Wednesday, February 12, 2014

The Nutrition Debate #183: My New Doctor and Me

I had an appointment recently with a “new” doctor – new to me, that is. He’s an established physician in a large group that is part of a larger consortium of groups. He practices “Family Medicine,” which means he’s a generalist, essentially a General Practitioner or GP with an added 3-year ­­­residency in Family Medicine and Board Certification, which gives him hospital privileges.

I met my new doctor in a bar. He was having broiled salmon, and I was having a drink (while my wife shopped). I recall that I initiated the conversation by commenting on his side dish, or possibly the bread. I don’t recall. Anyway, he told me he was a physician, and he mentioned the group name, and I told ­­­­­­­him I had just been “fired” (for being rude) to an endocrinologist in that same group. His response was to tell me to call his office the next day and make an appointment with him, so I did.

The appointment didn’t go well. I told him I had been off my Very Low Carb eating plan off almost 2 months, had gained more than a few pounds, and expected my A1C was going to be up from 5.7% to +/- 6.0%. My goal was to get it back to 5.6% or below again, and he said, “That would be ‘non-diabetic.’” He added that if I lost 40 pounds, “You would be non-diabetic.” I told him that a few years ago I was 50 pounds lighter than I am now and, “believe me, I was still diabetic.”

I then mentioned that when I am “on” my program, I eat between 10 and 15 grams of carbohydrate a day. He responded with a tone and air of certitude, “Twenty grams of carbohydrate a meal is what you should eat.” This really set me off. My new doctor knew everything there was to know about me and my insulin resistance and my carbohydrate intolerance, without even taking a history. I’ve been a type 2 diabetic for 28 years, the last 12 of which I have managed to get off virtually all my oral meds and keep (for the most part) good glucose control by diet alone, and now he was telling me how to manage my diabetes his way. I know. I know. He was just following clinical guidelines, as set down by the ADA, etc. etc.

That’s when somehow the subject of statins came up. I told him I would refuse a statin if he ordered it, and I told him why. I mentioned my latest (at the time) lipid panel (TC: 217; LDL: 122: HDL: 85; TG: 49; TC/HDL ratio: 2.6). I said I considered that stellar. He replied that the National Cholesterol Education Program (NCEP-4) Guidelines recommend a TC < 200 and an LDL < 100 (which is true), even though the new ACC/AHA guidelines no longer set LDL targets in absolute numbers. I called the NCEP guidelines pure BS and said the gurus and guidelines that I follow are very happy with a TC between 200 and 220.

Actually, I recalled later that one of my favorite resources, Paul and Shou-Ching Jaminet’s “Perfect Health Diet” says (page 366), “The ideal serum lipid profile – the one that produces the best health and minimum mortality – looks like this:

·         Total Cholesterol level between 200 and 260 milligrams per deciliter

·         LDL Cholesterol level above 100 milligrams per deciliter

·         HDL Cholesterol level above 60 milligrams per deciliter

·         Triglyceride level around50 to 60 milligrams per deciliter

At this point, I thought it was appropriate to emphasize my exceptional HDL (85) and TG (49) numbers and that my LDL (122) was Pattern “A.” My doctor’s response was (I can’t believe this!): “Define ‘Pattern A.” I replied, “large, buoyant, fluffy, rather than small dense, the better to avoid oxidized, small dense LDL particles getting stuck in the eroded endothelial layer of my arteries, if I had such erosions, which my low hs C-Reactive Protein (CRP) scores suggest I do not. I showed him my history of CRPs and he did admit it was “impressive.” They had plummeted from a high of 6.4 when I started very low carbing in late 2002 to a low of 0.1 last year, but have begun to creep up again. He agreed to help me look into that.

But then he said something that shook my faith that my new doctor and I were going to work things out. He said, “The latest science is that all LDL are alike. They all get stuck. I asked him to give me a citation in the medical literature for that. I said I read a lot of medical journals and scientific papers – probably more than he did. He didn’t like that, and replied I did not. How can he know? Anyway, when I asked him later for the “LDL are all alike” citation, he said, “Give it up.” Okay, I said.

What I gleaned from this appointment is that Family Medicine MDs are trained to diagnose and treat, primarily with pharmacotherapy, incipient type 2 diabetes. They’ve learned by rote what is “diabetic” and what is “non-diabetic.” They’ve learned that a “pre-diabetic” can “reverse” the progression to full-blown type 2 diabetes (and improve blood pressure) by losing weight. They know what Insulin Resistance is and that insulin sensitivity can be increased by severe carbohydrate restriction (and exercise) and “non-diabetic” A1Cs achieved. But that does not reverse IR or carbohydrate intolerance.  

After he ordered some tests we shook hands and the phlebotomist came in to draw blood. I gave him my card, and he said he would take a look at my blog. Maybe he’s reading this. I have a follow-up appointment in a few weeks, so I’ll find out.


  1. Sigh. Sometimes I think we'd all be better off with psychics than physicians.

    1. Good one! I go to the doctor to get my latest blood markers (glucose, lipid, inflammation, etc.), but I am tempted to try to proselytize sometimes. Maybe in this case just by showing him the improvement in my markers when I strictly follow my 'regime.' But, would you believe, even though we agree he would do it, and he knew I was diabetic, he did not order an A1c!!!. Unbelievable. He did order a hs CRP though and it was 1.2. I would like to see that drop to about 0.2, so we'll see. My next appointment is in early April. BTW, my HDL was 90 and my TG 34! TC 207 and LDL 110. He said my lipids and inflammation were okay. So, no statin script for me not to fill, but he knew that already, and probably knew he had the discretion not to prescribe on given the high HDL and low TG. I noted, however, that the "in range" for HDL for their lab was 40-60, and 90 was listed as "high"!!!