Monday, April 20, 2009

What is all of this I hear about “The Brentwood Diet?”

Before I answer that question, a little background information will help.  When I started practicing internal medicine in Brentwood, I started the practice from scratch; that is to say, no patients followed me from a prior practice.  I managed to pay the rent by doing what is called locum tenens.  Locums are temporary employment assignments in various settings.  Some were emergency medicine opportunities, while others were substitutions for physicians going on vacation or taking maternity leave. 

 One of these jobs consisted of replacing an endocrinologist in the South Bay area.  I had always enjoyed endocrinology and the office was a very nice setting in which to work. 

 On my first day there, I met a patient named Dino.  He was in his early sixties and was nearing retirement.  Before entering the examination room, the practice manager gave me a little background on Dino.  He said, “Dino is a very nice person.  He has been a patient for many years and is very compliant with his medications.  His blood work today is very good.  His hemoglobin A1c is in good range and his cholesterol is well controlled on Lipitor ”. 

 I entered the room and was taken aback.  As I was introducing myself to him, a loud voice was shouting in my head,  “How could this be? He must weigh over 300 lbs.  How could his numbers be in normal range at that weight?  Does it even matter?” 

 Because I was just substituting, I had rehearsed a whole speech to the patients to minimize disruption in the office routine.  I couldn’t do it.  As I began to speak to Dino, I could hear my wife tell me, “Can’t you just leave well enough alone?  Can’t you just leave things the way they are and just do the job that was asked of you?”  Obviously, I couldn’t.  So I asked Dino, “Dino, where do you see yourself five years from now?”  He told me, “Doc, I am retiring after working at the same place for forty years.  I have a heck of a retirement pension coming my way and life is going to be great.”  To that I replied, “Dino, at the rate you are going, you will be barely functional in five years.  Most likely, your wife will enjoy your pension with someone else.  You are close to three hundred pounds and climbing, seriously where do you think this is going to go?”  He looked at me perplexed.  “Doc I am doing everything I am told.  I take all of my medications.  I show up to all of my appointments, what else can I be doing?”  I told him, that the insulin he was taking was acting like a growth hormone.  The more he uses it, the hungrier he gets, and the more he eats, the more insulin he needs.  It’s a vicious cycle.  “Are you willing to try something new?”  He said sure.  I stepped out of the room and hand wrote the first version of the diet.  It was limited to lean protein, zero or near zero calorie vegetables and eliminated all traces of carbohydrates. 

 I returned to the room and explained to him what I needed him to do.  He would start right away and would return in one week.  I gave him my cell phone number and instructed him to call me should he have any questions or concerns.  He called me on Saturday morning, almost two days after meeting him, and he told me,  “My sugar level this morning is 70, what should I do?”  Celebrate?  “No seriously Doc, how much insulin do I take?”  I told him to stop all of his diabetic medications and let’s see what happens tomorrow.  The rest of the day he kept checking his sugar before each meal, and he called me on Sunday with the results.  His sugars had normalized and he did not need to take his Avandia or insulin.  I had instructed him to continue taking Glucophage, as there is no risk of hypoglycemia with this medication, but all others had to be stopped.  I waited anxiously for the week to pass to see him again.  As I was about to walk into the room, the practice manager told me, “You won’t believe this, Dino lost 12 lbs this past week.”  I stepped into the room and asked Dino “How do you feel?”  I feel really tired but I can’t believe that I lost 12 lbs.  Do you think that you can do this for another week I asked him?  He said sure.  The following week, he lost an additional 8 lbs and his blood pressure had dropped so low that I had to stop his blood pressure medications as well.  He felt a little better, but still a bit tired.  Again, I asked if he could continue another week, and he did.  He returned the following week, wearing shorts and reported that he had walked the length of the Strand in Redondo Beach, approximately one and one half mile each way with his wife on Sunday.  He told me that it had been over fifteen years since he felt like doing anything like that.  He had lost another 5 lbs and looked like a completely different person. 

 Diane was the next patient to try this program.   She became angry that no one had ever suggested to her that she there was an alternative approach to treating her diabetes, hypertension and dyslipidemia.  This combination of diabetes, high blood pressure and elevated cholesterol is also known as Metabolic Syndrome.  Diane is an engineer, and until her move to Arizona, she kept meticulous spreadsheets of her blood pressures, and glucose levels.  We still e-mail each other and she has continued her new lifestyle ever since.

It is easy to get people who are very sick to make dramatic changes, but how do we succeed with individuals who are not yet sick, but who will inevitably get there on their current path? 

 Many patients come to me after trying the diet on their own, but to a great extent, it is the advice I give them in the office that facilitates their success.  You are more than welcome to try this program on your own, but please, have your physician monitor your progress, your renal and liver function, as well as your lipid profile.

 Who should not be on this diet?  This diet will trigger an Atkins-like state of ketosis, a state of high fat burning.  Ketosis needs to be closely monitored in patients with heart problems, especially arrhythmias.  Individuals with renal failure should be monitored closely with regular renal function studies.  Type I diabetics would not need to consider this diet as they tend to be lean.  But if tempted to try it for nutritional purposes, Type I diabetics, need to be followed by their endocrinologist.  Pregnant patients should avoid ketosis mainly because we do not know the effects this would have on the fetus, although my bias is that it wouldn’t be harmful, but I do not know this with certainty. 

 It is my intention and my hope that with this blog, I will help a greater number of people than I am able to see in the office.

Sunday, April 19, 2009


When I graduated medical school, I made a deal with God.  I told Him, “You deal with all of the big stuff, and I will deal with all of the little stuff ”.  So, contrary to popular belief, I do not save lives for a living.  I don’t think that I have that power.  What I can do is enhance quality of the life of the people seeking my help.  I have to be honest; they are not always “seeking” my help.  Sometimes I just volunteer it because they aren’t able to run away fast enough!  Those are the times my wife tries to reassure them, “He really is quite good at this, you know.  He is able to cut to the core of things, able to focus like a laser beam!”

 I am frequently asked by patients, “Why are you so focused on weight, when I have so many other medical issues I need to deal with?” The answer is quite simple.  Imagine the plumbing in the house needs reworking because the old iron pipes are corroded and prevent good water pressure.  Simultaneously, the home inspector tells you that your home is horribly termite-infested, and if repairs are not undertaken at once the integrity of the house may be jeopardized.  (In California, the main destroyers of our homes are termites.  They will rot a house from the foundation up without ever being noticed.)  What would you address first?  The termite issue, of course.  Even though the low water pressure is the most noticeable problem every time you get into the shower, the termites are the more threatening issue.

 People are like houses.  Some are in move-in condition, some need a little clean up, and some need a lot of work.  Then again, some need so much work that tearing them down and starting over is a wiser approach!  The art of medicine is choosing when to use a broom, a hammer, or a bulldozer.

 In my patients’ cases, as in the majority of the American population, the overriding problem is obesity.  For many patients, it’s morbid obesity.  Morbid obesity, defined by a Body Mass Index (BMI) greater than 30, means that the weight is so high that the weight itself contributes to disease processes.

 To be clear, termites are not always obesity; they can take the form of depression, substance abuse, self-deprecation and sabotage of one’s happiness, and the inability to regulate the stressors in one’s life, to mention but a few.  In future postings, I will address The Brentwood Diet came to be.  I will walk you through the diet and show you how my patients are able to regain control of their lives. 

 Hilary Smith, one of my patients, has created a blog, Surviving The Brentwood Diet,  I found it very accurate and insightful.  I enthusiastically refer you to her blog and encourage you to use it as a forum to exchange ideas and recipes that you have found helpful.

Thursday, April 16, 2009

Welcome to the Brentwood Family Health Center

I was asked today why I spent so much time talking to my patients and not as much time examining them.

I was taught long ago that the history portion of a patient visit provides 90% of the information needed to arrive at a diagnosis and that the physical examination and the tests used to confirm the diagnosis account for 10% of the encounter. I still believe that this is true. I must admit that I cheat a little.

The way my office is designed, the waiting room is about forty feet away from my office. There are a couple of turns along the way, and since I usually escort patients from the waiting room to my office, I get to see how they get out of the chair in the waiting room, I observe the way they take their first steps and how steady their gait and balance are that day, as well, I smell them as I greet them with a hug. To most people, this wouldn't add up to much, but in those few instants, I have already determined whether or not they have a fever, if they have a streptococcal infection or diabetes, as well as the state of their hygiene. All of this and they haven't even embarked on the long walk to my office. This dynamic assessment of patients is more accurate and informative than the traditional disrobed patient waiting in an examination room. As we walk to my office, we talk and I assess the state of their mood, and vigor. Can they keep up with me or am I steps ahead of them? Do they stop at the corner to negotiate the turn or are they swift? Do they bob from side to side or do they use the wall to steady their steps? Are their hips level as they walk or are they favoring a particular side, or joint? Are they dragging their feet, or flapping them? You get the idea... By the time we sit down, I already have a pretty good general assessment of how they look and must feel. My first question: How are you doing?, is almost redundant, but it opens the conversation and allows the patient to fill in the blanks. While we talk, I study the rate of their speech, the tone and quality of their voice, their choice of words, and whether or not they are using first choice words or the ones that come first, because they are blanking on the word they actually want to use. Are the hands shaking, is the face quivering? Are they fidgety, anxious? Is their complexion normal or sallow? Are the conjunctiva icteric (jaundiced)?

There is so much information I gather during the talking part of the visit, that the examination is an opportunity to take a closer look at things I suspect are going on and to reassure the patient that I am actually doing something.

I ask my patients not to wear perfume prior to seeing me, and I would advise you to do the same. Along the same line, for those of you who still smoke, it's a good idea to try to not smoke prior to your visit as the cigarette smell on your clothes is overwhelming and distracting.

Lastly, I order the fewest tests possible, and this tends to bother some patients. I use tests to confirm or rule out what I already suspect. If I can't figure out what I am looking for; that's the time to send the patient to someone smarter than me.