Sunday, March 26, 2017

Type 2 Diabetes, a Dietary Disease #373: The “blame the patient” game

Let me be clear. I don’t really think your primary care doctor, who is perhaps an internist/cardiologist (like mine) or maybe a family care doctor, is being disingenuous when he or she writes in your file, “patient non-compliant.” They almost certainly, or for the most part, sincerely believe in the advice they have given you. They advised you how to lose weight (exercise a lot and eat a calorie-restricted balanced diet), specifically to eat a “healthy low-fat diet,” And when you failed to get the results they expected, they concluded it was because you didn’t follow their counsel. So, they deduce, you must have cheated. You were “non-compliant.”
Why do they expect this result, you ask? Because the Guidelines for Clinical Practice for each of the practice specialties, and the governing medical associations (the AMA, AHA, ADA, etc.), all told them to. That is the result of virtually all of the patient cohorts who were given this advice before you. So, the explanation – the reason – must be that it was the patient who failed to follow it…who was non-compliant. That’s also when the clinical guidelines tell them to start you on drugs to accomplish what you failed to do.
It never occurs to them that it could be the advice they gave you that failed to produce the outcome they (and you) desired. The advice to eat a low saturated fat, low cholesterol diet has now been in place for over half a century – since the time any doctor in practice today went to medical school. The advice was first popularized by the publicity given to the treatment of Eisenhower after his first heart attack in 1955. Before he died 14 years later, he was to have 7 myocardial infarctions, 14 cardiac arrests, and at least 1 stroke, but never mind….
The advice to eat a low saturated fat, low cholesterol diet was also strongly espoused by a University of Wisconsin physiologist, Ancel Keys. The bad science, publicized in his “Six Country Analysis” (1955), and later compounded in his “Seven Countries Study” (1958), has since been widely discredited, but never mind….
By January 1961, Keys was on the cover of then popular Time magazine and had been invited to join the Board of The American Heart Association. And to this day the AMA still espouses a low saturated fat, low cholesterol diet. The evidence that this advice is faulty – in fact, is the virtual opposite of the heart-healthy diet that you should be eating – has existed from “the beginning.” See this timeline, by Diet Heart Publishing.
The evidence supporting a healthy diet has now been well documented in the last decade in at least three thoroughly researched, landmark books: 1) Gary Taubes’s “Good-Calories, Bad-Calories”; Denise Minger’s, “The Big Fat Surprise”; and Gary Taubes’s new, “The Case Against Sugar.” There are many others, but these three are the best. They’re an easier read than the peer-reviewed scientific journals they’re based upon.
What got me going on this minor rant was this article in Medscape Medical News last month that described the efforts of scientists to “reprogram” alpha cells in the pancreas to regenerate new beta cells in mice. These are the cells that make insulin until they are destroyed by an autoimmune disorder, as in type 1 diabetes, or they just wear out from overuse due to Insulin Resistance in type 2 diabetes.
What set me off in this article was the suggestion that a similar advance (an “artificial pancreas”) “may enable tight glycemic control with minimal patient intervention” (my emphasis). Great news for type 1s, of course, but from my perspective (as a type 2) it just reinforces the notion that “minimal patient intervention” was the only course of treatment available for type 2s in the clinical setting since patients are “non-compliant” and fail to achieve the desired outcomes when they follow their doctor’s advice. THUS, THE PATIENT IS TO BLAME!
But what if you, the patient, took control of your diet and your metabolic health, and ate a healthy, low carb, moderate protein, high fat diet, including heart healthy saturated fat, without concern for dietary cholesterol? What if you did this and the outcome was a big weight loss and a lab report with an improved lipid panel?
 Or you could just follow the dietary advice given to President Eisenhower in 1955. Remember that outcome?

Sunday, March 19, 2017

Type 2 Diabetes, a Dietary Disease #372: My 10-week, 30-lb challenge, 5th wk Progress Report

I’ve changed the title of the Challenge from “2-month, 20-pound” to “10-Week, 30-Pound.” The primary reason is that it became clear I was going to over achieve my goal. This is the new mid-point report.
The second reason is that I have a doctor’s appointment coming up in Week 11, and I wanted to capture the best A1c and weight loss improvements possible. The challenges will be that, for a large part of the final 2½ weeks, the unique circumstances that gave rise to my beginning this gambit will change: 1) I will not be alone and preparing all my own meals, and 2) I will at times be “on the road” and eating most meals in restaurants.
That being said, the necessary adjustments will be good for me. They will allow me to transition to “real life” while at the same time being under the gun to preserve continue the gains. (See how easy it is to undercut one’s confidence and resolve?) Reference: for the Challenge, see #368, for the 1st week’s Progress Report, see #370, and for the 2nd week’s, see #371. Now, back to the 5th Week (new mid-point) Progress Report here:
Week 3: Having gained 1 pound in Week 2 (after losing 11 in Week 1), I was confident the “progress…was not really lost,” and “it [the progress] will show up on the scale this coming week.” Well, I lost 4 pounds in Week 3.
Better yet, my Fasting Blood Glucose (FGB) average also dropped again, from 88mg/dl (3.8mmol/L) to 86 (3.7). The actual readings were 81, 104, 90, 78, 84, 83 & 79. The 104 was a surprise. It came after a supper of veal kidneys cooked in onions and mushrooms with Marsala wine and a salad of Romaine lettuce, mushrooms, hazel nuts, shredded cheese and my homemade vinaigrette made with white wine vinegar. Go figure! Tonight I’m having the 2nd half of that kidney preparation, with the same salad, so we’ll see what happens.
Changes in Week 3: Going forward I’m going to cut my morning coffee from a 16oz mug to a 12oz mug. That should reduce the heavy cream from 2oz to 1½oz. I found that I had swallowed all my supplements with only half a cup and the 2nd half was an indulgence. The idea came to me after reading a blogger who was looking for people to join him in a 30-day coffee fast. I like coffee, but I am not addicted to it, and I don’t want to be.
Week 4: Well, it wasn’t the veal kidney and salad supper that gave me that anomalous 104mg/dl FBG (5.8mmol/L) last week. The same supper the 2nd time produced a FBG of 74mg/dl (4.1mmol/L) this morning. Conclusion: anomalies happen. Now, once again, the big news this week: My FBG average plummeted again, from 86mg/dl (4.8mmol/L) to 77 (4.3). I haven’t seen FBGs like this ever! True, on my own initiative, but with the concurrence of my doctor, about a year ago I increased my dose of Metformin from 500mg/day to 1,500. I had read somewhere that 1,500mg was considered a “therapeutic” dose. The inference I drew from that was that a dose of less than 1,500 was not therapeutic. And since I have been a diagnosed type 2 for 30 years, and on a reduced dose of 500mg for the last 15 since beginning VLC, it seemed appropriate to me that my medication should be therapeutic. But I think my doctor never suggested an increase because he thinks my diabetes is already “in good control.” I’m not blaming him. That’s the guidance he gets from the ADA, Medicare, etc. By the way, in Week 4 I lost 2 more pounds, bringing me to 16 total in the first 4 weeks.
Week 5: I’m settling into a groove. My weight dropped by another 2 pounds, bringing the 4 week total to 18. The big surprise this week is that my FBG continues to drop. This week I had 3 readings in the low 60s, and my FGB average this week dropped to 70 mg/dl (3.9 mmol/L). Recapping my FBG averages: 119 the week before starting, then 100, 88, 86, 77 and now 70. I hope they level off now. If not, I’ll cut my Metformin. My goal, though, is to lower my A1c, so I am willing to have some “low” readings so long as I feel I am in no danger of hypoglycemia. My sense is that my glucose levels are stable. I have some concern about the ones in the 60s, but I feel fine and am unaware of the “lows.” I have tested a few days in the late afternoon, when historically I have been lowest, and my readings have all been in the mid 70s. If my FBGs persist in the 60s, particularly after fasting days, I’ll test at bedtime, and if low, again during the night when my bladder calls.
Conclusion: I can’t believe that I have been so blind in my diabetes self-management for these last 15 years!

Sunday, March 12, 2017

Type 2 Diabetes, a Dietary Disease #371: My 2-Month, 20-lb Challenge, 2nd wk Progress Report

When you read this I will be 5 weeks into my “2-month, 20-pound challenge,” but I write it after 2 weeks “in.”  The first week I lost 11 pounds and lowered my FBG average by 19 points to 100mg/dl (5.6mmol/L). I did this by strictly following a program of eating 5 Low Carb meals prepared at home by me (2 or more at a time) and then fasting on Tuesdays and Thursdays. Note that in the first week I did not dine out once, as I had planned.
This week I report on week 2 of the challenge. Based on my FBGs this week, I have also revised the terms, to extend the duration from 8 weeks to 10½ weeks, to coincide with my next doctor’s appointment (4/18). My goal is to get the best A1c possible, lowering it from 5.8% to 5.5%, or better.  Note, however, that after 8½ weeks I will no longer be preparing my own meals, and my eating pattern will include more “dining out.”
Week 2 began uneventfully, with weight stable and FBGs in the mid-nineties. As the week progressed, my weight and fasting blood glucose (FBG) both dropped until I was down 3 pounds by Friday. I gained one back Saturday and 3 more by Sunday. So, my net for the week was up 1 pound; net for 2 weeks: down 10 pounds.
Saturday was the first day that I ate outside the home in almost 2 weeks, and I ate too much (2 meals – albeit “low-carb”), and I drank too much. I don’t regard the 1 lb. gain as much of a setback, though. The progress I made during the week was not really lost. I am confident that it will show up on the scale this coming week.
The big news, and the main reason I am reporting on this week, is what happened to my FBG (and presumably my serum insulin). My FBGs this week were: 94, 92, 95, 89, 81, 80 & 83. Average: 88mg/dl (4.9mmol/L). Recall that in the 1st week my average was 100mg/dl (5.6mmol/L) and in the week before I began the challenge it was 119mg/dl (6.6mmol/L). With FBGs like this week’s, and a stable blood sugar during the day, I think my A1c goal is reachable – if I continue to follow this Low Carb WOE…and with a little help from Metformin. We’ll see.
Other observations, comments and changes from the original “2 month, 20 pound” challenge:
     Cooking for myself has not been as onerous as I thought it would be. In fact, I’m enjoying it. In the weeks ahead I envision preparing all my meals at home. Since I always make enough for 2 days minimum, that means only making 2 or 3 meals a week, since I will be fasting 2 days (at least) every week.
     All day fasting is easy. The first week on the day after a fasting day I had a “snack” (1HB egg) or a “light lunch” (2 HB eggs). This week I did not. And I was not hungry on the fasting day or the day after.
     The quart of heavy cream lasted only 16-17 days. I use it only in coffee, so, alas, I put 2oz/day in my cup.
     I have a new Snack: a few “whole artichoke hearts in water,” and a Light Lunch: ½ can (60g) of “Sell’s Liver Pate.” Also, Bumble Bee is now packing the same wild caught Brisling Sardines as the King Oscar brand, in the same Baltic Sea factory, in EVOO (and Hot Jalapeno Peppers), and at a lower price point. 
     Virtually all my suppers are stove top. I love fish, especially cod and similar species. It’s usually the least costly “fresh” fish in the case, although it may have been thawed by the fishmonger after having been flash-frozen at sea. I’m going to check out frozen cod next time I see it. I’m fussy about country of origin.
     My veal supplier has given up, so I need to find a new source for my veal stew and veal kidney recipes.
     I loved the tripe dish I made last weekend. The smallest frozen honeycomb tripe package in the butcher’s case was 2 pounds, so I made it and had it 4 days in a row. I don’t mind eating the same thing multiple days in a row; in fact, if I like a dish I made, I look forward to having it again. (I can’t believe Jason Fung in his “Fructose 3” blog post this week said he couldn’t imagine someone eating tripe 2 days in a row. Jeez!)
The next report will catch up with the lag in reporting; it will be at mid-point (5 weeks into) my new, extended duration. Then, the last report (at 10½ weeks) will have a final weigh-in, and hopefully an A1c and lipid panel. My doctor is very good at reviewing the lab report and mailing it to me as soon as his office receives them.

Sunday, March 5, 2017

Type 2 Diabetes, a Dietary Disease #370: My 2-Month, 20-lb Challenge, 1st wk Progress Report

As you read this I will be 4 weeks into my 2-month, 20-pound challenge, but I write after only 1 week “in.” If you don’t know what prompted me to do this challenge, read #368 here to learn my motivation and other particulars. The short report: in the 1st week I dropped 11 pounds and lowered my FBG average by 19 points to 100mg/dl. If you’re overweight (as I am) and prediabetic or a 30-year diagnosed type 2 (as I am), even though theoretically “in remission,” and that outcome doesn’t pique your interest, you may as well stop reading.
The “challenge” is to stay on my current eating pattern 5 days a week and to fast on the other two. My current eating pattern is coffee with pure stevia powder and 1½ oz of 36% full cream in the morning. Then, only if I am hungry during the day, to eat either a light lunch (smoked herring in brine), a “big” lunch (brisling sardines in EVOO), or a snack (HB egg). My main meal (supper) is a stove-top preparation of cod with vegetables or a veal stew. Alternatively, I could make tripe in salsa roja or veal kidney with mushrooms, onions and Marsala.
This week I had cod with tomatoes, green olives and red pepper flakes Sunday and Monday. Then, I bought 2 pounds of tripe and made 4 suppers: Wednesday, Friday, Saturday and Sunday. I fasted on Tuesday and Thursday. On fasting days, besides my morning coffee, I had 1 red wine spritzer at the supper hour, and on the other days I had 2 red wine spritzers.
Next week (M, W) I will do different cod preparations (fennel and/or celery in chicken broth). I’ll also make a romaine salad with mushrooms, hazel nut pieces and shaved Pecorino Romano, with a vinaigrette.
During the last week I ate a light lunch (2 HB eggs) the day after the 1st fast day and a snack (1 HB egg) after the 2nd fast day. Saturday, I had a small can of pork liver pâté for lunch. There was no other need or occasion to have “lunch” or to snack during the day or after supper. Saturday night, after attending a jazz concert, I went “off plan” and stopped at a restaurant on the way home and had 2 stingers in front of a roaring fire.
And that’s all there was to it, folks. Eleven pounds (okay, half or more water), but the pounds just dropped off after each full day of fasting. My body maintained a high metabolic rate (translation: I felt great and had lots of energy and no hunger or cravings). It did this by transitioning from obtaining energy from the food I ate (S, M, W, F, S) to obtaining energy from breaking down and burning my body fat on Tuesday and Thursday.
My perennial goal is to maintain my FBG average below 100mg/dl (and keep it low and steady during the day). I hope thus to reduce my A1c from the current 5.8% to 5.5% or lower. I haven’t seen 5.5% in a few years.
My interim weight goal for this 2 month challenge is to get down to 228 (BMI=32). That’s still considered “obese” in the BMI chart. So, I can’t derive too much satisfaction from the first week. I have to persist and be satisfied with a slower pace going forward, spiked each week no doubt by the 2 full days of fasting.
I have to remind myself that several years ago I lost 100 pounds in a year (without full-day fasting) by strictly adhering to Bernstein. But the fasting part is not difficult since you don’t experience hunger or cravings. As I read in a tweet this week (@SBakerMD), “Beat cravings and you win.” He’s right, of course. That’s the beauty of a Very Low Carb Ketogenic Diet. By the way, Dr. Baker eats an all-meat (grass-fed) diet (“zero carb”).
So, that’s the 1st week’s progress report. I’ll write another next week (2 weeks “in”). I expect progress to slow a lot, but I am hopeful that my FBG average will drop below 100 and that the weight loss will continue apace.
I fully expect to continue to feel great and have lots of energy and no hunger, including on fasting days.