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At Wellness Garage - we believe that each of us should take control of our own health. Easy to say, but what does this mean? Simply put - our lifestyle behaviours are the most powerful medicine there is. Building better habits for
It is estimated that over 80% of health care costs are related to lifestyle related diseases and 80% of us have at least one modifiable risk factor for chronic disease. But diseases and symptoms are only manifestations of more important interactions. At Wellness Garage we believe in looking beneath the surface, beyond disease and symptoms to understand how the interplay of your behaviours, environment and genetics change the biological systems that ultimately thrive in good health or fail into disease.  This approach is backed by research that shows that the interaction of behaviours, environment and genetics determine most health outcomes.
While we cannot (yet) change our genes, we can change our environment and behaviours. But where to start? There is so much noise and conflicting information out there - fad diets and snake oil. This is why we founded Wellness Garage: Create a place where people can get the help they need, from trusted, evidence-based practitioners, to take control of their health. At Wellness Garage, the first step to taking control of your health is to do a Precision Health Tune Up (PHTU) A PHTU is comprehensive look at your health from your behaviours to your key biomarkers. Our team:
We also offer the most cutting edge, evidence-based advanced testing options that include:
As a team we compare your biomarkers to your current behaviours and develop a personalized set of actionable recommendations for you to make the necessary changes to improve your health. With these recommendations as your action plan, we then can provide you with all the support that you need to make the changes required to reach your health goals. Over the past year, we have helped hundred's of people take control of their health from:
The most inspiring realization that we have had since starting is that the human body is much more resilient than any of us can imagine. Treat it with the right behaviours and health improves, one habit at a time.
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Nuts are nutrient-dense foods rich in healthy fats, fibre, vitamins, minerals, anti-oxidants and other favorable bioactive substances. Yet because of their calorie density many people avoid, or strictly limit their nut consumption to limit potential weight gain. If you review the data on nuts - avoiding them is nuts!  Two large prospective studies in the US with almost 120,000 people followed for 15 to 30 years showed that people who ate nuts seven or more times per week had a 20% lower death rate than those who avoided nuts altogether. (NEJM 369;21)
Nut eaters had lower rates of death across most major causes including heart disease, cancer and respiratory disease. The benefits were similar for both tree nuts and peanuts. Concerns about weight gain were not substantiated, in fact across both these cohorts, nut eaters gained less weight over time. The benefits of nuts have been seen in other major trials:
Observational studies and other clinical trials have suggested that eating nuts will decrease coronary artery disease and improve key lipid biomarkers. Yet more studies have shown improvements in other key biomarkers indicating benefits including:
All of these benefits for something that tastes so good. In my thinking, “you would have to be nuts to avoid nuts!” Consider this: rates of obesity continue to grow at epidemic levels while at the same time weight loss is big business ($68B and growing). If what the weight loss industry promoted actually worked, wouldn't it be reasonable to think that obesity rates should be declining? The problem is that dominant approaches to weight loss are one size fits all, quick fixes known as diets. Most diets are temporary and highly restrictive programs of eating pursued purely for the purpose of losing weight and are unfortunately damaging exercises in futility.  Research shows that dieting is ineffective for long term weight loss and maintenance of weight. Most people who lose weight by dieting will regain it after a year. Worse, many regain more weight than they ever lost in the first place. This pattern of weight loss followed by weight gain has been termed “yo-yo dieting” and has been linked to increased risk of obesity, diabetes and cardiovascular disease.
Contributing to these poor results are the abundance of fad diets, overly restrictive and often lacking in essential nutrients. Requiring massive will power, these diets may result in weight loss, but since the behaviour required is not sustainable the rebound in weight is swift. Inevitably, the dieter returns to the poor behaviours that led to the initial weight gain in the first place. Finally, these restrictive diets can take the pleasure away from eating and lead to lifelong disordered eating. If you are going to lose weight and keep it off - you have to address the root causes of weight loss and address the lifestyle behaviors that resulted in weight gain. Rather than restriction, the initial focus of any sustainable and effective approach should be on improving the quality of food in the first place. Healthy eating is all about eating and enjoying real food - not counting calories, points or tracking macros. But what is real food?
There is now clear evidence that eating processed foods leads to increased food consumption and weight gain. Further, when diets do work, they often do so by having people shift from refined, processed, packaged and fast foods to real, whole foods (for more on this here is a previous post). Along with making the shift to whole food eating, other keys to losing weight for the long term are:
Small, sustainable changes go a long way! Finally, understanding your weight loss in context of your history and current health should come first. It is essential that you work with your physician to understand if there are any other potential causes for your weight gain - especially hormonal, metabolic or inflammatory abnormalities. At Wellness Garage, we offer a medically directed lifestyle program for weight management. All medical visits are covered by MSP, for those with a BMI over 30 or a BMI > 27, with an obesity related diagnosis. Our program leverages a personalized, multidisciplinary lifestyle behavior change approach - your care team will consist of a physician, nutritionist, exercise professional and health coach who will get to know you from multiple perspectives and work with you to make lifelong habit changes. Learn more about the Wellness Garage Sustainable Weight Management program and to see if you qualify. A very compelling read from a New York Times op/ed, making the point that we have made previously on our blog: today's chronic diseases have their origin in the evolutionary mismatch between our current environment and behaviors and what our bodies evolved to be. In this article, we learn how evolution set out to protect us from starvation, infections and injuries leaving us vulnerable to atherosclerosis - the disease process underlying heart disease. https://www.nytimes.com/2019/08/06/opinion/evolution-heart-disease.html?action=click&module=Opinion&pgtype=Homepage  At Wellness Garage - we take a precision health approach to atherosclerosis prevention, treatment and reversal, by working with our members through a structured change process: Assess, Change Behaviors, Re-assess and Adjust.
Learn more about what it looks like to do a Precision Health Tune Up and take control of your health. Sleep apnea is one of the most serious medical conditions that often goes undiagnosed. It is estimated that up to 30% of Canadians suffer from it, yet only 6.4% have recognized the diagnosis. What is it? Sleep apnea is a serious condition in which a person’s breathing is repeatedly interrupted during the night. During normal sleep, air moves in an unobstructed, regular rhythm, through the upper airway, the throat and into and out of the lungs. With obstructive sleep apnea (OSA), airway blockages, usually from soft tissue collapse, prevent the normal regular breathing rhythm  What are the symptoms?
The main symptoms of OSA are
However, some people have no symptoms or may not recognize that they have symptoms. Other symptoms may include one or more of the following:
Perhaps the best way to determine risk is the use of the STOP-BANG questionnaire which uses a series of questions and results of physical measurements to calculate the risk for sleep apnea in adults aged 18 and older. Snoring – Do you snore loudly (loud enough to be heard through closed doors)? Tired – Do you often feel tired, fatigued or sleepy during the daytime? Observed – Has anyone observed you stop breathing or choking/gasping during your sleep? Pressure – Do you have or are being treated for high blood pressure? Body mass index (BMI) – Body mass index more than 35kg/m2? Age – Age older than 50? Neck circumference – Neck size 17 inches or larger for males or 16 inches or larger for females? Gender – Male? Positive answers to the above questions are then used to determine risk: Low risk – Yes to 0 to 2 questions Intermediate risk – Yes to 3 to 4 questions High risk – Yes to 5 to 8 questions
How common is it? In 2017, 6.4% of Canadians self-reported a diagnosis of sleep apnea through the Canadian Health Measures Survey (CHMS) - this was more than double the rate reported in 2009. In the US, using the broadest criteria is estimated that 20-30% of men and 10-15% of women have sleep apnea. In all likelihood, sleep apnea is under-diagnosed - using the STOP-BANG risk tool, the CHMS found that nearly one-third (30%) of Canadian adults were considered to be at intermediate or high risk for sleep apnea - 15% were high risk and 15% were moderate risk. Rates are increasing along with the rates of obesity. What are the risk factors?
What happens if it is left untreated? The initial consequences of untreated sleep apnea are daytime sleepiness and difficulty concentrating results in increased errors and accidents. People with severe sleep apnea are two to three times more likely to have a motor vehicle accident - this represents an impact on morbidity and mortality that is similar to the cardiovascular sequelae of OSA. Over time untreated sleep apnea increase risk for cardiovascular disease, high blood pressure, abnormal heart rhythms, heart attack and stroke. People with OSA have higher rates Insulin resistance and Type II Diabetes. This association is partly manifested by the shared risk factor of obesity, but also appears to be independent. In one study, patients with severe OSA had a 30% higher risk of diabetes even after controlling for age, obesity, pre-existing cardiovascular disease. The physiological mechanisms underlying this risk are likely related to the increase in oxidative stress caused by lack of oxygen as well as activation of the sympathetic nervous system (with the insulin resistance effects of adrenaline and cortisol). For patients with existing metabolic syndrome - OSA is associated with poorer metabolic biomarkers: increased glucose, triglycerides, inflammatory markers, and overall increased cardiovascular risk. Nonalcoholic fatty liver disease (NAFLD) - given the increased risk of metabolic syndrome with OSA and the shared risk factors between NAFLD and metabolic dysfunction - OSA appears to contribute to the development and severity of nonalcoholic fatty liver disease (NAFLD), independent of shared risk factors such as obesity. Mortality - Severe OSA increases the risk of death by 2-3 time independent of other risk factors - interestingly an increased risk of mortality does not appear to be present for untreated mild OSA. What isn’t completely clear is how treatment of severe OSA affects the risk of mortality. Diagnosis: Once suspected due to witnessed apneic episodes, loud snoring, daytime sleepiness, resistant hypertension, or ineffective sleep - the next step is to get a sleep assessment. The gold standard is the polysomnogram - done overnight in a sleep lab (and requiring a referral from your physician), it measures breathing effort and airflow, blood oxygen level, heart rate and rhythm, duration of the various stages of sleep, body position, and movement of the arms/legs. A more accessible alternative not requiring physician referral is a Level III sleep study - using portable devices that can be used at home. Is it reversible? This depends primarily on the underlying cause of the sleep apnea - if the primary cause is obesity then weight loss can improve symptoms and lead to a cure. Brain damage caused by severe sleep apnea is reversible. A 2017 neuroimaging study is the first to show that white matter damage caused by severe obstructive sleep apnea can be reversed by continuous positive airway pressure therapy. There is high quality evidence that in most adults positive airway pressure therapy reduces the frequency of respiratory events during sleep, decreases daytime sleepiness, improves systemic blood pressure (BP), lowers the risk of crashes, improves erectile dysfunction, and improves quality of life across a range of disease severities. Unfortunately to date there have been no studies that have demonstrated that treatment improves mortality. What are the treatments?
References: https://www.uptodate.com/contents/sleep-apnea-in-adults-beyond-the-basics?search=sleep%20apnea&topicRef=7683&source=see_link https://open.alberta.ca/publications/level-i-and-level-iii-sleep-studies Canadian Thoracic Society Guidelines: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3070752/pdf/crj18025.pdf American Academy of Sleep Science: http://jcsm.aasm.org/ViewAbstract.aspx?pid=31513 https://www.health.harvard.edu/blog/weight-loss-breathing-devices-still-best-for-treating-obstructive-sleep-apnea-201310026713 https://aasm.org/brain-damage-caused-by-severe-sleep-apnea-is-reversible/ https://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea STOP-Bang Questionnaire. Property of University Health Network, for further info: www.stopbang.ca modified from Chung F., et al. Anesthesiology. 2008. Vol. 108: 812-821; Chung F., et al. British Journal of Anaesthesia. 2012. Vol. 108:768-75; Chung F., et al. Obesity Surgery. 2013. Vol. 23: 2050-2057; Chung F., et al. Journal of Clinical Sleep Medicine. 2014. The best feature of my exam room at Wellness Garage the glass "white board" that I inherited and repurposed from the gym that used to occupy our space. Many times per day, I find myself drawing the same diagram:  or more neatly drawn and shared with our Diabetes Reversal Group:  I have written about Insulin Resistance before:
Insulin resistance is, in my opinion, the single greatest health issue of our time, and is increasing at epidemic rates. When I review the mental model for insulin resistance with our members here is a quick summary of what I share: Metabolic health is one of the most important drivers of optimal health. Weight gain and metabolic health are tightly related: poor metabolic health leads to increased fat which further worsens metabolic health. Dysfunction in metabolic health manifests as insulin resistance - the process where the pancreas must release higher and higher levels of insulin in order to maintain blood sugars. Insulin resistance can happen in multiple organ systems: muscle, fat, liver as well as the pancreas itself. The initial phase of insulin resistance is marked by normal blood sugar levels but increasing insulin levels - the simplest biomarker for this is the TG/HDL ratio which generally increases with hyperinsulinemia. By the time the fasting blood sugar becomes abnormal - insulin levels are often 2-3 x normal - at the same time approximately 50% of the pancreatic beta cells are no longer functioning. In most people it takes 10 -15 years to reach this point. This marks the beginning of the second phase of insulin resistance, that of decreasing insulin production from the pancreas, and mildly abnormal blood sugars. We call this pre-diabetes. Type II Diabetes is diagnosed when fasting blood sugars are greater than 7.0 mmol/L. At this point, pancreatic beta cell function has been reduced over 80%. Insulin resistance is a major risk factor for cardiovascular disease, cancer, dementia, liver failure, kidney failure in addition to being the cause of Type II Diabetes. Risks for insulin resistance include: age, genetics, obesity - especially visceral obesity, sedentary behavior, stress, poor sleep and of course poor nutrition. I will be blogging more on this in the future as we prepare to digitize our Diabetes Reversal program. In the meantime, if you have Type II Diabetes, pre-diabetes, metabolic syndrome or insulin resistance (and you live within driving distance of our clinic in White Rock), you may be interested in our Group Diabetes Reversal Program For too many people with osteoarthritis (OA), life becomes a painful exercise in waiting for surgical joint replacement Mild to moderate symptoms from OA are often described as “wear and tear” and people avoid activity and exercise, take pain meds and learn to live with the pain until it gets so bad that they meet the criteria for joint replacement. This “usual care” paradigm is beginning to change.  Increasing evidence shows that there are a number of strategies that will improve pain from OA:
Targeted exercise has been pioneered by the Danes who have shown that a 6 week program teaching specific neuromuscular exercises can result in significant changes even 1 year after the program:
The benefit of these targeted neuromuscular exercises can even provide benefit for people with severre osteoarthritis. Perhap the most interesting research from Denmark, was the landmark randomized double blind study of total knee replacement vs a comprehensive lifestyle approach. In this study people were randomized to either a total knee replacement followed by a 12 weeks non-surgical lifestyle treatment program OR the 12 week non-surgical treatment program alone. This program consisted of five interventions: exercise, education, dietary advice, use of insoles, and pain medication. Not surprisingly, the outcomes showed that the group that received surgery followed by non-surgical lifestyle treatment had better function and less pain that the group that did not receive surgery. What was surprising was that 74% of the group that received non-surgical lifestyle treatment did pursue surgery in the one year follow-up. In other words, a 12 week lifestyle program was enough for people to avoid or at least significantly delay surgery (and the potential adverse effects of major surgery). This pioneering Danish work has been developed into a program called Good Life with Osteoarthritis in Denmark (GLA:D® Hip and Knee Osteoarthritis Program) and brought to Canada through the Canadian Orthopaedic Foundation in partnership with Bone and Joint Canada.
Developing a personalized, multifaceted lifestyle strategy to prevent and reverse symptoms related to osteoarthritis is a key component to the Wellness Garage approach to Vital Longevity.
One of the things we are constantly asked at Wellness Garage is what we think of various diets - low carb, keto, Paleo, Mediterranean, low fat, Atkins, Zone, Weight Watchers etc. While these questions are understandable given the $68B diet industry, sadly I think they miss the point about healthy eating. As a result, most diets fail people, and diets that do work have common characteristics that are unrelated to their macronutrient content.  Healthy eating should be about eating and enjoying real food - not counting calories, points or tracking macros.
But what is real food?
At Wellness Garage, we often point to research like Chris Gardner’s DIETFITS study which showed little difference between a healthy Low Fat diet and a healthy Low Carb diet. After 1 year there was no significant difference in weight loss between the groups - both lost 5-6 kg (about 5% body weight) on average. As with most diet studies there was considerable variation in the amount of weight lost (~40 kg). What was interesting in this case was that they tested for two common hypotheses that have been thought to predict who would do better on each diet:
Neither of these hypotheses were predictive. When you get people to eat healthy low fat or healthy low carb diets the overall success is significant but similar - so what was common? The common element in this study was that both diets restricted refined carbohydrates and added sugars and aimed for food that was minimally processed. To us the issue should not be about the macro-nutrient proportions of a diet it should be about diet quality - simply put, people lose weight when they eat real, minimally-processed food. So it was of great interest to us to see the results of Kevin Hall’s latest study showing that eating ultra-processed foods result in increased consumption of calories and weight gain. Ultra-processed foods have been described as “formulations mostly of cheap industrial sources of dietary energy and nutrients plus additives, using a series of processes” and containing minimal whole foods (Monteiro et al., 2018). Hall took 10 men and 10 women into the NIH in-patient metabolic ward where they were randomly assigned to receive an ultra-processed or unprocessed diet for 14 days followed by another 14 days on the other diet. The subjects were given three daily meals and could eat as much or as little as desired. The menu was matched across diets for total calories, energy density, macronutrients, fiber, sugar, and sodium, but widely differing in the percentage of calories derived from ultra-processed versus unprocessed foods. Breaking down the finding, Hall found that on the ultra-processed diet subjects ate over 500 calories a day more. (508±106 kcl/day; p=0.0001). The overeating was almost evenly divided between excess fat (230 calories) and excess carbohydrates (280 calories) while protein intake was unchanged. Interestingly, subjects ate faster on the ultra-processed diet. Blood tests comparing baseline with the final day of the ultra-processed diets showed no significant change - indicating that the ultra-processed diet was comparable to the subject’s normal diet. After the unprocessed diet, subjects showed:
It is our view that our bodies handle unprocessed foods in a way that our normal appetite control mechanisms can control our intake. Eating ultra-processed foods leads to excess intake and results in weight gain. One of the best ways to take control of your health is to simply eat real food - more veggies, greens, nuts, seeds and healthy fats. Learn more about the Wellness Garage Sustainable Weight Management program and to see if you qualify. (This post originally appeared in the Peace Arch News) I am a 78-year-old woman and my husband died last year. I’m getting used to living alone and have wonderful friends and a very supportive family. My only problem is that I’m having trouble sleeping at night. I can’t seem to fall asleep and then I wake up a number of times during the night. I don’t want to take sleeping pills but wondered if there is anything else I can do to improve my sleeping. I’m glad that you’re doing so well adjusting to living alone and I think I can help you with your sleep. You are very wise to avoid sleeping pills as they frequently cause more problems than they solve. Your problem sleeping is shared by many; lack of sleep has become epidemic in our society and is increasingly common as we age. There are many causes for poor sleep, some of which need medical assessment, but mostly our ability to sleep well is within our control. Without knowing more about your physical and emotional health, here is a safe and proven framework for sleep. If you are not sleeping well after implementing this, a visit with your physician is warranted. A good night’s sleep is all about optimizing your behaviours and environment to fit your body’s natural rhythm.  As humans we have evolved to be awake when it is light and to sleep when dark. Supporting this circadian rhythm are a cascade of different hormones that signal the body to be alert or sleepy. Our days start with a morning burst of the stress hormone cortisol, signalling that it is time to get up and greet the day. Over the course of the day our cortisol wanes, until in the evening our body releases melatonin to signal that it is time for sleep. Along with melatonin, levels of adenosine in the blood also tell us that we are tired. Adenosine is a by-product of energy expenditure – the more active we are the greater our levels of adenosine.
Aligning our behaviors to our body’s hormonal symphony is relatively straight-forward: First, avoid substances that will alter hormones and affect your sleep:
What do you do if this doesn’t work? This is where sleep restructuring comes in:
At Wellness Garage we are here to support you in your health journey to take control of your health, restore confidence, and optimize your wellness. We do this through solid evidence-based medicine, personal health coaching and instruction, providing you with the knowledge, skills and support you need to apply healthy habits to your life. Get more information about Wellness Garage For many physicians of my era (started practice in 1991) the story of hormone replacement therapy reflects the bandwagon nature of medicine. In the mid-nineties as I opened my practice, we actively recommended that almost all menopausal women should take hormone replacement (HRT) or estrogen replacement therapy (if they had a hysterectomy). As physicians we measured ourselves by our HRT percentage - feeling that if we were doing our jobs this should approach 100%.  The reasons for our enthusiasm for estrogen replacement seemed clear. In menopause, estrogen levels plummet to 1% of pre-menopausal levels. Using estrogen to replace this loss, appeared to have significant benefits:
...and while these benefits were offset by a small but real increased risk in venous blood clots - the benefits seemed overwhelming. Then on July 17, 2002 the world of estrogen replacement came crashing down. The Woman's Health Initiative - the largest and most expensive trial ($1B) ever done at that time was stopped because HRT increased the risk of breast cancer by 26%. Overnight, physicians jumped off the bandwagon and rates of HRT fell dramatically. Unfortunately most of us did not read the details of the study (once it was eventually released).  In the new book, "Estrogen Matters" by Dr. Avrum Bluming and Carol Tavris, the data from WHI is examined in the broader context.
Starting with the conclusion that HRT increases breast cancer by 26% - the first and most stunningly underappreciated fact was that this increase did not meet statistical significance, meaning that it did not clear the commonly accepted threshold that there has to be less than a 5% chance that this result could be random. Next, even if you accepted that the result was real and not random, then it is important to understand the result. There are two ways that the study could have shown an increased rate of breast CA, either the rate of breast CA actually increased in the treatment group OR the rate of breast CA went down in the control group. Of course if the latter explanation is correct then the study is flawed. Closer analysis of the WHI data has clearly shown that the reported increase rate of breast CA did not come from higher breast cancer rates than expected in the treatment group but resulted from the fact that the control group had a lower incidence of breast cancer than expected. Even more confusing was the fact that this reduction of breast cancer in the control group occurred because there was a significant number of woman who had been on HRT previously and in this group there was less breast cancer. So the WHI concluded that HRT increases breast CA because previous HRT experience decreased the rate of breast CA in the control group - incredible! The third thing to consider when reviewing the WHI findings is the absolute rate of the increase in breast cancer. So even if you accept that the effect is real and not the result of randomness or a decreased rate in the control group the absolute increase in was 8 more breast cancer diagnoses per 10,000 patient years. Taken together, this review significantly decreases, if not removes altogether, the concern that I have about estrogen causing an increase in breast cancer. Bluming and Tavris then revisit the benefits and risks of HRT - providing links to the best available current evidence and in doing so provide perhaps the best single source of HRT information for anyone considering HRT. Summary of the Risks and Benefits of Estrogen Replacement: Benefits
Risks
Bottom Line: For every woman going through menopause, HRT should be given personalized and individualized consideration. I highly recommend this book to anyone who wants to review the data for themselves and make a fully informed decision. As for my physician colleagues, I have already been recommending "Estrogen Matters" For a great listen - check out Peter Attia's podcast. with Bluming and Tavris |
AuthorDr. Brendan Byrne Archives
January 2020
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