Don’t End Up as NASHty as I Was…

by
Baber Ghauri, MD

Don’t Tread on Me

American FlagI am an American.  I believe in democracy and freedom of speech and choice.  Like any American, I vote with my dollar and take advantage of all the liberties that having some dollars affords me.  I started medical school in 1997, giving me almost 20 years in the noble field of health care- at least 12+ as a board-certified attending physician.  I also feel privileged to have had the opportunity to be recognized for many other honors and appointments, both clinically and otherwise.  My strong Punjabi heritage makes me a Foodie- like Americans, Punjabi’s can eat!  With the strong exception of pork, the Pakistani diet is pretty much meat, meat, and meat- sound familiar?  If you’d rather, stop reading right here, my Pakistani-American heritage is the double whammy that forms the basis of what I’m about to tell you.

I write this blog post today because I know I have friends, patients, and family members that are in the same boat.  Those of you that know me know that, like so many other physicians, my wife (also a board-certified physician) and I recently underwent a bit of a transformation, I’m talking in excess of the clinical transformation that everyone in health care is going through.  The additional growth we’ve experienced is the underlying reason for the inefficiency and poor performance we are trying to correct in health care.  It is undermining our entire health system, and it’s my obligation and professional duty to share my experience.  Going through this has made me a better physician, a better father, a better friend, and a better member of our great society.  Maybe it’s a reverse mid-life crisis, either way; it started about seven years ago with the result of a routine blood test.

I Was Fine!

I had a very mild transaminitis, which means my liver chemistry was a little off- barely a smidgen above the upper limit of normal.  I felt fine.  I played basketball and tennis regularly and arguably in the best form of my athletic career.  I was 6′ 1″ and weighed about 170ish lbs.  This translates into a body mass index (BMI) of about 23, which is well within a normal, healthy range.  Throughout my life, I’ve always been the skinny, lanky guy that could use a few extra pounds.  Having never been one that likes to nap during the day, I noticed here and there that I would feel drained and would often fall asleep right before dinner time.  Thinking back, I recalled that my father also often fell asleep when he came home from work, so I figured this was “normal.”  I saw my outstanding primary care doctor- he was mildly concerned about my findings and appropriately wanted me to get a liver ultrasound to see what was going on.  But I never did.  I was fine!!  I decided I would recheck in 3 months- though not exactly supported by the evidence, and this was not entirely unreasonable for a patient that wanted to take a conservative approach, or at least that’s what I convinced myself.
ABIMThe diagnosis was already clear to me- lab error.  After all, I had nothing!  I was fine!!  No complaints!  I was wayyyyy too busy to worry about it.  Guess what else…  I never even got tested again- I was soooo sure.  Hey, I am certified by the American Board of Internal Medicine and licensed by the State of Pennsylvania to know what’s up!!  Who knows better than me- no one!!  Time went on, I changed nothing, and a couple of years later the drained feeling became more frequent (by this time my weight jumped up to near 190 lbs), but I was still performing at a high level and doing the things that I needed to do- I continued to sweep it under the rug.

Wake Up Call

It was my Integrative Medicine training that caused me to reflect on this experience, and after I sustained a moderate injury to my knee (in part due to the additional weight), I finally realized that I was in denial.  The results were suggestive of either NASH (non-alcoholic steatohepatitis) or NAFL (non-alcoholic fatty liver)*- both fancy words for liver inflammation.  It was mild, but I was genuinely astonished- it was tough for me to accept and maybe that’s why I never followed through with the definitive ultrasound that would have confirmed it in the first place.  The liver has a very high tolerance for insult, but once it’s mad, can cause serious misery.  Mine was JUST beginning to get annoyed with the drained feelings I was having.
Even after I finally came to grips with the diagnosis, it took me another 1-2 years to get to my current station- as of mid-2016, I’ve:
  1. Basically given up soda and sugary drinks, especially those with high-fructose corn syrup.
  2. Reduced my meat consumption to very little red meat
  3. Pretty much eliminated processed meat (the World Health Organization has classified all processed meats as class 1 carcinogens- yes this means they can cause cancer)

    Processed meat is a Class 1 carcinogen
  4. All but eliminated oxidized cholesterol consumption (fast food or foods cooked at high temperatures)
  5. Memorized the Bristol stool scale and try to keep track (the disgusting link, what do you want me to do?  I’m a doctor!  The funny thing is that my 8-year old knows it better than I do!)
  6. Increased fish and seafood intake (wild caught, not farm-raised)
  7. Essentially cut out dairy, but was never really a big dairy person in the first place
  8. Tremendously increased my fruit, nut, legume, and vegetable consumption (which I always loved anyway)
  9. Basically stopped using my microwave (microwaves can wreak havoc on the nutritional value of good food)
  10. Focused heavily on staying hydrated
  11. Perhaps most importantly, I tremendously reduced my intake of sugary foods (I actually read labels now)
Having just returned 12 lbs heavier from a 2-week long family road trip, I need to reiterate that I am FAR from perfect!!  This was an incredibly fun time eating primarily at restaurants but also making many trips to the markets to maintain that fruit and fiber intake.  If not for this, that 12 lbs could easily have been 18 or 20!  Even still, just one day afterward, I dropped 2 lbs and anticipate to shed at least another pound of water weight from all that salty restaurant food.  And I have no doubt that the remaining weight will also come off now that I’m back to my usual routine that is mostly based on whole foods and home cooking.  Even still, given the decreasing nutritional value of food, it is becoming even harder to consume the right amount of dietary nutrients, but I digress…
The best part of all this is that I really do like the way I eat now as compared with prior; therefore, I insist that I am NOT on a diet.  I still eat “bad” things like cookies, cakes, iced tea, hot dogs, and many, many others- BUT at least now I KNOW what these things are doing to me.  There’s a difference.  The brain is extremely powerful, and I believe that knowing allows the body to better combat the effects of these harmful foods.  For example, I recently noticed that I tend to crave more green leafy vegetables when I eat, let’s say a cheesesteak (see- I’m far from perfect).  This is probably because my BRAIN knows the fiber causes less absorption of the oxidized cholesterol and carbohydrates.  In other words, this was something I feel I did subconsciously and wasn’t “on purpose” per se- it was something I realized after the fact.  But now it is more purposeful.

Exercise? Not so much…

Now for the controversial topic- EXERCISE.  I don’t do it…  well, let me clarify, I exercise like crazy, but it’s not “going running” and “going to the gym” exercise, but more like playing with my kids, playing basketball, other cardiovascular activities, and doing my own home improvement projects type of exercise.  In other words, I don’t say I exercise, I say I’ve increased my activity- tomato/tomahto to some, but important for me- because I have never liked to “exercise”.  For those who DO like to exercise, they should exercise!!  They should just know there is increasing evidence that intense exercise more than 3-4 days a week (especially with no recovery days) increases MORTALITY!!  Yes, this means they die sooner than those who don’t!!  But I digress again…  It’s my opinion that exercise itself only has a mild effect on body fat and weight loss- I believe that when you’re spending 1-2 hours a day exercising, that Big Mac just doesn’t taste the same and you think twice about the next one.  It’s my opinion that every pound of fat lost or transitioned to muscle growth is 80% due to diet and only 20% due to exercise.  Here’s some evidence on diet vs exercise in weight loss.

Fast forward to 2016 (before my vacation), I was back to my 172 lbs, and although my weight has redistributed a bit, there is no question I have a bit more truncal obesity than I would like- I’m developing Metabolic Syndrome X which is a precursor to type 2 diabetes mellitus.  My Dad has been on years and years of drug therapy for type 2 DM, and until recently, I was taught that it’s primarily genetic and there was little to no chance that I would be able to avoid it- I thought it was inevitable for me…  But no longer!  Not only can type 2 DM be prevented, but type 2 DM can even be reversed if you do get it!!!  But why didn’t I know this before?  Why are we NOT teaching this to our medical students?  Ok, maybe I’m just out of touch- but why do almost none of my colleagues know what it is?  Why??  Could it be because frosted Lucky Charms are NOT “a part of a nutritious breakfast”?  They do magically create a delicious 40%+ profit margin- but I digress again.

Knowledge is Power

I DON’T HAVE TO BE DIABETIC- I have a choice!!  What a great country!  It is this hope that has driven me to do better for myself.  I share my story with you today because I thought everything was fine- it wasn’t.  I thought grocery stores were there to provide food, not make as much profit as they possibly could.  I thought the nutritional powers that be were keeping an eye on the American diet and magically working behind the scenes so that I could not possibly buy food that was bad for me!  I was wrong.
If I hadn’t come to these realizations, I would probably be diabetic by now or worse.  I would be at high risk for cryptogenic cirrhosis (liver failure) if I really had NASH*.  Those that know me well know that this experience has been profound for me- I think it has saved my life.  I know now that it is NOT EXPECTED to develop high blood pressure, coronary artery disease does not need to be a normal thing that happens to everyone, dementia is not a “normal part of aging”- all of these things have reasons- some we know already, but many we do not.  Most significantly, it is NOT NORMAL to be on prescription drugs to counteract the effects of these diseases for the rest of your life.  Like any of my colleagues, for at least one decade I have prescribed a countless number of these drugs and told countless patients and family members that they will need to be on them for the remainder of their life.  With the help of our growing medical community of integrative practitioners, we need to now work on safely getting people OFF their chronic medications and shifting them to a treatment plan that is rooted in non-prescription interventions- we can’t afford them!  IT IS POSSIBLE!!!  I didn’t know it was before, but I feel blessed to have learned many of these strategies.

Food is Medicine

Pharmaceuticals will always be necessary for patients that are the sickest of the sick as well as for infections, symptom control, and secondary disease prevention.  But do we need them to poop?  Do we really want to believe that we should eat whatever we want and have to rely on pills to eliminate it from our body?  Who do you think benefits from this idea?

Drugs will have a place for people that can’t or otherwise don’t want to recognize that FOOD IS MEDICINE and that you can’t exercise off the detrimental effects of Kentucky Fried Chicken, you have not to eat it in the first place…  These poor patients are doomed to a lifetime of prescription medications and doctor visits- just like many of my now deceased patients and family members- even though I continue to have bad eating habits, I feel fortunate and even empowered that I now have the choice to remove this from my personal destiny.  But I also feel concerned that it took me almost ten years to get to this point.  As a physician, shouldn’t it have been much faster?  In many ways, I feel my original training made it HARDER for me to accept these realizations.  Had it not been for my integrative medicine training, there’s a near 100% chance that you would not be reading this right now.

I’ve learned that my Pakistani-American approach to eating IS the root cause of my health issues.  There’s a reason that immigrants from China, Africa, and Sweden die from the same coronary artery disease that kills every other American in our country- my friends, I’m extremely sorry to tell you it is our food choices that are making us sick.  I wish it wasn’t, but it is…  I’m not talking about the hamburgers and hot dogs, and I’m talking about everything!!  Even the dairy, the GMO vegetables, the concentrated animal feeding operation (CAFO) meat, and the “healthy” fast food!  Please prove me wrong if you think otherwise!!  I beseech you to convince me, and I love KFC!!  But until then, I need to do my best to set an example for my children, family members, patients, and all others around me- it has not been easy, but it has at times been quite fun.  I’m on a mission, and the good news is that I’m not alone…

It is reassuring that some of the smartest people I know are choosing not to look the other way and are independently coming to the same realizations.  The challenge is bringing this knowledge into today’s practice, which is becoming increasingly standardized.  This means we doctors need to understand the data and stop following the status quo if it doesn’t make sense- even if it’s a protocol.  With the current fiduciary position of our health system, reform, and adoption of the BEST possible means to increase the quality and reduce the cost of healthcare is inevitable.  Can the care of our sickest patients be protocolized?  I happen to believe some of it can, but we need to THINK creatively about each patient’s care BEFORE we institute protocols.  It turns out the sickest patients often require an individualized care plan.  This is the basic philosophy of Integrative Medicine- consider all evidence-based interventions, not just the ones that are traded during business hours on Wall Street.  The stakes are so high for pharmaceuticals now that increasingly we see trusted authorities looking the other way when it comes to sound process and logical reasoning to get the desired outcome, aka fraud.  Forget the human element, just thinking as an economist might, our health system has declared that we can’t afford to make these mistakes anymore- we just don’t have the money to pay for them.  But I digress again again again.

Summary

I have been extremely naive about the food that I’ve been consuming throughout my life.  There is increasing evidence that food that is processed or high in animal fat can be deadly to the human body- duh?!?!  Even being in relatively great shape, I probably started to develop a potentially very serious condition of my liver that can eventually lead to diabetes and serious health issues.  It’s my opinion that not only my patients but also a large percentage of my friends and family are also at extremely high risk to have NAFLD.  I share this personal message with you today because I’m concerned.  I’m concerned about how this happened to me so insidiously.  I also feel it is my duty and responsibility as a physician and a member of our society to share the knowledge that can benefit others.  If you have a family history of diabetes, have transaminitis, or are starting to have truncal obesity- see your doctor NOW.  Most of us doctors are not well-trained to discuss how your nutrition can very often reverse your illness- that’s OK, MAKE THEM learn or seek assistance!!  Finally, we all need to rethink our food choices- vote with your dollar, stop buying foods that have ingredients that you cannot pronounce and buy organic whole foods that are locally sourced.

More to come, this is important stuff- thank you for reading my story, your comments (yay or nay) are welcome…

*NAFLD stands for non-alcoholic fatty liver disease which is subdivided into NASH and NAFL.  As much as I would LOVE to talk about the pathophysiology of all the diseases mentioned in this post, others have already done a much better job than I could, and I encourage you to reference your favorite medical knowledgebase for more information.

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