Saturday, August 31, 2013

The Nutrition Debate #139: Nuts – the Very Good, the Also Good, and the Bad

I love nuts. I mean real nuts – not peanuts (although I love them too – I just don’t eat them anymore). Peanuts are legumes and toxic to my health, but nuts – true TREE nuts – are different. They’re all good tasting, and all high fat, of course, but some are much healthier than others, some are more of a toss-up, and some should be avoided. The basis for determining that is largely the type of fats they contain, and the rule here is the same as it is for all high-fat foods: saturated fat is good; monounsaturated fat is also good, and polyunsaturated fat is good or bad depending on their Omega 3 and Omega 6 fatty acids.  Unfortunately, many nuts contain too many Omega 6s and should just be shunned.

But before I categorize nuts according to fat type, and particularly their polyunsaturated n6s and n3s, we need to talk about context. If you eat three (or even two) small healthy meals a day, you will not be hungry. So, when would you eat nuts? 1) As a regular between-meal snack? 2) If you should “feel” hungry on occasion? 3) At a social gathering where nuts are one of the few offerings that are an “allowed” food? Or 4) perhaps as a salad ingredient at a sit-down dinner?

For me, the answers are 1) Never as a between meal snack. They are simply not needed; 2) I think you should listen to your body, but not to your “head.” Your head can send false signals. The brain is very adept at this. If I “feel” hungry (before or after dinner, the only times for me), I “deny” the feeling. I distrust my “feeling.” I either tough it out, and/or drink something non-caloric; 3) at a social gathering: I haven’t mastered this one yet. I will usually succumb and eat the nuts. I will regret it later, but I am weak when I SEE – that is, when I am VISUALLY seduced (conditioned?); 4) as an ingredient of a dish, say a salad: I like this option, especially when the main dish is low fat, like a non-fatty fish entrée.

Another issue is raw or roasted, unsalted or salted, and/or otherwise coated. The answer, again for me, is roasted, unsalted or salted, but otherwise not coated (as in “honey roasted”!). Some people like raw, organic nuts and others like to roast their own so they can control the heat and mediate the oxidation. Some people prefer the taste or “health benefits” of unsalted. For me, I don’t obsess about this. I like both unsalted and salted nuts and if I’m only going to add a few unsalted nuts to a salad, it’s really not going to make much difference. To summarize: for me, nuts then are only a “party option” (mea culpa) or a supplementary ingredient in a salad. Snacking and emotional eating are verboten!

Remember, the issue with nuts is which ones contain the fewest polyunsaturated Omega 6 fatty acids. Here is my list:

·         Low Omega-6 nuts: macadamia nuts and coconut (the fruit)

·         Moderate Omega-6 nuts: hazelnuts (filberts) and avocado (the fruit), and almonds

·         High Omega-6 nuts: walnuts, pine nuts, butternuts, Brazil nuts, pecans, pumpkin seeds, sunflower seeds.

Note that cashews and pistachios are not included on this list because, while moderate in Omega 6s, they are too high in carbohydrates. Other dietary choices which offer good, moderate and bad Omega-6 options as food choices are:

·         Low Omega-6 nut (and fruit) oils: coconut oil, macadamia nut oil, and palm oil

·         Moderate Omega-6 oils: olive oil

·         High Omega-6 nut oil: walnut oil

Nut oils, however, come with certain risks to health: the higher the Omega-6 content, the greater the danger of damage from high heat and chemicals in processing and manufacturing and the more likely they are to become rancid on the shelf. After opening, high Omega-6 nut oils should be refrigerated; they are fragile. And they should not be used in high heat food preparations. The same principles apply to nut butters.
If you’re influenced by the Paleo ideology, as I am, you might find it appealing to think of tree nuts in the same way we should think of fruit: as a local, seasonal treat. In today’s world, of course, that is no longer the case. Fruits, hybridized to make them larger and sweeter, are often produced half-a-world away are available year-round at the corner market, like fresh flowers from Amsterdam or Columbia. Nuts are too, but in our culture they tend to be consumed mostly during the holiday season from Thanksgiving to Christmas when they are displayed at the front of the supermarket in large boxes and barrels. These displays suggest to me the way we should think of both nuts and fruit: as something special to be consumed as a treat, not as a staple, and then only “in season.” I don’t mean to imply this in the literal sense. That would be orthorexic, and far be it for me to think that way (LOL). I mean it in a way that allows us to enjoy something special on special occasions: something to look forward to, like the first asparagus of spring or apples in October; or, on my WOE, a warm main-course dinner salad of frisée, lardons, and sautéed Baby Bella or Crimini mushrooms, all tossed in a homemade vinaigrette dressing and topped with chopped hazelnuts and shaved Pecorino Romano (or a poached egg). Bon appétit!

Wednesday, August 28, 2013

The Nutrition Debate #138: Fruit, the 3rd Rail for Prospective Low Carb Dieters

Whenever I am asked about what foods one “cannot” eat on a Low Carb Diet, the prohibition on eating fruit is always the “3rd rail.” If you’re not familiar with this term, on electrically operated trains, there are two types of power: overhead systems and 3rd rails. Third rails run along the ground between tracks on a 2-way system. They are very high voltage and very dangerous. To touch them is to die. Like 3rd rails, life without fruit to a prospective Low Carb Dieter is similarly “fatal.”

So, some bloggers I otherwise admire and respect make an exception for fruit. They have concluded to do otherwise would be to lose the battle advocating low-carb eating before you are engaged. That’s cowardly. From my point of view, integrity demands that I speak the truth to you. I love fruit too, just as I love pasta, and rice and potatoes and bread, but I have learned that my body no longer tolerates “sugar,” especially simple sugars (mono and disaccharides). I also can’t eat any processed carbohydrates, as in virtually all packaged foods, and I can’t eat all of the starchier and sugary vegetables.

Fruit is mostly sugar. Well, it’s mostly water, but all of the macronutrient nutrition is sugar. An apple is 86% water, 3% fiber, and 11% simple sugars (0% protein and 0% fat). The sugars are 20% sucrose, 57% fructose and 23% glucose. When the sucrose breaks down to free fructose and free glucose, an apple is then 67% fructose and 33% glucose. That’s all “simple sugar”!

It’s true, an apple has some micronutrients (vitamins and minerals in the skin), and the pulp has pectin, but there are other sources for these important components in a basic “real food” diet that “cost” fewer otherwise “empty” calories. Do not use these “good” components as an excuse to eat fruit. Rationalization is just self-deception. Own up to it, my friend.

So, what do you tell someone who wants to reduce their carbohydrate intake and who loves fruit? Three common approaches are 1) don’t snack on fruit. In fact, don’t snack at all, but if you must snack, snack on fat (like a portion-controlled serving of nuts), and 2) if you must eat dessert, eat fruit for dessert instead of ice cream or pie, and 3) eat mostly berries (strawberries, raspberries, black berries and blueberries), with some fat like cream (but no added sugar!). Berries also have phytochemicals, fiber, and minerals and vitamins too. But do not ever eat grapes, or cherries, or dried fruit!

Is it possible to take a more moderate stance on the issue of fruit? Sure. As far as your blood is concerned, all carbs are equal. They will all break down to simple “sugars,” mostly glucose, some slower and some faster. If you are only mildly carbohydrate intolerant, that is, if you have been told you are “pre-diabetic,” you may be able to tolerate more “sugar” (glucose) in your diet. But be careful. This is a very slippery and treacherous slope. You could, for example, lower your carbs by a third or even two-thirds, and eat low carb, but not very low carb. Your meter will tell you what you need to know.

But this is a no-man’s land for both the patient and the clinician. Your doctor most likely adheres to the practices and “Standards of Medical Care in Diabetes,” issued by the American Diabetes Association. If you are overweight, and your A1c test, which measures the glucose on the surface of your red blood cells, is elevated, your physician will advise you that you are “at risk of diabetes.” Your doctor will then probably tell you to lose weight by eating less (on a “balanced diet”) and exercising more, but they won’t tell you to eat fewer carbohydrates, and they won’t tell you to eat less fruit. And they will definitely not tell you that if you do not change the foods you eat, that your condition is progressive and that you will inexorably become a full-blown type 2 diabetic. And that, my friend, is an irreversible diagnosis. Repeat: Irreversible.

For some reason, doctors just don’t get it, yet. The glucose in your food causes your blood sugar to rise, and if you are insulin resistant, it (the glucose) will remain circulating in your blood. The only way to lower your blood sugar, and your circulating (serum) insulin that transports the glucose, is to eat fewer carbohydrates, including but not limited to fruit. It’s that simple!

Today’s fruit is different from the fruit of yesterday in two major respects: 1) it has been hybridized to be sweeter and larger than it ever was in nature, and 2) it is no longer a seasonal treat. Due to refrigeration and world-wide air transportation, fruit is available everywhere year round. In cities today, it is available in every street corner grocery store even in the middle of winter. It is up to you to treat fruit as a treat: to eat it only occasionally, on very special occasions.
I was inspired to write this column by two recent incidents. First, I read a Q & A in “Diabetes Today” in which Dr. Richard K. Bernstein referred to “sweet fruit” as something to be eaten sparingly. He has been a type 1 for 69 years and has A1c in the 4s. He regards a 5.8 as a full-blown type 2 diabetic. You don’t usually hear the phrase “sweet fruit,” so it stuck in my mind. The other was an article, “Fruit Restriction for Type 2’s: Good or Not?” in Diabetes in Control, a digest for physicians. It compared two groups of newly diagnosed type 2s: one was told to eat fruit only two times a week and the other “given the more common conventional medicine advice to eat no more than 2 fruits a day.” After 3 months they measured A1cs, weight loss and waist size and found little difference. They concluded, “We recommended that the intake of fruit should not be restricted in patients with type 2 diabetes.” What idiots! What bleeping idiots! This is “one size fits all” advice (writ large!)  If you want to live (a long and healthy life) with diabetes, eat to your meter! And eat fruit very, very infrequently!

Saturday, August 24, 2013

The Nutrition Debate #137: “How Ketogenic (Low Carb – High Fat) Diets Work”

Once again, the Low Carb Diet News site keyed me in to another blogger who was new to me and who thinks along the same lines as I do. He is a New Zealander named Professor Grant Schofield, and he blogs on “The Science of Human Potential” here. He is also an academic (Psychology) at the Auckland University of Technology, NZ, which leads to an interesting digression in his post that I liked well enough to repeat here. To quote “Professor Grant” (as he is known):

“A second excellent review article was also published in Nutrition Today by Volek (again!) and Phinney, the low carb gurus. This one is called “A New Look at Carbohydrate-Restricted Diets: Separating Fact From Fiction”. Again this is an excellent scientific review paper. What I should be doing in this blog is simply drawing your attention to this good work and you can go and check it out for yourself. Except I’m aware that unless you work at a university, that’s easier said than done. You’d have to buy the papers, which means that most of the people who stand to benefit from the knowledge won’t.”

How true. The new Volek and Phinney paper that the good professor was referring to is published in “Nutrition Today,” for the journal’s pecuniary benefit alone, and is available for $48 plus tax for this one article or $99 for an annual subscription. I passed on this offer, and am grateful that the professor reviewed the piece for me (us). But just think of all the practitioners out there, the very clinicians who would benefit from this the most, who will never see it for lack of an academic appointment, and the time to read it. What impediments we make to the advancement of learning!

Anyway, Professor Grant goes on to list his takeaway of the main points of the Volek and Phinney scientific article. He does gets a bit “in the weeds” so, as J. Stanton says on his website, “CAUTION: CONTAINS SCIENCE.”  The “Professor Grant” article, including the four points below, is found here:

1.      Saturated fat levels in the blood are not associated with dietary saturated fat intake, but dietary carbohydrate intake. They show evidence from both randomized controlled trials and population data for this.

2.      They discuss in detail what the keto-adapted (fat adapted) state is; how this comes about, including increased beta oxidation of fat, decreased hyperinsulinemia, and a re-orchestration of substrate utilization in the body, including the use of ketones to fuel brain function. It is interesting that the majority of practicing dietitians, endocrinologists, cardiologists, and public health physicians have never heard of any of this.

3.      They point out what is a very important and obvious set of outcomes, which are well documented in the scientific literature; that treating a patient with insulin resistance with a low fat/high carb diet is palliative and going to make the problem worse. If you are having trouble getting glucose into your cells, then reduce the glucose load stupid!

4.      They show a nice little diagram, which I have reinterpreted and redrawn below, to show the role of dietary carbohydrate in metabolic (dys)function. To quote the authors “The major point is that SFA (saturated fatty acids), and the response to eggs, has a totally different metabolic behavior when consumed in the context of a low carbohydrate diet.”

Here’s a link to Professor Grant’s re-interpreted JPG diagram. The interesting aspect of Volek and Phinney’s thesis to me is that first sentence in bullet Number 1 above, as illustrated in Professor Grant’s diagram. Take a look, or a second look, at it. They are showing with “both randomized controlled trials and population data for this,” that “high dietary carbohydrates” (symbol: CHO) results in “SFA synthesis up” and “SFA storage up” (we make and store more body fat in the form of triglycerides). That in turn, in the “metabolic health continuum,” leads to “plasma SFA up” (high blood fat, i.e. triglycerides), “insulin resistance up,” and “dyslipidemia up.”

The other side of the diagram shows that the inverse is true with lower dietary carbohydrate intake. Okay, this is a little heavy on the science. My wife likes to simplify it all by telling our friends and acquaintances that “Eating fat doesn’t make you fat; carbohydrates make you fat.” I like that. Most people just look at her in wonderment and disbelief. Some say, politely, “I never heard that before.” I secretly wonder if they think she is crazy. She’s not a scientist or a doctor, and doesn’t even play one on TV. Where does she get these crazy ideas? Maybe she reads my blog. Maybe she doesn’t believe everything she hears on TV, or reads in the popular press. Maybe…just maybe…the word is gradually seeping out there that “the conventional wisdom,” that we have been following for the last 50 years, has been wrong. Maybe it HAS all been a big fat lie, as Gary Taubes suggested in his seminal NYT piece, which appeared on the cover of the Sunday magazine on July 7, 2002. If you’ve never read it, you can access it here.

Wednesday, August 21, 2013

The Nutrition Debate #136: “No Butter on Your Corn?!!!”

“No butter on your corn?” I didn’t really say it, but I thought it. Our dinner guest the other night said he would “pass” on butter for the ear of corn that my wife had prepared as part of our dinner. In our house we only eat corn “in season,” and that means “in season in our immediate neighborhood,” so she can be certain it was picked that day. We also had local tomatoes and a meat course of beef short ribs prepared in a special way that I love. For dessert we had local blueberries with heavy cream. For a Low Carber like me, this was a “special occasion” when rules are meant to be broken (LOL).

But “no butter” on corn is not one of those rules. Besides, without butter, how can you get all the extra salt to stick? (LOL, again). Well, it turns out our dinner guest was taking a statin for his “high cholesterol” and was under the care of a physician who advised him to eat a diet low in saturated fat. That’s a surmise on my part – the saturated fat part, not the statin part – but a pretty safe one. Most physicians, and the general public, still believe the diet/heart hypothesis that associates saturated fat and dietary cholesterol with heart disease. Regular readers here, and in a gazillion other places in the Ethernet and in the print world, know that that hypothesis has been completely disproven – that ingestion of saturated fat does not cause heart disease, and dietary cholesterol (the cholesterol you eat)  has nothing to do with serum cholesterol (the cholesterol in your bloodstream).  Here’s one site of legions for a start if you want to do your own research: Heart-surgeon-speaks-out-on-what-really-causes-heart-disease.  If you prefer a book, Dr. Malcolm Kendrick’s “The Great Cholesterol Con” is a good read. His video “Statin Nation – The Documentary” (first 13 minutes) can be seen here.

The incident did give me pause for thought, though, and my mind drifted to my column. We hadn’t seen our guest for several years and so, for conversation, I mentioned that I was writing and publishing a blog twice a week. Our guest seemed interested and asked the subject. When I said “nutrition,” his reply was, to the effect, what qualified me to write about nutrition. I found myself on the defensive, and not very well prepared. Our guest was a very successful, now retired attorney, but his training, life-long experience and instincts were still sharp. And my answer pretty lame.

Nevertheless, I told him that my course of self-study included a large library of books, articles and scientific papers I had read. He didn’t seem impressed. Afterwards my wife told me that I should have added my personal (n = 1) experience. She was right of course. I had lost 170 pounds and put my long-term type 2 diabetes in remission, which allowed me to discontinue two oral diabetes meds and reduce the third by three-quarters (to 500mg Metformin once a day). I had also vastly improved my glucose control (as evidenced by my A1c’s) and had dramatically improved my blood pressure (on the same meds). But here’s the zinger I had in my quiver and had failed to use: I was able to discontinue taking statins!


I had at one time been taking 80mg of Lipitor a day to get my LDLs down to under 70, which my doctor advised due to multiple “risk factors.” I was able to discontinue the statin because, as I changed my diet, my HDL more than doubled and my Triglycerides fell by two-thirds. As a result, although my recent Total Cholesterol was still above 200 (215), and my LDL above 130 (133), my HDL was 70 and my triglycerides 58. My new doctor, an internist and cardiologist, wrote: “your cholesterol profile currently conforms to the NCEP-3 standards.”  The reason, in part, his letter continued: “A high HDL may mitigate some of this risk. Triglycerides should be 150 or less.” These National Cholesterol Education Program guidelines are used almost universally to inform clinicians on statin use, but they’re about to change, according to this story from “Nature,” reprinted in “Scientific American.”
On my latest visit, I asked for a VAP ™ cholesterol test to get more detail. This time my Total Cholesterol was 219, my LDL 131, my HDL 75 and my triglycerides 47. The best news in the VAP test though was that my LDL size/pattern was, “Pattern A – Large Buoyant LDL.” This news didn’t seem to impress my doctor, but it made my day. The doctor’s note on my lab report: “Stable, Similar to (previous visit).” So, bingo! No statins for me. Eat the right diet, not the so-called “healthy diet” that is making so many Americans, and people worldwide who eat a Western Diet, so very sick, AND YOU TOO MAY BE ABLE TO STOP TAKING A STATIN.  That is what I should have told our dinner guest. But I was too stupid, or too surprised, or perhaps too polite to tell him. Besides, it’s so much easier to have the perfect riposte, in writing, and a day late…

Saturday, August 17, 2013

The Nutrition Debate #135: What About Physical Energy?

“What about physical energy?” That’s the header of a paragraph on the home page of a website from the UK called “The Low Carb Diabetic.” It describes how many people report they feel more energized on a low carb diet than they do on a “balanced” diet that includes lots of carbohydrates. I have reported this myself many times in “The Nutrition Debate,” and J. Stanton of reported it in a blog post some months back here. His headline was “There’s Another Level Above ‘I’m Feeling Fine.” His conclusion: “Result: I’m in the best physical and mental shape of my life. I don’t feel ‘fine’: I feel great. Some days I even feel unstoppable.” I couldn’t agree more, but it’s very subjective. How do you measure it?

Well, “The Low Carb Diabetic” gives us a way to measure it. I never studied organic chemistry, so I can’t attest to the veracity of this quantitative explanation of the increased energy from a VLC ketogenic diet, but here is his postulation:

“Strictly speaking, we burn neither glucose nor fat for physical energy. Energy within our cells actually comes from a molecule called adenosine triphosphate, or ATP. When its molecular bonds are broken, energy is released in the mitochondria, the power plants of our cells. A glucose molecule will generate 36 ATP molecules. A 6 carbon fatty acid molecule will generate 48 ATP molecules. Therefore, when insulin levels are low and the body can access fatty acids as a fuel source, physical energy levels can actually increase on a low carb diet. Anecdotally, many on low carb diets often report feeling considerably more energetic, without the peaks and troughs of energy which appear to come with a diet high in carbohydrates.”

Do the math: 48 ATP molecules from a fatty acid molecule vs. 36 ATP molecules from a glucose molecule. That’s one third more energy! Of course, I don’t know if it really works that way, but it is reaffirming for me to see a tangible and plausible explanation for my sense of an increased and stable level of energy. I like to say I feel “pumped” all the time when I am in a ketogenic state. Is it because I am using ketones for energy? Who knows, and who cares really. It is a very real feeling to me. I like never feeling tired and always full of energy and “pep.” I feel like I’m a kid again.

Whatever the explanation, barring any thyroid condition, the reality is that you can feel great on a diet that is Very Low Carb (VLC). I am defining VLC at 20 to 30 grams of carbohydrate a day (or less, even). The body has no minimum requirement for dietary carbs. It will make all the glucose it needs (for certain cells that do not have ATP “power plants”). And the brain and the heart love to use ketones for energy. There are actually several medical conditions that benefit from very restricted carb diets, including childhood epilepsy and PCOS. Certain cancers use glucose for fuel, and several scientific papers have shown a ketogenic diet as therapeutic for treating those cancers.

Besides the increased physical energy benefit from eating VLC, there is the element of mood elevation. Again, this is anecdotal, but I am almost “hyper” when I am in a ketogenic state. I’m not talking about “ups” and “downs” though, as if I were taking “speed,” which is slang for amphetamines. I am talking about a stable and elevated mood level.

Amphetamines, as an aside, were once prescribed as “diet pills.” Dexamyl and Dexedrine were routinely administered to help people lose weight, or elevate mood (as anti-depressants) or stay up all night to prepare for an exam. In my youth I foolishly “did” them. Then, in the late 60’s, a Dr. Stillman came out with a “high protein/low fat” diet. I did that diet with amphetamines in the morning and barbiturates at night to regulate my body’s energy level. As I recollect, the Stillman Diet was the first “diet” I ever tried. I lost 65 pounds, but soon thereafter regained it all.

Anyway, all that was foolishness. I am an older and much wiser man now. I have come to accept that 1) I have a broken metabolism with the result that I am insulin resistant and as a consequence cannot tolerate carbohydrates in my diet; 2) that the best way to “correct” my hyperglycemia, hypertension and hyperlipidemia, as well as lose weight permanently and regulate and stabilize my energy levels, is to eat a Very Low Carb ketogenic diet every day for the rest of my life. It is a lifestyle change. It is a Way of Eating (WOE) that I find delicious and very satisfying – both in the sense of pleasurable as well as satiating. I feel “full” on very little food. I don’t feel hungry. I never snack and often “forget” to eat lunch.

Feeling full on a really small meal is a new paradigm, and it takes a little getting used to. When I told my egg vendor at the farmer’s market recently that I had decided to increase my daily serving of eggs at breakfast from 2 to 3, and reduce the bacon from 2 strips to 1, she asked me, “Is that all you have?” She was genuinely surprised. No juice. No bread. No jam or jelly. Just protein and fat. I told her “yes,” except for a heaping teaspoon of ghee in my coffee.

When I recently told the nanny of my step daughter’s children that I just eat a can of sardines packed in olive oil for lunch, she said, “Is that all you eat?” Again, I said “yes,” and I eat it even though I am not hungry at lunch time. Maybe I need to rethink that lunch. Why am I eating lunch if I am not hungry? Why indeed! I am running on my fat reserves, my body loves its ketones, and I am full of energy.  Maybe even one-third more physical energy than on glucose!

Wednesday, August 14, 2013

The Nutrition Debate #134: “You Really Don’t Need to Test”

“You really don’t need to test,” my new doctor, an internist and cardiologist (and PHD!), told me recently as I was leaving his office. It was only my second visit, and it was at my suggestion that I will see him 3 times a year instead of once, so I think it was a nice gesture on his part to give me assurances and comfort that my health in general, and in particular my type 2 diabetes and hypertension, were “under control.”

He was also telling me that my other labs, specifically my A1c, blood pressure, and Lipid Panel, all suggested – to him – that the therapeutic regimens that his predecessor had ordered and he was continuing, had me in good shape. I got the impression that seeing me, for him, was a bit of a relief – that most of the patients he saw on a daily basis were truly sick people. I was “healthy,” by comparison, and that made his time with me easier for him. He almost seemed, to me, to be having fun! I liked that. It made me feel good too.

But here’s the rub. He was telling me that my condition didn’t warrant the level of blood glucose testing that I had requested he prescribe for me: two times a day. His rationale was that my A1c, at 5.6% at the time, as it was less than 5.7%, was regarded as a value consistent with an “Decreased Risk of Diabetes.” This “Reference Range,” the Quest Diagnostics lab report said, was “supported by the current ‘Standards of Medical Care in Diabetes’ published in January of the current year in Diabetes Care, the Journal of the American Diabetes Association.” So, that’s that. He was ‘covered’ because the ADA says that I am at decreased risk of diabetes, so ipso facto daily testing was not warranted. For the new reader, and to remind regulars (and my doctor), I have been a full-blown, diagnosed type 2 diabetic for 27 years.

Never mind that the report generated by the blood drawn at that consult showed an increase in my A1c to 5.8%, which is considered consistent with an “Increased Risk of Diabetes.” But elsewhere in this same report, based on the results of a VAP (TM) Cholesterol Test that I requested, Quest advised, in response to the question, should the physician “CONSIDER INSULIN RESIST/METABOLIC SYNDROME,” the response was a flat “NO.” Never mind that I AM today insulin resistant and, before I changed my diet, had ALL of the indications of Metabolic Syndrome. See “The Nutrition Debate #9for a complete list of the indications and ranges if you would like to see if YOU have an undiagnosed case of Metabolic Syndrome.

So, how can all of these seeming paradoxes coexist? Why is it that my diabetes is no longer discoverable by a lab test or a clinician’s interpretation? They would be, of course, with a full medical history, but my new doctor is only acquiring that as he gets to know me. A good sign: he offered to be added to the email distribution of my twice-weekly diabetes blog. How cool is that! My previous (now deceased) doctor also was on the list and occasionally emailed me with comments.

 Anyway, I digress. My reason for writing this post is to make the point that the patient who has taken control of his diabetes health care, and treats it almost entirely with diet alone, can achieve these results EVEN IF HE OR SHE IS INSULIN RESISTANT. When you eat very few carbohydrates, your blood insulin level goes down, and your insulin sensitivity goes up. Insulin sensitivity is the inverse of insulin resistance. And importantly, your blood glucose stabilizes.

A few months ago I asked an endo in Florida to do a HOMA Assessment to determine my beta cell function and insulin sensitivity. The results surprised me, since I had been maxed out on a sulfonylurea for the better part of 20 years. Beta Cell Function: 68.2%. Sensitivity: 94.6% and IR 1.1 (1.057). I attribute these “good” results to my Very Low Carb diet.

And when you achieve these results through strictly eating Very Low Carb, YOUR TYPE 2 DIABETES WILL BE IN REMISSION. The lab can’t tell that you’re a full-blown type 2 diabetic. Neither can your doctor, if he doesn’t know your history. But that doesn’t mean you can rely on the assurances that you’re in “good control” just because you are well below the thresholds of the American Diabetes Association for being “Consistent with Diabetes (> or = 6.5). You don’t want to be there. You don’t want your type 2 diabetes to be a PROGRESSIVE DISEASE, as the ADA defines it. And by extension your physician will too, if he/she follows the “Standards of Medical Care in Diabetes, as most will likely do.

YOU can treat yourself through diet, and the best way to do that is to learn about the carb content of the foods you eat and how your metabolism handles them. And the only way to do that is to test.  Test before and 1-hour after a suspect meal. Adjust the menu to meet your goals. Test in the morning before eating (fasting blood glucose). Test to keep yourself honest - to remind yourself that you are diabetic and will always be carbohydrate intolerant. You cannot cure this disease. You can only treat it. And the absolute best way to treat it is with diet. Vigilance is required. And some discipline. But the food choices are endless, and very good. As your body adapts to using ketones, you will have increased physical energy. (See the next column.) You will feel better. And if you need to lose weight, you can do so easily (with calorie restriction) and without hunger. What more can you ask? 
What did your meter tell you today?

Saturday, August 10, 2013

The Nutrition Debate #133: The Edible Schoolyard (ESY)

“…and the abandoned school cafeteria became the kitchen classroom.” Wow! That’s transformative. I read this in a history of the Edible Schoolyard Project at the Martin Luther King, Jr. Middle School in Berkeley, California. Alice Waters, the legendary doyenne of California Cuisine, was the impetus behind ESY in 1995 and now supports it through her Chez Panisse Foundation. “California Cuisine is a style of cuisine marked by an interest in fusion cuisine (integrating disparate cooking styles and ingredients) and in the use of freshly prepared local ingredients,” according to Wikipedia. New American Cuisine derives from California Cuisine. Alice Waters’ influence the world over on cooking with fresh, local ingredients is undeniable. Would that how we teach our children about food everywhere were equally transformative.

I was directed to this site, and another, Edible Schoolyard New Orleans (ESYNOLA), by Randy Fertel, a neighbor. As co-chair of the ESYNOLA Task Force, Randy told me, with justifiable pride, that in just the last 7 years New Orleans has established an offshoot of ESY in 5 FirstLine public open-enrollment charter schools. In his words, paraphrasing, “…when children are engaged in the growing, harvesting, and preparing of food, they are far more likely to eat it.” According to their website,Edible Schoolyard New Orleans changes the way children eat, learn, and live...” “Our mission is to improve the long-term well being of our students, families, and school community by integrating hands-on organic gardening and seasonal cooking into the school curriculum, culture, and cafeteria programs.” What a great idea!

It’s hard for me to imagine an “abandoned school cafeteria” in a fully functioning Middle School (grades 7, 8 and 9), especially in an economically disadvantaged neighborhood. I have never been a parent, so my exposure to the policies and politics of school lunch programs is nil, but I do read the paper and listen to and watch the news. On the local level, the issues revolve around whether flavored milk should be banned from the cafeteria. Eight ounces of white milk contains 14 grams of natural sugar or lactose; fat-free chocolate milk has six grams of added sugar for a total of 20 grams, while fat-free strawberry milk has a total of 27 grams — the same as eight ounces of Coca-Cola. Flavored milk is like candy. Others argue that vending machines should be banned altogether, or just allowed if they are limited to “healthy” snack foods, defined as low in saturated (solid) fats like butter and made with just enough partially hydrogenated polyunsaturated vegetable oils to escape having to be labeled as containing dangerous trans fats.

At the Federal level, the U.S. Government has recently reentered the fray with the latest version of the USDA’s 167 page National School Lunch and School Breakfast Program. Even our First Lady, Michelle Obama, is out “on the stump” in support of the Healthy Hunger-Free Kids Act. Here’s an easier to read overview of school lunch and breakfast programs.

More fresh fruits and vegetables and less added sugar are great goals. The most worrisome part of the new school lunch guidelines is the emphasis on reduced saturated fat. Regardless of what you think about saturated fat in the adult diet, children are rapidly growing and developing brain tissue. The other functions of saturated fat (from The Skinny of Fats):

·         Cell Membrane Function – 50 percent of the fats in cell membranes must be saturated for the cells to function properly.

·         Lung Function – The lungs cannot function without saturated fats, which explains why children fed butter and whole milk have much less asthma than children fed margarine and low-fat milk.

·         Kidney Function – The kidneys operate through a process that requires saturated fat.

·         Brain and Nervous System – The normal brain is especially rich in saturated fat (and also cholesterol).

·         Immune System – Saturated fats are needed for healthy immune function.

·         Protection against Infection – Some kinds of saturated fats (found in coconut oil and butter) help fight pathogenic bacteria, viruses and parasites. Children fed skim milk suffer from infection five times more frequently than children fed whole milk.

·         Heart Function – Saturated fats are the preferred food for the heart. Children on low-fat diets actually develop blood markers indicating proneness to heart disease.

·         Vitamin Carriers – Saturated animal fats serve as unique sources of important nutrients such as vitamins A and D, and CLA.

So, the Edible Schoolyard is a breath of fresh air. I don’t care that there is no mention of animal products in any of the website offerings, except for eggs in the ESY Berkeley program. There are, after all, limitations to what you can do on a one acre plot of ground adjacent to a classroom building. And besides, if the Ruth’s Chris Steak House guy (Fertel) can get behind a program like this, he must have made a similar assessment about the program: “The mission of the Edible Schoolyard Berkeley is to teach essential life skills and support academic learning through hands-on classes in a one-acre organic garden and kitchen classroom. The Edible Schoolyard curriculum is fully integrated into the school day and teaches students how their choices about food affect their health, the environment, and their communities.” I like it.
What are you doing about nutrition in your school’s lunch program? Or what would you do if the government stayed out of what foods you could serve/not serve in your school instead of pimping for the agribusiness lobby in Washington DC?

Wednesday, August 7, 2013

The Nutrition Debate #132: Why I Despair for the Type 2 Diabetic Patient

Chatting with an MD Internist friend of mine, my hopes for the future of the medical care of his diabetic patients sunk to an abysmal low. Admittedly it was a social situation, and in fairness my friend did not express much interest as I proselytized about my self-treatment (VLC dietary) regimen for my own type 2 diabetes. However, the pain and despair I felt for his patients, when referring to how he treated them, was in his use of the terms “good diet” and, referring to blood sugar, “under control.” I rudely interrupted him on both phrases since I was sure he and I had a totally different concept of the meaning of these terms. I must have seemed insufferable to him.

This is a problem of immense dimension and import. Until the entire public health and medical establishment comes to see these two terms in a different context, I fear that the world-wide epidemic of obesity and diabetes (“diabesity”) will continue to worsen. The small town practitioners are not the root of the problem. They just follow what they have been taught and continue to learn on an on-going basis from their medical societies. And the patient accepts the scripts his or her doctor writes, as well as the assurances he or she gives the patient, because it conforms to the messaging from the corrupt Government/Big Pharma/Agribusiness/Media consortium. This is not conspiracy theory. Just follow the money.

I challenged “good diet” when my internist friend mentioned it since I was sure he meant a “balanced” low fat diet. In other words, the one-size-fits-all diet the government recommends: 60% carbohydrate, 30% fat, and 10% protein. It’s on the HHS/FDA/USDAs Nutrition Facts label. The fat category subdivides into only 10% “solid” (saturated fat) and more unsaturated fat, especially vegetable and seed oils (corn and soy bean oil, among others). These are unstable and inflammatory. See The Nutrition Debate #21, here. This is not a healthy diet for anyone.

“Under control” is the other phrase over which I became exercised. By this point my friend was backing away from the conversation so I didn’t get a chance to explore whether he was referring to an A1c of 7.0% (the ADA standard), or 6.5% which has for a few years now been the standard of the AACE, the endocrinologist’s society. If I had had the opportunity I would have mentioned that “good control” should be defined as an A1c <6.0%, as Dr. Ralph DeFronzo, MD, stated in his Banting Award lecture at the 2008 ADA convention in San Francisco: “Further, a more rational goal of therapy should be an A1c <6.0% …” His “Treatment Summary” in the published paper is as follows:

“Although this paradigm shift, which is based upon pathophysiology, represents a novel approach to the treatment of type 2 diabetes, it is substantiated by a vast body of basic scientific and clinical investigational studies. Because this algorithm is based upon the reversal of known pathophysiological defects, it has a high probability of achieving durable glycemic control. If the plasma glucose concentration can be maintained within the normal nondiabetic range, the microvascular complications of the disease, which are costly to treat and associated with major morbidity and mortality, can be prevented. Most importantly, this will enhance the quality of life for all diabetic patients.”

And Dr. Richard K. Bernstein, a type 1 himself, believes that diabetes patients (both type 1s and type2s) should be entitled to “normal” A1c’s, in the 4.0% to 5.0% range. Remember, heart disease risk rises steadily with an A1c above 5.5. 

“Good Control,” of course, from a doctor’s perspective, means controlled with medications, either oral or injected. And good control as defined by the associations (ADA and AACE) assures that the patient will take progressively more and more said medication as the disease “progresses.” Type 2 diabetes is defined as a “progressive disease,” due entirely to the treatment regimen that these same associations advocate. Why is that?

“That’s a very hard question to answer,” replied Dr. Jay Wortman, MD, a Canadian low-carb blogger, to Dr. Andreas Eenfeldt, MD, a Swedish doctor known as the Diet Doctor, in a recent video interview. You can watch the entire 25-minute video, but the 2 minute excerpt from 19:20 to 21:25 is particularly riveting. Here are parts of that dialogue:

(Wortman) “I think there’s a multiple answer to that question. I think there’re a lot of people in organizations and positions that are funded by the drug industry, and the drug industry doesn’t want people doing this (“a simple dietary change”). They’d get off the drug.” (Eenfeldt) “Bad for Business.” (Wortman) “Yeah. Bad for business – totally bad for business. And these big organizations (ADA, AHA, etc.) depend on drug industry funding.” (Wortman, later) “The other problem is there’s nothing to patent there. There’s nobody going to get wealthy from patenting this (simple dietary change). Our system runs on something that can be patented and marketed, and turn a profit, and that’s how the funding goes through the system in terms of both the research agenda and also how recommendations are generated, and there’s nothing to patent.”(Eenfeldt) “Right. It’s all free information, right?” (Wortman) “It’s freely available.”

What does your doctor consider “good control”? What do you aim for?

Saturday, August 3, 2013

The Nutrition Debate #131: Bernstein Goes Paleo

If you don’t know who “Bernstein” is, let me explain. Richard K. Bernstein, MD, is a type 1 diabetic who, in my opinion, single-handedly innovated and championed the wide-spread use of the personal glucose monitoring device. Forty odd years ago he was a practicing engineer, and his wife an MD, so he had access to her bulky hospital equipment that was the only way of determining blood sugar measurements “in the old days.” Bernstein had been following medical guidelines for type 1s up to that point in his life and was dismayed to see that he was developing diabetic “complications” (neuropathy and retinopathy) in his early 30’s. With the meter, he observed that certain foods caused his blood sugar to rise, and others not, so he reasoned that he could control his blood sugar by what he ate. Sounds reasonable, right?

Every diabetic in the world, and ideally every pre-diabetic too, should be using a meter both before and after meals and at other critical times of the day and night. When Bernstein did, he gained control over his blood glucose and reversed his complications. Ever since, his over-arching philosophy has been that “people with diabetes are entitled to the same blood sugar as people who don’t have the disease.” Bernstein has been a type 1 for 69 years. His A1c’s today are always in the 4s.

So, Bernstein went to school, both literally (to medical school) and figuratively, and has been promoting very low carbohydrate eating ever since. In an article in the magazine “Diabetes Health,” which I read recently through a link in Low Carb Diet News, Bernstein says, “To get normal blood sugars you have to do certain things, and one of the key things is a very low carbohydrate diet. This is because nothing else works. I’ve tried other approaches throughout my 69 years of having diabetes. I got my first meter in 1969, so I’ve had plenty of time to experiment and see what works.”

Over the years Bernstein has developed a “concept diet,” the Bernstein Diet, also called a Way of Eating (WOE). In it, you eat 30 grams of carbohydrates a day: 6 grams at breakfast, 12 at lunch, and 12 at dinner. The lower amount at breakfast is due to something called Dawn Phenomenon (DP) which some people experience. The body makes a little glucose and circulates it upon waking to enable it to be used for quick energy to get you going (before caffeine). Bernstein recommends that you eat 3 small meals a day, evenly spaced about 5 hours apart. He advocates that protein, a large part of which is glucogenic (i.e., will make glucose if it is not taken up my muscles, etc.), be roughly equal amounts in each meal and not too much. Gluconeogenesis, where the liver makes glucose from excess amino acids (digested protein), can sabotage very low carbohydrate (VLC) eating.

His popular book, “Diabetes Solution,” has gone through several editions and is a best seller. If you decide to try VLC, don’t be afraid to eat saturated fats. In fact, Bernstein says in the Diabetes Health article, “There’s no way the ADA diet or any high-carbohydrate and low-fat diet will enable you to control blood sugars.” He’s very definite about that.

But here’s what blew me away about the Bernstein article. He goes on to say, “It turns out that the kind of diet I recommend is essentially a Paleolithic diet, which is what humanity evolved on. Our ancestors did not have bread, wheat, sweet fruits, and all of the delicious things we have today. These have been specially manufactured for us nowadays. For food, our ancestors ate a paucity of roots, some leaves, and principally meat. If they lived near the shore, they had fish.”

Bernstein concludes, “My dietary recommendations boil down to what our ancestors ate. The ADA repeatedly says that while low-carbohydrate diets may work, they’re an experiment, and we haven’t had enough years of trial of these diets to see if they do any harm. But in reality the ADA diet is an experiment that was never based on any history. In fact, it is the cause of the epidemic of obesity and diabetes that is currently shaping our nation. Whereas the original diet, the Paleolithic diet, has been tested for hundreds of thousands of years, and it’s the only one when you deviate from it that you end up where we are now.” He’s absolutely right, of course. That’s the simple truth. I’m just surprised he said it.

So, my hat is off to Richard K. Bernstein, MD, for seeing “the big picture” and speaking the truth. It’s rare enough for someone “inside” the medical establishment to see, much less speak, truth to power, even as it takes the focus off his own well established brand and carb-centric reputation. In my view, it elevates him a notch or two. Dr. Bernstein’s place among the pioneers of medicine is secure. And his place in the firmament of diabetes treatment is likewise assured. Now, in advocating Paleo principles, his vision is more far reaching yet and embraces how all of us should eat going forward.

Eleven years ago I bought a meter and used it to “eat to the meter” and thereby learn what foods had an impact on my blood sugar and by how much. It was an invaluable adjunct to general principles and guidelines and enabled me to fine tune my eating habits to the point where I was able lower my A1c’s from the 8s, while maxed out on 2 oral diabetes meds and starting a 3rd, to the mid 5s, today, by diet alone, except for 500mg of Metformin once a day. This medication works to suppress unwanted glucose production by the liver, from eating too much protein in a meal. My pancreas is spared.
Do others see how Very Low Carb and Paleo can be compatible? For caveats on the Paleo part for type 2 diabetics, see The Nutrition Debate #124, “A Lamentable Confusion Between Diets.” Do you know any diabetics (type 1s or 2s) in their 70’s?