Sunday, July 31, 2016

Type 2 Diabetes, a Dietary Disease #339: Low Carb? “It’s not a diet,” I blurted.

Those in the know – the cognoscenti – know that eating Low Carb, or Very Low Carb, is not a diet; it’s a Way of Eating  (WOE). And in the parlance of the medical establishment (skewed to my purpose), it’s a lifestyle change.
It’s also true that if you make this lifestyle change – that is, follow this WOE – you will lose weight, but that’s a secondary or “side” effect. Of course, you might make this change with the purpose of losing weight (as my doctor suggested I do), but even if that’s your primary motive, the effect on your general health, in many respects beyond weight loss, will be a much broader benefit than the lost weight: e.g., lipids (cholesterol), blood pressure (hypertension), and inflammation markers like hsCRP.
It’s worth noting, however, that in “prescribing” Very Low Carb (VLC) my doctor didn’t know this. He must have had an inkling though because as he walked me down the hall to schedule my next appointment, he put his hand on my shoulder and said, “Dan, this might even help your diabetes!” I was morbidly obese and had been a diagnosed Type 2 diabetic for 16 years. That was 14 years and 140 pounds ago. And within a day of starting VLC, I had a hypo. I called him and he took me off the 3rd oral med that I had just started. The next day, after another hypo, he cut the other two “maxed out” oral meds in half, and a few days later he had to cut them in half again.
So I guess it’s fair to say the Very Low Carb WOE did help my diabetes, as my doctor thought it might – even though that was NOT the reason either he put me on it or I agreed to do it. We both wanted me to lose weight – he because he thought (wrongly) that obesity was a “risk factor” and possibly a “cause” of type 2 diabetes. In point of fact, as many doctors and others “in the know” now understand, insulin resistance, the condition that leads to Type 2 diabetes, is what causes obesity, as I’ll explain in a moment.
If it makes sense to you that eating low carb is a safe and effective way to lose weight, as is now generally accepted by most “establishment” medical researchers, clinicians, food writers, pundits and TV personalities, doesn’t it make sense that eating a high carb diet is how that weight got on our bodies in the first place? Surely you’ve heard it; it’s been reported ad nauseum. And everyone knows how they fatten feed-lot beef; they feed them corn from a trough for weeks on end! So, why does our government still push a high carb diet on everyone – one size fits all – even the overweight, obese, insulin resistant, pre-diabetic and Type 2s among us?!!!
If you’re genetically predisposed, a diet very high in carbohydrates (say 60%, the amount on which the % Daily Value is based on the USDA’s Nutrition Facts panel), especially carbs that are refined and thus “pre-digested,” leads to overload on the liver and on insulin receptors on the surface of cells that take up the glucose. The overload results in backup which results in resistance (in the destination cells) and conversion (in the liver).
The pancreas responds by secreting more insulin to help the destination cells take up the glucose, producing thus an elevated level of insulin circulating in the blood. In the liver, when it’s full of glucose (glycogen in the storage form), it makes fat. And when the brain gets the signal that there’s an elevated level of insulin circulating (to help the resistant cells take up the glucose it is transporting), it gets the message that it doesn’t need to break down body fat for fuel. It can run on all that glucose “going around.”
Eventually, with all that insulin circulating, the glucose gets taken up and your blood sugar crashes. Your body now needs, indeed craves, more fuel to maintain a steady energy state (homeostasis). But with your insulin still elevated, the signal to break down body fat for fuel is blocked, so your body tells you to eat. Your chance to burn body fat is lost. When you then eat or drink to satisfy your hunger, this overloads your already full liver, which converts the carbs to fat (de novo lipogenesis).
If you’re lucky, you’ll just get fatter; you won’t get non-alcoholic fatty liver disease (NAFLD).

Sunday, July 24, 2016

Type 2 Diabetes, a Dietary Disease #338: Moí? Grumpy or Grouchy?

“Claiming a [math] ‘block’ just doesn’t cut it with me,” I told a friend whom I’m mentoring…and she shot back, “You might have an empathy block.” Apparently I had touched a nerve, and I deserved that riposte.
She wasn’t through with me, though. She then raised another issue. She said that I said that exercise “makes me ‘grumpy or grouchy.’” I replied that I had said no such thing. I said exercise makes me sweaty and hungry, to which she replied, ‘Okay, I’ll give it to you. I stand corrected and apologize,’… but then she added this zinger: “Why would I think of you as ‘grouchy and grumpy,’ I wonder?” Hmmm…That got me to thinking.
Years ago I helped the circulation of a couple of local weekly newspapers by writing a “Letter to the Editor” every week during heated debates over issues like school district capital budgets and land use issues. One issue was a zoning change to permit quarrying in a rural residential district. Apparently my letters were such a boost to circulation that the editor of one of the papers and the publisher of the other invited me to write a weekly column. The editor actually suggested it be called, “The Country Curmudgeon.”
I declined. I didn’t think of myself that way, and I was dismayed that others thought of me as curmudgeonly. I was just trying to shine a light, I thought, on what was “wrong” for our community. My goal was to educate and thus influence the reader (and voter) on these issues. In the school district’s capital budget, I was a community member of the School Board’s Facilities Committee and faithfully attended weekly meetings to be informed and participate. My letters were pretty edgy though. One critic fairly and accurately called one of them “vitriolic.”
So, I am continually wary of being overly negative about nutrition. I do, however, occasionally rant about a particularly egregious pitch for some so-called “healthy” processed food. And I am angry, most assuredly with good cause, at our government, especially the USDA, and the ADA, the AHA and the AMA. The reason is simple, as Dr. Tim Noakes explains #334, “A Unifying Hypothesis of Chronic Disease, Part 1,” and particularly in his pithy #335, “Implications of Reaven's Unified Hypothesis, Part 2.” With titles like that, nobody’s gonna read them, so do yourself a favor and click on those links. You won’t regret it, and you’ll thank Dr. Noakes for his courage.
So, if I occasionally express a little anger and use a little invective, or even if I’m at times “vitriolic,” and that equates with “grumpy and grouchy,” well, that’s a price I’m gonna have to pay. As Evelyn Stefansson, wife of Vilhjalmur, said, in the preface to Richard Mackarness’s 1958 book, “Eat Fat and Grow Slim,”
“Stef used to love his role of being a thorn in the flesh of nutritionists. But in 1957 an article appeared in the august journal of the American Medical Association confirming what Stef had known for years from his anthropology and his own experience. The author of this book has also popularized Stef's diet in England, with the blessing of staid British medical folk.
“It was with the faintest trace of disappointment in his voice that Stef turned to me, after a strenuous nutrition discussion, and said: "I have always been right. But now I am becoming orthodox! I shall have to find myself a new heresy."
You should really read the entire 1-page preface (#151, here). It’s an homage to her husband, the famed explorer-anthropologist Vilhjalmur Stefansson. I wrote about him in “Stefansson and the Eskimo Diet” (The Nutrition Debate #61). If you don’t know his story, that’s another link I encourage you to read. Stef was “right,” and after a year on a special diet of just fatty meat and offal, the staff of Bellevue Hospital had to admit it.
Well, I haven’t gone to those extremes, but as Vilhjalmur did, I have improved my health tremendously, I by eating a diet of mostly fat, moderate protein, and very low carb. I’ve been doing it for 14 years now, and I feel great!

N.B.: Stefansson's "Eskimo diet" was 100% protein and fat, including lots of offal (organ meats). 

Sunday, July 17, 2016

Type 2 Diabetes, a Dietary Disease #337: Facts and Fallacies About the Nutrition Facts Panel

Probably more than half my readers are women, but I’ll venture that almost all (both men and women) are deceived, I believe intentionally, by the USDA’s design of the Nutrition Facts Panel on manufactured “food” products. Many women especially have been handicapped by their refusal to use their intelligence to do a little simple math. Claiming a “block” just doesn’t cut it with me.
The most recent example came to light when my pre-diabetic friend (and new LCHF acolyte) thought she was in compliance with her announced plan to eat only 15-30g of carbohydrates per meal. For her convenience, she wants to continue to drink a meal replacement or “snack” beverage called Glucerna Hunger Smart Shakes, which, according to their website, is “specially designed for people with diabetes.” The Nutrition Facts Panel on the product says it contains 180 calories, with 8g of fat, 15g of protein and 16g of carbohydrate.
I told my friend that this beverage was 35% carbohydrates and that that was a higher percentage of carbs than I thought she wanted to eat (on her new LCHF 60/20/20 eating plan). She replied by sending me the percentages on the label that she apparently believed were the percentages of calories in that serving: FAT 12%; CARBS 5%, and PROTEIN 30%. I inferred that she thought that the product she drank was just 5% carbs. In fact, the actual percentages of calories in that serving are 40% FAT, 27% CARBS (see footnote*) and 33% PROTEIN.
How can that be? Well, for starters, the percentages on the Nutrition Facts panel are the percentages of the USDAs catastrophic recommendations for “% Daily Values (%DV)”: That recommendation is CARBOHYDRATES: 300g a day for women and 375g a day for men; PROTEIN: 50G; and FAT: 67g. By percentage of calories, that’s 60% CARBOHYDRATE for both men and women, 10% PROTEIN AND 30% FAT. The USDA doesn’t care if you’re diabetic or pre-diabetic, young, old, active, or sedentary. USDA’s Nutrition recommendation is one-size-fits-all.
The % Daily Value then – the % that appears on the label on the Nutrition Facts panel – is a percentage of our government’s horribly flawed dietary regimen that is WHOLLY UNHEALTHY FOR ANYONE, much less someone with Insulin Resistance who has been told they are pre-diabetic. What matters is the percentage of calories by macronutrient in the product in hand. The Nutrition Facts panel doesn’t tell you that. You have to do the math.
     Protein contains 4 calories per gram, so to get protein calories, multiply the protein grams by 4 and then divide that by the total calories to get the percentage of protein in the product.
     Carbs also contain 4 calories per gram, so to get the carb calories, multiply the carb grams by 4 and then divide that by the total calories to get the percentage of carbohydrate in the product.
     Fat contains 9 calories per gram, so to get the fat calories, multiply the fat grams by 9 and then divide that by the total calories to get the percentage of fat in the product.
I do these in my head to get a rough number, which is always good enough. But if you don’t want to do that, you could just buy and eat real food. Real food doesn’t need a Nutrition Facts panel to tell you it’s good to eat.
The new changes coming in the Nutrition Facts panel will reshuffle the numbers and change the font size and where they appear on the label. They will not, however, make any substantive changes in the content, and they will not change the % Daily Value of the macronutrients. A “mostly plant based” diet that is 60% carbohydrate is still the USDA’s/HHS/FDA’s recommended “eating pattern” – with the same macronutrient distribution that has made many of us sick. Does this sound to you like rearranging the deck chairs on the Titanic? It does to me.
* The micronutrients listed on the label added up to 196 kcals (not 180) so I had an online chat with a Glucerna nutritionist who said “some sugar alcohols in the product contain fewer than 4 kcal/gram and some fiber is not absorbed.” So, I calculated that the number of carb grams contributing to the 180 calories was not 16 but 12.)

Sunday, July 10, 2016

Type 2 Diabetes, a Dietary Disease #336, Noakes: “It’s the fatty liver disease, stupid.”

Continuing my theft of Dr. Tim Noakes' excellent post on South African blogger Marika Sboros’s FOODMED.NET, Dr. Noakes relates how “more support for Gerald Reaven’s unifying hypothesis of chronic disease has come from an unexpected source – from those doctors, hepatologists, who specialize in…diseases of the liver.”
Dr. Noakes continues, “It has been known for some time that the added risks associated with obesity depend, in part, on where that extra fat is stored in the body.  Thus fat that accumulates under the skin – subcutaneous fat – is far less unhealthy than is fat that accumulates within and between the organs in the abdomen, so-called visceral obesity.
“The hepatologists have now gone one step further to show that the real killer in visceral obesity is the fat that accumulates within the liver causing NAFLD, a disease that is now reaching epidemic proportions.
“Their work shows that it is NAFLD and not obesity per se that produces the abnormal metabolic state – the atherogenic dyslipidemia (Table 2) – that causes heart disease in those with insulin resistance and the metabolic syndrome.
“Table 2: The metabolic features of atherogenic dyslipidemia present in those with NAFLD and insulin resistance
    Elevated blood glycated hemoglobin (HbA1c) levels
    Elevated fasting blood insulin levels
    Elevated fasting blood glucose levels
    Hyperinsulinemia and hyperglycemia (elevated blood glucose levels) in response to carbohydrate ingestion
    Low blood HDL-cholesterol concentrations
    High blood triglyceride concentrations
    Elevated numbers of small dense LDL-particles
    Elevated blood Apo lipoprotein B concentrations
“The absolutely key point is that dietary carbohydrates and not dietary fat cause NAFLD. For when the insulin resistant eat excess carbohydrates including fructose found in sugar and fruits, they must convert into fat any extra carbohydrate they cannot either use as a fuel or store immediately as carbohydrate in liver or muscles.
“Note that all these options are severely reduced in those with insulin resistance.  Instead under the action of insulin – the fat-building hormone – that fat is stored, initially as fat in the liver.  But as NAFLD develops, insulin resistance worsens, hyperinsulinemia increases, atherogenic dyslipidemia deteriorates and the seeds for the chronic diseases of obesity, diabetes, heart disease, NAFLD and perhaps cancer and dementia are sown.
“Thus it is that dietary carbohydrates and not dietary fat are the direct cause of this group of chronic diseases in those with insulin resistance.
    The work of Dr Gerald Reaven is as revolutionary to the understanding of medicine as were the works of Newton, Galileo and Darwin to their disciplines.
    By producing a unifying theory for perhaps six chronic diseases and by presenting the initial evidence that these conditions are initiated by high carbohydrate diets in those with insulin resistance, he has fundamentally changed our understanding of how these conditions develop and how best they should be treated.  And also how they might be prevented.
Our challenge is to incorporate this new understanding into our teaching and practice of medicine.

Sunday, July 3, 2016

Type 2 Diabetes, a Dietary Disease #335, Implications of Reaven’s Unified Hypothesis: Part 2

Last week’s column was heavily cribbed, with attribution, from Dr. Tim Noakes' recent post on South African Marika Sboros’s excellent blog FOODMED.NET. This week I’m going to continue it with an almost verbatim extraction. It is so well written, and so profound in its implications, I don’t want to botch it by editing a thing!
We left off with Noakes explaining how endocrinologist and Stanford professor Dr. Gerald Reaven presented at the 1988 ADA annual Banting lecture a unified hypothesis of chronic disease, which he called Syndrome X but which thereafter became known as Reaven’s Syndrome. Today it’s simply called Metabolic Syndrome.
Noakes continues, To determine whether nutritional factors contribute to the development of the metabolic syndrome, beginning in the 1980s, Reaven completed a number of RCTs of the effects of low-carbohydrate diets in patients with this condition. Without exception his studies showed that removing carbohydrates from the diet uniformly improved all measures of health in those with insulin resistance and metabolic syndrome.
“So besides establishing the fundamental role of insulin resistance in these chronic diseases, Reaven also discovered the optimum treatment – carbohydrate restriction. By any measures, Reaven should be a shoe-in for the Nobel Prize in Medicine.  But perhaps not.  For he failed subsequently to emphasize the curative effects of low-carbohydrate diets in insulin resistance.
“Why not,” Noakes asks?
“I suspect that during his daily work at Stanford Medical School, Reaven was in close contact with some of the more important cardiologists in the USA and perhaps in the world. They would not have taken kindly to their colleague’s suggestion that, to prevent heart attacks, cardiologists should be prescribing high fat diets instead of the low fat diet dictated, then as now, by the American Heart Association.
“Had he chosen that route, Reaven’s colleagues would have excommunicated him, his research funding would have dried up, and his career would have been over, exactly as happened to Dr John Yudkin in England for his (correct) suggestion in the 1970s that sugar, not saturated fat, causes heart disease.
“So it seems to me that Reaven kept quiet, choosing rather to continue researching insulin resistance without paying much attention to how a low-carbohydrate, high-fat diet might – simply, effectively and at low cost – prevent and reverse all the medical disguises through which insulin resistance reveals itself.
One disease, one cause, many symptoms:” Reaven’s unified hypothesis of chronic disease.
“Reaven’s problem is not unlike that faced by Darwin and Galileo whose findings estranged each from religious orthodoxy.  For Reaven’s unifying hypothesis of chronic disease must offend not just his colleagues in cardiology.  For his hypothesis strikes at the very heart (pun intended) of the pharmacological model that we practice in modern medicine.
“For if obesity, diabetes, heart disease, NAFLD and high blood pressure (and perhaps also cancer and dementia) are in fact all symptoms of the same underlying condition, insulin resistance, then our current model of medical management must be wrong, requiring as it does, specific but different pharmacological treatments for each separate condition, overseen by different hierarchies of medical specialists.
BUT WHAT IF THE CORNERSTONE FOR THE TREATMENT OF ALL THESE CONDITIONS IS A LOW-CARBOHYDRATE DIET – the very diet that has now been vilified by my profession for the past 50 years?  That must be an extremely frightening thought for very, very many.  How does one come to terms with the possibility that, by following medical orthodoxy, one may have harmed very many patients?”
What indeed?! Think about it…
Thank you, Dr. Tim Noakes, for the courage to speak out. Note: all CAPS, bold and italics added by this blogger.