Sunday, March 27, 2016

Type 2 Diabetes, a Dietary Disease #321: "Energy In" at the Cellular Level

Sometimes I can be pretty dense, or at least slow to comprehend something I have read or been told. A recent example is my understanding of the definition of Macronutrient Ratios and their application to “energy in.”
I first became interested in my “intake” ratios, that is, in the ratios of carbohydrate, fat and protein that I took into my body via mouth, i.e. what I ate – about 10 years ago. I was a pretty na├»ve “kid” at the time and created my initial ratio using a flawed model. Miraculously, it worked. Somehow, I lost 170 pounds altogether, and I did it without getting sick. In fact, there is not a doubt in the world about it: I got healthier and healthier!
Over the years the ratios changed somewhat, more from what I would call fine tuning than a conscious understanding of the model I was employing. I was just lucky, I guess, because the model was faulty. Anyhow, all of my ratio compositions had 3 things in common: a goal of being close to or in a mild state of ketosis most of the time. They were all very low carb, moderate protein and high fat. I gave special attention to the protein amount, ensuring it was adequate but not so much as to engender unwanted gluconeogenesis. And I was taking 500mg Metformin once a day for that. From the start I ate 3 small meals a day, equally spaced about 5 hours apart.
(One of the early errors I made was how to figure the amount of protein to eat at each meal. I erroneously based it on an amount in grams per pound (or kilogram) of total body weight. That is not correct. It should be calculated on grams of lean body weight (LBW), or “ideal body weight,” not total body weight. You don’t need to eat protein to support fat. Your requirement is based on muscle mass, and other bodily needs for protein.)
Nevertheless, the ratios changed from 7% carbs, 28% protein, and 65% fat to more recently 5% carbs, 20% protein, and 75% fat. All my ratios were based on “intake,” i.e. food by mouth. They did not take into account any energy that my body consumed when it was burning its own fat – the fat stores in my body. And whenever I was losing weight, my body fat was part of the equation and therefore a component of the ratio at the cellular level.
This error in my thinking was brought to my attention three times before it stuck. The first was by my editor. I have a vague recollection that when I first began writing this blog about five years ago, she mentioned it to me in an aside or comment on my writing. I glossed over it, but apparently it stuck somewhere in the back of my brain.
The second was in a chapter in Volek and Phinney’s, “The Art and Science of Low Carbohydrate Living,” in my opinion the best book on the subject for a popular readership. And the third was recently in a very good column, “Don’t Force the Fat,” by the blogger and nutrition consultant, Kelley Pounds, at Low Carb RN (CDE). She uses bar graphs from Volek and Phinney and pie charts from another source to explain the contribution of body fat to the fat portion of the macronutrient ratio during the fat loss phase. As Kelley puts it succinctly, “My formula is low carb + moderate protein + moderate DIETARY fat + BODY FAT = LCHF.” I couldn’t have said it better myself!
Kelley came to this insightful conclusion after some rather blunt introspection: “For a while I wondered how I could be in nutritional ketosis, and either not lose…or sometimes actually gain weight. How can that be if I’m burning body fat?  Then I realized, I was just taking my old overeating habits and changing the source. So while I was keeping my carbs very low, and my protein moderate, I was overeating dietary fat. I was overeating period. I wasn’t listening to my body’s satiation signals…” This is good stuff! You should open the link above and read it.
Kelly concludes, “So while fat is not something to be feared, it is also not something to be gorged on…unless you need to STOP losing weight. That sounds like a good problem to have…I’ll cross that bridge when I come to it,” she says. I know where she’s coming from. “How many of us out there have already reached the point where we need to STOP losing body fat?” Ruefully, I agree. Not many. And now I understand, finally, that my macronutrient ratios were more “extreme” than I’d thought. All I have to remember now (from #319 here) is to 1) strictly follow a low carb diet, 2) eat only when hungry and 3) “listen to my body’s satiation signals.” Simple enough, right?

Sunday, March 20, 2016

Type 2 Diabetes, a Dietary Disease #320: “Total Fasting Reduces or Eliminates Hunger”

As related in #319 here, to jump start weight loss I began a major change in my lifelong eating pattern. If successful, I am prepared to continue this new routine until I achieve my goal, then reassess. However, it is unlikely that I will transition at that point to “maintenance;” it is more likely that I will set a new goal and continue the weight loss. After all, why mess with success? I will still have a lot of weight to lose.
The modified plan basically incorporates a daily fast (7 days/week) from supper to lunch. That entails skipping my (our) traditional breakfast of eggs (mine was 3, any style). The plan also requires me to only eat when hungry, and only until I am sated. So, to work these parameters into my plan, I have prepared my lunch in advance: a covered container of hard boiled eggs in the refrigerator. That provides portion control and allows me to eat just enough to “satisfy.” As an alternate lunch, I also have a tin of Brisling sardines in EVOO, another portion controlled meal.
Here’s where it gets interesting. I decided to skip breakfast because I observed that after an overnight fast I was never hungry at breakfast. So from the standpoint of adhering to the new “plan” to incorporate a longer fast and eat only when hungry, skipping breakfast makes sense. But because I’m married and try to maintain an eating pattern compatible with a “family” lifestyle, I make a cup of coffee every day when I rise and then save some to “eat breakfast” (take my pills) with my wife. The coffee contains a little cream, but not enough to break my fast.
Then lunch time rolls around. My wife told me long ago (right after we retired) that she “married me for better or worse, but not for lunch.” So, not eating lunch with her was not a problem. Before my new eating pattern, lunch was usually a can of Brisling sardines packed in EVOO. (Omega 3s, MUFAs, portion control and no dishes.) This lunch, together with 2g of fish oil a day, has produced fabulous triglycerides for over a decade (all <50mg/dl).
Now, with the new dictum to “eat only when hungry,” around lunch time (1-3PM), I usually eat just 1, sometimes 2, hard-boiled eggs. Why? I am still not hungry at lunch, ‘cause I have become keto adapted. So, 1 or 2 eggs is a token, a “protein-sparing” offering to my body: 6 or 12 grams of protein, and some good fats to go along with it.
Naturally, I am now getting a little concerned about my total calorie intake. No conventional Registered Dietician (RD) or Certified Diabetes Educator (CDE), or clinician (MD), would counsel someone of my gender, age, weight and activity level to eat as little as 1,200kcal/day (which is how I achieved most of my 170 pound weight loss), much less as little as 800kcal/day. But that’s where it looks like I’m going. My “3-small-meals-a-day” plan had been 375 + 375 + 450 = 1,200kcal. My predicament was a bit of a conundrum, until I considered total energy expenditure. Fasting “reduces or eliminates hunger” because the body is happily feeding on its own fat reserves.
Total energy expenditure, at the cellular level, is what your body is oxidizing, or burning, to supply all your body’s energy needs. If you are eating a balanced diet that includes beaucoup carbs, it will burn the carbs (and protein and fat) you eat and then tell you that you are hungry for more. It does this because 1) it assumes you have access to more carbs and, therefore, 2) it does not (i.e. cannot) burn fat that it has conserved in your body, for this very purpose, because access to it is blocked. You are, in fact, quite literally starving. Your body does this “dirty trick” on you with hormone signaling between the gut and the brain. The hormone insulin is the switch.
But when you become ketoadapted, by abstaining from eating carbs for 1-3 days, your blood insulin level drops, opening the switch to your body’s fat reserves. From this point on, so long as you abstain from eating more than incidental carbs, your body burns whatever you eat first and then effortlessly (without hunger) switches over to burning fat, your body fat. Body fat breaks down into free fatty acids (FFAs) and ketone bodies, excellent sources of fuel for both brain and heart. You are in a blissful state called “ketosis.”
As the NIH’s Richard L. Veech told Gary Taubes here, “Doctors are scared of ketosis. They're always worried about diabetic ketoacidosis. But ketosis is a normal physiologic state. I would argue it is the normal state of man.” 

Sunday, March 13, 2016

Type 2 Diabetes, a Dietary Disease #319: Losing Weight and Keeping It Off

As anyone who has ever tried it knows, losing weight and keeping it off is the proverbial double-edged sword. When my doctor suggested I try Atkins Induction in 2002, I lost 60 pounds in 40 weeks. A few years later, I re-gained 12. Then, by browsing the web, I found Dr. Richard K. Bernstein’s diet. I had been a Type 2 Diabetic for about 18 years so I tried it and lost 100 pounds in 50 weeks. Eventually I lost another 20 or so (170 total); over the ensuing years I re-gained almost 70. Net lost after 14 years: still well over 100 pounds, but disappointing.
From the beginning my efforts have been challenged by compliance issuesand always somewhat constrained by culture, tradition, and habits. They die hard. Because I’m married and try to maintain an eating pattern compatible with a “family” lifestyle, I have settled into a Way of Eating (WOE) consisting of 3 small meals a day. We always eat breakfast together, eat separate lunches (she married me for better or worse, not for lunch, she says), and a small supper together. Our meals are spaced 5 hours apart, leaving a 14-hour fast after supper. My snack, if I eat one, is before supper. These days it’s sliced radishes with salt – I forego the butter – with a drink.
Last summer, with renewed resolve, I decided to deal with the “compliance issue” and began to lose weight again. However, after losing about 20 pounds, my weight loss stalled. We moved to Florida for the winter, and some old habits began to kick in. So, I decided a more radical approach was required to kick start my weight loss again. Andreas Eenfeldt, M.D., "The Diet Doctor," came to my rescue. As part of a bonus for being an email subscriber (not a “member”), I was entitled to watch two videos. The 2nd one did the trick for me. 
In his podcast Andreas advised a 5-step approach to weight loss, and I have adopted it. If you’re not a subscriber to his blog, you may not be able to view it, so I’ll summarize it here succinctly, as I have interpreted it:
1.  Follow strictly a low carb diet.
2.  Eat only when hungry.  
3.  Sleep 8 hours a night.
4.  Weigh yourself daily.
5.  Exercise (“No! Just kidding,” he says; LOL) Intermittent Fasting
The two forms of Intermittent Fasting (IF) that The Diet Doctor “prescribes” are: 
   a. 5:2, in which you eat “normally” for 5 days a week, and then no more than 500-600 calories a day on the 2 fasting days. I don’t really consider that fasting; to me, that’s a big meal and just an invitation to stall!
   b. 16:8, in which you fast 16 hours, and then eat all your food within an 8 hour window. I can do that easily. In fact, I can do better. I am never hungry in the morning. I am usually up and working or reading for 3 hours before we eat breakfast together, and I’m still not hungry then. So, I’ve started to skip breakfast. I make a cup of coffee when I rise, and I save some to take my pills at the table with my wife. Then, I eat a late lunch, my first solid food for the day, and our usual small supper, sometimes with radishes, salt, and diet tonic or vodka tonic beforehand.
Lunch is usually just one or two hard boiled eggs. If I’m not hungry, it’s one or none. Alternatively, I sometimes eat my old standby lunch: a can of Brisling sardines in olive oil. (Good for Omega 3s – I also supplement with 1 gram of fish oil twice a day.) And I plan to start supplementing with ketones. A lot more to come on that shortly.
Supper is just a small serving of protein and a low-carb vegetable roasted in olive oil or tossed in grass-fed butter, or a salad tossed in my homemade vinaigrette dressing. Some examples of other light suppers can be foundhere.
My goal now is to lose another 10 pounds before leaving Florida, and 20 more by the 1-year anniversary of this, my latest weight loss odyssey. That’s fifty total, and 150 from the start. I hope my marriage survives.

Sunday, March 6, 2016

Type 2 Diabetes, a Dietary Disease #318: The Mystery of Antonin Scalia’s Sudden Death

The headline in the LA Times/AP story:“Scalia's death probably linked to obesity, diabetes and coronary artery disease, physician says.” The lede in the story was, “Antonin Scalia suffered from coronary artery disease, obesity and diabetes, among other ailments that probably contributed to the justice's sudden death, according to a letter from the Supreme Court's doctor. He said the long list of health problems made an autopsy unnecessary.”
According to a letter from his attending physician, “significant medical conditions led to his death.” The AP said that the letter “listed more than a half-dozen ailments, including sleep apnea, degenerative joint disease, chronic obstructive pulmonary disease and high blood pressure. Scalia also was a smoker, the letter said.” That’s quite a list. So mainstream medicine comfortably reached a consensus that he was a very sick guy.
Antonin Scalia died peacefully and suddenly in his sleep at age 79. Given his multiple medical conditions, that was neither a surprising nor a premature outcome. But it didn’t have to be – premature, that is. He might have been expected to live well into his 80s or even longer. Given his multiple conditions, however, it is in fact somewhat surprising that he lived as long as he did. It’s a credit to modern medicine and to the medical care he received.
I have neither a prurient interest in his cause of death, nor do I suggest or support any conspiracy theories. Rather, I wish to use Scalia’s death to emphasize, as Jenny Ruhl (at “Blood Sugar 101”) points out here with more than a dozen links, “Heart attack risk more than doubles at blood sugar levels considered to be ‘PREDIABETIC.’”
As the LA Times headline shouts, blood sugar levels and obesity and cardiovascular risk are all related; and the risk of heart attack, or a fatal heart arrhythmia (the probable cause of Scalia’s death), can be reduced by losing weight and controlling blood sugar levels…as I have said here ad nauseam. More easily said than done, you say?
Well, consider this related Associated Press story, filed by David Warren in Dallas, TX, that included an interview with a physician of internal and emergency medicine at Northwestern Memorial Hospital in Chicago. He said, “The justice's many ailments, taken together, were ‘quite dangerous,’” and “he would advise a patient with those conditions who was still smoking to stop smoking first and then lose weight.” Okay, that’s fair, but so facile.
“Those are the main two things someone in his position can do himself,” the doctor said, without suggesting how to lose weight. He knew full well that most patients who follow medical advice on how to lose weight will fail, but that’s on the patient. (The doctor simply notes in the patient’s medical record, “patient non-compliant.) “The rest falls on the physician,” he said, “to medically manage blood pressure and make sure their blood sugar levels are controlled well.” But all of these things are related, and all of them are things someone can do himself. The effect on the body is synergistic. And the catalyst that gets them all to work together is a Very Low Carbohydrate diet.
The body can heal itself, can achieve homeostasis at a new, much lower set point: a “happy,” balanced, healthy body. As you eat Very Low Carb, 1) you lose weight (without hunger), 2) your blood sugar levels and your bloods lipids (cholesterol) improve; and 3) as you lose weight, your blood pressure improves and your cardiovascular risk declines. You feel good. You’re not hungry all the time. You’re not lethargic or sleepy after a meal. You have lots of energy.
You don’t need to rely on your doctor to over medicate you for blood sugar control or maybe even blood pressure. (I still take blood pressure meds, but after a large weight loss my BP went from 130/90 to 110/70 on the same meds.) And after eating Very Low Carb consistently, my HDL-C doubled and my triglycerides dropped by two-thirds; my doctor took me off the statin I had taken for five years. And all those oral meds for type 2 diabetes? Within days of starting to eat Very Low Carb, I had to give them up to avoid hypos!
Of course, after living a relatively long life, dying suddenly and peacefully in your sleep isn’t such a bad outcome.