Ep. 309 Psychological Distress and Food Addiction: Finding Solutions with Dr. Tro Kalayjian
- November 4, 2023
- No Responses
I am delighted to have my friend and colleague, Dr. Tro Kalayjian, back on the podcast today! He was with me once before for episode 54.
Dr. Tro has a background in internal and obesity medicine and is a founding member of the Society for Metabolic Health Practitioners. He managed to lose more than 150 pounds by challenging conventional medical advice.
In our discussion today, we dive into the impact of food addiction and how our current medical framework has compounded the difficulties of so many patients. We explore the limitations of the calories in calories out model and explain why the term binge eating does not adequately describe food addiction. We go into the role of macronutrients and discuss surgical interventions and medications for food addictions, highlighting the need for patient autonomy and shared decision-making. We also scrutinize the influence of institutions like the CDC, FDA, and insurance companies on how physicians and other healthcare practitioners practice medicine and help their patients manage hunger cravings, social interactions, emotions, and more.
Dr. Tro’s dedication to empowering practitioners to become strong patient advocates and oppose the conventional medical paradigm shines through in this impactful and thought-provoking episode. I truly admire him for his commitment to challenging traditional medical protocols!
“When you constantly blame yourself instead of advocating for yourself, you develop psychological distress and intense shame and guilt. That is a key hallmark of going from harmful use to addiction.”
– Dr. Tro Kalayjian
IN THIS EPISODE YOU WILL LEARN:
- Why should binge eating be called food addiction?
- How to address a food addiction proactively
- How most physicians and healthcare practitioners have failed people with food addictions
- The issue with surgical interventions and medications
- What can physicians and healthcare practitioners do to build insight into addicted patients?
- Dr. Tro shares his take on shared decision-making and patient autonomy regarding flu shots
- Why licensed healthcare providers should be obliged to have continuing education
- How the CDC, FDA, medical organizations, and insurance companies have influenced the way that physicians and healthcare providers help their patients
- The problem with central planners and their followers
- Why does a low-carb bias still exist within the medical community
Connect with Cynthia Thurlow
- Check out Cynthia’s website
- Submit your questions to support@cynthiathurlow.com
Connect with Dr. Tro Kalayjian
Episode 54: Losing Weight The Healthy Way with Dr. Tro Kalayjian
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I’m your host, Nurse Practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent, is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I was rejoined by my friend and colleague, Dr. Tro Kalayjian. He last joined the podcast on Episode 54, back when it was cohosted with Dr. Kelly Donahue. Dr. Tro, joins me today and his background is in both Internal Medicine and Obesity Medicine. He’s also a founding member of the Society for Metabolic Health Practitioners. He has lost over 150 pounds by challenging conventional medical advice. Today, we spent a great amount of time outlining the impact of food addiction and how our current medical model has exacerbated the challenges that many patients are experiencing.
[00:01:12] We spoke at length about what is wrong with the calories in, calories out model, why binge eating is not the appropriate terminology for food addiction and why, the role of macros, surgery, and medications, the emphasis on the need for patient autonomy and shared decision making, the impact of the CDC, FDA, and insurance companies on the way that physicians and other healthcare practitioners are practicing medicine, managing hunger cravings, social interactions and emotions, and so much more. This is a really impactful episode. I really admire Dr. Tro and his desire to encourage all practitioners to be able to better advocates for their patients and really flip the traditional medical paradigm. I hope you will enjoy our conversation as much as I did recording it.
[00:02:09] I would really love to start the conversation today talking about the fact that I think Oprah just put out a thing on social media yesterday that was saying the most underdiagnosed, but most prevalent eating disorder right now is binge eating. Would you agree with that?
Dr. Tro Kalayjian: [00:02:25] Yes, 100%. Yeah, binge eating is nearly ubiquitous in people coming to my clinic. I think the amount of food addiction, if you look at Gearhardt’s work from University of Michigan, it corroborates that food addiction and binge eating. I don’t like the term binge eating, by the way. It’s like saying, like, “Binge drinking or binge smoking.” I mean, it’s just a bad term. We should call it what it is, which is food addiction. Yeah, the amount of people with food addiction, even as old as 65, is upwards of 30% may have food addiction symptoms, and I bet it’s even more than that. So, yeah, I think binge eating, this idea of losing control, maybe feeling some shame or guilt around your food consumption, eating to the point where it hurts, not eating in front of other people, then losing control and eating a lot, sort of alone. I mean, these are some of the symptoms of binge eating, and they’re highly prevalent. In fact, 100% of the people coming to me have one of these questions answered positively. Yeah, I’m happy that Oprah is getting on the bandwagon.
Cynthia Thurlow: [00:03:27] Yeah. It was interesting because thinking about, when I asked you to come back on the podcast and you’re someone that I could easily talk to for hours and hours and hours and I could have you come back every year or every six months to kind of talk about relevant and timely topics. But that was really what stood out to me was this poor understanding of what food addiction represents, how prevalent it is, how many people suffer from it, many of them in silence because they don’t feel comfortable talking about their relationship, their disordered relationship with food. And it was interesting, I was looking at this Yale Addiction Scale and it was saying 16.2% of us experience food addiction according to a meta-analysis review of 51 studies that use the Yale Addiction Scale based on criteria in relation to specific types of foods. And so, I think that’s probably underreported.
[00:04:19] I would imagine it’s way more than that. And certainly, in your clinical experience with your own patient population when you are kind of getting a sense of what someone’s relationship is with food. I think that we are a nation that has largely extremes. It’s either a preoccupation with not eating or a preoccupation with restriction or a preoccupation with eating in silence and shame and somewhere in between, I think each one of us have a very personal interrelationship with food. And I think for you, given you speak so openly about your own experiences and your own trajectory and you’re so incredibly inspiring. And so, when you’re working with your patients, where do you really start from when you’ve acknowledged that they have some degree of food addiction? What is the first step for addressing this proactively?
Dr. Tro Kalayjian: [00:05:08] I think the biggest problem is actually not addressing it. Addressing it is easy once you know what you’re fighting. It’s sort of like my young kids when they have a little bit of a fear of the unknown or they would worry about a test, like,” What’s going to be on that test?” It’s a state test or this or that. They sort of be unclear of the enemy in front of them. When you’re dealing with food addiction, people even say, like, “I’m addicted to food or I love chocolate. I’m a chocoholic, I’m a breadaholic. I can’t stop eating bread. Whatever it is, this is what they say. So, one thing is understanding what exactly food addiction is from the clinician’s point of view. The other point is understanding the patient, understanding what it means. I’ve had people say the word, “I’m addicted to food,” and I’m like, “What does that mean to you?”
[00:06:00] They’re like, “Staring at me with a deer in headlights.” So, when a patient says, “I’m food addicted or they feel like they have food addiction symptoms,” they actually are saying, “I need insight to understand how my brain works, how it’s going to talk to me, how it’s going to negotiate with me, the feelings it’s going to have around the substance, the logic it’s going to employ, the outlook it’s going to take, the way I’m going to blame myself, the way I’m going to advocate for myself.” They don’t really get what it means. They just realize they have this connection and relationship to the food and it’s a problem. That’s what they mean when they say a food addiction. So, our job is to get them to understand what that means and that’s very challenging. And then the biggest problem is actually just clinicians understanding exactly what it is the patient is saying.
[00:06:56] So now I can have somebody in my office says I’m a chocoholic. Does that mean they’re food addicted? Not really. You have to go a step further. Is there some emotional distress around eating? Is there a sort of automatic response? So, for example, I have a problem with sweets, and yet I was 350 pounds 10 years ago and my wife would tell me, maybe you shouldn’t eat that. And my feelings, my emotional response would be, “Hey, Rosette, leave me alone. I know what I’m doing. I’m a grown man.” So, there’s an emotional disconnect between what it is my goals are, which is be a healthy, happy father for myself and my family. And my emotional response is actually against my goals. This is the first thing. There’s this emotional conflict between what it is somebody with food addiction wants to do for themselves.
[00:07:55] Everybody who comes to our clinic doesn’t want to be obese. Nobody wants to be obese, nobody wants to have diabetes, nobody wants to be unhealthy. Everybody wants to master their relationship to food. But there’s this emotional response that’s the antithesis to their goal. That’s one of the hallmarks of food addiction. And you could just have harmful use of a substance. You don’t want to use it, and you use it occasionally, and you don’t like that relationship. Maybe once a month you have something sweet and you know that’s not something you want to do, but it’s not having any long-term impacts on your body, and it’s not having any ill health, but you don’t like that relationship. Well, that’s just harmful use. Now, what makes something food addiction is that next step where there’s psychologic distress. So now the emotional conflict, this emotional disconnect, the experience, the agitation, the oppositional defiance, all the manipulative ways food addiction can get you to keep using a substance.
[00:09:00] The way that it’ll say, once you’ve gone off plan like just keep eating that way, eat the whole week. Or the way it’ll logic, you into eating that substance by saying, don’t waste food, you might as well eat the leftovers, or you’ve been really good, you deserve it. All this sort of manipulations on logic or emotions, that’s the power of food addiction. When this happens again and again and again and that emotional disconnect continues to happen, what ends up happening is you get psychologic distress. You feel shame and guilt, you don’t want to keep doing this, you want to change. And so, when you have that psychologic distress from this continued bad relationship, bad emotional response, bad logic response, bad outlook, constant self-blame, like, “Ah, I just need to do better. I’m the worst. Why can’t I say no.” When you constantly blame yourself instead of advocating for yourself, then you develop the psychologic distress and you develop intense shame and guilt.
[00:10:04] And that’s a key hallmark of going from harmful use to addiction, is that emotional disconnect, that logic disconnect, that outlook and advocacy, the self-blame, they’re so disconnected from what you want to be to what you’re actually doing that it leads to real problems with your overall mood and your approach to this. And then the last key hallmark is that psychologic distress. And this is somebody who has food addiction or binge eating to a degree that really needs attention, although I’d say any point on that spectrum needs attention. But when that psychologic distress becomes so regular and so powerful that you now change your behavior to accommodate the psychologic distress and accommodate that emotional friction around that substance. So, meaning, like, now you won’t eat in front of other people, but you’ll lose control alone, or you’ll hold out all day in an effort to fight this and then lose control and eat to the point you’re hurting.
[00:11:05] Or maybe you’ll hide wrappers or you won’t go to a social scenario because there’s going to be food there, or you don’t eat in front of other people because it’s a social event and you don’t want to eat in front of others. And so, what happens there with that behavior is you’re actually modifying your behavior to accommodate the psychologic distress instead of to change the underlying actions, to change the relationship to the substance. So that’s sort of the peak of food addiction, where now you’re not changing your actions, you’re not changing your relationship to the substance. Your emotional disconnect is driving the psychologic disconnect, which is now making you change your behavior to accommodate the substance and that’s like end-stage food addiction. That’s what it looked like. Hiding and sneaking wrappers, doing well all day, then losing control at night, avoiding social situations around food. That’s food addiction.
[00:12:01] And the clinician needs to know what’s going on here. Who’s a harmful user, who has some food addiction symptoms, and who’s really severely food addicted? I think the problem lies with the clinician. Because now if you have somebody with these symptoms, now you’re not giving them a nutritional message. It’s not like, “Count your hours, count your carbs.” That’s not going to give them insight as to what they’re fighting. So, the next step is like, “All right, what do you do with that patient now? Where do you start with that patient? Do they understand?” I don’t know. Does that answer the question?
Cynthia Thurlow: [00:12:38] No, it definitely does. And it provides some insights that I think as myself as someone who trained in the late 1990s, early 2000s, and back then, the kind of standard prevailing allopathic message was exercise more, eat less, you’re not exercising enough, you’re eating too much. Don’t eat fat, fear eating meat. I mean, there were so many conflicting messages that we’re sharing with patients. So, we had patients that maybe they had a propensity for food addiction and it gets fueled because they’re never satiated. Do you find that a lot of these patients, it’s the lack of satiety that kind of can drive some of these behaviors? Meaning if we, I say we as a culture are indoctrinating our patients into this model of eating more plant-based protein, overeating animal-based protein, fearing fat, focusing on carbs, I mean, certainly my plate is not doing any of us any favors.
[00:13:35] I’m sure we’ll probably touch on some of the industry-related messages that patients are receiving. But do you feel that a lot of the wisdom and I’ll put that in “that we’ve been conferring to patients for the last 20 some odd years have perhaps contributed to,” you mentioned that a lot of this is educating clinicians and I absolutely agree with you 100% that nutrition is important, but helping people and clinicians understand the trajectory of food addiction and understanding that it’s not a lack or desire to not lose weight, it’s that it’s something much larger than that.
Dr. Tro Kalayjian: [00:14:12] Yeah. I think most clinicians and most dietitians, if you look at literature, they’re 18 times more likely to have orthorexia or anorexia, meaning their food issues may be completely separate than the general population. Although that’s changed lately. I think the problem is we just stink. We don’t help people. We’ve been ineffective at managing the obesity epidemic, diabetes epidemic. It’s so bad that now we have a pediatric obesity epidemic, diabetes epidemic, fatty liver epidemic. So, we are unable to inspire change at a systematic level. We’re failing. And then what’s the beautiful part about the setup is their theory of energy balance has made it so that it’s the patient’s fault. So now, we are terrible at what we do, but it’s your fault because you’re eating too much. And that would be like if AAA said there’s more flat tires, so it’s all your fault because you guys aren’t driving safely enough. It’s a preposterous, self-serving message.
[00:15:21] So, yeah. I think the field, if were effective at what we did, we would not get the results we are getting, which is worsening obesity, worsening diabetes, worsening fatty liver, and at an earlier and earlier age in more and more of the population. So, I think the first thing that we need to do is accept that we failed. And I do think that there’s legacy harm from all the messaging. The first thing, if you even believe their theory of energy balance, I’m not sure that I completely agree with. There’re some parts that I agree, some parts that I don’t. But even if the goal is to eat less, well, what’s the side effect of eating less? Hunger. That’s the first side effect that you need to manage. How can I make my patients less hungry so they can eat less?
[00:16:07] And that leads you inevitably to eating filling foods, which is protein, fat, maybe. Fiber, maybe I’ll say. So, I think you’re right. I think the prevailing nutritional message got it wrong. And then the blaming patients and authoritative nature of physicians exacerbated the problem. And then the diet advise and the blame it instilled on patients the way that it made them feel responsible for what happened to them. It’s been terrible. It’s like the worst thing to be able to see. It’s affected my family. It’s affected everyone, my parents, my brothers, myself. And none of them have a lack of self-blame. None of them want to be obese. And I remember being a 13-year-old boy at the same weight I am now. It was before my growth spurt, obviously, but chubby little kid and doctor saying, “You’re going to be just like your family, you’re fat.”
[00:17:13] And I remember sitting in his office for like 2 hours, prior to that he was ridiculously late and thinking to myself, well, this guy sees my family, sees what we’re going through and his waiting room has a bunch of chairs and a TV and he made me wait here for 2 hours. I could have been playing outside. I remember thinking that at 13 that was one of my formative moments actually is thinking, telling me to go lose weight. And he makes me wait for two hours, the television in the waiting room. And not that Dr. Eddies[?] was the cause of my obesity. Nothing. He put a television and made me sit. So, this idea that we could just keep blaming patients and not accept radical responsibility as a profession is insane to me. If your patients have diabetes and they have obesity and you are not helping them, you need to take ownership, not your patients. You need to take ownership.
[00:18:13] And if it’s the patients who don’t want to take ownership, well, then they should say that. You should document that. You should say, “I’ve talked to the patient and the patient is aware of everything I’ve brought up and agrees that at this point it is their responsibility and they need it.” But I don’t think any doctor has ever effectively given somebody insight into their issue. I mean, I haven’t met them. I can count on my hands how many doctors said something more than eat less and move more. And if you look at it that would be like, AAA saying, “Oh, you got a flat tire. Pump more air in than you let out.” That doesn’t help. Or a financial advisor saying, “You need to make more money than you spend.” It’s true, but it’s dumb. And then you’re saying, “It’s my fault.” It’s just not acceptable.
[00:19:10] So, I think the whole system is against, really anybody making change. It leads to when they say, calories in, calories out. You need to eat less and move more. What it does is it says, “What’s under my control?” I need to consciously eat less. No, you need to subconsciously be less hungry to start with filling foods in your diet so that you have a fighting chance. So, I don’t know. You got me started.
Cynthia Thurlow: [00:19:40] No, no. I think it’s a refreshing perspective and the concept of radical responsibility is one that every licensed healthcare provider should be embracing. I know that when I worked in cardiology that we would have patients that would come in for what they call cardiac clearance. And you can imagine how litigious cardiology is, we would say preoperative risk assessment. But these would be patients who assumed if they had bariatric surgery, that it would solve all of their problems. And I had multiple women, just coincidentally, that would say to me, I need to gain 20 pounds to qualify for bariatric surgery. And how many of them it would be a yearlong process, they would see psychiatry, they would see pulmonary, they would see cardiology. I mean, they’d seed every specialty to get, “clearance.” And more often than not, they would say, “Cynthia, I have to gain 20 more pounds to get my insurance to cover this procedure.” And my standard response was always, make sure this is really what you want.
Dr. Tro Kalayjian: [00:20:41] So here’s the problem. You have these things that work, they work. Surgery works and you have these drugs that work. And then what doctors like to do is say, “Well, I can’t help the patient.” Well, they don’t say this, “The patient’s not doing it, so let me do it for them in the ways that work.” And you put them in these buckets, bariatric surgery medicine, it’s like, “No, build insight into your patients.” Help them understand what they’re fighting. Help them understand, like, “Okay, figure out what are the foods they struggle with. What foods are you struggling with? What foods do you have a hard time saying no to? Let’s figure out what you’re going to do in those situations for each one of those foods. What restaurants do you struggle at?” The average person, if you look at, they have 15 to 25 foods that they eat regularly.
[00:21:37] So you can address 90% of their diet by addressing 15 to 25 items. What are you going to do when you crave this? The average person eats in 5 to 15 different locations, 90% of their food. Meaning, let’s figure out what you’re going to do to these 5 to 15 places when it comes to your food choices. So, in a matter of, like, maybe minutes, you can actually effectively address 90% of somebody’s diet. In their most vulnerable moments where they struggle the most. It’s not hard. There’re about 50 items that need to be addressed to help somebody’s lifestyle. Then you get into some of the nuance. Like, “Okay, the feelings of deprivation that can be managed, we can help you manage feelings of deprivation.” Let’s talk about it when it happens. Let’s figure out what we’re going to do when it happens.
[00:22:30] We can manage social situations, hunger, at birthday parties and anniversaries and vacations and business meetings. We can help you manage those. People mess up when they feel deprived, when they feel bored with their diet, when they are at social situations and with their emotions when they’re stressed out or happy celebrating or when they’re so tired of saying, “No,” when they have decision fatigue. Managing those emotions is critical. So, managing somebody’s lifestyle from a pragmatic perspective, is about 50-line items. Not much. It’s some social situations that need some planning, maybe five emotions that we need to figure out and figure out what we’re going to do when they happen. I mean, you can do this in one visit. It’s possible. I have never met a clinician who’s done that. Not once, ever. So, I think this concept of physician radical responsibility is paramount.
[00:23:33] We have failed. Our profession has failed. It is the teachers that are failing. The students accept it. Figure out what you’re going to do because it’s not hard. I’ve asked people, reliably, if I get you not hungry, if I’m able to address your cravings, if you don’t feel deprived, if we have your social situations managed and your emotional relationship to food managed. Meaning, like, when you’re so tired of saying no, when you’re depressed and stressed out and angry, and when you’re happy celebrating, if we can manage your food in those circumstances, those five things, hunger, cravings, feelings of deprivation, social situations, emotions. How much of a food issue do you have? The answer is uniformly, I don’t have a food issue. So, notice how calories was not in there, exercise was not in there. None of this was in there. Macros and blah, blah, blah. None of that crap is in there. It’s, what are you going to do when you’re craving those, when you’re used to eating 15 to 25 foods, what are you going to do when you are in those five to 15 places? You eat the majority of your food with the 5 to 10 people you eat the majority of the food with. You have 50-line items and docs can’t figure that out. Get out of here, you failed.
Cynthia Thurlow: [00:24:51] I kind of feel like I was describing this to a younger clinician the other day. I said, “I know when I finished my nursing and nurse practitioner program.” And we’re always taught that we should evolve, shift, and change throughout our lifetime. As a clinician, that was the expectation, big teaching hospital. But I find most of my clinicians that I know they stay rooted in whatever time paradigm they trained in. Meaning I’m confident they go to CMEs and I know they’re reading the literature and I know they’re paying attention, but it seems much harder for people to change their viewpoints about whether it’s food addiction, whether it’s diabetes management, which you and I both know is really poorly managed, metabolic health. It’s almost as if some people just stay stuck in the time frame in which they trained and they’re just seemingly unwilling. And I say I’m making a generalization, which is probably unfair, but just for argument’s sake, it seems that there are less of us that are shifting the paradigm or reframing the way that we look at specific chronic conditions and health issues.
[00:26:04] It’s hard to be, but we signed up for this. And if you look, I mean, you look at teachers, it’s the same. You look at any accountants, it’s the same. Dentists is the same. When you look at anybody and you ask yourself, “How many people were born to do this?” When I train medical students, I train doctors, I train residents, I train them. And if I’m looking and I’m like, “How many people were born to be healers? How many people were born to figure out the mysteries that other people can’t figure out, go deeper than other people? How many were born to help somebody heal?” What, one out of five? Maybe one fifth was like, they did good in school or I know one fifth thought there’s money in medicine, there isn’t by the way. Maybe one fifth thought that it was some sort of prestige, there’s no prestige.
[00:26:57] And maybe, like, one fifth actually was born to do this. I say the same thing to my kids about teachers, like, “How many of your teachers were born to be a teacher?” Maybe one out of five. And there’s nothing against teachers. I think all professions maybe to some degree suffer from this issue. So, yeah, everybody’s just mediocre, and the profession doesn’t take responsibility, pressure, blames others. It’s funny. I was, like, looking online, and somebody was talking about the pandemic and they were somebody who’s very pro sort of public health measures. And after several years, seemingly this person got COVID and said, “See, we should have been masking hard enough.” I mean, that was the first instinct this person has to say, I go on walks on trails and I see masks on the floor. I go to the Hudson River and I see masks floating up.
[00:27:58] We sold trillions of masks worldwide, trillions. More than 5 billion vaccines were given. And yet this person was, like, blaming others for them getting COVID. And it hit me that we as a profession really, really suffer from this idea of radical responsibility. Well, you got COVID. How is your health? Peter Hotez was on Joe Rogan and Joe Rogan said, “How do you take care of yourself? Do you eat junk food?” Well, I go with my daughter and I eat French fries and a burger, the Coke and a milkshake every Wednesday. That’s our thing. Where’s the radical ownership of public health measures? Is there any radical ownership here? And so, I think our profession, when you’re looking, it’s easier for us to be authoritative than blame the patient, and it’s much harder for us to say, “What can I do more?”
[00:29:01] Peter Hotez is all about misinformation and vaccine hesitancy. At what point is he going to say, “What more could I do?” Well, stop being wrong, stop blaming others. Maybe they have a value difference than you or they just can’t do what you want them to do. So, then we have to pivot. So, I think the problem here is people– their values, the physician’s values are off. And at some point, we have to say, “We are here and our knowledge is going to inspire patients or it’s going to help patients, it’s going to help this person, our knowledge. Our insight is going to help this person and our ignorance is going to hurt them.” And as long as you have that value that you have to become more knowledgeable and you have to gain more insight over time. You have to be less ignorant, less experienced over time, your clinical practice will get better and better and better. But if you take no ownership over the outcomes, what do you do? You just don’t update yourself. You don’t update your thinking, you don’t reevaluate what you’re doing.
[00:30:05] Last year and generally when it came to my recommendations for flu shot, I said, “It’s your choice and if you’re elderly, you may want to consider it.” And I still believe that shared decision making, patient autonomy, do you think that you should take, it changes every year. We don’t know if we have the match rate. There’s no long-term sort of outcomes on side effects because they rotate the strain every year, but definitely reduces the flu. Especially years that it matches. Well, they did a study in 2000 and so that was my message. I was like, “I haven’t taken it personally and gave the information to the patient. I left it up to them.” Well, I’ve become a lot more positive over flu shots. Well, why? In 2021, a bunch of cardiologists got together and they said, “Let’s see if it reduces heart attacks.” And they did a double-blind, placebo-controlled trial for three years with flu shots.
[00:30:59] And it was a year that the strains weren’t– like 2016 to 2020 was not great match rate years, but they showed that if they gave it to people with heart disease who had a heart attack or CABG done that it actually saved lives. It decreased all-cause mortality. In fact, you needed to give it to 40 people to save one life in that group, which is pretty huge. Now I see this amazing data set and I change my view, even though I’m like the guy who’s like, “Look, be careful, there’s no long-term data.” Now, we have a well-done study showing that it decreases all-cause mortality in people who have heart disease. Now, I could just double down on my previous beliefs, but that’s not going to help my patients. What does that do for my own personal growth. You have to adapt to this new information. You have to be willing to challenge your own preconceived notions.
[00:31:54] Now, some may say, “Well, look at those people who got it.” The people who were blindly saying, “Take the vaccine.” Yeah, they were blind and they happened to get lucky. There was no data to support it. There was no good quality data. They happened to get lucky. So, would I rather be lucky or would I rather be a little bit late? Me, personally, my style is I’d rather make sure I have the evidence, make sure I’m right before I make a– but I am willing to change. It’s not about mantra, it’s about results. And I think the problem with our profession is they’re not willing to examine what’s going on. Now, what do I say about flu shots now, “I’m still not going to take it. I don’t have a heart attack; I don’t have any heart disease and I don’t have a CABG.” But I tell my patients who have a high CAC or have had a heart attack, it’s been shown in your group to just save lives.
[00:32:43] Well, what’s the process here? The process is we have to adapt and we have to put down– My identity is not being vaccine hesitant or challenging or contrarian. My identity is being evidence based and improving the lives of my patients. That is my identity. My identity is in my politics of don’t freaking force me to do something or any of my patients to do something. That’s not my identity. That’s what I want, my identity is the results of my patients. My identity is respecting my patient’s autonomy. My identity is respecting their decision making and giving them the best possible data. So just because slightly I lean a certain way politically doesn’t mean I’m going to throw a blind eye to great science and it doesn’t mean I’m going to ignore data to support my biases and my opinions and my values. So, I still value patient autonomy. I tell them it saves lives and then I say, “What do you want to do?” So, I think the problem is why–
[00:33:48] This is a long-winded discussion and probably we got lost in the middle there. But my point here is, as a profession, our mission is to serve our patients. If you have a mission, if your identity is to be a healer, and that’s what you were born to do, this is, like, easy for me. It’s easy. I love this. I love finding out that I was wrong because now I can serve my patients better. I love gaining experience because now I can serve my patients better. I love changing. Easy for me to read the literature and keep up to date. This is what I was born to do. And I think most of the people that you mentioned, you mentioned talking to a student, we have to put that passion into them. This is a sacred profession. We’re here to heal people. We’re here to help people. We’re not here to collect a paycheck from insurance company.
Cynthia Thurlow: [00:34:43] These are important conversations to be had. And I really applaud your transparency, your honesty, your integrity, because one of the reasons why I left clinical cardiology with a group that was willing to make anything happen to keep me was that I could no longer work in a paradigm where weren’t focused on any of the lifestyle. We weren’t given the opportunity to spend time talking about sleep and nutrition. And I kept saying, “These patients are vasculopaths.” Like, they’ve got carotid artery disease. They have peripheral vascular disease. They have epicardial disease. And what are we telling them to do? We’re talking to them about fear protein, eat more carbs, their diabetes is getting worse, we’re not making them better. And so, for me, it was definitively a shift in my thought process that I could no longer write 100 statin prescriptions every week. If I couldn’t then also be talking about the lifestyle piece, which was so important.
[00:35:46] And that was a very hard decision to make. And that’s why, in many reasons, this podcast for me is a passion project so that I can share the voices of experts in this space with the community to help them navigate choices that they’re making in their own lives. And so that patient autonomy, the shared decision making, talking and calling out clinicians for not wanting to do more for their patients, and to be in a position of constantly learning and applying things that they get in their CMEs. All of us, as licensed healthcare providers, have a certain amount of continuing education we have to do when we relicense. How many people are actually applying what they’re learning or are they in an echo chamber?
Dr. Tro Kalayjian: [00:36:31] I think that’s the problem. It’s hard. During the COVID pandemic here I am a metabolic doc, but I’m also board-certified internist, board certified in obesity medicine. But I’m [unintelligible 00:36:45], so that’s my nature. Throughout the pandemic, I’m reading everything. I read all of the protocols and trial results for every major therapeutic for COVID. I listened to every advisory committee, FDA advisory committee. I don’t know of another doctor has done that? I don’t know of one. Just to show you how insane I am. [chuckles] I read all the briefing documents for the advisory committee meetings and it hit me that—And I know there are other doctors out there because I follow them on social media, so I’m not like, tooting my own horn here. There are many, but I don’t personally know in my professional sort of world.
[00:37:25] But the point here is that how if I wasn’t inspired, if I wasn’t sort of like divinely inspired or inspired to be the best doctor, what would I have done? I would have relied on what the central authorities would have told me, and I would have relied on the insurance company to guide me. And so most doctors, 80% of 20%, if you believe my 20% rule, who are actually inspired to be in medicine and do great work, 80% are being guided by sort of the central planners. And the central planners and insurance companies, they don’t really prize shared decision making or patient empowerment as their principles. They think about population medicine. They think about what should we tell everybody to do? They think about giving your kids their fifth booster and mandating it in college despite the risk of slight increase of myocarditis in their group. So, they think, “Well, look, we just got to break a couple of eggs to make an omelet.” Whereas I’m like, “Well, what do you want to do?”
[00:38:38] Do you want to accept this potential one in 2000 or one in 5000 risk of COVID myocarditis in exchange for immunity? Have you had COVID already? These simple questions. When you’re dealing with results, which is– the dealing with results, is the person in front of you making sure that they have the best possible outcomes? You’re inspired to learn everything. You want to learn. You want to challenge yourself. You want to challenge your previous assumptions. You want to keep learning. But when you’re guided by sort of the CDC, FDA, and the medical organizations and insurance companies, you’ve sort of outsourced your work. And so, what happens is, well, when they’re right, when the central planners are right, well, you’re right. And the responsibilities off you, but now you’re just like a lemming and a cog in the wheel, and you’ve lost that critical piece, which is, “I am responsible for the person in front of me and their good outcomes.”
And not to say there’s anything wrong with our central planners. I mean, I can criticize them all day, but I would never take their job, just to be fully honest. I would never take their job. It’s a hard job. You can almost never be right. And as an insurance company, I’m not sure I would do anything different. I would try to obstruct care as much as they do if I was an insurance company, but I’m not. I’m a clinician that has a passion for– I’m curious, I’m passionate and I want to align myself with the people in front of me.
Cynthia Thurlow: [00:40:18] I think it’s important because the last three years has been challenging to navigate as a human being. And I know that you have a voracious desire to understand the literature, to understand what’s out there. I saw you in particular on Twitter, really challenging people to not fall prey to not questioning things. The whole scientific method is constantly questioning. And that’s good science to question everything. And so, I am so grateful to not only count you as a friend, but also applaud your efforts. Because it’s not easy when you have an opinion that is based in looking objectively at information that may be contrary to what some of those big organizations, insurance companies, etc., are putting out there for people to embrace and to share with their own patients. That’s not an easy place to be. And so, it really isn’t. And I want to acknowledge that I know that sometimes you get into a little bit of a tussle with individuals who you’re like, “No, that’s actually not the way you interpret that research. Let me explain this to you.” That’s not an easy place to be.
Dr. Tro Kalayjian: [00:41:33] Yeah. I mean, look, a lot of times patients are looking for a do or don’t do. Like, “Is a flu shot good or bad?” Well, in who for who? I just gave you an example. I can tell you that we have data saying it saves lives in this group. Do I take it, it’s bad for me? I don’t want it. And I’m young and healthy. It’s bad for me. It’s not good for me. You could give it to 5000 meals[?] and not save one life. But you can give it to 40 people who have just had a heart attack and save one life. And same thing with food. People are like, “Well, tell me what to eat.” Well, “What do you struggle with?” Telling you not to eat chocolate, I mean, I struggle with chocolate. You have chocolate once a year. So, telling you not to eat chocolate. We’re two different people. It’s not the substance, it’s the person. Are statins good or bad? I don’t like they have terrible side effects profile. They’re the only drug that has a decrease in all-cause mortality for people who have coronary disease. They’re the only drug that’s lowered all-cause mortality. There’s Repatha, there’s Zetia, there’s colchicine now there’s bempedoic acid, there’s Vascepa.
[00:42:43] The only drug to ever show decrease in all-cause mortality is statins. And almost, I don’t think any of those drugs have reduced cardiovascular deaths except Vascepa. Meaning that all those drugs that are multibillion dollar blockbuster drugs, it never saves a life. Do I like statins? No. They cause muscle aches, they increase insulin resistance, they make women, particularly, have higher blood sugars, terrible muscle aches, can cause liver issues, they deplete CoQ10, deplete K2 and D3. All these things need to be managed. So, the problem is our patients are looking for, “Do I take a COVID shot or not?” Well, is a COVID shot good or not? I can’t judge that. I mean, if I was 85 years old, never had COVID, have multiple medical issues, frail, I may consider taking it. I don’t care about five-year side effects if my five-year mortality is 100%.
[00:43:38] So I think it matters to just take the interest out of medicine, the lemmings out of medicine, and the non-critical thinking out of medicine and take off the automatons, take them out. Because I understand the public health thing. This is how the public health people think. So, everybody go recommend the vaccine. [Cynthia chuckles] That is what they’re doing. So, the problem with the central planners and the people follow them is that they’re mediocre. That’s the problem. And mediocre works for majority of people. I’m never going to be that. I’m never going to want to be that. I’m never going to try to be that. That’s the nature of it. And it took me a long time to understand it’s a value difference. Once you see the bias in medicine, you see it in nutrition, you see it in a lot of other things.
Cynthia Thurlow: [00:44:29] Absolutely. Now, I want to pivot just a little bit because you and I exist in a wonderful space of incredible clinicians. And what I always find interesting is the backlash against low-carb ketogenic diets, especially in the research. We can talk about that consensus statement that came out recently. Why do you think that there’s such a strong low-carb bias within the medical community? What do you think contributes to that? Because I know that in having the ability to interact with so many incredible researchers and clinicians on this podcast, it’s a question that I ask with some frequency. And yet it becomes something that I think in many ways can be really polarizing, which is unfortunate, because there is a lot of therapeutic value to utilizing a low carb or ketogenic diet with our patient populations.
Dr. Tro Kalayjian: [00:45:21] Well, let’s talk about the elephant in the room. So, the American Academy of Pediatrics recently said that they recommend against low-carb diets. Now, the academy as an institution, they’ve also recommended for obesity, the use of bariatric surgery and injection drugs. They’ve also recommended saying a plant-based diet is safe for every kid over two years old. None of these have really long-term outcomes data, but they accepted these off of surrogate endpoints.
[00:45:51] When it came to a low-carb diet, the people involved were two authors and they gave some credence to the data from pediatrics which showed in type 1 patients some improvement. They talked about some data in obesity that was slightly favorable, but they quoted, like esoteric data, like data from four to one, like 90% fat diets used for epilepsy and the protein deficiency that basically comes with that old sort of way of doing ketogenic diets and seizures from the 80s and 70s. It’s clear that they don’t do this. They don’t practice metabolic health and they’re trying to talk about metabolic health outcomes with faulty data, with inappropriate data. It would be the equivalent of me saying, “Well, nobody should get a flu shot, but it does work in people with coronary disease, but really, nobody should get a flu shot.”
[00:46:48] So that’s sort of like the approach that they’re taking. It’s not wrong. It’s just a shame. And if you step back so if you look at their consensus statement on low carb, basically says people need to be monitored if they want to take it. And that otherwise it shouldn’t be recommended, which is not terrible advice. In some ways, it’s giving an ounce of flexibility. But really, it came down to esoteric nutritional issues that don’t apply to the modern ketogenic diet, modified Atkins, Atkins which are the mainstay for seizure prevention diets, which they could have taken 20 years of data from.
[00:47:30] And they also did this trope where they somehow connected going low carb to getting an eating disorder. But there’s more data showing that lowering your calories causes eating disorders. So, it’s just like they didn’t make sense. They said, “Well, lowering carbs could cause an eating disorder, so instead, lower energy.” Saying the same thing, and in fact, lowering your energy, “has more of a risk of causing an eating disorder.” So, I think if I had really no understanding of behavior change and nutrition, I would have written something like that. If I was like, an 80% person that was tasked by the AAP to write something about low carb, you do a quick little search, you put some stuff together, and you’re an endocrinologist that’s what it looks like. And then when you step back and look at it as an institution, it’s highly favorable for plant-based diets off of surrogate endpoints. injection drugs and surgery. So well, how does that happen?
[00:48:34] Well, the data that they rely on is very well funded. Again, if you’re an 80% doc who is just, like, instigated by somebody with a bit of understanding about this, that’s the kind of papers you’d end up with. So now, as an institution, so what happens AAP says, “Don’t do low carb, do plant based, take injection drugs and get bariatric surgery.” And if you just step back so this is the problem right now is we need to get metabolic health doctors talking about metabolic health. And this is what the Society of Metabolic Health Practitioners is about. We now have 500 docs in there. We have a certification process for metabolic health. So, we’re going to have consensus statements. We have a journal. We’re absorbing the Journal of Insulin Resistance and making it the Journal of Metabolic Health. And we are going to be publishing consensus statements with doctors who practice metabolic health all the time and are experts in their field.
[00:49:34] So I think our job now to be great is just to reclaim they’re trying to comment on metabolic health, but they have no training or experience with metabolic health. Don’t blame them for writing what they did. It’s sort of like a handicapped person sort of running a mile. It’s going to be slower. It’s not going to look as pretty as somebody who’s able bodied. So yeah, that’s how I view it. It’s a shame. It’s really a shame. And if you step back, it’s embarrassing. Imagine being an institution and saying, “Don’t do low carb, just lower your energy. Plant based is fine, injection drugs are cool. And oh, by the way, go do surgery for 12.” There’s something wrong there.
Cynthia Thurlow: [00:50:14] I couldn’t agree more. And it’s interesting, my teenagers, I now have two teenagers, we’re talking about that consensus statement and I asked them– they’re both very physically active, very metabolically healthy. And I said, “Would you think if my recommendation to you as a clinician was,” and I kind of went through that and they just said, “That doesn’t make sense.” Now, these are teenagers, they’re not clinicians. But they said, “Why wouldn’t we start with changing that nutritional paradigm? Why wouldn’t we be talking about– they know the word satiety. Why aren’t we talking about protein and vegetables and more physical activity as opposed to going directly to a plant-based diet,” which for many individuals, if they’re already not metabolically healthy, they’re going to be eating more carbohydrates and thinking about GLP-1 agonists and thinking about surgery. They both looked at me and said, “That would be a terrible thing to have to consider at such a young age.” And these are teenagers.
[00:51:09] So, imagine the rest of us sitting back and hearing that consensus statement and then watching my peers, including yourself, speaking very outspokenly on social media and saying like, “Let’s bring more attention to this because we can do better. We can definitely do better for our pediatric population.”
Dr. Tro Kalayjian: [00:51:28] I think the problem is most of our profession is just to sleep at the wheel. And I think that’s how papers like this get published. They have no experience with metabolic health and then they go write about it and it’s very damaging. That’s the other thing. It’s very damaging and they don’t understand the damage. We talked about in the beginning of this, that legacy impact of poor nutrition advice and how it disempowers and disenfranchises people who are struggling. So, yeah, there’s a reason why the SMHP, the Society of Metabolic Health Practitioners exists. And it’s exactly this.
Cynthia Thurlow: [00:52:05] I’m so grateful for our time together today. I definitely would love to bring you back. In fact, we kind of started the conversation saying I should have you back a couple of times a year, because I think bringing greater awareness to my listeners about some of the things that clinicians are struggling with or that they’re seeing. And they’re feeling like maybe that voice isn’t being amplified enough to allow for greater understanding of some of the challenges that clinicians are facing right now.
Dr. Tro Kalayjian: [00:52:30] Yeah. I mean, look, there’s never been a better time to be a doctor. People are sick. People need us. But I think we just have to wake up our profession. And I appreciate everything you’re doing.
Cynthia Thurlow: [00:52:38] Thank you, my friend.
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