At first glance, it may seem strange for an orthopedic surgeon to be interested in diet. Let me explain how I got here.
Throughout my life I "knew" that fat was bad, whole grains were good, and when people were overweight it was because they ate too much and exercised too little. Simple. Like many people, I did my best to keep a low fat, high carbohydrate diet. I felt guilty when I ate steak, bacon, and ice cream. When I was hungry between meals, I would often snack on pretzels because they contained no fat. When I was thirsty, I would often choose 100% fruit juice.
I remember hearing about the Atkins diet while I was in medical school. This was a diet that involved limiting carbohydrate intake and eating mostly fat. It sounded completely ridiculous to us at the time. Everyone knew that a high fat, low carbohydrate diet was clearly dangerous. I recall a biochemistry lab session where we "proved" eating in such a way offered no metabolic advantage with regard to weight-loss. The explanation was that the diet was so disgusting that people were repulsed by the fat they had to eat and therefore simply ate less.
As a practicing orthopedic surgeon, I see patients with severe arthritis involving knees, hips and shoulders everyday. Since obesity is a risk factor for osteoarthritis of the hips and knees, many of my patients are above an ideal body weight. The knees and hips are subjected to multiple times body weight with every movement and thus losing weight can have a multiplicative effect on reducing joint pain. This is a standard first-line recommendation for joint pain. This was something that we routinely recommend, but rarely occurs.
I routinely evaluate my techniques and results in an attempt to maximize good outcomes, and minimize complications. In the course of doing this, I identified 3 major risk factors linked with orthopedic infections: obesity, diabetes and smoking. This prompted a literature search which revealed that my experience was not unique. The bad news is that a large proportion of our patients had at least one of these risk factors, many had all three. The literature suggests synergy between these factors. This means the negative effects aren't just additive, but may multiply the danger.
Based on this information, I changed my practice immediately. I discussed this information with the local primary care doctors, attempting to enlist their help to keep our patients safe. I feel that each of these risk factors is modifiable. Just as we wouldn't take a patient to the operating room for a total joint replacement if they had active pneumonia, or severe coronary artery disease, we should make every effort to improve these risk factors.
I continued to get a steady stream of patients that had one or more of these risk factors referred to me because they were "ready" for their joint replacement. I then had the challenging and unusual task of explaining that while they may be mentally prepared for surgery, but were not yet medically optimized. Needless to say, patients were often surprised to hear a surgeon talking them out of surgery. An orthopedic infection is generally a big deal, often requiring multiple operations and long-term intravenous antibiotics. Once I explained my concerns to patients, many agreed to try to improve their risk profile.
Stopping smoking can be relatively simple compared to losing weight and controlling diabetes.
We gave examples of the USDA food pyramid, recommended low calorie options, focused on appropriate serving sizes, and offered referral to nutritionists. Several patients became frustrated with me, because they were unable to lose weight. They tried to eat less and exercise more. A common theme was that exercise was impossible due to the arthritis and they could only be hungry for so long until their willpower was exhausted. Some patients decided to find another orthopedic surgeon that didn't care about their risk factors. Some patients decided to undergo bariatric surgery (sleeve gastrectomy) and lost weight rapidly, but this seemed to be an extreme measure to control weight.
One day I was discussing this information with a couple. The husband was rail thin, and his wife (who was here to discuss joint replacement) was very heavy. While explaining my concerns and discussing nutrition with this couple I had a life changing revelation. The husband explained that they both eat the same food, that his wife often ate less than he did, and that he knew that she did not snack or eat secretly because she didn't drive and he did all the food shopping. I suddenly realized something we were never taught.
Different people must process calories differently. And maybe all calories are not equal?
I began researching alternatives to the standard American diet. I came across a very interesting book. "The Big Fat Surprise" by Nina Teicholz. This book alleged that all of what I knew about nutrition, despite my training as a physiology major in college, and medical school was wrong. This prompted me to read yet another book. "Good Calories, Bad Calories" by Gary Taubes. I couldn't get enough. I came across a podcast "Bulletproof Radio" by Dave Asprey. Self-described as a "bio-hacker" this network security expert managed to lose over 100 pounds and keep it off eating a high-calorie, high-fat diet. Since then I have read many thousands of pages and listened to hundreds of hours on diet, nutrition, biochemistry, and exercise. The recurrent message was that carbohydrates aren't as healthy as we think and fat isn't necessarily dangerous. Our modern diet has progressively emphasized processed carbohydrates and excluded dietary fats. While the evidence suggests that Americans are indeed following the recommendations, our difficulty with obesity, diabetes, heart disease, and dementia continues to worsen.
I never had a weight problem. Like most people I had gained a bit of weight since high school, but appeared fit. Nevertheless, I decided to do an experiment on myself. I began a high-fat, low carbohydrate diet. Just like the diet we discredited in medical school. My plan was to try this for 2 weeks. The changes were immediate. I felt much better. I lost 10 pounds and my pants were loose. I decided to extend the experiment for another month. I was so amazed at the results it is now 2 years later and I continue to eat this way. I lost a total of 25 pounds. My waistline shrunk by 3 inches. My body fat percentage is now 10%.
This was awesome, but it gets much better:
I was always mildly hypertensive (high blood pressure), and I had an occasional migraine. By the end of my first 2 week experiment, my blood pressure was perfectly normal. I have not had another migraine since the week before changing my diet. I still have a "type A" personality, but my colleagues have noticed that I am much more relaxed. I have noticed improved mental sharpness, and physical stamina.
Although this experiment was started in secret, the results were immediately obvious to friends, family members, and colleagues. Once I finished reassuring everyone that I was not ill, I then had to explain how dramatically reducing my carbohydrate intake and increasing my fat intake was responsible for my dramatic weight loss.
Even more amazing, is that my weight loss occurred rapidly and without hunger.
I believe there is mounting evidence that the long-term consumption of processed carbohydrates and exclusion of dietary fats is responsible for most of the health problems in western society. Subsequent blog postings will further develop these concepts.
7/26/2016 11:33:38 pm
7/28/2016 07:47:37 am
I am a 53 yrs old lawyer from Brazil. I had exactly the same experience. Started ketogenic diet thinking in reducing the probability of proatate cancer recurrence and my body fat just started to desapear...
8/3/2016 01:31:50 pm
i am very interested in finding out if i have the willpower to do this and if i can lose some weight also..thank you for your advice and referral.
8/4/2016 08:31:01 am
This way of eating takes very little willpower. It requires thinking a little differently about food.
8/4/2016 03:00:14 am
Thanks for the story. My story started in 2004 when a friend gave me Dr. Bernstein's Diabetes Solution. I had similar results with one big difference. My HbA1C went from around 7.2 to 5.9. As a T1D since 1965, I can say that a LCHF diet saved my good eye and, more importantly, my life.
8/4/2016 08:12:42 am
I could not agree with you more. It amazes me that the first step in diabetes management is not severe carbohydrate limitation. I define diabetes as carbohydrate intolerance. I believe the "modern" method of diabetes management is actually counterproductive. Lowering blood glucose levels using drugs is not magic...that sugar ends up being converted to and stored as body fat. Increased body fat makes insulin resistance even worse. Thus, over the long-term the disease worsens.
8/4/2016 08:29:30 am
DietDoctor sent me. Already a believer. Now we need to figure how to compensate orthopods for guiding folks on how to avoid using their art and skills in the O.R.
8/4/2016 11:02:05 am
Jim, while I truly appreciate your concern about my finances :) I think we are a long way away from that. Organized medicine, with government support (coercion) is in the business of managing diseases using drugs. Government also encourages the consumption of carbohydrate rich, highly processed foods which I believe contribute substantially to the chronic diseases of modern society. So, industrialized food producers, pharmaceutical companies, and hospital systems all make lots of money under the current system.
8/5/2016 07:56:08 am
Great blog, I found the low carb - healthy/high fat diet 2.5 years ago and lost steadily more than 15 kg mostly body fat. I also gained a lot of muscle mass by replacing endurance exercise by some HIIT training and weight lifting. I also got off my hypertension medication, and feel better then ever. Since I was a teenager I've always been overweight, and struggled always with my weight. This new lifestyle has given me a new life without hunger with a steady mood. The only problem I have is retropatellar chondropathy at my right knee, but strangely without any pain. It gets only swollen after high intensity biking of hiking in the mountains. Maybe my diet prevents me from having pain?
8/5/2016 08:54:08 am
It is amazing to me how consistent these experiences are. Weight loss, muscle gain, normalization of blood pressure, mood improvement. Your diet certainly may be contributing to your lack of pain/inflammation.
8/8/2016 03:45:20 pm
Emergency Physician here, been on a low carb high fat diet 5-6 years, thanks for sharing, this is a game changer in modern medicine. A fellow Psychiatrist enlightened me... Funny how the gastroenterologists and endocrinologists I know are in the dark... but then they are also more dependent on big pharma...
8/8/2016 06:19:30 pm
It amazes me that the first step in managing type 2 diabetes is not carbohydrate restriction. I have helped patients and friends improve their glucose control and even discontinue diabetic meds by simply restricting their carbohydrate intake. I have an upcoming blog post on exactly this topic. Thank your for you comment.
8/9/2016 01:22:08 am
8/13/2016 09:56:26 am
Thank you for this article.
8/13/2016 06:47:20 am
8/13/2016 09:54:10 am
I have been in full time practice for 10 years. Until about 2 years ago I also recited the usual diet and exercise advice we were all taught throughout our training. It was only after hundreds of hours of my own research that I decided to do my own self-experiment. My results were so dramatic: no hunger, improved mood, enhanced physical and mental performance, that my perspective was immediately changed. This further fueled my research.
11/6/2016 07:06:47 am
Can you comment on low-carbohydrate diets and their influence on type 1 Diabetes? Thanks.
11/6/2016 10:47:00 pm
As compared to Type 2 Diabetes, where insulin levels tend to be high and insulin resistance is present, Type 1 Diabetes occurs when the body does not make enough insulin. The result of making inadequate insulin is elevated blood glucose levels, and the inability of cells to absorb the sugar.
12/30/2017 05:48:41 am
The obesity epidemic will finally get checked when more physicians get better educated on fats, proteins, carbs, and the evils of too much sugar-starch. I congratulate you on being able to move beyond your med school knowledge, and keep expanding your own knowledge.
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Orthopedic Surgeon focused on the entire patient, not just a single joint.