7 Principles that Drive Poor Health

Dr. Yaman Abdullah is a board-certified physician in Internal Medicine who practices as a Hospitalist in the Houston area. His areas of interest include lifestyle changes conducive to disease prevention and overall wellness. Below are some of his thoughts on this topic. The views expressed are those of the author and do not reflect the official position of Wasat Institute.

This is meant to be a comprehensive post on the topic of general health and disease prevention, so just be warned in advance that it’s dense and lengthy. As an internal medicine physician, I had to spend quite a while researching disease prevention and see what works in the real world with myself, family, friends, and patients. In this era of a global pandemic and the declining health of our society, it’s an obligation on us healthcare professionals to do our due diligence in educating ourselves to be able to pass that knowledge on to our families, neighbors, and fellow human beings when it comes to optimal health. We should make this information easy to understand, free, and widely accessible. I am of course open to critique and feedback for whoever bothers to read through until the end. The advice below is mainly for the average sedentary person on the standard western diet. I address the psychosocial, dietary, and lifestyle principles that drive poor health. There are 7 main principles: purpose, social support, do no harm, intermittent fast, food habits, exercise, and natural supplements. After discussing the principles, I comment on tools you can use to assess your basic state of health and monitor your progress. References are posted at the end.

1. Purpose — When it comes to habits, human beings are creatures of emotion, not reason. I can’t count the number of times I’ve come across a chronic smoker with severe COPD struggling to talk at rest while breathing extra oxygen through a nasal cannula, who despite my extensive counseling insists that they’ll continue to smoke cigarettes until they die and no amount of evidence or logic will change their minds. There’s a lack of purpose here, not intelligence. Extrapolate that to every other bad habit. What’s really driving this behavior and what’s worth fighting for in your life to fix it? One method to answer this that I recommend is stream-of-consciousness journaling. Put pen to paper and just write whatever comes to your heart. You’ll find yourself sifting through quite a mess but it’s a cool experience in getting to know yourself and a necessary part of achieving clarity. It’s worked wonders for me personally. For the sake of clarity, my answer to this question boiled down to God’s pleasure and acceptance of me, and the only way to achieve that was to try to tread the path of Prophet Mohammed ﷺ (peace and blessings be upon him) that he laid out for us at God’s behest and direction.

2. Social support — Loneliness and lack of family connection have been identified as risk factors for many diseases; the equivalent of smoking 15 cigarettes a day in one study (see bottom reference). This is one of the most overlooked culprits of disease and stigmas of modern society. The quality of those relationships matters too, and when it comes to building good habits, transparency is the most important part in my opinion. I suggest you identify one person in your life you can be completely transparent with. This is not meant to offload responsibility or dump your problems on someone else’s lap. This is just for you to practice transparency, to be open about your good days and bad days on this journey. Group effort can be a good kick-starter (i.e. group workouts) but can also give a false sense of security. It’s easy to get excited in the beginning but the excitement always tapers off, and with it the effort. What will you do when you’re away from your group/partner or they cease to exist in your life for any reason? Prepare for when you inevitably have to trek this path alone (so revisit #1 often). Practicing transparency gives you a chance to get to know yourself, identify self-limiting patterns, and is quite a liberating experience to be bluntly honest with someone without putting on a mask or making excuses.

3. DNH (Do No Harm) — The Prophet ﷺ said: Let there be no harm or reciprocation of harm (لا ضرر و لا ضرار). “First, do no harm” is part of the Hippocratic oath we take on the first day of medical school. It’s not just a way to practice medicine but to live a healthy life. An ounce of prevention is really worth more than a pound of cure. Below are what I believe to be the most harmful habits of today that are necessary for disease prevention:

3A) Bad carbs — Carbs are misunderstood. There are good carbs and bad carbs. Good carbs are found in vegetables, fruits, legumes, nuts, and unprocessed whole grains. Bad carbs or refined carbs (also termed by Dr. David Kessler as “fast” carbs) are highly processed and designed for your body to soak them up quickly into your bloodstream like a sponge, thus bypassing the natural pathway that leads to the feeling of satiety and fullness via the balance of the hunger and satiety hormones ghrelin and leptin. It’s why you never feel full chomping down on chips, crackers, cookies, candy, soda, etc. Examples of bad carbs are processed grains (white bread/rice/flour, cereal, granola, breakfast bars, etc), sugar, high-fructose corn syrup, alcohol, soda, juice, and energy drinks. Cow milk might as well be on the list too. Lactose in cow milk is composed of galactose and glucose, so even without all the added sugar in modern milk products, it can raise your blood glucose levels.

Bad carbs are so pervasive in the western diet and are responsible for the explosion in obesity, type 2 diabetes, cardiovascular disease, and many other diseases over the last century. Cut these out as much as possible. How to hydrate? Take a tall glass of water and either sprinkle a tiny bit of sea salt (shouldn’t even taste it), or add a teaspoon of unfiltered apple cider vinegar, or lemon, cinnamon, or infuse a jug of water overnight with mint, berries, or cucumbers. Have a sweet tooth? Fruits, dark chocolate (at least 80% dark), and mixed nuts are a healthier alternative.

3B) Poor sleep hygiene — sleep deprivation is an epidemic of modern times and is implicated in many disease processes. In a comprehensive article review published in Nature and Science of Sleep in 2017: “In otherwise healthy adults, short-term consequences of sleep disruption include increased stress responsivity, somatic pain, reduced quality of life, emotional distress and mood disorders, and cognitive, memory, and performance deficits. For adolescents, psychosocial health, school performance, and risk-taking behaviors are impacted by sleep disruption. Behavioral problems and cognitive functioning are associated with sleep disruption in children. Long-term consequences of sleep disruption in otherwise healthy individuals include hypertension, dyslipidemia, cardiovascular disease, weight-related issues, metabolic syndrome, type 2 diabetes mellitus, and colorectal cancer.” There’s much to say about this, but part of what’s responsible for this is screen-time. Sleep quality is a function of screen quantity at night as it interferes with the production of the natural sleep hormone “melatonin” amongst other disruptions to go along with over-stimulation. Set a bedtime, turn off all screens at least 1 hour beforehand, and learn to wind down by doing something off-screen that relaxes you. Personally, I don’t believe in these cookie-cutter recommendations like “Everyone should get 8 hours of sleep.” Everyone’s different, and I don’t think it’s necessary to recommend 8 hours of sleep as a blanket statement. Just turn off all screens and white light, wind down, and go to bed as soon as you feel tired. It’s really that simple. Of note, if despite proper sleep hygiene you find yourself having excessive drowsiness during the day, day-time headaches, or never feel refreshed after awakening then you need a sleep study to evaluate for obstructive sleep apnea or other sleep disorders. The main natural sleep aid over-the-counter is melatonin (always start off low at 1 mg if needed), but melatonin is naturally produced by our brains in the evening to set our circadian rhythm and can be disrupted by artificial light (mainly screens and white light). L-theanine and magnesium supplements over-the-counter help relax you prior. L-theanine is found naturally in green tea and magnesium in nuts, eggs, and dark leafy greens. So after turning off the screens and white light, try drinking green tea or snack on mixed nuts as you wind down. It’s best to go to bed once you feel sleepy and not lay in bed wide-eyed before feeling sleepy.

3C) Tobacco use is obvious and has been on the decline for the last several decades so there’s no point in expanding further on this.

4. Intermittent fast — We eat too damn much for the amount of movement required of us nowadays. Who said we need to eat three meals a day? With technology making us more sedentary, there’s really no need or logic for stuffing our bodies with so much fuel. Your body needs a break from consumption. Insulin resistance (from chronically elevated insulin levels due to excessive carb consumption) drives much of the mechanism behind obesity, type 2 diabetes, high triglyceride levels in the bloodstream, cardiovascular disease, even certain autoimmune diseases, and cancers. Insulin resistance can be remedied by fasting which almost immediately brings insulin levels down. There are countless benefits to fasting which can easily be researched (fat loss, immune cell regeneration, cellular repair, cognition). One practical way to incorporate this daily is with a 16–8 fast: pick an 8-hour window to eat all your meals within and do not eat anything outside of this window (not a bite) in order to achieve a 16 hour fast. For example, I try to eat my meals from noon to 8 pm, essentially skipping breakfast, eat lunch, a snack, catch dinner with my family, and then no food outside that window. During the 16 hours, you can do a dry fast (without any drink — this method has more physiological benefit in my research) or wet fast (hydrate with zero carb drinks like water, black coffee, or unsweetened tea).

Warning: if you take medications for diabetes and/or blood pressure, please check with your physician prior to attempting fasting. Fasting induces ketosis which has a diuretic effect (loss of water and salt through urination). Fasting can drastically lower your blood pressure and glucose to dangerous levels if you’re on these medications so please be mindful and seek counsel with a physician prior.

5. Food habits — I hate the word “diet” because there’s really no such thing. The word itself is empty and implies temporary fads. “Going on a diet” is like “going on vacation” — the novelty of the experience is exciting, then you get bored and you’re back home to business as usual. Instead of “I’m starting this diet”, say “I’m starting this HABIT”. I can’t stress how important this mindset is. Just to review a couple of popular trends: one is “caloric deficit”: counting calories that you consume vs what you burn and to try to stay in the red. This sounds logical but is not scientifically sound. It treats all calories as equal. How can 100 calories of Pringles chips be the same as 100 calories of broccoli? This ignores the biochemical and hormonal effects of those calories. Hormones like insulin, glucagon, ghrelin, and leptin are an intricate part of this process and intimately tied to our appetites, what we consume, and how we metabolize it.

Now if I was to put a label on my ideal food habit especially in light of the standard western diet, it would be LCHF (Low Carb High Fat): lower consumption of rice/bread/pasta/grains, higher consumption of quality meat, and healthy fats (butter, ghee, lard, olive oil, eggs, full-fat yogurt/cheese). This is based on a simple biological fact: protein and fats are ESSENTIAL, meaning our bodies are unable to make certain amino acids and fatty acids which we must consume from external sources in order to survive. Carbs are NON-essential, meaning our bodies are capable of storing and synthesizing glucose (the building block of carbs and primary source of energy) through mechanisms like gluconeogenesis (creating glucose from scratch) and glycogenolysis (breaking down stored glucose from our liver and muscles) without the need for consumption from external sources. If we run out of glucose, our bodies have an ingenious mechanism called “ketosis” which switches to an alternative source of fuel: ketones derived from fat-burning. This is how human beings were able to survive without food for days to weeks prior to the advent of agriculture. Again, we need to make the distinction between good and bad carbs. “Essential” here does not mean “important” because good carbs are very much important. The term only points to the need for external consumption as an absolute necessity for survival. It’s important not to get too dogmatic here. I don’t demonize all carbs and I believe good carbs are important — vegetables, fruits, nuts, legumes contain vital vitamins and minerals that we do need for good health. Restriction of these makes little sense except in patients with metabolic syndrome, obesity, type 2 diabetes where restriction of some of these good carbs is necessary, like root and tuber vegetables that have lots of starch such as potatoes, sweet potato, yams, peas, carrots, and beets. There is an ongoing debate about this — some advocate for the opposite high carb, low fat which is essentially a vegan, fully plant-based, and oil-free diet like Dr. Caldwell Esselstyn’s diet for reversing heart disease. “Keto” involves severe carb restriction which basically paints all carbs with the same brush (even within the Keto community there is debate about net carbs and fiber) — this can play a therapeutic role in obesity and type 2 diabetes but is not practical for most people and unnecessarily restrictive most of the time in my opinion. People all around the world have been eating good carbs, fats, and meat for thousands of years without being afflicted by the prevalent metabolic diseases we see today.

On a final note, the concept of “low fat” that the medical community has been pushing over the last several decades was well-intentioned but based on flawed science. We ended up replacing the fat with carbs, further exacerbating the metabolic apocalypse. We had people believing that a low-fat donut with 40 grams of carbs was somehow a health food. Again, human beings for thousands of years have been eating healthy fats like oily fish, animal fat, butter, lard, and eggs, and these metabolic diseases were virtually non-existent. We have to identify the correct culprit in order to know how to move forward.

6. Exercise — this is near the bottom of the list of priorities in my opinion, although it is still very vital. The best exercise for beginners is low-impact cardio exercises with some resistance training for building muscle (i.e. a combination of power-walking or bicycling along with bodyweight exercises like push-ups, squats, abdominal V-crunches, pull-ups). Keep it simple and don’t feel the need to overdo it because the last thing you want is an injury. World-class MMA trainer, Firas Zahabi, has a rule of 70% — never exercise to 100% capacity, keep it closer to 70%. If the absolute maximum number of pushups you can do is 10, always do 7. If you’re destroying your body each and every time you exercise, there is no way you’ll stay consistent and you’re just raising your risk of injury. There’s plenty of material to look up to ensure you’re keeping good posture and form to avoid injury. If you make exercise too complicated and torturous you’ll give it up fast. It has to be enjoyable, and you’ll only enjoy it if you feel good afterward.

7. Natural supplements — this is a largely unregulated multi-billion dollar industry and much of the benefits touted in this area are fabricated or exaggerated. There is no benefit to taking a plethora of supplements blindly without basic bloodwork that can identify certain deficiencies and the vast majority of what your body needs will be covered by consuming an unprocessed, colorful diet. If you decide to take a supplement, make sure to carefully research the brand for quality: for example, the “USP verified” stamp ensures that the manufacturer tested their product for purity. Also beware of the many fillers used in supplements like food coloring, starch, sugars (high fructose corn syrup, sucrose, maltodextrin) that end up causing more harm than the benefit of the supplement. The only two I personally recommend for everyone as a general rule are fish oil or cod liver oil (for essential fatty acids like omega-3) and vitamin D3 (cholecalciferol is D3 as opposed to ergocalciferol, D2, which is plant-based — it is an inferior form to D3 because it’s not as bioavailable and does not last as long in the human body). Vitamin K2 is vital for bone mineralization and prevention of calcification of the arteries and it may be beneficial to supplement K2 along with D3, but it should be covered if there is adequate consumption of green leafy vegetables and healthy fats.

Tools to evaluate basic levels of health and progress:

1. Waist circumference — this is one of the most independent and direct measures of health. It is far more informative than weight. Weight as a raw number means nothing because it includes water weight, muscle mass, subcutaneous and visceral fat. Fat naturally occurs in certain parts of the body, but inside your abdomen and around your abdominal organs should NOT be one of those places. Abdominal fat (aka visceral fat) is a major sign of insulin resistance and is an independent risk factor for many diseases. As a general rule, if your waist circumference is 36 inches or above, you should be concerned (the threshold a bit lower for women). Buy a waist tape measure and look up how to measure waist circumference accurately. The most efficient way to lose abdominal fat, in my opinion, is a combination of IF (intermittent fast) and LCHF (low carb high fat) as detailed above.

2. Electronic smart scale — (to measure visceral fat, body fat %, water weight, muscle mass). Renpho smart scale is one I personally use, costs ~ $30 on amazon, and syncs with a phone app by Bluetooth.

3. Blood pressure monitor — always use a brachial cuff (the one that goes around the arm, not the wrist), and check once in the morning when you’re most rested. The general target is below 140 mmHg systolic (top number), 80 mmHg diastolic (bottom number). In patients with a history of congestive heart failure, coronary artery disease, and stroke, the target goal is even lower so this needs the close eye of a physician in such cases.

4. Continuous glucose monitor (CGM) — Usually reserved for diabetics. These aren’t as accurate as fingersticks but close enough to where it’s not a big deal. Only available by prescription (the common one I prescribe is Freestyle Libre) and can be a bit pricey but worth the investment. Instead of spot checks by fingerstick, the sensor is placed above the skin and the machine can scan it to check the glucose level immediately (no lancets, no blood). More importantly, it self-monitors your glucose levels hourly and graphs it. If the graphs are looking like a roller coaster ride, this is a problem indicative of glucose intolerance and poor diabetes control. You can observe in retrospect which foods are responsible for spiking your blood glucose and adjust accordingly. A note on diabetes: It is a complicated subject, but there are two broad types which are type 1 diabetes (insulin deficiency requiring insulin shots for survival, usually in young and thin patients) vs type 2 (the opposite — a disease of chronic insulin excess in response to excessive carbs leading to insulin resistance, usually in older obese patients). You can also have patients with pancreatic dysfunction (either due to chronic pancreatitis from a number of causes, or pancreatic fatigue in type 2 diabetics) who become truly dependent on insulin shots. Be sure to seek medical evaluation regardless. Any drastic change to your diet (like fasting or carb restriction) while taking insulin shots can result in dangerously low blood glucose levels, so never do this without the guidance of a healthcare professional.

5. Bloodwork: I recommend the following six basic labs as a general assessment of health. * = must be done in fasting state (nothing by mouth for at least 8 hours):
– Complete blood count (CBC) — checks for anemia and other blood diseases
– Complete metabolic panel (CMP) — checks your electrolyte levels, kidney and liver function, and fasting glucose. Should be done in a fasting state.
– Lipid panel — checks your total cholesterol, triglyceride, HDL, and LDL levels. This should be done in a fasting state. A note on LDL: it is no longer scientifically sound to automatically label LDL as “bad” cholesterol and HDL as “good” cholesterol. This is outdated science. Our bodies synthesize LDL for a reason (delivery of energy to cells, synthesis of hormones, immune cell function, neuron development, storage of fat-soluble vitamins). There are different sizes of LDL particles, some of which are atherogenic (cause atherosclerosis which can lead to heart disease, stroke, peripheral vascular disease), like small dense LDL (sdLDL). Particle testing can be requested from your physician but tends to be expensive. A cheaper method is to use an indirect marker for LDL particle size, and that is the triglyceride to HDL ratio (target < 3.5, a higher ratio indicates the presence of smaller, therefore more dangerous, LDL particles). I believe what drives high triglycerides and small LDL particles are excessive processed carbs, but this is a whole other subject.
– Hemoglobin A1c — screens for diabetes. A1c 6.5 or above is diagnostic for diabetes, while 5.7–6.4 is indicative of prediabetes. Prediabetes is not to be dismissed because there are still real health consequences to prediabetes without having to go to full-blown diabetes. It should carry the same concern as a “pre-cancerous” lesion would.
– Thyroid-stimulating hormone (TSH) — screens for thyroid disease. Often overlooked and responsible for many symptoms and diseases (i.e. low thyroid is associated with obesity, fatigue, high triglycerides, high diastolic blood pressure, constipation).
– Vitamin D level — one of the most common deficiencies that is too important to miss. Vital for our immune system, heart health, and calcium homeostasis. We get vitamin D from the sun when our skin is exposed to UV-B sunlight rays (the best time for this is around noon). However, this is highly variable based on geography, degree of melanin in your skin, and our indoor lifestyle so supplementation is usually inevitable. It is very difficult to overdose on vitamin D. I usually recommend vitamin D3 2,000 IU daily with food. As explained above, vitamin D3 (cholecalciferol) is superior to D2 (ergocalciferol). Vitamin D levels can get toxically high and raise your blood calcium to dangerous levels but you would have to take way more than 10,000 units a day to achieve this or have medical conditions that raise calcium levels (like overactive parathyroid glands, sarcoidosis, and certain cancers). A common loading dose with vitamin D2 is 50,000 IU per WEEK and has proven to be safe and effective, but again, I do recommend D3 for better maintenance. Always best to have your complete metabolic panel and vitamin D level checked prior.

References:
Public Health Relevance of Social Isolation and Loneliness: https://academic.oup.com/ppar/article/27/4/127/4782506
Comprehensive article review on sleep disruption:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5449130/
Dr. Jason Fung’s online lectures and book “The Obesity Code”
Dr. Jeff Volek and Dr. Stephen Phinney’s book “The Art and Science of Low Carbohydrate Living”
Dr. Aseem Malhotra’s online lectures and book “The Pioppi Diet”
Dr. David Kessler’s book “Fast Carbs, Slow Carbs”
Dr. Caldwel Esselstyn’s book “Prevent and Reverse Heart Disease”
Dr. Uffe Ravnskov et al’s comprehensive literature review on LDL published in the journal Expert Review of Clinical Pharmacology in 2018: https://www.tandfonline.com/doi/full/10.1080/17512433.2018.1519391