The Nutrition Debate #112: “Treating the Obese Diabetic”

My Type 2 Diabetes “Topic Alert” at Medscape recently emailed “Treating the Obese Diabetic,” an article published in Expert Reviews in Clinical Pharmacology at www.expert-reviews.com. It is a thorough, comprehensive and, in my opinion, balanced review of anti-diabetic pharmacological agents for the treatment of the obese type 2 diabetic. It also, as so many articles in the mainstream medical literature do these days, seems to me to make a big push to boost the business of the bariatric surgery industry. They’ve got boat payments to make and apparently are underemployed, as so many are today.

I can spare you having to read the whole paper. The abstract is brief and to the point. Here it is in its entirety:

“Type 2 diabetes and obesity are intimately linked; reduction of bodyweight improves glycemic control, mortality and morbidity. Treating obesity in the diabetic is hampered as some diabetic treatments lead to weight gain. Bariatric surgery is currently the most effective antiobesity treatment and causes long-term remission of diabetes in many patients. However, surgery has a high cost and is associated with a significant risk of complications, and in practical terms only limited numbers can undergo this therapy. The choice of pharmacological agents suitable for treatment of diabetes and obesity is currently limited. The glucagon-like peptide-1 receptor agonists improve glycemia and induce a modest weight loss, but there are doubts over their long-term safety. New drugs such as lorcaserin and phentermine/topiramate are being approved for obesity and have modest, salutary effects on glycemia, but again long-term safety is unclear. This article will also examine some future avenues for development, including gut hormone analogues that promise to combine powerful weight reduction with beneficial effects on glucose metabolism.”

The only pharmacological agent that gets a clean bill of health in this comprehensive review is metformin. All the others come with qualifiers like weight gain (!) and doubts over their long-term safety. Here is their review of metformin:

“Metformin, as per current American Diabetes Association (ADA) and European Association for the Study of Diabetes recommendations, is the first-line medication used for those with Type 2 diabetes and has an established safety record. It inhibits hepatic gluconeogenesis, and to a lesser extent glycogenolysis, but also increases insulin sensitivity. The UKPDS 34 study suggested improved cardiovascular (CV) outcomes in those taking metformin, although recent meta-analyses have failed to confirm this. Metformin not only offers useful glycemic control but has also been shown in some trials to induce weight loss, although two meta-analyses comparing metformin to placebo have shown its overall long-term effect appears to be weight neutral. Metformin has been in use clinically since the 1950s (in the USA since 1995), so it has a well-understood long-term safety profile with the most common side effects being transient gastrointestinal symptoms. Lactic acidosis is a rare side effect but cases have been reported in the literature.”

The Expert Commentary is succinct and pithy. The first paragraph tells the story. The rest of this section is also a good read.

“Faced with a newly diagnosed obese diabetic patient in a real world setting, it is important to ensure that the antidiabetic medications prescribed are effective and safe, without inducing weight gain. Ideally, our therapeutic strategy would utilize treatments with a long-term safety record that can induce weight loss and have been shown to improve CV outcomes. The only two treatments that offer this level of evidence at present are bariatric surgery and metformin.”

The paper includes 204 references and has a very interesting forward-looking “Five-year View” section near the end which is worth a look for any healthcare professionals among my readers. The “Sidebar” titled “Key Issues” summarizes the paper:

·        Bariatric surgery is currently the most effective route to tackle the linked pathologies of diabetes and obesity. It produces durable weight loss and long-term remission of diabetes. In addition, cardiovascular morbidity and overall mortality are reduced in those diabetics who undergo surgery.

·        Mechanistically, the improvement in glycemia following some forms of bariatric surgery, such as Roux-en-Y gastric bypass, may be driven by changes in gut hormone levels, thus providing a potentially attractive target for future medical therapies to treat diabesity.

·        GLP-1 analogues produce significant weight loss along with an improvement in glycemia. DPP-IV inhibitors are well tolerated, effective and weight neutral. Neither therapy has a proven long-term safety record nor definitive evidence of benefit on cardiovascular risks.

·        Recent additions to the US market are centrally acting lorcaserin and phentermine/topiramate. Both are effective at producing limited weight loss and have minor effects on glycemic control. Long-term safety data are lacking and they are still awaiting European approval.

Sadly, but understandably, this article treats only what the medical professional can do to “treat the obese diabetic:” write multiple scripts or, in eligible cases, recommend surgery. It does not address counseling the patient to change their diet to reduce the one thing that causes elevated glucose in the first place (in the disregulated metabolism): dietary carbohydrates.

If you read this blog regularly, you know the drill. In persons with insulin resistance, excess carbohydrates, and too much protein which can also be glucogenic (convert to glucose), cause elevated blood glucose. There is no “fix” for this condition once you have developed it except to eat many fewer carbs (and moderate amounts of protein). If you continue to eat a “balanced diet,” even with progressively more anti-diabetic medications, you will lose the battle. Your pancreas eventually will be unable to produce the extra insulin to transport your blood glucose to your cells that won’t take them up, and you will eventually become an insulin-dependent type 2 and/or develop the “inevitable complications” of “inadequately treated” type 2 diabetes: increased morbidity and mortality from a host of causes too tedious to mention.

So, you can let your doctor “treat the obese diabetic” in the manner prescribed in this paper, with the risks they frankly explain (and the outcomes I have suggested above), or… you can change your diet and “treat” yourself. It’s up to you.

The Nutrition Debate #111: “…the usual complaints” of aging

This column, unlike most, will be an entirely subjective and personal (n = 1) account of my condition. It will not, except as noted in paragraph #2, include any laboratory reports or other metrics or links to research. I have been grappling about how to address this matter for some time. It is hard, perhaps because it is so intangible. It has been reported in the literature, of course, but even then it is hard to quantify. My topic is qualitative. I am talking about the quality of life I have experienced and am experiencing since I began to eat a Very Low Carb (VLC), medium protein and high-fat diet, almost 11 years ago, to treat my Type 2 diabetes. I was diagnosed a Type 2 in 1986.

I am now a 72 year old male who is still overweight…in fact, obese (BMI = 33). In 2002 I weighed 375 pounds (BMI = 52). I now weigh 238 pounds. At one time, about 5 years ago, I was down to 205. I also had high blood pressure with prescriptions for a “cocktail” of 3 meds. My blood pressure is now “normal” (120/80) on the same meds. I also had low HDL and high triglycerides. My HDL has now doubled and my triglycerides have been cut by 2/3rds. My total cholesterol and calculated LDL have been constant, LDL up slightly actually; but more than offset by the other lipids so, in the opinion of my doctor, all is ‘copasetic.’ And my fasting glucose’s (mid-80s) and HbA1_c (5.6mg/dl) look “non-diabetic” so long as I stick strictly to a VLC diet, Bottom line: Today, I am a lot healthier than I was 10 years ago.

I was at a cocktail party last fall in which a few old men were standing around talking about “the usual complaints” of aging. When it was my turn to share, I said to an 89-year old retired ophthalmic surgeon that I had no complaints whatsoever. In fact, I announced to the group, I felt better much better than I did 10 years ago. They all looked at me in disbelief, like I was being disingenuous or just in denial. I quickly explained I had lost 140 pounds in those 10 years, and one of them commented that that explained everything. The subject quickly changed, perhaps not to embarrass me by any further probing. Or perhaps it made perfect sense to them (all doctors, btw) in a gross sense.

Anyway, I have been thinking about their reaction to my honest response for awhile and want to explore if not explain it. For one thing, I am happier. I no longer have the fear that I will die an early death as I did when I was morbidly obese. Besides all the physiological risk factors (and there are indeed many that could be cited), this fear was well founded and was probably a stress generator, which produces inflammation. So, if for no other reason than I am not as fat as I once was, and therefore likely to live longer from an epidemiological perspective, my mood has been elevated. Of course, I could also have an elevated mood because of the foods I am eating, but that is a whole other area of scientific investigation. Suffice it to say, for whatever reason, I am happier now.

Of course, the most common question people asked, especially when I was at my lowest weight (205), was “Don’t you feel ‘better’?” My response then was always, “Not really…although I did feel, once when I was walking across a parking lot (when my weight was about 250), that my step was ‘lighter’.” But that was all I recognized or felt, at the time. Today that different ‘feeling’ has been lost by so much time and sameness.  But looking back, I would say now that I am much happier, and that really is a big difference. Had I realized it then, I would have mentioned it.

Additionally, I and my doctor are very pleased that my health markers (BP, cholesterol, and glucose metabolism) have all improved so dramatically. Because of the weight loss, my dramatic blood pressure improvement signals an improved prognosis for both health and longevity. The improvement in inflammation markers, triglycerides, HDL, HbA1_c and fasting blood glucose, I attribute entirely to the foods I eat on a VLC diet. Taken together, they constitute a much improved health outlook and sense of well being. That’s something hard to measure… but priceless.

Perhaps the most remarkable (and inexplicable?) change in my health is that in my 63^rd year, about a year after starting on Atkins (I eventually changed to the Bernstein diet for diabetics), I began to have arthritis in two fingers of my left hand. Anyone familiar with the symptoms will recognize it: persistent pain and swelling in the 2^nd joint. It came and went for a few weeks and then mysteriously disappeared…forever. I had it, I’m sure. And it’s gone, completely for 10 years now. It just disappeared without a trace. This is, of course, simply an association. I do not suggest causation, but who knows. I’m just glad not to have to endure it, as so many others do, as one of “the usual complaints” of aging.

So, it’s good to be happier and healthier, to paraphrase Mel Brooks. Happier and healthier are mutually supportive aspects and integral parts of “the entire harmonic ensemble of the human body,” to borrow a phrase Gary Taubes’s 10 “certain conclusions”* in his seminal 2007 work, “Good Calories-Bad Calories” (titled “The Diet Delusion” in the UK). They are inextricably intertwined into our fabric. Together, they are the essence of health and well-being. I feel and believe that I have it now, and I just wanted to share that. I hope that I have successfully conveyed it to you, my readers.

*All 10 conclusions are listed in The Nutrition Debate #5 on this blog. There is also an index of all columns on the blog.

The Nutrition Debate #110: My Body and Me

Homeostasis, I have come slowly and begrudgingly to accept, is a controlled condition with a “compound” predicate. It is controlled, I now recognize, by both my body and me. I used to regard it differently. I used to think that my body and I were one entity, and that I was in control. I am wiser now. Let me explain how I came to recognize that change.

The first step, which occurred more than 10 years ago, was when I recognized that I was in sole charge of my health care. I still went to see my doctor, and in the beginning at least, I took his advice, usually; but as I educated myself in diet and nutrition, I came gradually to believe that he was hopelessly out of touch with developments in nutritional science as it related to my long-term type 2 diabetes. I credit him with suggesting that I start eating Very Low Carb (Atkins Induction), but it was to lose weight, not to treat or control my blood sugar, or dramatically improve my lipid chemistry.

As my knowledge increased over the years, I paid less and less attention to what my doctor told me. I requested to be titrated off statins and refused his suggestions to renew them later. I also refused his suggestion for new prescriptions. To be fair, as my doctor saw the health outcomes I had achieved through dietary means, he also began to back off a little. As my weight dropped, so did my blood pressure (duh!). On balance, as my doctor’s influence on me diminished, my sense of empowerment increased. Naturally, this new power led me to be overly self-confident. This was the “I’m in control” phase.

My doctor actually encouraged me too. He frequently said I should go on local (NYC), even network TV, to tell others of my accomplishments and how I did it. I declined, of course, knowing that I was just an amateur who was entirely self-taught and without any “credentials”. I also know that there are hundreds of much better trained professionals in practice and in research out there who understand and advocate for this Way of Eating (WOE) and who have a well-deserved place in the blogosphere and in the publishing world.

The bottom line is that as I gained a sense of empowerment I came to think of myself as being “in charge,” not just of what others had to say and do with my body (with respect to diet and nutrition), but with what I did with it myself. This arrogance, I hope you will think, is a natural consequence of the transition that I have described above. I consider it a major accomplishment. It is, I think, one that very few people make. Most people in our culture – the ones who are getting sick and sicker on the Standard American Diet (SAD) – are doing so diligently and conscientiously following the diet that their traditionally trained clinicians advise. We put our destiny – our precious health – in their hands, for better or worse. To switch from professional medical advice to going your own way on the basis of what you read in a blog is…well, crazy, right?

Well, I did it. And so have many, many others. My doctor did monitor me once a month for a year, and the standard 4 times a year thereafter; he happily observed and approved of all the outcomes. So, in that sense, I didn’t do it alone, but I was in charge (of what I ate). I stuck to Very Low Carb, and I got the results. And my doctor looked on approvingly. That was Phase 1. This is where it gets dicey, perhaps complicated by my being male, do you think?

After some years of successful weight loss and dramatically improved metrics (BS, BP, HDL, TG, A1c, CRPs, etc.), my weight loss slowed. At one point, during a lax period, I regained some and then lost some again. But weight loss became harder. I fiddled with ketosis for awhile using a K/G ratio of 1.5:1.0, calculated by detailed record keeping of everything I ate. That grew tiresome after I no longer needed to learn about the effects certain foods had on my blood sugar. I also began to regularize what I ate for breakfast and lunch every day and to eat smaller evening meals: “Supper” instead of “dinner.”

I have also over time adjusted the daily calorie target and the macronutrient ratios. Carbs have always been very low (from 7% to 5% now), protein always “moderate” (from 28% to 20% now), and fat always high (from 65% to 75% now). Calories have ranged in recent years (after I had lost well over 100 pounds) around 1,200 calories (typically) a day. I have always believed that a calorie deficit was necessary. You cannot burn body fat, even in a mildly ketogenic state, if your dietary fat is sufficient to maintain your metabolic activity level. You must call on your body for that additional energy, i.e., the difference between the energy content of what you ingest and what you require for homeostasis.

This was never a problem for me. So long as my carb intake was very low, my serum insulin level was low, I had access to body fat, and my blood glucose was low and stable. I was not hungry because “my body” made up for the energy deficit. It catabolized and oxidized (broke down and burned) my body fat as needed. But that is where “my body” came into play. I did “my part” – ate low carb, moderate protein, high fat and still low calorie – and my body did “its part.” It continued to break down and burn fat and tell me “it” was “happy” (by not sending me hunger signals, and the good lab results).

That’s when I realized that “my body,” not “I’, was in charge. And “it” has “a mind of its own.” I just slavishly follow its demands. I try to “listen” to “it” and feed “it” what it needs. My body is, after all, a much more powerful and better controlled and disciplined “person” than I am. We both live in the same skin, so my goal now is to keep us both “happy.”

The Nutrition Debate #109: “Prisoner for Life”

Sounds like a Merle Haggard song, doesn’t it? But this column is not about music; it’s about the life-long travails of a type 2 diabetic. But before you get all mewlish, or repulsed in shock and denial, let me try to explain why I think this is a good thing. Let me tell you about how, seriously, a little over ten years ago I thought I would be dead by now. Today, I am much healthier and am looking forward to a long and healthy life. Two things occurred this week to remind me of how lucky I am.

First, in a side bar conversation (PM) with an on-line friend, we were discussing one of the confounding problems of weight management: set point theory. One point in particular caught my attention:

“Weight management is really a multi-faceted issue, and it's different for everyone. I'm really happy for you that you can lose weight with what you are doing, but even so, it seems to me that you are still walking a very fine line between successful weight loss and keeping the weight off. If you stray even a little bit from your protocols, you gain weight. To me, that seems like you are also dealing with a broken metabolism, and you will be a prisoner of lower calorie and diet (carbohydrate restriction) the rest of your life. It is not about calories in calories out. There is something happening with your metabolism that is not working right, but I don't know what it may be for you.” (Emphasis mine)

Well, of course, my friend was right! I know it, and I have known and accepted that reality for quite a long time. For reasons that are at this point too tiresome to repeat, I am seriously intolerant of carbohydrates, and that includes virtually all (50% to 60%) of the foods that I have been eating for my entire life. I am now required to limit carbohydrates to about 5% of my diet, or just 10% of what I previously ate. I needed to eliminate 90% of the carbs I formerly ate! That’s the reality of it.

That kind of undertaking calls for a big adjustment. And the medical establishment has decided you can’t do it. They have concluded that it is too difficult to make dietary changes of that magnitude, even if it means saving your life. And they’re right. Most people can’t do it. Or won’t do it. Wives complain their husbands won’t give up this or that food. Wives who try to do it look for “substitutes” that have the “mouth feel” of the favorite food they have had to give up. Both husbands and wives cheat. Some diet programs are so sure you can’t do it that they have cheat meals or even cheat days built into their program. In general, there is an attitude that to do this, you have to “give up” a lot. Well, you do! If you want to live.

This is further complicated by the prevailing wisdom in the medical establishment: that “heart healthy” means avoiding saturated fat and dietary cholesterol. You cannot, you will not get well if you follow this advice. Saturated fat and dietary cholesterol is not the problem with our diet. It is the refined carbohydrates and sugars, (including excessive amounts of fructose), grains, particularly wheat (even the “whole grain” forms), and vegetable oils that are making us sick. And type 2 diabetes will continue to be a “progressive disease,” with the onset of the “inevitable complications,” so long as we continue to follow the establishment’s prescription of “balanced diet and exercise,” and progressively more medications.

I came to these realizations by accident. I started on Atkins Induction, on my doctor’s advice, to lose weight! And to our mutual surprise, my diabetes went into remission almost immediately. I quickly was able (forced) to drop my diabetes meds. Next, my blood lipids improved, slowly but very dramatically (HDL doubled, Triglycerides came down by two-thirds). And as I lost lots of weight my blood pressure went from 130/90 to 110/70 on the same meds. After a few years I switched to the Bernstein diet and learned a lot by asking questions on a low-carb forum for people like me. Great support!

The second thing that occurred to me this week is that I was reminded by a CDE (Certified Diabetes Educator) that “attitude is all important.” Diet, exercise, medication, she says – they’re all important too; but without the right frame of mind, you won’t stick with it. And you have to like the foods you will be eating for the rest of your life. I do. I cook more now than I ever did before. There are so many good foods, whole foods, real foods, from which to choose. And great cook books, and fabulous web sites with daily recipes. The varieties of meats, fowl, fish, vegetables, salads, and healthy fats are endless.

So, as to being a “prisoner for life,” I think just the opposite is true. I have been freed from a progressive worsening of my disease as it was being managed by the “standard of practice.” While I will always have a “broken metabolism,” by radically changing my diet I have been liberated from the inevitable complications that would have inexorably overtaken me if I had continued my “balanced” diet and the medical course of treatment my doctor (and the mainstream medical establishment) had prescribed for me. I have been paroled from my life sentence. And as long as I am on good behavior, I expect to live a long and healthy life.

So, what’s the takeaway? As I said at the beginning of this piece, if you had told me a little more than 10 years ago that I would be healthier today than then – way healthier, I wouldn’t have believed you. I expected to be long dead by now. So that’s the takeaway: (You) Take care of yourself, and you will be “freed” of this disease and live a long and healthy life.

The Nutrition Debate #108: “You’re Eating Too Much Dairy”

This link from Janet (JEY100), a helpful member on a popular Active Low-Carber Forum  led me to a popular new blogger named Kris Gunnars and his blog Authority Nutrition. The link was to his "Top 15 Reasons You Are Not Losing Weight on a Low-Carb Diet." Reason #7 was “You’re Eating Too Much Dairy.” This is what Kris said (emphasis mine):

“Another low-carb food that can cause problems for some people is dairy.

Some dairy products, despite being low in carbs, are still pretty high in protein.

Protein, like carbs, can raise insulin levels, which drives energy into storage.

The amino acid composition in dairy protein makes it very potent at spiking insulin. In fact, dairy proteins can spike insulin as much as white bread (7, 8).

Even though you may seem to tolerate dairy products just fine, eating them often and spiking insulin can be detrimental to the metabolic adaptation that needs to take place in order to reap the full benefits of low-carb diets.

In this case, avoid milk, cut back on the cheese, yogurt and cream. Butter is fine as it is very low in protein and lactose and therefore won’t spike insulin.

Bottom Line: The amino acid composition in dairy proteins makes them spike insulin fairly effectively. Try eliminating all dairy except butter.”

The low-carber forum blogger also provided a link to Mark Sisson’s Mark's Daily Apple with his "17 Reasons You're Not Losing Weight" of which #17 is “You’re Eating Too Much Dairy.” His text is provided below (again, emphasis added by me):

“Some people just react poorly to dairy. We see this time and time again listed in the forums; dairy just seems to cause major stalls in fat loss for a good number of folks. There are a couple speculative reasons for this. One, folks coming from a strict paleo background may not be acclimated to the more relaxed Primal stance on dairy. Reintroducing any food into the diet after a period of restriction can have unintended consequences on body composition. Two, dairy is insulinogenic, which is why it’s a popular post-workout refueling tool for athletes. Does a non-strength training PBer need to drink a few glasses of milk every day? Probably (definitely) not.”

What caught my interest in both of these posts, obviously, was the reference to insulin secretion with respect to protein and dairy protein in particular. My interest was further piqued when I read Kris’s “very potent” hyperlink above, which as it turns out is to Mark’s elucidation of his “tip.” That excellent post by Mark, “Dairy and Its Effect on Insulin Secretion (and What It Means for Your Waistline),” is too long to copy here, so I’ll just provide an excerpt (all my emphasis):

“Cream and butter are not particularly insulinogenic, while milk of all kinds, yogurt, cottage cheese, and anything with casein or whey, including powders and cottage cheese, elicits a significant insulin response. In one study (PDF), milk was even more insulinogenic than white bread, but less so than whey protein with added lactose and cheese with added lactose. Another study (PDF) found that full-fat fermented milk products and regular full-fat milk were about as insulinogenic as white bread.”

Do you see where I’m going with this? Finally, footnote #7 in Kris Gunnar’s post takes you to this study by scientists from the highly respected universities in Malmo and Lund, Sweden and Copenhagen Denmark. Again, the underlining is mine.

“Glycemia and insulinemia in healthy subjects after lactose-equivalent meals of milk and other food proteins: the role of plasma amino acids and incretins1,²,³

Authors: 1. Mikael Nilsson, 2. Marianne Stenberg, 3. Anders H Frid,  4.Jens J Holst, and  5.Inger ME Björck

Background: Milk products deviate from other carbohydrate-containing foods in that they produce high insulin responses, despite their low GI. The insulinotropic mechanism of milk has not been elucidated.

Objective: The objective was to evaluate the effect of common dietary sources of animal or vegetable proteins on concentrations of postprandial blood glucose, insulin, amino acids, and incretin hormones [glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1] in healthy subjects.

Design: Twelve healthy volunteers were served test meals consisting of reconstituted milk, cheese, whey, cod, and wheat gluten with equivalent amounts of lactose. An equicarbohydrate load of white-wheat bread was used as a reference meal.

Results: A correlation was found between postprandial insulin responses and early increments in plasma amino acids; the strongest correlations were seen for leucine, valine, lysine, and isoleucine. A correlation was also obtained between responses of insulin and GIP concentrations. Reconstituted milk powder and whey had substantially lower postprandial glucose areas under the curve (AUCs) than did the bread reference (−62% and −57%, respectively). Whey meal was accompanied by higher AUCs for insulin (90%) and GIP (54%).

Conclusions: It can be concluded that food proteins differ in their capacity to stimulate insulin release, possibly by differently affecting the early release of incretin hormones and insulinotropic amino acids. Milk proteins have insulinotropic properties; the whey fraction contains the predominating insulin secretagogue.”

Okay, this is getting a little thick, but you get the point, I hope. If not, go back and read this link by Mark Sisson, seriously. If you are wondering why you are not losing weight on a low-carb diet, milk protein could be the reason – particularly, but not exclusively the whey protein fraction. Butter (ideally from grass fed cows) and heavy cream, may be excepted, but here’s the takeaway: “…milk of all kinds, yogurt, cottage cheese, and anything with casein or whey, including powders and cottage cheese, elicits a significant insulin response.” And elevated insulin drives fat storage. That insight sure resonated with me.

The Nutrition Debate #107: “even…whole grains and fruits and vegetables”

This quote has stuck in my head since I first read it in an opinion piece in the New York Times last year (June 30^th 2012). The full title of this article was, “What Really Makes Us Fat.” It was written by the acclaimed and controversial science writer Gary Taubes. The full sentence containing the quote is: “From this perspective, the trial suggests that among the bad decisions we can make to maintain our weight is exactly what the government and medical organizations like the American Heart Association have been telling us to do: eat low-fat, carbohydrate-rich diets, even if those diets include whole grains and fruits and vegetables” (my emphasis). I like the quote ‘cause I think it’s kinda edgy, even “snarky.”

Taubes didn’t write this piece for me in my situation. I have been a diagnosed Type 2 diabetic for 27 years (probably, therefore, 35 or 40 years). He is addressing the many who have gained a little weight and may also be starting to have blood pressure and cholesterol issues.  The fact is that many, like me, who first became “fat” in our 40s, will develop Type 2 diabetes. Many who are even a little overweight, or slightly technically “obese” (by BMI measurement) will have developed Metabolic Syndrome and not even know it. (See The Nutrition Debate here #9 for the indications.) This, however, is exactly the population that is most likely to contract one of the myriad Diseases of Civilization – heart disease, stroke, some forms of cancer, and even dementia. It may start with high blood pressure, high cholesterol (especially in combination with low HDL and high triglycerides), and maybe even fatty liver disease (NAFLD).

It is now widely thought that this syndrome and all of these diseases are related to the Western Diet that we have adopted. That is why we are hearing the advice “eat more whole foods,” including more “whole grains and fruits and vegetables.” The thing is, whole grains and fruits and vegetables are all carbohydrates. Taubes’s point, I think, is that if the “healthy, non-diabetic” population continues to eat these “low-fat, carbohydrate-rich diets” to maintain our weight, that it would be a “bad decision” because it is a “carbohydrate-rich” diet.

With this statement Taubes reminds us of his second of 10 “certain conclusions” in his epic tome “Good Calories-Bad Calories”: “The problem is the carbohydrates in the diet, their effect on insulin secretion, and thus the hormonal regulation of homeostasis – the entire harmonic ensemble of the human body. The more easily digestible and refined the carbohydrates, the greater the effect on our health, weight, and well-being.” Boy, does he nail it! You should really read all 10 of his conclusions, maybe a couple of times. I listed them all here in The Nutrition Debate #5.

Now, for the “healthy” individual – that means, with no weight, no blood pressure and no cholesterol issues – eating whole grains and fruits and vegetables in moderation, without refined carbohydrates and excessive simple sugars, is okay. And for a fair-sized portion of the population who may not be genetically predisposed and susceptible to the metabolic derangement, it may also make no difference to you. But, the official advice is one size fits all and if you are overweight and slowly gaining, and are starting to have blood pressure and cholesterol issues, you would be among the ones for whom, to maintain your weight, it would be a “bad decision” to do “exactly what the government and medical organizations like the American Heart Association have been telling us to do: eat low-fat, carbohydrate-rich diets, even if those diets include whole grains and fruit and vegetables.”

Neither Taubes (not that I speak for him) nor I, of course, are saying that you should stop eating whole grains and fruits and vegetables unless your metabolism is already deranged or in the process of derangement. But if it is, as mine certainly is, you really have no choice if you want to regain, to the extent possible, and maintain “your” homeostasis. For me, I have virtually eliminated all grains and almost never eat any fruit (just a few berries wreak havoc with my blood sugar for days). The only vegetables I eat are low-glycemic ones with dinner, usually tossed in butter or roasted in olive oil. This is admittedly extreme, but necessary for me to deal with my broken metabolism as a 27 year type 2 diabetic. 

If you are prediabetic or have self-diagnosed Metabolic Syndrome (if your doctor never told you!), you will only need to moderate your intake of carbohydrates, especially the refined ones (as in bread, pasta and cereals!) and the simple sugars (as in fruit and honey!). If you do, and you substitute healthy saturated (e.g. coconut oil) and monounsaturated (e.g. olive oil) fats, I am confident you will eat less, lose weight and have healthier blood lipids (including higher HDL and lower triglycerides). Supplementation with a 1-gram fish oil tablet twice a day, and avoiding foods fried in corn or soy bean oil, or baked goods made with them and HFCS, will also help a lot. To do all this you will need to go against the advice of “the government and medical organizations like the American Heart Association” that Taubes mentions.

I know that’s going to be tough: Do what I say, or do what the government and the AHA tell you to do. Right?  But, if you are getting ready to jump into the fray and you need to gird your loins, read The Nutrition Debate #1 through #5 for added support. You can also find an index of all the columns I have written in the upper right-hand corner of the blog.

The Nutrition Debate #106: Dinner is Now Supper for Us

Cultural change is big. That’s partly because cultures are big. It’s also because it involves “change,” and we generally try to avoid that. Change involves risk…and adjustment. Of course, change can be good. So “upside” risk needs to be assessed and measured against “downside” risk. And then there’s the “deciding,” and then there’s “acting on that decision.” It’s big.

Big change is about big things like moving, changing jobs, marrying…and eating. As kids we all seemed to be “programmed” (seriously, I mean genetically programmed) to avoid change and risk in eating by refusing foods with which we were unfamiliar, particularly bitter foods. We tended to like the sweet. Is it because they were “safer” and less likely to poison us in our ancestral, primordial existence? There’s science to support that view, but that’s OT (off-topic), so back to the present.

I’m not a cultural anthropologist or sociologist, so I can only comment on what I’ve read and heard about cultural change. I can, however, compare my culture’s eating habits and cultural traditions to my own experience. Like most Americans, I grew up eating three meals a day: breakfast, lunch and dinner. We sat down for breakfast at home, took a lunch box to school, had a snack at home after school, and sat down with the family for dinner, which was generally the big meal of the day. On Sunday morning we sometimes had a special breakfast. Sunday dinner for my family was generally at the end of the day, but it was earlier if other family members came over on special occasions. Many American families had the big meal of the day on Sundays after everyone came home from church. This is the way it used to be here, just as a reference point.

I was a bachelor for many years, from age 25 (after an early divorce) to 50, during which time I didn’t cook much for myself. I was very engaged in my work, often working 10 to 12 hours a day. And over those years, I perfected some bad habits. I generally skipped both breakfast and lunch and went out to dinner at the end of an extended work day. I ate a big dinner, with lots of carbs and often with wine; then I went home and fell asleep. Is it any wonder, that over the years I gained a lot of weight, rising from 225 to peak at 375 pounds, and developed type 2 diabetes?

After remarrying, I returned to more regular eating: I ate 3 meals a day, but still ate a big dinner at the end of the day. Not much better. More calories and carbs, and on a “balanced” diet, no break for my pancreas.  No periods of fasting to let my body use its own fat for fuel. I didn’t lose weight, and my type 2 diabetes worsened. Does this sound familiar? Are you pre-diabetic? Or are you a diagnosed type 2, taking oral anti-diabetes medications, and still eating a “balanced” diet with lots of “heart healthy, whole grains and vegetables,” and avoiding all those animal-based saturated fats and cholesterol? And are you getting “sick,” i.e., are you overweight with high blood pressure and “high cholesterol” on this “healthy” diet?

Well, in 2002 everything changed for me. At the suggestion of my doctor, I started on a very-low carb diet (Atkins Induction). I later changed to Dr. Bernstein’s diet designed specifically for diabetics. But the big change was that I took control of my own health. I took responsibility for what I ate. My doctor just watched in amazement as my diabetes improved dramatically. So did my blood pressure, dropping from 130/90 to 110/70 as I lost weight. And so did my HDL cholesterol (doubling from about 40 to 83 average) and my triglycerides (dropping by two-thirds from about 150 to about 50 average. How did I do it? I changed what I ate of course, but I also changed the way I thought about eating and meals.

I ate breakfast every day, from a street vendor or a “greasy spoon” restaurant near my office. But it was just eggs and bacon along with coffee with artificial sweetener and half and half. No potatoes or bread or jam or juice, EVER. About 5 carbs. In the beginning I skipped lunch because I was NOT HUNGRY, and I was, as ever, very, very engaged at work. I began eating a can of sardines for lunch when I started on Bernstein after I retired. I love sardines. I know they’re “not for everybody” (LOL), but I could (and do), mostly eat them every day, usually 5 to 6 hours after breakfast. The reason is to keep my muscles from breaking down for energy. I want my body fat to break down, not my muscles. My lunch has zero carbs, so I can stay in the ketoadapted state that began some 4 or 5 hours after the previous night’s meal and continues.

In retirement my wife and I eat breakfast together, but not lunch. She doesn’t like sardines (to put it mildly); besides, she likes to joke, “I married you for better or worse, but not for lunch!” It’s an “oldie” but “goodie.” Then comes dinner. I think my wife feels that dinner is when she needs to nourish me, as she did with her children. She’s my caregiver. She needs to nourish me. Now we’re talking not just cultural tradition. Caregiver and nurturer are hard wired into her genes. My challenge was to convince her that the best way to do that, i.e. nurture me, was to think of “dinner” as “supper,” a small meal at the end of the day. I made this transition first, as I came to understand the way I thought my metabolism needed to work to best advantage for me. But my wife is a good student, and now she has come to think about the meal that way too.

So, we just eat a small supper every day. We shared a “petite” filet last night that she buys at Sam’s Club. It was almost too much for both of us. The side dish was a cup of boiled broccoli finished in sautéed garlic and butter. That’s all. The meal is still about 400 calories, which is larger than either breakfast or lunch, but smaller than dinner used to be. And we save a lot of money. It’s like eating “2 for 1,” or going out for dinner and taking half home in a box. We do that a lot now too.

The Nutrition Debate #105: My Low-Carb Eating – Then and Now

A couple of people who read my column before it is published (my wife and then my editor), have told me recently that the Very Low Carb diet that I now espouse is either “too hard” or “unpalatable” or otherwise not likely to be tried, especially by “newbies” or other people who are interested in and otherwise convinced that low carb is the way to go as a Lifestyle or Way of Eating (WOE). So, my wife tells me, I need to address that.

Many people are now open to the prospect that good outcomes are at least possible through reducing the carb content of the diet:  losing weight, feeling great, and other good health markers like blood glucose, blood lipids and blood pressure. This applies to people who, through diet alone, or with minimum medications, wish to delay the onset or treat conditions like Type 2 diabetics, pre-diabetics, Metabolic Syndrome, and to avert heart disease, stroke, many cancers, and even cognitive impairment (Alzheimer’s, etc.). Such outcomes are seen by many people who try this Lifestyle.

Improvements in the way you feel will manifest quickly when you switch from being a sugar burner to a fat burner. You will see it in the loss of hunger, in feeling full of energy instead of sleepy, in your elevated mood, and in the lab report numbers your doc will see. Your doctor should also be aware that reductions in all-cause mortality and the co-morbidities of all these diseases of (Western) civilization are now also widely reported in the scientific literature.  All you have to do, in addition to limiting carbs in general, is eschew our Neolithic ways, including eating grains (especially in processed foods), excessive fructose (in sugar mostly) and excessive use and reuse of (damaged) vegetable oils.

You must also avoid telling your doctor how you managed to achieve all these good things. Unless he or she is very enlightened, they won’t believe you anyway; but they will be very happy with your “outcomes,” which covers their backside. And, if they’re like mine, who does know (in fact, he suggested I try Atkins Induction, to lose weight), they will be very happy for you. Besides, they won’t have to cajole or hector you to change your ways. They’ll just look at the results and smile. Then, they will say to you, “Just keep on doing what you are doing.” Either they are in denial that what you are doing should work, or they don’t want to admit that their “prescription” for healthy eating is wrong, or they don’t want to take the time to find out. They just want to make a few notes on your chart and move on.

That’s okay. You’ve taken over. You’re in charge. You decide what you eat and what you don’t eat. And how much. You eat when you’re hungry, and you eat mostly to satisfy your hunger. You listen to your body. It will tell you if it is “happy” (or “unhappy”). Actually, if you listen to your body, you will learn that “you,” in the conscious sense, are actually not in charge. It is. Your body (a much more powerful force than your willpower) maintains you in the harmonic state called homeostasis. It tells you when to eat and how much. And if you stick to a low carb eating program, it will also not tell you that it is “hungry” very often. Your metabolism will work the way it is supposed to. Eat and digest (the ‘fed’ state), and don’t eat (the ‘fasting’ state). No grazing. A good way to lose weight is to not eat for at least 14 to 16 hours every day, and don’t snack between meals. Just eat three small meals, of mostly protein and fat, spaced 4 to 5 hours apart.

Anyway, this is all preface to “then and now.” What my “constructive critics” meant was that I was being too zealous. My wife said, “Not everyone is like you.” And my editor gagged at the idea of eating a can of sardines with a tablespoon of coconut oil on top. Okay, I get it. But I didn’t start off like that. I recall that when I first started eating low carb more than 10 years ago, I ate on average maybe 50 grams of carbohydrate a day some weeks, and maybe 1,800 or even 2,200 calories a day, and I occasionally binged. But I weighed 375 pounds, and I was transitioning from a lifestyle of indulgence to a much more disciplined Way of Eating. But I still lost weight – about 2 pounds a week, altogether 170 pounds.

The amazing thing is that within a day or two of starting on strict Atkins Induction I was getting “hypos” every day, and I just had to eat a candy bar (LOL). I called the doctor, and he first told me to drop one med altogether.  Then, a day or two later, when the hypos continued, he ordered me to cut the other two medications in half and then soon thereafter to cut them in half again. Eventually, when I started Bernstein, I was able to drop one of those (the sulfonylurea) altogether. From the beginning (on Atkins Induction) my blood sugars came into control (which they were not even on all three meds), and my A1c dropped into the “non-diabetic’ range, where it has stayed now for more than 10 years.

So, the message is: You don’t have to be a fanatic to make this Way of Eating work for you. It is a hard transition from a high-carb lifestyle to one of good health and feeling good, both physically and about yourself. But it is gradual. Start out wherever you can – say at 20g of carbohydrate a meal, or maybe even 100 grams a day. Remember, the Recommended Daily Allowance (RDA) on the Nutrition Facts panel on processed (boxed and bagged) foods is 300 grams of carbohydrate a day. That’s 60% of your daily food intake on a 2,000 calorie a day diet. Reducing that by two-thirds (to 100g/day) is a big step in itself. Then, after your body (and your conscious you) has acclimated, if you still haven’t met your BG targets, cut it again to say 20g/meal. Eventually, you may get to where I and my body am/are happily now: under 15g of carbs a day.

The Nutrition Debate #104: It’s Not Feckless to Be Fickle

I have mused a few times about how most doctors and dietitians are in a bind, especially the middle aged and older ones. The younger ones can still have an epiphany without ruining their practices. It must be a rude awakening when they do, but they can do it with integrity if they are truth seekers. The older ones, as I see it, have three problems:

1) The mantra when they were schooled in medicine (doctors) and nutrition (dietitians) – never to be cross-fertilized – was the coda of the day: the diet-heart hypothesis (the saturated fat/cholesterol/heart disease hypothesis) from the now widely discredited work of Ancel Keyes. When he joined the Board of the American Heart Association, and made the cover of Time Magazine in 1961, the “die was cast” from that day forward. Everybody read Time in those days. (Now, it’s just a pamphlet!) But the message spread, and the media and the health establishment to this day trumpet it.

2) The specialties in medicine are governed by medical associations that set “Standards of Practice” that are in turn adopted by Medicare and private medical and liability insurance companies that stipulate “accepted practice.” In some ways it makes medical care simpler, quicker and less risky. The older clinitian gives you the standard reimbursable tests, for which he gets paid using the standard medical codes, and the standard exam and the standard treatment: a script for pill(s) and advice to lose weight (eat a balanced diet) and exercise. Then you’re outta there. Next patient.

3) The problem is, how can a doctor deviate from this? Will he get paid for that non-standard test? How can a doctor change when he has an open mind and sees something that works after so many years of the exact opposite? That what he has been prescribing for many years, doesn’t work? Admit that what he has been telling you all these years is wrong? That it is exactly backwards? That the diet-heart hypothesis was just a bad “take,” not good science? Many doctors and scientists have said so, but what will the patient think if his doctor, his trusted personal health advisor, does a complete about face, a 180 degree turnaround? Is he a quack? Is this patent medicine? Has it all been a big fat lie? ;)

Many doctors and scientists are saying that now, but not to the same patients they have been treating for years with the bad medicine. And if they are, they are certainly not trumpeting it. Although to be fair, my doctor, who was a board certified internist and cardiologist, suggested that I try Atkins Induction. He had just read Gary Taubes’s New York Times Sunday Magazine cover story on July 6, 2002, “What If It’s All Been a Big Fat Lie.” He tried it himself, lost 17 pounds in a little over a month (with no ill effects), and suggested I try it. Ever cautious, he did monitor me monthly for a year, to be sure.

Anyway, most doctors would have a hard time doing what my doctor did, even if they believed in it. But you are not in the bind they are in. You can be “fickle without being feckless.” You’ve got nothing but your improved health at stake (LOL). Not that that’s inconsequential. Most everyone would say that is the most important thing of all in this life: good health. But you do not have your professional reputation at stake, your practice, the respect of your colleagues, your reimbursement percentages, and your liability insurance premiums, not to mention sanctions from professional organizations that license and certify you in your specialization. You, the patient, can be fickle. You can change.

Now, all you have to do is figure out: change in which way? Well, if the way you are eating is starting to make you “sick,” if you are overweight, hypertensive, prediabetic, have “high” cholesterol, you might consider eating in a different way. If low fat (which means very high carb and moderate protein), is making you sick or diabetes runs in your family, then one alternative is very low carb, moderate protein and very high fat.

Okay, you don’t have to do the full Monty to start with, or ever, for that matter, if you are not already too “sick” to eat a more moderate diet. You could start with just a low carb, moderate protein and high fat diet. That’s still a very big improvement over the way you are probably eating now. The Recommended Daily Allowance (RDA) of the Standard American Diet (SAD), the one on the Nutrition Fact Panel on packaged (boxed and bagged) foods is 60% carbohydrate, 10% protein and 30% fat. You could do 40% carb, 30% fat and 30% protein. That would be a reduction from 300 grams of carbs to 200. Better yet, work your way down to 20% carbs (100 grams/day on a 2,000kcal/day diet).

Then, after you adjust (and lose weight and lower your triglycerides and raise your HDL), you could try 20 grams per meal, with no snacks (you won’t have any cravings – in fact, you won’t be hungry). Or, you could do Bernstein (6-12-12 = 30/day), or Atkins Induction (20g/day), or me. I do 12-15g/day. I now eat 2-3 grams of carbs at breakfast, zero at lunch, and 10-12 at supper, unless I have a glass or two of wine, which I might do a couple of times a week, if I feel like it.

The point is: You are not constrained by your profession. You will not be feckless if you change the way you eat. You can be fickle. You can try eating lower carb, or low carb, or very low carb the way I do. It’s okay to be fickle. It’s okay to do what works for you. It’s your health. It’s your life. And now, it’s your time to decide.