Saturday, October 27, 2012

The Nutrition Debate #72: How to “Fix” Your Cholesterol

Physicians all over the world want to “fix” your “cholesterol.” They’re well meaning, and they know there is a small benefit, probably due to a reduction in inflammation, associated with a reduction in the LDL lipoprotein component of your Total Cholesterol, all other components being equal. They know that by lowering your LDL, your Total Cholesterol will be lowered by the same amount. And they know they can do that with a pill. They can get it to within the range recommended by the “standard of practice” by prescribing a statin drug: Crestor or Lipitor or Zocor or another brand, or one of the generics, commonly simvastatin. So, what’s wrong with that? The answer: it’s not enough!

In the first place, lowering LDL Cholesterol is by far the most common intervention for which your doctor can write a “script” (prescription).That’s why they do it. It must be frustrating for them though since “high cholesterol” (meaning both Total Cholesterol and LDL) is almost always associated with low HDL and high triglycerides. They are all so common in the population, and they are seen in the same patient. The result, however, is that sales of statins in the U.S. alone passed $20 billion a few years ago, but since HDL and triglycerides are more difficult to “treat,” they remain unchanged.

It must be doubly frustrating that “high cholesterol” is commonly associated with hypertension (high blood pressure) and obesity. Collectively these indications are called Metabolic Syndrome. See The Nutrition Debate #9 here for the indications and ranges. The particular cholesterol markers associated with Metabolic Syndrome are, interestingly, low HDL lipoproteins and high serum triglycerides. This is why in medical terms this cholesterol condition is called “dyslipidemia,” which means dysfunctional blood lipids (fats).

Although progress is being made in treating high triglycerides, unfortunately there is no pill to beneficially raise HDL. But dietary intervention works for both of these. See The Nutrition Debate #67 “HDL Cholesterol and the Very Low Carb Diet” here, #68, “Triglycerides, Fish Oil and Sardines” here, and then #27, “…the strongest predictor of a heart attack” (the Trig./HDL ratio) here for evidence of the CVD benefits of dietary intervention from both HDL and triglycerides.

Of course, hypertension can be treated with medications, usually a “cocktail” of two or three, but obesity stubbornly resists medical interventions. It is up to the patient, the doctors say, and the doctors usually report the patient is “non-compliant.” That is to say, the patient either cannot lose weight on the recommended restricted calorie balanced diet, or the patient who does lose weight soon gains it all back and often “then some.” Hunger wins out. The body doesn’t want to be starved even with fat reserves. It tells you to eat lots of glucose (carbs) for quick energy, even between meals.

So “high cholesterol” and hypertension, seen together, are still the targets most doctors treat together. The problem is: Total Cholesterol is an antiquated and almost useless term. It is only used because it can be easily measured and the calculated component lowered to the standard-of-practice range by statins. HDL and triglycerides remain unchanged. But, a Total Cholesterol that would be “too high,” because of its LDL component, would be perfectly okay with your doctor if the LDL were the same but the HDL was much higher and the triglycerides much lower. See The Nutrition Debate #25, “Understanding Your Lipid Panel” here, for two identical Total Cholesterols with different components.

The reason for this is evident from the formula used for the lab test of your cholesterol. It is called the Friedewald formula. In it, Total Cholesterol and HDL and triglycerides are assayed (actually measured), but the LDL value is calculated, thusly: LDL = T.Chol – HDL – TG/5 (where triglycerides/5 are a surrogate for VLDL within a wide range).

So, the best way to truly “fix” your cholesterol is to significantly raise your HDL and lower your triglycerides. And if you follow my “prescription” for doing that, by following a restricted-calorie Very Low Carbohydrate diet, you will also lose weight without hunger, because your body will be free to burn your body fat. And as a result, you will get control of your blood sugar (if you need to), and lower your blood pressure. Your Type2 diabetes (if you have it, or you are pre-diabetic) will go into remission and you will have no clinical signs of dysglycemia. Your Metabolic Syndrome will go undetected because the indications will have abated. Your doctor can’t do that. You can. But first you have to know your cholesterol – not just your Total Cholesterol and LDL, but also your HDL and triglycerides. Take charge of your health and find out!
© Dan Brown 10/27/12

Saturday, October 20, 2012

The Nutrition Debate #71: Weight Loss Maintenance

After losing 170 pounds on a Very Low Carb diet (first with Atkins and then Bernstein), I later regained 72. And although I still ate Very Low Carb most of the time, and always at breakfast and lunch, and most dinners, I occasionally “binged,” and I routinely ate too much dinner. I also sometimes snacked after dinner even though I was not hungry.

 Altogether, it was more than my body needed to maintain my weight, and it ultimately led to the loss of blood sugar control that I enjoyed while I was eating “strictly according to plan.” My A1c went from 5.4 to 6.3. And my blood pressure went back to 130/90 (with the same meds) from 110/70. My HDL and triglycerides were still very much improved, but my LDL had also begun to creep up. And my doctor was urging me to start statins again.

So, that is how I regained weight: Too much food, snacking after dinner, and occasional binging. It didn’t take “much” (the way I saw it), but it was enough. It took almost four years to regain the weight, with a few ups and downs along the way, and I’ve finally decided “enough is enough.” It’s time to turn it around again. About a month ago I set a goal to lose 55 pounds: 30 (to get to 247) by the end of the year (4 months’ time) and then 25 more (to get to 222) “eventually.” It’s my “let’s see how it goes approach.” Thereafter, I will strive to keep my weight within 5 pounds of 225.

By all accounts in the literature, my situation is very common. Many of those who find it easy to lose weight on a Very Low Carb eventually relapse and tumble into the same pitfall. Most gain back most of the weight they lost, especially if they abandon the principles of Very Low Carb eating. That’s a “fatal flaw” of any diet. But I didn’t, really (I tell myself). Why therefore did I fail? Everyone wants to know why they failed. And everyone wants to tell you. But nobody really knows for sure. Until now, maybe.

Before I share with you what I intend to do to maintain my weight loss (once I attain my goal weight of 225lbs.), I need to describe the diet I am using to lose weight again. I call it a Restricted Calorie Very Low Carb Ketogenic Diet.  It has 3 components: 1) Restricted Calorie: you need to have a calorie deficit to burn body fat; 2) Very Low Carb (VLC): you need to eat VLC to allow insulin to NOT BLOCK the breakdown of body fat in storage; and 3) Ketogenic: you need to supply ketone bodies from both dietary and body fat breakup, and glycerol and amino acids from fat and protein, to provide alternate fuels (e.g., ketone bodies) and mechanisms (gluconeogenesis) for synthesizing glucose for your central nervous system and other cells that require them. These processes and mechanisms are called “complementary pathways.”

For me this diet is 1,200kcal/day comprised of 5% (20g) of carbohydrate, 25% (75g) of protein and 70% (90g) of fat. This formulation produces a ketogenic/glucogenic (K/G) ratio of 1.66, and should produce a weight loss of 2 pounds per week. A 1,000 kcal/day calorie deficit x 7 days = 7,000 kcal/wk = 2 lbs., since there are 3,500 kcal/pound.

The way I propose to maintain my goal weight is described in “The Art and Science of Low Carbohydrate Living” by Jeff Volek and Stephen Phinney.  This is a very good book, but there are lots of good books out there about the Low Carb way of eating. However, none that I have read specifically describes in terms of macronutrients WHAT TO DO, once you have reached your “goal weight,” in order to maintain it. This book does, and it explains why. It describes the mechanisms and processes the body goes through ESPECIALLY WHEN YOU ARE CARBOHYDRATE INTOLERANT.  The authors use this new “buzz” phrase repeatedly. Accept it. It applies to all Type2 diabetics, pre-diabetics, and the majority of overweight, obese and morbidly obese people, as well as those who have Metabolic Syndrome. That means you.
The following excerpts from Chapter 16, “The Importance of Dietary Fat in Long-Term Maintenance,” outline Volek and Phinney’s rationale. The authors reason that “long term adherence to carbohydrate restriction is an important issue, and capturing the benefits of a low carb diet for the management of chronic conditions associated with insulin resistance requires that we address this challenge. Given the dramatic improvements in the dyslipidemia associated with metabolic syndrome, and the marked improvement in diabetes management when adequate carbohydrate restriction is sustained” (pg. 205), they conclude that dietary carbohydrate intake cannot be increased in weight maintenance. So, the need “…to feed the post-weight loss patient adequate energy for weight stability, while maintaining the degree of carbohydrate restriction necessary to sustain the diet’s benefits” (pg. 206), as carb intake must remain flat, then only protein and fat remain. And if about half of protein is glucogenic (can convert to glucose in a secondary process in the liver called gluconeogenesis), the amount of protein in the maintenance diet can only increase slightly and then only as an equal percentage of total energy intake in the maintenance diet as it was in the weight loss diet. Thus, the macronutrient that must increase in the maintenance diet, both as a percentage of total intake and in absolute calories, is fat.  I’m thinking ghee and coconut oil.  And maybe snacks of nuts and cheese once in a while. Wheeeeee...                                                    

 © Dan Brown 10/20/12

Sunday, October 14, 2012

The Nutrition Debate #70: LDL Cholesterol and Statins

My doctor is hinting that I should start taking statins again. Knowing that I know a little something about lipid health, and that I have “taken charge” (in a sense) of my own healthcare, I expect he knows he has to tread softly with me on the subject of statins. He also knows that I respect his knowledge (he is an internist and cardiologist), and he has worked well with me for over 20 years.
After failing to get me to lose weight on a balanced diet, under his nutritionist’s supervision, in August 2002 my doctor suggested I try Atkins. It worked. In 9 months I lost 60 pounds, and a few years later after gaining back 12 pounds I started on Bernstein and lost 100 more in less than a year and then later another 22 (170 total). Upon starting Atkins I immediately needed to greatly reduce and/or eliminate all three classes of oral diabetes medications I had been taking. (I have been a Type 2 diabetic for 26 years.) By my lowest weight my blood pressure had also gone from 130/90 to 110/70 on the same BP meds.
In addition, my lipid health completely turned around. My HDL Cholesterol more than doubled from 39 to 81 (averages), and my triglyceride averages went from 137 to 49. (For details of the HDL story go here and for the triglycerides go here.) But, you may ask, how did my LDL Cholesterol fare during this transformational period? At a glance it appears to me that it did pretty well, but bear in mind that LDL Cholesterol is a calculated number (not an assayed value). Also, statins lower LDL very effectively.
Between 1992 and August 2002, when my doctor suggested I try Atkins, my LDL had been tested 12 times. The average was 142mg/dl. For reference, from 130 to 159mg/dl LDL is considered “borderline high.”Over the next 16 months, while I was on the Atkins diet and losing weight, it was tested 16 more times, and the average was 125. The clinical guidelines consider under 130 “near/above optimal.”  But, for patients who have either hypertension, Type 2 diabetes or are obese, the guidelines suggest <100, and if the patient presents with more than one of these conditions, the guidelines are <70mg/dl.
So, since I was obese, hypertensive and a Type2 diabetic, in December 2003 my doctor suggested I start on a statin: I started on 80mg of Lipitor, as I recall, and it definitely lowered my LDL Cholesterol. Over the next 5 years the average of the 21 LDLs taken was 60! I was lucky. I had no side effects that I can recall (but maybe cognition was one of them – LOL). And, soon after starting them I switched to a generic (Simvastatin,) and over a period of time took less and less until my doctor finally took me off them completely in December 2008.
Since that time my LDL has been tested 11 times for an average of 123, and that includes the last two: 146 and 149. This 123 average is virtually the same average as my first year on Atkins (125). It is also under the 130 “near/above optimal” value, and I still weigh today more than 100 pounds less than when I started Atkins.
However, my weight, blood pressure, fasting blood sugars and A1c’s have been creeping up a bit recently. So I find myself at a crossroads: Either I stick closely to my Very Low Carb Restricted Calorie diet (as I have been for the last 6 weeks) to lose weight, improve my BP, A1c and LDL Cholesterol, or I start to take a low dose statin again (for the LDL only). My doctor wants me to look into pitavastatin. So I did. It did well recently in a prospective, randomized, double blind, double-dummy trial reported on here. A minimum dose of 2mg had a 39% reduction of LDL compared to a 35% reduction of LDL for a minimum 20mg dose of Simvastatin. I didn’t check out the side effects or “adverse incidents.”
I think my approach (should the subject arise at my next office visit) will be to say “no” to starting on a statin again so long as I am making improvements in my weight, BP, A1c and LDL Cholesterol. (See, your subtle approach worked, doc.) If I can consistently keep my LDL between 100 and 130 without a statin, and lose weight again, and improve my BP and A1c and FBG entirely through my Very Low Carb Restricted Calorie diet, I think I can keep the doctor off my back. Let’s see, after he reads this, if he will agree with this plan.
© Dan Brown 10/14/12

Sunday, October 7, 2012

The Nutrition Debate #69: In Praise of Small Meals

Like many Americans and increasingly people around the world who have eaten a “Westernized” diet, I succumbed to one of the ubiquitous Diseases of Civilization: Metabolic Syndrome. See The Nutrition Debate #9 here for the symptoms. The major signs are obesity, hypertension (high blood pressure) and dyslipidemia (especially high triglycerides and low HDL). It is also nearly synonymous with Type 2 diabetes. I don’t have to tell you: Obesity and T2 diabetes are epidemics of “epic” proportions (pun intended).
Many have already discovered an effective treatment for Metabolic Syndrome – one that can reverse virtually all of the symptoms and avoid further damage to organs and arteries (endothelial dysfunction). Lose weight. And in a way that is without hunger, using the Very Low Carb (VLC) restricted calorie diet advocated in this blog. The benefit of the VLC restricted calorie diet is that it will ameliorate all the symptoms of Metabolic Syndrome: the obesity, the hypertension, the dyslipidemia and dysglycemia (pre-diabetes or even full T2 diabetes).
You can lose weight without hunger. I lost 170 pounds.  Your high triglycerides will plummet and your HDL can soar. For evidence of my own improvement in these areas, see the Nutrition Debate #67, “HDL Cholesterol and the Very Low Carb Diet,” and #68, “Triglycerides, Fish Oil and Sardines.” In addition your blood pressure will likely improve. Mine did. I went from 130/90 (with medications) to 110/70 (with the same medications). Finally, and this is the best news of all: your blood sugars will greatly improve, eliminating or substantially reducing the need to take oral diabetes medications.
In addition, if strictly adhered to, a Very Low Carb diet will put your T2 diabetes in full remission with no clinical signs of disease. Mine is. And once you have reached your goal weight, all of your gains will be retained so long as you continue to eat Very Low Carb. So long as you keep the weight off, and continue to eat VLC, you will have “normal” blood sugars and lower A1c’s, great lipids, especially triglycerides and HDL, and improved blood pressure. But, you can’t go back. You must keep the weight off. And you must continue to eat VLC. Very Low Carb must become your Way of Eating for life (double entendre intended).
 This Way of Eating is very effective for weight loss and weight maintenance because if you aren’t hungry, you should not eat as much. You can eat a small meal and be satisfied. Not sensing hunger, that is, by eliminating the biological imperative your body senses to eat to survive to avoid starvation, you will not want to eat between meals and at every opportunity, and you will not have the desire to scarf down more food than you need when you do sit down to eat.
But hunger is not the only driver of eating. Another force/response that I discuss in the Nutrition Debate #63 here is Impulse Control. Thinking about food, or seeing food, even a visual image on TV, is a stimulus. It induces a hormonal response. Insulin and other hormones start to flow. The stimulus could be one of those Red Lobster TV commercials that depicts an “endless shrimp” dinner. Delicious! Or it could be just the thought of that “half-gallon” of ice cream you know is in the freezer. Resisting this impulse requires self-control: you must deny this biological imperative/response too.
A similar type of behavior modification is involved in proactively understanding that 1) if a small VLC meal satiates your hunger, you should be satisfied and thus learn to eat it and no more. Similarly, if you are not hungry for 5 or 6 hours after a small VLC meal, 2) you should learn that you do not need to eat a between-meal snack. I have learned these two lessons during 10 years of eating VLC and found it easy to apply them. Small meals and no snacks. Let me illustrate:
For 10 years I have been eating a breakfast of 2 fried eggs, 2 strips of bacon and a cup of coffee with half and half and artificial sweetener. It is about 6 grams of carbohydrate (2 eggs = 1, 2 Splenda = 2, and 2oz H&H = 3). It is mostly protein and fat (21g protein; 27g fat). Total calories: about 350. Believe it or not, this small meal is good for 6 or 8 hours!
However, for lunch I have a can of sardines eaten from the can: 13g protein, 24g fat and zero (0) grams of carbohydrate. Calories, including the olive oil in the can: 270. If I have a beverage, it is either a glass of water or diet ice tea. I eat this meal approximately 5 hours after breakfast not because I am hungry (I am not), but because I want to eat some protein (with some fat) at lunchtime to prevent my muscle protein from being used for energy. Because I am not eating carbohydrates for energy, none are stored and dietary protein and fat are needed with each meal as energy sources.
Dinner is likewise mostly protein and fat; however, it is still just a “smallish” serving of protein plus a non-starchy vegetable (carb) tossed in butter or roasted in olive oil (fat). Alternately, I sometimes eat a salad with vinaigrette dressing. Together, the three meals combined are about 1,200 calories, 75g protein, 90g fat and 20g of carbohydrate. This meal plan is about 25% protein, 70% fat and 5% carbohydrate. And all of these meals are small and very satisfying. © Dan Brown 10/7/12