Paul E. Lemanski, MD, PLLC
Internal and Lifestyle Medicine
Your first few visits
At your first few visits, you and I will discuss:
What you eat
What you drink
When you eat
How you move
How you cook
How you sleep
How gratefully you live your life
The practice of Lifestyle Medicine involves strategies for the prevention and treatment of diseases and conditions created by an unhealthy lifestyle.
These strategies include:
1) Weight Reduction and Weight control: Obesity or a BMI > or = 30 (please see www.cdc.gov>bmi>adult_bmi) places the patient at risk for a variety of conditions including Heart Disease, Diabetes, High Blood Pressure, Sleep apnea, and GERD (see below). Although an individual may be 30 or 40 pounds or more above their ideal body weight, a loss of only 5% of their weight (10 lbs for a 200 lbs woman) may decrease conversion from pre-diabetes to actual diabetes by 57%. A loss of only 5 lbs may result in a reduction of High Blood Pressure.
I can help determine if you either have or are at risk for the development of the above-mentioned conditions, and then can individualize a plan to safely and easily lower body weight and teach you how to keep the pounds off. Over the last 18 years, I have helped > 5,000 individuals lose on average of 15 lbs in 12 weeks. I can teach you how to use either a High Protein/Low Carbohydrate KETO diet or a Whole Food Plant-Based diet for weight loss and then a High Omega-3 Mediterranean Diet (a whole food, predominantly plant-based diet) for weight maintenance. For those interested in weight reduction using an alternative approach to that mentioned above, I offer support in the use of MEDIFAST portion controlled meal replacements.
2) Blood Cholesterol Reduction: High LDL “the bad” cholesterol can cause heart attacks, strokes, and other cardiovascular conditions. While standard treatment for High Cholesterol is medication, diet and exercise done correctly may accomplish similar reductions in LDL without side effects or the additional cost of medication. If one is unable to achieve optimal levels without drugs, I can show you how to use doses of drugs that may allow the needed drug to be used, but also avoid such unacceptable side effects as muscle aches and pain and muscle weakness.
Additionally, not everyone with High Cholesterol needs to be treated. The requirement for treatment and how low the LDL or “bad” cholesterol needs to be is based on a total or global cardiovascular risk assessment. My approach is comprehensive and may involve advanced testing. I employ detailed personal history and family history, the American Heart Association CV risk calculator, the Framingham CV risk calculator, the Reynolds CV risk calculator, Advanced Specialized Blood Tests, including those done for us by the Cleveland Clinic Laboratory and/or non-invasive imaging including Carotid and Abdominal Ultrasound and Coronary Artery Calcium (CAC) scoring.
3) Heart Disease and Stroke Risk Assessment and Reduction: Atherosclerosis is the process by which elevated LDL “the bad” cholesterol gets deposited in a plaque within the walls of the arteries of the heart and those leading to the brain. This cholesterol plaque deposition is a silent process and the necessary first step for heart attack and stroke. As a largely silent process (until a heart attack or stroke), the clues to the possible presence of atherosclerosis must be searched for with a careful history taken from a patient, a careful physical exam, but also with a focused and detailed family history and the global cardiovascular risk assessment described above and, as appropriate, Advanced Specialized Blood Testing and non-invasive cardiovascular imaging. The Advanced Specialized Blood Testing may include tests such as the inflammatory markers High Sensitivity C-Reactive Protein (Cardiac-CRP) and LDL-associated PLA2 (PLAC-2) which can determine if cholesterol plaque is inflamed and thus at risk for causing a heart attack; it includes NMR LipoProfile which can determine LDL and HDL particle number and size, both helpful in refining cardiovascular risk; it includes Trimethylamine-N oxide (TMAO), a test pioneered by researchers at Cleveland Clinic, measuring the risk posed by one’s diet and a resultant unhealthy Gut Microbiome. Such Advanced Specialized Blood Testing, its interpretation, and specific recommendations for risk reduction are available through my office for those who are interested and would be especially of potential benefit for those having progressive disease despite optimization of more traditional measures. Once risk is determined or evidence of the presence of atherosclerosis is identified, Lifestyle Medicine serves as the foundation of prevention and treatment with the degree of CV risk determining the degree and type of lifestyle modification recommended. For example, a high TMAO blood level might require not Pro-biotics, but rather consumption of the Pre-biotics found in selected foods (as well as a reduction in the frequency of consumption of other foods) to reduce the TMAO blood level and reduce risk. Those at highest risk with evidence for existing atherosclerosis are encouraged to consider both medication and aggressive lifestyle modification to stop the progression of disease and begin the process of reversing disease.
4) High Blood Pressure Reduction: High Blood Pressure is very prevalent in our society and for adults over age 20 years about 33% have high blood pressure. Uncontrolled or poorly controlled high blood pressure dramatically increases the risk of heart attack and stroke. Thus, the majority of those with high blood pressure will be given a medication and most individuals with high blood pressure end up on multiple medications. While effective, medications for high blood pressure are both costly and have side effects. However, diet, exercise and lifestyle changes can also lower blood pressure effectively without the cost or side effects. For example, by simply cutting back on sodium those who are salt sensitive may lower blood pressure. How to cut salt without compromising flavor and food enjoyment is part of the lifestyle approach to lowering blood pressure. Additionally, weight loss of even 5 pounds in those who are overweight or obese may lower blood pressure, with greater weight loss potentially allowing reduction or discontinuation of blood pressure medication. Likewise daily brisk walking 10 minutes 3 times a day can help lower blood pressure. Smoking cessation will lower blood pressure. The consumption of certain foods such as ground flax seed also has been shown to lower blood pressure. Finally, meditation techniques focused on breathing and isometric hand exercises may lower blood pressure significantly without medication. The above techniques done individually may lower blood pressure and achieve your blood pressure target. When done in combination, however, the results are additive and may allow reduction or complete discontinuation of medication while achieving your blood pressure target. Such approaches, techniques, and strategies are routinely employed in my practice.
5) Prevention of Diabetes: Currently there are 25 million Americans with Diabetes and 75 million Americans with pre-Diabetes. Untreated, those with pre-Diabetes are converting to Diabetes at a rate of 11% per year. Within less than 10 years America will have 100 million people with Diabetes, less the ones who die. Even more unfortunate, most people with pre-Diabetes are unaware that they are at risk. Identifying those at risk is the first step in a lifestyle approach to preventing diabetes and in my practice involves a careful personal medical history, a detailed family medical history, a measurement of abdominal girth, BMI, fasting blood sugar, a three month average blood sugar test called Hgb A1c, a LIPID profile (full cholesterol profile), and the measurement of blood pressure to ascertain the presence and the degree of Metabolic Syndrome (the scientific term for pre-diabetes). Using the criteria for Metabolic Syndrome allows me to actually tell you how close to diabetes you are and thus allows you to determine how quickly and how aggressively you pursue prevention strategies. The Diabetes Prevention Program study proved that in those at risk for diabetes who are overweight or obese a weight loss of 5-7% of body weight could decrease the development of diabetes by 57%. While the National Diabetes Prevention Program has attempted to achieve such reductions, it is hampered in my opinion by the program being taught by non-medically trained coaches, instead of by physicians and dietitians. Moreover, the National Program also suffers from a lack of a specific diet. Our Prevent It Now!® program is taught by a dietitian and myself and provides several specific diets that can successfully be used to lower body weight and keep the weight off.
6) Remission of Diabetes: Type-2 diabetes is preventable. But what can Lifestyle Medicine offer to those who already have it? The answer is not just better blood sugar control and a reduction in the number and amount of diabetes medications. Most significantly, Lifestyle Medicine offers the possibility of achieving normal blood sugar levels without any medication at all or a “so called” remission of diabetes. While remission should not be viewed technically as a cure or reversal of diabetes and is not possible in all persons with diabetes, it is possible in the majority of those with Type-2 diabetes and for all intents and purposes it represents a reversal of the ongoing disease process. Indeed, the untoward effects of an elevated blood sugar on the organs of the body cease with normalization of blood sugar. Diabetes induced progressive retinal eye damage, kidney damage, and blood vessel injury cease with control of blood sugar. Moreover, the associated blood cholesterol alterations that include: 1.) Elevation of non-HDL cholesterol (a measure of all plaque-producing particles), 2.) Elevation of triglycerides and 3.) Depression of HDL or the “good” cholesterol, as well as 4.) Increase of production of plaque producing small dense LDL, all may be arrested and reversed.
Remission of Type-2 diabetes is accomplished by a combination of compositional changes in one’s diet, intermittent fasting or time limited eating, weight loss, and exercise. Those taking diabetes medications including insulin will be given my recommendations for medication reduction, as appropriate, and have those recommendations sent to your PCP and endocrinologist for their concurrence prior to starting the program. After the program begins, participants must agree to self-monitoring blood glucose levels a minimum of 4 times a day (or via continuous monitoring) with any blood sugar <100 or>200 called to me on my cell phone for instructions for further modification of medication dose. I also communicate all suggested medication modifications after program start to your primary care physician and endocrinologist for their concurrence.
7) Reversing Sleep Apnea: Obstructive Sleep Apnea is a common condition caused by genetic predisposition, an individual’s anatomy, increasing age and increasing body weight. As one falls asleep, the tone in the muscles in the throat relaxes, becoming maximally relaxed as one enters the deeper, restorative stages of sleep. Unfortunately, when combined with the excess fatty tissue in the neck occurring with increasing body weight, this loss of tone results in an obstruction to air flow. The early sign of partial obstruction to air- flow is snoring. However, with maximal relaxation in tone complete obstruction to air flow or apnea may occur. The bed partner of an individual with sleep apnea will hear deepening snoring until the snoring and breathing stop abruptly and completely for up to 30 seconds. Such discontinuation of breathing causes blood oxygen levels to fall and carbon dioxide levels to rise until the individual awakens in order to take a breath. Such awakenings occurring just as the individual enters the deeper stages of sleep prevent the restorative benefit of deep sleep from being achieved. The individual awaken un-refreshed and more likely to fall asleep during the day in inappropriate and sometimes dangerous situations (e.g., while driving behind the wheel of a car). Additionally, untreated obstructive sleep apnea may elevate blood pressure, cause arrhythmias of the heart, and increase the risk for diabetes, heart attack and stroke.
Obstructive sleep apnea is usually diagnosed by either an at home or in sleep center sleep study or Polysomnogram. Once diagnosed, obstructive sleep apnea is typically treated with a device which forces air into the nose and airways of an individual with the condition. This continuous positive airway pressure or C-PAP serves to counter the collapse of the airway as the individual reaches the deeper stages of sleep and thus allows the restorative benefits of deep sleep to be achieved. Unfortunately, only 40-50% of individuals tolerate C-PAP. In those who do not tolerate this approach surgery can be used to remove the tonsils, remove the uvula, and trim tissue from the soft palate so as to make the air passage wider and thus less likely to collapse. Alternatively, if an individual is overweight or obese, significant weight loss can achieve a similar benefit. The Prevent It Now!® program provides the strategies, support and time needed to reverse sleep apnea including effective strategies for weight loss and oropharyngeal exercises proven effective in clinical trials of patients with moderate obstructive sleep apnea.
8) Reducing Gastro-esophageal Reflux Disease (GERD): GERD is a common condition in which acid from the stomach refluxes up the esophagus from the stomach causing burning discomfort in the chest, acid taste in the mouth, hoarseness, and cough. GERD is typically treated with a PPI or proton pump inhibitor. These powerful medications reduce acid in the stomach to extremely low levels. The benefit is that there is no acid to reflux back up the esophagus. The downside, however, is that low acid levels in the stomach allow harmful bacteria that may be swallowed to survive in the gut. PPI’s also reduce the absorption of certain minerals such as magnesium and calcium from the gut. Finally there is evidence that PPI’s may injure the kidney.
Thankfully, Lifestyle Medicine offers an alternative treatment without the downsides of PPI’s. My Prevent It Now! program helps effectively treat GERD without the use of PPI’s by addressing the underlying pathophysiology of GERD. GERD is caused by a combination of factors including increased abdominal girth pushing the stomach up into the chest (e.g., hiatal hernia), eating too close to the time of sleep (so food and high acid levels are still in the stomach), and eating and drinking foods which relax the lower esophageal sphincter (a muscular band at the base of the esophagus which keeps acid in the stomach and prevents it from refluxing backward toward the mouth). Prevent it Now® can help you to lose weight, alter the time of eating, and avoid those foods and drink which can relax the lower esophageal sphincter. Additionally, I will show how simple maneuvers can alter your sleeping angle and dramatically reduce the tendency for reflux. If needed, we can recommend extremely safe, non-PPI medications which when combined with lifestyle recommendations can achieve control of GERD.
9) Smoking cessation: Smoking cessation is the single most important prevention strategy for optimal health and longevity. Nevertheless, it is also one of the most difficult strategies to implement. My approach, which is based upon the National Cancer Institute program, How to Help Your Patients Stop Smoking, employs education, psychology, addiction medicine, acupuncture, and when needed medication to help you stop smoking and stay off tobacco going forward. As with most aspects of Lifestyle Medicine, one size does not fit all, and I work with you and modify evidence based approaches as you require to achieve a tobacco free life.
© 2019 Paul E. Lemanski, MD, FACP. All Rights Reserved