Starting with the second paragraph, this is a reprint of an article first published on KevinMD.com, where authors retain copyrights. The link to that original publication is on my "Articles" page.  Their editor changed the title, so I am using my title for this reprint.  Implicit bias takes many forms, one being obesity bias.  We think of bias an obese patient might face, but what if the physician is obese?  Let's take a look from that direction. 

Obesity affects one-third of the adult US population, including physicians, and is estimated to cost $147 billion annually. How does the Body Mass Index (BMI) of the physician affect the relationship with patients and the care provided? According to a study in Obesity magazine, “Understanding physician body weight as a possible barrier to obesity care is critical given the important role physicians can play in helping patients manage or lose weight.”

First off, there is little research available examining the impact of physician obesity on the care of obese patients, and the few studies available are all a decade old. Despite the timing of those research studies, the information they contain remains applicable today. The fact that there are limited studies points to the importance of examining this timely issue when obesity is at epidemic proportions.

The complexity of Obesity as a Disease

• Beyond simple calories: Obesity is a multifactorial chronic disease.
• Genetic Factors: Children have a 50% risk of obesity with one obese parent, 75% if both parents are obese.
• Multiple Drivers: Biological, genetic, environmental, hormonal, mental health, and trauma factors all play a role in obesity and must be addressed.
• Systemic barriers: Food deserts (areas with little access to healthy food options), socioeconomic limitations, and cultural norms also play a role.
• Why this matters: Understanding the complexity of obesity helps reduce the stigma for both patients and providers.

Bias Against Physicians with Obesity

• Professional Stigma: Weight bias from colleagues and within the medical community is well documented. Medscape Medical News recently published an article examining the bias and stigma experienced by obese physicians. Three physicians were interviewed and discussed experiencing bias from both directions. Their colleagues often view obese physicians as less credible and fail to recognize the complexity of obesity.
• Patient perceptions: Their patients sometimes assume their obese provider can’t help them if the physician is struggling with the same issues. A study in Obesity magazine showed patients had less confidence in obese providers, were less likely to follow medical advice from the provider, and were more likely to change providers if their provider was obese.
• The “physician heal thyself” expectation: There are unrealistic standards applied to physicians’ personal health. One of the physicians interviewed by Medscape stated: “In medicine there’s an implicit expectation that knowledge equates to immunity — that we should be exempt from chronic conditions. This bias is prevalent within the system, among colleagues, and even within ourselves.” That expectation can weigh very heavily on the shoulders of a physician with a high BMI.
• Career Impacts: Obesity can have a negative impact on physicians’ professional advancement and peer relationships.

Clinical Impact: How Physician Weight Stigma Affects Patient Care

• Diagnostic hesitance: Another study in Obesity showed that normal BMI physicians, as opposed to physicians with a high BMI, were more likely to discuss obesity with their clients, provide weight counseling, and give an obesity diagnosis.
• Missed opportunities: The physicians who were overweight or obese often waited to discuss weight with their patients until the patient's BMI was greater than the provider's BMI. This can result in delayed interventions and referrals due to provider discomfort.
• Reduced treatment confidence: One of the physicians interviewed in the Medscape Medical News article said, “I felt like a fraud or a hypocrite talking to my obese patients about health risks while being obese myself.”

Moving Forward: Practical Solutions

• Self-awareness without self-judgment: Physicians need to honestly look at their lifestyle and make changes they would recommend to their patients. Taking time for self-care will yield significant dividends not only in physical health but also in mental and emotional well-being for the physician. The result can be a more trusting relationship between doctor and patient when they see their provider taking their own advice.
• Evidence-based protocols: Providers need to stop focusing on just BMI. Physicians need to be trained to focus on muscle strength, metabolic flexibility, inflammation reduction, and blood sugar stability. These factors tell far more about long-term health than just weight. The positive changes that may result from this broader focus can lead the way in the creation of evidence-based protocols for obesity treatment.
• Education and Training: In one study in Obesity magazine, only 36% of physicians reported very good or good obesity-related medical training in medical school or residency. The need for more in-depth training for medical students and residents about the complexities of obesity is obvious, considering the obesity epidemic we are experiencing in the US.
• Integrative approach: Because obesity is a complex disease, referral to an integrative or functional health practitioner may be appropriate. Not every physician is trained in integrative medicine, so knowing when it is appropriate to refer is crucial. The time it takes to dig deep for success is time most providers don’t have, as they are focused on comorbidities such as diabetes, hypertension, and heart disease. Physicians on a weight loss journey may also benefit from an integrative approach to their personal health if they are struggling to make positive changes.
• Challenging current culture: The three physicians interviewed by Medscape all challenge our culture’s current oversimplification of the obesity epidemic as a willpower issue. If colleagues link obesity to patient willpower, the interviewed physicians say they would remind their colleagues that no one chooses to be obese. Willpower fails when fighting biology. We would not have an epidemic if willpower worked.
• Shifting clinical approaches: Physicians who are successful in lowering their BMI find that their clinical approach has changed. The first physician interviewed by Medscape shared that knowing the struggle of weight loss allows her to approach the issue with more compassion. She would like to see colleagues approach obesity with compassion rather than scare tactics or reprimands. Another interviewee, who personally lost 150 pounds, said his approach has undergone a complete transformation. He now approaches obesity as a neurohormonal disease influenced by processed foods, environment, and metabolic dysfunction. He now emphasizes education, compassion, and not willpower. The last interviewee emphasizes metabolic health instead of weight loss. He emphasizes building lean muscle mass, optimizing protein intake, stabilizing blood sugar levels, improving sleep quality, and managing stress.

Conclusion

Addressing weight bias from all angles will help improve obesity care. Improving physician well-being by encouraging a healthy lifestyle and/or weight loss may have a secondary effect of enhancing physician care for obese patients. Physicians who have lowered their BMI may have more confidence in the care they provide for obesity and may discuss weight loss with patients earlier, potentially preventing unnecessary complications. Patient trust and compliance are likely to increase when physicians practice what they preach, maintaining a healthy weight themselves while providing care for their patients with obesity.

Sources:

https://pubmed.ncbi.nlm.nih.gov/23507996/

https://pmc.ncbi.nlm.nih.gov/articles/PMC3645927/

https://pubmed.ncbi.nlm.nih.gov/22262162/

https://www.medscape.com/viewarticle/physicians-obesity-reflect-bias-stigma-and-their-evolving-2025a1000k7y?ecd=mkm_ret_250803_mscpmrk_MOB_e41_C2_etid7611523&uac=537807MY&impID=7611523

Why did I come into this room? I was on a mission, but forgot what I was after. I had an appointment this morning, but I forgot it. I misplaced my keys and can’t find them. Do these scenarios sound familiar? As we age, our brains also age, and it can be scary when these changes occur.

Dr. Dale Bredesen, an internationally recognized expert in the mechanisms of neurodegenerative diseases such as Alzheimer’s, recommends a KetoFlex 12/3 diet to prevent and reverse cognitive decline. In his Book The End of Alzheimer’s: The First Program to Prevent and Reverse Cognitive Decline, he introduces this diet as the “Anti-Alzheimer’s Diet”.

While the brain accounts for only 2 percent of our body weight, it consumes over 20 percent of the energy produced each day. With such a high demand for fuel, we need to consume things that nourish our brains, not harm them.

When we eat the Standard American Diet (SAD), our brain and body are fueled by glucose (carbohydrates). Dr. Heather Sandison, author of "Reversing Alzheimer’s." The New Toolkit to Improve Cognition and Protect Brain Health. New York, HarperCollins, 2024, explains that ketones are the brain’s preferred form of fuel, not glucose. Ketones are the fatty acids that the liver creates when using fat, and not glucose, for fuel. Our brains function more efficiently when fueled by ketones, and when we burn ketones for fuel, we enter a state of ketosis. These ketones give the ketogenic diet its name.

Dr. Bredesen states that "Insulin resistance is arguably the single most crucial metabolic contributor to Alzheimer's disease development and progression”. Many of us are insulin-resistant due to eating a diet high in simple carbohydrates, such as sugar and processed foods containing high-fructose corn syrup. Sedentary lifestyles, stressful jobs, and stressful home lives also contribute to insulin resistance. Restoring insulin sensitivity and metabolic flexibility ( the ability to switch between burning glucose and ketones for fuel) is crucial for enhanced cognition. Eating a ketogenic diet restores both of these.

The basics of the KetoFlex 12/3 diet are:

Keto refers to the state of ketosis discussed above. One would utilize a low-carbohydrate diet to promote ketosis, while minimizing simple carbs such as sugars, bread, white potatoes, white rice, soft drinks, alcohol, candy, cakes, and processed foods. Consuming MCT oil (medium-chain triglycerides) or unsaturated fats, such as olive oil, avocado oil, avocados, or nuts, promotes mild ketosis.

Flex refers to two different facets of the plan. First, the KetoFLEX 12/3 lifestyle is heavy on vegetables, but it can be flexible enough to include meat or be vegetarian. Eating fish is optional, but remember that quality is a top priority. Avoid large-mouthed species like sharks, swordfish, and tuna, which live long and have the highest levels of mercury. Instead, choose SMASH fish (salmon, mackerel, anchovies, sardines, and herring). Whenever possible, get wild-caught fish, not farmed fish, which will provide a better omega-3 to omega-6 ratio and fewer toxins. Second, it promotes metabolic flexibility, restoring the body's ability to burn either fat or glucose as fuel. This maintains insulin sensitivity to maximize the fuel supply to your brain.

12/3 refers to fasting times. Fasting is a highly effective way to promote ketosis, improve insulin sensitivity, and improve cognitive function. The 12 in KetoFLEX 12/3 refers to fasting for 12 hours between the end of dinner and the first meal of the next day. If you carry the ApoE4 genotype, the strongest genetic risk factor for Alzheimer’s, aim for 16 hours of fasting. This fasting encourages autophagy, where cells “clean house,” recycling and destroying damaged proteins and mitochondria. The 3 in the KetoFLEX 12/3 refers to a minimum of three hours between the end of dinner and bedtime. This three-hour window keeps your insulin level from spiking before bedtime. An insulin spike before sleep will contribute to insulin resistance. It will also inhibit the production of melatonin and growth hormone, which are essential for sleep, immune function, and tissue repair.

Dr Sandison stresses that no one, not even people with severe dementia, need to be in ketosis continually for the rest of their lives. Spending three to six months on a ketogenic diet will jump-start the brain’s healing in someone who already has cognitive decline. If you are in prevention mode, spending about a quarter of the year in ketosis - whether that’s one week per month, one month a quarter, or two to three days per week - can help increase how many years your brain stays healthy and sharp.

This is good news for anyone concerned about their cognition. A ketogenic diet takes some planning, but is very doable, as this author has been mainly keto for almost nine years. Shop the perimeter of the grocery store, where you will find fresh produce and fresh meats, as well as the freezer section for frozen vegetables and meats. Avoid the inner aisles, where most boxed and processed foods are located. If the ingredient list on a prepared food package has words you can’t pronounce, then it’s a food best avoided! Batch cook on the weekend so you have several meals of each item you prepare, allowing you to heat and serve for busy weekday meals. The extra effort it takes to plan keto meals is a small price to pay for a sharp and vibrant mind.

Image by vecteezy.com

      I Researched Brain Supplements So You Don't Have To!

So you cared for your mother as she journeyed through Alzheimer’s disease. You carry one copy of the Alzheimer’s gene (ApoE4) just like she did. This means you have a thirty (30) percent chance of developing Alzheimer’s compared to the general population risk of nine (9) percent. What do you do? You have this vital nugget of information; so, how do you proceed with your life?

This has been my scenario for the last two decades. I have spent more hours than I can count watching webinars, starting with Awakening From Alzheimer's.  After watching numerous webinar series, I now follow several notable experts who are researching and preventing Alzheimer’s disease.  I will introduce them shortly, but for now, I want to focus on one prong of their multi-faceted approach.

Studies show that Alzheimer’s disease starts thirty years before symptoms appear. YES, thirty (30) years! One of the crucial things we can all do to protect our brain health as we age is to take targeted supplements.  Let’s take a look at several categories of supplements that dementia specialists recommend.  I take many supplements, including those from the following categories.

1. Nootropics

Nootropics is a fancy word for any supplement that supports cognitive function. There are many options available on the market, often featuring a blend of vitamins, fats, amino acids, herbs, and sometimes caffeine.

Dr. Robert Love (the internet’s most viewed neuroscientist, whose mission is to help us prevent Alzheimer’s with science) has two nootropics he has formulated. The first is called Roar Lion’s Mane. Lion’s Mane is a medicinal mushroom that has been shown to:

• improve memory
• help grow new brain cells by increasing growth factors in the brain
• reduce stress and anxiety
• enhance sleep quality
• activate the brain’s waste clearance activity.

His Roar Lion’s Mane supplement is a combination of Lion’s Mane with Chaga, Shiitake, Cordyceps, and Reishi mushrooms, which reduce inflammation and increase neurogenesis (the growth of new brain neurons) by nearly 40 percent. When I had my Montreal Cognitive Assessment (MoCA) test done by the social worker at my provider’s office, the one thing he recommended I add to my daily supplement list was Lion’s Mane.

The second nootropic Dr.Love formulated is called Neuro Plus Brain and Focus Formula. This product combines 40 nootropics, including Bacopa, Inositol, various vitamins and minerals, and Huperzine-A, to enhance memory, focus, and overall brain health. Dr. Love’s supplements can be found on Amazon as well as his site robertlove.net.

Another highly recommended nootropic is Qualia Mind. Dr. Heather Sandison, a naturopathic physician and director at Marama, an inpatient dementia treatment center in San Diego, recommends Qulia Mind by Neurohacker Collective. This is a doctor-formulated nootropic designed to fuel focus and concentration. It supports long-term brain health and helps maintain drive and productivity. This nootropic is available on Amazon. Dr. Sandison is also the author of the New York Times 2024 best-seller, Reversing Alzheimer’s: The New Toolkit to Improve Cognition and Protect Brain Health. She published her research study in 2023 in the Journal of Alzheimer’s Disease. In her study, clients demonstrated statistically significant gains across all cognitive domains, including memory, reasoning, verbal ability, and concentration when they followed the Bredesen protocol, which I’ll introduce shortly.

2. Creatine

Creatine Monohydrate has been studied extensively in recent years. Studies show it may be beneficial for adults in the domains of memory, attention time, and information processing speed. Bodybuilders have used it for years, but most recently, the focus has shifted to its benefits for brain health. Because Creatine is a tasteless white powder that can be easily mixed into any liquid or food, it is recommended to be taken daily in a typical dose of 5 grams. The dose for larger individuals can be increased to 10 -15 grams per day. Dr. Andrew Huberman, a renowned neuroscientist and tenured professor at Stanford School of Medicine, ranks Creatine among the top three supplements he would choose for brain health. Dr. Huberman runs the Huberman Lab at Stanford, which focuses on brain development, function, and neuroplasticity.

3. Vitamin D3 with K2

Vitamins D and K are fat-soluble vitamins that play crucial roles throughout the body. Some of the most essential roles are their contributions to maintaining bone health, and they are also directly related to cognitive function. Although the connection between vitamin D and cognitive function isn’t clearly understood, it has become clear that having sufficient Vitamin D seems to prevent mental decline. Vitamin K works in conjunction with Vitamin D to direct calcium into our bones, making it equally important. Having higher levels of Vitamin K is also associated with better cognitive function. Aim for 5,000 IU of Vitamin D3 and 100 Mcg of K2 per day and a Vitamin D blood level of 50-80ng/ml. If you are taking blood-thinning medication, consult your doctor before starting any form of Vitamin K, as it may interact with blood thinners.

4. Omega-3s

Omega-3s, commonly called fish oil, are essential fatty acids and are anti-inflammatory.

Omega-3s are believed to help reduce neuroinflammation and heart disease risk (and what’s good for the heart is good for the brain). Having higher levels of omega-3s in the blood correlates with a bigger hippocampus (a part of the brain crucial for memory), a stronger ability to use logical reasoning, and -in people with at least one ApoE4 allele- healthier small blood vessels. Dr. Dale Bredesen, arguably the leading internationally recognized expert on the mechanisms of neurodegenerative diseases like Alzheimer’s, recommends taking one gram (1,000 mg) daily of omega-3 DHA/EPA from fish oil, krill, or algae. Ensure you select a reputable brand such as:

• EcoSmart Omega-3 by Carlson
• Omega MonoPure by Xymogen
• Ultimate Omega by Nordic Naturals.

Store your Omega-3s in the refrigerator to prevent them from going rancid. Rancid Omega-3s will harm your cells, not help them.

I promised I’d introduce the experts, and Dr. Bredesen deserves a paragraph. Dr. Bredesen has protocols for preventing Alzheimer’s disease (Precode) and reversing Alzheimer’s disease (ReCode). He has published several studies, most recently demonstrating that cognitive improvements from his protocols can last for years, in some cases over 10 years. He is the author of several best-selling books. The two most helpful to the general public are The End of Alzheimer’s Program: The First Protocol to Enhance Cognition and Reverse Decline at Any Age and The Ageless Brain: How to Sharpen and Protect Your Mind for a Lifetime. Dr. Bredesen is currently the senior director of the Precision Brain Health Program—the first of its kind—at the Pacific Neuroscience Institute in Los Angeles.

5. Probiotics and Prebiotics

Documentation abounds showing the connection between a healthy gut and a healthy brain. Friendly gut bacteria help break down and digest your food, making the nutrients more readily available for use. Those same friendly bacteria also produce neurotransmitters, which have a significant impact on your risk of dementia. Those friendly little guys also reduce inflammation and fight infections, such as C. difficile and H. pylori, which are associated with cognitive issues, before they have a chance to take hold.

Dr. Sandison suggests mixing up the strains of probiotics you take, as taking a variety of bacterial strains helps promote diversity and longevity in the gut. She recommends brands such as:

• Once Daily by Garden of Life
• Ortho Biotic by Ortho Molecular Products
• ProbioMax by Xymogen
• Ther-Biotic Complete or Vital 10 by Klaire Labs
• Akkermansia by Pendulum.

According to Dr. Bredesen, take 30-50 billion CFUs per day of a reputable probiotic with food. Probiotics can also be found in fermented foods like:

• sauerkraut
• kimchi
• sour pickles
• miso soup
• Kombucha.

If you take antibiotics for an infection, be sure to take probiotics to repopulate your gut microbiome.

Prebiotics are strains that feed the healthy bacteria in your gut. Prebiotics are available in capsule form, but they can also be found in foods such as:

• jicama
• onions
• garlic
• raw leeks
• raw Jerusalem artichokes
• dandelion greens.

6. Digestive Enzymes

As you age, your levels of hydrochloric acid, which aids in digestion, decline. Taking digestive enzymes in supplement form can aid digestion. There are different types of enzymes, such as:

• Lipase - helps break down fats
• Protease - helps break down proteins
• Lactase - helps break down the sugar called lactose found in dairy products
• Hydrochloric acid - helps digest everything, but it can aggravate acid reflux if you have it.

It would be wise to work with your provider to determine which enzyme would be the most helpful if you are experiencing issues such as bloat, indigestion, and nutrient depletion.

The supplementation options available to us are endless. This list is basic and pertains to everyone. Because Alzheimer’s disease typically starts 30 years before symptoms appear, the prudent approach would be to take these general supplements in conjunction with exercise and a healthy diet low in carbohydrates and processed foods. Let’s all be proactive with our health and kick cognitive decline and Alzheimer’s disease to the curb!

Sources:

https://pmc.ncbi.nlm.nih.gov/articles/PMC11275561/

Sandison, H., Callan, N. G. L., Rao, R. V., Phipps, J., & Bradley, R. (2023). Observed improvement in cognition during a personalized lifestyle intervention in people with cognitive decline. Journal of Alzheimer's Disease, 94(4), 1–15. https://doi.org/10.3233/JAD-230004

https://www.researchgate.net/publication/382928610_Sustained_Cognitive_Improvement_in_Alzheimer's_Disease_Patients_Following_a_Precision_Medicine_Protocol_Case_Series

https://www.readandrewhuberman.com/p/creatine-andrew-huberman

Bredesen, Dale. The End of Alzheimer’s. The First Program to Prevent and Reverse Cognitive Decline. New York, Avery, 2017.

Sandison, Heather. Reversing Alzheimer’s. The New Toolkit to Improve Cognition and Protect Brain Health. New York, HarperCollins, 2024