RHR: Taking Charge of Your Metabolic Health, with Dr. Naomi Parrella

In this episode, we discuss:

• Dr. Parrella’s background story and how she ended up interested in a low-carb approach to weight loss
• Why high LDL cholesterol isn’t a reliable marker for cardiovascular disease risk
• Why progress depends on confronting the status quo of conventional medicine and it’s inherent biases
• The biggest challenges to weight loss
• How to determine the best amount of carbohydrates for weight loss
• What Dr. Parrella has changed over the years in her approach to weight loss and metabolic health

Show notes:

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Hey, everyone, Chris Kresser here. Welcome to another episode of Revolution Health Radio. The latest statistics suggest that a little over 40 percent of the U.S. population is now obese and about 70 percent are overweight. The consequences of this epidemic of obesity and overweight are profound. These conditions lead to an increased risk of diabetes, cardiovascular disease, cancer, and many other chronic conditions. Helping people effectively lose weight and keep it off is still one of the most important things we can do to prevent and reverse chronic disease and extend life span. Unfortunately, despite decades of effort in this direction, the results have been pretty disappointing, frankly. The rates of obesity and overweight have continued to climb, and many people who attempt to lose weight are either unsuccessful to begin with, or they experience short-term success but are unable to keep the weight off.

I’m really excited this week to welcome Dr. Naomi Parrella as my guest. She’s the Chief Medical Officer for Readout Health, which makes the only class I [U.S. Food and Drug Administration] (FDA) registered breath ketone meter. She’s double board certified as a family physician and obesity medicine specialist and sees patients in the Chicago area. Naomi has an interesting background. She grew up in Japan, so she experienced both Eastern and allopathic medical care philosophies, and early on in her practice, she obtained additional training in Chinese herbal medicine. She’s an associate professor and the Chief of Lifestyle Medicine [and] Medical Director for Rush University’s multiple weight loss and lifestyle medicine clinics. She has a lot of experience helping people from diverse backgrounds lose weight, and I’m really looking forward to talking with her about her integrative approach.

We’re going to talk about Naomi’s experience in the multiple weight loss clinics [that] she runs, the difference between overweight, obesity, and metabolic health, and where those overlap, what some of the difficulties that she has faced in the clinical setting are, what some of the biggest obstacles to weight loss are, from her experience, and how to address some of those obstacles. [It’s] a really important subject, and [I’m] excited to discuss it with Dr. Naomi Parrella. Let’s dive in.

Chris Kresser:  Naomi, welcome to the show. It’s a pleasure to have you on.

Naomi Parrella:  Thank you so much, Chris. I’m super excited.

Chris Kresser:  Over the almost 15 years that I’ve been a clinician, sometimes patients will ask me, “What’s the hardest, most difficult condition that [you] treat?” There are a lot of ways to answer that question, and oftentimes, I think the expectation is going to be some autoimmune disease or mold illness or something like that. And those can certainly be difficult to treat. But I would say one of the top three would be recalcitrant excess weight. In other words, people who are carrying excess weight, who’ve tried all the basic stuff that you would try, and that hasn’t worked. It’s relatively easy, in some cases, to help people lose weight. But when that person has done all the [right] things and they still haven’t lost weight, that can be a really difficult situation. So I’m really happy to be talking to you because this is pretty much what you spend every day doing, right?

Naomi Parrella:  Yep, pretty much. It’s really quite a bit of fun.

Chris Kresser:  Why don’t you just give a brief background on how you came to be in the position you’re in. What position are you in now? How are you spending your time in terms of weight loss and all the different things you’re involved in? How [did] you [come] to this? What’s your personal story? Because that’s always interesting to me, to learn a little bit more about how people ended up where they are.

Dr. Parrella’s Background

Naomi Parrella:  Absolutely, sure. Well, I mean, I don’t even know where to start. Basically, I grew up in a bicultural family and attended international schools growing up in Japan. So I always had the experience of more than one way of thinking about things because my parents, from two different cultures, had their own opinions of how you take care of yourself and just everything, in general. Then, of course, I had a lot of my friends at the international schools that also thought about their bodies in different ways. So we all were very open to many different ways to take care of yourself [and] many ways to be healthy. Then, fast forward, [I] went to medical school, and in medical school we were taught best practices, or the one best way, to take care of something. There was very little conversation about things that patients could do, unless it had medications [and] intervention. You know this, right? “Unless I can do something to you, you’re kind of stuck with this.” And it really bothered me to think there’s only one way, because I saw growing up [that] there were so many different ways to be healthy.

If I had a fever, my dad, who’s Japanese, would say, “Hey, you got to sweat it out. Your body’s trying to sweat, raise your temperature for a reason.” And my mom would be like, “Here’s a Tylenol; we can bring down your temperature.” And both ways worked, right? So it depended on what was going on.

Chris Kresser:  Yeah, you have an interesting experience of seeing the difference in how things are handled, culturally, like you just said. In the [United States], we might think there’s just one single approach to obesity and overweight, or even [that] we have a sense of how common those conditions are. But in Japan, it’s very different, right?

Naomi Parrella:  Right, totally. So that’s been really fun. Basically, there’s a cognitive dissonance during medical training. But I wanted to learn everything that Western medicine was doing. And again, growing up, I had both Chinese medicine and Western medicine. It was integrated. I had access to both and saw different kinds of doctors for different things. During training, I saw there was one answer for everything. It’s like a multiple choice test. That’s how I was taught. Then going into practice, I became a family doctor and was taking care of people of all ages, and they would have all sorts of chronic health problems that I was told in med school, “It just goes one way.” For example, diabetes. You just get worse, and the goal is to slow down how bad it gets. My patients would come in, and I wasn’t really solving problems and I wasn’t helping people get better. It was very frustrating.

So I went back and learned some more about Chinese herbal medicine. I did some additional certifications there [and] started opening my mind to what is available elsewhere. Long story short, I noticed that weight was a good marker and a good signal from the body that the body was off track. Just by paying attention to weight, I could start seeing the foundational problems that led to a lot of the chronic issues for my patients, and I was able to start turning that around. My patients taught me that weight loss is a side effect of getting better, and that you can get better and reverse diseases that I had been trained [were] not reversible.

Chris Kresser:  That’s fascinating. Now you’re the Chief of Lifestyle Medicine at Rush [University], [the] Medical Director for multiple weight loss and lifestyle medicine clinics, and also the Chief Medical Officer for Readout Health, which makes [the] Biosense breath ketone measurement device, which is how you and I met since I’m on the advisory board of that company. Along the way, you discovered the benefits of lower-carbohydrate dieting for weight loss, which is also contrary, I imagine, to what you were taught in medical school and what so many of us were taught is the best approach for weight loss. How did you get interested in lower-carbohydrate dieting along the way?

Naomi Parrella:  Well, Chris, I was taught calories in, calories out, eat less, exercise more. So, of course, I was preaching that. I was an aerobics instructor and personal trainer, I went out into the community, and I was like, “I’m going to change the world.” And what happened? Not much success, long-term. I was like, “Why are these people not doing what I’m asking them to do?” After a while, you start noticing, “You know what? Actually, everybody says they’re doing the right thing. Either everybody’s lying to me, or my information sucks. I must be doing something wrong because I’m the common variable here.”

It turned out, I had several patients who said to me, “You know, Dr. P, I think there’s some other things that are going on here. I’m doing everything you said, and I’m willing to try anything.” I said, “Okay, well, I heard about this thing called [a] high-fat diet. I don’t really know, but some people are saying it’s really amazing, and they’re getting results. Do you want to try it out? I have no idea. I’ve been told this is a terrible thing to do. But if you’re at that point where you’re like, ‘I’m willing to try anything,’ we could do an N equals one experiment. You can see how your body responds.” I had somebody who had been told that her diabetes was so bad [that] [she was] going to lose her legs. She was frightened, and she said, “I’ll do anything; I’ll try this.” So we pulled out every book about low-carb diets, which in those days, weren’t very many. I was Eric Westman or Atkins, essentially. And we tried it. We checked labs three months in, [and the] labs looked better. And this was happening with all of the patients [who]t were willing to try this. Anecdotally, I started seeing [that] somebody told me that this is not possible, and I have multiple patients who are miracles. In fact, it wasn’t a miracle. The body was just getting the right signals. So I learned fast.

Chris Kresser:  Absolutely. It’s such a similar experience to so many clinicians. For me, when I came into it, I was already sort of disenchanted with [the] high-carb, low-fat approach. I’d seen in my training how ineffective that was for most people. Granted, there’s no one-size-fits-all approach, and I know that this has been your experience in your role. You see patients from really diverse backgrounds with diverse needs, and you have to adapt your treatments accordingly. But would you say, at this point, from across all of that experience, that you have better success with that approach, in general?

Naomi Parrella: We have six different clinics across the Chicagoland area with very diverse populations, just like you’re describing. In [medical] school, I’d been taught [that] it’s about what neighborhood or what zip code you have, and so on. Some people can follow and some people can’t. But that’s actually not true. Across all of our clinics, if individuals are able to understand how carbohydrates, particularly ultra-processed carbohydrates and sugars, negatively impact their health and they’re willing to cut that back and adjust and make some simple changes, it doesn’t matter where you come from. It doesn’t matter what zip code you have, [and] it doesn’t matter what your background is. You can make significant change[s].

We’ve seen that across the clinics, and it is so much fun. [The] joy that people get when they come in and they’re seeing their labs come back to normal, they’re able to come off medications, [and] they have more energy. I love when I hear, “Dr. Parrella, I have a confession to make.” I say, “What is it?” [They say,] “I couldn’t help it; I had to start exercising more. I joined a gym, I did some extra stuff, so I’m doing more than you said.” And I’m like, “This is great.”

Chris Kresser:  That’s the opposite of your experience before, right? Where people were doing all the things you told them, and they weren’t making any progress and feeling discouraged. In this case, they’re actually accelerating their own progress. We call that an upward spiral, instead of a downward spiral. Some things get better, [then] other things that are connected get better, like energy levels, which then enables more physical activity, which then either accelerates or maintains the weight loss. It’s this whole cascade of events that happens.

Naomi Parrella:  Totally.

LDL as a Marker for Cardiovascular Disease Risk

Chris Kresser:  I just released a video on my YouTube channel [about] a new study that was published, looking at trying to answer the question of whether high LDL cholesterol in people [who] are following a low-carbohydrate diet is actually correlated with an increase in cardiovascular disease risk. It was a fascinating paper because we know from some large observational studies that, generally, high LDL is associated with a higher risk of heart disease. But we know that that’s correlation and not causation. There are lots of mitigating factors. The conclusion of this paper was that, in people on low-carbohydrate diets that don’t have other significant risk factors, the increase in LDL is not actually associated with poor outcomes over time. I’m wondering, [with the] patients you see, which again, are from very diverse backgrounds, if that’s something that still comes up in the conversation. Because it’s still out there. I think it’s changed a lot in the last 20 years, but there’s still this very strong fear of saturated fat and dietary cholesterol and blood cholesterol levels.

Naomi Parrella:  Oh, my gosh, absolutely. This is the biggest fear. Of course, there’s a lot of controversy that surrounds us, which I don’t really think is controversy. We just don’t have long-term data on high-fat, low-carb diets with regards to cholesterol, and an LDL doesn’t tell you anything. My favorite [quote], [and] I don’t even remember who to credit this to, but whoever it was said, “When there’s a fire, if you are seeing a lot of firemen around a fire, does that mean the firemen started the fire?” Same thing in the body. You see lots of LDL cholesterol, [but] does that actually mean that’s the problem? No. Maybe they’re the firemen. Maybe they’re helping repair. It doesn’t tell us anything. It just means there [are] some correlations. But again, if you’re looking at a population, more than 88 percent of the population is sick, so using population norms is not helpful. Our goal is not to be like everybody else with regards to metabolic health. [It’s] not a good measure to say [that], in the regular population, this is what would be considered a normal level. That doesn’t tell us anything.

Chris Kresser:  Right. I’m sure you see this, too, but this was in the paper, and I’ve written a lot about this over the years.

Naomi Parrella:  Thank you for that.

Chris Kresser:  If you take a hypothetical patient or a real patient from your practice or my practice, and let’s say they have numerous cardiovascular and metabolic risk markers. They’re overweight, they have abdominal obesity, they’ve got high blood pressure, they’ve got high glucose, high insulin, high LDL cholesterol, low HDL, high triglycerides. We could go on down the list. A lot of people know what they are. High C-reactive protein and other inflammatory markers. Then they go on a low-carb diet. Virtually all those markers improve, except LDL cholesterol maybe stays the same or, in some cases, might go up. The conclusion, at least from the mainstream perspective, is that [the] person is worse off and their cardiovascular disease risk has somehow increased, despite the fact that literally 19 out of 20 markers have improved. They’re feeling better than they have in years, or maybe ever in their memory, and multiple strong risk factors have changed. Do you see that in your practice, as well, with the patients you treat?

Naomi Parrella:  Chris, absolutely. I mean, we’re speaking the same language. It’s so fun to talk to someone who gets it. But yes, absolutely. And here’s the bottom line. If an organism, a human that’s meant to move, feels great and they’re moving more, there is no way in hell that one number means that there’s increased risk and it’s bad for you. There’s no way. When people don’t feel good, they don’t want to move, [and] other markers start getting worse. I absolutely see and have lots of conversations about this. People get very stressed out about their LDL, which, quite frankly, on a regular lipid panel, [is] a mathematical calculation. It’s not even that the lab is counting the LDL, and it doesn’t differentiate the different sizes of the LDL. There’s just so many things wrong with it. You see, you’re getting me on my soapbox here.

Chris Kresser:  Well, yeah, there’s a whole other discussion about cholesterol versus looking at particle number, which is far more relevant. And if we’re going to look at a number, APO-B would be a much better marker to look at, or lipoprotein(a), which is a particular type of low-density lipoprotein that is independently associated with cardiovascular disease. Even then, you still have to interpret the significance of that marker in the overall context of what’s happening. I think part of the issue is that we have such a reductive approach to human health and medicine where we’ve come to see the body as a collection of separate parts, and we just myopically focus on one part or one marker, and don’t consider the relevance of that part or marker in the overall context of the ecosystem. And we’re really bumping up against the shortcomings of that approach now. This is just one of many examples of where that can go wrong.

Naomi Parrella:  Absolutely agree.

Chris Kresser:  One thing I mentioned in the video was somewhat amusing, and somewhat horrifying, I guess, depending on how you look at it. I’ve often found that advocates of the conventional view of LDL cholesterol and its value as a risk marker don’t even use their own calculators or tools as a means of really parsing out what impact LDL has. I used an example.  There’s a calculator called QRISK2, which is one of the more validated, popular 10-year cardiovascular risk calculators. I used a hypothetical person. A Caucasian male, six [feet] two inches tall, 180 pounds, normal weight, not overweight, 50 years old, nonsmoker, and no significant risk factors. No diabetes [or] history of heart disease, not taking blood pressure medication, etc. Let’s say that person went on a low-carb diet. Or [let’s say] they were a little bit overweight, maybe they were 200 pounds, and then went on a low-carb diet and lost 20 pounds, and now they’re 180. If that person plugs those numbers in and they have a hypothetical total cholesterol of 300, which by any account is very high.

Naomi Parrella:  Considered high, yep.

Chris Kresser:  That’s probably familial hypercholesterolemia. Then they have [a high-density lipoprotein] (HDL) of 65, which is in the normal range. If you plug that person’s numbers into this calculator, their 10-year risk of cardiovascular disease will be about 4 percent. That doesn’t change much if you lower the total cholesterol level. A lot of that risk is just coming from age. Age is the number one risk factor for heart disease. I’m always telling people that. There was a study that showed that statins may only be beneficial in terms of reducing total mortality in people with a cardiovascular disease risk of 20 percent or higher, but I can almost guarantee that patient would be prescribed a statin in a conventional medical practice, despite their own calculators and studies saying that’s not going to help in that situation.

Naomi Parrella:  That’s exactly it, and it’s very, very frustrating. If you have a well-established physician who’s not read the recent literature with a critical eye saying [that] this is what you need to do or you’re going to die, [it’s] really hard to help people recover from the trauma of thinking they’re going to die because otherwise, everything else looks fine. They’re doing great. It’s very, very challenging. I think individuals struggle with that a lot and rightly so. It’s unfair for anybody to make that kind of judgment. Again, it’s a bias. It’s not accurate. It’s not based on evidence. It’s completely old data that is not actually even real data.

Chris Kresser:  Old ideas die hard, though, right?

Naomi Parrella:  Yeah. Well, they say it takes 20 years for something to catch up in medicine. We’re so slow, but I think we’re getting better.

Confronting Conventional Medicine Biases and Status Quo

Chris Kresser:  I think we’re a little overdue on that 20-year thing because some of these low-carb studies go back longer than that. Kurt Lewin’s theory, I’m going to butcher it, but it’s basically [that] with change, there are forces for change and forces against change. There’s [a] dynamic that’s always there that change doesn’t happen until the forces for change are greater than the forces against it. And there’s still a lot of forces against that change. There’s still a lot of money that’s tied up in maintaining the status quo. All the drugs and the big food companies that are invested in the low-fat paradigm, and then there’s just groupthink and even seemingly small things, but that medical textbooks that are printed and still in use by universities that are teaching this methodology. It’s like turning a huge, mega Titanic ocean liner around. I have that visual in my head. We’re somewhere in that process, where it’s slowly turning, [but] it’s not linear. It turns, it stops, it goes back in the other direction a little bit, it keeps turning. That’s my sense of it, [that] maybe by the time our kids are grown up, we’ll [hopefully] have a more nuanced view on this. But it’s a shame that it takes [at least] a generation, if not two generations, when you have the data. The data [is] there.

Naomi Parrella:  I agree. One of the things that I think has been helpful is [that] people are curious. There’s a lot of great physicians, scientists, healthcare providers, Functional Medicine [practitioners], a lot of different people speaking up and saying, “Hey, does this make sense to you? Because here’s another way to think about it.” So people are asking questions. They come in, [and] they’re seeking out better conversation where they can really understand. I think this is the future. I’ve had several patients come in and say, “I’m scared to ask my doctor this question.” And I say, “Doctors need to get the questions, also, right?” Sometimes we might not have time to look everything up. But if a patient comes in, and [then] another patient comes in and says the same thing, we’re like, “Well, I gotta go look at the research here, tonight, immediately.”

Chris Kresser:  Well, that’s one response, Naomi. That’s the response that we want to see. But I can’t tell you how many times my patients come in and tell me that’s not the response they got when they asked their doctor a question. The response is sometimes an eye roll; it’s sometimes an attack, “How dare you question my authority? I’m the person with all the answers.” In my experience, the more training that doctor has, the more of a specialist they are, the more highly regarded they are in their field, the more likely that it’s going to be that kind of response. I actually just, it’s a little off topic, but I’m going to tell the story anyway because someone close to me in my life was having unexplained fatigue. This is an older man [with] unexplained fatigue. I saw him not long ago, and he looked pale and he was trying to figure out what was going on. He was going to his doctor. [The] doctor just wrote him off [and] said, “You don’t have anemia. Nothing’s wrong; you’re just getting older.” Because he’s in his late 70s. I asked him to send me his lab work, which he did, and he had an absolutely textbook case of anemia. Low red blood cells, hemoglobin, hematocrit, high [red cell distribution width]. I’m not talking about functional ranges either. I’m talking about flags right there on the Labcorp lab report. He’d seen a hematologist, which, for those who are not familiar, is a specialist in blood disorder[s]. This is the person that you would see who would [catch this].

My sense is, and this has happened to me before when I’ve referred people to specialists, they’re so used to seeing people who are almost dead or dying, with really acute severe problems, that if they see somebody like him who had anemia but was not going to die the next week, they don’t take it seriously and they just send them away. So then I asked him to send me a few more labs that he’d said he had. It turns out [that] he had several markers for myeloma, which was probably what was causing the anemia. Again, for people who are not familiar, that’s a cancer that starts in the bone marrow where red blood cells are produced. If you have that issue, [it] can be one of the causes of anemia. His other doctor [who] he saw, [who] actually recognized [he] might have anemia, just kept telling him [to] take iron over and over and over without even testing his iron levels, or looking at any other causes. Now I’m on my soapbox. But I was so furious for so many days after seeing that. I wish I could say that was a one-time thing. But I’ve seen that over and over, through the course of my career. I just wish there were more doctors like you, [where] when somebody asks them a question, they go home and research and find and learn what they don’t know. Or if a patient comes in and shares an experience that was transformative for them, like, “Hey, I did this diet or this approach that’s different [from] what is typically recommended and it really worked for me,” the response is, “Oh, wow; that’s amazing.”

Naomi Parrella:  “Tell me more.”

Chris Kresser:  “I’m so curious. Tell me more. I want to learn more about that so I can use it with my other patients.”

Dr. Naomi Parrella shares some of what she’s learned and integrated to effectively help patients achieve long term success with weight loss, in this episode of Revolution Health Radio. #chriskresser #weightloss #obesity #metabolichealth

Naomi Parrella:  Exactly. That curiosity. First of all, I want to apologize on behalf of any doctor who is dismissing a patient or a patient’s complaints because obviously, that’s just flat-out wrong. Secondly, good for you for pursuing and listening and discovering a diagnosis. Shame on that hematologist for not figuring that out. That’s their job. In medical school, there was one thing that somebody said to me that really stuck with me, and it was, “The further you get in your training and the further you go in your career, the less people are going to give you honest feedback.” So when somebody says something that kind of rubs you a little bit not so great, or you’re like, “Man, I was wrong,” it gives you that sort of chip, like that little knock, listen, because that might be just the tip of the iceberg. If you hear something like, “Man, I missed something,” then you better open your eyes because you might not get that warning again.  And to your point about [how] sometimes the more seasoned or more esteemed a physician is, the less likely they might listen, that’s exactly the reason. Be open.

Chris Kresser:  Yeah, and here’s a clue on both sides, whichever side you’re on. If someone gives me feedback [that’s] difficult to hear but I know there’s some truth in it, I can feel that. There’s a visceral response in my body. Usually, some defensiveness might pop up, or some irritation or anger, but that provokes a response. Whereas, if someone gives me feedback [and] there’s no part of me that recognizes any truth in it or relevance or value, it just bounces right off. It’s not something that’s going to bother me much at all. And I would say the other way is true, too. I’ve been in the seat of being a patient. That’s how I even got into this career. I know what it’s like to be in the patient’s shoes and be looking for answers and be dismissed and get the eye roll and get all this, and I can say [that] if I’m on the patient’s side, and I asked a question like that to the doctor and the response is angry [and] defensive, I know I’m [probably] onto something.

Naomi Parrella:  That’s such a resilient way to think of it.

Chris Kresser:  Because if I wasn’t and there was really nothing to that at all, there wouldn’t be that kind of response.

Naomi Parrella:  I think the biggest challenge, and we talk about this in society, in general, is about biases. And in medicine, we have that in spades. Nevermind racial biases or gender biases, but it might be about age or weight. Those are very common. “Oh, this is just aging.” That’s probably not true. Some of it, yes. We get some more wrinkles, okay. But you can still climb a mountain if you’re taking good care of yourself and you’re addressing the foundational problems. Same thing with weight. I’ll have a patient who’s lost 50 pounds, they go to see somebody, and the doctor says, “Oh, man, all your problems are because you’re overweight or obese,” and the individual comes back, and they’re crying, and they’re like, “They didn’t even notice that I lost 50 pounds. I’m working on this.” That dismissing and saying, “Oh, it just is the way it is,” is so frustrating because that’s not true.

Chris Kresser:  Yeah, it is. It’s a cop-out.

Naomi Parrella:  We can always improve.

The Biggest Challenges to Weight Loss

Chris Kresser:  So, along those lines, what are some of the biggest challenges you see in your practice with weight loss? Is it more a question of compliance? Or is it more a question of doing what they’re supposed to be doing, but [they] hit [a] plateau that’s difficult to move through? What are the biggest issues?

Naomi Parrella:  That’s a great question, and it’s a multi-faceted situation. The biggest challenge is people’s beliefs, and particularly, other people telling them what their body can or can’t do. To blame it on nonadherence really makes me mad. “Oh, you’re just not doing this, or you’re not trying hard enough.” Again, this calories in, calories out. “If you just worked a little harder, or you were 100 percent consistent, you would have had the miraculous success.” It’s actually not true. So part of it is the thing that’s most important, developing that self-compassion so that you can recover and respond to your body. I think the biggest mistake we make is [that] we look at an outcome like, let’s say, weight gain, or developing diabetes, or high blood pressure or something, and we say the body is malfunctioning. That’s actually the wrong attitude. If your body is designed to heal and thrive, and it’s giving you this outcome, what’s the signal that’s causing this outcome, which is not the outcome you want? I think [it’s the] same thing if somebody hits a plateau. It’s not necessarily a bad thing. Maybe your metabolism is shifting, your waistline might still be shrinking, there might be other things going on under the skin that you can’t see that’s good stuff. It could be that you’re losing weight, and that might be a bad thing if you’re losing muscle. So again, it’s paying attention to and having a good guide, somebody who’s not going to just say, “Oh, you’re not trying hard enough; that’s why this has happened.” No, let’s figure out what’s going on. You understand this so well, Chris. It’s so great that there [are] people out there who recognize [that] we need to find out what the foundation of the problem [is]. That’s the challenge. People just want a Band-Aid. They want just the number on the scale to change.

Determining the Best Amount of Carbohydrate for Weight Loss

Chris Kresser:  Right. And regarding that, how often these days do you find that you’re using [a lower-carbohydrate approach]? I know you mentioned [that’s] your preferred approach and you get the best results with that. But that’s a spectrum, right?

Naomi Parrella:  Absolutely.

Chris Kresser:  So you have the Standard American Diet [of] 400 plus grams of carbohydrates; 200 grams would be lower-carbohydrate, relative to the Standard American Diet, and then you have full-on nutritional ketosis. Where do you find yourself on that spectrum? I imagine it varies. Then how much are you using Biosense as a way of learning about when they’re in ketosis? What are the various inputs, not just diet, but exercise, sleep, and things that affect ketosis? How has that been?

Naomi Parrella:  I think about metabolic health, or the way the body can use different fuels. The more variety of fuels you can use, the better. If you can burn sugars or fats, and each of them whenever you need to, that’s the best metabolic health. I think about a spectrum. [At] one end, you’re super, super healthy, you can eat whatever you want, your body can burn it, do what you need to do, you’ve got the energy, etc. [At] the other end of the spectrum, [you’re] very, very sick. Depending [on] where you are on the spectrum of health and well-being, you’ll have different tolerances of how much you can deviate. If you’re already very sick, then you’re going to have to be more strict, so it’s better to be closer to a ketogenic diet, where you [have] your carbs down to like 20 or 30 grams per day. But not everybody needs to start there. You could start at 50 grams, and you can make some pretty good progress. Or you might be very physically active and able to tolerate a little bit more, especially if you haven’t had metabolic dysfunction in the past. So it kind of depends on the history. We look at labs, [and] we look at body composition. Because I’m the Chief Medical Officer for Readout, [who] makes Biosense, I can’t directly recommend to my patients to use Biosense. There’s a conflict there.

Chris Kresser:  Right, yeah.

Naomi Parrella:  Many patients look me up online and find out that I’m working with Biosense, and then they ask me a lot of questions about it. Biosense is great because it’s diet agnostic. If somebody comes in and they say, “I’m starting at 400 grams of carbs per day,” or they show me their food log and it’s clear [that] it’s about 400 [grams] or more, I can say, “Here’s the goal. If you use this device and you are blowing zeros, which means you’re not burning any [significant] fat at all, then our goal is to see if we can get your body to start burning fat.” So we can cut back the carbs. And somebody might say, “Well, I’m going to go 20 carbs,” or somebody might say, “I’m going to cut it in half and see if I can get my numbers up.” But they can be a part of that decision-making, instead of me arbitrarily choosing a number. I can tell them what to look at on the biomarker device.

If they start blowing a one, okay, now we’re starting to make progress, right? They need to blow a five or higher if they want to be losing more fat mass than they’re putting on their body. We can also look at the patterns with Biosense. If somebody says, “I don’t know what I’m doing; it’s not working for me,” I can ask them to check it three times a day. They blow into the device three times a day, and we can look for patterns. Is it an upward slope [where] the number is going up throughout the day? Is the slope going down? Is it a U shape? Or a hill? Or is it straight across? That tells me different things about their metabolic flexibility, their cortisol levels, what’s going on with their body, [and] how their sleep might be, so I can help direct and say, “You know what, it looks like your ketones are really low in the morning. Even though you’ve been fasting all night long, your sleep might not be that great. Let’s start thinking about sleep. Or maybe you’re dehydrated, and before you go to bed, you need to have some bone broth or something to help support your body overnight because maybe you go a long time without fluids.” So there might be different things that we can start articulating that help us understand what’s going on with the body and how we [can] help you get into that healthy metabolic state.

Chris Kresser:  Have you found that’s been helpful for patients to have that kind of objective data, rather than just relying on their own experience or intuitive sense? To actually be able to see, “Oh, I did this and that happened,” and have that feedback in black or white, or in this case, in digital format from the app or the device.

Naomi Parrella:  I think it’s helpful to have feedback. Let’s say a patient’s not going to see me for a couple of weeks. That’s a long time to wait and cross your fingers and hope everything is going in the right direction or to get feedback. Same thing with the scale. That doesn’t tell you what you did half an hour ago or an hour ago. It doesn’t show you what your walk did for you. You can’t tell. Was it the walk? Was it the fact that I ate less carbs? It’s hard to fine-tune and respond to your personal body, so it does help to get that feedback and say, “Oh, my gosh, that 15-minute walk was actually even better for me than whatever other activity I might have tried previously. Now I can see my body needs more of this aerobic gentle walking in nature, walking the dog. Maybe that’s going to be just as effective as something that I’m trying to force myself to do, that I really don’t want to do for exercise.”

Chris Kresser:  Yeah, that makes a lot of sense.

Naomi Parrella:  I like giving people the power to choose.

Chris Kresser:  Yeah, and also just educating along the way, right? Not just saying, “Do this, do that,” but helping people understand how the choices they make affect their body and lead to changes, which means that they’re going to be much more able to pivot or adjust if something changes. That kind of understanding, I think, just knowing how our bodies work and knowing what influence we have and the levers that we can push that are going to make the biggest difference, is really half the battle.

Naomi Parrella:  Absolutely. I think that is it. The body responds to signals, and if we can help people understand which signals result in which outcomes, people have the freedom of choice to decide what outcome they want and say, “Okay, I’m going to do this behavior, like eat less carbs, so I can reverse my diabetes, so my knees feel better, so I [can] go for a walk, so I can hang out with my grandkids or family or go travel the world.” That’s really the key.

Current Perspective on Weight Loss and Metabolic Health

Chris Kresser:  Any other things [like that] come to mind that you are doing differently now than you were 10 years ago, in terms of your approach to weight loss and metabolic health?

Naomi Parrella:  I think the thing that I’m doing most differently is really listening and looking for answers and being much more curious about all the different ways that we can affect weight, and how people are successful. Which things interfere? I recently was at a meeting learning about obesogens. Obesogens cause excess weight gain [and] fat tissue without equivalent caloric intake. I had not really considered this very much in my conversations with people. But again, that’s not [the] individual’s fault. If we can identify, “Oh, my gosh, this environmental toxin causes weight gain, and it happens to be in your environment.” By changing that, or by taking a supplement or doing something to help eliminate that toxin effect, you could actually, without changing anything else, maybe make a difference. I’m just way more curious [about] everything that doesn’t make sense exactly. I want to get to the bottom of that, and I realize now [that] it’s not necessarily in the medical field that I’m going to learn it. I might learn it from environmental studies, [or] I might learn it from a different country in a different language. So I have to really be very curious and open, much more than I was before. Now, I’m just obsessed. I just want to learn everybody’s different perspectives.

Chris Kresser:  Yeah, and the obesogen factor is interesting. Just for people listening, this can be anything from bisphenol A (BPA) and plastics in the ecosystem, to other environmental toxins, glyphosate, heavy metals, [or] other chemicals that have been shown to have estrogenic activity. Ironically, some of the BPA-free plastic alternatives have higher estrogenic activity than BPA. It’s kind of like going from the frying pan to the fire, so to speak. This is another reminder that obesity and excess weight and metabolic problems are not purely individual problems. In other words, the complex of factors that led to somebody gaining weight in the first place are not all under individual control. There’s a lot of studies that have come out, in the past five years especially, showing the relationship between air pollution and obesity. That’s something that most people have zero control over, especially when they’re kids and have no say over where they live. There’s a razor’s edge there that I think sometimes trips people up, understandably. It’s this difference between responsibility and blame.

Naomi Parrella:  Exactly.

Chris Kresser:  That’s a situation where we recognize that there are factors that I have some control over, factors I have complete control over, [and] factors I have almost no control over. The key in that situation, even for the ones that you have control over, is not blame and shame and guilt, but responsibility. In the true sense of that word. Ability to respond appropriately in that situation, whatever that response is. So I think it’s a good reminder because we tend to see things in a very individualistic framework in this country. There’s a lot of good that comes from that, [but] there’s also some challenges, as well.

Naomi Parrella:  I totally agree. Totally agree. And I think that is where we [are]. Dr. Bruce Blumberg, the person [who] coined the term obesogens, [has] recently shown that the effects last for generations. It behooves us to be aware that our actions today affect generations later. And as we understand this, we can no longer pretend we are not responsible and that it’s, “Oh, I’m only affecting my own body.” We affect each other’s bodies, and generations ahead and behind. It’s really important for us to think about stewardship. Really taking care of not just ourselves and our close family, but the future generations that are going to be affected, too.

Chris Kresser:  Yeah, absolutely. Well, Naomi, thanks so much for joining me. It’s been a fascinating conversation. [It’s] great to know there are doctors out there like you [who] are approaching this with an open mind and curiosity and willingness to learn and change your mind as new information comes to light. To me, that’s a foundational element of being a clinician and having a scientific approach. One thing I like to say is, “The history of science and medicine is the history of most people being wrong about most things most of the time.”

Naomi Parrella:  So true.

Chris Kresser:  That’s really objectively true, when we look back at scientists and physicians 100 years ago, and sort of scoff at them and [think] they didn’t know anything. And [then] we arrogantly assume that people 100 years in the future are not going to be looking back with the same derision that we do today.

Naomi Parrella:  Totally.

Chris Kresser:  Whenever I think I’ve got it all figured out, I just try to remember that and realize that, even in the course of my relatively short career, I’ve changed. I’ve had to change my mind on so many different things because [of] either my clinical experience or new research coming to light or some combination of both. So it’s always a good reminder. It keeps us humble as clinicians, too. And if we can flip that to actually be excited when we’re wrong, that’s when it really gets fun. I think physicists are the best at that.

Naomi Parrella:  Totally agree.

Chris Kresser:  They, more than any other type of scientist, are ecstatic when they’re wrong, [or] when they find out there’s something that doesn’t fit with their current theory, because then it means there’s something new to be discovered. If only we could all embrace that same excitement about discovery and openness to being wrong. I think in medicine, it’s a little more complicated because people are relying on doctors for advice that directly affects their health. Whereas with [the] Higgs boson, it’s a little less direct in terms of the relationship between someone’s day-to-day experience. But I think we can learn something from physicists.

Naomi Parrella:  I agree. And for all of your listeners, obviously, they’re intensely curious and constantly learning, so if anybody is thinking they want to help in the medical profession, please apply to medical school and join the club. Help us help others learn and tap back into curiosity because sometimes it just gets squished out of you, and you need to snuff people around and say, “Hey, this doesn’t make sense. Let’s understand this better.” Just like you said. “This is wrong. Oh, my gosh, I was wrong about this.” It’s so fun to have colleagues to be able to talk to about the things that we got wrong, and to learn and get better. So I think that’s really fun.

Chris Kresser:  Yeah, and I’m encouraged. I know a lot of young people who are going into medicine via the traditional route, going into medical school, and they’re going into it with eyes open. They understand the limitations of conventional training, but they also understand the benefits. I mean, there are plenty of benefits. There’s a lot of really good, useful things you learn in medical school. But they’re going into it with a plan already. They already know [that] they’re going to go into Functional Medicine, or they already know they want to work with people who are on the metabolic spectrum and they want to use low-carb or ketogenic diets. It’s cool to see that because I think that’s how things really do change in the end. The younger generation replaces the older generation, and they have new ideas and different ideas, and that’s how progress marches on.

Naomi Parrella:  Absolutely.

Chris Kresser:  I will be happy to be replaced by the young and bright future generations.

Naomi Parrella:  Exactly. The curious and open-minded, that’s what we want. We want to encourage curious and open-minded people to come in and shake things up. Discover better ways. That’s the goal.

Chris Kresser:  Well, thanks again, Naomi. Where can people learn more? If they’re in the Chicago area and they might want to come see you, what’s the best way to do that?

Naomi Parrella:  Just [by] looking up Rush University weight loss. That’s where I am. I’m also at Readout, so MyBiosense.com. I’m the Chief Medical Officer there. If anybody has questions, they can reach me in so many different ways. I’m very easy to find.

Chris Kresser:  Right. Folks who are longer-term listeners know that I’m on the advisory board of Biosense. Full disclosure there. I joined the board because I believe in their tech and their mission. I found it to be super helpful in my work with patients with metabolic issues. You can check out the Biosense device at MyBiosense.com. See how it works, [and] see if it might be right for you. Thanks, everyone, for listening. Keep sending in your questions to ChrisKresser.com/podcastquestion. We’ll see you next time.

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