Isomers, CRP and diet

I have been learning recently all about the Ketogenic diet.

The ketogenic diet requires people to limit the amount of carbohydrate they eat, inducing a glucose-starvation state, which results in the body metabolising fat for energy, rather that its more common fuel – sugar.

This might all seem barmy, but there is a global movement which believes that by altering our diets in this way we can become healthier, have more energy, reduce the risk of diabetes and cardiovascular disease and another host of other chronic-lifestyle related conditions.

In learning about the diet, I have heard discussions about glycogenolysis, gluconeogenesis, ketosis, isomers, polymers, gamma hydroxyl butyrate and a host of other words that I learned in medical school.

It is funny how far I have drifted away from all of this, living in my holistic, person-centred world of care and compassion. That is not to say that my days aren’t fuelled by my patients’ sodium, potassium and haemoglobin levels – it is just, that I sort of take them for granted; maybe it is because I have been doing this for so long that I have stopped looking underneath to see what is happening.

An example, which I find particularly pertinent relates to nutrition. We know in the West, we are exposed to diets that far exceed what we need to survive – we have to be selective, not just following our Palaeolithic drives to eat everything in front of us.

In hospital, with the patients I support, food abundance is not entirely part of the contract; you come to hospital and meals are provided. It is difficult to graze in hospital unless your family bring-in bottles of Lucozade (which still happens today, despite us not living in the 1980’s – thanks Daley Thomson!) and chocolates (grapes seem to be on the decline).

Often the meals arrive when a person isn’t hungry, or when they are not available – off the ward having an important test, or some other interruption, confusion or complication arises – for example, they are feeling nauseated because of the medicine.

On my ward (Mallard J) we have freely available food, and as most people spend their time in the day area, they can access the fridge, although, it is nothing like being able to rifle-through your own cupboards or fridge at home.

We have come a long way in understanding the importance of nutrition and hydration in the support of older people, particularly in relation to their recovery from acute illnesses such as pneumonia or sepsis.

Yet, we don’t routinely sit and think, metabolically, what is going on, who is using-up their glycogen stores, who is in a state of ketosis? (this being different to the state of ketoacidosis we do worry about in those with diabetes);

My brother who lives in Israel sent me the other day a download of all of his blood work.

Blood work isn’t to my knowledge something that is discussed day-to-day in the UK. Nor is the sharing of this information in its entirety with the people who have had the work done. (In the NHS we routinely copy patients in to clinic letters; sending them all the blood results is still quite unusual).

The sight of all the numbers at first left me dumbfounded. He had results on the level of his Uric Acid, Creatinine Kinase, Calcium, Phosphate, Vitamin D, PSA and other investigations that many people in the UK never have, event after a spell in hospital.

And what to do with this information? Do you use it to become complacent about your wellbeing? Does a full-house of chemical normality mean that you are in a state of ‘health’? What of the subtleties that cannot be picked-up – tests of happiness, contentment, anxiety, fear, hope and, meaning?

And, if you do find something amiss, where do you go from there? Do you set-out on a voyage of investigation? Like someone I know recently who was committed to undergoing a ‘whole-body MRI’ which, despite not being ‘a thing’ is also not that helpful, given than of all the multitude of disease states which can befall a human, only a tiny proportion can be picked-up by the Wonder Machine.

The generally accepted approach to obscure investigations in the UK is that we shouldn’t test for the sake of a test; sure, if something hurts, is swollen or misshapen, get out the x-ray, ultrasound or CT machine, but don’t just test, as more often than not you find something that isn’t 100% normal and just adds to anxiety.

The concept of a ‘reassurance scan’ is particularly treacherous, for often, odd abnormalities are discovered – with such frequency in medicine that they even have their own name… ‘Incidentalomas’

So this is the morass of science, technology and art that I try to navigate with my team, that often leads me to holism, although holism within the confines of my limited human abilities;

How far do we go with holism? Surely a holistic approach to medicine takes-in everything? The oligomers, disaccharides and smiles, skin texture, blood pressure, past, present and future – where do we begin and where do we end?

I guess we are limited by our human, technical and organisational abilities (I don’t know of any healthcare system that has the whole think sussed) –

And the message? Well, I suspect that is, relax.

If things feel OK, it doesn’t hurt, you aren’t short of breath, losing weight, gaining weight, aren’t too high or too low; I believe they call this Mahayana in Buddhism – the middle path; it isn’t quite burning-out, nor is it fading-away.

Oh, and CRP – well, this doesn’t seem to be something they routinely check in Israel or the UK, although the Americans are on to it – analysing the subtleties of the inflammatory cascade.

And me – I’d rather have someone who listens, who hears me when I talk, than a machine that produces data that to some has become a religion or way of life.

For the moment, I’m happy with the humans.