leaders at the church we grew up in, and I had an earlier introduction into that whole thing than I would have otherwise, part of it is that is just how the age ranges of my extended family shook out. Nevertheless, I often felt that I needed to get attention somehow, which often leads to negative aspects coming forth through behavior.

I thought it was "randomly" funny to hold nutritional pamphlets up to a car window and point to them while riding in a car.

I'm glad that incident ended with no, relative, harm done. No knfing. No GSW. Sorry old friend, I definitely felt bad after that happened.

What makes people react with such a quickness to anger? The dude who struck my cousin, if I remember correctly, was probably in his early 20's and I think he was white -- which is not a stretch in Portland. Sometimes I feel like I can sink into a reactive quagmire where my first, subconscious instinct is to feel anger -- that someone is imposing on me, or threatening to me, or is it a need to threaten them first? I think all those elements can get mixed in there, and, while I can only speak definitely for myself, I don't subscribe wholeheartedly to Solipsism as a framework for my reality and am willing to ascribe the previous ratios to other human beings. But I'm not usually like this, and when left to my own devices, with a relatively (and I say this with a big relative component here) low stress stretch, I feel like I am well adjusted with an ability to pause and process a situation before assuming the worst of everyone.

Another element comes to my mind while thinking this through; getting burned by patients and seeing how deceptive and manipulative some people are takes a toll. Often to feed a substance abuse problem, but also anxiety and true mental illness can force patients to lie about symptoms. This is not news to anyone, especially those in healthcare, but we, as providers, get better and while it is a headache and a time sink (taking away from patients who legitimately need medical attention, by the way) but this is not my point.

I wonder what that guy is up to now -- the one who took such offence to my nutritional pamphlets that he needed to strike one in our party. Does he remember that night? I would guess not -- someone that prone to physical violence probably has a lot of incidents over the years. I hope whatever pushed him into such an explosive reactionary mindset is resolved. Hopefully he isn't teaching his kids to respond in a manner as he did that night.

Friday, April 27, 2018

"Fascism is a Religion. The Twentieth Century will be Known in History as the Century of Fascism" Benito Mussolini


Good friend of mine introduced me to this podcast around a year ago while helping drive a moving truck down I-5. We made it almost all the way through a very intriguing episode called "The Prophets of Doom," an exploration of Martin Luther's reformation and the Anabaptists and the colorful and murderous exploits of one German City. Of particular fascination was the fact that the church I grew up in and that a large number of family and friends still attend hail from an Anabaptist heritage via Samuel Frohlich -- a trivial piece of information that, if you aren't familiar with, thankfully you will not find your edification compromised while listening to this.

A luxury of being so darn busy all the time is that consumption of media is lessened and when faced with some free time there is a pile of entertainment to pick from (a Stockholm Syndrome kind of thing to say, to be sure!) and the same stands for the available episodes on this podcast. However, I started listening to another incredible episode, concerning itself with the idea that ponders whether or not Human Beings are able to 'handle" the unimaginable destructive power of the nuclear weapon. Around a month ago I started and only today did I finally finish it.

I've written here, on this platform, and even before starting a blog, I have written short stories concerned with growing up under the threat of nuclear annihilation. In college, the best non-writing class I ever took was an elective all about the history of "the splitting of the atom" and was taught by a biochemist, who followed his passion of all things atomic and taught the class in a way that still has me pondering ideas -- political, scientific and really, the essence of the human experience. I like to think that I had the pleasure of growing up under the belief that armageddon was a heartbeat away, coupled with the threat of the rapture -- both happening in a blink of an eye -- from which a logical conclusion is arrived stating that this life, the only life we get on this planet, isn't worth much. Don't hope, plan or waste time thinking about the future because there is no future as you know it, or, as I knew it as a child. I'm off track again.

By the late 1800's the direct foundation for splitting the atom had been laid. Fundamental principles regarding electromagnetism and chemistry had been established; Newtonian Physics (which got us to the moon, by the way) had been a overwhelming success in terms of proving to be a true thing -- to be able to elucidate the unseen and hitherto unexplainable laws of the Universe.  140 years, or so, removed from when this science began to take hold we can look back and see the how this Earth has changed in ways never before seen. Truly, the wonders that we take for granted on a daily basis is astounding. We have devices that rely on technology developed by people who grasp certain fundamental rules of the natural Universe and even now, this technology is used by people who have efforted not to gain this understanding but espouse ideas that discount the efforts of those who sent us to the moon and even worse, those who deny the very basic geometry of residing on a sphere.

The idea of Generation "this" or Generation "that" seems, on its surface to be a irrelevant construct and who is to say who or what are in what groups, or demarcation lines arbitrarily drawn and the idea of what they mean, or why we think like this seems to be obscured, in general. In the terms of simple timelines and brackets of generations, the major defining events of recent history, worldwide, are easy ways to try and interpret the events as we see them in real time, today. World War I ended November 11th, 1918 -- almost 100 years ago. Anyone who played a role in the actual war is dead. I suppose a ten year old kid may have been in the war and is now 110 somewhere, smoking unfiltered Lucky Strikes and chasing it with a swig of Old Grandad, but nevertheless, no-one in our daily lives was a soldier in WWI; the same is going to happen to WWII veterans soon, too.

The people who remember what life was like when the shadow of nuclear annihilation first brought the shade to everything they did and knew are also in short supply. Dan Carlin makes an analogy of the threat of atomic warfare acting as a gun to the head of humanity. When life has been going along, while not perfect (and even less stellar for those digging out of the rubble of yet another world war) noticed the gun against their head and acted as such -- panic, fear, anger, progressive discussion and schemes of leverage, was everywhere. As the Cold War progressed and the Arms Race blossomed into a specter of death unlike the world has ever seen, people who grew up in this environment, and while they didn't remember life without the gun pointed at their head, they were raised by people who did. People who still felt the presence of the gun very much. We are removed enough at this point where very few people remember life before the gun to the head.

Within the past day it seems, at least on the surface, that the DoomsDay Clock has moved slightly backwards. North and South Korea lessening tensions, if sincerity exists on both sides, cannot be a negative thing. Remember the United States has pledged, through treaties to defend South Korea with nuclear arms, if necessary -- and for that matter, a few dozen or so other allies have this umbrella of protection with the United States -- for now. And what has the supposed problem been with North Korea? Their exploration in becoming a nuclear capable state -- while problematic, to be sure, it is that which pushes the foreign policy needle -- not torture, starvation and brainwashing of the people.

Amongst more than a few other reasons, a significant concern of our current national leadership lays in the little reason to trust or have confidence in responsible stewardship of our nation's strategic responsibility. A person like this, who currently holds the office of President, would not have been elected when people felt the gun to their head. People are easily whipped up into a frenzy over immigrants, the myth of Christian persecution (specifically in the US; not discounting oppressive totalitarian regimes and their religious militant dogmatism) and the trappings therein and the gun, which is still there, is nothing but another line item in the pantheon of complaints and murky conspiracy theories. We have moved into a day and age in this nation where real nazis and Ku Klux Klan members are walking around, with no shame. I fear that this is how the world has always worked, that the rise and fall of empires, nations and dynasties have always had the generation which eschewed the wisdom of the past, but only because of the corruption of the generation that raised them. Who complains about the "participation trophy" generation? The same f'ing generation that gave the trophies out!

And what does it take to bring a society together? A tragedy. A war.

Do you trust North Korea? Interesting to ponder what's up the sleeves of his Mao Suit.

Saturday, April 14, 2018

Concerning the Body and Internal Combustion Engines, Carbohydrates are to Fat as Gasoline is to Diesel

Post #113.

July 25th, 2011 was the date of the first post.

2450 days since first post.

An average of 1 post every 21.68 days.

Like our brains are wont to do, 7/25/11 in some ways feels like yesterday, and in some ways it seems like a different person typed out the words of the first post.

I remember one of the first lectures in medical school from one of the more insightful professors included a thoughtful discussion about the process we were about to undertake -- one that I'm still going through and in essence, will continue to have as long as I practice clinical medicine. Specifically he spoke of the propensity of this process to bring forth and manifest the vulnerabilities that each of us have. Not completely earth shattering in that people under pressure and stress show weakness where their biggest weakness lies -- of course they do! But this sticks with me, and I remember sitting in the lecture hall thinking about what my biggest weaknesses are. For me, there are plenty of aspects to pick from; my curiosity lay in wondering which particular one might show up.

Well, I can safely say that plenty of them did "show up" but one, with the help of age, history and perhaps familial propensity has had lasting ramifications. Weight gain.

I spent the year between graduating with a B.S. in biology and chemistry (don't forget my minor in creative writing!) and starting medical school, working and running. I ran a few half-marathons and worked at the same coffee roaster as I had been during my whole time in Denver, but back in a full-time capacity. Tossing around 160lb green coffee bean bags was no big deal. Running 30 or so miles every week; I was in great shape. I felt great. So hopeful for the future, for the doctor I was to be.

Abruptly going from that to lectures from 8 to 5, 5 days a week with a tragically large increase in cortisol due to stress left me rapidly piling on the pounds.

I've bounced around in various states of "fatness" since that time. Many months have been simply to busy to adequately exercise, and usually those months are stressful enough that adhering to a caloric deficit, or simply eating an overall healthy diet is difficult to maintain.

And here I am, roughly 6 and a half years from the last time I considered myself to be in "good shape." And here I am, approaching the end of intern year. An intern year that has had some of the most stressful days and nights of my life. And here I am, on the downside of the most demanding periods of training, with undoubtedly much left to learn, but also with the steepest learning curve behind me. In other words, as my youth continues to be ever more fleeting, now is the time to make moves -- to redirect the discipline and frankly, stubbornness, that has gotten me to this point in my career to another, more personal objective: weight loss and physical fitness.

I am a large human, relatively, in that my skeleton is taller and broader than most. Throughout my life, in various phases of intensity, I have worked to hang large muscles from my skeleton. The Body Mass Index does people like me a disservice (I could easily get distracted and go on and on about how BMI is severely flawed and that the creator of the equation never meant it to be used as it is today but perhaps another day, another post)  in that even at an appropriate body fat percentage, I will still be solidly "overweight," close to the numbers that equate obesity. Well that's okay -- at least I have that understanding.

So what am I doing to facilitate this change? I am hesitant to get into it -- to explain it, and as a physician I am even more reluctant in that I'm held (starting with me, I hold myself to a higher understanding of physiology) to a higher level of scrutiny when it comes to things like diet and lifestyle changes. This is because of the fervor and obnoxiousness that exists around American fitness, or lack thereof and efforts to counter the obesity and deconditioned nature of the people of this country.

Simply put, I'm facilitating the usage of stored energy (fat) instead of using new energy (food) to live and stay alive.

There are many ways to get to this state of metabolism. After all, our bodies in some ways are simple machines in their overall function and aims -- when excess energy is available it is stored, and the reason for storage, obviously, is to have it available for usage at a later date. Less energy pushed into the system, say, on a daily basis that is not sufficient for daily operations means the body will dip into the energy reserves. A caloric deficit is what this is. It is necessary as dictated by the 2nd law of thermodynamics in order to decrease mass of adipose tissue in each and every one of our bodies. Many people call this "Calories In; Calories Out" (CICO) and state that the argument over how best to lose weight ends here and it is this simple. And while yes, it is simple, it is an incomplete understanding of how best to optimize the usage of the energy reserves tied up in fat cells. Our body uses enzymes (which by definition lower the activation energy needed for a given chemical reaction; think of enzymes are able to get the ball rolling much easier and faster than it would on its own) hormones, and a complex feedback system to balance our energy usage and management of our reserves. Of course, perhaps the most important aspect is how we feel in that feeling hungry, having cravings equates to a conscious realization that our metabolic machinery prefer fast burning, efficient energy by way of eating food -- often in the form of the best bang-for-the-buck-compound our bodies can use -- carbohydrates. Gasoline is a carbohydrate (well, technically a hydrocarbon, as there is no oxygen atoms in the compound, but for this analogy, it works) and the power it unleashes when burned is obvious -- I took the fact that when I accelerated my automobile to get on the freeway this morning for granted; no appreciation at all for the controlled explosions occurring a meter or so in front of me, pushing me and a few thousand pounds of steel, glass and leather to a velocity unheard of for human travel for the overwhelmingly whole of our history. Regardless, a loose but workable analogy can be made here: gasoline is to diesel as carbohydrates are to stored fat. Shaquille O'neal, a man who makes me look petite had a nickname (among others) of "The Big Diesel" in that he was huge and slow, but steady and extremely powerful. Our bodies operate with an exaggerated difference; carbohydrates are fast burning, easy to metabolize and as such our senses are built to favor these compounds -- bread, sugar, pastries -- whatever, we naturally feel pleasure when consuming such things. A gratification that keeps us doing the things that our bodies need us to do.

Throughout our history, access to pure dietary glucose was minimal. Fruits. Honey. Grains. Natural syrups. That is all we had. Our bodies were exceptionally adept to take excess energy, in the way of a big influx of carbs, and store it. Our liver is able to take the sugars (carbohydrates = sugars for our purposes here) and turn it into something called glycogen, which is a stored form, and relatively easily accessible form of sugar. Our liver is a large storehouse of glycogen. Our skeletal muscles hold a lot of glycogen too. If our glycogen "tank" is full, well then, what happens to excess carbs that we eat? Our liver turns it into fat and it goes to the fat cells.

Modern humans overwhelmingly have less and less physical exertion as a component of daily living. I mean, the idea of paying to go to a place that has specialized machines to facilitate energy expenditure is a ludicrous idea for most of our history -- but here we are. 500 years ago, glycogen levels would be highly varied as that human, 500 years ago, depended on it for living. It takes a day or two to exhaust glycogen and if the glycogen was exhausted, that body would pull from the fat stores, as there was no other energy available, provided food was unavailable, or even if that person had a caloric deficit.

This speaks to what I'm trying to explicitly accomplish -- maintain depleted glycogen stores in my body so that the cellular machinery that keeps each and everyone of my 37.2 trillion cells (give or take a few billion) alive and functioning are burning fat, instead of carbohydrates for fuel. Simple, right?

Theoretically simple. Restrict carbohydrate ingestion to a degree where the body must pull from glycogen reserves. The body, at least at first,  dislikes this. Sugar is easy to burn. Energy required to burn it versus energy from burning it is good; it is efficient. We are built for efficiency, if nothing else. But then if carbohydrate ingestion is continued to be restricted, the body must acquiesce and use a much less efficient fuel -- you guessed it, the diesel of our diet and energy stores: fat.

As I said above, I hesitate to evangelize a certain diet above others, provided that there is evidence behind a given way of eating. For me, relying on endogenous "diesel" decreases the ups and downs of blood sugar and subsequently, feeling good and bad, with cravings and hunger a large component of daily life. Much of our "feelings" are driven by our insulin response; and perhaps more importantly, insulin dysregulation, whether it be at the factory (pancreas) or at the affected tissue (insulin resistance) leads to diabetes and other types of dangers associated with an excess of adipose tissue, including inflammation which, as we are learning, is highly correlated with atherosclerosis to a higher degree than simply over ingesting cholesterol or dietary fats.

Lastly, I think it is important as a physician to be very critical of the consensus guidelines that direct our clinical practice. For the past few decades, we leaned on the "fact" of a low fat diet and the evils therein. Study after study showed the correlation of high fat diet and cardiovascular disease, obesity and a myriad of other issues. It is now becoming clearer that at least some of this was pushed by the food industry in that cheap sugars needed to be sold as healthy. Eliminating fats, and having "fat-free" printed on a package was a panacea to the burgeoning obesity epidemic, so thought the American masses, and understandably so. Instead we were and to a lesser degree every year, depriving ourselves of essential fats and cholesterol that our body needs to function. Our body requires these things to function. Interestingly enough, our body does not require any carbohydrates to function. Now listen closely, I am not advocating everyone aim for a zero-carb diet, but just this realization is in direct conflict with the "common sense" of our age. Food for thought.

As a brief sidenote, consensus guidelines in medicine are controversial by the very fact they are consensus meaning that a group of scientists and doctors had a pow-wow and they all compromised to a certain degree to arrive at the decision of what to tell doctors to do in their clinical decision making. This means that the truth is not necessarily guiding the decisions, but the amalgamation of opinions. I didn't spend the last 8 years of school along with the years of clinical experience to simply abandon my own judgement and reasoning; and I, even now, can see evidence that guides me away from consensus guidelines in pursuit of providing truly the best care possible for a given patient. Again, I could go on and on...

I'm not even going to name this particular way of eating. Through my understanding of how the body works I am simply aiming to help my body use the energy reserves. And that is post #113.

Tuesday, March 27, 2018

Na Na Na Na Na Na Na Na LEADER!

Over the weekend I binge watched Wild Wild Country a documentary on Netflix about the Rashneeshi movement and their effort to build a city in Central Oregon, basically isolated by dozens of miles in either direction. I can't recommend it enough, of course I have a unique element allowing for, perhaps, extra exuberant enthrallment in that I remember this unfolding on the 5 o'clock news, as I grew up in Portland. It was edifying to see the fiasco from both sides; the "free-love, humanistic sannyasins" versus the "ultra-conservative, undereducated white normies" in the nearby town of Antelope, population of 40, at the time. The Rashneeshis were actually Sannysins, followers of Bogwan Shree Rashneesh. They, for most of their time in Oregon, wore all red clothing and were easily identifiable as such.

Cult of personality if there ever was one. Many of his followers spoke about his "presence" and less of his teachings.

This film inspired me to ponder the nature of leadership. Undoubtedly there are untold numbers of humans who have had good ideas, who have had the self-sacrificing nature and altruistic nature that we often say comprises a good leader. I would counter that many of our leaders, from unofficial "leaders" of a small group of friends, to middle-management in any corporate setting, anywhere USA to leaders of industry and those at the highest levels of elected governorship have many discernible attributes, but self-sacrifice and altruism are hardly elements that allows one to climb rank.

Not always is this the case, thankfully. From my perspective, however, I think our culture in the United States has shifted slowly over the decades to espouse and honor results at all costs, and many times, short term gains over long term losses. I could go on and on. I can point my finger at a few specific aspects of our financial system that not only reinforces, but under penalty of law, enforces this dynamic. Of course, if The Citizens United ruling actually made sense, corporations would be interested in their long term viability and not only immediate profits.

I digress.

"Doctor" in latin, translates as "to teach." Not all teachers are leaders, but I argue that most effective leaders, to some degree, are teachers. Perhaps not in an official capacity, but an effective leader needs to educate those in their service to a point where toil is performed with willful duty. You may forgive me for not immediately thinking of a martial structure, where rank and file do as they are told with no questions or concern. This system works when there is punitive action for disobeying orders. It is effective, this is why armed forces and totalitarian regimes adhere to this chain of command. However it is fragile pending loss of punitive measures. It is far better to have willful adherents to your etiology. Whether it be "cubicle troopers" who understand the need for TPS reports (may not like doing them, but they understand their utility and thusly dutifly complete them) or Sannyasins who would willingly die for a man named Bogwan Shree Rashneesh.

I never watched Nurse Jackie when it was airing on Showtime. I remember it was very popular when I was in undergrad. Last night I watched the first episode. Within the first few minutes we learn that doctors are idiots and that (at least Jackie) nurses are the only ones that care for patients well being, much less their medical outcomes. Makes for good TV, if you've never been a doctor, I guess. Not to demean the role nursing has in patient care (I always feel compelled to state that when talking about nurses) but the doctors, at least in the first episode are so careless and cavalier with their medicine, much less their demeanor with patients and other staff that they would not last a week in modern healthcare. At least not in the last century. And why do I bring this up? Because it flies in the face of everything I strive to be as a physician, and overwhelmingly everyone I've ever met in this process -- whether at the end of their career or an aspiring pre-medical student.

So what do I care about leadership? I worry that it stems from a place of ego -- from desiring power. I then remember that just having that worry, the fact that this is a concern of mine is a prognostic factor for a healthy leader. What capacity will this aspiration grow into? I don't know. Simply being a physician thrusts me into the role, like it or not. And there are days where I like it less than others.


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