Saturday, June 28, 2014

The Nutrition Debate #222: Better Diabetes Self-Management with Cognitive Therapy

The very next day after the 2nd of the two bombs dropped in my inbox (see The Nutrition Debate #221 here), another one “exploded.” I am interested whenever diabetes self-management, in contrast to “treatment” by clinicians, is advocated in the medical literature. Type 2 diabetes patients need to be more involved in their own care.

Better Diabetes Self-Management With Cognitive Therapy” is a Medscape Psychiatry Minute by Dr. Peter Yellowlees. The video synopsis, with accompanying transcript of a paper, “A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes,” appeared in Diabetes Care. The Medline ABSTRACT appears here. The work, with 87 adults, was done at Massachusetts General Hospital in Boston.

The “better” outcome is not surprising, of course, and is not what interested me about this study. This was just another expensive, “randomized controlled trial” in a controlled hospital environment with a “usual care” component, and with a predictable outcome: the intervention group (depressed patients with uncontrolled type 2 diabetes), received cognitive behavioral therapy and, after 4-, 8-, and 12-month follow-up time points, “maintained 24% higher medication adherence, 17% greater adherence to self-monitoring of blood glucose, and lower A1c values, with both groups being less depressed.

Hmmm. They took their pills, had blood tests, and their A1c’s were lower. Both groups were exposed to the same hospital food as part of their “usual care,” so presumably the A1c improvement was a result of their “treatment” protocol: taking their meds. And because both the intervention and control groups saw themselves as receiving this expensive “care,” an outcome was that both groups came out less depressed! Well, that’s good for both patients and the psychiatrists who, after all, need to see themselves as helping patients (not least for the support they received).

Not to put too fine a point on it, in the ABSTRACT the only mention in RESULTS about depression was this: “For depression, there was some evidence of continued improvement post-treatment, but no between-group differences” (emphasis mine). One must conclude, therefore, that the cognitive behavior therapy did not help with depression since both the intervention group and the control group saw “some” improvement.

I don’t mean this to be critical of Cognitive Behavioral Therapy (CBT). In fact, I think CBT is a good thing. My main frustration with this study is that these seriously-ill, hospitalized patients, all with uncontrolled type 2 diabetes, were being taught, through CBT, “adherence:” Take you pills and test your blood regularly to see how sick you are and how much sicker you’re getting. No wonder they’re depressed! Aren’t we all when the medical therapy we’ve been prescribed doesn’t work?

I guess it never occurred to these docs (they’re psychiatrists, after all) that type 2 diabetes is a disease of hormonal disregulation caused by insulin resistance arising from impaired glucose tolerance/impaired fasting glucose: in other words, carbohydrate intolerance. The most effective treatment protocol, rather than “adherence” to a pharmacotherapy treatment regimen, is to dramatically curtail dietary carbohydrates! (Good luck with this with hospital food!)

But that’s what I did. When I started, at my doctor’s suggestion, to eat a very low carbohydrate diet (Atkins Induction: 20g of carbs a day!), I was on three different classes of oral anti-diabetic medications, and maxed out on two. Within a day, I was getting hypos, and I called him. He carefully (and very quickly) titrated the meds. I was left me with only one, a small dose of Metformin (500mg once a day). That was 12 years and 125 pounds ago.

Dietary “adherence” with Very Low Carb, is, for me, easy (and delicious). I don’t need expensive therapy, although I don’t knock any kind of therapy. Do whatever works. The important thing is to choose the right therapy for treating type 2 diabetes. If you’ve been diagnosed with pre-diabetes or type 2, self-management (under supportive medical supervision) is the most effective course of action, and the most effective self-management protocol is diet. Learn what carbohydrates are. Test your blood sugar regularly, including post prandial, to see what the foods you eat do to your blood sugar, and adjust what you eat accordingly, i.e. “Eat to your Meter.” Your doctor should approve of the results (outcomes), if not the methods. Hopefully he/she will do both.
And as you lose gobs of weight and gain energy, you and your doctor will see results in your A1c’s, your lipid panel (e.g. HDL-C and triglycerides) and your inflammation markers. With outcomes like these, you too could be less depressed”!!! At minimal cost (perhaps more test strips and some good butter), and you did it yourself! Now that’s good self-management.

Wednesday, June 25, 2014

The Nutrition Debate #221: Medscape dropped 2 bombs in my inbox last week

Medscape Medical News dropped 2 bombs in my inbox last week, and my post-bombing analysis of the papers is that they both missed the target. Individually, they’re hardly worth a whole column, so I’ll give them each a third and then share with you a piece of my mind.  I’ll need that time to cool off sufficiently.

Congratulations! We're Making Strides in Diabetes Care,” by Dr. Anne L.Peters, MD, CDE, a highly respected diabetologist (of the “old school”), is simply a cheerleading piece timed for the ADA convention. She gives three links: recent articles in 1) the Journal of the American Medical Association (JAMA), 2) the Annals of Internal Medicine, and 3) Diabetes (the Journal of the American Diabetes Association) to support her “This is great news. We are doing a better job than ever” quote.

Would her audience, comprised largely of “treating” physicians (like herself,) agree? But then, maybe that’s the point of her getting ginned up to deliver this Pollyannaish piece. It seems to me likely that the treating physicians convened at the Annual ADA Convention are in need of a morale boost.

In spite of the “strides” claimed (which I don’t dispute), I feel there must be among the vast majority of practicing physicians a frustration, a frantic despair, in fact, a feverish frenzy over the failure of the “usual care treatment protocol,” dictated by their medical associations  and their government overseers. Dr. Peter’s problem, and that of the entire medical and public health establishment, is that they simply have the wrong target.

The 2nd bomb, which appeared just 2 days later, was titled “Diabetes Prevention Programs: A Waste of Money.” This was a Medscape Interview of Richard Kahn, PhD (Professor of Medicine, University of North Carolina, Chapel Hill). A controversial counter message, it focuses, as it should in my opinion, on “lifestyle modification programs geared for weight loss,” since these programs have been shown to “delay or prevent the onset of type 2 diabetes.” The Medscape Editors note that “as many as 82 million Americans are thought to have prediabetes.” “These people” (referring to people who had completed a “usual care” Diabetes Prevention Program) had an enormous amount of attention given by health professionals.” “Those interventions – almost every one – were expensive,” Dr. Kahn asserted.

Dr. Kahn adds: “The first thing you see is that the overwhelming number of studies didn’t even go out to one year,” and “the assumption the authors make” is “that that amount of weight can be lost forever. That has simply never been seen except in bariatric surgery.” “From a medical point of view, it doesn’t look like that initial weight loss does much, if anything. For some clinical effect you have to lose substantially more weight – 20%, 25% of your body…,”and, Dr. Kahn continues, “it would have to stay off for a long time” to be a cost-effective program worthy of “society pay(ing) for the intervention,” given “how difficult it is to keep weight off.”

So, Dr. Kahn’s “after bombing assessment” confirms the ineffectiveness of the “usual care treatment protocol” you are likely to receive in your clinician’s office (“wrong target”) and the reason why so many physicians and patients feel frustrated. Dr. Kahn: Under such “diet and lifestyle” diabetes prevention programs, “the assumption that the weight will be lost and held off for life… is unrealistic. Or maybe it’s realistic, but not in today’s world” (emphasis mine). Dr. Kahn isn’t asked about what he meant by that, but I think I understand: his analysis of the data shows unproven assumptions and tenets; his conclusion: the present modus operendi (a low-fat, “balanced” diet) is simply not cost-effective.

But Dr. Kahn does leave a door open to what I suspect he knows about anecdotally, and I know personally: That long term, permanent weight loss is indeed possible – if we re-program our bomb sights and set our targets on carbs. He says, “Some people decide, ‘I’m going to do it. They’ve invested nothing. That’s great for them, but we’re not arguing about whether people should be encouraged to lose weight. What we’re arguing against is having society pay the bill for this when it hasn’t been effective.” “The individual should pick up the cost,” he says. And I say, choose the target (carbs), and go.
Medscape then asks, “What’s the main takeaway for clinicians, then?” Dr. Kahn’s final remarks, “People who are overweight or obese should be strongly encouraged by their healthcare provider to lose weight and keep it off. If a provider feels that there is a good resource in the community, he or she should refer the person to that resource.” Hello. Anyone listening? Check out how I lost and kept off 33% of my body weight here and here (The Nutrition Debate #213 & #214).

Saturday, June 21, 2014

The Nutrition Debate #220: “Eat protein to lower stroke risk”

“Eat protein to lower stroke risk” is the title of a recent article in The Telegraph, a British newspaper. I advocate eating protein, and who doesn’t want to lower stroke risk? But that’s not what was interesting to me about this piece. The article is drawn from a study that appeared in the scientific journal Neurology titled, “Quantitative analysis of dietary protein intake and stroke risk,” by 5 MDs/PhDs at Nanjing University School of Medicine in Nanjing, China.

The headline writer, in my opinion, did a better job in reporting on this meta-analysis of 7 prospective studies of over half a million participants than The Telegraph’s “science” correspondent. Case in point: The Telegraph’s story begins, “Eating a high protein diet [emphasis added] significantly lowers the risk of stroke and could prevent 10,000 deaths in Britain every year, a study has suggested.” High protein diet? Just a little bit of hyperbole on the part of an eager reporter, perhaps, combined with bad editing. The lesson here: stories by science journalists in the popular press are not peer reviewed.

The story quickly comes back to earth, though: “The amount of protein that led to the reduced risk was moderate – equal to 20 grams a day,” it says. That’s a small amount (by American standards). The Standard American Diet (SAD, ironically) on the Nutrition Facts Panel of manufactured and processed food packaging calls for 50 grams a day, and most Americans eat a great deal more than that. Remember, the “Dietary Guidelines for Americans” are heavily influenced by the vegan lobby who advocate a plant-based diet to save the planet from greenhouse gasses (caused by bovine flatulence), etc., etc.

The study RESULTS, from the ABSTRACT, are more specific: “The pooled RR [relative risk] of stroke for the highest compared to the lowest dietary protein intake was 0.80 (95% CI [confidence interval] 0.66-0.99).” That means the risk of stroke was 4/5s as great (0.80) for the highest compared to the lowest dietary protein intake.” Unfortunately, the full text paper is only available with a subscription to Neurology, or a big one-time payment.

The ABSTRACT had another interesting result: In addition to the 20% relative reduction in stroke risk for overall dietary protein intake, they reported that “stratifying by protein type, the (relative risk) of stroke for animal protein was 0.71 (95% CI 0.50-0.99).” For the mathematically challenged, that translates to an almost 50% greater (29% versus a 20% reduction) in relative stroke risk. In simple terms, in the words of The Telegraph’s science correspondent, “The reduced risk of stroke was stronger for animal protein than vegetable protein.” This intriguing point deserves further investigation. (100 grams of chicken at 172 calories will do the trick. Or 770 calories of potatoes.)

The study does have a bias. According to the study’s lead author, Dr. Xinfeng Liu, “people should avoid red meat,” which has been associated with increased stroke risk, according to The Telegraph. “Consuming as little as one chicken breast, or a salmon fillet, -- the equivalent of 20g – reduced the risk of stroke by 20 per cent,” The Telegraph said. And, Dr. Liu said, “These results indicate that stroke risk may be reduced by replacing red meat with other protein sources, such as fish” Hmmm. I guess the Brits have a vegan lobby too; Or, Dr. Liu was pandering to the “perceived wisdom” to get published. 

The bias deepens in the accompanying editorial in Neurology. In a long preamble, the authors review what “many experts recommend”: “…a low-fat diet such as the AHA diet, formerly the National Cholesterol Education Program or NCEP, based on the evidence for a atherogenic role for fasting cholesterol levels.” In other words, get your Total Cholesterol (TC) below 200mg/dl (with a statin) regardless of the lack of hard evidence to support lower TC in coronary care and CVD prevention.

“However,” they say, “evidence-based dietary recommendations for reduction of stroke risk are limited.” And then, interestingly: “The current recommendation for monounsaturated fat instead of saturated fat reflects the evidence that the source of dietary fat matters more than the proportion of calories from fat” (emphasis added). Very interesting, indeed! More evidence in the medical establishment’s thinking that the proportion of calories from fat now matters less than the type; still a lagging bias against saturated fat, but a green light for monounsaturated fat (olive oil, etc.) and no mention, and especially important, no advocacy for polyunsaturated fat (vegetable oils like soy bean and corn oil, e.g.).

If this sounds like the Mediterranean diet, well, it is. The editorial then swings full speed into an incestuous vortex of “validating the expectations of the perceived wisdom.” “Therefore,” it concludes, “it seems invalid to focus exclusively [?!] on protein (‘Eskimo Diet’) or what we have done with lipids in the past.” [Well, okay; that sounds like a mea culpa ON FAT]. “In other words,” they say, “eating vegetables, fruits and protein every day will help to keep stroke away!” A not very clever attempt at drollery, to be sure, but nevertheless, to this observant skeptic, some signs of transition in “the establishment.”

Wednesday, June 18, 2014

The Nutrition Debate #219: “Surgery Tops Usual Care in Obese Diabetics…”

The phrase “usual care” caught my attention in this otherwise unsurprising (I’ll explain) headline. These days the bariatric surgery business in on the rise, and self-serving articles like this one are all too common in the best peer-reviewed scientific journals. I found this one in an article by Marlene Busko in Medscape Medical news who was reporting on the June 11th special diabetes-themed issue of the Journal of the American Medical Association (JAMA), timed to coincide with the American Diabetes Association (ADA) 2014 Scientific Sessions which started in San Francisco last Friday.

“Usual care” is a “term of art” and so commonly used that Busko saw no need to describe it. It is certainly defined in the study itself or by reference in the practice guidelines of bariatric surgery physicians, but I will not bother now. That’s not what this study was about. This was about promoting bariatric surgery as the preferred course of action for the treatment of obese diabetics. For the record, the findings on the bariatric surgery option were from this 15-year Swedish Obese Subjects (SOS) study by Lars Sjöström, MD, et. al., at Sahlgrenska University Hospital in Gothenburg, Sweden.

The Medscape piece also quotes Anne Cappola, MD (Perelman School of Medicine at the University of Pennsylvania), a co-author of an accompanying editorial and a JAMA associate editor. Dr Cappola says, the study findings “validate the expectations of bariatric-surgery-associated weight loss and provide concrete numbers to cite.” Perfunctorily, she adds, “Diet and lifestyle measures will always be the cornerstone of diabetes therapy, but bariatric surgery is an option for patients who are unable to lose sufficient weight with diet and exercise and who are willing to accept the risk of bariatric surgery and comply with the lifestyle changes required after bariatric surgery” [emphasis mine].

So, let’s see what we’re being told here: 1) “Usual care,” whatever that is, usually doesn’t work, for many if not most obese diabetics; “Diet and lifestyle measures” (exercise, d’ya think?), as counseled by physicians who treat obese diabetics, are the cornerstone of diabetes therapy. “Usual care,” it would seem, are these “diet and lifestyle measures” (and counseling, of course). And when such measures fail over the long term to result in “sufficient” weight loss, the patient will then be counseled to consider the option of bariatric surgery. That is, if the patient is “willing to accept the risk of bariatric surgery and comply with the lifestyle changes required after bariatric surgery.

Okay, let’s review: “Usual care,” as currently defined by the standards of medical practice, is such a hopeless cause as to be forlorn. And, of course, the failure to achieve sufficient weight loss with “usual care” is laid on the patient, who was obviously “non-compliant” with the diet and lifestyle measures the physician had “prescribed.” So, surgery to the rescue! The doctor takes charge again, providing the patient is “willing to accept the risk of bariatric surgery and comply with the lifestyle changes required after bariatric surgery.” Risk? Wanna know more about the risks of bariatric surgery? Look here:

Note that many other surgeries have higher mortality rates, but they are performed on people who are quite ill.

And the “lifestyle changes” after bariatric surgery? What are those? Liquid meals only for weeks or months after surgery? Thereafter, only very small meals at frequent intervals because the stomach is no longer a large expandable storage pouch. And if you happen to eat more than your greatly reduced stomach capacity: nausea, projectile vomiting, “dumping,” etc.

Another point to bear in mind: These “lifestyle changes” are now life-long requirements. In contrast, the “lifestyle changes” of a low-carb “diet and exercise” program are volitional. You get a “holiday” from them now and then, if you want it, and the major downside is guilt (and a temporary weight gain or loss of blood sugar control). After bariatric surgery, you had better not try to take a break from your regimen; you will pay dearly for it. As a consequence of accepting the risk of bariatric surgery, you must comply with the lifestyle changes required after bariatric surgery. You are no longer “the master of your fate;” you are no longer “the captain of your soul.”
Of course, none of these consequences are necessary. You do not need to opt for bariatric surgery. You simply need to opt for a diet that works to achieve “sufficient” weight loss. Admittedly, it is also a lifetime requirement, if you want to maintain the weight you have lost (and all the other improved health markers) for the remainder of your lifetime – a lifetime that’s likely to last longer as well. My regular readers know, of course, that I personally adhere to a low-carb lifestyle. I don’t exercise. I don’t enjoy it. You can, if you like it, wait until you’ve lost 50 or 100 pounds (or more) to start an exercise program. You’ll enjoy it more and reduce your risk of injury when it isn’t so much work to lug around that extra weight. You could start off (as I did) on a Very Low Carb program (Atkins @ 20g/d or Bernstein @ 30g/d) to get a jump start.

Saturday, June 14, 2014

The Nutrition Debate #218: “Diabetes Causes Nerve Pain” – NOT!

Advocacy advertising riles me all the time, almost as much as grammatical errors by news anchors, talk show hosts and United States Senators. But advertising that is misleading, especially advertising that claims that others are being misleading while being themselves misleading, is the worst. They must think we’re all dummies!

My current favorite is a teachers’ union advocating for the Common Core curriculum. In it, a teacher (or an actor playing a teacher) says (I’m paraphrasing), “those opposed to the Common Core are misleading the public”; she protests “that Common Core does NOT tell teachers HOW to teach” (emphasis mine). “THAT is misleading,” she says. What she fails to say is that the Common Core DOES tell teachers WHAT to teach! Grrrrrrrrr!

Another TV commercial I’ve heard over and over says “Diabetes causes nerve pain.” I guess it’s a scare tactic. You’re supposed to rush to your doctor and ask him to prescribe this drug. It unnerves me to hear it. Diabetes does NOT cause nerve pain. Uncontrolled diabetes may lead to all kinds of complications (read the Introduction, 2nd paragraph in particular). Uncontrolled diabetes damages the microvascular system, specifically the tiny blood vessels in the extremities (legs usually), the eyes (the retina), and the kidneys. These complications can lead to amputations, blindness and end-stage kidney disease, requiring dialysis, until the end…

The mechanism is that when the blood supply is cut off to the tiny blood vessels, they don’t supply the nerves with the oxygen they need to function (receive and send signals); thus you become insensitive to pain or injury to your feet, for example.  A cut or some other undetected injury with the slow healing of an uncontrolled diabetic can thus lead to infection, then gangrene and amputation. One leg usually leads to another and before long you’re a short-timer. Okay, I’m resorting to scare tactics too, but it’s true.

Uncontrolled diabetes is the culprit, NOT diabetes. Frankly, I don’t understand how nerve insensitivity results in pain. How can something you can’t feel be painful? But that’s not the point. The point is that uncontrolled diabetes (Am I repeating myself?) is what needs to be avoided – and “treated” when it’s encountered. The worst thing you can do is ignore a blood sugar that is not in control. Over a period of time – admittedly, years – it will manifest itself. And you will likely die from it.

Getting your blood sugar to the point where it never exceeds 140mg/dl at any point after a meal and returns to under 100 mg/dl (if you are pre-diabetic or a diagnosed type 2) should be the goal. Any postprandial excursions above 140mg/dl are going to do damage to your microvascular system, slowly, very slowly, but surely. And remember that an A1c of 7.0% (the ADA recommended target!!!) is equivalent to an estimated Average Glucose (eAG) of 154mg/dl. If you have an average blood glucose of 154mg/dl (i.e., an A1c of 7.0%, the ADA recommendation!), just imagine how much of the time your blood sugar is above 140. Now, that’s scary.

So, how to you “treat” uncontrolled type 2 diabetes? You could ask your doctor, of course. He/she will prescribe a course of oral anti-diabetes meds, and tell you to lose weight, probably on a low-fat diet (to keep your cholesterol under control). You’ll probably also need blood pressure medication, maybe a cocktail of them. Oh, and of course, a statin, to lower your Total and LDL Cholesterol (because there are medicines that do that effectively, although the benefit of doing so has not been shown). Under this regimen, type 2 diabetes is a “progressive disease.” That is, your condition will worsen so, with time, you will take more and more medication, ultimately leading to injecting insulin 4 or 5 times a day. And don’t forget the complications. They’re in your future too. This is getting too scary even for me. But there is an alternative. Interested?

YOU could treat your type 2 diabetes. That’s right, YOU. You can control your blood glucose levels simply by controlling the things you put in your mouth. The foods (and beverages) that make your blood sugar rise ALL contain carbohydrates. Carbs, both the simple sugars (mono and disaccharides) and the more complex carbohydrates (both low and high glycemic index carbs) all convert via digestion to glucose, or sugar in the blood. When they are absorbed through the small intestine into the blood stream, they circulate throughout the body as glucose, accompanied by insulin secreted in your pancreas.

If you have T2 diabetes (or are prediabetic), your body is resistant to insulin uptake, so the glucose continues to circulate. You now have impaired glucose tolerance (IGT), which leads to impaired fasting glucose (IFG). In essence, you have become carbohydrate intolerant. To control your diabetes, you need to control (i.e., limit) the amount of carbohydrates you eat. It’s that simple…and not scary at all.

I’ve been writing about this subject for a few years. I’ve been a type 2 diabetic for 28 years, the last 12 on a Very Low Carb program, eating (mostly) healthy foods. I’m human. I slip a little sometimes, sometimes a lot, but for the most part I am much, much healthier today that I was 12 years ago. That’s when I discovered how important (and easy, really) it is to eat Low Carb. And, so far, I have avoided the “dreaded complications.” You can too, if YOU take charge of your diabetes health.
 Do you know any 25+ year diabetics without complications?

Wednesday, June 11, 2014

The Nutrition Debate #217: Type 2 Diabetic says, “I can eat whatever I want.”

I was seated next to a type 2 diabetic acquaintance at a fundraiser church supper last weekend. As the plates of food were passed around, I took a nice portion of ham and then (guiltily) a serving of cole slaw. I knew it was loaded with added sugar, but I also knew my other choices would be limited. I passed on the scalloped potatoes au gratin and the peas, and the bread basket, and the sweetened ice tea, each time passing the dish to my friend, who took a regular portion of each.

I didn’t say anything, but I thought to myself how can he do this to himself? This man is somewhere in his eighties, skinny as a rail and looks very healthy. Maybe the question, however, should have been, how does he get away with eating like this? So, somehow I managed to open the subject with him. He responded by saying, “I can eat whatever I want.” He then reached down to his belt and, out of a small pouch, raised his pump controller to show me how he does it. My friend, it turns out, is an insulin-dependent type 2 wearing a pump that allows him to set the amount of basal and mealtime insulin (or “bolus”) before each meal. So, he knew what was for supper – it’s the same every year – and he had given himself a “shot” via the needle imbedded under his skin. Voila! He can now “eat whatever he wants” and “cover” it with insulin.

Managing type 2 diabetes with injected insulin has heretofore always been the last resort of pharmacotherapy. Type 2s used to be started on a course of oral pharmaceuticals and told to continue to eat a “balanced diet.” As one drug failed to achieve the desired control (A1c’s within the ADA recommended range of 7.0%), the dose was increased and/or another class of oral antidiabetic drug was added until the patient, still eating “a balanced diet,” was maxed out on three classes.

Then, the dreaded insulin injection, by needle and later by pen, was employed for basal (slow acting for 24 hour control) and mealtime “boluses.” Today, the introduction of other classes of orals, and the GLP-1 injectables (Byetta, Victoza and the once-a-week Bydureon), and most recently new drugs (flozins) that work on eliminating sugar in the blood via the kidneys, have enabled some patients to delay multiple daily injections. And “the pump” has replaced them all, for those who use it.

Another recent development has been the introduction of insulin as a first course of treatment (after the oral Metformin). The rationale is that if you eat a low carb dietary, and inject a low dose of basal insulin once or twice a day, you can potentially achieve better control by reducing postprandial spikes (elevated blood sugars after meals), thus achieving A1c’s in the 5s or even 4s vs.7.0%. Better control means the surviving beta cells of the pancreas get a rest. An A1c of 7.0% is equivalent  to an estimated average glucose (eAG) of 154mg/dl, but an A1c of 6 is an eAG of 126 and an A1c of 5 is an eAG of 97. This improvement will surely reduce the possibility of the complications of poorly controlled diabetes: retinopathy, neuropathy, and nephropathy. Translation: blindness, amputations and end-stage kidney disease. Plus a much greater chance of a heart attack. Any time your blood sugar is above 140, you are causing damage, and an average of 154 means it is above 140 a lot. It is, in my opinion, bordering on criminal to counsel patients to only strive to achieve an A1c of 7.0%.

I don’t write about insulin dependent type 2s because I know very little about it. Years ago I read Richard K. Bernstein’s Diabetes Solution, the definitive source book on the subject (for both type 1s and type 2s), but promptly forgot most of the details. His latest edition is very highly regarded among the cognoscenti. It is the “bible” for the growing numbers of T2s as well as T1 diabetics who have discovered the best way to manage and control their disease is to eat Low Carb with an insulin regimen. It is the blue print for anyone interested in or required to inject insulin to control their diabetes.

But because I rely on my dietary choices to directly limit the response of my (broken) blood sugar metabolism, I’ll bet my blood sugar is more stable, with fewer excursions, and therefore better controlled, than my friend’s, except at this particular supper. I’d even venture to wager that my A1c is lower than his. I didn’t ask him his, as A1c’s can rise with age anyway. He, and his doctor apparently, are happy with whatever it is, and he was very happy to “eat whatever he wants.” That is another way to go. Not mine, but it apparently works for him.
My friend was not among these people who “eat low carb with an insulin regimen,” and he chose to “eat whatever he wants” at the church supper. In this instance he had the advantage over me, and I admit to being a bit jealous. If he calculated his carbs accurately (a very big “if”), his blood sugar excursion would be lower than mine since I had no counter measure to employ to control mine other than “passing” on the cole slaw, and the strawberry shortcake for dessert. I succumbed there as well, by the way. Alas, under some circumstances, eating Very Low Carb can be difficult and frustrating.

Saturday, June 7, 2014

The Nutrition Debate #216: Is Low-Carb High-Protein or High-Fat?

The cognoscenti (my regular readers, who are “in-the-know”) know that the answer to this question is high-fat. But I squirm in my seat when I hear someone who appears to be informed on the subject of low-carb dieting say, “it is high-protein.”

That happened again last night while I was watching – reveling  really – in a discussion on one of my favorite TV shows in which the subject of an entire segment was the recent Wall Street JournalSaturday Essay,” titled, “The Questionable Link Between Saturated Fat and Heart Disease.” This person accurately blamed the obesity epidemic on the American (or Western) diet which is very high in carbs and processed foods; but then he proceeded instead to advocate for a diet high in protein! That is WRONG, WRONG, WRONG!

Of course, I shouldn’t complain about the “back side” of the message being garbled. The “front side” was right: diets that are very high in carbohydrates and processed foods ARE the reason we as a civilization for 50 years have been getting fatter and fatter.  And the Wall Street Journal article got it right. Had the person who “appears to be informed” done his homework (read the WSJ article), he would have known that. If you haven’t you should read the Journal piece now. They also correctly noted that the beginning of this very large, population-wide, public health “experiment” in eating “low-fat” can be attributed to Ancel Keys. Gary Taubes (#5 here) brought him to my attention, and I first wrote about Keys here (#3).

Keys was an American physiologist whose “Six Nation” and later “Seven Country Study” was just bad science and, incredibly, became dietary dogma when it was first published. Keys made the cover of Time Magazine in 1961 and joined the board of the American Heart Association. This was just a few years after President Eisenhower had had his heart attack and went on the Pritikin diet. Keys’s studies, which were later revealed to be “cherry picked,” focused on the Mediterranean Diet. He reported the use of very little red meat (there isn’t much red meat to eat there anyway) but the sampling was done during Lent in a Catholic country!

Anyway, a low-carb diet, which is the antidote to the fattening low-fat diet (you read that right), is high fat and not high-protein. Let’s talk numbers (percentages) for a few minutes. Diets can be classified in what are called Macronutrient Ratios:

The Low Fat Diet: The Standard American Diet (SAD, for short!) is high carb, moderate fat and low protein. The FDA’s Nutrition Panel on processed foods, based on a 2,000 calorie a day diet, is comprised of 60% calories from carbs, 30% fat and 10% protein. The dietary Dictocrats have moved slightly away from that formulation in recent years, advocating as low as 40% to 50% carbs, but steadfastly maintaining at the same time a target of less than 30% fat. That can only mean an increase in protein. To the extent carbs are reduced (from 60%) and fats do not exceed 30% (and a lower percentage is advocated by the FDA), only protein can rise. Remember, there are only three macronutrients: carbs, fat and protein. Something’s gotta give.

Another thing: To the extent that the Vegan lobby has stealthily exercised its stranglehold on the government‘s dietary bureaucracy, a plant-based diet is increasingly being advocated. Plants are carbohydrates. Most protein (not all, there are some proteins in legumes and nuts) is animal-based. So, the struggle to maintain a high-carb, low-protein macronutrient ratio goes on within the establishment. It will be interesting to see the 2015 Nutritional Guidelines for Americans.

The Low Carb Diet: The macronutrient ratios for a low-carb diet are all over the place. This is okay with me since making a transition from 60% carb to 40 to 50% to say 20% is a very good thing – but it takes time and a lot of effort. Besides, there is no “official” percentage for a low-carb diet. So, let’s say for our purposes that a standard low-carb diet is 20% carb, 20% protein and 60% fat. That’s really scary to some people, especially when there is so much confusion about “good” fats. That’s why the WSJ article caused such a stir. (Google “the nutrition debate good fats” for some of my columns on fat.) But there is another mitigating factor: All these percentages are in calories, and since fat has more than twice as many calories per gram as both protein and carbohydrates (9 vs. 4), you really are eating less than half as much fat as you think.

Very Low Carb: When I first started low carb dieting, it was on Atkins Induction, which is actually Very Low Carb: My ratios (not Atkins’s) were 10% carb, 30% protein and 60% fat. I later tweaked that to 7% carb, 25% protein and 68% fat. Today, I aspire to eat 5% carb, 20% protein and 75% fat (by calorie, remember). Of course, you don’t eat percentages of food; you eat grams, which are actually a measure of weight of the macronutrient content of a particular food, not the weight of the food itself. These quantities are determined by software that some of the compulsive among us (including me) have used.

So, low-carb is really moderate protein and high fat. The lower the carb percentage, the higher the fat. Some call it LCHF. Google The Diet Doctor (Andreas, Eenfeldt, MD) if you want to learn more about LCHF.

What does your eating plan look like?

Friday, June 6, 2014

The Nutrition Debate #215: Just Google “The Nutrition Debate”

I’ve been writing this column, and blogging twice a week at, for several years. Blogger, the platform that I use, has a “follower” function, but it no longer works in Internet Explorer (Google wants me to switch to Chrome). Many of my regular readers follow me by RSS feed, available at the top of the blog in the Blogger format, but most of my new readers are introduced to “The Nutrition Debate” by Google searches on topics of interest to them, and that’s fine.

Blogger provides me with some simple statistics or my readership by day, week, month and all-time. It also tracks my audience by country, traffic source, and post (column), so I have a broad idea of who, how and what my readership is. More than half of my readers are in the U. S. Other countries where I am widely read include the UK, Canada, Germany and France. Recently I had over 1,000 page views in a 1-hour period from Israel. (I’d love to know how that happened and what the Israelis found so interesting. So if somebody knows, please leave a comment or send me an email.)

I also have a loyal following in Sweden, Russia, Hong Kong and Singapore. The Singapore readership in on a site where a very popular and avuncular social network leader writes on the subject of “Clean Eating.” He provides occasional links to my columns and has even posted a few as permanent resources for his multitude of followers.

It also appears that someone in both China and Ukraine has “hijacked” my content (with or without attribution, who knows?) and appears to post everything I write. They may use Google Translate to post them in Chinese and Russian – again, who knows? I just know that in the last year I have been getting many thousands of page views from China and Ukraine. If somebody there can tell me how that is happening, I’d like to know. I don’t object, mind you. I write this column for educational purposes and have no pecuniary interest in it. There is no revenue, and I have no interest in ever commercializing it.

This might also be a good time to mention that I have a wonderful and intrepid “volunteer editor,” a person who makes my writing clearer, checks my facts, and whose digital resources are almost as vast as Google’s (slight exaggeration there). Her acumen in all things health and nutrition is only exceeded by her generous heart and her interest in spreading the word about good nutrition and healthy eating.

So, as Google seems to be the main, continuing source of new readers, I encourage this method of using that search engine. Just as Google has a “feeling lucky” search function, you could do the same. Just type “The Nutrition Debate” in the “window,” hit “enter,” and let ‘er rip. I guarantee that my blog will come up first and perhaps again on the first page as well. Who knows what Google will find for you that may be of interest? Google’s selects. You choose.

Of course, if you want to do a more targeted search, you could do something more “advanced.” Enter “The Nutrition Debate” and then another word or phrase of interest to you. Let Google do the work. To see how well this works, I just entered “the nutrition debate triglycerides” and all ten (10) Google results were columns that I have written on triglycerides. This works very well in the absence of “tags,” “labels,” or “key words.” Who needs an alphabetical Index or even a Table of Contents?

On the other hand, if you’d like to see a list of all my columns, in some browsers you can see a list in the order written at the top right corner of the homepage, listed first under “Favorite Links and Videos.” Alas, this no longer works in IE either.

So, if you are one of those who increasingly rely on Google (or another search engine), as I do, I encourage you to try the advanced search technique described above. I am too lazy, and too much of a Luddite, at this point, to go back over 214 columns and enter tags, labels and key words. Use technology to search instead. It works for me. Just Google “the nutrition debate” and another key word or phrase, press “enter,” and “get lucky.”

Then, if you like what you have read, go to the RSS feed and get my blog delivered twice a week to your hand-held device, tablet, laptop, or work station. And by all means, send me your comments and ideas. I’m always looking for subjects of interest to both me and my readers.