Saturday, November 30, 2013

The Nutrition Debate #165: Obesity is Not the Problem

Robert Lustig’s UCTV YouTube video sensation, “Sugar, the Bitter Truth,” has been seen almost 4 million times. Recently, the UCSF pediatric endocrinologist made a sequel, “Fat Chance: Fructose 2.0,” that will also go viral. It’s 86 minutes long, so you’ll need to set aside a block of time to watch it, but it’s worth it. Here’s a 45 second excerpt I transcribed (starting at +/-12:00) that fits in with a theme I’ve been beating the drum about since The Nutrition Debate #9, “The Metabolic Syndrome,” published almost 3 years ago.

Lustig: “Obesity is not the problem. It never was. They want you to think it’s the problem, but it ain’t the problem. What is the problem? Metabolic Syndrome is the problem. The cluster of diseases that I’ve described to you. That’s where all the money goes. Obesity costs almost nothing. Metabolic Syndrome is 75% of all health care costs today. And there’s the list right there. [Slide lists: DIABETES, HYPERTENSION, LIPID ABNORMALITIES, CARDIOVASCULAR DISEASE, NON-ALCOHOLIC FATTY LIVER DISEASE, POLYCYSTIC OVARIAN DISEASE, CANCER, DEMENTIA] Everybody with me now? Do I have your attention?”

A brief recap – What is Metabolic Syndrome”? And how is it diagnosed? Definitions vary but most have five “risk factors” in common, with the first always being obesity. It is variously defined as “central obesity,” or what I have coined “omental adiposity”, or a Body Mass Index (BMI) ≥30, or elevated waist circumference (men ≥40 inches, women ≥35 inches). The other four “risk factors” are elevated triglycerides (≥150mg/dl), reduced HDL, the “good” cholesterol (men ≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg, or use of medications for hypertension) and elevated fasting glucose (≥100 mg/dl, or use of medications for hyperglycemia). If you “present” with 4 out of 5, you have Metabolic Syndrome. Do I have your attention?

The corollary to “obesity is not the problem” is equally riveting: “everyone’s at risk,” as Lustig explains: “Everyone’s at risk, because everyone is exposed.” That, of course, begs the question: exposed to what?

Dr. Lustig precedes his “obesity is not the problem” mantra with a nice explanation of the implications of the difference between subcutaneous fat (fat near the surface of the skin) and visceral fat (fat around the abdominal organs).The latter is the “bad” type of obesity. He starts with a diagram showing 30% obese and 70% “normal” weight, “and everybody assumes that the problem is this group over here [the 30% obese] because 80% of the obese population is sick in some fashion: type 2 diabetes problems, lipid problems, hypertension, cardiovascular disease, cancer, dementia, non-alcoholic fatty liver disease, polycystic ovarian disease, etc.”

“But,” he continues, “you do the math on this, 80% of 30% [of the 240 million adult population] is 57 million, and it is those 57 million that are bankrupting the country, so it’s the obese person’s fault only, and that’s the way everyone views this. This is wrong. This is a mistake. This is a disaster, actually, ‘cause it’s not correct. Here’s the real story. In fact, 20% of the obese population is completely metabolically normal. They have normal insulin dynamics. They don’t get sick. They live a completely normal life, die at a completely normal age, cost the taxpayer nothing. They’re just fat.”

“Conversely, up to 40% of the “normal” weight population has the exact same metabolic dysfunction that the obese do. They’re just normal weight, and so they don’t even know they’re sick until it’s too late; because normal weight people get type 2 diabetes, they get hypertension, they get dyslipidemia, they get cardiovascular disease, they get cancer, they get dementia, etc. etc. And so, when you do the math on that, that’s another 67 million, and so that’s actually outclassing the 57 million obese, and so the total is 124 million; that’s more than half [the adult population] of America.”

So, that’s why Dr. Lustig says, “Everyone’s at risk, because everyone is exposed.” Exposed to what, you ask? Metabolic Syndrome! And how do you treat Metabolic Syndrome? Answer: you “treat” the risk factors: 1) central obesity, 2) elevated triglycerides, 3) reduced HDL, 4) elevated blood pressure, and 5) elevated fasting glucose. And what treatment, pray tell, addresses all five risk factors for Metabolic Syndrome? In case you haven’t figured it out yet, the answer is a Low Carbohydrate Way of Eating. No pills, no injections, no surgery. Just a different way of eating.

Okay, you say, I can see how a low-carb Way of Eating can help me lose weight and control my blood glucose. And I can see that as I lose weight (as almost everyone wants to do anyway), how my blood pressure will go down. (Mine did, from 130/90 to 110/70 on the same meds.) And maybe I can believe that by eating low-carb, I can lose weight without hunger and without snacks, and even keep the weight off, so long as I continue to eat low-carb. But how can I expect that eating low-carb will cause my elevated triglycerides to go down and my HDL to go up? Well, mine did, dramatically: My HDL doubled from 39 to 81, and my triglycerides dropped by about two-thirds, from 137 to 49, just by eating very low carb. Scientifically, an n = 1 means nothing, unless that n = 1 is you!

PS: Here’s another interesting n = 1 on Low Carb Lowers Triglycerides from Dr. Art Ayers’s blog.

Wednesday, November 27, 2013

The Nutrition Debate #164: The Best Snack?

As a long time (27 year) type 2 diabetic who has pretty much controlled the disease (and gotten off 3 classes of oral diabetes meds) by diet alone for the last 11 years, I have long argued that snacks are unnecessary. If you haven’t eaten a Very Low Carb (VLC) breakfast and a no-carb lunch every day, as I do, you may doubt this. You may even say it is not credible. But as incredible as it sounds, it is absolutely true. You have to try this VLC Way of Eating (WOE) to discover this for yourself. You will not be hungry between meals.

I admit to snacking sometimes, either before dinner (radishes or celery usually, sometimes with salt and a little butter or a little whipped cream cheese, respectively), and occasionally after dinner (a controlled portion of nuts). Why? Not because of physical hunger or any other known nutritional need. I describe it as nervous eating, and I always ask myself if I am hungry before I do it, and I always answer “no;” then, I do it anyway. Go figure!

So, when I saw a link to David Mendoza’s column in the Low Carb Diet News titled, “The Best Snack for Weight Loss and Diabetes, I was interested. Mendoza is a well-respected and well read blogger (well-read in both senses) who describes himself as a “freelance medical writer, advocate, and consultant specializing in diabetes.” He has been a type 2 diabetic since 1994 and he started writing about it online in 1995. So, David Mendoza has credibility.

But after I read through his piece about the “best snack,” I felt his credibility was somewhat tarnished, as I’ll explain shortly. First, I want to point out some of the good stuff. Early on in his blog piece he emphasizes this:

“Unlike some other tasty nuts like cashews, almonds are much lower in carbohydrates, which are the part of our diet that is almost solely responsible for raising our blood sugar level. Nothing else in our diet is more important for managing our diabetes than keeping that level in check.”

His point about cashews and carbs is good. Cashews and pistachios (drats; I love them.) are both too high in carbs to be considered as part of a healthy diet for type 2 diabetics. I address this in my column about nuts.

“Some other nuts have a somewhat more favorable ratio of those super-healthy monounsaturated to polyunsaturated fats than almonds. But I avoid them as a matter of taste. I can eat macadamia nuts nonstop until the container is empty, but my body gets so full that I can easily put on a few pounds. On the other hand, I don’t particularly appreciate the taste of other healthy nuts like pecans or walnuts.”

I certainly agree with his point about macadamia nuts. They’re also very expensive. (Does anybody know a source for buying macadamia nuts wholesale?) However, as I mention in my column, for me the only basis for selecting which type of nuts to eat (besides carbs) is their Omega 6 content. In that respect, I disagree with Mendoza. Pecans are marginal at best and walnuts are totally verboten. The very best, excluding again cashews and pistachios because of the carbs, are macadamia nuts, hazelnuts (filberts), and then almonds.

Now, to the problem: It turns out “the best snack for weight loss and diabetes” is almonds. And although Mendoza expresses a personal preference for raw almonds (which he keeps in the freezer to give them a little “crunch”), the study he cites is with roasted and salted almonds. The study, however, as Mendoza points out, seems to have a fatal flaw: it was funded by the Almond Board of California. Oh dear…

“A few days ago the European Journal of Clinical Nutrition published the study online in advance of printing it. The abstract of “Appetitive, dietary and health effects of almonds consumed with meals or as snacks: a randomized, controlled trial,” is available at the journal’s website.”

In the positive, Mendoza says, “A big strength of this study by Purdue University and Australian researchers is that it was randomized and controlled. This is a good sized study conducted with the standard controls.”

In the negative, Mendoza states that he sees 3 problems with the study: 1) he cites the funding source, “…although they [the authors] also report that they have no conflicts of interest;” 2) “… we still don’t know why the study participants who snacked on almonds didn’t gain weight.” (For an explanation, check this out); and 3) “…this was also a short study that couldn’t measure the long-term impact of snacking on almonds.”

These are all good points. I’m only disappointed that I had to read to the end to learn that the almond study’s authors, and David Mendoza’s recommendation, were flawed by the study’s inherent conflict of interest. Almonds could be my favorite snack too, but bear in mind that the study’s snack size, 1½ ounces (20 almonds) is 250 calories! That’s half a dinner-time meal (for me). How can anyone hope to lose weight eating a 250 calorie snack on a regular basis?

Saturday, November 23, 2013

The Nutrition Debate #163: So You Think You’re Just Pre-Diabetic?

The lede in a recent piece on USAToday sets the stage: “Higher blood sugar levels, even those well short of diabetes, seem to raise the risk of developing dementia, a major new study finds. Researchers say it suggests a novel way to try to prevent Alzheimer’s disease -- by keeping glucose at a healthy level.” The article was based on a study at the University of Washington, Seattle, and was published in the New England Journal of Medicine.

A piece by Megan Brooks in MedScape Medical News quotes the study’s lead author, Dr. Paul Crane, as saying, “We considered blood glucose levels far into the normal (nondiabetic) range, and even there found an association between higher glucose levels and dementia risk.” “He said the results suggest that the ‘clinical determination of diabetes/not diabetes may miss important associations still there for people who are categorized as not having diabetes’.”

The Associated Press story on the USAToday piece was written by Marilynn Marchione. She quotes Dallas Anderson, a scientist at the National Institute on Aging, the federal agency that paid for the study: “It’s a nice clean pattern -- risk rises as blood sugar does.” According to Marchione, Anderson said, “This is part of a larger picture” and adds evidence that exercising and controlling blood pressure, blood sugar and cholesterol are a viable way to delay or prevent dementia.

Marchione then also quotes Dr. Crane, “At least for diabetics, the results suggest that good blood-sugar control is important for cognition.” And, for those without diabetes, he said, “it may be that with the brain, every additional bit of blood sugar that you have is associated with higher risk. It changes how we think about thresholds, how we think about what is normal, what is abnormal.”

Charles Bankhead of The Gupta Guide at MedPageToday commented, “Nondiabetic patients who developed dementia had a mean blood glucose level of 115mg/dl in the preceding 5 years compared with 100mg/dl in similar patients who did not have dementia. According to Dr. Crane, “the higher levels were associated with almost a 20% [18% actually] increase in the hazard for dementia.”

This piece by Paula Span in The New York Times has another quote from Dr. Crane: “We found a steadily increasing risk associated with ever-higher blood glucose levels, even in people who didn’t have diabetes. There’s not threshold, no place where the risk doesn’t go up any further or down any further.” The association with dementia kept climbing with higher blood sugar levels and, at the other end of the spectrum, continued to decrease with lover levels. He said that this held true even at glucose levels considered normal, she said.

Another recent article from MedPageToday ties blood sugar (A1c) levels to cognitive function NOW, not to the far-off future risk of dementia. The group studied was a population of non-diabetics, aged 50 and up, with BMIs between 25 and 30. Their mean A1c was 5.8%, with a range from 4.3% to 6.5%. The researchers found that “each of the three cognition parameters evaluated was significantly associated with A1c levels…”

The article, titled “Blood Sugar Tied to Cognitive Function,” appeared in The Gupta Guide, Sanjay Gupta, MD, Editor, and was reviewed by staff of the Perlman School of Medicine at the University of Pennsylvania. The researchers “added that ‘lifestyle strategies’ to achieve strict glucose control could prevent age-related cognitive decline, even in individuals with A1c levels currently considered normal…”

So, what’s the takeaway?  What does it mean to change “how we think about thresholds, how we think about what is normal, what is abnormal”? Well, well-designed prospective controlled trials are needed to prove causation, but the association of progressively higher and lower blood glucose with cognitive function, and ultimately dementia, even at so-called “normal” and “nondiabetic” blood sugar levels is undeniably true.

What is considered “normal”? And what is “prediabetic”? From 1979 to 1997 the threshold for type 2 was two consecutive visits with a fasting blood glucose of ≥140mg/dl. In 1997, ≥126mg/dl became the threshold for diabetes. In 2010 the ADA added A1c standards, with an A1c of 6.5% for diabetes (with a “treatment goal” of 7.0%!), and an A1Cs of 5.7--6.4% regarded as “pre-diabetic”. Some physicians, notably Richard K. Bernstein, consider 5.8% to be a full-blown type 2 diabetic. Another, Dr. Ralph DeFronzo, in his Banting lecture at the 2008 ADA convention, said that “By both pathophysiological and clinical standpoints, these pre-diabetic individuals with IGT should be considered to have type 2 diabetes.”
IGT, or Impaired Glucose Tolerance, is defined as a fasting Oral Glucose Tolerance Test result of >140 at 2 hours. Statistically, you are 7-10 years away from diabetes and your heart disease risk is already rising. To test your glucose tolerance, follow the directions here: But if there are no thresholds for an increased risk of dementia, shouldn’t we all adopt “‘lifestyle strategies’ to achieve strict glucose control” and thus potentially “prevent age-related cognitive decline, even in those individuals with A1c levels currently considered normal…”?

Wednesday, November 20, 2013

The Nutrition Debate #162: The ADA’s Glycemic, Blood Pressure and Lipid Goals

I hope I have made it clear how absolutely thrilled I am by the ADA’s new Position Paper titled “Nutrition Therapy Recommendations for the Management of Adults with Diabetes.” It proclaims that “there is not a ‘one-size-fits-all’ eating pattern for individuals with diabetes.” Importantly, the ADA declares “it was written at the request of the ADA Executive Committee, which has approved the final document.” The committee was comprised almost entirely of MSs, MPHs and PhDs who are all also RDs and/or CDEs. Please take note of this important fact.

However, we do not live in a perfect world, and there is only so much one committee can do to turn the Titanic. This is an apt metaphor because we who have adopted a Western Diet are all in the same boat. We are going to die from one of the diseases of Western Civilization if we stay on our present course, i.e., if we continue to eat the Standard American Diet (SAD) that we have been told to eat ever since the diet/heart hypothesis was first promulgated in the 1950s.

Think back - Ancel Keys made the cover of Time magazine in January 1961 and joined the board of the American Heart Association. In 1977, George McGovern’s Senate Select Committee’s staff produced Dietary Goals of the United States. To say that both of these individuals were misguided would be an understatement of, well, Titanic proportions. They will be remembered as the principal enablers of the corrupt consortium of agribusiness, big pharma, and self-serving, so-called “scientists” in the professional organizations and government agencies who continue to perpetuate this mess today.

Today, the ADA committee’s changes represent just one voice in the ADA, on the nutrition therapy side. Their goal, it seems to me, was increased flexibility to help patients by “individualizing” the therapeutic approach. I think it was a brilliant and a practical ‘workaround’ for the proscription on low-carb diets in previous iterations: low-carb nutrition therapy was first deemed “safe” for one year in 2008 and then more recently, for two years. Now, the time limit has been eliminated. A low carb “eating pattern” is now perfectly okay to use indefinitely. It is now at full par with others. There are no limitations.

So, with that as preface, what outcomes can be expected? What goals do we set our sights on achieving? How aspirational can we afford to be without seeming to be unreasonable? Of course, I know what is possible, but my n = 1 experience is purely anecdotal. What I am more interested in seeing is what the ADA thinks may be possible. What goals do they set for glycemic control, and blood pressure and lipid improvement? The answer, sadly, is abysmal. But don’t blame this committee. That was, as it should be, beyond the scope and purview of their recommendations. Who then?

Answer: the ADA’s doctors. The goals the ADA hopes to achieve for the management of adults with diabetes are as follows:

1.       Attain individualized glycemic, blood pressure, and lipid goals. General recommended goals from the ADA for these markers are as follows*:

·         A1C < 7%

·         Blood pressure < 140/80mmHg

·         LDL cholesterol < 100 mg/dl

·         Triglycerides < 150 mg/dl

·         HDL > 40mg/dl for men; > 50mg/dl for women

2.       Achieve and maintain body weight goals

3.       Delay or prevent complications of diabetes

* A1C, blood pressure and cholesterol goals may need to be adjusted for the individual based on age, duration of diabetes, health history, and other present health conditions. Further recommendations for individualization of goals can be found in the ADA Standards of Medical Care in Diabetes (emphasis mine). This asterisk is by way of saying that doctors may find it necessary to set less ambitious goals (gasp!) than the already lax goals they have specified above. This is truly shocking.

So, in case you have not divined where I’m coming from, it is the ADA’s medical doctors who set these goal and who are not yet “up to speed.” Or, continuing the Titanic metaphor, as the mighty ship of state (our health) continues to sink, “the band [the medical doctors] plays on.” The  RDs and CDEs “rearrange the deck chairs” in issuing new nutrition therapy recommendations – but will this make a difference or will it just be a futile exercise as our health continues to sink? We’ll have to wait and see if the doctors at the ADA come around. Or, even if not, if more patients will do as David Letterman has done and aspire to higher goals to control their diabetes (and blood pressure and blood lipids),”through diet, mostly.”
If you do work to control your type 2 diabetes “through diet, mostly,” you can reasonably expect to “achieve and maintain body weight goals” and “delay or prevent complication of diabetes.” And you can achieve splendid lipids! As I am always crowing, I have now lost 140 pounds, my most recent blood pressure was 110/70 (with meds), and my A1c 5.7%. My latest Total Cholesterol was 217, LDL 122, HDL 85 and TRIG 49. In a separate test my LDL particles were Pattern A (large buoyant). I have achieved and maintain this with a Very Low Carb WOE: 75% fat, 20% protein and 5% carbohydrate. The triglycerides are particularly influenced by carb in the diet. This puts my Trig/HDL ratio at a stellar 0.57, indicating a very low risk of CVD. Does you doc do that ratio for you? If not, look at your own #’s and do the interpretation yourself!

Saturday, November 16, 2013

The Nutrition Debate #161: Why Go to the Doctor?

Why, indeed! When my doctor of 21 years died last year (the one I eulogized here), his practice was sold and my medical records transferred to a nearby internist/cardiologist who used to ‘cover’ for him. At my first appointment, after the physical, the doctor asked me what he could do for me. I said I would like to be seen 3 or 4 times a year, to which he replied, to my surprise, that it didn’t seem necessary. True, I played my hand first, and he didn’t protest too much at my request to be seen that frequently, but I’m sure he would have settled for less.

What did this tell me? It told me that from his review of my file, and the physical examination, that I was a fairly “healthy specimen” compared to his patient base. I think his view of me was also influenced by my comment that I thought my previous doctor, of whom I was very fond – he saved my life, I used to tell him – had perhaps “milked the system” to help “pay the rent.” But I say this about others too, like my auto mechanic: I know I am helping him make his boat payments.

What this also told me was that my desire to be seen 3 or 4 times a year was being driven by my desire – that it was not “medically necessary.” Of course, my desire is in no small part influenced by the fact that I am on Medicare and I have good supplemental coverage. The result is that, since my doctor accepts Medicare (and must accept the Medicare allowed amount as “full payment,” and my supplemental pays the remaining 20% of what Medicare allows, I have absolutely no co-pays and a very low annual deductible. So, since I have “no skin in the game,” I can see a doctor as often as I want without any financial outlay (beyond the annual deductible). I think this is a lousy way to pay for medical care, but it is what it is.

My desire to be seen 3 or 4 times a year also gave me some insight into what motivates me to want to. Now, no offense intended, doc (I think he reads the column sometimes, and certainly will read one titled “Why Go to the Doctor”); but, I don’t go to see him for his personality. Although his is great; he is always positive, conversational, jaunty, indeed, almost bubbly. And, interestingly, besides being board certified in his specialties, he holds a PhD – a Doctor of Philosophy. How cool is that! But, on the specific treatment modality for type 2 diabetes that I follow, nutritional therapy, I bet I could hold my own – no, I daresay, I would whoop him handily on any “certification” examination.

But that’s all beside the point. In areas where I have no expertise at all, e.g., the medical aspects of diagnosis and treatment and etiology, pathophysiology and therapeutic interventions for the diseases of Western Civilization, there is of course no contest. So, one could say that is good enough reason to go to the doctor. And it is one of the reasons I go to see mine. But, as I said, my doctor (and I) see me as being “healthy,” for the most part. So, I don’t have to go to the doctor 3 or 4 times a year to monitor that. What other reason(s), then, do I have for more than, say, an annual or semi-annual visit?

The answer, my faithful readers, is to monitor the metrics that I use to track my diabetic health. Note the emphasis that I put on “that I use.” That is because the metrics that I use are very different from the ones my doctor uses.  In fact, my metrics differ from virtually all doctors who follow the government’s and the medical association’s and the insurance agency’s guidelines for the management of type 2 diabetes. I don’t want to get into the reason(s) for those differences here – I tend to go off on a rant when I do. I’ll explain more fully in the next column.  I just want to point out and stress that if you do the same, that is, rely on the standards that your doctor uses, you do so at great risk to your health. I’m sorry, doc, but that’s the truth, folks.

I have written on this subject before, and will again, as I said. It could become my mantra. And it certainly deserves articulation and recapitulation (as in the musical sonata form where the exposition is repeated in an altered form). Understanding this point is crucial to the type 2 diabetic who is taking responsibility for his or her own healthcare and has chosen to do it “through diet…mostly,” in the words of David Letterman in his recent conversation on TV with Tom Hanks.

So, to repeat, if you leave the evaluation of the measurement of your health to your doctor, most of whom will rely almost entirely on the standards which they must follow to assure that both they and you get covered by your insurance, you will, in my opinion, be poorly served. That’s a bit strong, but that’s the truth.

Bottom line: the main reason I go to the doctor is for a lab report. And until I have him trained (sorry, Doc) in what I am interested in knowing each and every time I go (and which my insurance will cover), I may have to ask for what I would like to have tested. Of course, his office weighs me and takes my blood pressure, as I do at home. I also test my fasting blood glucose daily for discipline and as a reminder and a “check.” It’s the other blood tests that I want: the lipid panel, the A1c, the C-reactive protein, and once a year the thyroid tests (free T3, free T4 and reverse T3) and kidney function tests (creatinine).
Last week a copy of my most recent tests arrived in the mail. My doctor is good about that; I don’t have to request it. And the lab report is accompanied by a modified form letter too. That’s nice. My blood pressure, by the way, was 110/70 (on meds). The lab test results: Total Cholesterol = 217; LDL = 122; HDL = 85; triglycerides = 49; A1c = 5.7. My fasting blood glucose, though, was 109mg/dl (!). I don’t know how that happened. It was 89mg/dl when I left home three hours earlier.

Wednesday, November 13, 2013

The Nutrition Debate #160: Letterman to Hanks: “…through diet, mostly.”

On the David Letterman show recently, 57-year old Tom Hanks blurted out that his doctor had told him that after 20 years of high-normal blood sugars, “You’ve graduated. You’ve got type 2 diabetes, young man.” And all the coverage the next day was about how Hanks had “performed an important role in raising awareness.” In the medical news, as in this piece, “The Tom Hanks Effect: Diabetes Diagnosis Great for Awareness,” in M­­edscape Medical News, all I heard was banal generalities about how a “regular guy,” who “doesn’t appear to lead an unhealthy lifestyle,” can develop diabetes. And that “Diabetes is a very treatable disease with good guidelines for effective treatment.” Boy, don’t get me started on those “good guidelines.”

Nobody…I mean nobody covered the most important utterance in the Letterman interview. It was Letterman’s response to, “It’s controllable…” to which Letterman added, “…through diet, mostly.” Letterman then said that, “I suffer from high blood sugar – had to go on a special diet myself.” Now, I’m not a fan of Letterman, but he got it right, and nobody covered it. It’s true, Hanks is the news, and Hanks did smother what Dave said with his funny rejoinder about getting back to his high school weight. But his doctor had said, if he did, “he would essentially be healthy and would not have type 2 diabetes.

In a BBC interview, Hanks said that he “gets regular exercise, eats right, takes certain medications, and, so far, feels fine.” It sounds to me like he’s making the same mistake as Paula Deen, except that she concealed her diagnosis until she had lined up a pharmaceutical endorsement. They’re both leaving the control of their diabetes health care in the hands of medical practitioners.  Tom Hanks (and Paula Deen) should listen to David Letterman: type 2 diabetes is “controllable…through diet, mostly.”

But I don’t think either of them will listen to Dave, or me either. If Hanks had high blood sugars for 20 years and hadn’t figured out what to do about it in that time, I don’t expect he will now. Of course, I was in a similar – actually, identical situation for the first 16 years after my type 2 diagnosis in 1986. So if I put myself in Hanks’s shoes, I can be sympathetic. But I know better now, and that’s why I work hard to try to persuade others not to follow in my footsteps. If you are pre-diabetic, you don’t have to develop full-blown type 2 diabetes. And if you do, you can control it “…through diet, mostly.

I know I’m “beating a dead horse.” I persist because I know it’s hard not to, by default, leave your health care in the hands of your doctor. Doctor knows best and what is best for us, presumably. Unfortunately, though, that’s not always true. They are human and fallible. They know that, but they also know that, in order to gain and hold your trust, they must preserve and maintain the appearance of omniscience.

They are constrained by a multitude of factors: most were trained in the era of Ancel Keys’s diet/heart hypothesis in which they were taught that saturated fat and dietary cholesterol were killer foods. How can they now do a 180 degree turn and tell you that saturated fat is good for you and that “cholesterol in the diet doesn't matter at all unless you happen to be a chicken or a rabbit,” in the words of Keys himself later in life. And virtually no MDs have training in nutrition.

They are also constrained by the standards of practice of their medical specialty. It takes a long time for research findings to influence clinical practice through updated guidelines. Not to follow those standards would risk professional sanction and possible loss of licensure. They are also constrained by the reimbursement rules of Medicare and the insurance companies; they are constrained by limited time with patients and limited time for continuing education. And, sadly, they and their medical associations are so influenced by the big pharmaceutical companies that conflicts of interest are inevitable. So it’s tough to be a doctor these days, but from the patient’s point of view, there’s a workaround: self-care also known as patient-centered care.

If type 2 diabetes is controllable through diet, mostly, Tom Hanks can do as David Letterman does and “go on a special diet” himself. But it sounds to me like he doesn’t want to. “Hey, you gotta live, you know?” Hanks has tweeted. He’s decided he’s going to just “eat right,” exercise and take some meds. If he follows this course, I don’t have to tell my readers that his disease will be progressive, just as it was for the last 20 years that he followed his doctor’s advice. And look where that got him: he “graduated.”

What does he expect? To be congratulated? Wake up, Tom. Take responsibility for your own health. Take charge of your own nutrition. Stop being in denial. You’re carbohydrate intolerant, Tom. For whatever reason, including genetic predisposition, or body type if you like, or past eating patterns. Don’t act like a victim. Show some character. Show me some grit, Tom.  Show the world that you can be a positive role model. Show us you’re a good man, Tom, like James Francis Ryan…

Saturday, November 9, 2013

The Nutrition Debate #159: While ‘Rome Burns,’ the GACD fiddles and the EASD naps

Please excuse me if once in a while I tear into a rant. I get frustrated and then very cynical with some of the things I read. I also know that, individually, I have so little power to influence outcomes beyond my own…and if I’m lucky, a few others. But I still have to get some things off my chest. I could throw the print copy out, but the content would still be swirling around in my head. So, the only thing for me to do is to write about it. What set me off this time was a piece that appeared in The Lancet last month, “Funding: Global Alliance for Chronic Diseases tackles diabetes.”

Here’s what the BBSRC science writer Arran Frood said: “To meet the challenge in emerging economies, the Global Alliance for Chronic Diseases (GACD) has launched a call for research proposals to prevent and treat type 2 diabetes. The GACD is an alliance of some of the world’s biggest publicly funded research organizations, ranging from the UK’s Medical Research Council to China’s Ministr­­y of Health and the European Commission.” Okay, that’s benign enough; it’s an employment program for government scientists, a kind of job security. Here’s what set me off:

“Refreshingly, GACD members have realized that the science of type 2 diabetes is well understood; this is no high-spending, high-tech genomics initiative but a strict focus on implementation of existing policies, present knowledge, and proven interventions.” It is reading arrogant bull$#%& like this, I think, that gave me high blood pressure. Of course, it could also be related to my weight, hehe, (because when I lost 140 pounds, my BP went from 130/90 to 110/70 on the same meds).

So, these government bureaucrats, who know all about type 2 diabetes, are going to disseminate their message to “low-income and middle-income countries, such as China, India, and South Africa where the biggest emerging problems are to be found, but where success might pay the highest dividends.” That’s just great!!! The “developed” world, where this type 2 diabetes problem arose as a result of “developments” in the growing, processing, manufacture and marketing of the very foods that have made us sick, is going to spread the word about fixing the problem, which is our Western Diet. Sell the problem and then sell the solution!

Boy, that’s irony for you, but obviously Mr. Frood doesn’t see it that way. He’s refreshed. The GACD is going to “strict(ly) focus on (the) implementation of existing policies, present knowledge, and proven interventions.” It doesn’t occur to him that existing policies and present knowledge have not led to proven interventions. They have produced the growing and out-of-control epidemic of not only type 2 diabetes, but obesity (an outcome, not a cause of T2DM), dyslipidemia (characterized by low HDL, high triglycerides, and Pattern ‘B’ LDL particles), and hypertension, collectively known as the Metabolic Syndrome.

Okay, Ivory Tower Dictocrats live in a special world – a world in which a primary duty is to “call for research proposals” from other “publically funded research organizations.” They are isolated from the real people-populated world in which we mere mortals spread the word about the most effective intervention “to prevent and treat type 2 diabetes” - Eat Real Food.” Now that would be “refreshing.” ­­­­­But where’s the money? No drugs to market. No processed foods to manufacture and sell. Simply small scale farming – just like they do now in low-income and middle-income countries like China, India and South Africa!

So, the best thing we “developed” countries can do is stay the hell out of the management of type 2 diabetes in the underdeveloped and developing world until we get the message right. I’m not hopeful, though. This is not likely to happen so long as the Agribusiness lobby remains so thoroughly insinuated in the interstitial tissue of our nation’s and the world’s advisory and regulatory bodies. I do not see an end to this pernicious and insidious influence soon.

Meanwhile, diabetes experts from all over the world met in Barcelona last month for the annual meeting of the European Association for the Study of Diabetes (EASD). They listened, I’m sure, to riveting presentations, and maybe got in a round of golf. Among the reports, chronicled in Diabetes in Control here, was a research paper titled, “Big breakfast rich in protein improved glycaemic control and satiety feeling in adults with type 2 diabetes mellitus.” I wonder how much the taxpayer of some nation paid for that earth shattering news. I really shouldn’t knock it, though. It’s the right message, and yet so many clinicians and dietitians still don’t know this. For diet-controlled diabetics like me, this is Nutrition 101, 1st day of class stuff.

My favorite news flash, though, came from another Diabetes in Control item, here: “Afternoon Napping Tied to Increased Risk for Diabetes.” It begins, “Since afternoon napping is very common in China, Fang et. al. conducted a study to determine if the duration of a person’s nap affected their risk for developing diabetes or an impaired fasting blood glucose (IFG).” Their conclusion: “Napping duration was associated in a dose-dependent manner with IFG and DM” (emphasis mine). And “This finding suggests that longer nap duration may represent a novel risk factor for DM and higher blood glucose levels.”
Okay, but association is not causation. Perhaps the Chinese scientists will now apply for a grant to undertake a randomized controlled trial (RCT) to determine if the outcome observed by Fang et. al. can be attributed causally to the blood glucose crash of some of the 27,009 participants a few hours after eating a bowl of overcooked white rice. Maybe they’ll “discover” insulin resistance (IR). It will certainly keep the scientists busy interpreting and reporting the results for publication. Whew!

Wednesday, November 6, 2013

The Nutrition Debate #158: Demolishing the Saturated Fat Bogeyman

In a commissioned, peer-reviewed and foot-noted “Observations” column published October 22, 2013, in the prestigious BMJ (British Medical Journal), interventional cardiologist Aseem Malhotra presented this stunning conclusion: “It is time to bust the myth of the role of saturated fat in heart disease and wind back the harms of dietary advice that has contributed to obesity.” The ground shook and a tsunami rolled around the world. Ripples were even felt in the mainstream.

Dr. Malhotra reminds us that, “Saturated fat has been demonized ever since Ancel Keys’s landmark ‘seven countries’ study in 1970. This concluded that a correlation existed between the incidence of coronary heart disease and total cholesterol concentrations, which then correlated with the proportion of energy provided by saturated fat. But correlation is not causation; and Keys cherry-picked his data. Nevertheless, we were advised to cut fat intake to 30% of total energy and saturated fat to 10%.” That was and is a core recommendation incorporated into the “Dietary Guidelines for Americans” from its inception in 1980 to this day.

“The mantra that saturated fat must be removed to reduce the risk of cardiovascular disease has dominated dietary advice and guidelines for almost four decades,” Dr. Malhotra continues. “Yet scientific evidence shows that this advice has, paradoxically, increased our cardiovascular risks. Furthermore, the government’s obsession with levels of total cholesterol, which has led to the overmedication of millions of people with statins, has diverted our attention from the more egregious risk factor of atherogenic dyslipidaemia.” Translation: Low HDL and high triglycerides, plus small-dense LDL lipoprotein particles (“Pattern B” LDL) accompanied by systemic inflammation, all of which are potent cardiovascular disease risk factors.

To explain how that comes about, Dr. Malhotra continues, “The aspect of dietary saturated fat that is believed to have the greatest influence on cardiovascular risk is elevated concentrations of low density lipoprotein (LDL) cholesterol. Yet the reduction in LDL cholesterol from reducing saturated fat intake seems to be specific to large, buoyant (type A) LDL particles, when in fact it is the small, dense (type B) particles (responsive to carbohydrate intake) that are implicated in cardiovascular disease.” Translation: Reduced saturated fat intake = fewer large buoyant (type A) LDL particles; Increased carbohydrate intake = more small dense (type B) LDL particles. Conclusion: Saturated fat: good; Carbohydrates: bad.

Dr. Malhotra covers some familiar ground as well: “Scientists universally accept that trans fats – found in many fast foods, bakery products and margarines – increase the risk of cardiovascular disease through inflammatory processes.” And he nicely clarifies a point: “Consumption of processed meats, but not red meat, has been associated with coronary heart disease and diabetes mellitus, which may be explained by nitrates and sodium as preservatives.” But he comes back to saturated fat with this: “Indeed, recent prospective cohort studies have not supported any significant association between saturated fat intake and cardiovascular risk. Instead, saturated fat has been found to be protective.” See his citation here.

“In previous generations cardiovascular disease existed largely in isolation,” he says. “Now two thirds of people admitted to hospital with a diagnosis of acute myocardial infarction really have metabolic syndrome – but 75% of these patients have completely normal total cholesterol concentrations. Maybe this is because total cholesterol isn’t really the problem,” he quips (emphasis mine). Metabolic Syndrome is “the cluster of hypertension, dysglycaemia, raised triglycerides, low HDL cholesterol, and increased waist circumference.” Do these sound familiar? Does it apply to you? Does it worry you, yet?

Dr. Malhotra reminds us that, “The notoriety of fat is based on its higher energy content per gram in comparison with protein and carbohydrate,” but he cites Richard Feinman and Eugene Fine’s work on “metabolic advantage” to show that “different diet compositions showed that the body did not metabolize different macronutrients in the same way.” “The ‘calorie is not a calorie’ theory has been further substantiated,” he adds, “by a recent JAMA study showing that a low fat diet resulted in the greatest decrease in energy expenditure, an unhealthy lipid pattern, and increased insulin resistance in comparison with a low carbohydrate and low glycaemic index diet.” This is beginning to sound like a broken record.

So, will this message resonate? Were there aftershocks? Sure, I was startled awake one morning with a ‘teaser’ on an early morning TV news program. Later, the Diet Doctor, Andreas Eenfeldt, featured it here. The BBC Health News featured it here, and they also had a morning show video segment. The had this piece by Melissa Healy. And early tremors were registered at here.  Maybe it will resonate this time, if enough people hear it, over and over…
Finally, Dr. Malhotra comes at it from a different angle: “When you take the fat out (of food), the food tastes worse.” “The food industry compensated by replacing saturated fat with added sugar. The scientific evidence is mounting that sugar is a possible independent risk factor for the metabolic syndrome.” He’s now come full circle. “Saturated Fat is not the major issue,” the title of the piece shouts. The sub-title, “Let’s bust the myth of its role in heart disease…” Bravo! This stake to the heart will help. But ‘SFAs = bad’ is an undead concept that will persist to eat away at our health, like a zombie apocalypse.

Saturday, November 2, 2013

The Nutrition Debate #157: The ADA’s Problematic Position on Dietary Fat

Having just sung the praises of the American Diabetes Association’s new Position Paper on nutrition therapy guidelines, it’s painful for me to have to criticize their unbending adherence to the “conventional wisdom” with respect to saturated fatty acids (SFAs), aka saturated fats. They dodge the issue. Instead of saying “the evidence is inconclusive…so goals should be individualized” (as they did with macronutrient distribution), they say: “Due to a lack of research in this area (?!!), people with diabetes should follow the guidelines for the general population,” from the Dietary Guidelines for Americans. What a cop-out.

The ADA deserves to be cut a little slack, though, for not taking on too many giants at once. For the ADA to have officially said, “It is the position of the American Diabetes Association (ADA) that there is not a ‘one-size-fits-all’ eating pattern for individuals with diabetes,” that’s enough for me, for now. All who have suffered the angst of having the n=1 experience of losing weight easily, without hunger or cravings, and having their Metabolic Syndrome disappear on a Very Low Carb (VLC) dietary, have been frustrated. And we did it all without approbation (and occasional outright hostility) from the “dietary authorities,” We can applaud the ADA now as it is the first major organization in the U.S.A. to break with that outdated idea.

For this diabetic, as my weight dropped, so did my blood pressure, from 130/90 to 110/70 (on the same meds). And while my LDL cholesterol particle number didn’t go down, the particles changed from small-dense (“Pattern B”) to large-buoyant (“Pattern A”), making it less likely that they could get stuck in any erosion in the endothelial layer of my arteries. Such erosion, by the way, is caused by inflammation, but on this VLC Way of Eating, my C-Reactive Protein test, a blood marker for systematic inflammation, is often below 1.0, the level generally considered “ideal” for cardiovascular risk.

Serum cholesterol attempts to repair the small-dense LDL trapped in the eroded arteries, by creating plaque. That’s why cholesterol is blamed for plaque, but it’s like blaming the fireman for putting out the fire. Statins are thought to work by stabilizing plaque. Low systemic inflammation, large-buoyant LDL particles, and high HDL to carry excess LDL particles away from the heart and back to the liver, prevents plaque formation. It is a much better way to mediate CVD risk.

The ADA now recognizes that Low Carb eating is “healthful,” but they still tow the line of the AHA, AMA, HHS and the USDA with respect to which fats are healthful. (If you reduce carbs in your diet, those calories will be replaced primarily with fats, so it is important that you choose healthy fats.) The dietary authorities all suggest that MUFAs (monounsaturated fats like olive oil) are healthful, and all now admit trans fats (artificially saturated vegetable oils) are deadly; but that naturally saturated animal fats, and the dietary cholesterol that accompanies them, are unhealthful. And that PUFAs (highly processed polyunsaturated fats found in vegetable oils like corn and soy bean oil) are healthful!!!

They unfortunately still lump naturally saturated fats found in animal products with the artificially saturated trans fats manufactured from highly processed vegetable oils. This conflation is an egregious and malevolent perfidy perpetrated and perpetuated by industry influence, specifically the Agribusiness lobby which is so thoroughly insinuated in the interstitial tissue of our nation’s advisory and regulatory bodies. It is a bogus association. They are totally dissimilar in their structure and effect on the body’s cells. 

The “authorities” also fail to recognize the dangers from the disproportionate amount of inflammatory Omega 6s we are eating (relative to Omega 3s) since vegetable oil has become so prominent in our diet. Vegetable oils are everywhere, particularly if you eat restaurant meals, processed foods or commercial mayonnaise and salad dressings. It is very difficult to
correct the balance of Omega 6s to Omega 3s without avoiding as completely as you can all vegetable oils (high in Omega 6s). 

The ADA’s position on SFAs leads them inexorably to advocating one “eating pattern” in particular, the Mediterranean style. That’s fine if you’re not diabetic or pre-diabetic. If you can keep a healthy metabolism eating “abundant plant food (fruits, vegetables, breads, other forms of cereals, beans, nuts and seeds)”, good for you. I’m jealous. (Note to the ADA: Diabetics can’t.) But for those who can, by all means eat “fruit as the typical daily dessert and concentrated sugars and honey consumed only for special occasions,” and “olive oil as the principal source of daily lipids, dairy products (mainly cheese and yoghurt) consumed in low to moderate amounts,” etc. Of course, it allows only very limited amounts of red meat and eggs and thus is definitely skewed away from dietary cholesterol and saturated fats – all misguided, unnecessary, and in fact, unwise IMHO – especially for the metabolically compromised, as we diabetics all are.
I do not blame this ADA committee, though. Rather, I praise the courageous stand of this committee comprised of PhDs and MPHs, all of them RDs and CDEs. They prepared this groundbreaking report, and the ADA Executive Committee commissioned and approved the final document. They deserve our acclamation for having made the turn in accepting – no, verily promoting and supporting any and all “healthful eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion sizes, in order to improve overall health…” And even though they incline towards the “Mediterranean style” for reasons relating to what I regard as a vestigial bow to orthodoxy, they now explicitly and unambiguously include the low-carb diet as a healthful Way of Eating. Wunderbar! What will be the next canon of orthodoxy to fall? Will it be saturated fat? See the next column.