Jun 2004 Table of Contents

PRACTICE DIARY

Chapter 56

Fam Pract Manag. 2004 Jun;11(6):59.

Losin’ it

Ron was a 33-year-old park ranger who came in for a physical without any particular health concerns, outside of some dyspepsia and knee pain. His physical exam was unremarkable, but his blood work was notable for hyperlipidemia. A lipid profile was markedly abnormal: total cholesterol 239 mg/dL, triglycerides 389 mg/dL, LDL 135 mg/dL, HDL 29 mg/dL. In addition, his ALT level was 103.

“What should I do?” I thought to myself. His elevated liver enzyme made me wary of trying a statin, and his triglycerides made me worry about the risks of pancreatitis and consider fenofibrate, but I was especially concerned about his low HDL. I wanted to try niacin for that but disallowed it for the same reason I had disallowed the statin. Ron was overweight, although not obese, and he might have had fatty liver, although he didn’t drink any alcohol. Weight reduction would help, but should I be doing anything pharmacologically besides? A quick curbside with Gregg, my cardiology colleague who subspecialized in lipids, was reassuring.

“This could be syndrome X or familial combined hyperlipidemia, but for the time being I’d just prescribe diet and exercise. He’s only 33,” Gregg said.

“Did you have any particular diet in mind?” I queried.

“A low-carb diet,” he said. “The Atkins is pretty radical. You might consider the South Beach Diet. It goes harder on the saturated and hydrogenated fats and trans-fatty acids and doesn’t ban all carbohydrates.”

I didn’t want to confess to Gregg that I had never heard of the South Beach Diet, but that night, after a low-carb chicken Caesar salad dinner at the Mendocino Hotel, I dragged my wife into our local bookstore to look for a book about it. “Hey,” she said, “if I had told you about this diet, you wouldn’t be looking for the book. How come you listen to Gregg?”

“Because he’s a cardiologist,” I said. “If he’s willing to tell his patients with high cholesterol to eat eggs, there may be something to it.”

The book was easy to find. Its cover proclaimed it to be a number one New York Times bestseller and featured a blurb that said, “Lose belly fat first.” Now that perked my interest. Who doesn’t have some belly fat that they’d like to lose – and within one to two weeks at that? I read on. The first two weeks looked tough, but doable. I would miss not having bread, rice, potatoes and pasta, not to mention the occasional ice cream. “Let’s try this,” I said to my wife. “That way I can see if it’s right for my patients.”

Sue was skeptical but willing. I really needed her on board because shopping and cooking for myself was hard enough when I wasn’t looking for fat-free cheeses, collard greens, cilantro mayonnaise for my turkey roll-ups and 10 varieties of beans so I could make my own hummus. Over we went to the local health food market, buying $250 worth of groceries, none of which looked much like comfort food. “This stuff is expensive,” I complained.

“It’s organic,” my wife explained.

The next morning, we decided to celebrate our new diet by going out to breakfast. There was nothing on the MacCallum House menu that I could eat except for the tofu scramble. I opted for á la carte scrambled eggs, two pieces of peppered bacon and some sliced tomatoes. I really wanted their signature potatoes but, alas, that was not to be. I left feeling unsatisfied but not too hungry. A midmorning snack of low-fat mozzarella cheese sticks got me through until lunch, when Sue made a salad with slices of chicken. Hummus and turnips got me past the midday until dinner, where I ordered a topopo salad (minus the tortilla) at our favorite Mexican restaurant. Later that night, I ate 15 pistachio nuts before bed. I had survived the first day!

My first patient the next day was Gerald, who had lost 45 pounds the preceding year. I hadn’t seen him in months. “How did you do it?” I asked him.

“Atkins,” he said.

“What medicine are you taking now?” I asked.

“None, except for gout pills.” he said. Previously, Gerald had been on atorvastatin, irbesartan and metformin. His blood pressure was slightly up, but he confessed he hadn’t been exercising recently due to a twisted knee from his step aerobics class.

“You’ve been coming to me for 10 years,” I said. “What finally made you change your lifestyle?”

“I have this doctor who kept telling me to exercise and diet,” he said. “I thought I’d try it for two weeks. I lost 10 pounds. That was motivating.”

At noon, over a lunch of split pea soup and ham, I couldn’t help but wonder if this new diet was the real deal or just another fad. Did it really work, or were the proscriptions on food so onerous and the food preparation so time consuming that people simply ate less?

When I came home that night, my wife was busily cooking. “What’s for dinner,” I asked.

“How about artichokes benedict with mock hollandaise sauce and lemon zest ricotta crème for dessert?” she said.

“Hmm,” I said.

“What was that?” my wife asked, tired of all the extra cooking she’d been doing to eat by the rules.

“I mean … yum,” I said. “I can’t wait.”

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family medicine has to offer. No real patient names have been used.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

Copyright © 2004 by the American Academy of Family Physicians.
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