“Broken & Unaccountable:” American Healthcare – What to do instead?

Many health professionals, especially early in their careers, would tell you healthcare is a calling. I’m not sure that there is a better job in the world than taking care of a patient. There are many doctors that are trying to fix the problems, but are facing some very strong headwinds. We’ve inherited a system that makes it difficult to prioritize the patient without neglecting the business’s bottom line.

As a chiropractor using functional medicine I have seen first hand that appropriate care is not being delivered to treat the root cause of illness. Drugs and surgeries are prescribed in way that forestalls the resolution of underlying pathology. If you have high blood pressure does it make sense to artificially lower it, or treat the cause of elevated blood pressure.

We all deserve healthcare that is patient-endorsed and that gets results.

What is driving healthcare problems?

1. Consumers have waited for politicians to ride to the rescue

2. There is a cost crisis and total lack of price transparency

3. Preventative care is rarely covered

4. Delivery of care is not designed to treat the root cause

5. Medicine is overprescribed (in 1997 2.4 billion prescriptions were written. By 2016 that number doubled to 4.5 billion)

We’ve all been taught that if you are going to criticize something that you should supply an alternate solution. Numbers 1 and 2 open up Pandora’s box. Therefore I’ll share a few observations and opinions, but spend the majority of this article on numbers 3,4, and 5. I’ll provide a case study that should help the reader relate to how this applies to you.

The media and politicians have polarized public opinions on healthcare and will continue to perpetuate this two-sided affair. You’re either pro affordable care act (ACA) or anti-ACA. You support a one-payer system or you believe in free market and competition. In reality it’s much more involved and we have yet to establish a meritocratic approach that reins in the cost, optimizes the delivery of valuable care, and ensures all Americans access to care.

This is especially important when speaking broadly about chronic disease (diabetes, obesity, heart disease, hypertension, fatty liver disease, etc) because it’s responsible for approximately 80 % of healthcare expenditures in the US ($3.5 trillion in 2017)

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Did the affordable care act accomplish some things? Not denying people insurance with pre-existing conditions and keeping kids on their parent’s plans until 26 is embraced by the large majority. Did the ACA lower the price of health insurance in the United States by $2,500 per year? No! Will getting rid of it fix healthcare? I would argue that it would not, because in order for healthcare to be fixed we need a total re-haul. Does conventional medicine excel at preventing or reversing chronic disease?

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The US healthcare system runs on a fee-for-service model where doctors get paid for the pills and surgeries they prescribe. This rewards quantity over quality. Doctors don’t get reimbursed for spending time with patients counseling them on the benefits of healthy eating and other lifestyle modifications. Until that reimbursement model changes medical care and education will continue on unchanged.

We need to be aware of what’s happening in the medical system.

• A national study found that 21% of medical care was deemed unnecessary by physicians

• A new study out of John Hopkins details how 48% of all Federal spending goes to healthcare

• 1 in 5 Americans have medical debt in collections

There is zero transparency when it comes to healthcare costs. Predatory billing and price gouging are hard to detect, but are commonplace.

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The current system plays a game of inflating prices for insurance companies and making exorbitant amounts of money on the backs of patients. The days of plans with great benefits are gone.

Outside of your monthly premium it’s nearly impossible to know how much you will pay out of pocket, what the hospital or doctor will bill the insurance, and the degree to which what you paid for was medically appropriate.

People are getting crushed by their premiums and our health continues to deteriorate. If you’re interested in learning more about cost crisis and how to navigate within conventional medicine see the link Dr. Marty Makary new book, The Price We Pay.

Most doctors want to provide meaningful care to their patients.

What this means to me is keeping patients out of disease and empowering them to take health into their own hands.

If we look at the statistics around chronic disease it demonstrates that the current approach to healthcare is failing. Until patients have the right platform we will continue to go in the wrong direction.

Why don’t expensive insurance plans pay for the tests and therapy we need to prevent and fix disease at its core?

In the 1960’s the AMA [American Medical Association] agreed to drop its opposition to Medicare and Medicaid. They demanded that the new laws would back usual, customary and reasonable fees.

This was the beginning of ‘corporatized” care that lead to disproportionate fees for hospital visits, surgery, and technologic procedures for treating acute illness. Where reimbursement waned -- office visits for maintenance, treatment of chronic illnesses and/or for prevention. It’s important to note that during the time these fee structures were developed much of what we know about preventative evidence-based care has changed dramatically.

When creating a treatment plan or in doctor speak an “interventional therapy”, you should aim for a plan with a “curative effect.” Sounds simple but conventional medicine is not designed to provide us a cure. It’s meant as a way to manage disease.

Here is a very simple example. Patient goes to primary care doctor. Blood tests are run and results show high LDL cholesterol and triglycerides. Doctor then prescribes a statin drug to decrease cholesterol production and runs a basic lipid panel every year for 20-30 years while re-filling the prescription.

You should know that statins have not been shown to extend the lifespan in men under the age of 80 without heart disease, in women of any age, and in men over the age of 80 with heart disease. Moreover, statin side effects are often underreported!

If you have read any of my articles on heart disease you know that what’s important are the LDL particle numbers (lipoproteins) as well as markers for diabetes and inflammation.

How should you approach medical care?

Start with P4 medicine.

• Personalized

• Predictive

• Preventative

• Participatory

Healthcare practitioners want to spend our time on things that matter. So what matters to the patient?

• Getting answers

• Piece of mind

• Understanding the treatment

• The total perceived value of the care

• Personalized care

• Getting them back to what’s important in their life

• Being included in the decision making process

• Integrated care based on patient priorities

At this point in time if you are looking to stay healthy, reverse chronic disease, or even obtain a diagnosis you will have to do some work. This might mean working with an integrated team. For example I assist patients that are working with an endocrinologist, an obstetrician, personal trainer, and a psychiatrist. It’s key to find providers that can spend enough time with you. You will have to pay more up-front, but you will save beyond your wildest imagination long term.

Case Study: Functional medicine approach

Let’s talk about Karen. She is a 41-year-old, 5’4” woman who weighs 165 pounds and is premenopausal. Her goal weight is 135 lbs which was her weight before becoming pregnant with her second child.

She goes to the gym 3 times per week and performs some type of cardio i.e. elliptical or gentle yoga. She drinks red wine a few nights a week and has a self-confessed sweet tooth. She was recently diagnosed as pre-diabetic. Five years ago she was diagnosed with thyroiditis, but was told last year that her thyroid is “okay.”

She doesn’t sleep well and stays up late watching tv sometimes. She suffers from bloating and stomach upset. Conventional doctors have been unable to diagnose her with any gastrointestinal issues. She has tried Weight Watchers and paleo, but regains whatever weight she loses. Based on her 24-hour food diary her total calorie intake is about 2,400.

What are some of the things we did?

Recommend a “simple” Paleo diet template that provides around 1,900 calories per day, 25 percent protein (about 110 g), 25 percent carbs (about 110 g), and 50 percent fat (100 g). What the heck does that look like?

• 10 to 12 ounces of meat/chicken/fish/eggs

• 1.5 to two cups of starchy plants

• one serving fruit

• six tablespoons of added fats

We gave the patient the option of intermittent fasting with an eight-to-10-hour feeding window and suggested that she consume the recommended amount of food within that window.

We recommended that the patient get the following testing: SIBO breath test, Cyrex testing (as finances allow), and stool testing if needed. In her case we performed the stool test as her TSH levels were elevated as were her Anti-TPOs and it’s important to see if microbial imbalances may be promoting autoimmunity.

We ran a cardiometabolic panel and a full thyroid panel.

After 3 months of treatment (targeted supplementation, dietary and lifestyle modifications) Karen was able to loose 20 lbs. Her SIBO retest came back negative, and her blood sugar improved (HgA1C, fasting blood glucose and insulin). She has had 1 or 2 episodes of bloating, but her stomach pain has resolved.

What these results mean

• Karen feels like she has control over her diet and weight

• She won’t need to be on insulin or metformin in the future

• She’s decreased her cardiovascular risk profile

• She won’t need to take thyroid medication (at least not in the near future)

• She has improved energy and anxiety has decreased since her stomach pain resolved.

This was a bit longer than I intended so I’ll wrap it up.

The best part about taking a comprehensive approach is the opportunity to “upgrade” a patient’s overall paradigm of health to one of prevention and empowerment as opposed to passive and reactive therapies.

Keep advocating for your health. Map ouT your health risk(s) sooner than later .Try to find resolution to health concerns now so that you can avoid the future pills, surgeries, and medical bills.

Is Your Liver Happy

Here we are a month into 2019 and what we knew about health last year remains pretty much the same.  For the large majority of people we find a “health lane” and stick to it. For one person that may look like high-activity levels 5-6 days of “training” per week, a Whole 30 eating protocol, 5-day work week at the office, and the occasional cocktail outing with friends. On the other end of the spectrum person “x” eats mostly vegetarian, engages in yoga once a week, prefers snuggling with their cat, and enjoys church activities.  

People tend to find their comfort zone and begin habit building from a young age. In many cases adopting practices and ideas from their parents and peer groups. Cue the “my mom and dad had this or that issue, must be my genetic cards,”

However we choose to behave it is altering our bodies and physiology at a cellular level. In some ways, and much like our current healthcare system, these behaviors feel uncoupled from our health trajectories. This is because while some activities (injuries, sleep, caloric consumption, food choice, activity levels etc.) have short-term effects the long-term patterns result in ramifications that trickle out over 5 -20 years before we realize their full effect. Often times it’s very difficult to rule out early stage pathology or disease barring an invasive diagnostic test.

Overtime the body gives back, adapts, based on what has been required of it. As a student of the musculoskeletal system the research is quite clear when it comes to how quickly the neuromuscular complex can refashion itself. The Center for Healthy Aging and the Department of Biomedical Sciences at the University of Copenhagen concluded that it takes two weeks for a young person not using a leg to lose 1/3 of their muscle strength and mass leaving them on par with a person who is 40-50 years their senior.  

Inactivity does not discriminate and affects both young and old. What is more interesting is that after 2 weeks of immobilization participants cycle trained 3-4 times per week for six weeks. This was not enough for them to regain their muscle strength unless they included weight training.

This example demonstrates how quickly the body adapts to inactivity and results in rapid muscle loss.  The real kicker is that it will take you three times the amount of time to regain the lost muscle mass.

 Let’s look at a few examples of disease that require a period of 10-20 years before the disease has fully developed and spill over into other organ systems.  Most people don’t realize that cirrhosis of the liver and the deposition of connective tissue (scarring and fibrosis) requires about 80 grams of ethanol daily for 10- 20 years.  For those wondering what’s 80 grams - there is roughly 14 grams of ethanol in a 12 oz beer.  

More importantly, non-alcoholic fatty liver disease or NAFLD parallels that of obesity and has steadily risen over the last 30 years. NAFLD is projected to become the leading cause of liver related morbidity and mortality within 20 years and a leading indication for liver transplantation in the next few years.

Some researchers are calling diabetes a disease of the liver first. The liver is an important organ especially for energy metabolism and storage. The development of Type 2 Diabetes takes around 5-10 years in adults and can take much less time in children. These are 2 examples of long-term metabolic disorders. Atherosclerosis (think plaque and eventual heart attack) would be another example of inter-related long term metabolic stress that leads to maladaptive changes to an individual’s physiology.

Nutrition in the broader context of caloric intake

If you overload the system with continued doses of  “fuel” whether alcoholic beverages, sugar, or fat/protein for that matter, eventually the body will be unable to effectively process, detoxify and utilize these energy sources. A fatty liver is a signal that it is unable to burn fuel appropriately. A healthy liver ranges from 1-3 % fat and once it is at 5% normal function is on the line.

Judging by the statistics, if you’re an American, chances are you may stand to shed a few pounds. This tradeoff, excessive pounds for improved function, will increase your overall health and longevity. I’ve heard firsthand from patients, friends and family how difficult it can be to shed some weight and how to track progress when the scale seems to stall. Even exercise has its limits if your liver is struggling. Exercise is not a game changer for healthy weight loss as much as it is for maintaining a healthy weight. 

Most of us aren’t having routine blood work that looks at our liver enzymes, and even if you are by the time they are elevated your liver has been under insult for a while. The only way to rule out fatty liver is with a biopsy. Dr. Alan Christianson shares an interesting statistic: in situations where healthy individuals are undergoing testing to provide liver tissue donation 40.2% were found to have fatty liver disease. These are individuals with otherwise healthy blood markers.

Height to waist ratio

How do I know if my liver is strained or how it is handling the cumulative energy load? One of the most important metrics is your waist circumference. Your waist should be less than ½ your height. If it’s larger you may be more likely to have higher triglycerides, lower HDL cholesterol, higher LDL particle size, elevated inflammatory markers, elevated blood pressure, and higher fasting glucose.

If you want to quantify your risk of fatty liver disease Dr. Christianson has a built a calculator (because, as we know, short of a biopsy every other marker is inherently imperfect).

Fatty Liver Index

All you need are some results and some measurements:

The measurements you need:

• Weight in pounds

• Height in inches

• Waist circumference in inches

The blood test results you will need:

• Fasting triglycerides

• Fasting GGT

Unlike your car, your liver doesn’t want to be “topped off” at every meal.  Whenever we eat above and beyond our basal fuel requirements metabolic processes result in elevated free radicals and inflammatory compounds. Energy production is a “dirty process” metabolically speaking and requires the liver to run it’s detoxification pathways.

 Trust me, the body is not trying to carry trapped fat around our midsection. If you give the liver no choice and subject it to fuel overload this will result in high density fat storage, high blood glucose aka pre-diabetes/diabetes type 2, suppressed metabolism, and increased levels of pro-inflammatory adipokines.

In addition to eating nutrient dense meats, dairy, fruits and vegetables, do I take any evidence-based supplements for liver health?

Liver specific support

• N- Acetyl-L - Cysteine: can raise the liver’s protective glutathione

• Milk thistle: shown to protect liver cells and safeguard it from cell death

•  Alpha lipoic acid, Taurine, and Betaine Anhydrous  

• Dandelion tea to enhance bowel secretion and liver function

The Conscious Professional Series: Fernanda Mello

I had the pleasure of meeting with Fernanda Mello, a Health Coach (Institute for Integrative Nutrition) and Certified Specialist in Fitness Nutrition (ISSA) in Orange County. She is a business owner, traveler, surfer, jiu jitsu competitor, cook, photographer and abides by the tag line “healthy choices with real food” Trust me when I say that you need a mobile spine to be effective and injury proof while training Brazilian jiu jitsu.

As a non-native orange county resident, it never ceases to amaze me the quality and number of health conscious professionals in our OC community. I'm finding that the area is rich with those seeking and helping others live a healthier lifestyle. 

From what I can tell Fernanda has a unique approach and wisdom when it comes to health. Even more she brings passion to her work, with emphasis on awareness and smart dietary solutions.

Check out her answers from our min-interview.

At what point did you decide to prioritize your own nutrition? 

I decided to prioritize my own nutrition around the time that I finished my bachelor's degree . However, I began to fully understand the power of nutrition when I started to cook all my meals and this happened when I moved to California, 5 years ago. 

You have a great list of principles that guide your overall philosophy. Of the 8 principles which one do your clients grasp first and which can be more difficult to sustain? 

My clients are usually really good at getting active, not all of them can easily stick to an active schedule, but most of them can. I guess the most difficult thing to sustain is making their own meals at home, because people tend to overthink making food at home and end up eating out in restaurants too often. I try to teach my clients that they can create easy and healthy meals without being a chef! I help with grocery shopping guides, grocery shopping lists and some tips such as good brands, places to purchase such as local farmers markets and healthy food stores.

If I’m not mistaken, you have experience recognizing and treating clients with Candida overgrowth? In your experience does a recent round of antibiotics set off your alarm? Or is there more to it and what can you share with people unfamiliar with this condition?

Yes I have experienced a lot of clients struggling with candida overgrowth and I believe it is a combination of both: use of excessive antibiotics and unbalanced lifestyle. Antibiotics kill not only disease-causing bacteria; they also kill beneficial bacteria that control our inner ecology. Friendly bacteria are so important to our immune system, ensure absorption of nutrients from the food we eat, help our mood, and many other heath benefits. Candida is a pathogenic yeast or fungus normally present in our inner and outer body, in small quantities along with good bacteria. The problem is when candida starts to thrive due to a high-sugar, low-nutrient, and low fiber diet. Fungus is an opportunist microorganism and they can spread fast if we don’t control them. A balanced diet and controlling stress can be a really successful and low invasive treatment to prevent candida.

It’s pretty clear that you practice what you preach in terms of life balance and activity. Is food the source of your activity levels or does getting out (surfing, jiu jitsu, yoga) act as a catalyst for eating healthier?

For sure!! Eating real food is always a good way to keep my energy levels steady, provide enough vitamins, mineral, and phytochemicals to help better recover results and performance! Eating natural food is also an amazing self-care practice and keep us more in tune with nature!

What sort of nutrition programs do you employ with your clients (duration, macros, elimination, etc.) 

I mostly encourage more real food consumption and minimize industrialized food. I focus on quality rather on quantity. It depends on people’s body type, energy levels, lifestyle, and regular schedule. I don’t focus only on what people eat, but how they manage their stress, self-care, etc.
I try to keep track of food intolerances or allergies as well, so sometimes elimination diet can be super helpful.

Okay, on a serious note. Favorite yoga pose and Jiu jitsu submission?

I love crow pose and child’s pose (amazing reset and resting pose)
Jiu Jitsu submission: cross collar choke. 

Finally, can you speak to what your ideal client looks like from a mutual fit perspective.

I believe that being healthy can have many definitions! It depends on each person and their lifestyle. But most importantly, being healthy is a constantly practice of self-care. Food plays a huge role in how we balance our inner ecology and overall energy levels, but it also important to balance other important aspects of life (physical activity, spirituality, personal relationships, work environment, increasing nature contact, and more). I love to see my clients having healthier choices, feeling more energized, sleeping better, having more energy, and loving themselves for what they are.