Obesity – a hormonal disorder

Obesity, or having a BMI greater than 30, is becoming a more common health problem over the last few decades with about 40% of adults now dealing with this.  It is also a health problem that is stigmatized and the patient is frequently blamed for.  Everyone knows that if they just ate less and moved more they wouldn’t have this problem. Right? People are stereotyped as lazy and not watching what they eat.  Research shows that there are other things that contribute to patients having problems controlling their weight, besides eating too much. In fact it is common for obese people to eat fewer calories than their thinner friends, Dr. Jason Fung is a kidney doctor who believes that obesity is primarily a hormonal disorder, and not a caloric disorder.

Dr. Fung is the author of several books that have been talked about recently – including the “Obesity Code” and “the Complete Guide to Fasting” and most recently “the Diabetes Code”.  He has a program called Intensive Dietary Management which is available online to provide further support to people who are interested.

Insulin Resistance and increased insulin levels are what Dr. Fung believes has contributed to our obesity epidemic and what makes it harder for people to lose weight the longer they have been obese.

Hormones are molecules that move throughout the body and deliver messages to the target cell.  One of the main hormones involved in obesity is insulin.  Insulin is made in the pancreas and helps the body use energy and store excess energy for a time when it can be used – and thus causes weight gain.  If you decrease the amount of insulin you are exposed to, you can decrease the weight,

How can you decrease insulin levels?

Insulin levels are decreased by

  1. eating foods that don’t raise insulin as much – carbohydrates raising the insulin levels more than proteins or fats.
  2. decreasing levels of the hormone cortisol that increases in response to stress and
  3. decreasing insulin resistance 
  4. decreasing how often you eat. 

How can you treat obesity and reverse diabetes?

So to reverse this epidemic it may help to:

  1. reduce added sugar consumption.  Read labels.
  2. eat whole unprocessed foods.
  3. avoid refined grains like white flour to decrease insulin spikes.
  4. increase consumption of natural fats – healthy fats like avocados, walnuts, virgin olive oil, fatty fish – helps with feeling full by stimulating the fullness hormones peptide yy and cholecystokinin – and fats don’t raise insulin levels as much.
  5. improve stress control and sleep hygiene to decrease the stress hormone cortisol from stimulating insulin.  Try Tai Chi, yoga, meditation, massage and regular exercise to help with this.
  6. increase physical activity to improve insulin sensitivity of tissues.
  7. limit the bodies exposure to insulin by decreasing the frequency of meals. Insulin is released each time we eat so decreasing how frequently we eat decreases how often we are exposed. If cells aren’t as frequently exposed to insulin, then they will be come more sensitive to its effects and less will be produced. And decreased insulin helps with weight loss. 
  8. don’t drink diet soda or artificially sweetened things that increase insulin release even though they don’t contain calories.
  9. increase fiber – to help with digestion and decrease production of the hunger hormone ghrelin.

Dr. Fung recommends people consult with their physician to see if intermittent fasting is appropriate for them and to do lab work in order to monitor their treatment progress.  There are different protocols that people follow when fasting and it can be used with many different diets – although many people chose to pair it with a Keto diet to decrease exposure to foods that increase insulin levels. 

 

***Note *** This post, like all my other posts, is for general medical information only and is not to be taken as direct advice.  Please consult your personal physician for more information.

Healthcare 3.0 or ZDogg discusses Direct Primary Care

ZDogg, well known by those in the medical field for his musical parodies, has talked about something called Healthcare 3.0. He calls Healthcare 1.0 to be the old time family medicine, without clinical guidelines, and a paternalistic relationship between doctor and patients. Healthcare 2.0 is how many offices are functioning now – owned by corporations, driven by quality numbers and productivity goals, they may lose the relationship with the patients they aim to serve. Medicine becomes more of an assembly line, neither the doctor nor the patient are in charge and their healing relationship is disrupted.

Healthcare 3.0 is a combination of Healthcare 1.0 and 2.0.  Healthcare 3.0 provides personalized care that recognizes the needs/wants of the individual patient in the context of the greater whole. It is a partnership between the physician and patient that recognizes the mind-body connection and helps the patient work towards goals that are important to them. The video he created “Healthcare 3.0” was to inspire those in the medical field to dare to try something different that may allow us to create a better future for our patients – as well as ourselves as practitioners. It is the type of care that many of us wanted to be able to provide when we went to med school. 

ZDogg had a practice called Turntable Health from 2013 to 2017 that was his attempt to create a Healthcare 3.0 environment – while they ultimately closed due to multiple factors – large overhead and depending on venture capital funding being two  major ones, they improved medical care, touched many patients lives and inspired many physicians to work towards creating their own version of Healthcare 3.0 – Direct Primary Care being one of these versions. Click here to see an article about his practice.

One of the things that Turntable did was allow patients to have access to many services that would improve their health – nutrition, yoga, health coaching were just a few of the things they could access. I would have loved to join Turntable if it had been located in the Cincinnati/NKY area. I have no venture capital and am trying to keep my overhead low, but I am trying to figure out a way to incorporate nutrition and mental health care into my DPC practice over the next year – as these are two areas that a lot people would benefit from having better access to.  Stay tuned for further updates as I work through this thought process. If you have thoughts on ways for me to do this, or know people who may be interested in working with me –  contact me via email CVillacisMD@HealthConnectionsDPC.com.

ZDogg recently did an interview with Dr. John Bender who has a DPC practice in Colorado, and is on the board of the American Academy of Family Physicians.    Click HERE to see the interview.

Colorado is the other state, that along with Kentucky, doesn’t allow patients with Medicaid to pay for direct primary care memberships with their own money. Yes, you read that correctly.  If you have Medicaid through the states of CO or KY, you can spend your money on things that damage your health, but not healthcare. KY is having problems paying for their Medicaid expansion – but won’t allow for patients to pay for things they want to improve their health. Direct Primary Care provides better access and longer appointments for patients and this helps decrease ER visits and improve health outcomes.  All of this would help patients, and provide the state considerable potential savings. I went to Frankfort last week with 2 other DPC doctors from KY to try to change this. I find it ironic that the coverage that is supposed to help patients obtain medical care, is preventing their ability to obtain medical care on their own. Hopefully as we go forward with this conversation, we will be able provide care in a way that doesn’t discriminate against people based on their insurance status. 

Everyone I know who has opened a Direct Primary Care practice has done it because they want to provide better health care than they are able to do within the current system.  We are moving towards Healthcare 3.0 – come join us!

 

***Note *** This post, like all my other posts, is for general medical information only and is not to be taken as direct advice.  Please consult your personal physician for more information.

Diabetes – Diabetic Neuropathy and Tips for Healthy Feet

What is Diabetic Peripheral Neuropathy?

Diabetic Peripheral Neuropathy (DPN) is nerve damage that is caused by high blood sugar and triglycerides. It is unfortunately very common and up to half of all people with diabetes may struggle with diabetic peripheral neuropathy. DPN can cause people to have both pain and numbness and lead to severe problems like ulcers, bone infections, and even amputations. It can also cause problems with balance, problems walking, decrease muscle tone and lead to structural changes in feet. People may not always be aware that they can’t feel their feet enough to protect them – and this is why it is essential to have a diabetic foot exam at least once a year.

Pain

People with DPN have a burning, tingling, pins and needles sort of pain that is often worse at night or after being on their feet a lot. It is usually symmetrical and progresses from the toes up the legs over time. After a while, it can also affect the hands.

Numbness

If you can’t feel your feet, then it is harder to protect them. People with diabetes have problems sensing pressure, pain, and temperature at times. This can lead to foot sores developing. These sores can develop by stepping on something, friction or other causes. Once established they are then often hard to heal and have a higher risk of infection if the person’s blood sugar isn’t controlled. If the person is a smoker or has peripheral vascular disease, it can be especially hard to heal.

Sometimes people can have so much numbness that they may not be able to feel if they have a broken bone in their foot. This can lead to them walking on it and developing a problem called a Charcot foot – which could need surgery or even lead to amputation.

Unusually shaped feet may not fit right in shoes, which leads to an increased risk of ulcers and adverse outcomes. DPN can lead to other structural changes feet which can make it more common to get ulcers. Once people have one ulcer, they are more likely to get another one. If these sores aren’t tended adequately they can get infected, this infection can spread to the bone and lead to amputation. Treatment may involve removing dead/infected skin, staying off feet, using a special brace to care for it. Frequently patients will be under the care of a podiatrist or a wound care clinic to help care for foot sores. If your PCP refers you to one these specialists – please go!

Treatments:

While DPN can be very painful, there are treatments which your doctor may recommend for this nerve pain. Antidepressants – like amitriptyline or duloxetine, anticonvulsants – like gabapentin or pregabalin are effective and reducing pain and increasing function for people dealing with DPN. Physical therapy can help with strength and balance, and bed cradles can be used to keep blankets off feet during the night.

Tips for healthy feet:

  1.  Inspect your feet daily – use a mirror or ask someone to help if you can’t see. Check your whole foot – big toes, little toes, the ball of the foot, sides of foot, heel… 
  2. Bathe feet in lukewarm water every day
  3. Moisturize feet – but not between toes. Extra moisture can lead to infection. Feet can become drier because the nerves that control the oil/moisture in your feet aren’t working right anymore.
  4. Cut nails carefully – straight across, file edges if needed.
  5.  DON’T cut corns/calluses yourself – talk with your family doctor or podiatrist about it. If not appropriately treated these can turn into sores.
  6. Wear clean, dry socks – maybe diabetic socks.
  7. Wear socks and shoes all the time. Don’t walk barefoot
  8. Protect feet from hot and cold – wear shoes on the sand/sidewalk, test water with fingers before getting in the tub, no hot water bottles or heating pads to your feet.
  9. Look and feel in shoes before putting your feet in. You could walk all day with a pebble in your shoe and injure your foot without knowing it.
  10. Consider special shoes or orthotics – Buy them later in the day when feet are larger and break them in slowly.
  11. Stop smoking – smoking damages blood vessels and makes it harder to heal and dramatically increases your chance of amputation.

***Note *** This post, like all my other posts, is for general medical information only and is not to be taken as direct advice.  Please consult your personal physician for more information.

What is Addiction?

As a family physician who also practices addiction medicine, it is common for me to find that patients are confused about the difference between physical dependence on a substance, and addiction. Any substance that causes withdrawal symptoms when discontinued has created a physical dependence. Withdrawal symptoms can be caused by many classes of medications and drugs – from alcohol, opiates, and benzodiazepines to some blood pressure medications, sleeping pills, and cold medicines. Withdrawal symptoms may or may not be accompanied by other features that are characteristic of addiction. If you have a surgery and take opiate medications regularly for two months and suddenly stop – you will probably have withdrawal symptoms. Having withdrawal doesn’t mean that you have become addicted to opiates – it merely means that your body has adjusted to having these medications on board and need to come off of them more gradually to avoid feeling sick. If you are taken off opiates because you are no longer in pain, and aren’t having withdrawal symptoms and just want more pain pills because you like the way they make you feel (not because you are still hurting) and you are craving them – that is more characteristic of addiction – now called substance use disorder, or SUD.

Types of Substance Use Disorder

Substance Use Disorder is a new way of looking at and diagnosing addiction that came with the DSM-V, the most recent diagnostic tool put out by the American Psychiatric Association in 2013. These criteria are based on several decades of research. The category of SUD is broken further into different categories based on type of substance used, and how severely the substance has impacted the individual’s life. The following are the different categories:

  1. Alcohol Use Disorder
  2. Tobacco Use Disorder
  3. Cannabis Use Disorder
  4. Stimulant Use Disorder (ex. meth, cocaine, Adderall)
  5. Hallucinogen Use Disorder (ex. LSD, Mushrooms, PCP)
  6. Opioid Use Disorder (ex. Percocet, heroin, fentanyl)
  7. Sedative Use Disorder (ex. Xanax, sleeping pills)
  8. Inhalent Use Disorder
  9. Caffeine Use Disorder

Criteria for Substance Use Disorder

Substance use disorder covers a wide range of symptoms and it focuses on problems that people may have as a result of taking a substance. There are 11 different basic criteria that make up a diagnosis of Substance Use Disorder, and they can be lumped into different groups – impaired control, social impairment, risky use, and pharmacological indicators.

Impaired Control 

People can have impaired control can show up in a number of different ways – 

  1. Taking a substance in larger amounts or for longer than you meant to
  2. Wanting to cut down or stop using a substance but not being able to
  3. Having cravings for the substance
  4. Spending a lot of time getting, using or recovering from using the substance

Social Impairment

As SUD worsens it can effect more different aspects of people’s lives – 

  1. Struggling to meet your responsibilities at home, school or work due to substances
  2. Giving up activities due to substance use – social or work-related
  3. Continuing to use despite causing relationship problems

Risky Use

Continued use despite the harm that it can cause to your person – 

  1. Continuing to use despite knowing you have a physical or mental health problem that could have been created by or made worse by the substance – like cirrhosis and continuing to drink
  2. Using the substance in a way that could put you in danger – such as using drugs while driving 

Pharmacological Indicators

These can develop as part of regular use, but may or may not be indicators of SUD – 

  1. Tolerance – needing more of a substance to get the desired effect
  2. Withdrawal Symptoms – which are relieved by taking the substance.

The Severity of Substance Use Disorder

If an individual has 1 of these 11 above symptoms – ex. just the withdrawal symptoms – it does not indicate that they have a substance use disorder – just that they have become physically dependent on that substance.

  • If a person has 2 or 3 of the above symptoms then that may indicate a mild substance use disorder,
  • 4-5 symptoms indicate a moderate substance use disorder, 
  • 6 or more indicate a severe substance use disorder.

I have had some patients who thought that because they were still functioning well at their job, and their family wasn’t aware, and they were still participating in their same activities – they didn’t have a substance use disorder. It is true that person likely doesn’t have severe substance use disorder. However, if they are now having health problems that are related to their substance use, have tried to stop and haven’t been able to, then they probably have at least a mild substance use disorder. If you think about the person who has been diagnosed with COPD and told by their physician that they need to stop smoking – and find that they are unable to quit – that person probably has at least mild tobacco use disorder.

Treatment for Substance Use Disorders

The first thing that people need to realize is that they are not alone. There are millions of people in the US who deal with substance use disorders every year – and many of them recover from it. The earlier a person is in their substance use disorder, the easier it is for them to make changes. However, it is never too late. The thought that a person has to hit bottom before they make a behavior change is not true. The goal of getting someone into treatment is to keep them from hitting that bottom and allowing them to get back what they have lost due to the substance use disorder, and minimizing future damage. 

I recommend that people talk openly with their physicians about their substance use so that they can learn about how it may be affecting their health and what is the best way to get healthier. Also, there are some substances, such as benzodiazepines and alcohol, that when stopped abruptly can be dangerous to one’s health – leading to withdrawal symptoms such as anxiety, agitation, hallucinations, and seizures. These problems can often be avoided by appropriate treatment. Talking with your physician also gives the doctor a chance to be aware of any things that they may need to do differently when treating you – so that they don’t hurt you by accident. I have seen multiple cases of someone with an opioid use disorder that is in remission, end up relapsing due to being prescribed opiates for an injury “just in case they need them.”

I base recommendations for substance treatment on the severity of the disorder, home environment, patient preference, prior treatment experiences, and several other factors. Frequently, I recommend a combination of counseling and medications. It is important to address any underlying issues that may have led the person to develop the substance use disorder in the first place, as well as the substance use itself. If someone started using opiates in response to psychological distress, treating the substance use disorder without also addressing the mental health issue is going to be less effective. Some people find that participating in groups such as AA, NA, Celebrate Recovery or Smart Recovery provide them with support as well as skills on their path to recovery. Other people may participate in group sessions that meet several times a week for several hours at a time or may have individual sessions on a weekly or monthly basis with a counselor trained in addiction.

There are a lot of different paths to recovery and sometimes it takes a while to find what is right for you!  Just because you have tried to quit in the past and started using again, doesn’t mean you can’t stop in the future. The most important thing is to learn from your past attempts, forgive yourself for not being perfect, and reach out for help again. 

If you have a friend or family member who you think may be struggling with a substance use disorder, or if you think you may have a substance use disorder yourself – please consider talking with your/their physician. There is help available, but the first step is realizing there may be a problem and asking for help.

For more information on substance use disorders, please check out www.samhsa.gov or www.drugabuse.gov or talk with your personal physician.

***Note *** This post, like all my other posts, is for general medical information only and is not to be taken as direct advice.  Please consult your personal physician for more information.

Happy Thanksgiving!

One thing I sometimes recommend to people is that they make a gratitude list to remind themselves of all the good things that they have going on in their lives.  There are several things that I am particularly aware of being grateful for this year.  Probably the top 2 things are my family and the strength I have found in the Direct Primary Care community.

Most Primary Care physicians today are employed by groups or hospital systems.  As a former employee, I can attest that this is a difficult spot to be these days.  While as an employee I did have the relative security of having an income, I lacked much control over the process of how I cared for patients. Even though I became involved in leadership teams, I was a piece in a much larger system and did not have the authority to make many decisions.  It was frustrating to have ideas about how I could better care for my patients and create a better environment to practice in, and not be allowed to implement any of my ideas for a multitude of reasons.  I found out about Direct Primary Care while reading a practice management magazine – and a light bulb went off. I had a choice.  Patients had a choice.  There was a better way to do things. 

As an independent DPC physician, I am responsible to make sure my office runs the way I want it to as well as providing excellent patient care.  I am a small business owner – something I received precious little training on in residency – which was 16 years ago… I have had so much to learn in this area and I am truly thankful for those who have helped me along the way.  From DPC physicians who opened their practice for me to visit them, to people who coached me on how to write a business plan and sagely advised me to make it for 3 years and not 1; from SCORE mentors advising me on commercial real estate to other members of the Chamber and BNI who have given me suggestions on marketing and bookkeeping.  I am part of a tribe of over 1000 physicians nationwide who are going down parallel paths in opening independent businesses and the support we give each other through Facebook groups, and conferences has been amazing.  I am blessed to have my family who has listened to my ideas, gone to conferences with me, and helps me keep things in perspective as I go through the rollercoaster of being a new business owner.

I am thankful that my mom has completed chemotherapy this month and that my sister and I are living in the same metro area for the first time in 30 years.  I am thankful that my daughter is still able to enjoy her dance and that my son will be graduating from college this summer.  I am thankful that my husband is able to remind me of where I have been and where I am trying to go and WHY I am going there when I get bogged down with daily challenges. And I am thankful for the unquestioning love that our furry friends give us on a daily basis. 

I am privileged to be able to share people’s journey towards better physical and mental health.  Patients open their lives to me and we are able to talk about their goals, dreams and hopes – and how they can try to achieve them.  They share their pain and grief – and I am allowed to counsel them, or just be present with them in the moment. Being a doctor is not a matter of just writing a prescription or a referral – it is much more than this – it is a calling where one human is able to care for another to try to restore and/or maintain health – by drawing on their previous experiences, research and knowledge and melding that with what the other person wants and needs. 

It has been a crazy year and I have much to be thankful for and I am looking forward to what the next year brings.  It’s quite a journey!  Thank you for coming on it with me!

 

How to Measure Your Blood Pressure

Blood pressure measured in my office can be different from blood pressure people may have when they are at home or at work.  In order to figure out how much of a problem someone’s blood pressure is we frequently need them to monitor it on their own.  Below are some common situations where I recommend people check their blood pressure.

1)    If the diagnosis is unclear.  Patients sometimes blame an elevated blood pressure reading on “white coat syndrome” – in other words it is just up because they are in my office but it is really ok the rest of the time.  While sometimes this is true, I really hope that coming to see me isn’t the most stressful part of their life.  If their blood pressure is up when they see me,  I frequently wonder what it is when they get home at the end of a long day!

2)   Sometimes people have concerns like headaches – which can be related to blood pressure – or a number of other health issues.  If they have a headache and check their blood pressure we can see if these problems are related or not.

3) When someone has a diagnosis of hypertension – they can see how their blood pressure is between visits and how it is influenced by different things in their life like stress, smoking, weight loss/gain and also how their blood pressure is in between doctor visits .  Hypertension is a chronic health problem – and like all chronic health problems – people tend to do better when they are actively involved with their own care.  If someone monitors their blood pressure and is seeing that it isn’t where we want it to be then they can let me know and we can figure out what the next steps are instead of waiting for their next scheduled visit.

 

***Note *** This post, like all my other posts, is for general medical information only and is not to be taken as direct advice.  Please consult your personal physician for more information.

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