Introduction to Dr. Naomi Parrella
Dr. Eric Westman: It’s my great pleasure to have Dr. Naomi Parrella with me today.
Dr. Naomi Parrella: Thank you so much for having me.
History
Dr. Eric Westman: For someone who doesn’t know who you are, please introduce yourself and how you got into obesity medicine.
Dr. Naomi Parrella: I wear three different hats. I’m a family medicine board-certified and obesity medicine board-certified specialist. I work here in Chicago at Rush University, and with that hat, I see patients and take care of them using lifestyle interventions and all the different approaches for weight loss.
Then, I have two other hats. One is where I do a lot of community and company engagement activities around health on a large scale. Out of that, I started seeing that we needed some digital support. So, my third hat is that I’m the Chief Medical Officer for Zero Longevity Science, which is a fasting app. That role is really about democratizing and spreading these concepts around the world.
Dr. Eric Westman: That’s a full plate. We’ve crossed paths around obesity medicine. What’s the typical kind of patient that you see?
Are you, like me, using low-carb, keto, or other medicines? Describe your clinic.
Dr. Naomi Parrella: You asked how I got into this space. I started in primary care, doing family medicine, and I had a private practice. I was doing all the things, telling people to eat less and exercise more.
Then, it was actually your work and Gary Taubes’ book, Good Calories, Bad Calories, that really changed how I saw things. I had some really cool patients who were willing to experiment with me, and we discovered that what works better is changing lifestyles in ways that affect insulin.
In our clinics, we are very focused on performance optimization – not just weight, but all areas. Whether it’s your health, work, relationships, or just having fun, we want to help people achieve their best.
They might come in for weight loss or weight management, but our goal is for them to walk out better, stronger, more productive, and feeling more like themselves. A lot of times, weight loss is just a side effect of getting better and getting our metabolism on track. That’s what we do.
Lowering insulin levels
Dr. Eric Westman: You mentioned lowering insulin levels. Why would that be important?
Dr. Naomi Parrella: As I’ve learned over time, from reading the literature, seeing patients, and hearing from so many wonderful contributors to this field, such as yourself, we know that insulin is crucial because it determines where your fuel is coming from and, specifically, if you can burn fat or not.
To put it simply, I tell people, if your insulin is very high, there’s no fat burning happening. If your insulin is low, that’s a pretty good sign that you can burn fat. If we can manage insulin, we can manage weight and obesity.
Dr. Eric Westman: Yet, do most doctors check for insulin?
Dr. Naomi Parrella: I don’t know anymore. In the past, definitely not. It was the outlier. Insurance companies often don’t cover the cost of the medication. However, it’s so powerful to understand, especially now with these injectable weight loss medications.
Depending on where your insulin is and what you’re eating around it, it’s going to affect your insulin levels, which in turn affects whether you’re going to burn off muscle or burn off fat. That’s a very, very different long-term outcome.
Diets being a powerful factor
Dr. Eric Westman: Before we get to the medications, what kinds of things can diet alone do?
Dr. Naomi Parrella: Diet is actually the most powerful factor. One of the most powerful things with regards to diet is that it gives you the nutrients you need to build and maintain cells. Depending on what you put in, that determines the quality of the cells you create.
Also, diet helps your body decide whether you’re going to burn fat or not. As much as we used to think it’s all about the calories, it’s really about what those calories are doing to your insulin. Anything that helps lower insulin, lower carbs being number one, including sugars and all the starchy foods, and what we can pretty much eat a lot of, and ultra-processed foods are often, sort of lumped into that as well.
Making sure that you get adequate protein, fats, and vegetables helps your body have the nutrients it needs to build and maintain healthy cells so that you burn off fat for fuel and then build muscles and other healthy tissues.
Fat as a fuel source
Dr. Eric Westman: Carbs basically compete with fat as a fuel source. If you want to burn fat, you have plenty on your body already. You cut the carbs out, and then the fat starts to burn. It’s pretty amazing.
Dr. Naomi Parrella: Yes, totally.
Dr. Eric Westman: There’s a lot of discussion about foods causing ‘fullness’ and all that, but this is a different kind of thing. People wake up in the morning, and they’re not hungry. It’s like they’re not eating food that’s satiating or making them feel full, they’re already fat burning. The hunger going away, I saw that very quickly, and yet nobody believed it because they thought you had to cut out what you ate to lose weight. The fat burning is almost unbelievable because it happens on its own.
Dr. Naomi Parrella: Totally agree. I think that’s one of the fun things when people say, “Oh, my body’s not working. My metabolism is broken.” I’m like, “No, you just aren’t tapped into that largest fuel source that runs so clean.”
We know when you burn fat, you breathe off carbon dioxide and pee off water. So, basically, it’s a clean fuel. When your body is running on that, the ketones that come from it cause that satiety. It’s so powerful that people are fine not eating.
That’s what happens as we go to sleep at night, our body gets into that fat-burning state. I think that’s one of the powerful things people don’t recognize. When you’re hungry all day, it’s because you haven’t let your body get into fat burning. It’s trying to stay in that sugar-burning and fat-building mode.
Dr. Eric Westman: It finally occurred to me after years of watching this happen that it’s normal for people to burn fat. If you don’t eat for a couple of days, it’s normal. I mean, we all do it. In fact, animals do it because we all store energy as fat, and the fat burning starts automatically.
Kinds of teaching
Shifting now to the teaching you’ve done for other audiences, what have you learned in terms of messaging? How do you talk to a large group? Explain the kind of teaching you’ve done and what you find to be effective.
Dr. Naomi Parrella: I think the hardest part is getting very complex physiology simplified in a way that people can remember it without taking notes or carrying around a booklet. It’s so hard if you have to, at a restaurant, pull out your notes and books and start digging into it. I really want you to go off and live your life.
I think when we give people language and visual stories, they can understand what’s going on with their body. I think that’s why you and I love to teach. Helping people carry that message into action and then tell somebody else. If you’re wildly successful with your weight journey, and you have all this energy and feel so good, people are like, “What are you doing? I want to do that too!”
It’s nice to teach in a way where it’s logical, easy to remember, and use language that people normally use. They don’t have to know about complicated receptors and the language we learn in med school. That’s useless when you’re out there. I think it’s really helpful to simplify the messaging to get to the key actions that deliver results.
Dr. Eric Westman: Sometimes when I teach other doctors, I’ll just explain that I’m not at the point where I want to know what the mechanic did so much when I take my car in, and it’s like, “Did you fix it? How much do I owe? When do I need to bring it back?”
Doctors can get into the weeds, thinking that the more we teach, the better. I think that’s right: the simpler the message, the better.
Dr. Naomi Parrella: Absolutely! A lot of times, you go to conferences, and people are on their phones, zoning out, because even for physicians, it’s so dry, not interesting, and not applicable. You can’t use that in the clinic. When you can find a way to explain key concepts and the specific behaviors that result in the outcomes people want, now that’s magic! Then, it can change not only an individual but their families, friends, neighborhoods, communities, and often their work environments as well.
Patients
Dr. Eric Westman: To someone new to this idea of lowering carbs or even tackling the insulin inside, can you give a story, a typical patient who comes in, and what happens? What do you see in your clinical practice?
Dr. Naomi Parrella: Sure! It might be somebody who’s very, very busy. They come in, and whether it’s busy with work, kids, travel, busy with whatever is going on in their life, or a combination, they come in and say, “I have tried everything, and I don’t have the time or energy to do all the homework. I tried all these different programs where there’s a lot of tracking and many steps to understand what’s going on. I just want to understand, what can I do with my medical history, with the medications I’m on, with the lifestyle that I have? What can I do to make a difference?”
It’s always so fun, because, if we check some labs, get some additional history, and look at the med list, we can start quickly figuring out which sort of lever is the easiest for that person to move that will make the maximum difference right away. Because once you start feeling better, everything else seems easier. In the past, I used to tell people to exercise first, and it’s just so hard to exercise if you don’t have access to your fuel sources. You might have high insulin, so you can’t burn fat. Now you have to eat all the time to be able to exercise, which is counterproductive. What I found was, by looking at somebody’s eating pattern, I’d ask them to bring in a food log. The food log doesn’t have to have all the details; I just need to get a general sense of the kinds of foods they’re having and the times that they’re having them.
Oftentimes, I’ll see somebody who either believes they need to eat multiple times throughout the day or that they feel like they have to because they get the munchies or they’re hungry. They might be snacking, even if it’s just one little Tootsie Roll. Or they’ll have half a bagel over here and the other half a little bit later, and they’re just kind of eating throughout the day. We call that grazing. Of course, when an animal, including humans, is grazing, that’s a sign to grow. That’s exactly what happens. If you’re done getting taller, you kind of grow sideways instead.
I think that’s the key messaging. Once people can see what’s going on, we can ask, “Why are you so hungry? What’s going on here? Let’s figure out how to change the signaling so that you’re not so hungry, so that you are in control, so you have the freedom to choose what you’re going to eat, not because you have to eat.” And that’s a game-changer. We’ll go through, we’ll look at the labs, and we’ll understand how sensitive or resistant somebody is to insulin. If they have very high insulin, then I know they can’t burn fat yet. Like you said, they naturally will become a fat burner once we get that machinery back up and running.
The key is to start understanding what needs to change, and almost always, it begins with:
- You need to at least not eat for 12 hours overnight.
- Cut down those carbs and sugars so that the insulin has a chance to come down low enough that your body starts turning on that fat-burning machinery.
Then off you go! You get so much more energy, and the weight starts dropping as a side effect of getting better.
Weight loss
Dr. Eric Westman: Do people lose weight? What’s the average weight loss?
Dr. Naomi Parrella: Average is all over the place, but people lose a lot of weight. We all have those patients that have lost 150 pounds, no meds, no surgery, and they are just crushing it by making sure they’re prioritizing the right things. For them, that was really important. Other people are like, “I’m going to have a little bit of carbs, maybe 100 grams of carbs, so I’m going to have to do more work to be able to manage that.” If somebody starts out metabolically unhealthy or their body isn’t burning fat all the time regularly, then we have to be a little bit more strict early on.
I think you’ve got several books that do a great job of showing the phases of change, where you train your body back to the original setting, where you can burn fat relatively easily. When you need fuel, you can burn it off your body.
Dr. Eric Westman: Listening to your comments, I’m struck by the personalization that we do in the clinic. It’s automatic. It’s hard to teach that.
If you’re watching this and you’re struggling, you’re at a stall, or you’re just getting started, what we can do is make it easier to take a full history and then pull that one lever, or maybe two, that we think will make the biggest difference. Rather than searching on the internet and getting a hundred different answers. I came from a meeting recently where people were searching online, trying this and trying that, what we do as obesity medicine specialists is help simplify and help people. In my experience, still, most people have never been in a medically supervised program. Is that your experience too?
Personalizing weight loss
Dr. Naomi Parrella: Yes, my experience too. A lot of times, people get confused because many weight loss programs only do one thing, they’re not personalizing it. Like you said, that is the most important thing.
Due to medications that somebody has to be on, or might have inadvertently stayed on or been put on, can affect weight. We can also see weight changes from untreated sleep apnea. There could be a bunch of different things that, unless you see somebody who’s looking at the big picture and thinking, what are the pieces of the puzzle that, if you have them, you are going to be wildly successful and it’s going to be so much easier?
I think that’s the part where an obesity medicine specialist really understands the full picture. Instead of going to a one-stop shop where they only offer one thing, you go to a one-stop shop where you have all the options. They can tell you and teach you about which one is relevant to you specifically.
Dr. Eric Westman: Probably the most common misconception still is that you have to exercise to lose weight. I’ll have people come to me in wheelchairs, and they lose weight! Then people start listening.
If you’ve never been to an obesity medicine specialist, we’re there to make things work. It has to work, at least in most people, or we have no job. Does it ever occur to people that if what we did didn’t work, no one would come back? It’s kind of a return-volume sort of business, but we want success for our patients.
Dr. Naomi Parrella: For the long term. I think we know a lot of people will have a 16-week program that they tried, and they might have done well during those 16 weeks. But what happens after?
Dr. Eric Westman: What happens at 16 weeks and a bit?
Dr. Naomi Parrella: Exactly. We’ve all heard this story, I’m sure you have too, where somebody’s lost an incredible amount of weight doing something, but they don’t know how to sustain it. It doesn’t matter what method it is. There are certain things we have to understand to be able to maintain that success.
Weight loss phase and a weight maintenance phase
Dr. Eric Westman: That’s why I’ve come to teach that there’s a weight loss phase and a weight maintenance phase. These could be very different things.
If you lose weight using a version of what you’re going to do when you maintain, you’re going to get comfortable with it. You’re going to learn that you don’t have to have as many carbs as you used to, if you use a low-carb diet.
These days, I see people coming in on the weight loss shots, and they’re not getting any sort of advice on what to eat. I wonder, is that your experience too? It’s the obesity medicine field; you have to tell people what to eat.
Dr. Naomi Parrella: You hit on something really important.
For all of us in obesity medicine, we know that weight loss medications can be very helpful if done properly for some people. But for many people who are not given that education, it sets them back. Down the road, it trains the body to regain weight rapidly. I think we’re not taking care of patients if we put them on a medication but don’t tell them how to use it safely or consider the long term. Many of my patients, I work in a clinic that also offers bariatric surgery, will come in and say, “I want to lose weight naturally.” They may or may not consider medications in that process, but they’re basically telling me they don’t want to have bariatric surgery. I say, “That’s fine. Let’s figure out the long-term plan. What’s going to be possible for you?” We can design and plan accordingly.
Then, somebody else comes in and says, “I want bariatric surgery. I’m going to lose a ton of weight. This is great”. They come in, and they do that, or they’ve been somewhere else where there isn’t a lot of long-term follow-up. They’ve had the surgery, and they’ve regained the weight. Now they’re really upset. And people will say, “Why didn’t anybody tell me what I needed to do long term?”
It’s the same thing with these injectable weight loss medications. You get success early on if you’re doing something along the right path, but it can end up where, in the future, the weight regain is almost guaranteed unless there’s some other additional knowledge and changes along the way.
Zero Longevity fasting app
Dr. Eric Westman: Yes, that’s been my experience too. Switching gears, your third hat that you wear. Tell me about Zero Longevity.
Dr. Naomi Parrella: Zero’s a fasting app.
Dr. Eric Westman: It’s a fasting app?
Dr. Naomi Parrella: Yes.
Dr. Eric Westman: What does that mean?
Dr. Naomi Parrella: It’s an app where you can monitor and track your fasts and other behaviors such as your sleep and weight.
Dr. Eric Westman: Fast, meaning a period without eating?
Dr. Naomi Parrella: Yes. Sometimes we use it for other things too.
This app is a way to track your eating times. It’s quite helpful if you just want to make sure you’re nailing, for example, 12 hours, or if you’re doing a 14- or 16-hour fast. The purpose is for you to recognize patterns and be able to track and see the streak of what happens if you get, let’s say, three days in a row or four days in a row where you’re able to establish some kind of awareness and consistency. What we’ve found is that just by the simple act of setting the time, saying, “I finished eating for the day,’ and then the next morning or next afternoon, “Now I’m starting to eat”, just by clicking on that, it primes the brain. It makes you more mindful that you’re taking care of yourself, being deliberate about what you’re putting in your body.
That’s been helpful for many people. And we find it’s very cost-effective. You end up eating less. It also facilitates low-carb eating. Low-carb and keto help make intermittent fasting almost happen naturally. Is that what happens automatically if you’re low-carb or keto? Again, it’s just marking your natural physiology. When people start becoming aware, it becomes so much easier.
Sometimes people will say, “I don’t know about fasting, but I’m definitely willing to cut out these sodas or this pop.” I say, “Great! Let’s get rid of the sugary beverages.” Then you can set the timer when you last had one, and let’s see how long you go without it. People often surprise me! They’ll come back and say, “Turns out I didn’t need it at all.” We can use it for many different things, but I like the simplicity of being able to track when you’re deliberate about whatever choice you’re making.
Intermittent fasting and what it is
Dr. Eric Westman: If someone hasn’t heard of intermittent fasting, can you describe what it is?
Dr. Naomi Parrella: Intermittent fasting is so easy to describe because it’s basically not eating for a period of time. Some people call it “time-restricted eating,” where they focus on the number of hours that they’re eating versus intermittent fasting, where you focus on the number of hours you’re not eating. The purpose of that, again, is to lower insulin, the same thing that we’re doing with low-carb and keto. It also has a different effect because it gives the gut rest, which helps with the circadian cycling of the gut microbiome. Then there’s neurochemistry, it helps allow the body time to clean house.
Autophagy is a term that’s commonly used, and it’s basically about cleaning up and recycling cells that need to be removed from the body. When that happens, you then eat something during your eating window or your feeding window. If you’re eating proteins, fats, and vegetables, then your body is going to rebuild the cells that it needs. It’s able to build back much cleaner, more functional cells when you put great products into your body like real food, protein, and vegetables.
Incorporating intermittent fasting into teaching
Dr. Eric Westman: My teaching is, let your hunger tell you when to eat, at least at first. I kind of look at intermittent fasting or one meal a day, which is a 24-hour fast, as a second-level, sort of troubleshooting thing. How do you incorporate that into your teaching?
Dr. Naomi Parrella: I do that as well. I think about it as, first, when are you hungry? When do you want to eat? What’s the longest period of time you can go without eating? If you’re saying, “I’m not hungry for breakfast. If I don’t need it, then I’m not going to have it,” and you find that you’re not eating until 10, 11, or 12, you’re intermittent fasting already. That’s super helpful.
If, on the other hand, somebody’s like, “I can’t go eight hours without eating. I have to eat right before I go to bed. Sometimes I have to wake up at night and eat something. Then I wake up in the morning, and I have to get something right away. I have to kick people out of my way so I can get to the refrigerator.” If that’s the case, then that means the insulin is very high, probably at baseline. That likely means your body can gain weight very, very quickly, and not in a great place, usually around the waistline, around the organs, and the liver. When we see that pattern, then the goal is to start pushing that fast so that you can go a little bit longer. That’s a treatment that starts training your body, putting a little stress on the body, to start wanting to burn fat to be able to bring that insulin down.
It’s very difficult, but it’s also a wonderful marker as it becomes easier (and it always does if somebody actually does this). If they start cutting out their sugars and the starchy carbs, then they start noticing, “Wow, I just wasn’t hungry. I actually forgot to eat,” or, “It got a little bit later than I expected,” or, “I was able to skip that time and shift it a little bit later in the day.” Fabulous. Now you’re getting that metabolic flexibility. Now you’re starting to improve your health. Now you’re going to start feeling the energy come.
Dr. Eric Westman: So the app is called Zero?
Dr. Naomi Parrella: Just Zero.
Dr. Eric Westman: Why does Zero, which tells people not to eat so often, need a medical director?
Dr. Naomi Parrella: We like to teach the science and also examine the science.
Dr. Eric Westman: I’m sorry, I looked, and there’s teaching inside, and you review it?
Dr. Naomi Parrella: Yes. I think it’s not fair that only the people who come and see you and me get this information. Just like what you’re trying to do, we’re trying to make sure more and more people can understand and tap into how fabulous they can feel.
A lot of people don’t know it’s possible. I can’t believe that, in this day and age, I’ll still have physicians who don’t know it’s possible to reverse (type 2) diabetes, to come off of medications. Teaching people how to come off of medications is so fun! A lot of doctors weren’t trained in that. I wasn’t trained in that. I was only trained in how to add medications. We have to be a little rogue and explore what’s happening, what’s possible.
Food matters
Dr. Eric Westman: A lot of doctors, their education, once they’re in practice, comes from the drug companies.
In my practice, I’ll ask people to write out what they’re eating and drinking for a day. It’s simple. In fact, if they do it before I enter the room, it’s very quick for me to scan what people are eating and drinking. I’ll ask, “Has any other doctor ever asked you to write down what you’re eating and drinking?” They say, “No.”
When did doctors stop thinking that food mattered? Or maybe we were never really taught that it mattered.
Dr. Naomi Parrella: Yes, I don’t remember learning much about that in med school.
All of us who recognize that we went into medicine to take care of people, to help them feel better and get better, then, when you start seeing that, wow, I’m fighting with people because they’re not taking meds that make them feel terrible, and that ends up being like more meds, meds for the side effects of meds, and so on, there’s a cognitive dissonance there. Where you’re like, “This isn’t why I did this. There’s something wrong with this picture.'”
I grew up in Japan, and in Japan, we think about things very differently. We think about the long game all the time. It’s like, “Is this going to be better long-term, or is this a short-term fix?” There’s a word, gaman, basically, “suck it up.” If you have to do something that just takes a little bit longer but is better for you long term, you’re going to suck it up, and you’re going to do it. It is like they’re having a high-carb, standard American diet, and they’ve been told to cut out all the proteins, the animal foods, or something like that. So now they’re eating only carbs. I say, “We’re going to kind of change this up a little bit, but for the first couple of weeks, you might not feel that great. You might have headaches, feel a little bit nauseated, feel jittery, and feel dizzy. There might be all these things because your body is shifting gears, and the fluid shifts and the salt shifts in the body.
As a result of getting into this better, optimal-functioning metabolism, you might not feel great for about a week or two. But suck it up! Curse me out in your brain, that’s okay. In two weeks, you’re going to be so in love with yourself because you’re going to be like, “I can do this! I am amazing! I can have all this energy!” That is way more motivating than, “I can give you something that’s going to help you this minute, but a week from now, you’re not going to be better off. Three months from now, you’re not going to be better off. In fact, I’m probably going to be adding more meds for you in the future.” That’s not as inspiring.
Dr. Eric Westman: I like that, and I usually barter for two days.
Dr. Naomi Parrella: You’re nicer than me!
Dr. Eric Westman: That reminds me of other teachers that teach this. I was talking to someone who works with psychiatric patients. He said, “I portray that it’s going to be very hard. It’s going to be difficult. You suck it up.” Then people come back and say, “Doc, it wasn’t nearly as bad as you said it was going to be!'”
Dr. Naomi Parrella: Exactly!
Dr. Eric Westman: I’ll have to try mixing and matching that kind of teaching because usually people come to me and I have the wall chart of the foods on a wall. If they come in and say “Oh my, I have to give it all up!” But, I think that motivating technique kind of depends on the individual.
Then there’s a book written by a man in Chile where he said, “For 29 days, I want you to be super strict. You have to follow it. And on the 30th day, you can have anything you want.” Of course, what happens by the 30th day? You don’t want that anymore! This is the psychology of getting people over that initial barrier, that inertia to get started.
This is great, and I think it shows that we all personalize things just a little differently. Yes, if the doctor you’re working with isn’t listening, or isn’t helping to personalize things, and isn’t talking about food, well, there are other doctors around.
The movie The Cholesterol Code
I want to switch gears again. I just came from an amazing meeting of the Citizen Science Foundation. There was a fundraising meeting, and they helped to fund a movie called The Cholesterol Code. Have you been following Dave Feldman?
Dr. Naomi Parrella: I have! I have some people who’ve done labs with him.
Dr. Eric Westman: The movie debuted, world premiere, last Friday night!
Dr. Naomi Parrella: So exciting! Congratulations!
Dr. Eric Westman: I didn’t make the cut into the movie, but it’s the story of Dave’s self-experimentation and curiosity. You follow him traveling around, talking to experts, and then the stories of people. The conundrum, it rings true in my clinic, all the people they portrayed had all got better, the diabetes, the mental health issues, and they were all being told not to do it.
One little blood test, all the LDL. Just that one number! So the movie is a great risk-benefit portrayal of, if people get all this benefit, should they worry about this kind of relatively minor thing? And they give all of the latest research on type 2 diabetes being the most important risk factor. It’s a teaching movie as well as about the science.
Dr. Naomi Parrella: It’s awesome! Good to know that it’s finally out!
High LDL-cholesterol
Dr. Eric Westman: It is! They have in there just a sneak peek of the one-year data. The baseline data have been published in an abstract, and it turned a lot of heads because most people with these super high LDLs, on average for four years, didn’t have any coronary atherosclerosis based on a CT angiogram. That was remarkable in and of itself. But they followed these people over a year with ketone measurements and all, and they leaked just a little bit of the results. It’s not perfect, but it certainly isn’t the disaster, plane crashes that everyone had predicted. I highly recommend The Cholesterol Code movie! It is not going to be out until the fall, I think, but I wanted to give you that update. The great one-year data actually looks really good. Hopefully, that paper will be published soon so that we can kind of defend this. I find myself defending my patients against the LDL-focused doctors. Are you finding the same?
Dr. Naomi Parrella: This is a wildly challenging area to look at because, first of all, the labs are not very good. The LDL is a calculation on the standard test. It’s a calculation based on a standard American diet, which my patients are not doing, because they’re coming into my office, so it’s not really helpful. It’s like assuming you’re sicker than you are, and it’s just a different pool of people you’re being compared with. Plus, ‘normal’ is not a number you want to be in the United States for metabolic health. Because ‘normal’ means you’re part of the majority, and you have similar labs with the majority of people. We know that 97% of the U.S. population is metabolically unhealthy. Do you really want to be in that bucket? Not so much. That’s why you’re coming to my office.
If we think about it and we talk about it, and I say, “This is what is currently the American Heart Association’s stance,” they might say, “These are really important numbers, and this is what you need to do.” You need to do what you think is right, but here’s another way you may look at it. Dave Feldman’s work has been very helpful because, as an engineer, he’s very particular about his numbers. The patients that have come in to get lab orders to enter his study, it’s very, very specific. He is doing really clean science, and I very much value that. Somebody who’s not getting pharma funding is looking into this and trying to figure out what’s best for the citizens. For the human, for all the rest of us. So I do love it.
Citizen Science Foundation
Dr. Eric Westman: At this meeting, the Citizen Science Foundation, they announced that they had raised money and they’re almost to the level where they could do a similar study again, but widening the parameters and including a control group. They didn’t really have a control group before. It was like a contemporaneous comparison, but not exact. That was exciting to see.
If you don’t know about the Citizen Science Foundation, please look it up. Please donate. Any amount helps. The idea is to be totally transparent about the data that they collect. Yes, they’re focusing on the LDL and keto issue, but it’s a broader group.
There was a vegan speaker at the Citizen Science Foundation meeting, and he made fun of it – “Don’t kick me out!” But no, it was really good to have that kind of view. The other speakers, just as a highlight, Brett Scher at Metabolic Mind, cardiologist David Diamond, who has reviewed the LDL literature, Fahmi Farid, Nadir Ali in Houston, videos of their talks are available. They’re all on this panel. I was up there too. Probably the most interesting thing that came up, for me, was that these guys know the data, they know the literature. There’s one study of cholesterol-lowering medicine that was done by the government. It’s called the ALLHAT study.
Do you know the ALLHAT?’
Dr. Naomi Parrella: I remember. Yes.
First Do No Pharm movie
Dr. Eric Westman: The 4S, all the SS studies. The one that was funded by the government didn’t show any benefit. In a movie recently with Aseem Malhotra, I think First Do No Pharm …
Dr. Naomi Parella: I saw that at a conference.
Dr. Eric Westman: In First Do No Pharm they interview the former editor of the British Medical Journal, and she says, “We’ve tried to get the data from these companies, and they won’t let the data be looked at or scrutinized by a third party.” If the findings are so robust, you would think, “Look at my data! Here, we’ll show you! Prove it!”? I’m not a conspiracy theorist by any means, but I’m not overwhelmed by the benefits of these medicines that are being used.
Even the PCSK9 inhibitors might have a 5% to 4% mortality change. So you need tens of thousands of people. There’s an alternative way to go about it, and that’s changing your lifestyle.
LDL-cholesterol
Dr. Naomi Parrella: I think it comes down to every single doctor knowing metabolic syndrome has five criteria, none of which are LDL. Nobody cares about LDL when you’re actually talking about risk factors, if you actually look at the data that’s not doctored in some way. If LDL was that important, metabolic syndrome would have one of the five criteria be an LDL number. And it’s not.
I think it’s universally agreed that the risk factors are more associated with triglyceride and HDL ratio. With your waist circumference, your blood pressure, and blood sugars. If those get better and your LDL is doing whatever it’s doing, it’s almost not even interesting from the standpoint of when we say, “Is somebody metabolically healthy?” We don’t even look at their LDL to determine if they have metabolic syndrome.
Dr. Eric Westman: Yes, we don’t. A lot of other doctors do, and I try to use language like, “That’s the old paradigm.” Or, that’s like if you’re in a country where they drive on the right-hand or left-hand side, it’s not the only way to do it.
Dr. Naomi Parrella: Yes, exactly.
Using calcium scores and CT angiograms in clinic practice
Dr. Eric Westman: I still feel like I’m protecting my patients from the prescription path for cholesterol.
Then we did get into the discussion of the anatomic measurements for which tests can be done. With Brett Scher and Nadir Ali being practicing cardiologists, there was discussion about calcium scores, CT angiograms, and the role that they play. Are you using those in your practice at all?
Dr. Naomi Parrella: We do a lot more, but the coronary calcium score is really interesting because it depends on what’s already been there before you decided to take care of yourself. Also, we know that with statins, the number goes up. So if it was that fabulous, it should go down. Anyways, that’s a yes. We do look at it. I don’t want anybody to think these numbers don’t matter at all. We just don’t know the significance of what they mean in different lifestyles and different diet patterns. And it’s not just one number. We were taught in med school. You don’t treat to a number, just one number. You have to look at the whole person. You have to see what else is going on.
If their energy is better, they’re now moving, their sugars are better, their weight around their waist is shrinking, they are sleeping better, they’re on fewer medications, and their blood pressure is better controlled. If their LDL is bumping up, I’m less concerned about that because every other marker in their body, and their energy, is better. It’s so hard to imagine that would be a terrible thing.
Dr. Eric Westman: I would give a slide at a meeting with the Virta Health study results, and basically, everything gets better. And then I click, “except the LDL.” So my value judgment was that if the LDL went up, it was worse. I finally woke up one day thinking, “No, everything gets better. The LDL should go up because everything is getting better.” It wasn’t.
So we come at it with a preconceived notion, yes, of prejudging that any change in LDL, without regard to the size, whether it’s small or large, or particle number is automatically negative.
It’s fascinating to see this study that had super high LDLs in these people, and it did not lead to coronary atherosclerosis with the best technology we have to measure it. Well, they did not get an arterial catheterization, but it was a CT angiogram. If you played this out, like, the long game, it might be the wake-up call that maybe LDL shouldn’t be the focus for other people as well. Right now it’s being contained into this “high HDL, low triglyceride, lean mass hyper-responder” box. I’m beginning to think that it’s going to spill over and start having people wake up to the fact that maybe the focus should be on metabolic syndrome, triglycerides, and HDL. It’s a transition that isn’t coming quickly, I have to say.
Dr. Naomi Parrella: Not quickly enough. And it’s confusing a lot of individuals.
One of our fortunate things about being a physician is we get time with patients over time, where we can really see and learn together. Even from one person to the next, I’m carrying the experiences and history of thousands of people. And you even longer. We’re looking at the whole person and seeing lots of the nuances that a study can’t control for. We’re understanding things about individuals that aren’t listed in the studies, that aren’t able to be controlled for, because we know their stories.
So you can start seeing there are different patterns that, together, look not as good. Then you might say, “We need to change, we need to pivot,” or, “Maybe you do need this med,” or, “You do need to change something.” So it’s not “all meds are bad” or “no meds are the answer.” That’s why the specialists are important. You and I can sit with a patient and take all the pieces of information, that’s very complex, and simplify it for a patient who just needs to know what to do next and why. Once that’s there, it’s like, get off their back. If they’re doing things and they’re making an effort and they’re improving all of their markers except for one, maybe that one is not the one to anchor to.
Dr. Eric Westman: Are you still teaching with residents and students?
Dr. Naomi Parrella: I am, yes, residents and students. It is interesting because there’s a lot of focus on plants.
Teaching approach
Dr. Eric Westman: What? Plants? What do medical residents and medical students think of your approach?
Dr. Naomi Parrella: There’s a lot of questions. I love the curiosity. Like, okay, try with your patients. Let your patients tell you. If you give them a plan and they’re able to do it, and all their numbers and their energy get better, and their life gets better, and they’re on fewer meds, high fives, you’re doing a great job.
Try different things. If you find that you’re walking around saying, “Nobody follows directions. Everybody’s non-compliant. Nobody will do what I tell them to do,” maybe reflect a little bit. And think maybe the advice isn’t that great. It’s not helpful for the long term. If somebody’s not able to do something for the long term, it’s short term. That’s the thing that was really compelling when I first started. I was telling people to eat less, and I couldn’t understand why they weren’t able to lose weight long term. They could lose 10 pounds, maybe 15, and then they would be ashamed of the fact that they got hungry, that they wanted to eat, and that they couldn’t restrict calories anymore. Then, of course, that happened for me. I was like, “It’s not a discipline problem after all. It’s hormones.” It’s too grandiose to think that we’re in control of evolution and the way we’ve been designed.
Once you can see and you start practicing what you believe with your patients, what the literature you believe you’re reading is telling you, then you can start seeing. If you are noticing a lot of failures, or you’re becoming frustrated because your patients don’t look like they’re getting better, think, why is that? That is critical thinking. That’s what I like to help my patients, my students, my residents, my fellows, everyone, to think for themselves. It’s telling you something when you feel like, “This is not working. This is so frustrating. Why?” What’s going on there?
Dr. Eric Westman: I had to pull out, and I have on my desk, the world researchers’ summary of fats that said saturated fat isn’t a problem for heart disease. I have that out because I got some flak. “How come you say you don’t worry about saturated fat when every other clinic they go to is worrying about saturated fat?” So I’ve learned to have those studies at the ready. That’s just a reminder, you and I are both in established university settings where we have to have data to support what we do.
You can go out in rural Illinois, in your own practice, and pretty much do what you want within reason, as long as you’re not harming people. But we have oversight. And people will say, “Well, Dr. Parella says blah blah blah…”. Fortunately, we’re both at institutions that value science. I’ve never been told I can’t do what I do.
Dr. Naomi Parrella: It’s about safety. It’s about quality. Quality of life for the patients. Both of those, if we’re true to our patients, and we make sure they’re doing better, and we’re following the science, and we are being very thoughtful.
I think the hardest part as a physician is the science. There’s constant information coming out. The key is to identify the noise and learn how to look at the evidence. See where the funding is coming from. Did somebody have an intention to show something? Or were they inherently curious? Like, “I’m curious if this is true or not. “Very different if someone’s trying to prove something to make a bunch of money versus somebody who’s genuinely trying to take care of other people and say, “What can we learn from this? And what can we do to take care of people?”
To your point, I think you and I have been very, very clear from the start. Most physicians, when we start, we’re like, “I want to take care of patients.” That’s why we’re taking calls on holidays, and why we do all the things we do, because we genuinely care and we want to do right by our patients. Being in an academic institution is beneficial. We get to be constantly bombarded with curiosity. “Why are you doing this?” “Why aren’t you doing that?” and to be able to share the evidence, and to help people think through what they are reading, what they are learning, what they are seeing, and how do you integrate that information so that we can best take care of people? That’s the key, and that’s what’s so fun.
Where to find Dr. Naomi Parrella
Dr. Eric Westman. Yes, absolutely. How do people find you?
Dr. Naomi Parrella: I’m on the app, the Zero app, and also I’m at Rush Medical Center. That’s here in Chicago, and we have hybrid clinics.
Are you doing hybrid clinics as well?
Hybrid clinics
Dr. Eric Westman: I don’t know what that means.
Dr. Naomi Parrella: In-person and virtual.
Dr. Eric Westman: Yes, I do one half-day of virtual.
Dr. Naomi Parrella: We have clinics. I now actually have a lot of different clinics in different areas. What we’re trying to do is make sure as many people as possible can have access to the kind of care and information, especially with all the noise out there right now.
Dr. Eric Westman: Thanks again, and I hope to see you soon in person.
Dr. Naomi Parrella: Thank you for all your contributions. You’ve, like, single-handedly added so much to this pool of knowledge.
Dr. Eric Westman: Passing along batons, it’s time for you to take them and run.
You can watch the full video here.
