In January of 2021 I travelled to Honolulu, Hawaii where I spent three weeks working remotely. It was a memorable and rejuvenating experience which I also judged to be safe and responsible.
I decided to somewhat shift gears for my next post. Part of the plan behind my latest venture was to travel for more extended periods of time and work remotely from different corners of the globe. To say that the COVID-19 pandemic made this more complicated would be an understatement.
But, I finally had my chance to realize this plan in January of 2021 when my wife and I decided to spend 3 weeks in Honolulu, Hawaii. I decided to share my experience with you.
Working abroad wasn’t super convenient but it was doable. I am fortunate to have a flexible schedule. It took a few days to find a good rhythm as for when to work and for how long, especially when tempted by all the wonderful things to do in close vicinity. I eventually decided that working in the morning was most suitable for me so that I could get it out of the way and enjoy the rest of my day. My wife did not have the same schedule flexibility as I did and she unfortunately had a few long days and early mornings. But thankfully, I think she also adjusted.
When it comes to jet lag, I have read that it takes one full day to adjust for one hour of time difference. This is likely dependent on the individual as it took me more than two weeks to adjust for the 5 hour time difference, and soon after it was time to fly back.
Overall, remote work away from home requires one to address multiple logistical challenges but it is worth if it means getting to spend more time at your destination.
Travel during the Pandemic
Traveling during the pandemic is certainly not the same as it was before. The decision over whether to travel is a decision that everyone has to make for themselves based on one's own risk tolerance. It requires carefully coordinating various rules and restrictions both at your destination and when you return home.
The state of Hawaii takes pandemic precautions seriously and at the time of this writing, they have had the lowest case rate among all the 50 states in the US. A negative COVID test is required within 72 hours of boarding your flight for the final leg of the trip. The test needs to be performed specifically with one of the state’s trusted partners labs. I perform COVID tests all day as part of my day job, but the lab used by my practice was not on the list of those acceptable.
We opted to use the “Vault” lab to perform our test. This was a saliva based test that needs to to be performed in front of supervisor via a Zoom conference call. They can guarantee results within 72 hours as long as you carefully follow the directions. The process of performing the test is not difficult but the awkwardness of spitting into a tube on camera is amplified by the pressure to not mess it up and risk not getting your result in time. If you are traveling with a group, it is possible that the results may come back at different times. I received my result early in the morning before our flight but my wife’s result was nowhere to be seen, which resulted in a panicked call to the customer service line. Thankfully her result arrived in the early afternoon.
Once we arrived at the Honolulu Airport, the screening process took no more than 15 minutes. On the ground, mask compliance in public was widespread, as is what we have come to expect at home. There were noticeably fewer people on the streets compared to our previous visit. Otherwise, things seemed fairly normal. Beaches and hiking trails were lively but not overcrowded. Most restaurants and shops, with the exception of bars, were open.
We paid a visit to the Polynesian Cultural Center where we enjoyed a traditional luau. The food is typically served buffet style but was instead served by the staff. This was followed by a broadway style show, which was a nice taste of normal. Precautions were taken off course. In addition to being held in an outdoor amphitheater, the audience was well spaced out. There was an additional safety measure that I had not seen before. Each member of the cast was outfitted with a clear see through mask The masks were not exactly discreet, as they often visibly fogged up from the performer’s breath. But if this is what’s necessary for the return of performing arts then it’s a compromise I will gladly accept.
What to eat
The incredible array of local food offerings is one of the highlights of any Hawaii trip and it is easy to get carried away, The traditional cuisine is heavy on local Polynesian specialities and crops, many of which we got to sample at our Luau, These include Kalua pork, Lomilomi Salmon, Poi. You will not find the word “tuna” used, “Ahi” is the only word used for it. The local crops; “canoe crops” as they are known from being brought over on canoes by the early Polynesian settlers: coconut, banana, breadfruit, taro.
The local farmers markets offer a vest arrow incredibly ripe mangos, papaya, local avocados and perfect pineapples. Easy to make new discoveries, such as the soursop or “eggfruit” (a somewhat mealy custardy fruit that needs to be eaten at peak ripeness.)
What to see and do
Here there was no shortage of things to do. On Oahu, you have access to some perhaps the most famous beach in the world (Waikiki) to world class hiking destinations (Diamond Head) and perhaps the world’s most famous snorkeling location (Hanauma Bay). The latter two recently reopened after an extended pandemic related closure. Crowds still small and capacity is restricted.
I discovered the sport of Stand Up Paddleboarding (SUP). Looks a bit similar to surfing (both sports were invented in Hawaii). As the name implies, it involves balancing yourself on a large board and paddling along the waves. A bit of a learning curve involved here as well as a private lesson in my case. I’ll be the first to admit that I fell off the board multiple times, but once you get the hang of it, the idea of being able to stand up on the waves is thrilling.
Snorkeling and free diving in Hawaii is amazing. It does help to develop some technique but once you do before you know it you will have the confidence to swim further out and take longer and deeper dives. Have your underwater camera ready and be ready for an array of tropical fish, sea turtles, dolphins, and even sharks. Don’t worry the sharks were harmless, you can see them with one of the catamaran tours that leave off the island’s north shore.
To sum it up: for those that are interested in working remotely, if you are able to work out the logistics, then Hawaii is a terrific option. Wish I was still there rather then dealing with all the snow we are getting on the east coast these past few weeks. Plenty of opportunity for sunshine, fresh air and unforgettable outdoor activity. The island of Oahu is not that big, takes an hour or so to drive from one end to the other. This means that there will be plenty of time to do the things you want to do and still balance that out with the work.
In terms of the pandemic, Hawaii has the lowest COVID infection rate among the 50 states of the US. In order to keep it safe it requires cooperation and responsibility on behalf visitors. If that is something you're willing to do then you will find plenty of locals and businesses eager to welcome you back to this side of paradise.
In today's world, processed foods are ubiquitous. Familiar brands of soda, chips, cookies, and candy line the shelves of our supermarkets and convenience stores. They bring back thoughts of carefree childhood. They taste great and when consumed make you feel like you want just one more bite.
Thankfully, people in general are starting to recognize that these items are not the most nutritious options. But the problem goes beyond just an absence of nutrition, the issue lies in the direct harm to our health that is inherent in these products.
1. Why is it so cheap?
Ever stop to ask yourself? Why is processed food so cheap, especially when compared to healthier natural foods.
At my local supermarket in Manhattan, a 12 oz bottle of Coca-Cola cost $1.29 while a 12 oz cartoon of blueberries costs around 5 dollars. A candy bar and a bag of chips is comparable to the cost of the coke
Surely, these processed foods, that require extensive manufacturing processes, and include multiple unpronounceable ingredients, are much more complex to create and distribute when compared to whole foods, like blueberries, which seemingly just need to be picked and shipped. So why are unhealthy foods so much cheaper?
The answer is that, at least in the U.S, the government heavily subsidizes farmers to produce many of the components of processed food, which makes them incredibly abundant. These include:
Corn - not the sweet corn that is consumed as corn on the cob, but the field corn variety that stretches for millions of acres throughout the great planes of the United States. Inedible by humans in its unprocessed form, it is so abundant and cheap that it is converted into ethanol for gasoline, sweeteners like High Fructose Corn Syrup, and animal feed. (wonderfully documented in the 2007 documentary "King Corn")
Soybeans - mostly converted to oil rather than the more familiar products like tofu and soy sauce
Dairy - so much is produced, and because low fat milk has long been preferred, the industry has needed to figure out what to do with leftover dairy fat. Hence the ubiquitous presence of cheese in countless processed items.
Wheat and rice are also heavily subsidized, but their uses are more straightforward.
Farmers growing fruits and vegetables generally don't have access to this kind of subsidy.
2. Processed food is addictive
You may be familiar with advertising slogans like “betcha’ can’t eat just one” (Lay’s potato chips) and "once you pop you just can’t stop” (Pringles).
These advertising slogans are no lie, in fact processed food companies work hard to ensure this to be the case.
The book “Salt, Sugar, Fat: How the Food Giants Hooked Us” author Michael Moss documents the elaborate processes used by food companies to carefully engineer their products to ensure that they sell.
Food scientists working for these companies manipulate the textures and colors of foods, and combine ingredients that would never be found in one’s home kitchen. These products are often overloaded with various forms of sugar, salt, and processed oils to overwhelm the palate in order to hide various off putting flavors that are created in the manufacturing process. The amounts of said ingredients that can be stuffed into the products can be obscene. For example, a 12 oz can of coke contains the equivalent of 9.75 teaspoons of sugar.
The result of these processes is that food companies work to make these foods hyperpalatable by exploiting our brain chemistry to work in their favor. Processed foods overwhelm our taste receptors making us think that all food is supposed to taste this way. Thereby we become numb to the more subtle favors present in normal food. This problem is especially pernicious in younger children who are heavily targeted by these companies and may reject healthier home cooked food as a result.
There is now extensive research documenting the addictive properties of sugar through its effect on the dopamine reward center in our brain. This is not unlike the mechanism involved in other addictive behaviors such as drug use. A major difference here is that unlike other addictions, people become hooked early in childhood. This also helps to explain why, after consuming these products, rather than feeling satiated, we crave more of them.
Food manufacturers are certainly aware of this fact. It has been reported that added sugar is found in 74% of processed foods. This is in part because of sugar’s properties as a preservative and it’s effect on food texture, but surely this is also to make these products more palatable.
3. Processed food has detrimental metabolic effects
The specific mechanisms by which these products cause harm is extensive but I will briefly mention what I think is most important.
Stay tuned for future posts where I will describe these mechanisms in more detail
In the meantime I can recommend avoiding packaged processed foods to the extent possible. Shop on the outer edge of the supermarket, avoid the inner isles. Stick with fresh meat, eggs, and produce. Say no to the big food conglomerates and the harmful products they are pushing.
- Siegel KR, McKeever Bullard K, Imperatore G, Kahn HS, Stein AD, Ali MK, Narayan KM. Association of Higher Consumption of Foods Derived From Subsidized Commodities With Adverse Cardiometabolic Risk Among US Adults. JAMA Intern Med. 2016 Aug 1;176(8):1124-32. doi: 10.1001/jamainternmed.2016.2410. PMID: 27379488; PMCID: PMC6512298.
- Cooper ID, Crofts CAP, DiNicolantonio JJ, Malhotra A, Elliott B, Kyriakidou Y, Brookler KH. Relationships between hyperinsulinaemia, magnesium, vitamin D, thrombosis and COVID-19: rationale for clinical management. Open Heart. 2020 Sep;7(2):e001356. doi: 10.1136/openhrt-2020-001356. PMID: 32938758; PMCID: PMC7496570.
- Lim JS, Mietus-Snyder M, Valente A, Schwarz JM, Lustig RH. The role of fructose in the pathogenesis of NAFLD and the metabolic syndrome. Nat Rev Gastroenterol Hepatol. 2010 May;7(5):251-64. doi: 10.1038/nrgastro.2010.41. Epub 2010 Apr 6. PMID: 20368739.
I thought it would be appropriate to start my blog by sharing the story of my background and how I discovered the field of nutrition and metabolic health. Much has been written online and elsewhere. I don’t hope to supersede this content but to add my own voice to the discussion.
Like many others, I had struggled with weight for most of my life. I was never particularly thin throughout childhood and the issue was compounded by the stress of college, medical school and then particularly during residency training. Residency was a unique combination of stress and interrupted sleep along with, for a first time in my life, a steady salary allowing me the ultimate freedom about what to put in my body.
I had become increasingly aware of my weight problem and I knew I needed to take action to correct it. Attempts at calorie restricting diets never lasted very long. I developed an intensive exercise routine. I took up jogging and eventually cycling. I was really enthusiastic about it. I was proud of all the 5K events I completed and I extra long bike rides throughout the city including the “5 Boro Bike Tour” in 2018.
But, I was never able to sustainably lose much weight. I resigned myself to the fact that I was doing all I can. After all, how bad it would it be if I didn’t do all this exercise?
My relationship with food was another story. I had convinced myself that I “live to eat.” The NYC restaurant scene was super exciting to me and I had developed a reputation among my friends as the go to “foodie.” The thought of changing what I ate was unbearable to me as it had become part of my identity.
I had gotten married in November of 2018. It was a lovely event but the whole night I was dealing with a poorly fitting tuxedo even though it was supposed to have been adjusted for my size. I was bothered by how big I looked in all of the photos.
The Eureka Moment
A week or so after my wedding, I was browsing my Audible app and I received a serendipitous recommendation for the book “Why We Get Fat” by Gary Taubes. To this day I cannot explain why it was recommended to me as it was quite unlike any any of my previous purchases, but it could not have come at a more opportune moment. I was in the right mindset to make a change.
The concepts espoused by Mr. Taubes now seem basic to me, but when I first read it, the book completely turned the conventional wisdom on its head by negating many commonly held beliefs. In summary
The idea of giving up many of my favorite foods (pizza, bread, rice, cake, sugary fruit) was a major psychological hurdle but I knew I needed to try something different. So one random day, I told my wife that I was going to try out a “low carb” or “Keto” diet. Thankfully she decided to join me.
The first one or two weeks were not easy. Meal planning was a struggle. Carb cravings were present throughout the day. Finding options at the convenience store was exceptionally frustrating. The disruption to my usual routine was the biggest obstacle to overcome.
But after a few weeks, I started getting used to it. Even better, I was starting to notice some benefits. I became less hungry, my sugar cravings disappeared and even my afternoon post prandial crash vanished, I started thinking more clearly, and slowly but surely, the numbers on the scale started to drop.
Thankfully the pounds haven’t returned. At the time of this writing, I have been “low-carb” almost two years. I have maintained weight loss of about fifty pounds. Rather than being a passing phase, this lifestyle has become routine for me and I have no intention to change.
My personal experience with diet resulted in me taking a professional interest in the subject of nutrition. I was trained as a Family Medicine doctor. During my training I witnessed first hand the damage done by diseases of poor lifestyle. I saw the devastation inflicted by diabetes and cardiovascular disease, including strokes, heart attacks, amputations, and kidney failure.
My experience with trying to medically manage these conditions was deeply frustrating. Despite extensive counseling and medicine, these patients continued to get sicker. It is a major reason why I did not continue with primary care medicine after my training.
After discovering “Keto” I was inspired to take a fresh look at what was wrong with our approach. After consuming many books and articles, and attending multiple conferences I have come to the realization the food that we consume is the most important factor in protecting and improving our health our health. The main points that I emphasize are the following.
Each of these points has a lot of nuance that can be discussed. But, on the whole, I truly believe that this approach offers our best opportunity to tackle this problem on a wide scale. This is the way prevent metabolic dysfunction at its root. On a personal note, both my wife and I have extensive family history of diabetes and we had both resigned ourselves to the thought that we will get it too. We can now say, with some confidence, that we can prevent this. This is a real source of optimism.
I work for an Urgent Care chain in Brooklyn. Winter time is always our busiest season and the early months of 2020 were no exception. The flu season of 2019-2020 hit earlier than usual and January was an exceptionally busy month. I was ready for a break.
Around this time we began hearing rumblings on the news about a new respiratory virus circulating through the city of Wuhan in Hubei province, China. We watched TV images of figures in biohazard suits busily scurrying around. This virus was supposedly related to the SARS outbreak that hit many parts of Asia in 2003.
A quick internet search about the original SARS outbreak revealed data that did not appear to be very severe, with the worldwide death toll being less than 800. Any random flu season in the US far exceeds this without nearly the same panic and disruption. My wife, who was living in Taiwan at the time, can personally attest to the level of anxiety and fear surrounding this event.
Determined not to be a harbinger of panic, I settled into my familiar role of the reassuring doctor. Patient visits throughout the day are normally filled with anxiety, and I felt that it was my job to lessen this anxiety. I thought that my attitude was well justified. I had worked through previous viral panics. The 2014 Ebola outbreak resulted in a total of 11 cases within the US. The 2016 outbreak of Zika virus was only a concern to a relatively small number of pregnant women. I felt that it was my role to counteract the fear stemmed by these events, to remind people to keep things in perspective.
But the chatter about this new outbreak in China did not subside. Coronavirus Disease 2019, as it came to be called, was now making headlines. We learned that the first confirmed case was identified on December 1, 2019 and there was speculation that the Chinese government had taken steps to limit information about the virus from getting out, including its potential for human to human spread. Ironically in late November 2019, my wife and I visited China for vacation, though we were not anywhere near Hubei province. It was a wonderful trip and, in retrospect, may have just been the calm before the storm.
By February, the virus had escaped the borders of the China. It was spreading through Iran, and then Northern Italy. All of a sudden it was in the U.S, in Washington state, then California. Back at work it had seemed that the flu season was coming to a most welcome end. February seemed almost lighter than usual. But, people were asking questions. The headlines had resonated with patients in the clinic. Patients began worrying that their mild respiratory or febrile illness may be caused by the coronavirus. I had no way to give them an objective answer. For weeks I relished in reassuring patient after patient that there had not been a confirmed case in the New York metro area.
And then, on March 1st, a woman who had recently traveled to Iran, was confirmed to have coronavirus after developing respiratory symptoms. Soon after, a cluster of infections was identified in Westchester county, just north of the city, with a synagogue being its epicenter. A "containment zone" was established inside New Rochelle, a commuter town with a direct rail connection to Grand Central Terminal in Midtown, Manhattan, near where my wife and I lived.
The atmosphere started to change. Masks started to become commonplace, despite the insistence of various government entities that they were not necessary for the general public. Companies began advising their employees to work remotely. Many conferences and conventions were cancelled.
Amazingly, a conference that I attended in mid March in Colorado did take place as scheduled. The conference was quite enjoyable but last minute closure of the region’s ski resorts left us scrambling to catch a flight home earlier than expected. When we returned to New York, most of the remaining theaters and cultural institutions announced their closures. Two days later, all bars and restaurants were forced to close, despite assurances from the mayor just the prior week that this would not happen. These events were unprecedented and because of their devastating economic effects I could not imagine they would last more than a few weeks, at most.
The reasoning presented by government officials was that the closures were needed to “flatten the curve.” The goal was to avoid a massive spike in cases during a short period of time. They were worried that such an event would overwhelm hospital and ICU capacity. We were told that this was happening in Northern Italy at the time, resulting in doctors needing to ration care, needing to pick and choose who lives and dies. Such a scenario had to be avoided at all costs.
Back at work, things also took a different direction. All staff were suddenly instructed to wear protective gowns and N95 masks for the duration of the shift. Several of my colleagues were forced into a 14 quarantine after coming into contact with patients presenting with seemingly mild respiratory symptoms. These patients did not raise any suspicion for high risk illness but were subsequently confirmed positive for Coronavirus.The staff were not wearing any kind of PPE for these encounters.
During the following shifts I had encountered a number of patients presenting with pneumonia. This was not uncommon during the late winter month of March. At this time our testing capability for coronavirus was quite limited, we were told we could only perform a handful of tests per day. We were given testing criteria, but these were highly subject to interpretation. Nevertheless, I performed tests on the cases that I thought were suspicious.
A colleague of mine was noticing a similar trend. One day, she anxiously contacted me. Following up on some patients from a previous shift, she had noticed that, not just one or two, but multiple patients from a single shift, who were given COVID tests were coming back positive. I followed up as well and confirmed the same trend among my patients. It was irrefutable now, the beast had reached our shores.
What happened next is widely known. The occasional pneumonia cases increased in frequency to the point where almost all the patients in a single shift presented with the same thing.
While I did not work in the high acuity setting of the hospital, from where most of the horror stories were emanating, my experience at the urgent care nevertheless made it clear that we were not living in normal times. Every shift included multiple ambulance calls and emergent hospital transfers. Our sites were equipped with oxygen tanks. Previously they were used only in rare emergencies, now they were being used every day. In fact at one point we were instructed to try to conserve the tanks and instead use the lesser powered oxygen concentrators in non-critical cases. I found this hard to comprehend because any patient requiring supplemental oxygen in our office is a critical case. It got worse, there were reports of at least two patients having died while still in our offices waiting for EMS to arrive.
One particularly challenging situation that I remember was of a patient who I felt that, for multiple reasons, for heading towards a poor outcome. EMS was called, she was evaluated by the medics but then refused by them for not being sick enough. I could never have imagined such a scenario.
My shifts developed a strange routine. Almost every patient had the same presentation, some more severe than others. Each needed a chest x-ray and most of the x-rays appeared interchangeable. On x-ray most typical pneumonias appear as a thick consolidation in one area of the lungs. With Coronavirus, there are faint cloudy patches spanning both lungs. I felt like the treatment I was able to provide was very limited. Most patients were prescribed antibiotics, which is standard of care for bacterial pneumonia. But deep down I was doubtful about whether this would do much to treat this specific infection which we knew to be secondary to a virus. I was able to recommend breathing exercises and laying in the prone position, but that was about it. Many experimental treatments were being tried but one would have to be sick enough to be hospitalized to receive one of those. In the outpatient setting standard of care was mostly limited to a wish and a prayer hoping that one’s condition would not deteriorate.
One of the most difficult things I had to deal with was deciding who would be eligible for a test. Testing capacity continued to be very limited for quite some time and I had access to the same handful of tests per day as when the crisis started. The difference now was that almost every patient not only met criteria for a test but likely had coronavirus. In fact coronavirus was so widespread at this time that performing a test in the face of an obvious clinical presentation could lead to a false negative result, further clouding the picture. My explanation of limited testing and presumed diagnosis was deeply unsatisfactory for many patients who wanted something objective. I was left with a decision to make. Should I reserve a test for the high risk patient with an obvious presentation, or for the less high risk patient with an unclear diagnoses for whom a test can change management? Many times I would simply use up all the available tests toward the beginning of the shift and subsequently explain to the later patients that no more tests were available, thereby absolving myself of needing to make a decision.
A notable trend that I noticed was the discrepancy between different neighborhoods. I worked in a variety of different settings. The busiest shifts took place within the lower socioeconomic immigrant and working class communities. Countless primary care and specialist offices closed their doors and people were left with limited options, either us or the hospital emergency room. The situation was quite different in the higher socioeconomic white collar and gentrified communities. The people here had the option to skip town to their vacation homes or to sequester at home and work remotely, and maybe consult a doctor via tele heath if necessary. In such neighborhoods the volume dropped so rapidly that multiple previously busy sites temporarily closed.
And then, at some point in early May, the cases just stopped. The typical coronavirus presentation which I personally saw again and again, as of the time of this piece, I have not seen a single case in months. It was around this time that testing capacity within the region increased dramatically. The citizenry was encouraged to get tested regularly. Ironically, the opposite problem had later developed. So many tests were performed that the labs become unable to handle the volume and wait times for results stretched to unacceptable levels. A small percentage of these tests continues to come back positive, well under 1% when I last checked, but it was a massive drop from the peak seen in April. In the region, hospitalization and death rates dropped accordingly. The numbers have continued to decrease despite multiple industries reopening.
Despite all of this, this episode wounded the New York region in a way that will take a long time to recover from. The level of anxiety is palpable. There is a harmful level of suspicion of fellow citizens. Countless small businesses has already closed, with restaurants and bars being hit especially hard. Many people were laid off from their jobs
In normal times the city has its usual rhythm. It’s streets being filled with tourists, shoppers, restaurant and theater goers. This pace of life has not yet returned. I feel that this was a major factor in the unrest seen during the month of June which saw multiple instances of looting in high profile business districts. Looting cannot take place under normal circumstances if there are countless people on the streets going about their business.
At the time of this writing, we are on the verge of the fall season and the eventual start of the usual seasonal respiratory infections. Museums have just been allowed to reopen and restaurants have also returned but only for outdoor dining. Schools are on the verge of reopening, at limited capacity at best. I get the sense that the fate of the remaining, still shuttered industries will be dependent on the result of the school reopening. The continued decline of Coronavirus in the region gives me a sense of optimism that things will be allowed to return to normal. But, I will be the first one to admit if I am wrong. I have to be, I am still working on the front lines. We are approaching a turning point in history where things can go one way or the other. Only time will tell.