I am finding more people coming in with vexing problems that cause them to be miserable, and me to scratch my head wondering what could be going on. I have read a lot of journals, listened to many webinars and podcasts, and gone to conferences to expand my knowledge. I’ve also contracted with some new labs to be able to offer tests that are not commonly available. I’m finding many of these things quite helpful for my patients, and hope I can help even more of you.
For those of you worried about heart disease, diabetes, and obesity, we can do specialized testing to look at your risk and to find the best treatments. Blood tests through Health Diagnostics Labs, Quest Labs Cardio IQ and the Atherotec Labs (VAP) can tell us if your high cholesterol is a problem, or if you have a problem even though your cholesterol is low. We can look at how your individual genetics impact your risk, several different inflammatory markers, and how well your body is processing sugars. In addition, we can do a CIMT, which is a specialized type of sonogram, to see how likely you are to have stroke or heart attack in the near future.
When it comes to treatment to prevent that heart attack or stroke, we can discuss not only which medications may help, but also other ways such as diet and exercise. There is a wealth of information out there on what types of diets are best for preventing not only heart attacks and stroke, but also diabetes, cancer and autoimmune disorders. What foods are most likely to make your irritable bowel syndrome or fibromyalgia worse, and what is the best way to eat to treat acne. Unfortunately, we don’t have really good studies proving certain foods can prevent cancer etc, but we are starting to get some good ideas of what a good, healthy preventative diet looks like. I especially enjoy working with patients eating a low carb diet, paleo or primal diet.
I see many patients who feel sick and tired. For those we can do testing for adrenal fatigue, sophisticated hormone testing, testing for leaky gut and SIBO through Genova Diagnostics Labs. Treatment may include supplements, but also discussions about sleep, stress reduction, meditation, and specific exercises. Of course, diet plays and important role in this also.
This is just a smattering of the options available to you here at my office. If you suffer from, or are worried about any of these issues, give us a call!
Weight Loss Program
Most of my patients are either trying to lose weight, improve their cholesterol, and/or trying to live a healthier lifestyle with a better diet. For the past 20 years I have tried all sorts of things to help them, and none have had long term success. We have tried various diets, pills (phen-fen being a spectacular failure), and surgery. None, with the possible exception of surgery, have given any significant long term success. I’ve finally found something effective!
We offer a diet and wellness program called Cornerstone Wellness. This program is physician supervised, and based on the patient’s needs, preferences, and lifestyle. The program itself is based on the most recent scientific findings in weight loss.
The Mechanics of Weight Loss
When the body is deprived of energy, it will preferentially break down lean body mass (i.e. muscle) and try to leave the fat stores intact. When weight is gained back, it will be gained preferentially as fat. That is why yoyo dieting is so bad, after a few cycles of dieting you may weigh the same, but you will generally have much more fat compared to muscle than you had before. To make things even worse, your basal metabolic rate (the minimum amount of energy you need, AKA resting rate) is tied to lean body mass. So if you weigh 200 lbs, and 100lbs are lean body mass, you will need to eat a lot less to maintain that weight, than if 150 lbs of that was lean body mass.
So how can you lose fat preferentially? One way to do this is by eating lots of protein. Protein protects the muscle, and is a natural appetite suppressant. The Adkins’s diet has lots of protein, and people who follow this do lose weight, and their cholesterol will usually get better, even though that diet is very high in fat. The problem is that people feel bad on that diet, and they find it difficult to stay on this long term, the diet is just too limiting.
In addition, we need fiber and the other good things (bioactive food components like antioxidants and phytochemicals) we get from fruits and vegetables. What we don’t really need are starches (but they taste so good….)! There is one other consideration. Most tissues of the body require a continuous supply of protein and amino acids, and muscle is the only reservoir. When we eat protein, most of it goes to replenish that muscle that has been broken down since the last time we ate some protein.
The Ideal Diet
So what are we looking for in a diet? We want lots of protein, lots of fruits and vegetables and minimal amounts of starch, so you don’t feel deprived. This diet should be low in calories, but individualized for each person. We should be looking towards losing fat, not pounds. It needs to be easy to follow, and not too expensive. It needs to be safe for everyone, especially diabetics, patients with heart disease, patients who have had weight loss surgery, children, elderly, and women who may become pregnant while on the program. It should have a maintenance program that can be followed once the dieter has reached their goal. And the program should be with real food, so the dieter can learn to eat correctly for the rest of his life. Cornerstone Wellness fits all those criteria.
Those of you who know me, know I live a crazy schedule. Between seeing patients, doing the business aspects of the practice, learning new medical techniques, taking care of my 2 teenagers, etc, I don’t have time for complicated diets. So I figured, if I can follow the diet, most anyone can. I found the diet very easy to follow, and was even able to incorporate it into our family meals. In the first month, my exercise level stayed the same, and I had 10 restaurant meals (meetings) during that month. I lost 5 lbs, did not feel hungry, and I wasn’t cranky. Needless to say, I was hooked.
Our patient results have been similar. They all have reported feeling energetic and well, and found this diet not difficult to follow. We have modified the diet over the past 2 years, lowering the starch intake, and increasing allowed fats (yes, you read that right). We have found people feel well, lose weight, and their cholesterol and sugar values usually improve by significant amounts.
Details About the Diet
When you come in for a consultation, you will get weighed, measured, and have a body fat analysis done. We’ll discuss what you think would be a reasonable exercise program to follow (need to build that muscle!). That gets put into the computer, and we’ll give you a diet to follow. The diet will contain 2 protein shakes, 2 meals, and a snack, if you need one. You are given a list of how much of each type of each food to eat daily, i.e. so many protein, fat, starch, vegetable and fruit exchanges. These exchanges can be moved around (I had to do that to be able to eat in restaurants), but the daily total should come out right. We see you monthly to remeasure you so we can track you progress, and revise the diet, if necessary. Your goal will be measured in loss of excess body fat, as opposed to pounds.
The protein shakes are made from whey and immature green pea. They are mixed with milk (or other liquid). Since you mix your own, lactose intolerant persons can use lactose free milk to prevent the gassiness and bloating found in many other shakes. They are a high quality source of protein, with a good mixture of essential amino acids, and contain 23 grams of protein, 31 if mixed with milk. This is an important source of low calorie, low carbohydrate protein. In addition, the protein powder contains 50-400% RDA vitamins, including plenty of vitamin D. BTW – in response to a recent Consumer Reports article on heavy metals in protein supplements, these shakes were thoroughly tested and found to have levels considerably below what is considered safe.
In addition, everyone gets an Omega 3 (fish oil) supplement. Omega 3 is an essential fatty acid which the body cannot produce on its own. Omega 3 oils combat inflammation, lower triglycerides, and help with many medical and psychiatric illnesses. These are medical grade supplements refined to have the lowest possible levels of mercury and other toxins. They are one of (if not the) purest fish oils on the market, and you should not have any fishy burps. Taking these will also help keep the skin, hair and nails in better shape while dieting.
The final supplement is called MetAssist. This is taken 3 times daily, before meals. It helps regulate insulin levels, blood sugar levels, prevent carbohydrate craving, and promote fat loss. It contains several things, including hydroxycitric acid or HCA which limits the body’s conversion of excess blood sugar to fat as well as regulating appetite. Chromium helps insulin function better to get excess glucose into the cells. Green Tea has fat burning properties as well as potent antioxidant substances.
As far as the cost is concerned –
We see you once a month for an office visit, and you will need to pay your copay. We will bill your insurance for the visit. If you do not have insurance, or if you have an HMO and I’m not your primary doctor, the initial visit will be $75. The supplements cost $200 + tax/month and are not covered by insurance. If you have a flexible spending account however, you can usually use it to pay for the supplements, as this is a medical treatment.
We are constantly revising and updating the program as more information becomes available about the science of weight loss. We also factor in the experience of our patients to customize and improve the program. We have had great results so far, and expect them to get even better as we continue to improve the program.
Offering Advanced Lipid Blood Testing
80% of people with coronary artery (heart) disease have normal cholesterol levels. Despite “adequate” control on medication, many people still have heart attacks and stroke. Obviously, today’s routine cholesterol tests are failing to identify the majority of people who are at risk for heart attacks. The limited focus of these tests on “good” and “bad” cholesterol is simply not good enough to accurately identify those most at risk. So, how can you protect yourself?
Cholesterol guidelines are made by committees, and therefore are compromises. They also lag years behind the research, and have to take into account the cost of implementing them for the entire population. However, some people would like more information to enable them to make informed decisions about their health. Advanced lipid testing are comprehensive blood tests that are based on current research targeting vascular disease risks such as heart attacks, strokes, and diabetes. These blood tests combine chemical and genetic testing. It allows us to personalize treatment plans based on genetics, the size of cholesterol particles, and the level of arterial inflammation. It also allows us to predict likely reactions to different medications, foods, alcohol, stress, and exercise.
What does Advanced Lipid testing include?
An evaluation would be based on a panel of specific test of your blood sample. All of these tests help assess risk for vascular disease (heart attack, stroke, diabetes). A typical evaluation would include:
- Routine lipid panel, including total cholesterol, LDL, HDL, TG
- LDL particle size
- HDL particle size
- Apo A and HDL particle number
- Apo B –and LDL particle number
- Lp(a) – high levels can cause blood to clot too easily, inherited, can alter with medications
- Vascular inflammatory markers such as Lp-PLA2 and Myeloperoxidase
- Highly Sensitive CRP – measures inflammation
- Fibrinogen – another measure of inflammation
- NT-proBNP and Galectin-3 – measures of cardiac stress
- Cholesterol production and absorption measurements
- Omega 3:6 fatty acids profile
- Diabetes Tests:
- Glycemic control – how well glucose is controlled on a short and long term basis
- Insulin resistance – how well the body is utilizing insulin by looking at leptin, adiponectin, free fatty acid levels, and others.
- Beta cell function – looks at the health of the pancreas, which produces insulin.
- Genetic Tests:
- Apo E Genotype – identifies how people respond to dietary fat
- Factor V Leiden & Prothrombin Mutation – identifies people who clot too easily, thereby increasing risk for heart attacks and stroke
- MTHFR genotypes – a gene that is generating a lot of interest in heart disease prevention, but also in mental health and cancer research
Who would be a good candidate for this test?
Anyone who has any of the following risk factors:
- Heart disease
- High cholesterol (High LDL, Triglycerides or low HDL)
- High blood pressure
- Cigarette smoker
- Family history of heart disease, diabetes, or kidney disease
How much does it cost?
Insurance generally covers most or all of the cost. Depending on your insurance, we can often give you a good idea if you will have any out of pocket expense, and how much. Out of pocket expenses are eligible for reimbursement by medical spending accounts.
So, how do I sign up?
Please make an appointment to discuss testing with one of us. You will need to fast for 12-14 hours for the test and usually the blood can be drawn at the time of your appointment. The results will take about 2 weeks to come back.
Dr. Moghissi will review your results with you in detail, give you a cool color copy of your results, and make recommendations for possible treatment. These recommendations may include medication, dietary changes, exercise and/or stress reduction. We may want to do follow up testing in several months to see how you respond to the treatment.
We are pleased to offer these exclusive state of the art tests for all those who are interested in proactively improving their health to live a longer and healthier life.
About the CIMT
In late 2008 I introduced a blood test known as Advanced Lipid Testing to my patients; a test which goes much deeper than the traditional lab testing for both cholesterol and genetic testing. This test helps reveal markers and genetic predispositions that can drastically improve both preventative and current treatment plans.
For the past few years I have been offering my patients a new type of testing, Carotid Intima Media Thickness, or CIMT scanning. CIMT scanning is one of the most accurate non-invasive screening tests available for predicting the risk of heart attack or stroke. Until recently, this test wasn’t even available for anything other than research, but now I’m pleased to offer it to my patients.
Some of you may recall the news story about Tim Russet, moderator of Meet the Press, who died a few years ago after suffering a massive heart attack. What was shocking about this news story was the fact that just two months previous he had a complete physical and had passed a stress test.
Cardiovascular disease is the number one killer in our population, and as many as 50% of those who died from heart attacks or strokes had no previous signs or symptoms. Now, we have the technology to detect subclinical atherosclerosis and follow disease stability with structural testing (the CIMT scan) and biomarkers. This is a ten minute procedure that is simple, painless, and free of any radiation. An ultrasound is performed on your carotids (on the neck) which shows if any plaque has accumulated in your arteries. There is a 96% correlation between plaque in the carotids, and plaque in the coronary arteries of the heart. This test will not only reveal if you have any plaque, but also the number of lesions, their size, and often their stability. This test allows me to be even more proactive in your medical care and treatment.
More About Your Arteries
Carotid Intima Media Thickness is the thickness of the inner two layers of the wall (the intima and the media) of the carotid artery. CIMT scanning can identify this at the early stages of atherosclerosis, alerting us to give you the chance to modify your lifestyle. Many things can affect the thickness of the vascular lining, and both genetics and environmental factors (including smoking, exercise, and diet) each play a big part.
Billing and Scheduling
If you decide to have this testing done, we will submit the bill to your insurance company; at this time, most insurance companies are covering this procedure.
The test is performed in our office, by a CardioRisk technologist. If you’re interested in having this scanning done, please give our office a call to schedule your appointment, as spaces are limited. Once you’ve had your CIMT scanning, we will schedule you for a follow up appointment so I can discuss the results with you.
What is Paleo/Primal, and Why to Go to a Doctor that Understands It
Paleo (and Primal) lifestyles refer to living like our ancestors did. This does not mean you need to rent a cave to live in and wear animal skins! We as a species have spent many generations becoming optimized to certain foods and activities. We have now drifted away from them, to the detriment of our health. Let me explain.
Humans have been around for about 2 1/2 million years. For most of that time we were nomads, following our food supply. For the most part, we ate a lot of hoofed animals, but not so much plant material. We appeared to be pretty healthy, were tall and strong, but also probably pretty lazy, and only spent a few hours a day hunting, gathering, and sheltering. Our life expectancy was not very high, but that’s because we had a high infant mortality rate and also had a higher rate of dying from infections (no antibiotics) and trauma. But if we lived past those issues, we were generally very healthy in our old age, and had a similar life expectancy to what we have now. BTW – some of this information was extrapolated from knowledge of the health of hunter gatherer tribes which still existed 100 years ago.
Starting about 10,000 years ago, we began settling down, domesticating animals for food and growing crops. We consumed more calories, and began reproducing at a higher rate. But we also started developing diseases of the modern age, such as heart disease, cancer, osteoporosis, autoimmune disorders, even things like appendicitis, gall bladder disease and acne!
Today, when we have epidemics of obesity, diabetes, heart disease, and cancer, many people are looking at where we went wrong, and what we can do to fix it. With all of modern medicine, what have we accomplished? Our infant mortality rate is much lower, and we survive trauma much better. We also don’t die of complications from urinary tract infections and strep throat (at least not often). But aside from that, we are not living any longer, and we are often wracked with pain and disability as we age.
What is so different about how we live now? That’s where Paleo comes in. I don’t have the time nor the space to explain this fully, but there are several key elements.
The most important element is diet. Ancient man (and woman) did not eat grains, legumes or dairy. Potatoes were inedible, and sugar did not exist. The tribe would take down an animal, maybe a mastodon or a rhino or a pig, and eat the entire thing raw. The meat itself would have been lean, but they would have eaten all the organs including the marrow, making the entire meal fairly high in fat. We would have eaten our fill, then when we got hungry again, we’d take down another animal. (No 6 small meals a day!)
Edible vegetation would have been less available. Those that tasted good (like fruits) would have been smaller and less sweet than we have now, and also only ripe and available for a very short period during the year. Many vegetables would have been bitter and/or toxic. Also, we would not have hunted a mastodon and milked it, and even if we’d found some milk, we would have lost our ability to process milk sugars once we were past weaning age for human milk (generally age 3-6 years).
Our diet would have consisted mostly of animal products, some vegetables and fruits when they were ripe. We probably did a fair amount of walking and ran only when we were running after prey, or away from predators. We lifted and squatted and threw things. And we were apparently quite healthy.
For young people, trying to follow the paleo or primal lifestyle should hopefully give them a long healthy life. Using modern medicine judiciously should help assure they don’t succumb to their ancestors’ nemeses of infection, trauma or early death in childbirth.
Unfortunately for those of us who are little older, we may need a little more help. Because we often have done irreparable damage (through misguided advice we may have followed so far), diet and general lifestyle changes may not be enough. We may need some help from modern medicine to keep us healthy and prevent premature death. But we also don’t want to be over treated, and to inadvertently make us worse off by taking medications, which are too aggressive and cause adverse effects.
So, why would you want to see a physician that understands paleo/primal?
There is a fine line between too much and too little medical care. I try to balance that fine line, looking at the risk vs. benefit ratio for each intervention I do with my patients. You don’t need antibiotics every time you get a cold, but it would be stupid not to treat a significant infection with antibiotics and die of sepsis. Not everyone needs medication for their cholesterol, but there are clearly people alive today who would be dead if they hadn’t been on those medications.
My job is to work with you by advising you which interventions are most beneficial to you. We do that by discussing the risks and benefits of each therapy. Some aspects of the paleo/primal diet conflict with recommended guidelines. As a physician with 2+ decades experience, I’ve learned what tends to work and what doesn’t, and we can decide together to achieve meaningful goals.
I do specialized testing (like the Advanced Lipid testing and CIMT for heart disease) so we can get a better idea of what your risk really is, before I recommend a treatment. I listen to you, so we can try to fit any treatment recommendations into your lifestyle. And most importantly, I follow many of the same recommendations I give you, so I know what is involved.
The goal I have for all my patients is to live a healthy long life, requiring as few medical interventions (including pills) as possible. If that is also your goal, then we should talk.
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