Clinical Challenges, solutions and supporting research
Not losing weight?
Send for a sleep study to rule out obstructive sleep apnea.
Low energy, Fatigue, Leg cramps, Leg weakness and Palpitations?
This collection of symptoms is united by an effective treatment: Magnesium supplementation.
- Magnesium 500 mg daily for 2 weeks – caution if there is a history of kidney disease.
New or worse menometrorrhagia?
I have found no effective treatment for this condition but it does affect a small group of women and can be quite troubling. It seems to lessen overtime.
New or worse hot flashes?
Try Folic acid 1 mg daily for 30 days – continue if effective. Stop if ineffective.
Hair loss?
Try Zinc 50 mg daily for 2 months taken with food.
Back on carbs?
I tell my patients emphatically there is no way forward but to stop eating the sugar and starch that has caused their central obesity. I remind them that sugar and starch causes an insulin bolus to be secreted from the pancreases, which drives the liver to turn that same sugar and starch into stored fat. The physiology of obesity is so simple that we should be embarrassed as healthcare providers to have breathed a word of low-calorie to our patients. But we must forgive ourselves for being caught up in the low-calorie hysteria that was the last 50 years and move on.
We know obesity is a result of the consumption of sugar and starch. We know that the solution is a marked reduction in sugar and starch intake. And yet, we do not communicate this effectively through doctor's office visits or public health messages. Is it any wonder our patients regress back to their high carb dietary patterns and put weight back on?
We need to focus on a message of abstinence. Smoking cessation is an effective comparison to sugar and starch cessation:
1) If a patient smokes, he or she must stop smoking! Smoking regularly for years destroys the elasticity in the lungs and blood vessels causing chronic obstructive lung disease, vascular disease and a host of cancers.
2) Yet, smoking a little from time to time, say in a First Nations ceremony, where it may be culturally inappropriate to abstain, is of absolutely no health consequence.
4) If a patient does successfully stop smoking, at no point in the future will it makes sense to start smoking again!
5) All too often, friends and/or family seem to impede smoking cessation efforts by continuing to smoke in the presence of the patient.
This analogy is effective because I see carbohydrate cessation in the same light. The major difference is that in 2019, we know that smoking is terrible. We are investing significant primary care and public heath resources into helping people quit. The same is not true of carbohydrates. When it comes to carbs, we are in the 1970's of smoking cessation: there are a few of us warning that carbs have caused the obesity and diabetes epidemic that has come to define the current practice of medicine. Yet others, including the Dieticians of Canada and Diabetes Canada, continue to endorse carbs as just fine and actually encourage patients with diabetes to consume them, alleging they are necessary. I suspect that in a few decades, we will have well-resourced 'carbohydrate cessation programs', similar to our smoking cessation programs. In the mean time, we enlighten healthcare providers must continue to build our grassroots movement from our offices, pharmacies, etc.
The shame of this under-resourced movement is that those who need extensive counselling support to maintain carbohydrate abstinence have difficulty accessing it. When this subgroup of patients, who seem to use carbs as a coping strategy, fail to maintain a low carb dietary pattern, they are told by ignorant healthcare providers "See, that fad diet isn't sustainable!" What we should be asking ourselves as healthcare providers is "What is driving the patient to seek a coping strategy and what can we do to help said patient find better ways to cope?"
As for the first question, why are patients looking for a coping strategy? I think that many use carbs to cope with the highs and lows of life. Be they "thank you" donuts in the breakroom or a bag of chips in front of the TV after a bad day at work, carbs are used to augment emotions. Carb use in these scenarios seems episodic and a motivated patient with timely information from a family doctor about the harm of this behaviors may be effective at curbing carbohydrate intake and achieving meaningful weight loss.
Sadly, some patients face stress from a much deeper place. I have come to the realization that amongst us there are individuals who have suffered untold horror during childhood, adolescence and/or adulthood at the hands of "family friends", family members and trusted individuals including priests, teachers and coaches. Patients suffer the impact of these atrocious events everyday, trying to live as those they were not raped, beaten, or neglected, sometimes over and over again. They turn to comforts that help them forget: alcohol, drugs, cutting, and in the present case: sugar and starch. Consuming these substances allows them to manage their psychological pain. As healthcare providers, we only see the negative manifestation of the sadness inside them. We see the alcoholism, the broken family, the liver failure, the homelessness and in the present case, the obesity. We contribute to their cycle of shame by asking them, "Why can't you just stop doing that? Can't you see your hurting yourself?!" The astute family doctor will recognize the depth of trauma in this patient, understand the behavior is only a symptom of the pain, and refer the patient on to professional counselling.
Your patient will inevitably fall off the 'low carb wagon' because he or she is only human and carbs are abundant. When this happens, remember that the physiology of carb restriction for amelioration of central obesity is well understood. There is no way to lose weight other than to stop feeding the body the substance that both supplies the 'fat building blocks' and turns on the 'fat making machinery'. Secondly, support your patient as you would a patient trying to abstain from cigarettes: help your patient to forgive him or herself for falling off the wagon, explore why the slip happened and help him or her to make a new quite plan.
Consider reading Food Junkies by Dr. Vera Tarman and The 12 Steps and The 12 Traditions of Overeaters Anonymous.
