Clostridium Difficile - India vs UK

Clostridium Difficile, affectionately known as "C- diff" to the staff working on the geriatric care wards in the UK NHS hospitals, is a huge problem. Wards get shut down, people die. 
It's what is described as a superbug, sometimes. Like the MRSA that makes the headlines.

C.diff is sometimes found in normal people, without any symptoms. The problems arise when they find their way into the guts of elderly patients or otherwise weak individuals who have had their normal gut flora depleted because of various reasons. 
Malnutrition, pre existing diarrhoeal disease due to microbes other than C.diff, but mainly because of broad spectrum antibiotic use.

Now, these antibiotics were prescribed in the first place to save their lives(pneumonia) or limbs (cellulitis) The use of antibiotics in the UK in my experience is far and away more reasonable than what I see in India. So,seeing that antibiotics are used more judiciously in the western world, we should be seeing less C.diff there than in India. That isn't the case.

I'd never seen a case of C diff till I started working as a senior house officer in the NHS.
It didn't make any sense. In India, we hand out antibiotics like candy. The wards are filthy beyond words.

I asked my registrar about this paradox. He theorised that it might be because hand washing is not followed strictly enough. That was easy enough to shoot down. The hospitals I trained in India, had running water only for a few hours a day, if we were lucky. It wasn't the hand washing. 
We got flooded with admissions that night and we never got to continue that discussion.

Years later, I picked up that train of thought after I read some great posts on immunity and the human microbiome.
What if it was really the hygiene and the handwashing? But not the way we thought.
What if my Indian patients were beating back the C.diff exactly because the hygiene is horrendous here?

As distasteful as it sounds, the patients here, in India, are constantly bombarded with the most bewildering array of bacteria and parasites. They eat with their hands. No cutlery here ! I don't want to paint any pictures, but you get the idea. 
The bacteria that comes from their surroundings, from the food(which is still mostly unprocessed)from the soil,water from the pathetic city supply, all those bacteria have set up base in the guts of these patients. These bacteria are street smart and can handle themselves in a scuffle, when C diff rolls in. Being less hygienic helps.

Standards have gone up now, wards are cleaner, and suddenly, we're starting to see C diff here. I don't think its because we're detecting them better. No. I've smelt C diff on the NHS wards. it's unmistakeable. I would have remembered that smell. The only time I picked up that smell during my training in India was around some HIV patients.

So, where am I going with this? 
I'm not saying, we should give up hand washing or keeping the wards clean. That would be crazy. Obviously, handing out antibiotics like candy isn't a great option either. 
The best way would be to 
1.avoid ending up in a geriatric ward. 
2.And if we do, then we shouldn't pick up C.diff
3.If we do pick up Cdiff,we should beat it back. 
4.if we can't beat it back with conventional antibiotics, we should beat it back some other way. 
How would we do that?

The NHS seems to be doing step 2,right. 
But there's 3 other steps we could work on.

1.An ancestral/paleo type diet in combination with sensible resistance training could keep out of hospital, a lot of our senior citizens.

3.The ancestral diet with fermented foods and exposure to beneficial bacteria in the soil and surroundings( barefooting, gardening,playing in the dirt ? )

4. The use of probiotics should be investigated in cases of C.diff. Maybe, even some form of phage therapy should be considered.

All theories. Maybe, some of you might have more. Maybe, you might disagree. I'd like to hear from you in the comments section.

If we don't learn to co operate with our evolutionary partners, evolution is going to try it's best to get rid of us. C diff is just one of it's nasty ways. 

LDL cholesterol

LDL cholesterol is what most doctors focus on.
But that is like treating someone for acne while he's bleeding to death from a gunshot wound.
Ok, maybe I'm being melodramatic here, but I need to get my point across.

LDL is carried in the bloodstream by apolipoproteins. ApoB100, mainly.

Indians tend to react very poorly to a high carbohydrate diet. That is why we have such a huge population of diabetics here. Its probably one of the few areas where we beat China to the top.

When we indians eat too much carbohydrates, (All of us do, trust me) the body struggles to deal with the rush of sugar into the bloodstream. It pushes as much as it can into the muscles. Then into the liver and the rest into fat cells.

Muscles will not take up much sugar because we dont do any intense exercise anymore. Hell! We dont even walk to the neighbouring shops these days. Its always "live to drive!"
The liver will not take up any sugar, because its stores are full too. It takes around 12-16hours without food to empty your liver glycogen stores significantly. How many of us go without food for 12hrs continuosly?
The fat cells come to your rescue!
They soak up all the excess sugar and save you temporarily, but in the process make you fat.

At some point, even the fat cells cant take anymore sugar, the sugar is then converted to triglycerides and floats around in VLDL, LDL and displaces cholesterol from the lipoprotein vehicle that is carrying it.

The body senses that there are not enough lipoprotein carriers to ferry around the LDL and grossly excessive triglycerides. The liver responds by making more ApoB100 among other things.
The increased apob100 exposure, combined with the inflamatory state of too much sugar and body fat, then triggers atherosclerosis.

Indians cant push enough sugar into their fat cells like the europeans can. Even if they do, they push it into visceral fat(the fat around the organs) That fat is dangerous, it pumps out inflamatory chemicals at an alarming rate. That inflammation further feeds into the atherosclerosis.

This is why you'll see relatively thin indians dying of heart attacks at 30.
It doesnt mean we need drugs. It means we need to fix our lifestyle.
Our grandparents had heart attacks at 70 or 80. Our parents at 50-60, us at 30-40. Our children are next. The availability of medicines has increased from the time of our grandparents, but the incidence of heart disease has increased. Our genetics have not changed in 3 generations.This is not a deficiency of medicines. This is a deficiency in our lifestyle.

My frustration with mainstream medicine and its practitioners

This is going to be anther whiny, rant.
I'm sorry, but I have to get it out of my head.

It feels a little hopeless doing things differently from the rest of my colleagues in medicine.
I keep worrying about when someone from the profession is going to point fingers at me and say I'm doing the wrong thing by advising a low-carb, high-fat diet. Maybe I'll get sued. Maybe I'll lose my license.
Its tiring to keep pushing this message when media, government and the the medical profession are all pushing this misguided agenda of "fat is evil".

I'll spend an hour with a patient clearing their doubts and teaching them how to eat low carb, and on the follow up visit I'll see them exhausted, because they have dutifully cut carbs like I asked them to, but stubbornly refuse to up the fat or protein. My message got across when I sent them home from the clinic. I'm sure. I make them repeat back to me what I tell them, I cross question them to make sure they understand the concept, and once they reply satisfactorily, I set them loose,back into their lives.
That's when things go wrong for a majority of these people. They see stuff on TV that tells them animal fat and coconut oil are bad for them. They meet a friend who is shocked that a doctor advises them to eat eggs, butter and meat. They clash with relatives who can't believe that grains are off limits. And I lose them.
Its enough to make me want scream and beat them over their heads with the chairs in the waiting room.

Why cant doctors see that the current paradigm works for only a minority? Does it?
Why cant they change their view when they see that the treatment isnt working?
Its type 2 diabetes, the problem is insulin resistance. How can adding even more insulin into the mix help?
If blood sugars go up when patents eat oats, wheat and rice, why would you ask them to eat that trash 5 to 6 times a day?
If someone walks in asking for solutions for weight loss, why do they stick to the same old eat less move more mantra? Have they tried it themselves? Its a scam.
I work in a hospital that has around 30 other doctors. Only one other doctor is not overweight, and she is skinny fat. Quite a few of them are pre diabetic. All of them are in denial. None of them would do a HbA1c. All of them have had their total cholesterol levels checked. Go figure!
The nursing staff are obese, and pre diabetic.
The paramedical staff as young as 25 are pre diabetic.
Are they all blind? Can't they see they're dying?

I'm probably now known as the crazy doctor who lost 20kilos of bodyweight and doesn't let his patients eat grains. I'm sure a good majority of them laugh behind my back for talking crazy stuff like LCHF.
Its a little lonely out here. I thought people would try this method before laughing it off. They're not even trying.
Is it because I'm giving free advice? Should I start charging for this stuff? Will it make my patients and unwell colleagues more receptive? I get much better results advising my friends. And they dont need tis much hand holding. We talk for an hour about the diet, and a month or two later, they call back and tell me they've lost 10 kilos.

I find people attending every conference in town, mainly for the free booze and oppurtunity for socialising that it offers. These events are sponsored by our favourite pharma companies. They talk about stronger, faster acting insulin analogues, about DPP4 inhibitors and GLP1 analogues, but none of them want to even hear about the dietary modifications that are necessary.
A patient walks in with backache, they get hit with NSAIDs, not even one of them gets advised on how to strengthen the lumbar and abdominal muscles. You can forget about advice on hip flexibility and posture.

If you look at the recommendations from any diabetes related organisation, the first mode of treatment which everyone needs to be put on, is diet and exercise. Then comes metformin(which I quite like) and then comes all the other crap that I detest.

When a diabetic walks in, most doctors, will tell them to watch their diet and do some exercise. Thats it! Then they reach for the prescription pads, because we all know medicines are the only thing that will really, truly, control diabetes. *facepalm*
If the patient is lucky, a rare doctor might tell them to eat less rice, and go for regular walks every morning.
No one tells them how truly awful using wheat as a substitute for rice is.
No one tells them that oats will spike their blood sugars and leave them hungry and eating more an hour later.
No one tells them that walking for an hour is useless, compared to a HIIT session lasting 8 to 10 minutes
Most doctors don't even remember that resistance training improves insulin sensitivity, bone density and balance.
If some one has osteoarthritis of the knees, they still get advised to go for a vigorous walk every morning. Knee pain be damned! Do you want to lose weight or not?

I'm a little tired of this bulls***!
I might just retire at the ripe old age of 40, if I can afford to keep a roof over my head, and start a farm or something. healing people is dirty, thankless and tiresome business.

PS- I realise that this is almost a replica of an earlier post, but I just had to vent. The internet has a lot of soapboxes and crazy people. This is mine.

Doctors and type 2 Diabetes

Uptil last year, I used to believe that as a doctor, my job was to use medication to bludgeon a patient's blood sugar into submission.
On some level, I knew there was something wrong with it. The dietary advice I was taught to give them didn't seem to be working, and I was either blaming the patient for lying to me about what they were eating, or I was blaming the inevitable progression of the disease.
The vast majority of patients with T2DM would start of with dietary modifications and exercise, they would continue to slide down to worse glycaemic control, they would get put on Metformin, then Sulfonylureas, a Glitazone along with an aspirin and a Statin. 5 to 6 years later, they would continue to get worse, I'd despair and start them on Insulin after much argument and cajoling. No one likes going on Insulin, I can vouch for that.

To me, that was the best thing to do. There wasn't enough insulin to bring down the blood sugars, therefore I was supposed to inject insulin to top them up. Of course, there was the "small" issue of hyperinsulinaemia and insulin resistance, but it just didn't register. It was the elephant in the room that no one talked about.
I just followed protocol.

In quite a few of the early T2DM patients, there is an excess of insulin due to the constant overloading of the system with carbs.  Adding more insulin to a patient who's pancreas is pumping out an excess of insulin doesnt make sense to me, now, after using a Paleo based low carb diet.

I ask my colleagues about this, and they look blank. How else do you control the blood sugars? They ask in return. Like me, a year ago, it doesn't cross their mind that the most effective method to control blood sugars, is to stop shovelling in the "healthy" whole grains.

Recently I spoke to a very intelligent and knowledgeable endocrinologist I look up to, about the rationale of giving a hyperinsulinaemic patient even more exogenous insulin, and he was honest enough to admit that it makes the problem worse, but his justification was that there was no other way to bring the blood sugars down. I didn't get into a discussion about this with him, because we ran out of time, but it was disappointing to see such an experienced endocrinologist come so close to the solution, but then not think it through to its logical conclusion.

Stop the carb overload, and the insulin levels will drop, the insulin resistance will settle, they will lose weight, the dyslipidaemia will settle. All without a truckload of meds. Too bad there is no money to be made from taking people off meds.

Sometimes it's like banging my head against a brick wall. I speak to every physician I know about this, but either their eyes glaze over, and they lose interest, or, they look at me like a crazy dangerous person, who is out to rock the boat. How long before people see the light?

The dangers of a Paleo "cult"

Almost everyone who's on a Paleo diet now and has dealt with obesity and related issues will probably remember their attempts at weight loss before they found out about Paleo.

It was always- "eat less, exercise more". If it didn't work, it was the individual's fault.

People who couldn't lose weight were labelled gluttons/lazy/weak willed.

I've been guilty of the same. I've judged people around me and even myself on occasion when weight loss didn't happen. 

Then, the people who discover and use the Paleo lifestyle effectively, realise that they have been lied to all along by mainstream media, the doctors and fitness gurus, they trusted. They implement the Paleo diet and their weight melts off, they get healthier. It seems so effortless, that they become evangelists! Really annoying ones!

I'm a case in point. I talk nothing but Paleo to people around me. I'm sure I'm driving people insane with my smug comments.Paleo is my answer to everything. 

Weight loss?- Paleo!, Diabetes?- Paleo!, Hypertension?- Paleo! Dyslipidaemia?- Paleo!

Migraine. IBS, memory loss, fatigue, aches and pains, allergies, skin conditions, hair loss, thyroid disease, infertility, depression- My answer is always the same- Paleo!

My friends, family and colleagues are sick of me and my Paleo diet.

I do however have the opportunity to educate my patients on a Paleo type diet and have had insane success  with people who buy into it. Younger individuals improve drastically, and come off meds and even insulin. They attain significant weight loss.

Then I make their follow up visits a little less frequent, and they slide back. I can see the guilt in their faces when they come back to me with deranged blood sugars. 

Most of the time, I remember how I had judged my patients while giving them advice that was doomed to make them fail (healthy whole grains, low fat, vegetarian and all that jive) I sit them down and talk to them about where they made mistakes and how to avoid them in the future. However, when the same people return again and again after falling off the wagon, it becomes difficult to stay calm and non judgemental. Especially when the exact same people have had spectacular success earlier

My point is...

This diet/lifestyle, is not a cult. It is not a religion. It is not set in stone. 

The freedom from counting calories and the leeway to interpret the diet according to our personal situations is what attracted me to this diet.

Our job, as people who have succeeded with this diet and way of living is to get the information across to the rest of the world. If they follow it and succeed, good for them. If they need help, we should be there for them.But browbeating them, and judging them for not succeeding where we have is stupid, and wrong, and makes us no different from the trainers and doctors who advocate a high carb diet and then blame their clients for not losing weight and getting healthier.

I guess, this post is mainly a reminder to myself about what my goals are.

Get the information out there.

Help those who want to be helped.

Be non judgemental about the people who don't agree with the "cult" and its ideology.

Thanks for reading.

Coconut oil as the ultimate Paleohack

Strictly speaking, Coconut oil is not "Paleo"
I cant imagine a caveman pressing dried coconut kernels to extract oil. Inspite of that, Coconut oil gets a lot of good press from us paleo people.

Physically, it stands heating well, without undergoing much degradation. It keeps and stores well.
Biochemically, it is highly saturated, it is composed mainly of medium chain triglycerides and has anti inflamatory and slight anti bacterial properties

Where I live, south India, coconuts are abundant, and relatively cheap, so finding good, fresh and pure coconut oil is not much of an issue. I'm not sure how it is for people who don't live in the tropics.

Using Coconut oil as a Paleohack.
At some point you will achieve your desired weight on the Paleo diet. At that point, you might want to stop losing further weight. You might then struggle to get in enough healthy, Paleo calories to maintain your body composition  or improve it. That's where the coconut oil makes things easier
It is a good source of healthy fat calories. A few teaspoons of coconut oil can fill a big caloric deficit much easier than chomping through tons of veggies or a large quantity of meat.
Using meat as a calorie source, in my opinion, is wasteful. I don't enjoy veggies on their own, and the prospect of finishing a large bowl of okra and spinach is not very appealing to me, even if I grow them myself.

It is an excellent fuel for endurance events.
This is mainly because it is digested faster and absorbed directly via the portal vein instead of via esterification and transport via chylomicrons in the lymphatic system into blood.
Mitochondria can deal with the medium chain triglycerides(MCTs) easily, almost as easily as they deal with glucose. MCTs are preferentially oxidised in the mitochondria, rather than elongated and stored.If someone can find a way to mix BCAAs, glucose and coconut oil into a nice palatable gel/paste, it will be a hit. Who knows? maybe, someone is already working on it.

Coconut oil promotes ketosis.
Ketosis is what we want to get rid of body fat while preserving lean mass. If you still believe all Ketosis is dangerous, you need to do some reading. I'd recommend this link Ketosis explained by Mark Sisson

Coconut oil suppresses appetite.
Lke all fats, it does delay gastric emptying, leaving you feeling full for longer. Like all fats, it does impact the satiety center too. But, over and above that, in my experience it seems to work better at supressing hunger than other fats that I've tried.

How do you use Coconut oil?
Use it as the primary cooking oil. Scramble eggs with it, deep fry fish and vegetables in it.

Add it to the "safe starches"-
Coconut oil mixed with white rice will let me cut back on the rice necessary to make me feel satiated.
Coconut oil spiced up with red chillies and mixed with Tapioca is delicious
Potatoes are great, fried in coconut oil, or even mashed with coconut oil. I personally think, mashing potatoes with butter is far tastier, but coconut oil can make for a little change.

The "extreme" version
Add it to coffee and tea.
Coffee tastes better(than tea) with coconut oil (4 teaspoons briskly stirred into a medium sized mug)
Cardamom tea with a dash of honey and 4 teaspoons of Coconut oil is sinfully delicious
When pressed for time, or running out of stuff to cook and consume as calories, I can run a whole day on just one or 2 cups of this Coconut oil laced tea or coffee.

Other Paleohacks with  coconut oil.
Its pretty effective for Pink eye.
Its great for scrapes and bruises
Its brilliant for nappy rash on babies- my two sons have been guinea pigs for that experiment.
Its very good as a moisturiser for the skin.
Works very well for dandruff, when massaged into the scalp.
Fresh coconut oil can go rancid in humid climates, and needs to be stored in several small airtight containers instead of one large one. A pinch of salt in the container prevents the moisture fromreacting with the oil.

I'm hoping to put together a blog post on the science behind why coconut oil is so useful in improving our health. That hopefully, will be posted soon.
Please do let me know in the comments,if you use coconut oil in other ways in your day to day life. 

The Paleo experiment

The Paleo diet is now very popular, and has gained a bit of momentum in mainstream media and the internet. This post is about how I got into the Paleo lifestyle,
For people not familiar with this diet or lifestyle, it is explained a lot better by people who have been doing great work for much longer than I have been a practicing doctor. Trying to put it across clearer than them is overly ambitious. Here is a link from someone I am a huge fan of. http://robbwolf.com/what-is-the-paleo-diet/

What I want to do is to put across to you my personal experience with this diet.
Hopefully, it may resonate with you, and get you going in your quest to get healthy.

At the worst shape of my life, I was 82kilos at 168 cms and looking like the typical portly Indian doctor. Not the model of health to my patients, but compared to my colleagues and patients, I looked pretty normal.
India is known in the west as a place where people starve. Well, that was a few decades ago. Obesity is the norm in our urban areas now. Diabetes, hypertension and dyslipidaemia are exploding.

I had quit exercising when I had moved to the UK and never restarted it after I returned home.
Deciding that enough was enough, and feeling slightly hypocritical while advising my patients to lose weight, I decided to turn things around. I turned to my old friend, the bicycle. The last time I had used it regularly, I had dropped 10kgs with ease but that was in 1996.
I started biking and got up to a steady mileage of 20-30kms a day before work.
I didnt change my eating habits much. I was still downing large quantities of "healthy grain" Indian breads like chappathis, and dosas. I lost 6kilos in a few months and people were congratulating me on how much better I looked. I felt alright, except for falling sick with viral infections every 2 to 3 weeks, I didnt think much of it, because thats the way I'd always been. I figured, being exposed to sick people in the hospital everyday predisposed me to become sick more often. It was "normal"

One night, suffering from the flu, and browsing a cycling forum, I came across the "Paleo diet"
It pretty much changed my life.
I eased into it, after I failed once, going cold turkey on grains.
The weight loss was effortless, I was getting stronger, I stopped falling sick, I had more time because I didnt have to exercise for 12hrs a week to keep my weight loss going.

I'm now at 65kgs for the last 2 months. I'm now as light/heavy as I was when I was in school.
But thats not the full story. I'm faster stronger and healthier. I dont fall sick, I have almost unlimited energy.
I can go without eating for 24hrs and then return home and haul rocks around the garden.

How I did it, doesnt really matter, but I thought, if I get my story out there and it inspires someone, atleast one other person to take charge of their own health, then I've succeeded.
I'll try and put it out in bits and pieces so that this post doesn't become a crashing bore.