What’s the deal with Intermittent Fasting?

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Intermittent fasting (IF), also known as therapeutic fasting (TF) or intermittent energy restriction (IER) has been getting a lot of attention lately in the news media, internet and also in the doctor’s office because it has been shown to help people lose weight and also help those with diabetes (both type 1 and type 2) lower their blood sugar and insulin demands.

Disclosures:  I have no conflicts of interest from any pharmaceutical company or research organization.  I do not make any money from sharing this information.  The purpose is for informational value for patients or others who are interested in learning what I have discovered about how to lose weight and also help improve the health for patients with diabetes or prediabetes.  I believe it’s very important to work with a doctor familiar with your diet, especially if you take medications to treat diabetes or heart related conditions so that together, you can ensure you remain safe whenever you change your diet.

Weight loss is a popular topic, both in social media and in the doctor’s office.  I would suggest that a majority of major healthcare problems facing Americans today are related to being overweight or obese.  In fact, 75% of Americans are currently either overweight or obese and this statistic is rapidly worsening.

Complications from the obesity/overweight epidemic:

  • Metabolic syndrome (high blood pressure, high cholesterol, obesity and diabetes)
  • Increase risk of heart attack
  • Increased risk of stroke
  • Increased risk for some forms of cancer
  • Arthritis/joint pain due to the extra stress from the weight
  • Back pain
  • Low testosterone/sex drive
  • Low energy levels
  • Difficult to exercise because of the extra weight
  • Heat intolerance
  • Obstructive Sleep Apnea
  • Lower self confidence
  • Difficulty with bucket list items on to-do list after retirement such as travel due to decreased endurance, joint/back pain

The problem with traditional “Eat Less Move More” model for weight loss:

The most common model that all of us have heard about (and tried) in order to lose weight is to decrease the amount calories that are consumed and exercise more.  Unfortunately, we all know that this doesn’t work over the long term because whatever weight that is lost (if any) is regained 99% of the time in just a few months.

As an example of the failure of this strategy, consider the popular TV series “The Biggest Loser.”  The show documented over-weight contestants who often successfully lost a surprising amount weight using the eat less, exercise more model that at first seemed to work remarkably well.  Susanne Mendonca, a contestant on The Biggest Loser – season 2 said “the reason why NBC never does a reunion is because we’re all fat again.”  In other words, although the contestants lost weight during the show, it was not sustainable long term.

A study in the New England Journal of Medicine (N Engl J Med 2012; 366:2247-2256) examined the same calorie-deficit approach and found that over 5 years, the Body Mass Index (BMI) of the participants did not improve (an in some cases worsened).  Multiple other well-designed studies, including the Women’s Health Initiative have shown similar results over a 9 year period. This is unfortunate because many medical professionals profess that the eat less, move more approach to weight loss works, but the evidence shows the opposite is true.  

Why doesn’t simply eating less and moving more work for long term for weight loss?

Slowing metabolic rate:

Over years, if you take in more calories than you burn, your body may increase the set-point of what it considers your normal body weight to be and will try to maintain it.   For example, if you are now 230lbs and have been that weight for months or years, your new  normal weight set point may change from the initial set-point of 180lbs to 230lbs .  This can make it much more challenging for you to lose weight, because the body will do all it can to maintain this new body weight.  If you decide to lose weight by taking in less calories, say 1500 calories per day instead of 1800 calories, your body will recognize that you’re not getting enough calories to maintain this weight of 230lbs and will actively try to stop losing weight.  You may feel cold as your metabolism slows down.   Instead of your body burning 1800 calories/day to maintain your weight, your body may decrease its basal metabolic rate to burn only 1300 calories per day, so you feel cold, sluggish, hungry and irritable.  You may start losing weight at first, but as your body changes your basal metabolic rate, you might actually start gaining weight gain (remember you’re taking in 1,500 calories and the body has slowed its rate to burn 1,300 calories/day).

Hunger Signal:  As we lose weight, our body releases hormones which signal us that we’re hungry.  Unfortunately, even over long periods of time, these hormones stay elevated and make it difficult for us to overcome the uncomfortable feeling of hunger.

Energy input/output – Two compartments for energy

The energy that we need for living can either come from stored fat or from food that we eat.  When we eat, insulin levels rise and the energy from the food that we don’t immediately use for energy will be stored in the liver as glycogen or as body fat.   Insulin is the hormone in the body that signals food energy to be stored as fat. Insulin levels rise whenever you eat, and they rise to the highest levels when you eat carbohydrates/sugar. The benefit of a low carbohydrate, high fat diet in addition to intermittent fasting, is that both work to keep your insulin levels low to help prevent storing body fat.

The pathway that your body chooses for energy usage depends on whether calories are coming in or whether you are in a state of fasting.   When you eat, insulin levels rise, and your body will preferentially use calories from the food you eat as energy and store the excess calories from each meal that aren’t immediately needed as fat. At the same time that the body is storing energy as fat, it will not break down fat that is already stored. This is important to remember, because the insulin (which is triggered by eating) turns off lipolysis (breakdown of fat) and turns on the fat storage process.

Intermittent Fasting:  IF is basically described as not eating for a prescribed period of time.  When you take away the food energy coming into the body, insulin levels are decreased and all the energy that we need to maintain our metabolism for living can be mobilized from our fat stores.  Intermittent fasting is synergistic with the low carbohydrate, high fat diet because this treatment works to lower insulin levels and help prevent fat storage and promote the the usage of stored fat for energy.  Intermittent fasting is flexible however and can be used with any type of diet and can be used for short or long term.

If you decrease the frequency of your meals to once or twice a day, do you eat just as many calories as you would normally eat if you weren’t fasting?

Yes, you can in some forms on intermittent fasting.  Some people prefer to eat a large quantity of food all in one meal.  They might for example eat 2,000 calories in one meal rather than eating the same amount spread throughout the day. The idea is to eat until you are full and not more than that.   If you’re trying to lose weight and improve your diabetes, it is still important to pay attention to what foods you eat and the quantity. Lower carbohydrate foods are usually better for weight loss.

How often can you eat with intermittent fasting?

There are different patterns to intermittent fasting – some examples are below:

  1. 16:8 Fast – Skip breakfast and eat lunch and dinner during a 6-8 hour period of time (16-18 hours of fasting each day)
  2. 24 hour fast – aka One Meal A Day Diet (OMAD).   Skip breakfast and lunch and eat dinner (24 hour fast each day)
  3. Alternate day fasting (ADF) – Eat only 500 calories on the fast day alternating with eating whatever you want the next day (feed day)
  4. 5:2 fasting – Normal diet for 5 days, following by 2 days of only 500 calories on each day.

Deciding to fast for longer periods of time than 24 hours is generally considered prolonged fasting which is a different topic.

It should be clear that intermittent fasting is limiting in caloric intake but does not limit water.  In fact, it’s very important to drink even more water throughout the day than you normally would as your body needs extra water to help breakdown fat to use for energy.  Water is essential while fasting.

Is intermittent fasting safe?

Fasting has been used therapeutically since the 5thcentury BC.  Mark Twain said, “A little starvation can really do more for the average sick man than can the best medicines and the best doctors.”  Albert Einstein said, “The best of all medicines are resting and fasting.” Plato said, “I fast for greater physical and mental efficiency.” Even Hippocrates recommended periods of fasting. Nearly every major religions have a period of fasting that they observe.  Christians observe Lent where and other periods of fasting.  In the Muslim religion fasting is observed during Ramadhan.  Fasting is also an integral part of the Hindu religion. Many Buddhist monks and nuns follow the rules of Vinaya and commonly due not eat after noon each day. Traditionally, observant Jews fast and many Native Americans often used fasting before participation in a vision quest.

So yes, I think fasting can be very safe in patients who are overweight.  In patients who are pregnant, have anorexia, trouble gaining weight, or are underweight, fasting is not appropriate.

I recommend working with a doctor who understands your medical history and what you’re trying to accomplish.  If you have a history of diabetes, hypertension or other cardiovascular problems and take medications for these conditions this is especially important.  This is because within a few days of this diet, you will likely require less medication.  If you already use insulin, you can expect to lower your insulin requirements (or better yet,  be able to stop injecting insulin) when you decrease your carbohydrate intake.  If your insulin requirements aren’t monitored closely with this dietary change, you can become sick.  Lowering insulin demands can however be very beneficial because you’re treating the cause of the problem in type 2 diabetes which is taking in too many carbohydrates and insulin resistance.

In my type 1 diabetes patients who have adapted to a LCHF diet, they report more stable blood sugars (less extreme highs or lows) and a lower overall A1c.

When you fast, does your metabolism decrease?

No,  metabolism actually increases slightly with fasting according to a study from the Journals of Clinical Nutrition.  (Zaunder C Am J Clin Nutr 200; 71:1511-5).  As insulin and glucose decrease, the body makes up for this by breaking down fat and using ketones and fatty acids for energy.  Norepinephrine increases and is a key reason why you maintain your metabolic rate. This is why intermittent fasting is more successful for weight loss than the simply eating less and moving more model of dieting which causes your metabolism to decrease.

When you fast, do you just keep getting more and more hungry?

No, we know that ghrelin (the hunger hormone) typically rises and falls over a 24-hour period and usually peaks around breakfast, lunch and dinner times.  If you don’t eat a meal, your hunger hormone levels go back to baseline after a short length of time.  Hunger does not continue to build if you don’t eat because your body is able to provide the energy that it needs from its stored body fat.

If I fast, will I lose muscle mass instead of fat?

Multiple studies have demonstrated the effects of fasting on fat loss verses muscle loss and have found that the body preferentially burns fat rather than muscle in times of fasting.  This makes sense because since the body stores fat when it has more calories than it needs so why would it preferentially decide to burn muscle instead of fat during periods of fasting?

Can women fast?

Yes, there have been studies which show that women and men can lose fat equally when fasting – approximately ½ pound of fat per day of fasting on average (Drenick EJ. Am J Publi Health Nations Health. 1968 ME; 58(3): 477-484)

Advantages of Fasting:

  • Flexibility (you can do it some of the time, and not others)
  • Convenience (save time with shopping/cooking)
  • Free
  • Simplicity
  • Unlimited power – you can keep losing weight until you get to your appropriate weight.

Benefits of Fasting beyond just weight loss:

There are several benefits to fasting which are being studied other than to simply lose weight. Many of these studies have been done in animal models are ongoing studies in humans is currently taking place. Some of these benefits may include:

  • Increased lifespan – this has been seen in animal models.
  • Decrease risk of some cancers.
  • Decrease risk of age related neurogenerative disorders such as dementia (Alzheimer’s or Parkinson’s disease)
  • Improved cognitive function (learning and memory)
  • Improved mood

What is the theory behind fasting causing a boost in brain power?

The idea is that fasting causes challenges to the brain in the form of a mild oxidative stress which causes the brain to adapt by increasing mitochondria and producing neurotrophic factors.  These factors cause the brain to become more active, increasing neurogenesis (creating of more nerve cells), growth and synapse formation (more connections between brain cells) and resistance to degeneration.  This makes sense from a biological perspective because if you’re hungry and haven’t found food, you need to adapt in order to find food or you will not succeed in life.

What are the possible side effects of intermittent fasting?

Some people develop what is called the “keto flu” which really isn’t a flu or infection at all.  It is a constellation of symptoms that can occur while their body is adjusting from using glucose as fuel their fuel source to using ketones for fuel. It is usually caused from a deficiency in one or more of the important minerals.

Symptoms may include:

  • Decrease energy or dizziness
  • Body aches
  • Sugar cravings
  • Difficulty focusing
  • Nausea
  • Irritability
  • Nausea and stomach irritability
  • Constipation or diarrhea

All of these symptoms usually go away within a few days and can be minimized by keeping well hydrated (drink more water) and getting enough sodium (salt).

Why could your salt levels (sodium/potassium) potentially become low with a fasting?

Ketosis (from breaking down fat to use as energy) causes the kidneys to accelerate the excretion of salt.

How much salt do I need per day?

5 grams of sodium per day which equates to about 2.5 level teaspoons of salt per day.  Most naturally healthy, whole food containing diets have about 3 grams of sodium that can come from foods that you would normally eat such as olives, pickles, sauerkraut, kimchi, bacon, etc. For this reason, it is likely that you may need to support a fasting diet with additional salt that can come from broth or salty foods (if you choose a calorie restricting fast).   If you have hypertension or heart failure that you take medications to treat, it is very important to work with a doctor familiar with this diet.

 Adequate intake of minerals is extremely important and those include:

1)  Sodium – if depleted, can cause lightheadedness, dizziness, fatigue when exercising and/or constipation.  With nutritional ketosis your kidneys excrete more salt so you need to increase the salt in your diet as long as you do not have heart failure or severe hypertension.  Some people find may prefer to use bouillon cubes instead of bone broth to help ensure adequate sodium levels.

2)  Potassium important for heart and muscle function.  You can get this from broth

3)  Magnesium – depletion can lead to muscle cramps after exercise or at night.

4)  Calcium – necessary for bones, nerve and muscle function – this is also found in broth.

If you have a medical condition such as diabetes (type 1 or type 2), hypertension, heart failure or take medication, it is very important to work with a doctor familiar with the ketogenic/high fat, low carb diet.  This is because you will likely need to modify your medication regime because you may likely need a decreased dose or may even be able to stop some of your medications.  If you don’t carefully adjust your medications while changing to this diet, you could become sick.

Can I eat or drink anything other than water while I’m fasting?

This is controversial.  You should definitely drink water and I recommend adequate intake of salt from consuming broth.   The goal is to keep your insulin levels from rising so that your body is able to mobilize your stored fat and use that as energy.  If you eat or drink anything with calories, this could jeopardize the entire process.

How to know you are in ketosis with intermittent fasting:

Some people prefer having some sort of physical evidence (lab test) so they can verify that their body is in ketosis (breaking down fats to use for energy).  There are several ways of verifying ketosis.  A method that was popular in the past was to use a urine ketone dipstick which is a chemical test strip that is dipped into a urine collection cup to test the urine for ketones.  That urine test unfortunately isn’t very accurate.  A more reliable test to determine if your body is in ketosis is to check your blood ketone levels using a ketometer. The device is very similar to a glucometer that diabetic patients use to test their blood sugar.   There are multiple brands of ketometers on the market. I cannot recommend one over any others, but they can help you determine whether your body is breaking down fat for energy (in ketosis).

You may also be interested to find out how your blood sugar rises/fall depending on the foods that you eat. Even if you don’t have diabetes, you are able to buy a glucometer and test your blood sugar.  You might be surprised to learn about how your blood sugar changes depending on which foods that you eat.

It would be great to be able to test our insulin levels.  Unfortunately, we don’t have a good over the counter test to check insulin levels, but you can get an insulin level test done at your local laboratory with an order from your doctor.  Usually, if your blood sugar is low, that means your insulin level is also low – unless you have diabetes and are injecting yourself with insulin.

This is written for informational purposes only, and I hope you find it helpful.

 

Scott Rennie, DO

 

 

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What’s the skinny on how to lose weight?

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Disclosures:  I have no conflicts of interest from any pharmaceutical company or research organization.  I do not make any money from sharing this information.  The purpose is for informational value for patients or others who are interested in learning what I have discovered about how to lose weight and also help improve the health for patients with diabetes or prediabetes.  I believe it’s very important to work with a doctor familiar with your diet, especially if you take medications to treat diabetes or heart related conditions so that together, you can ensure you remain safe whenever you change your diet.

Weight loss is a popular topic, both in social media and in the doctor’s office.  I would suggest that a majority of major healthcare problems facing Americans today are related to being overweight or obese.  In fact, 75% of Americans are currently either overweight or obese and this statistic is rapidly worsening.

How do you define a healthy weight, overweight or obese? 

Body Mass Index (BMI) is the measurement that we use in the medical field and it’s a measurement of your weight vs your weight.

Normal BMI  –             18.5 to 24.9

Overweight BMI –       25 to 29.9

Obese BMI –               30 to 39.9

Morbidly obese BMI: 40 or above

BMI measurement doesn’t work for professional athletes because they have so much muscle mass that the BMI calculation would say that they are obese, even though their percentage of body fat is very low.  For those patients, a % body fat calculation is more accurate:

For Men:                                                                                 For Women:

Obese – 25% or above                                                            32+ or above

Average – 18 to 24%                                                               25 to 31%

Fitness – 14 to 17%                                                                 21-24%

Athletes – 6 to 13%                                                                14-20%

Complications from the obesity/overweight epidemic:

  • Metabolic syndrome (high blood pressure, high cholesterol, obesity and diabetes)
  • Increase risk of heart attack
  • Increased risk of stroke
  • Increased risk for some forms of cancer
  • Arthritis/joint pain due to the extra stress from the weight
  • Back pain
  • Low testosterone/sex drive
  • Low energy levels
  • Difficult to exercise because of the extra weight
  • Heat intolerance
  • Obstructive Sleep Apnea
  • Lower self confidence
  • Difficulty with bucket list items on to-do list after retirement such as travel due to decreased endurance, joint/back pain

Many of my patients are struggling with weight gain issues and they often come in to ask my advice about how to lose weight.  Over the years, I’ve learning quite a few tips that have helped myself and my patients who want to accomplish this goal.  Most all of us have tried a diet.  We may lose a few pounds and then get discouraged when the weight loss stops or when we start feeling a lack of energy, cold, hungry and irritable.  Even more, if we do finally reach our goal weight and stop the diet, the pounds start piling back on leading to the yo-yo effect that is so common with dieters. So, what can you do to lose weight and keep those pounds off?

Physiology of weight gain:

Let’s start with discussing a little physiology regarding weight gain.  Most people don’t become overweight or obese overnight.  The body has a set-point that it considers as it’s “normal weight” that it would like to maintain.  For example, if you normally weigh 180lbs and then go on spring break and gain 10lbs by taking in lots of extra calories during that week, your body will increase your metabolism and actively try to burn those calories to get back to 180lbs. This is great, but there is also another side of this.

Over years, if you take in more calories than you burn, your body may increase the set-point of what it considers your normal body weight to be and will try to maintain it.   For example, if you are now 230lbs and have been that weight for months or years, your new  normal weight set point may change from the initial set-point of 180lbs to 230lbs .  This can make it much more challenging for you to lose weight, because the body will do all it can to maintain this new body weight.  If you decide to lose weight by taking in less calories, say 1500 calories per day instead of 1800 calories, your body will recognize that you’re not getting enough calories to maintain this weight of 230lbs and will actively try to stop losing weight.  You may feel cold as your metabolism slows down.   Instead of your body burning 1800 calories/day to maintain your weight, your body may decrease its basal metabolic rate to burn only 1300 calories per day, so you feel cold, sluggish, hungry and irritable.  You may start losing weight at first, but as your body changes your basal metabolic rate, you might actually start gaining weight gain (remember you’re taking in 1,500 calories and the body has slowed its rate to burn 1,300 calories/day).

Insulin and weight gain:

You probably recall hearing about insulin in the context of diabetes, but it’s also a very important hormone in the context of weight gain.  Insulin is the hormone that helps us take energy that we eat which is processed into sugar and remove it from the blood and turn it into energy for use to power our brain, muscles and internal organs.  The problem is, if we take in too many carbs which get processed into sugar, that sugar will need removed from the bloodstream and either stored (as fat) or excreted (perhaps in the urine).  Our bloodstream can only hold 1 teaspoon (4 grams) of sugar at any given time so that sugar has got to go somewhere or we’d all get sick and end up in the hospital with elevated blood sugars.  Most of it gets stored as fat.  We don’t want that when we’re trying to lose weight.  We also don’t want to excrete sugar in the urine because that damages the kidneys.

In some circumstances it is very appropriate to store food energy as fat, and insulin does its job, allowing you to store energy in your fat cells so that if you get sick or go through times when food is not available, you have reserves to get through those periods.  Most of us however, do not want to store fat, and we would rather that our bodies break it down and use excess fat as fuel, so we can lose weight.  The body is smart however and doesn’t want to break down your fat storage (lipolysis) at the same time it’s storing that orange juice (with lots of sugar) that you just drank.  It’s important to understand that certain foods stimulate the body to secrete insulin more than others.  In general, high carbohydrate foods cause the pancreas to release more insulin which signals the body to store the food you ate as fat.

Carbohydrates:

What is a carbohydrate anyway?  You probably already know that there are three main macronutrients that we take in as food.  Proteins, fats and carbohydrates (carbs).  Carbs can come in the form of sugar, but also are in starchy foods such as rice, potatoes, noodles, grains/breads.  They are also in foods such as fruits and vegetables.  We already know that some foods have more carbs than others.   Carb intake stimulates the body to secrete insulin in order to bring down the blood sugar and store that sugar in our fat cells.  Of course, we don’t store all the sugar that we consume as fat, but since our 5 liters of blood supply can only hold about a teaspoon of sugar (4 grams) at any given time, we have to use it up quickly (some athletes such as marathon runners can do this) or it will be stored as fat (and a little as glycogen in the muscles and liver).

The USDA food pyramid that was released in the 1970’s that we are all familiar with put carbohydrates at the base and indicated that we should get 50-60% of our calories from carbohydrates such as breads, cereals, rice and pasta.  Fruits (which are also high in carbs) are listed in the middle of the pyramid. Unfortunately, since these recommendations were released, the obesity and diabetic epidemics have become widespread public health concerns.  Many experts are now suggesting that consuming so much of our food for carbohydrates is what is leading to the obesity epidemic in America.

Fat:

When I was growing up and learning about nutrition, I remember hearing that fat is bad, and we should avoid it.  The truth is, our body needs fat in order to function properly.  It’s also a myth that eating fat will make you fat. Certain populations of people around the world consume large amounts of fat and have lower body weights overall than Americans.  These populations of people have less diabetes and obesity related health problems. There are different forms of fat, some good and some not-so-good. Fats can be solid or liquid at room temperature. If a fat is solid at room temperature it is a saturated fat.  If it is liquid at room temperature, it’s unsaturated fat or oil.

We now know that we should try to avoid polyunsaturated fats such as margarine, Crisco, and certain oils (canola, vegetable/soybean, corn, sunflower, grapeseed, peanut, safflower, cottonseed).  These polyunsaturated and trans fats are often found in processed foods at the grocery store and fast food restaurants.

Oils that are considered much better for you include olive, coconut, palm, avocado, walnut, hazelnut, almond, macadamia nut, sesame, fish.

In the 1970’s there was some controversial research that came out that recommended that Americans “cut the fat” from our diets.  The food pyramid that we are all familiar with put fats at the top of the pyramid (along with sweets) indicating that we should consume them sparingly.  I say that this is controversial because there is growing evidence that consuming a high fat diet is not necessarily bad for you, and many researchers have shown that a high fat/low carb diet is beneficial for weight loss because consuming fat does not cause insulin spikes that lead to weight gain.  Consuming fat also leads to a feeling of satiety and that means that you feel full for longer after eating a meal higher in fat than you would if you had consumed a meal with a similar calorie count that was made up of mostly carbs.

Protein:

Protein is the other macronutrient that is important in our diet.  It is important to remember that protein, although it does not inherently contain sugar/carbs, can be processed by the liver and turned into sugar in our bodies if we consume too much.  I’m explaining this because some people who are new to low carb diets decide to eat multiple servings of meat and other high protein foods and when they consume too much protein their bodies can process these foods into sugar through the process of gluconeogenesis thus leading to difficulty losing weight.  If you’re trying to lose weight, I recommend a moderate intake of protein.

The diet for weight loss: Low carbohydrate/High Fat (LCHF)

I recommend a low carbohydrate, high fat diet which is also known by the abbreviate LCHF.  Others may call it a ketogenic diet.

In general, I believe that eating “real food” as opposed to highly processed foods is much better for your health and for weight loss.  Foods that are lower in carbohydrates do not stimulate the body to secrete high levels of insulin and thus have less of a fat storage effect and will allow your body to go into a state of ketogenesis.  Ketones are a byproduct of fat burning and can fuel the body much like glucose (sugar).

What foods are good to eat that are low carb/high fat (LCHF)?

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  • 1). Avocados
  • 2). Cheese
  • 3). Eggs
  • 4). Fatty fish
  • 5). Nuts
  • 6). Olive Oil
  • 7). Grass fed beef
  • 8). Coconut
  • 9). Dark Chocolate
  • 10). Greek Yogurt (without fruit)
  • 11). Wild Salmon
  • 12). Heavy cream/milk
  • 13). Tuna
  • 14) Duck
  • 15). Bacon
  • 16). Butter
  • 17). Cottage cheese
  • 18). Best nuts – macadamia, pecans, hazelnuts, Brazil nuts, (avoid peanuts, pistachios and cashews)
  • 19). Most vegetables (careful with some root vegetables such as carrots that have higher sugar content).

 What are foods that I recommend avoiding to lose weight?

  • Sugar sweetened beverages (soda, fruit juice, sports drinks, frappuccinos, etc.)
  • Breakfast cereals
  • Cookies
  • Candies
  • Crackers & chips
  • Pastries, doughnuts and muffins
  • Ice cream
  • Jams and Jellies
  • Yogurt with lots of sugar
  • Be careful with fruit – most have lots of sugar
  • Most items that say low fat are actually high sugar
  • Processed foods – most foods in the grocery stores are processed foods these days
  • Avoid too much protein

Do I need to count calories?

Yes and no.  When eating a lower carbohydrate –  higher fat diet, people tend to feel full faster and for longer periods of time compared with eating sugar/carbs.  If you eat too much of anything, including fat, you can gain weight however.  This is much less likely with fat than carbohydrates.

Why should fat/protein make you full faster and for longer than carbohydrates?

Carbohydrates/sugar do not stimulate the satiety hormones ghrelin and leptin.  These hormones that are normally released when you eat a higher fat diet are what signal the brain to tell you that you’re full after you eat a meal.  The bad thing is that these hormones aren’t released after eating sugar/carbs, so after drinking a 300-calorie soda, you aren’t as likely to feel full as you would be after eating 300 calories of avocados and eggs for example.

Can I just exercise and lose weight instead of control my diet?

There is no denying that exercising is healthy for your body.  The question about using exercise for weight loss is more interesting. I don’t know about you, but I could eat a 200-calorie cookie in just a couple minutes (maybe less) and I would have to run for at least 20 minutes to burn those calories off.  I could also easily eat 3 or 4 cookies in just a few minutes and I would not be able to keep up with burning all those calories with exercise alone. Most experts would agree that it’s much easier to lose weight by changing your diet than it is to simply start exercising more.

Exercise is great for your body and it helps improve mood.  Being physically fit helps you feel better in general.  Physical fitness helps improve longevity and decreases muscle pain.

What about alcohol?

Certain kinds of alcoholic drinks have more carbohydrates and sugar than others. Beer can be very high in carbohydrates and so can spirits/hard liquor that’s mixed with fruit juices or soda. Wine and spirits (without mixers) tend to be lower in carbohydrates than beer and mixed drinks.  Be careful with alcohol because it’s easy to drink more than you meant to and eat foods along with the alcohol that are unhealthy.

Is it safe to use the Low Carb/High Fat Diet (LCHF) or Ketogenic diet if I have type 1 or type 2 diabetic?

Certainly, but I recommend working with a doctor who understands the ketogenic diet. This is important because within a few days of this diet, you will likely require less medication.  If you already use insulin, you can expect to lower your insulin requirements (or better yet,  be able to stop injecting insulin) when you decrease your carbohydrate intake.  If your insulin requirements aren’t monitored closely with this dietary change, you can become sick.  Lowering insulin demands can however be very beneficial because you’re treating the cause of the problem in type 2 diabetes which is taking in too many carbohydrates and insulin resistance.

In my type 1 diabetes patients who have adapted to a LCHF diet, they report more stable blood sugars (less extreme highs or lows) and a lower overall A1c.

How many carbohydrates should I limit myself to?

I usually recommend trying to keep your carb intake to 20 grams or less per day.  This can be very challenging in the beginning as you learn how much sugar and carbohydrates are in so many of the foods that you’re used to eating.  It’s important to check to nutritional labels on the back of the foods to determine sugar and carbohydrate content to make educational decisions about your food.

How to know you are in ketosis and intermittent fasting:

Some people prefer having some sort of physical evidence (lab test) so they can verify that their body is in ketosis (breaking down fats to use for energy).  There are several ways of verifying ketosis.  A method that was popular in the past was to use a urine ketone dipstick which is a chemical test strip that is dipped into a urine collection cup to test the urine for ketones.  That urine test unfortunately isn’t very accurate.  A more reliable test to determine if your body is in ketosis is to check your blood ketone levels using a ketometer. The device is very similar to a glucometer that diabetic patients use to test their blood sugar.   There are multiple brands of ketometers on the market. I cannot recommend one over any others, but they can help you determine whether your body is breaking down fat for energy (in ketosis).

You may also be interested to find out how your blood sugar rises/fall depending on the foods that you eat. Even if you don’t have diabetes, you are able to buy a glucometer and test your blood sugar.  You might be surprised to learn about how your blood sugar changes depending on which foods that you eat.

It would be great to be able to test our insulin levels.  Unfortunately, we don’t have a good over the counter test to check insulin levels, but you can get an insulin level test done at your local laboratory with an order from your doctor.  Usually, if your blood sugar is low, that means your insulin level is also low – unless you have diabetes and are injecting yourself with insulin.

Intermittent fasting (IF) is another hot topic in weight loss and does relate to ketosis.  I will not go into detail here about intermittent fasting except to explain that the idea is to decrease the frequency of the meals to 1-2 times per day or less to help your body develop an increased level of ketosis for more rapid weight loss. Individuals who fast often take in the same number of calories that they would usually eat spread out throughout the day but instead, they just eat once or twice day. There are some researches who have even reported that patients who using intermittent fasting can have longer life expectancy and reduced rates of cancer development.  More research is clearly needed in this field.

What are the side effects of the low carbohydrate, high fat diet (LCHF)?

Some people develop what is called the “keto flu” which really isn’t a flu or infection at all.  It is a constellation of symptoms that can occur while their body is adjusting from using glucose as fuel their fuel source to using ketones for fuel. It is usually caused from a deficiency in one or more of the important minerals.   Symptoms may include:

  • Decrease energy or dizziness
  • Body aches
  • Sugar cravings
  • Difficulty focusing
  • Nausea
  • Irritability
  • Nausea and stomach irritability
  • Constipation or diarrhea

All of these symptoms usually go away within a few days and can be minimized by keeping well hydrated (drink more water) and getting enough sodium (salt).

Why could your salt levels (sodium/potassium) potentially become low with a ketogenic diet?

Ketosis causes the kidneys to accelerate the excretion of salt.

How much salt do I need per day?

5 grams of sodium per day which equates to about 2.5 level teaspoons of salt per day.  Most naturally healthy, whole food containing diets have about 3 grams of sodium that can come from foods that you eat such as olives, pickles, sauerkraut, kimchi, bacon, etc. For this reason, it is likely that you may need to support a ketogenic diet with additional salt that can come from broth or additional salty foods.   If you have hypertension or heart failure that you take medications to treat, it is very important to work with a doctor familiar with this diet.

Adequate intake of minerals is extremely important and those include:

  1.  Sodium – if depleted, can cause lightheadedness, dizziness, fatigue when exercising and/or constipation.  With nutritional ketosis your kidneys excrete more salt so you need to increase the salt in your diet as long as you do not have heart failure or severe hypertension.  Some people find may prefer to use bouillon cubes instead of bone broth to help ensure adequate sodium levels.
  2. Potassium important for heart and muscle function.  You can get this from broth, vegetables and unprocessed meats
  3. Magnesium – depletion can lead to muscle cramps after exercise or at night.
  4. Calcium – necessary for bones, nerve and muscle function – this is found in vegetables, dairy, cheese and broth.
  5. Vitamins – Vegetables are a good source of vitamins that you might otherwise get from fruit.

If you have a medical condition such as diabetes (type 1 or type 2), hypertension, heart failure or take medication, it is very important to work with a doctor familiar with the ketogenic/high fat, low carb diet.  This is because you will likely need to modify your medication regime because you may likely need a decreased dose or may even be able to stop some of your medications.  If you don’t carefully adjust your medications while changing to this diet, you could become sick.

A rare but possible side effect for some people who try the low carb/high fat diet is a raise in their bad (small dense LDL) cholesterol. This is rare, but I have had a few patients in who we noticed this. We don’t have a good explanation for why bad cholesterol increases in some patients but not others.   For patients who decide to try this diet, I monitor their cholesterol very closely and note that approximately 90% of the time, their cholesterol levels actually improve with the low carbohydrate/high fat diet.

Other than weight loss, are there any other benefits to the low carbohydrate/high fat diet?

Many of my patients have noticed the following:

  • Increased energy
  • Improved mood
  • Increased ability to focus
  • Increased testosterone levels
  • Improved diabetes – I’ve been able to take patients off insulin and put their diabetes into remission (type 2).

 

I hope this information is helpful to you,

 

Scott Rennie, DO

 

 

Celiac Disease – Adopting a Gluten Free Diet to Manage Intolerance or Sensitivity

shutterstock_146760950One of the hottest topics in medicine these last few years has been the gluten free diet.  I’ve had countless numbers of patients ask me about “going gluten free” to help with weight reduction, low energy levels, gas, constipation, heart burn, or for various other reasons.  The information about gluten and reasons for avoiding it are rather widespread – some of the information released is valid while others are rumors or just downright advertising.

What is Celiac disease, gluten intolerance and gluten sensitivity?  In the medical field we refer to a condition called Celiac disease which is a condition that affects perhaps up to 1% of our population.   The affected patient’s immune system can damage their small intestine as a reaction to Gluten, a common protein found in most modern day diets. People with the condition are advised to avoid wheat, rye, barley and many prepared foods because they may feel very ill if they consume these products.

Celiac disease is also called gluten sensitive enteropathy, Celiac sprue or nontropical sprue.  Gluten intolerance may also be sometimes called gluten sensitivity, a less severe disorder that affects perhaps up to 10% of our population.  Symptoms may be milder than with Celiac disease and may affect other areas of the body in addition to the gastrointestinal tract. The definition of gluten intolerance has been changing over the years as we work to understand more about the condition.

The small intestine is the part of the body which absorbs nutrients from the food that we eat.  In patients with Celiac disease, the small intestine becomes damaged by the immune system so patients have problems absorbing nutrients from the food that they eat.  Gluten is fairly indigestible in most people and some experts believe that there is a certain amount of gluten intolerance in all of us.

What are the symptoms of Celiac disease?  Patients may experience diarrhea, weight loss, abdominal discomfort, excessive gas and vitamin/mineral deficiencies.  Patients with gluten intolerance may be more prone to osteoporosis, iron deficiency anemia, autoimmune problems with the thyroid, liver, type 1 diabetes, and nervous system problems.

In addition, patients with Celiac disease may be more likely develop lymphoma which is a cancer of the intestinal lymph system.  This is uncommon but we think that avoiding gluten can help prevent the development of lymphoma.  Celiac disease has also been associated with a skin condition called dermatitis herpetiformis.  This causes itchy, raised fluid filled areas on the skin mostly in areas such as the elbows, knees, buttocks, lower back, face, neck, trunk and sometimes in the mouth. The symptoms of this skin condition are mostly the intense itching and burning.  Once the blisters rupture, the itching is relieved but scratching the blisters can rupture them and leave dark areas of skin and permanent scarring.  Eliminating gluten for the diet may help the condition improve after several weeks of remaining on a gluten free diet.  A medicine called Dapsone may be taken to help with the itching but this medication does not help heal the intestine which was damaged by the immune system.

How can you test me for Celiac disease?  If you have symptoms that are very suspicious for Celiac disease there are a variety of tests that can help make the diagnosis in addition to being evaluated by a medical provider.  One of the gold standard tests to help us determine whether you have Celiac disease is to take a biopsy of the lining of the small intestine.  A small sample of tissue from your intestine is examined with a microscope after it has been collected during a procedure called an endoscopy.  As you can imagine, this is not a procedure that is done while patients are awake so it is usually performed in the hospital or an outpatient surgical center where nurses and other medical providers can give you medication through an IV to help make you comfortable.

There are also blood tests that can help determine whether a patient has Celiac disease.  These tests are often part of a “Celiac blood panel” but can be ordered separately.  They are antibodies called the anti-total tissue transglutaminase (TTG) and anti-endomysium antibody (EMA) total imunoglobin A (total IGA), anti DGP antibody, antigliadin antibody (AGA), anti-F-actin test and sometimes antireticulin antibody (ARA).  Your medical provider will help determine which tests are appropriate and interpret the results.

There is not a test however for gluten intolerance.  The blood tests and intestinal biopsies may be completely normal for those who have gluten intolerance but they simply feel better eating a gluten free diet.

Who gets Celiac disease?  We aren’t sure why people get Celiac disease but we think there is a genetic component.  It is rare if people from northern Asia or Southern Africa and more common in patients from Europe, North and South America, South Asia, Middle East and North Africa.

Treatment:  About 70% of people feel better two weeks after they stop eating foods with gluten.  The blood antibody levels often return back to normal as patients stop eating foods with gluten.  Gluten is the group of proteins found in wheat, rye and barley.  It’s also hidden in a large number of prepared foods and supplements.  It can be very challenging to eliminate gluten from your diet because it takes some major lifestyle changes.  It is important to avoid eating gluten and being exposed to it in the air as well.

I recommend consultation with a dietician who specializes in helping patients with Celiac disease.  They can help patients learn what foods to avoid and what foods you need in order to get a balanced diet.

There are a large number of stores that are now offering gluten free foods in certain areas of the United States.

1)      Examples of gluten free foods are rice, corn, potato, beans, legumes (beans, etc.), nuts, seeds, and soy

2)     Foods to avoid are obviously anything with wheat, rye, barley, brewer’s yeast, oats (unless labeled gluten free), and malts

3)     Some people with Celiac disease cannot tolerate oats even if they are labeled gluten free

4)     Wine is usually gluten free unless it contains gluten free flavorings

5)     Most beers have gluten unless they are labeled “gluten free”

6)     Many people with Celiac disease have trouble with dairy products until their intestines return to normal.

7)     Make sure you are getting enough calcium and vitamin D

8)     If you have Celiac disease, you should have blood tests for iron, folic acid, vitamin B12 and vitamin D to make sure your levels are adequate.

9)     There is concern about patients with Celiac disease developing osteoporosis (low bone density) so some clinicians recommend getting a bone density test (DEXA) to measure your bone density.

I think that I may have gluten sensitivity, gluten intolerance or even Celiac disease – should I try a gluten free diet?  I suggest you talk with your health care provider and a dietician before starting a gluten free diet because cutting out gluten doesn’t mean you will be healthier.  After consultation with a medical provider, perhaps you be get tested for Celiac disease with some blood work and/or a biopsy.  If these tests are negative, you can still try a gluten free diet to see if you feel better, but I’d recommend getting help from a dietician to make sure you understand where “hidden sources” that are not obvious in the foods that we eat.  You also don’t want to miss out on the vitamins and minerals that wheat products provide.  Manufactures of gluten free products may add sugar or fat to their products to simulate the texture of foods that contain gluten have.  Gluten free products also often contain less iron, vitamin B and vitamin D than bread products so it’s important to make sure you’re getting enough of these in your diet from other sources.

Where can I find more information about Celiac disease? 

1)      American Celiac Disease Alliance:  www.americanCeliac.org

2)     American Gastroenterological Association:  www.gastro.org/patient-center/digestive_conditions/Celiac-disease

3)     Celiac Disease Foundation:  www.Celiac.org

4)     Gluten Intolerance Group of North America:  www.gluten.net

5)     National Foundation for Celiac Awareness (NFCA):  www.Celiaccentral.org

6)     National Library of Medicine: www.nlm.nih/gov/medlineplus/Celiacdisease.html

7)     North American Society for the Study of Celiac Disease:  www.nasscd.org

8)     Celiac.com:  www.Celiac.com

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

References:  Ciclitira PJ, King AL, Fraser JS. AGA technical review on Celiac Sprue. American Gastroenterological Association. Gastroenterology 2001; 120:1526

Type 2 Diabetes – Information for the New Diabetic Patient

shutterstock_128763464When a patient comes into the clinic and is diagnosed with diabetes, they usually have lots of questions.  Often we discover that they are diabetic when they come in for another reason and time is often limited so I thought it would be helpful to discuss some information that I think is important for a newly diagnosed diabetic patient to understand.

Diabetes:  A condition that disrupts the way your body uses blood sugar (glucose).  We classify diabetes as type 1 or type 2.  About 90 percent of people in the United States, Canada and Europe with diabetes have type 2.

To understand the difference between type 1 diabetes and type 2 diabetes, it’s important to understand a little about insulin.  Insulin is a hormone in the body that allows all the microscopic cells inside your body to absorb and use glucose (sugar) which is one of the fuels for your body.  Without enough glucose you may become tired, shaky, and not feel well.  People with diabetes usually have enough sugar (digested from food) and insulin in their blood, the problem is that the cells inside the body can become resistant to insulin.  Insulin is like a key that unlocks the cells inside our bodies and allows us to absorb the glucose that is present in the bloodstream.  If our body cannot use our  insulin effectively, the sugar in body will rise.

Type 1 diabetes  is a problem where the pancreas (an organ inside your abdomen) does not make enough insulin.  Remember, insulin is the key that unlocks cells/organs inside the body so that we can absorb glucose (sugar) from the blood.  Without enough insulin, our blood sugar goes up and cannot be absorbed.  We often treat patients with type 1 diabetes by giving them insulin because their body does not make it at all.  That way the insulin will allow their body to absorb the sugar in their blood and use this “fuel” to live. Our body can also use fat as fuel instead of sugar/glucose.  Some patients who have type 1 diabetes do really well by eating a low carbohydrate, high fat diet (LCHF).  Many of my patients who have type 1 diabetes are able to keep their blood sugars more stable with an LCHF diet than they can with a standard high carbohydrate diet.

Type 2 diabetes is a problem where the body cannot use the insulin effectively because of an overconsumption of carbohydrates.  We sometimes refer to patients who have type 2 diabetes as having insulin resistance because their bodies becomes resistant to their insulin over time.  We often treat patients with type 2 diabetes by helping them lower their blood sugar naturally by taking in less carbohydrates and may also prescribe medications that help the body use insulin more effectively.  Usually, patients with type 2 diabetes are overweight because of an overconsumption of carbohydrates/sugar that is stored in body fat.  As body fat accumulates, our bodies become resistant to insulin and may develop type 2 diabetes.

Causes of type 2 diabetes:  The most important risk factor for developing type 2 diabetes is the overconsumption of carbohydrates (carbs).  Food nutrients come in the form of carbohydrates, protein and fat.  When we consume carbohydrates, our insulin levels rise to help us use and store the sugar energy that comes from these carbs.  Most of the storage is in the form of body fat because the insulin that is released by the body to help us process these carbs is the “storage hormone.”  As fat stores in the body get filled up, the body naturally becomes more and more resistant to insulin – the body doesn’t want to store anymore fat.  The end result is that the body has to produce increasing amounts of insulin to overcome this insulin resistance and keep the blood sugars under control.  Our body can compensate for the overconsumption of carbohydrates for awhile (months or years), but eventually the body may fail to produce enough insulin to keep the blood sugar low enough and then type 2 diabetes can be diagnosed.

The likelihood of developing diabetes is higher in certain ethnic groups such as people of Hispanic, African and Asian descent. Environmental factors such as what you eat and how active you are the most important risk  factors for  developing type 2 diabetes.

Fat, an alternative fuel source for the body instead of sugar:

There is good news when it comes to diabetes and also losing weight.  We can use fat as a source of energy to fuel the body instead of carbohydrates.  By consuming a low carbohydrate/high fat diet our body will use body fat as an energy source by breaking it down into ketone bodies.  As we eat less carbohydrates, we allow our insulin levels to remain low and therefore as a natural consequence, we breakdown stored body fat instead of becoming more overweight.  Losing weight helps us become less resistant to insulin and improve our blood sugar naturally.  In my opinion, this diet is one of the best ways to treat diabetes.

Pregnancy:  About 3-5% of patients who are pregnant develop “gestational diabetes” or diabetes in pregnancy.  Diabetes during pregnancy usually resolves after the delivery of the baby however these women are at increased risk of developing type 2 diabetes later in life.

Symptoms of diabetes:  Some people develop symptoms and many people who have diabetes don’t have symptoms.  Possible symptoms include:

1)   Feeling thirsty

2)   Fatigue or feeling tired frequently

3)   Needing to urinate frequently

4)   Blurred vision

Testing for diabetes:  There are several tests to measure blood sugar (glucose) to establish a diagnosis of diabetes:

1)   Random blood sugar:  If you check your sugar and at any time of day regardless of when you ate and your blood sugar is 200 mg/dl or higher, and you have symptoms – it is likely that you have diabetes.

2)   Fasting blood sugar:  A blood test that is performed after not eating or drinking anything except water for 8-12 hours (overnight usually).  If your blood sugar is less than 100mg/dl  – you probably do not have diabetes.  If it’s between 100-125, you have an impaired test and are at risk of developing diabetes if lifestyle changes are not made.  If the fasting glucose is greater than 125, and symptoms are present, you have diabetes.

3)   Hemoglobin A1c:  A blood test that measures your average blood sugar over the past 3 months.  The normal value is usually 4-5.6%.  This test can be done at anytime of day. A result of 5.7-6.4 indicates a high risk of developing diabetes and greater than 6.4 indicates diabetes.

4)   Oral glucose tolerance test:  A patient who is fasting for 8-12 hours usually comes in and then drinks a special glucose solution (usually orange or lemon flavored) and your blood sugar is tested before drinking it and again an hour and sometimes 2 hours after drinking the solution.  If your blood sugar is higher than 200 two hours after the glucose tolerance test, you have diabetes.

Other medical problems:  Often people who have diabetes also have high blood pressure, and/or high cholesterol as well.

Reasons to get your blood sugar under control:  Many newly diagnosed diabetic patients aren’t really sure about the value of having good control of their blood sugars because many people don’t have symptoms when their blood sugar is elevated.  I think it’s important to remind ourselves of the adverse consequences of poorly controlled diabetes:

1)  Increased risk for heart attack/stroke – with poorly controlled blood sugars, you increase your risk of heart attack or stroke dramatically

2)  Diabetic retinopathy – diabetes can cause blindness

3)  Diabetic nephropathy – diabetes can cause permanent kidney damage and is a leading cause for patients to require kidney dialysis

4)  Diabetic neuropathy – diabetes can cause chronic pain or numbness which usually starts in the toes and feet.  This can progress and become very painful with time.

5)  Poor wound healing – when blood sugars are not well controlled, wounds such as a common scrape or cut can take much longer to heal and become prone to infection.

6)  Poor circulation – many patients with poorly controlled diabetes have such poor circulation into their feet or toes that then have partial amputations of limbs performed when chronic infection or death of tissue occurs because of poor circulation.

My recommendations:

1)  Talk to your primary care physician.

2)   Decrease the quantity of carbohydrates/sugar that you’re consuming.  Avoid soda pop, fruit juices, sports drinks, energy drinks, frappiccinos, candy, pastries (doughnuts, cookies, brownies), potatoes, rice, noodles, breakfast cereals, ice cream, jams and jellies, yogurt that has lots of sugar, and processed foods.  Do not add sugar to foods that you eat.  Be careful with fruit because there is a lot of sugar in fruit.

3)   Meet with a diabetic nurse educator to make sure you understand how to use your glucometer, check your blood sugars and take your medication.

4)   Record your blood sugars every day with a glucometer.  Usually, I recommend that when you first are diagnosed with diabetes that you check more frequently including first thing in the morning before breakfast, 2 hours after breakfast, 2 hours after lunch, and right before going to bed.  Write the dates and times down in a journal or computer spreadsheet and remember to bring this with you when you come to your doctor appointment.  You can also email or fax these records to your doctor if this is easier for you.

5)   Record your blood pressures twice a day – first thing in the morning and also right before going to bed.  Try not to check your blood pressure right after exercise or after drinking a cup of coffee, tea or other caffeinated beverage.

6)   Make a list of all the medications that you take, and bring the list with you each time you go to your doctor.  If your doctor changes any of your medications or dosages, have them write the change on your medication list and update the list at home at your first opportunity.

If you think that you or someone that you know has diabetes, please make sure to be seen by a medical provider.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

 

Resources:

The following organizations also provide reliable health information.

  • National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

  • National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov)

  • American Diabetes Association (ADA)

(800)-DIABETES (800-342-2383)
      (www.diabetes.org)

  • The Hormone Foundation

(www.hormone.org/public/diabetes.cfm, available in English and Spanish)

All About Knee Pain

shutterstock_94626553I often have people come to the Urgent Care who have problems due to knee pain. Pain that originates in the knee can be complex because there are quite a few areas within the knee that can cause pain. The knee is a “hinge” type joint that is at the greatest risk of injury, age-related wear and tear, arthritis as well as infection related arthritis.

Causes: As I mentioned above, there are many causes of knee pain. Several are listed below:

1) Patellofemoral pain syndrome – Group of symptoms that is sometimes caused from overuse of the knee. It can affect running athletes, and is more common in women. The pain is usually in the front of the knee and is made worse with squatting, running, prolonged sitting or when climbing or going down stairs. We also call this Patellar tracking syndrome because it is related to the knee cap (patella) sliding out of the groove that it normally sits in.

2) Meniscal tears – The meniscus is a specialized shock absorber that provides cushion on both sides of the knee. They can become damaged or torn from an acute knee injury or from overuse that comes with age. They have a very poor blood supply, so they don’t heal very quickly

3) Bursitis – The knee is lubricated by joint fluid that is produced by a lubricating bursa (or sac). These bursa sacs can become irritated as a result of injury or even overuse. Inflammation of the bursa is called bursitis

4) Arthritis – This refers to inflammation of the cartilage covering the ends of the bones and undersurface of the knee cap. When it gets worn down, irritated or irregular, it can become painful and is known as arthritis.

5) Tearing of a ligament – The knee is held together by a combination of ligaments including the anterior and posterior cruciate ligaments as well as the medial and collateral lateral ligaments. These ligaments function to hold the bones together and prevent side-to-side or back and forth motion.

6) Muscle strain – If the muscles on the front or back of the knee area become injured, or in spasm they can cause pain around the knee joint. These muscle groups are the quadriceps (located on the front of the top of the knee) and the hamstrings (located on the back part of the leg). These muscle groups work to give support to and move the knee joint

7) Fractures – Broken bones around the knee can obviously cause pain

8) Infection – If bacteria get into the knee joint, this can cause pain, swelling and decreased range of motion

9) Gout – This is caused by the formation of uric acid crystals that build up within the knee joint and is less common in the knee than some other joints

10) Baker’s Cyst – a cyst in the back of the knee can cause pain

Diagnosis: Since there are so many different possible causes of knee pain, it is important to make an accurate diagnosis to treat the underlying problem. In addition to getting a good history from the patient about their pain, a physical evaluation will be performed and sometimes knee x-rays, an ultrasound, or an MRI will be ordered. Additionally, a small sample of synovial fluid is sometimes removed from the knee using a needle. This fluid can be examined under a microscope and/or sent for culture to look for bacteria, crystals or signs of inflammation.

Treatment: The individual patients injury will dictate the kind of treatment that they need to recover the fastest. Physical therapy is often used because it speeds recovery and regain motion. We also often recommend ice, elevation of the leg and muscle-toning exercises when appropriate. Sometimes a knee brace or immobilizer may be appropriate. Medications such as ibuprofen, Aleve or Tylenol may be appropriate for knee injuries. If infection is present, antibiotics may also be prescribed. If injury to the bone or ligaments is the cause, surgery can be helpful in some patients.

Limiting certain activities: Speeding the recovery and helping prevent further injury sometimes involve limiting activities temporarily. Excessive pressure on the knee joint by the following activities should be avoided to help recovery:

1) Kneeling
2) Jogging
3) Squatting
4) Twisting and pivoting
5) Aerobics/Dancing
6) Playing stop and go sports such as basketball or racquet sports
7) Swimming with frog leg or whip kick techniques
8) Rowing machine
9) Stationary bike
10) Stair stepper
11) Leg extensions with weights

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com