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Krishni

About Krishni

http://therunawaydoc.com

Posts by Krishni Ratnam:

choleserol post

Lower cholesterol; why your diet is not working and other pitfalls

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I know I need to lower my cholesterol. That did not stop me from eating lunch at Pizza Express and ordering a whole pizza for myself. It had peppers so that made it marginally more healthy…right?

I am going to ignore the fact I also ordered dough balls and fried calamari.

The truth of it is whilst I am trying to be more mindful of my diet, it’s actually damn hard. I have always said food addiction is the hardest addiction to beat because…you need to eat. You can’t simply abstain from it wholly. So I really do empathise with anyone trying to lower cholesterol.

Whilst working through a food diary with my personal trainer, I decided to do some research. Just to see if there was anything I was missing in my own knowledge or any myths. However let’s get the basics right:

Cholesterol is a necessity and not all cholesterol is bad

What even is cholesterol? It’s one of many types of fat found in your body. Pretty simple. It’s implicated in cell membranes structures (your little building blocks of the body) and a number of hormones which keeps your body going. However, much like anything in life, too much of a good thing can be bad

You have probably heard of good and bad cholesterol i.e. HDL (high density lipoproteins) and LDL (low density lipoproteins)*. Technically, these molecules are not cholesterol, just the structures in which cholesterol resides. What differentiates them is LDL molecules carry more fat than HDL molecules and where they end up eventually depositing said fat. To keep things simple, HDL helps to remove fat from the bloodstream and LDL does the opposite and because LDLs carry more fat, you can see how you could end up with more fat in your circulation which is what leads to atherosclerotic disease (in simple english, “fuzzied up vessels”). This means an increased risk of arterial clots leading to heart attacks and strokes.

4 little known facts about lowering cholesterol

1) Lower Cholesterol Diets Don’t Work; Trans and Saturated fats are the problem

It makes sense intuitively right? Don’t eat cholesterol, you can’t have high cholesterol right? Actually a lot of research has shown that dietary cholesterol in itself is not likely to be the problem.  It’s also well worth pointing out that only roughly a quarter of your cholesterol is dietary, your liver is responsible for making the majority of it.

What has been shown though is a diet high in trans or saturated fats, rather than cholesterol itself, seems ot be the culprit in increasing  LDL in the body. Furthermore it can reduce levels of HDL as well. This is particularly true of hydrogenated (artificial) trans fats, so think of all your processed meals such as microwave meals. They are also implicated in more oxidative stress on your vessels just to add further insult, which means more chances of a clot forming.

Ideally for your lower cholesterol diet to work, you need to be eating foods without them. See this link for a list of foods which work (Editors note 04/2024: Post to be done in the future!).

2) Sleep helps to lower Cholesterol

Why do we ask patients to take a statin at night time? It’s because a lot of cholesterol metabolism occurs at night time. A few studies have shown that disrupted sleep leads to an increase in not only cholesterol but also triglycerides (another topic altogether). There is one study which suggests no association directly related to cholesterol however mentions another study in Finland which found disrupted sleep, rather than the length of sleeping being a potential cause.

There are three theories, the first one being an increase in appetite. This is due to decreasing leptin and increasing ghrelin levels (your gut hormones which tell you if you are hungry or not) so you may end up inadvertently facing the first problem of eating poorly. The second is a lack of energy to do physical exercise, discussed below. The third theory is the increase in stress and the implications it has on cholesterol directly.

3) You Can’t Lower Cholesterol Without Tackling Your Stress

Now the mechanism behind stress and cholesterol is thought possibly related to cortisol release or even due to adrenaline. Whilst I could not find any studies looking directly at the impact on cholesterol from cortisol (bar this one  and few others looking at triglycerides mentioned here, there are a lot of studies which correlate with stress overall being a factor in high cholesterol and overall poor cardiovascular health.

4) You have to do the right type and mix of exercise to lower cholesterol

So I’m a runner (I used that term loosely!). What shocked me was that in spite running at least three times a weak for at least half an hour, along with dancing once a week for an hour to a reasonable intensity, my LDL was very high. My HDL was not too bad, could be better.

This meta-analysis (a study looking at loads of studies) actually shows there was a good correlation for increasing HDL with aerobic exercise (which was what I was doing). The problem was the level of intensity. Whilst prolonged runs are in on itself fine for HDL, the increase in intensity of my runs (measured again what my max heart rate can reach) is the key to reducing LDL (and triglycerides).

I also had not factored in any resistance training either. Resistance training from this analysis seems to have bigger implications for LDL and triglycerides rather than increasing HDL unless you increase the intensity.

What does this all mean for me (and for you!)?

It all boils down to this:

  1. Stress less
  2. Less broken sleep
  3. Mix up my exercises and intensity
  4. Avoid trans and saturated fats.

How to go about all of this without going overboard and inevitably failing is something is tough. All this while I am navigating a career change (Maybe). Even though I am doctor and I give advice around high cholesterol, the actual realities of doing it from my reading and my own experience is humbling to say the least. I hope at some point in the future this blog also serves to be a place where people can learn about better health in a simple manner.

I say this as I tuck into last night’s take out.

*There’s more than just LDL and HDL but keeping things simple for now.

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Leaving medicine; it’s a divorce

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I had another reminder of why leaving medicine is so difficult for doctors. I had the following interaction recently:

“How much for the rear light to be repaired?”

“Oh it’s about £200 for the parts alone Miss….oh no wait, you’re a Dr?!”

“Erm…yeh, ahaha…”

“You worked so hard to become a doctor! Why do all the doctors I speak to never address themselves as doctor?!”

To be honest, I don’t know why either. Is it years of being a junior doctor, kowtowing simply to get to the next stage?

Indoctrination of not raising your head above the parapet so as to not appear boastful to other MDT members?

Or maybe it’s simply years of feeling like a fraud knowing very well just that morning I typed into google “I want to leave medicine!”. Something which I have typed multiple times at various points over the past 15 years.

Leaving medicine is like a divorce

The interaction I had with the sales clerk reminded me of how I often compared my feelings towards medicine to a loveless arranged marriage. Something which very nearly happened to me.

When I was with my then “forever person”, I was incredibly proud to show him off. I had made it. I was acceptable in society. Medicine made me feel the same.

There’s other benefits similar to marriage too. It gave me some semblance of stability financially, and my days on average have generally been “okay” and “safe”.

My problem with medicine is it just continues to take so much away from me. It’s a very needy partner with increasingly no boundaries. I say this having spent my evening finishing my clinic notes, never mind my referrals. This is just one example of the encroach the job has on my life outside of work, and why I feel I must leave medicine a lot.

A loveless marriage

I akin it to an arranged marriage in my culture because doing medicine, my family were expecting it. Of course I was going to be a doctor, I was clever and come form a line of doctors. And much like the arguments still levelled at me about just settling down with someone my family picks, I will simply learn to fall in love eventually.

It’s been 15 years. It has not happened.

In a marriage (or a relationship in my case), if there is no love, it’s a recipe for a slow death. Much like how I felt about my relationship to my ex, I feel like I have given enough over the past 15 years to medicine. The stability, the pride and even the honest to good parts of helping people are just not enough anymore to keep me committed to the long term, and the feeling wanting to leave medicine just never dissipated.

Grief when it all breaks down

Sadly even in the worst of relationship breakdowns, there is still very real grief. I wanted so badly for this to work out. Why can’t I just love it like my peers? Even just find the best of a bad situation and make peace and not leave medicine?

I know the the five stages of grief well. Denial ? For years I denied how I felt as a way to preserve myself through training, otherwise I would have ended up quitting midway. Anger? Plenty of anger directed at myself over the years. Bargaining? That’s probably where I am right now, with me trying to explore other avenues inside medicine in a desperate attempt to find something which does not mean leaving medicine. Depression? I crossed that off many years ago and it still comes to haunt me from time to time.

Acceptance? Now that comes in waves but I think it is now staying with me for longer periods of time thankfully.

The shame of a divorce

Feeling torn between staying because of sunk cost fallacy, and just quitting, at the heart, lies very real shame. Quitting is seen as a very negative thing. A sign of you just not trying hard enough. Being spoiled even.

Something I know divorcees are often accused of.

I am not a trust fund baby (I wish!) but I did grow up in relative comfort, my student loans are all paid off now, and I have zero experience of the reality of the job world outside of medicine. Medicine is a safe place, there will always be a need for doctors*. I have a lot going for me and the job itself is a privilege too.

Being a doctor means I get to know people in a more intimate way than most, being privy to people’s very real fears. I also know I can help people to reach their highest as well (health wise). The role of a GP, although sadly decreasingly so because we just simply can’t, is almost sacrosanct to this in some ways as we really do see people from birth until death.

So leaving medicine given the shame of letting of such privileges lead to wrestling with myself internally for years.

I want to fall in love

At the end of a relationship or a marriage I think there is usually a feeling of “I’m never committing to anything ever again”. Sometimes it stays forever . Most of the time however, later on you realise why you ended things in the first place, or if you didn’t end it, it blossoms into this.

You want to fall in love (again)

I really really want to find that career that gives me that feeling. I know it exists. A multitude of experiences over the years has lead to me realizing the lie that “no one loves their job” is just that.

A lie.

Don’t get me wrong reader, it might be through working as a GP. Working post completion of training, life gets better apparently. The old saying “the grass is not always greener on the other side” remains true. Not a lot of jobs also afford me the flexibility of how I can work currently.

I think for now though, given the flexibility still afforded to me**, much like finding the right partner, I want to explore not looking for “perfect” but “perfect for me”.

*With the advent of extended roles and AI, I believe medicine is going to become similar to other degrees in the future in that you may end up having to do something else entirely and/or diversify. See this 2022 report of fresh graduates being without a job. Those foundation year applicants would have eventually found jobs but the fact that there has been an increase each year is troubling.

** The locum market as a GP is tenuous at the time of writing. Many things have contributed to this and will write more on this at some point. In the mean time if you are a GP or a GP registrar reading this, I implore you to join the BMA and get involved. The junior doctors have shown what can be done, now it’s our turn.

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I’m a doctor and I’m living with my parents

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(Building a website is both fun and frustrating, I miss the good old days of angelfire…if you don’t know what that is then you’re probably young enough to be my son or daughter, shudder the thought)

I finally started packing my flat last weekend. I had been putting it off since I found an estate agent to lease my flat out. It’s so odd seeing my life packed away in a few small boxes.

I had told myself that it was going to be easy to move out. I already spend so much time with my parents anyway after my friend’s mother passed away which triggered all manner of anxieties in the last year. I was frustrated with having half of my stuff at my parents and half at mine. I was wasting money on heating and electricity if I am only there for a few weeks a month.

But boy did I cry when I looked at my empty room devoid of all the character which I had brought to it over the past few years after I had packed it up.

Why on earth was I moving out? I can afford to live here, the mortgage has decades on it. I just need to work more sessions or do a few more locum posts to cover it each month.

That was the problem.

Forget about the rubbish contract the government has imposed on practices nationwide yearly meaning practices who are also dealing with every increasing costs just can’t afford to hire locums. Forget about how the ARRS scheme has reduced demand for locum GPs even more. Forget about how partnerships and salaried jobs just aren’t attractive enough for GPs to really take the plunge and commit.

I also just did not want to work that much at all this year.

The best way I can describe it is that the more sessions I work, the amount of other work generated which does not get accounted for increases. And it’s not linear the amount, it often felt more akin to a logarithmic scale. The mental exhaustion certainly felt logarithmic.

Without meaning to sound dramatic but coming from a doctor practicing for the past 10 years, I can honestly say this:

GP is the hardest f***ing job I have ever done.

I knew from my first GP placement in ST1 (the first year of specialty training) I had to go less than full time training in ST3 where I would be in GP for a whole year. Otherwise I would have a stroke.

So whilst I could try and find some salaried posts, I would be tied down to doing potentially a number of sessions which I am not comfortable doing, only to take more work home and then leaving me with no time to do figure out where I want to go with my career because I would just be too damn exhausted to think.

I don’t want to live my life like a zombie forever, being a slave to work on the off chance I might end up unemployed. (link GPonline article)

So considering that I am in a career flux, and I have to be sensible about my expenses to pay, I realized that sacrifices must be made and that came in the shape of my flat. My flat represented so much more than just a sanctuary for me. It marked a point in my life where I felt like I had made it to adulthood, whatever that meant.

So it felt like a step backwards

But after I was done packing my car up, I decided to try and reframe it in my mind. What if this was actually a massive step forward? A hero’s journey is not without it’s troughs and this was mine.

What if my whole stepping into adulthood is me actually taking responsibility for my choices in life for once, rather than continuing down the conveyor belt blindly as I had been doing so for years?

That sounds a lot better right?

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Running towards a new future; a lost doctor

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As I sat staring at my blood test results on my NHS app telling me at the tender age of my early thirties that my cholesterol is high and I am one point away from being deemed prediabetic, as a doctor, you go through the whole gamut of questions around why?

And yes early thirties is still young if you whipper snappers think my age has anything to do with it, so you can park that thought swiftly, thank you.

Is it my diet? I mean sure, Christmas was not too long ago, I went on a very long trip around Japan which was filled with food. I could do with eating more vegetables, true. But I rarely drink alcohol, rarely snack and in all honesty my portion control is borderline criminal according to my mum. Sure thing, I’ll do a food diary just to see.

Is it my weight? I don’t have any central obesity and my BMI is well within normal limits. If anything I can do with gaining weight…

Is it a lack of exercise? I’m a GP and play around with computers a lot. I like my social media and Netflix. This all leads to an awful lot of well sitting with cups of tea. I would have said that a few years ago but I consistently run at least 3 times a week with a minimum of 1.5 hrs of high intensity exercise, precisely to avoid this scenario from occurring.

Genetics? Sure, that was the reason why I had asked my GP for the blood tests, let’s get that referral.

But my cholesterol is ridiculously high, and not quite referral threshold to seriously consider that purely genetics are to blame.  My HBA1c too, the standard belief is that it’s all related to weight and diet and I am okay on all these fronts.

No there was something else afoot.

I was stressed and had been stressed for a very long time.

As a medic, there is a degree of just keep going no matter what. Apart from one instance where I had a mental breakdown, wholly due to someone else in my life, and few years as an FY3-4 (“gap” years between foundation training which you’re expected to complete after finishing medical school and specialty training), I had been on the treadmill of training for years, almost 15 years in total. 

Even in my FY3-4 years, I knew I would return back. Because…well I’m not entirely sure why and that’s the reason why this blog exists.

The stress of facing “what the hell am I going to do now?”as a fully qualified GP started in my last year of training. Whilst I am immensely grateful and dare I say it, proud to have reached where I am, I am no wiser as to what I want to do with my life.

What on earth are you talking about, you’re a GP, you’ve made it!

A number of events in my life and people/patients I have met have unfortunately broken my little bubble of “stop dreaming, shut up and put up”. I had spent years suppressing any thought of “there has to be more, this is not the life I have envisioned for myself”.

Quite successfully may I add, I got here after all. Getting though GP training is not a walk in the park.

However, there was a little voice in me which would cruelly pipe up now and again which would whisper

“You managed to get this far doing something you don’t feel a great deal of passion for…

…imagine what you can make of yourself doing something you really loved”.

What a b**** of a voice, eh? And all it did was kept getting louder and louder until I could ignore it no more.

And now I actually have to do something about it.

So join me as I try and figure out a career for myself as a doctor who is not entirely sure where she is going with it all.

(I also like to run so will talk about that too along with discussing general practice in the UK and what it’s really like…basically I’m just going to throw in a good natter as it were)

Ciao x

P.S. those links are some good articles on stress and the impact it has on cholesterol and glucose regulation. I have not critically appraised them fully but seem reliable enough.