Max Lugavere: Hi, everybody. My name is Max Lugavere, a science journalist reporting for Medscape. I am sitting here with my friend and colleague, Dr Paul Grewal. Dr Grewal has an interesting personal story that I want to share because it informs the way that he practices medicine. Thanks for being here, Dr Grewal. Paul S. Grewal, MD: Thank you for having me, Max. Mr Lugavere: Tell me a little bit about your background—how you got started in medicine, and what led to you create the concierge practice that you have today. Dr Grewal: That is a long journey. As all the physicians watching know, everybody has their own path through medicine. I am a board-certified internist, but I focus my practice around the things that I am most interested in. I am lucky enough to create an environment where I can do that. I have a deep, deep interest in metabolic health and the things that contribute to, cause, and perpetuate obesity—which is the underlying phenomenon behind a lot of chronic disease, including hypertension, diabetes, and vascular disease. They all dovetail into the same set of problems. A lot of how we practice traditional medicine really forgoes looking at the deep root cause of the problem in favor of a number of pills. To kind of bring it from my journey to patient care, my greatest joy as a physician is having somebody come to me who is on two to three blood pressure medications, two to three diabetes medications, and is grossly overweight or obese—and, using some dietary changes for the motivated patient, having them come off of many or most or all of their medications. When I saw the power of a few rather simple techniques that were not being taught in med school (or in residency, for that matter), I realized that there was a whole world to explore in terms of benefiting patients. I would never have stumbled upon that if I had not had my own issue. I grew up with childhood obesity. I was about 270-275 pounds until I was about 20 years old. I was basically completely obsessed with it. I became an adult, and I was like, this is going to be the rest of my life if I do not do something about it. Before I had any medical training, I just did some research; calories in, calories out, eat less, exercise more, and that seems to be the extent of a physician's advice to a patient. There is good news, and there is bad news. The good news is, it works. The bad news is, it only works for as long as you are completely obsessed with doing it. As research has shown, as people lose weight, their metabolism slows down significantly. If you go from 270 pounds down to 200 pounds, you now have the metabolism of somebody who is 170 or 180 pounds. You essentially have to undereat forever in order to maintain that weight. Knowing that you have this metabolic slow-down makes it difficult to find strategies that work in the long term. What I did initially was 1200-1500 calories a day and running 6 miles a day, and the weight came off. It came off dramatically. The minute that I went away from my total, total focus—ie, going back into medical school, having some additional stresses, having other things in life interfere with the meticulous calorie counting that I was doing... I have a notebook; it is about 400 pages, and it has everything I ate for over a year—every morsel of food. That is, itself, a neurosis. When I went to medical school and I had to focus on other things, the weight all came back. That was a difficult and disheartening thing. When I realize how much of my intelligence and willpower and attention goes into it, it immediately made me feel a lot more empathy for other people who are doing it. When I see other doctors dismissing it with "eat less, exercise more," or making a moralistic argument about why somebody is overweight, I actually get almost red in the face with frustration and anger. Mr Lugavere: Wow. Obviously, there is no such thing as a one-size-fits-all dietary approach for weight loss, but what are some of the more salient aspects of a diet that you found to work for you and be effective in your patients? Dr Grewal: Over the years, with my own self-experimentation and reading into the literature, I found some things that worked for me and worked for many others that basically take a lot of that calories in, calories out [approach] and tweak it so that yes, we do need to maintain a caloric deficit, but are there easier ways of doing it? Realizing that if you are insulin-resistant, your body is making three, four, or five times more insulin than the normal person in response to the same amount of food. We are monitoring fasting blood sugar, we are monitoring A1c, but you are having metabolic dysfunction for 10 or 15 years before that. We all have patients who are on 150 units of insulin. In perspective, the average person really is only supposed to synthesize about 25 units of insulin per day. You can imagine the insulin, the primary anabolic hormone in the body, being present at four to five times the level that it should be just to drive down blood sugar. We need to drop those insulin levels. That becomes the key to unlocking weight loss—an effortless weight loss in some cases. In many of my patients, and what worked initially for myself, was just a straight, low-carbohydrate diet across the board—high-fiber, real, unprocessed foods that basically naturally regulate your hunger mechanisms. Yes, it works by reducing caloric intake, but you reduce caloric intake subconsciously because you are eating foods that do not drive that hyperinsulinemia. Mr Lugavere: It frees up a lot of cognitive resources, which is great, but then if you live a real life and you are subject to the stresses of modern life (which we all are), it becomes a lot more manageable. Dr Grewal: There are other strategies, and it is all about getting a marginal benefit. You can free yourself with a lot of knowledge. There are metabolic chamber studies that show that eating two meals a day is equivalent to eating six meals a day. If you are talking about decision fatigue, if you're trying to make six small decisions throughout the day, it can be more difficult and less satiating than having two large meals, even all calories being equal. And it has absolutely zero effect on your overall metabolic rate, which is freeing knowledge. Instead of being hyperobsessed about every little meal that you are having every 2-3 hours, you now can kind of "set it and forget it" and create an eating pattern that works for you. When you combine that with resistance training, your added muscle mass gives you additional capability to dispense of glucose. Your ability to store and cycle through glycogen becomes critically important. Your muscle mass can hold about 300 g of sugar, stored as sugar. That becomes an important buffer for the processed foods and hyperpalatable sugary, starchy foods and gives you a little wiggle room to have more of a normal rather than a restrictive lifestyle. There is insulin, there is muscle mass, and the point I'm trying to make here is that physicians have a very narrow-minded view about this. They need to be able to say, okay, what is the best evidence available and treat each person as an individual. It is an iterative process. For some people, calorie-counting can work, but when that stops working, or if metabolic slowdown occurs, then you have to look into the things that have perhaps less clinical evidence but are still worth trying, because solving that obesity problem should be the overriding prerogative of the physician and the patient. I feel very bad, and very lucky, because in the way that I have decided to practice medicine, I knew that I could not have these lengthy conversations with people, do this iterative process, in the current operating environment of the US healthcare system. Mr Lugavere: I think that is a wrap. Thank you so much for being here, Dr Grewal. Thank you for joining me and Medscape. For Medscape, I am Max Lugavere. Source
