I have a serious problem with the term “pre-diabetes.”

The prefix “pre” is used to describe what comes before something.

In reality, “pre”-diabetes is actually AFTER or “post” 15 years of the high insulin levels & inflammation associated with the modern lifestyle. Prediabetes is usually diagnosed by checking an a1c level, which is the percentage of hemoglobin that binds to sugar as a percentage of normal hemoglobin.

If you a1c is between 5.7 and 6.4, you are considered to have “pre-diabetes”

There are 5 types of hunger that ideally should be taught to all patients with obesity

Without cultivating an awareness of appetite, hunger and cravings, a patient with obesity will not know what they are fighting against

So Let’s start! We are going to start with some easy ones…

The Cephalic phase response aka food cues - this is hunger stimulated when in presence of food.

These signals are deeply ingrained and can be conditioned

Think of Pavlov & commercials - these aren’t going away quickly or ever

The Crisis in Medicine Part 1/3🧵

“I want to paint a picture of how corrupt our medical system is.”

Doctors, the traditional gatekeepers of health and wellness, have abandoned their role as advocates for patients in favor of compliance with a system that rewards volume over value. This shift has eroded the foundations of trust, compassion, and accountability that once defined the doctor-patient relationship. Over the past several decades, the profession has devolved into a series of disconnected, transactional encounters, leaving patients sicker and doctors disillusioned.

The tragedy is that this decline wasn’t inevitable. It is a failure born of choices… choices made by physicians, healthcare administrators, and policymakers who prioritized financial gain over human well-being. Doctors, rather than rising above the constraints imposed by insurance companies and dogmatic guidelines, have allowed themselves to be reduced to cogs in a profit-driven machine.

The results speak for themselves: skyrocketing rates of chronic disease, polypharmacy as the default treatment, and a complete abandonment of empathy and rapport as tools for healing.

The Shackles of Insurance and Dogma

Accepted insurance contracts have transformed healthcare into an assembly line, where the primary objective is to maximize RVUs rather than optimize patient outcomes. Physicians are incentivized to see as many patients as possible within an eight-hour day, often spending less than 15 minutes with each person. In this time, they must review charts, check boxes, and meet pre-approved insurance guidelines—leaving little room for meaningful conversations or root-cause analysis.

Motivational interviewing, a cornerstone of behavioral change, is nearly nonexistent in this environment. Listening to a patient’s story… truly hearing their struggles, fears, and goals… has been replaced with a perfunctory review of symptoms and a prescription pad. When the system demands efficiency above all else, the doctor’s role shifts from healer to bureaucrat.

But this isn’t just about time constraints. The deeper issue is the abdication of intellectual curiosity. Doctors have become so entrenched in dogmatic guidelines that they no longer question whether those guidelines are effective. Lifelong learning, once a hallmark of the medical profession, has been reduced to obligatory continuing medical education (CME) credits, which often reinforce the very guidelines that perpetuate the problem. The result? A workforce of physicians who are well-versed in polypharmacy but blind to the tenets of metabolic health.

The Forgotten Tenets of Metabolic Health

Metabolic health is the foundation of human health, yet it remains one of the most neglected aspects of modern medicine. Simple, evidence-based strategies like reducing ultra-processed foods, improving sleep, managing stress, and encouraging movement are rarely discussed in primary care settings. Instead, doctors reach for sleeping pills, antidepressants, and, most recently, anorexic injections like GLP1s.

The medical system’s reliance on pharmaceuticals as a first-line solution reflects a broader failure to address root causes. It is easier to prescribe a pill than to engage in the hard, messy work of behavior change. But this convenience comes at a cost. Patients remain trapped in a cycle of dependency, their symptoms managed but their underlying conditions ignored.

The neglect of metabolic health is not just a failure of individual doctors; it is a systemic failure. Medical schools dedicate minimal time to nutrition education, and residency programs prioritize acute care over preventative strategies. The result is a generation of physicians ill-equipped to address the chronic diseases that now dominate their practices. The Crisis in Medicine - Part 3/3 🧵

Accountability in Medicine: A Missing Standard

One of the most glaring deficiencies in modern medicine is the absence of accountability. Unlike other high-stakes professions, doctors are rarely held to measurable standards of success. There is no quarterly or annual evaluation of patient outcomes, no system to reward exceptional care or address poor performance. The only metrics that matter are RVUs and salary, both of which incentivize quantity over quality.

This lack of accountability is particularly striking when compared to other fields. If airplanes were falling out of the sky, we would hold pilots, maintenance crews, and engineers accountable. We would investigate every failure, implement corrective measures, and ensure that it never happened again. Yet in medicine, where the stakes are equally high, there is no such culture of responsibility. Doctors who consistently produce poor outcomes face little consequence, and those who achieve exceptional results receive no recognition.

Without accountability, there is no incentive for improvement. Physicians have no reason to question their practices, explore new approaches, or challenge the status quo. They become complacent, and patients suffer the consequences.

The Erosion of Empathy and Community Leadership

Perhaps the most tragic aspect of modern medicine is the loss of empathy and human connection. The role of the doctor as a community leader, a neighbor, and a trusted confidant has been replaced by a faceless bureaucracy. Patients are no longer seen as individuals with unique stories and struggles; they are cases to be managed, codes to be billed, and data points to be entered into an electronic medical record.

Empathy, once the cornerstone of medical practice, has been sacrificed on the altar of efficiency. Doctors no longer have time to listen, let alone build rapport. Motivational interviewing—a simple yet powerful tool for fostering behavior change—is rarely practiced. Instead, patients are met with a litany of prescriptions and referrals, each one a tacit acknowledgment of the doctor’s inability (or unwillingness) to engage on a deeper level.

This loss of empathy is not just a personal failing; it is a systemic issue. The medical system actively discourages doctors from forming meaningful connections with their patients. Time spent listening and understanding is time that cannot be billed. And so, doctors learn to suppress their humanity in order to meet the demands of the system.

Should Doctors Be to Blame?

Absolutely. While the system bears much of the responsibility, doctors themselves must also be held accountable. They have allowed their profession to be co-opted by insurance companies, pharmaceutical giants, and hospital administrators. They have accepted the constraints of RVUs and dogmatic guidelines without protest. And in doing so, they have failed their patients.

It is tempting to absolve doctors of blame, to view them as victims of a broken system. But this perspective ignores the agency that every physician possesses. Doctors have the power to question, to challenge, and to change. They have the power to demand better for their patients and for themselves. But too many choose the path of least resistance, prioritizing financial gain and professional convenience over the hard work of advocacy and reform.

If doctors don’t take ownership of their failures, why should patients? If physicians are not willing to rise above the system, to challenge its shortcomings and demand accountability, then they are complicit in the harm it causes.

1/ 🚨 Big news for #Type1Diabetes: The Society of Metabolic Health Practitioners @TheSMHP has published its position on Therapeutic Carbohydrate Reduction (TCR) as a viable, evidence-based option for improving glycemic control.

Here's why this matters... 🧵doi.org/10.4102/jmh.v7… 2/ Despite advances like hybrid closed-loop insulin systems & CGMs, T1DM outcomes remain suboptimal. Only 21% of adults w/ T1D achieve an A1C <7%, & complications like insulin resistance & "double diabetes" are rising. We need better solutions. Enter TCR.

THREAD: 🧵

CGMs - continuous glucose monitors

Having looked at 10,000+ CGMs let me tell you what you will learn...

1/9 Lesson 1: Hidden carbs are everywhere
- you will find hidden sugar & carbs everywhere.

You didnt know you could find carbs/sugar but you will:
hotdogs, sausage, beef jerky, spices, condiments, sauces, soups, broths, basically everywhere you didnt look.

2/9

🚨 THREAD ON WEIGHT LOSS & EXERCISE 🚨

Many patients ask me about exercise for weight loss, and getting toned.

We are often advised to exercise, however, if we are severely overweight this can be quite challenging. I typically advise patients to focus on fixing the diet first and forgo exercise for the first 6-8 weeks of any weight loss plan. if your diet isn’t in order & your appetite isn’t controlled, exercise will increase appetite and likely stall weight loss.

After helping thousands of patients lose weight, here’s my advice for those looking for lifelong, sustainable life changes. These are the “5 MUSTS” anyone trying to lose weight lifelong NEEDS to do.

🧵/Thread Before you understand my “5 musts”, simply ask yourself -what are the side effects of your prior weight loss attempts- NOT your reasons, NOT what you want to happen, what went wrong, what made you stop?

🚨THREAD

Why calories NEVER mattered...

Summary:
Poorly calculated
Don’t quantify hormonal effects on appetite
Labels/Tracking don’t effect intake
Worse outcomes vs. dieting

Follow along with this fully cited thread 1/n We have known as far back as 1982 that tracking calories, food logging is inaccurate & doesn’t predict weight loss

10.1093/ajcn/35.4.727

I have a serious problem with the term “pre-diabetes.”

The prefix “pre” is used to describe what comes before something.

In reality, “pre”-diabetes is actually AFTER or “post” 15 years of the high insulin levels & inflammation associated with the modern lifestyle. Prediabetes is usually diagnosed by checking an a1c level, which is the percentage of hemoglobin that binds to sugar as a percentage of normal hemoglobin.

If you a1c is between 5.7 and 6.4, you are considered to have “pre-diabetes”

There are 5 types of hunger that ideally should be taught to all patients with obesity

Without cultivating an awareness of appetite, hunger and cravings, a patient with obesity will not know what they are fighting against

So Let’s start! We are going to start with some easy ones…

The Cephalic phase response aka food cues - this is hunger stimulated when in presence of food.

These signals are deeply ingrained and can be conditioned

Think of Pavlov & commercials - these aren’t going away quickly or ever

How statisticians and researchers arrived at the conclusion that the BlueZones are a FRAUD. 🤔

🔑 Thread with key excerpts

1/n “When these states transition to state-wide birth registration, the number of supercentenarians falls by 80% per year“

2/n

🚨 Thread on LDL Lowering & low carb🚨

How I approached high LDL in my patients, and how we observed a DECREASE in LDL of 480mg/dl !!!!

About my published case-series of 5 patients and clinical experience with thousands of patients …

(1/20) As data supporting low carb diets has proliferated for weight loss, diabetes, seizures, mental health and other conditions, patients are now presenting with various issues related to the diet

2/20

THREAD: 🧵

CGMs - continuous glucose monitors

Having looked at 10,000+ CGMs let me tell you what you will learn...

1/9 Lesson 1: Hidden carbs are everywhere
- you will find hidden sugar & carbs everywhere.

You didnt know you could find carbs/sugar but you will:
hotdogs, sausage, beef jerky, spices, condiments, sauces, soups, broths, basically everywhere you didnt look.

2/9

THREAD ALERT 🚨

I love the curious & creative thinkers, the patients who question everything, b/c answering these questions makes me a better educator & confirms my commitment to lifelong learning & shared decision-making

1/10 I don't “kick patients out” for presenting difficult questions… a cruel, yet common, practice among paternalistic/authoritarian doctors... I instead embrace the questions

I use them as an opportunity to dig deeper, understand more and understand better.

2/10

🚨 THREAD ON WEIGHT LOSS & EXERCISE 🚨

Many patients ask me about exercise for weight loss, and getting toned.

We are often advised to exercise, however, if we are severely overweight this can be quite challenging. I typically advise patients to focus on fixing the diet first and forgo exercise for the first 6-8 weeks of any weight loss plan. if your diet isn’t in order & your appetite isn’t controlled, exercise will increase appetite and likely stall weight loss.

How to INCREASE your low testosterone?

Thread 🧵 Testosterone is a steroid, anabolic hormone made in the testes and ovaries

After helping thousands of patients lose weight, here’s my advice for those looking for lifelong, sustainable life changes. These are the “5 MUSTS” anyone trying to lose weight lifelong NEEDS to do.

🧵/Thread Before you understand my “5 musts”, simply ask yourself -what are the side effects of your prior weight loss attempts- NOT your reasons, NOT what you want to happen, what went wrong, what made you stop?

🚨 THREAD 🚨

GALLSTONES & GALLBLADDER DISEASE

Everything you need to know about gallstones as it relates to diet and dietary composition.

👇🏻👇🏻👇🏻👇🏻👇🏻 In the obese during rapid weight loss from a very low-calorie diet, a relatively high fat intake could prevent gallstone formation, probably by maintaining an adequate gallbladder emptying, which could counterbalance lithogenic mechanisms

nature.com/articles/08006…

🔔 10 woke takes from the world of Modern Medicine in 2024 🔔

1) climate change is more important than human nutrition
2) obesity is genetic disease that requires drugs
3) obesity is healthy & should be embraced
4) diets don’t work, carbs are good, meat is bad
5) masking kids prevents death & causes no harm
6) any living thing needs 9-10 COVID shots, especially pregnant women & young children
7) COVID shots prevent long COVID & myocarditis
8) DNA & chromosomes don’t mean much, they are fluid, so is biology
9) the AMA covering the ethics of banning meat & NEJM covering climate change is more important than the diabesity epidemic
9) take drugs for every chronic disease
10) luck charms is healthier than eggs People wanted context - lie 1

1) “Meat is unhealthy”

Meanwhile it’s associated with improved mental health, improved bone and muscle health and newer studies like that from PURE show that excluding it is bad for mortality

There are 5 types of hunger that ideally should be taught to all patients with obesity

Without cultivating an awareness of appetite, hunger and cravings, a patient with obesity will not know what they are fighting against

So Let’s start! We are going to start with some easy ones…

The Cephalic phase response aka food cues - this is hunger stimulated when in presence of food.

These signals are deeply ingrained and can be conditioned

Think of Pavlov & commercials - these aren’t going away quickly or ever

How statisticians and researchers arrived at the conclusion that the BlueZones are a FRAUD. 🤔

🔑 Thread with key excerpts

1/n “When these states transition to state-wide birth registration, the number of supercentenarians falls by 80% per year“

2/n