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Don’t Eat More of Anything (Until You Decide What to Eat Less Of)

A year ago this week, I made a stir with my post about five common weight loss myths. Today I had a patient conversation I have had so many times before: Someone was trying to eat healthier and lose weight at the same time. They are not necessarily the same thing.

This person was using flavored coffee creamers. I pointed out that they often have harmful fats, like palm and coconut oil, and chemicals that may not be good for humans to consume (corn syrup, trans-fats, milk protein [yet it’s called non-dairy], phosphoric acid [found in Coca-Cola, pesticides and fertilizer], mono- and diglycerides, sodium aluminosilicate [also known as feldspar, a ceramic glaze; it is explosive in powdered form] and proprietary artificial flavors). I even told her about Björn Gillberg, the Swedish chemist who in 1971 washed his shirt on TV with the powdered non-dairy creamer Coffee Mate.

“So what kind of creamer should I use?” She seemed flustered.

“Cream or half and half”, I answered. “They’re not all that good for you, but better than the alternatives.”

I pointed out that most of us want to do both things, eat healthy and achieve or maintain a healthy weight. But salmon, avocado, almonds and olive oil have calories, just like pizza, ice cream and Coca-Cola.

So it helps to prioritize a little. My recent patient, after some thought, wanted to attack the weight first. So my advice was about what to eliminate, rather than what to substitute it with. My point is that it makes little sense to skip the nightly ice cream and start eating yogurt instead if your number one objective is to lose weight. “Eat the real thing that you love, but only do it on the weekend”, I might say.

I scribbled down the math behind the lazy man’s guide to calorie counting, the theoretical 1 lb weekly loss if you eliminate 500 calories (kcal, to be correct) from your daily routine. I do it often enough I might save some time if I created a handout, but I believe in showing the math evolve on the paper as I talk – it’s more like telling a story.

Only after someone who wants to lose weight has eliminated some things do I discuss substitutions in earnest. People want to see results, and giving up ice cream, soda, donuts or beer brings results and makes people believe they can do it. Then, it makes more sense to talk about adding back something with fewer calories.

Like in so many other clinical scenarios, I like to “chunk it down” (see Leveraging Time by Doing Less in Each Chronic Care Visit) and to focus (see The Power of Focus): Reversing a disease process that has been going on for a long time is not usually something that happens quickly.

Five Weight Loss Myths I am Constantly Fighting

Why Can You Have Angina With Normal Coronary Arteries? For the Same Reason You Can Have Heart Failure With Preserved Ejection Fraction

Just in the past few months I have had three patients with crippling chest pain brought on by exercise who were dismissed as having noncardiac chest pain. All three are now essentially symptom-free on isosorbide and metoprolol – common antianginals. I may not know exactly how this treatment works, but I am passionate about providing for my patients the common medications we know work. Even a simple country doctor can do that.

Once upon a time there was only one common kind of angina and only one kind of heart failure. Now we know there are two kinds of each. For some reason doctors are all excited about the new epidemic of heart failure with preserved ejection fraction, but skeptical and uninterested in angina with normal coronaries. Both of these more recently discovered diseases turned the old definitions upside down. Doctors of my generation (and younger) have had to unlearn what they taught us in medical school. Many are still bucking.

Angina pectoris is a syndrome, a group of clinical signs and symptoms with several possible causes. When I went to school we talked of blocked coronary arteries or a rare form of angina occurring during sleep and caused by spasm, Prinzmetal‘s angina. We now know that many people, perhaps half of all angina patients, have normal coronaries as far as we can see them on catheterization but poorly functioning smaller blood vessels rather than pure spasm. This type is triggered by exertion, just like angina caused by major blockages.

Heart failure is also a syndrome. For the longest time it was believed that the problem was that the heart didn’t push the blood out well enough with each beat. Only relatively recently did it become obvious that about half of all heart failure patients have poor relaxation of the heart. We have been measuring what percentage of the blood is pumped out with each heart beat. That number should be greater than 55%. But if there is less than the normal amount of blood in the heart and you pump out only half of that, you don’t get enough pumping done for things to work.

Neither angina nor heart failure are strictly disorders of a mechanical system of plumbing. These days the term neuroendocrine pops up everywhere in the literature. Our arteries, big and small, and our heart muscles are not static but constantly changing and adapting. And our understanding of how this all works is still in the early stages.

Maybe we should trust our clinical assessment more often and not look blindly at the results of imperfect tests like Lexiscans, crude angiographies and blurry echocardiographies: If it walks like a duck and talks like a duck, maybe it really is a duck?

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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