Sunday, October 28, 2018

Type 2 Nutrition #456: “Why am I taking insulin?”

You’re a newly-diagnosed type 2, and you’ve proved to be intolerant of a couple of oral prescription meds, so you’ve been prescribed a basal (once-a-day) insulin injection to lower your blood glucose levels. You know this, but it seems to contradict the advice you’ve heard that the dietary goal of eating Very Low Carb (VLC) to self-treat type 2 diabetes is to lower your blood insulin, so you ask, “How will this “lower your blood glucose?”
Treating an elevated blood glucose with injected insulin will lower your blood glucose, temporarily, but by continuously keeping your blood insulin level high, with a long-acting (24hr) insulin, 1) your insulin will “progress” to larger doses, 2) your Insulin Resistance will worsen, leading to the dreaded complications, and 3) you will gain weight – remember, “insulin is the fat storage hormone.” And that’s the establishment’s advice.
You reply, “So If reducing insulin according to this is the answer, then more sugar will be channeled into the bloodstream.” Do you see the fallacy? You’re making a logical error. “More ‘sugar’ [glucose] will be channeled into your blood stream only if you eat more ‘sugar’ [carbohydrates]. On a VLC diet, you eat far fewer carbs.
If you are eating far fewer carbs, your blood glucose and blood insulin will both naturally lower, because endogenous insulin (secreted by the pancreas) is the transporter of glucose in the blood. But if you are injecting a long-acting insulin, your blood insulin level will remain high all day and night, even as your blood glucose level comes down. Eventually, if you eat VLC at all meals, your blood glucose level will be so low that you will have to reduce the amount of insulin you inject to prevent hypoglycemia (too low blood sugars).
If you don’t eat VLC and continue to inject insulin (the establishment way), you will have all the consequences described above: 1) worsening IR, 2) higher insulin doses and later complications, and 3) weight gain.
So, you’re “taking insulin” now to lower your blood glucose because your doctor knows that untreated high blood glucose is very dangerous for your health, long term. She is treating your symptom (high blood “sugar,” caused by Insulin Resistance). By self-treating your disease at the cause, a diet high in “sugars” and refined carbs, your aim is to reverse the metabolic dysfunction caused by your diet and put the disease in remission.
And you can do it yourself.  Here’s how: 1) accept that you need to change your “lifestyle” (at least with respect to what and when you eat), and 2) learn about carbs and other things that raise your blood sugar, 3) commit to adopt this Way of Eating, and then, 4) #justdoit. This last is perhaps the hardest, but there’s lot of help out there: mentors, books, blogs, and Facebook pages and groups. For the last 16 years I’ve used them all, to great advantage.
Two of the very best websites are 1) Andreas Eenfeldt’s (500,000+ subscribers) and 2) the Intensive Dietary Management (IDM) program run by Megan Ramos out of Jason Fung’s Toronto office. Fung’s book, “The Obesity Code,” is one of my favorites. Another: “The Art and Science of Low Carbohydrate Living,” by Volek and Phinney. Another, Richard Feinman’s, “The World Turned Upside Down.” All good reads.
Two programs I can recommend are Eric Westman’s at Duke Health, and Phinney and Volek’s Virta program ( Eenfeldt, Fung, Phinney and Westman are MD’s. Volek is a widely published PhD exercise physiologist, Feinman is a PhD researcher/activist, and Ramos started out as Fung’s patient.
Tweeters I try to follow include: Nina Teicholz (@bigfatsurprise), Franziska Spritzer (@lowcarbRD), Dr. Eric Westman (@drericwestman), Dr. Feinman (@DrFeinman), Dr. Zoe Harcombe (@zoeharcombe), Dr. Jason Fung (@drjasonfung), Dominic D’Agostino (@DominicDAgosti2), Andreas Eenfeldt (@DietDoctor1), Thomas Dayspring (@Drlipid), Tim Noakes (@ProfTimNoakes), Tom Naughton (@TomDNaughton), gary taubes (@garytaubes), Georgia Ede MD (@GeorgiaEdeMD), Adele Hite (@ahhite), Marika Sboros (@MarikaSboros), Dr. Jay Wortman (@DrJayWortman), Amy Berger (@tuitnutrition), Dr. Aseem Malhotra (@DrAseemMalhotra).

Sunday, October 21, 2018

Type 2 Nutrition #455: Are red grapes healthier than green grapes?

I’m not kidding. A new friend, who is a recently diagnosed, insulin-dependent type 2 diabetic, asserted that he ate red grapes in preference to green grapes because they are healthier. When I strongly disagreed, he said, “Red grapes have resveratrol in the skins, and resveratrol has health benefits.” I don’t attribute this misguided point of view to ignorance. He’s a bright, generally well informed guy. I attribute it to a combo of denial and rationalization.
My friend is on insulin injections because he couldn’t tolerate metformin or Januvia (a DPP-4) and a SGLT2 was counter indicated. His fasting blood glucose (FBG) was so high (225mg/dl) his doctor knew she had to get his blood sugar under control as soon as possible, and she thought that injecting insulin was the only, if not the best, way to do it. With fasting blood sugars that high, I couldn’t disagree, but only because they were so high.
(In my own case, in 2002, after having been a diagnosed T2 for 16 years, and maxed out on a sulfonylurea (SU) and metformin and starting a 3rd oral (a TZD), my FBGs were also out of control but just in the 150s. My doctor believed (at the time – it seems like ancient history) that T2D was caused by obesity (I weighed 375 pounds), so he suggested I try eating Very Low Carb, or VLC (20g of carbs a day), to lose weight. He had just read about it in a New York Times Sunday Magazine cover story by Gary Taubes, “What If It's All Been a Big Fat Lie,”
So, I began the VLC program and within the first week I had several hypos. By phone consultation, he ordered me to stop taking the TZD and then the very next day to cut the SU and the metformin in half. Later that week I had another hypo, and he told me to cut them in half again. I later discontinued the SU altogether.)
So, as a newly diagnosed T2, my friend surely has a steep curve to learn about carbohydrates and his glucose metabolism. Type 2 diabetes is a dietary disease. His body’s ability to process glucose, the compound into which all carbs break down, is impaired due to a condition called Insulin Resistance, developed over many years, decades even. As a result, his body doesn’t “take up” glucose easily.  He is thus Carbohydrate Intolerant – intolerant of all carbs. Red and green grapes alike, and all other fruit and all starches too. They are all carbs.
Fruits are just sugar and water. Your body doesn’t give a wit that they contain “natural sugars.” Your body processes “natural sugars” and “added sugars” the same way. Fruit sugars are mostly sucrose, a disaccharide made up of one molecule of glucose and one molecule of fructose, plus some free fructose and free glucose (monosaccharides). The fact that whole fruits have fiber or other micronutrients is just as irrelevant as the color and content of the skin of the grapes. They are inconsequential to you, compared to the glucose content.
To think otherwise is to deny the consequences to your health of ignoring the truth. You are Carbohydrate Intolerant. Red grapes have the same glucose content as green grapes, period. I’m sorry, but that’s the truth.
According to the USDA database, “grapes (red or green), European type, such as Thompson seedless, raw,” are 80% water and 18.1% carbohydrate, of which 15.48% are sugars. The remaining carbs are oligosaccharides. There are also trace amounts of protein, fiber and ash. Each 2.9g grape contains 3.5kcal, or almost 1g of carbs.
Now wine, that’s a different matter. LOL. Most carb counters say that a dry white table wine has fewer carbs than a dry red table wine (3 vs. 4). It depends, of course, on the specific wine, but according to the same USDA database, a typical 5 oz glass of Chardonnay (white wine) is said to contain 3.18g of carbs, and a 5oz glass of Cabernet Sauvignon (red wine) is said to have 3.82g of carbs. But the total calories in each are the same (123 vs. 122kcal). The difference is that the white wine tested had a slightly higher alcohol content (15.7g vs. 15.4g).
And while alcohol has more calories per gram than carbs (7 vs. 4), it does not raise blood sugar, as glucose  does. However, the alcohol in either glass of wine is “empty” calories. Still, it doesn’t affect your glucose metabolism; so, bottoms up, tipplers, but don’t eat grapes, red or green. You’re grape intolerant!

Sunday, October 14, 2018

Type 2 Nutrition #454, “Are vegetable chips okay?”

My wife served a popular brand of “real vegetable chips” as a side dish at a poolside lunch with friends the other day. I helped return the uneaten chips to the bag, and out of curiosity…I looked at the nutrition label.
A one ounce serving contains 16 grams of carbs, including 3 of fiber and 2 of sugar, with 0 grams of “added sugar.” It also contains 1 gram of protein and 9 grams of fat, of which 0.5 grams are saturated.
What the label doesn’t tell you (because they don’t have to) is that the remaining 11 grams of carbohydrates are starches (long chain glucose molecules) from “diverse root vegetables” that have been milled and are easily digested. The 2 grams of sugars inherent in the tuberous ingredients are combinations of monosaccharides (100% glucose) and disaccharides (50% glucose/50% fructose). So carbs from the starches (100% glucose) will raise your blood sugar faster and higher than the 2 grams of sugar. 
The label also doesn’t tell you (because they don’t have to) that the other fats in this manufactured “food” product are all unsaturated fats, the vast majority of them polyunsaturated (PUFAs). The actual percentage is not determinable because the label says the product includes, “expeller expressed Canola oil and/or safflower oil and/or sunflower oil.” So who knows what percentage of which oil was used, or if it was all one of them?
Of course, “expeller expressed” canola oil is listed first because that would be the best of the worst. “Expeller expressed” means it is less processed and refined. And of the three “seed” oils, Canola oil has the highest percentage of the good monounsaturated fats. But the other “and/or” seed oils are not “expeller expressed.”
Rounding out the ingredients list, after tubers, PUFAs and sea salt is “beet juice concentrate (color).” Note: the word “color” is within the quotes lest you think they added “beet juice concentrate” as a sweetener. But just in case you weren’t aware of it, the USDA reports that U.S. beet sugar production is almost 50% greater than cane sugar production, and sugar beets for food use is 1½ times greater than sugar cane for food use. Do you think the beet sugar juice in these chips is used just for color, as they say? I don’t. But the USDA allows it.
It’s just another deception, but I’ll get to that in a moment. First, let’s admit the consumer is a willing dolt. We are prepared to be snookered by clever marketing to assuage the guilt we feel for eating something that we know in our hearts (pardon the double entendre) is bad for us. These days, the bogey man is “added sugar,” so labels now have the new subcategory “added sugar.” This has recently been added to the requirement that it specify “saturated fat,” but not polyunsaturated fat, or refined starches, both arguably much worse for our health than "added sugar."
But here’s the contradiction and irony: “Vegetable chips” are a manufactured food. They are not a whole, unprocessed food with inherent sugars, such as the “taro, sweet potato, batata, yuca or parsnip” from which they are made. So, if you put a label on taro, sweet potato, batata, yucca or parsnip, I could understand how and why you could claim that there were no “added sugars” (although we’d have to ignore the successful efforts of agronomists to hybridize fruits and vegetables.) But these “vegetable chips” are manufactured!
So what have we got here: You take a natural whole food, mill it, process it and refine it, then add a sweetener camouflaged as an additive for color, then cook it in highly processed, inflammatory, oxidized and unnatural fat and you get a snack food with a nutritional halo: “real vegetable chips.” Good marketing, I’d say.
I’m sure the USDA rule that allows a snack “food” manufactured from processed and refined tubers (starchy root vegetables), combined with unhealthy, polyunsaturated seed oils, and salt, and sugar juice concentrate to create a product that has by definition, no “added sugar,” is a common practice. But then, I don’t think adding the sub-category “added sugar” has any meaning or value, except to delude us and help the consumer (and the lobbyists and politicians who made the law) feel good. So, just eat your “vegetables, ” kids, and forget it.

Sunday, October 7, 2018

Type 2 Nutrition #453, Fish oil supplementation, triglycerides and platelet formation

Fifteen years ago, I began taking 4 grams of fish oil a day (plus a can of sardines for lunch) After a few months, I lowered my dose to 3 grams and then to 2, which I have continued to take, until now. During this time I dramatically lowered my triglycerides from 143mg/dl (aver. of 11 tests) to 49mg/dl (aver. of 25 tests) 5 years later. After writing this post, I reduced my daily fish oil to 1 gram.
In discussing fish oil supplementation with a friend recently, the risk of high-dose fish oil “causing bleeding” came up. Googling “fish oil, bleeding” dredged 2 articles at Evidence-Based Medicine Consult (EBM Consult), a free searchable, online medical education database. The first discusses the mechanism for how Omega-3 fatty acids could increase the risk of bleeding; the second discusses the bleeding risk. Both were revelatory for me.
“As it relates to CVD, fish oil is most commonly used to treat high triglycerides. When clinicians refer to the use of ‘fish oil,’ they are generally referring to omega-3 fatty acids (aka as polyunsaturated fatty acids (PUFA)). These specific omega-3 fatty acids include DHA and EPA. For the most part, neither DHA nor EPA causes any major side effects or clinically relevant drug interactions, but they are known to influence platelet formation.”
“As such, some clinicians perceive that this can put the patient at greater risk of bleeding, especially during surgical procedures or while on medications that are known to affect coagulation and platelet aggregation.” So, if you’re going to have surgery, or you have CVD and take Coumadin (Warfarin) or another blood thinner, your doctor might advise you against taking more than 1 gram of fish oil, or to stop taking it before surgery.  
In the mechanism article my revelation was not about bleeding but about platelet aggregation. It turns out “omega-3 fatty acids compete with [the omega-6] arachidonic acid (AA) for incorporation into the platelet cell membrane, thereby increasing the ratio of omega-3 fatty acids:AA.” They inhibit platelet aggregation.
I’ve been writing for years that the Standard American Diet (SAD) is very high in omega-6s, with a ratio of omega-6 to omega-3 of at least 20 to 1 (20:1) vs. the 2:1 or 1:1 ideal. And that supplementation with fish oil alone is not enough to reverse that ratio. We must also avoid fried foods and “vegetable” (seed) oils, baked goods and some nuts. It seems I may have been too successful at taking my own advice! For the last 11 years my Complete Blood Count (CBCs) have consistently been slightly out-of-range on platelet (and related) counts.
The EBM Consult site is intended to educate doctors and other medical professionals, but the gist is still comprehensible to me. Too much DHA and EPA from fish oil supplementation has anti-platelet effects that 1) interfere with intracellular pathways, 2) increase prostaglandin formation and 3) decrease the production of platelet activating factors. Eureka, my overcorrected ratio may be the cause of my out-of-range CBC counts!
The other EBM Consult article, concerning the bleeding risk, concludes with a simple (paraphrased) message:
       The AHA recommends 1 gram of fish oil per day for patients with coronary artery disease and 2 to 4 grams per day for patients with high triglycerides. They also advise those who take more than 3 grams per day do so under the care of a physician “since high doses could cause excessive bleeding in some patients.”
       In an analysis by the National Lipid Association, of 4,357 patients who took 1.6 to 21 grams [not a typo!] of DHA/EPA per day in combination with some type of prescription anti-platelet or anticoagulant, only 1 patient developed blood in their stool and 1 other experienced a gastrointestinal bleed.
       Clinical trial evidence to date does not support an increased risk for bleeding in patients taking fish oil supplements…even when combined with other medications known to increase the risk of bleeding [!].
If you take more than 3 grams of fish oil a day, or have out-of-range CBC labs, or are concerned about bleeding, you should read these two EBM Consult articles. Otherwise, I would conclude that taking fish oil supplementation is a good way to treat high triglycerides. It sure worked with me, to a fare-thee-well.