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.