Tuesday, December 31, 2019

Retrospective #318: The Mystery of Antonin Scalia’s Sudden 2016 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 was also 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. 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 this man’s cause of death, nor do I support a conspiracy theory…here. Rather, I wish to use Scalia’s death to emphasize, as Jenny Ruhl points out, with more than a dozen links, in Blood Sugar 101,” “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, and very good advice, 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 him/herself. The effect on the body is synergistic. And the catalyst that gets them all to work together is, ta dah, 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 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 fewer meds.) And after eating Very Low Carb consistently, my HDL-C doubled and my triglycerides dropped by two-thirds; and my doctor took me off the statin he had prescribed five years earlier. And all those oral meds for type 2 diabetes? Within days of starting to eat Very Low Carb, I had to give them all up (except a minimum dose of Metformin) to avoid hypos!
Of course, after living a relatively long life, dying suddenly and peacefully in your sleep isn’t such a bad way to go.

Monday, December 30, 2019

Retrospective #317: Patient, heal thyself!

“Physician, heal thyself” is a familiar proverb attributed to Luke the Evangelist (4:23). It was made famous, and is often quoted from the Latin translation of the Bible, as Cura te ipsum, or simply “cure thyself.” According to a citation in Wikipedia,The moral of the proverb is counsel to attend to one's own defects rather than criticizing defects in others.” I prefer to think of it in a more positive and proactive way; I say: Take control of your own life.
In other words, don’t feel sorry for yourself and tempted to blame your condition in life on others. Or, for that matter, don’t be tempted even to look back at one’s own mistakes, except to avoid repeating them. Instead, think of your life in the present and make wise choices going forward. Someone once referred to this attitude as Jungian. I trace its origin in me to a program I took many years ago called “the est Training.” It was, as they promised, transformational.
A knowledgeable reader of this blog, whose views I respect, related this philosophical view to the current Dietary Guidelines debate. In a recent comment he said, “It's been pretty well documented…that T2D is a self-inflicted malady. You might not have been pointing the gun (the ‘guidelines’), but you pulled the trigger.” I replied, “I like that. You have to accept responsibility first, and then, do something about it.” Right?
The relevance to Type 2 Diabetes, which I have coined “a dietary disease,” is that YOU control pretty much everything you put into your mouth…and thus you could control your Type 2 Diabetes from your next bite forward. Thus, you CANcure thyself.” You just have to believe in this Way of Eating and then follow it diligently. It’s not easy to “give up” so many foods to which you have become habituated, but this much I can tell you: You won’t have to wait for the hereafter to see the results. You will see results almost overnight. You will have to take fewer meds and you will lose weight without hunger, and your doctor will be astounded (as will you) at your improved health markers and labs.
Luckily, for me, I started eating Very Low Carb on the advice of my doctor. I weighed 375 pounds, and my doctor had been trying to get me to lose weight for years. It was summer of 2002, and he had just read the New York Times Sunday Magazine cover story, “What If It's All Been a Big Fat Lie,” by Gary Taubes, an award-winning science writer.  When my doctor next saw me, he said, “Have I got a diet for you!” I tried it, strictly following the original Atkins Induction plan (just 20 grams of carbs a day), and over the course of time, I lost 170 pounds.
My doctor’s heresy in recommending such an “extreme” diet in 2002 wasn’t as irresponsible as the mainstream medical establishment would have you believe. Low Carb – even Very Low Carb (like mine) – has been around for a long time. It just went out of fashion about the time older doctors practicing today got their training. Saturated fat and cholesterol were declared verboten for heart health, and all fats were targeted for reduction in the diet. AS A RESULT, CARBOHYDRATES WERE ASCENDANT, achieving and maintaining to this day their 60% (300g/day) Recommended Daily Allowance (RDA) of total calories on a 2,000kcal diet. As a result, we as a nation have gotten fatter and sicker.
Now, in the face of advancements in the science of healthy eating, and in the absence of good science to support the dangers of saturated fat, dietary cholesterol, and salt, the worm is turning. The 2015 “Guidelines” have totally banned trans fats and ELIMINATED THE LIMIT ON TOTAL FAT and DROPPED THE LIMITATION ON DIETARY CHOLESTEROL. The DGA Advisory Committee told the USDA/HHS: “cholesterol is no longer…of concern for overconsumption.”
And in the opinion of many who follow these developments, as the multitude of dangers from highly processed, oxidized and rancid polyunsaturated fats from vegetable oils, such as corn and soybean oil, are exposed, we will eventually return to eating healthy, natural, saturated fats like butter, coconut oil, lard and tallow.
I was lucky. My doctor suggested Very Low Carb to me. But if your doctor doesn’t suggest you try eating Low Carb, I hope he/she will at least support your decision to try it, at least to lose weight. Let him/her see you at frequent intervals, if they want to, to check on your progress. I benefitted from my doctor’s monitoring of key blood markers monthly for the first year, and he learned a lot too. Why don’t you suggest yours do the same? I warrant it will work…

Sunday, December 29, 2019

Retrospective #316: With so much carb restriction, what can I eat?

If you’re a newly diagnosed Type2 or Pre-diabetic, and you’ve investigated your choice of “treatment plans,” and you are willing to consider treating your condition as a “dietary disease,” you next need to know how to choose what to eat and when! Like most folks faced with this challenge, you will ask, “With so much carb restriction, what can I eat?”
Most of us have lived our lives eating a surprisingly limited variety of foods. Culture, convenience and habit play a big role, so the answer will be different for everyone. Generally, in recent times that limited variety has consisted largely of CARBOHYDRATES. That’s how we got into this mess in the first place!! So, the foods we have eaten for most of our lives are necessarily going to have to change. And that change will include eliminating a lot of favorite foods.
So, naturally, most people have come to think of carb restriction as deprivation. And, in the sense that you will need to forego many of the things that got you into trouble, that’s fair. But another way to think of it is to ask yourself if what you ate gave you intestinal distress (cramping and diarrhea), as it does to gluten or lactose intolerant people, wouldn’t you readily and speedily give it up? C’mon. You be fair! Wouldn’t it?
By this way of thinking, foregoing excessive CARBOHYDRATES in the diet is a similarly life-long change; you will restrict eating excess carbs to avoid future blindness, amputations, and end-stage kidney disease! Plus, you are avoiding a much higher risk of heart disease, stroke, sexual dysfunction and certain cancers! This motivates a lot of people.
Under these circumstances, I think you’ll agree that learning what you can safely eat takes on a much more positive aspect. And you have a lot of good choices. Let’s start with the basics: There are three “macronutrients”: protein, fat and carbohydrates. Most animal protein is “complete protein” (contains all the essential amino acids), and also contains some fat (largely saturated). That’s okay. Even dietary cholesterol is okay. In 2014 the Dietary Guidelines Advisory Committee finally said “dietary cholesterol is no longer a nutrient of concern for overconsumption.”
So, every meal should contain some animal protein and fat. After that, a small amount of carbohydrates is okay, but entirely optional. Our body requires both protein and fat, but the body has no minimum dietary requirement for carbs. But, if we’re going to consume carbs, let them be 1) unprocessed, whole foods, 2) non-starchy vegetables such as greens, and 3) low in “sugar.” I avoid peas, beets, carrots and corn (except for locally grown ears in summer: LOL).
Some good advice I gleaned from Dr. Richard K. Bernstein’s book, “The Diabetes Diet” (Little, Brown, 2005), was to eat the same food every day for one or even two meals each day. Bernstein is now an 85yo Type 1 Diabetic, so his advice eliminates the carb and protein variable from his insulin regimen, but I find that I am perfectly content to just eat eggs and bacon, and coffee with cream, for breakfast. No juice. No bread. This meal is very filling and easily carries me to lunch. Still, five hours after breakfast I usually eat a can of sardines in EVOO. Just one small can. And a bottle of water.
Five hours later I eat another small meal for supper: a serving of animal protein with fat, and a medium-sized serving of a low-carb vegetable prepared with fat. Examples are: asparagus spears or cauliflower tossed in olive oil and roasted; broccoli steamed with garlic and finished with butter; young green beans tossed in butter; or a salad of romaine, endive, mushrooms, chopped hazelnuts and grated cheese, well tossed in a homemade vinaigrette dressing.
The meat course is always small and always enough: one roasted chicken thigh (skin on); two small lamb chops (a rack of 8 is enough for two people for two meals!); one 8 ounce filet mignon, cut in half to serve two; ¾ pound of cod (for 2), poached stovetop with celery and fennel; Good foods all, and the choices are endless, if you think about it.
If these seem like small meals, well…they are. But because they have lots of satiating protein and fat, they are filling. Animal protein is expensive, you say. True, but you eat so much less of it when you limit carbohydrates. All these healthy foods are unprocessed and nutrient dense. They will satisfy the body’s nutritional needs, so you will eat less. You will not feel the need to snack because you will not be hungry between meals, and you will lose weight easily.

Saturday, December 28, 2019

Retrospective #315: “Carbohydrates and Sugars” Redux

When Type 2 Nutrition #31, “Carbohydrates and Sugars,” was originally published in 2011, it was an instant hit, now with almost 10 thousand pageviews. And since my new emphasis is on the recently diagnosed Pre-Diabetic and Type 2 Diabetic, demystifying carbohydrates and sugars is a good place to start again. So, let’s get down to basics.
The premise for educating the reader about carbohydrates, including sugars, is that you have independently researched the medical condition, Type 2 Diabetes and its precursors, Pre-Diabetes and Insulin Resistance, and have discovered that all of these conditions are dietary diseases. Not everyone who eats the Standard American Diet (SAD) develops them, but it is widely accepted that 1) a genetic predisposition is required and 2) that the SAD triggers a genetic “expression” in those who eat it and are so predisposed. So far, this affects about half the U.S. population.
One “expression” of this metabolic dysfunction is the associated development of fat accumulation in about 80% of Type 2s and Pre-diabetics. In fact, they are so closely related that the word “diabesity” has been coined to link them. Most medical sites actually cite obesity as a “cause” of diabetes. That is simply wrong. In fact, the opposite is true. The cause of obesity in Type 2s is Insulin Resistance (IR), the medical condition that develops and is the cause of Type 2 Diabetes and Prediabetes. The actual mechanism is described in Retrospective #308 and again in Retrospective #313.
So, what is the SAD? According to Wikipedia, “The typical American diet is about 50% carbohydrate, 15% protein, and 35% fat. Are you surprised? You shouldn’t be. Starting in 1977 our government has been recommending that we eat a diet that is 60% carbohydrate, 10% protein and 30% fat!  See the Nutrition Facts panel on processed food packages and do the math yourself. You should know now that it is not in your best interests to follow these recommendations.
So, if you’re going to eat fewer carbohydrates, it’s necessary to know something about the macronutrient composition of food. All foods are composed of protein, fat and carbohydrates. Period. (Alcohol is not a “nutrient.” LOL)
1) All carbohydrates are saccharides; that’s Latin for “sugars.” For nutritional purposes, they are divided into two broad classes: simple sugars and so-called “complex” carbohydrates. In the blood, ALL carbs ALL become glucose.
2) Simple sugars are further divided into compounds of one or two molecules (monosaccharides and disaccharides). Examples include sucrose (table or cane sugar, a disaccharide composed of one molecule each of glucose and fructose). It is the same disaccharide sucrose found in all fruit, together with the monosaccharides free glucose and free fructose. Sugar in fruit has the exact same effect on your blood sugar as table (cane) sugar.
3) Disaccharides break down quickly and easily into glucose and another monosaccharide. The glucose circulates in the bloodstream until it is absorbed by receptor cells. Excess glucose is returned to the liver and stored as glycogen. When the liver stores are full, these sugars are converted by de novo lipogenesis to fat. Repeated slugs of liquid sugar hitting a full liver can ultimately lead to “fatty liver disease.” All fruit juices and sugary soft drinks are such sugar “slugs.”
4) Complex carbohydrates are comprised of long chains of single glucose molecules. They are divided into two classes: oligosaccharides comprised of 3 to 10 glucose molecules linked together, and polysaccharides, comprised of more than 10 glucose molecules linked together. Examples are all starches (breads, cereals, potatoes, rice and pasta).
5) The so-called complex carbohydrates are commonly (and erroneously) thought to be better dietary choices than simple sugars. That’s like saying arsenic is better for you than cyanide because it works more slowly. Remember, bread is how the glycemic index is defined. It has an “index” of 100. After highly processed and “refined” (more aptly “stripped”) white flour, and water, the third ingredient in every loaf of bread is some form of added sugar, a highly refined carbohydrate. When carbs are “processed,” these “complex” foods break down easily to “simple” sugars.
And if you have Insulin Resistance, your blood sugar will remain elevated and be harmful to your health. Just remember: If you are Insulin Resistant, you are Carbohydrate Intolerant. Type 2 Diabetes is a Dietary Disease.

Retrospective #314: Carolina Panther Eats Horse

In early February 2016, on a Facebook post, there’s an image of a panther with the caption, “I’m hungry enough to eat a horse.” I replied, “Yeah, and he won’t be hungry or eat again for a week, ‘cause in a fasting state, he will be in ketosis, burning the fat he put aside. That’s the ‘normal state’ for all mammals.” To which the poster said, “Dan…this is a Carolina Panther ready to eat the Denver Broncos!!!” “Oops,” I replied. “How embarrassing (LOL).”
This exchange said two things: 1) I was living under a rock and 2) hunger for people who are “carb addicted” is a condition far too familiar in our society today. As to the first observation, I plead “guilty.” People who read this column know that I am obsessed with the many benefits of very-low-carb eating. And the absence of hunger is the first and most surprising one. The corollary benefit is that it makes losing weight “a piece of cake.”
When you eat mostly protein and fat for energy (with some incidental carbs), you just have to listen to your body. The fat and protein will make you feel full and won’t raise you blood sugar the way carbs will. Your glucose metabolism will be steadier and more stable – smaller peaks and smaller valleys. It’s the dips in blood sugar that make you feel hungry and tell your body to eat. On a “balanced” diet, it’s the rollercoaster that never ends.
Why, you ask, do carbs do that, while protein and fat do not? It’s because your body thinks you can eat more carbs. It must be harvest season. The fruits are ripe. The vegetables are ready to be picked. Even the animals are fat, from eating the carbs (grains) they graze on. So, your body is signaling you to “eat hay while the sun shines,” ‘cause soon it will be dark and cold and you need to “fatten up” on carbs to get ready for the long hard winter.
Your body does this wondrous thing with hormone signaling. Insulin was thought for decades to be just 1) a transporter of glucose in the bloodstream and 2) a gateway, via receptors, for the uptake of glucose at the cellular level. In a person with normal glucose metabolism, it does these two things well. In a person with a degree of Insulin Resistance, insulin struggles with opening the receptor door, so the pancreas continues to make insulin. Therein lies the problem. Until the glucose is “taken up,” the blood INSULIN level remains elevated.
That’s when the 3rd important mechanism of insulin was discovered. High amounts of insulin in the bloodstream signal that energy from carbs is sustaining your energy balance, and so the body does not need to switch energy sources. It can hold on to your energy-dense fat reserves that you set aside for that long winter. Problem is, in today’s world, winter never comes. There’s an endless supply of fattening carbs to keep your blood insulin level elevated enough to shut off access to your body’s energy reserves stored in body fat – thighs, abdomen, etc.  
The result? You guessed it: You’re so hungry you could eat a horse. In fact, you are starving! That’s not just a figurative term. You are literally starving, because your body doesn’t have access to your fat reserves when your blood INSULIN level remains high. When you eat carbs at each dip in your blood sugar, your blood sugar and blood insulin level goes up…and then dips, again. So you snack between meals, on more carbs. You know the drill. Eventually your insulin level stays up, your blood sugar does not come back down and this condition, Insulin Resistance, is called Type 2 Diabetes. That’s why you’ve been on a rollercoaster ride for all this time.
When you reduce your intake of carbs, your blood glucose level will drop. You’ll be hungry for a while (after you use up the stored glucose in your liver, and then your blood insulin level will drop too. That’s when your body will switch over to using your stored body fat (your fat reserves) for energy. Your blood insulin level will stay lower so long as you eat small meals of protein and fat. For a day or two, you will pee a lot. That’s not fat, but it is encouraging to see it on the scale. Then, as you body adapts to not expecting carbs (“it must be winter”), you will continue to break down body fat to fuel your body so long as you have fat. Remember to drink water, eat salt, and mostly protein and fat. You won’t be hungry, and you will begin to burn stored fat and lose weight. 

Thursday, December 26, 2019

Retrospective #313: What Does Insulin Resistance Have to Do With It?

This blog and this column in particular are intended for the recently diagnosed Pre-Diabetic, Type 2 Diabetic, or family member or friend of someone who thinks they or another they care about may be one of the nearly half (so far) of Americans who have developed a degree of Insulin Resistance. Insulin Resistance is what causes Type 2 diabetes, but it is a relative term. It develops slowly on a continuum and worsens progressively if no dietary changes are made. 
Most clinicians who treat Type 2 diabetes and its associated obesity do not test for Insulin Resistance. Instead they measure your blood glucose, either fasting (FBG) or with a surrogate, the A1c test, that counts the percentage of glucose on the surface of your red blood cells. The A1c test is preferred now because it gives a better indication of your Insulin Resistance, thus your carbohydrate intolerance. It incorporates the “excursions” (ups and downs) that your blood glucose takes, after meals, for example, 24/7, over the 3-month life of your red blood cells.
For all intents and purposes, Insulin Resistance = Carbohydrate Intolerance. The degree of your Insulin Resistance is directly correlated with the degree to which you have become Carbohydrate Intolerant. To mitigate your Insulin Resistance, and thus to increase its inverse, “insulin sensitivity,” there are several things you can do: 1) eat a low carbohydrate or very low carbohydrate diet, 2) exercise (to increase insulin sensitivity, NOT to lose weight), and 3) take Metformin, an oral anti-diabetic medication. Metformin improves insulin sensitivity as a secondary outcome. The primary reason to take Metformin is to suppress unwanted glucose produced by the liver from stored amino acids.
Insulin Resistance is also the cause of weight gain, NOT gluttony or any other “character fault.” In brief, when you are always hungry, it is because your Insulin Resistance caused an elevated circulating insulin. Your pancreas produced the extra insulin because it sensed you needed it to help your cells take up the circulating glucose accompanying the transporter/gateway hormone insulin. And so, as long as your circulating insulin is elevated, your liver “thinks” that the body does not need to break down stored fat for fuel. As a result, you have an “energy deficit.” Put simply, you are hungry, so you scarf down more carbs (“energy in”) for quick energy to restore your “energy balance” (homeostasis).
This, unfortunately, can go on for days, months, years, a lifetime. Once you’ve developed Insulin Resistance and continue to eat a “balanced” diet (including beaucoup carbs), your blood insulin will be continuously elevated and your body will be unable to utilize its own body fat for energy. So, you will always be hungry and crave carbs. So, you eat, and overeat, but only because your body is unable to use its own body fat for energyThe only way to interrupt this cycle is to lower the level of insulin circulating in your blood. And that will only happen, after a few days of eating very low carb or low carb, when stored glucose (called glycogen) in your liver and muscles is all used up.
Then, when your serum insulin level is sufficiently lowered, other hormones will signal the brain, and your body will automatically switch to breaking down and burning stored fat for energy balance. Stored fat, broken down to fatty acids, is now the “Energy In” part in the formula “Energy In = Energy Out.” And when you are burning your own fat, you will not be hungry. You will not crave carbs. And because you are using stored fat for “Energy In,” you will lose weight. Remember to be mindful and don’t eat if you are not hungry. You will soon discover that three or even two small meals a day, of healthy animal protein and fat, will provide all the energy you want. No snacks are needed!
In addition to weight loss, your glucose metabolism (A1c’s) will improve. As you lose weight, your blood pressure will too. And your HDL cholesterol should increase (mine doubled) and triglycerides should plummet (mine by 2/3rds). Your systemic inflammation marker (hsCRP) should also improve, and you will need to take few if any meds.
You will in fact feel totally energized. Your body wants to eat high quality, nutrient dense, real food, and it likes to use its body-fat reserves, the stores it put aside for that very purpose. The body is a self-healing organism. It wants to be healthy. It is the natural state of the mammalian species to be lean and strong. Why not give it a chance to be all that it can be? All you need to do to be healthier is to cut back on the carbohydrates in your diet.

Wednesday, December 25, 2019

Retrospective #312: Isn’t eating Very Low Carb…well, extreme?

A person who is neither Pre-Diabetic nor a clinically diagnosed Type 2 invariably asks me, “Isn’t eating Very Low Carb…well, extreme?” In a word, my answer is, “yes.” I am highly Insulin Resistant; therefore, I am highly Carbohydrate Intolerant. Carbs are “poison” for me. However, Insulin Resistance is a relative term, measured on a continuum, a sliding scale; its inverse (1/IR) is Insulin Sensitivity, a measure of how well your cells take up glucose. And the degree to which you are Insulin Resistant will determine how many carbohydrates you can eat. The determining factor for you will be your degree of Insulin Resistance/Carbohydrate Intolerance. For me, it’s…well, extreme.
How does the “treatment-na├»ve” (untreated) patient with a slightly elevated fasting glucose or hemoglobin A1c determine the degree of Insulin Resistance/Carbohydrate Intolerance they have developed? Well, there are laboratory tests, like the OGTT or Oral Glucose Tolerance Test. Upon diagnosing me 33 years ago, my GP referred me to an Endocrinologist who ordered this 2-hour test in a hospital outpatient setting. It confirmed the GP’s diagnosis: I had T2DM. At the time (1986), the prevailing clinical standard for an office diagnosis of frank Type 2 Diabetes was 2 consecutive visits with a Fasting Blood Glucose (FBG) ≥ 140mg/dl. In 1996 the standard changed to ≥ 126mg/dl.
Today, while the Fasting Blood Glucose is still commonly used, the new diagnostic standard is the A1c test. It measures the percentage of glucose on the surface of your red blood cells. Since red blood cells have an average life of about 3 months, this test is a surrogate measure of the rise and fall of your blood sugar 24/7 over a 2 to 3-month period. The idea is that it captures the after-meal spikes, and therefore your Impaired Glucose Tolerance (IGT), or Carbohydrate Intolerance, and is therefore more “convenient” than the OGTT and much better than a fasting glucose measurement.
Be careful, though. You are at the point I described in Retrospective #306. You are at a juncture. If you leave the matter of “what's next?” entirely up to your “treatment team,” including your clinician and RD or CDE, after you fail to lose weight following their advice to “eat a restricted calorie, balanced diet and exercise,” your clinician will treat your symptom (high blood glucose) by prescribing a pill (or pills) to lower your blood sugar. As such, so long as you continue to eat a restricted calorie, balanced diet, the CAUSE of your elevated blood sugars will NOT be addressed, and YOUR DISEASE WILL PROGRESS. The CAUSE of your elevated blood glucose and associated weight gain is the INSULIN RESISTANCE that you developed from eating a balanced diet way too high in processed carbs and sugars.
This errant course of treatment is in part based on the erroneous belief that being overweight or obese caused your Type 2 Diabetes. That’s the reason your doctor wants you to lose weight. But, in fact, the opposite is true. Read Retrospective #308 for an explanation of “What Causes Type 2 Diabetes.” Insulin Resistance is the cause of both Type 2 Diabetes and obesity. And Insulin Resistance, for us who are genetically predisposed, became “expressed” from a diet that is composed of excessive amounts (+/-60%) of processed carbs and sugars, i.e., all carbohydrates.
So, the only course of treatment that treats both the cause of Pre-Diabetes or Type 2 Diabetes, and obesity if you have it, is one that reduces the carbohydrates in your diet. The current government sanctioned dietary is 60% (300g) carbs, 10% (50g) protein and 30% (65g) fat (% by calories), on a 2,000 kcal/day diet for a “woman of a certain age.”
The current draft of the 2020 Dietary Guidelines for Americans (DGA) erroneously defines “Low Carb” as 45% (225g or 900kcal) carbohydrate. That’s an improvement for a healthy eating pattern for a person who has a normal glucose metabolism but it is NOT low carb. It is only lower carb for people with a normal glucose metabolism. IT IS WRONG.  
Low Carb is usually defined as 10% carbohydrate (50g of carbs a day), 20-30% protein, 60-70%. Is this “extreme”? You’d think so if you’re Pre-diabetic and you followed the recommendation of the draft 2020 DGA, as your doctor will advise you to do, and your condition will worsen and you will progress to more medication and risks of complications.
Very low carb is usually defined as 5% carbohydrate (15 to 30g of carbs a day), 20% protein and 75% fat. That is my extreme Way of Eating (WOE), the way I have to eat to maintain good glucose control (even while still taking 1 low-dose Metformin a day), fasting blood glucose below 100mg/dl (often in the 70s and 80s) and A1c’s in the low 5s.

Tuesday, December 24, 2019

Retrospective #311: How Can I Manage My Type 2 Diabetes?

Type 2 Diabetes is a Dietary Disease. Your blood sugar (glucose) rises and falls depending on what you eat. When you eat carbohydrates, there is a direct and simple relationship to your blood sugar level. It goes up. And when you eat more protein than your body needs, there is, to a lesser extent, a secondary and delayed rise in blood sugar. Fat, the “other” (third) macronutrient, has virtually no effect on blood sugar.
Carbohydrates – including simple sugars and more “complex” carbs, especially those in packaged foods that have been processed and refined to the point where they are virtually simple glucose – will have the most impact on your blood sugar. In contrast, unprocessed, whole vegetables – “real food” -- although also carbohydrates, will digest at a slower pace. However, all carbohydrates – simple, processed or “whole” – will become glucose “under the curve” (in your blood) within an hour or two of eating them. That’s better than a few minutes, but it’s still an elevated blood sugar.
So, to manage your type 2 diabetes yourself, by what you eat, you’ll need to educate yourself about what carbs are and what foods contain them. You will need to study the Nutrition Facts panel on processed foods, paying attention to the carbohydrate grams. And don’t forget to check the portion size. It is usually much smaller than you will eat.
You will also need to learn what effect carbs have on your blood sugar. That depends on your degree of Insulin Resistance (IR).  As a frame of reference though, if you fasting blood glucose is not between 70 and 100mg/dl, you have a degree of Insulin Resistance. If it is between 100 and 126mg/dl, you are considered Pre-Diabetic. If your fasting blood glucose is 126mg/dl or greater, you are, frankly, a Type 2 Diabetic. Do you know your fasting blood sugar?
You’re thinking that your doctor will test your fasting blood sugar (or A1c) if he or she suspects you have IR or are Pre-diabetic or Diabetic. True, but he/she can only monitor your Type 2 Diabetes at the time of your office visit. Type 2 Diabetes is a Dietary Disease, so it’s up to you to manage your blood sugar. And to do that you’ll need a meter.
In addition to testing your blood after an overnight fast, you’ll want to know how your blood sugar responds to the foods you usually eat. You do this by testing both before and after “test” meals. To find out how high your blood sugar spikes, test before and then 1 hour after starting to eat. To find out how close to “normal” it returns, test again 2 hours after that meal. If your blood sugar doesn’t drop to near where you began by 2 hours postprandial (after eating), you are Pre-Diabetic. If it isn’t below 140mg/dl, you have Type 2 Diabetes and you have eaten way too many carbs in that meal. Blood sugar in a “healthy” person never goes above 140mg/dl, even 1 hour after a big carb load.
You will learn quickly what you should eat and what you shouldn’t. Carbs are hidden everywhere, especially in plain sight. Fruit, for example, is just a simple carbohydrate: sugar and water. At least whole fruit contains some fiber, so it’s better than juice, but otherwise it’s not much different from a candy bar. Fruit juice will send your blood glucose through the roof, and put a load on your liver, and if your liver is already full of glycogen, it will make fat from sugar!
Bread has a glycemic index of 100, meaning it is the definition of a high carb food. The ingredients list of virtually all breads begin with flour (a highly processed, 100% carbohydrate), then water, and then always some form of sugar.
Proteins digest slowly, and the component amino acids not taken up by your cells will be stored in the liver. By a process called gluconeogenesis, the liver can make glucose from some of them, which is a good thing. It can also make glucose from the glycerol backbone of a triglyceride (fat) molecule. Small amounts of glucose are essential, whereas the body has ZERO requirements for CARBOHYDRATES. But the liver of Type 2s makes glucose even when the body doesn’t need it. That’s why clinicians prescribe Metformin to suppress this unwanted glucose production.
So, take charge of your Pre-Diabetes or Type 2 Diabetes. Manage what you eat. Monitor your blood sugar. And eat to your meter. It’ll take time to learn what affects your blood sugar level and by how much. How strictly you eat low carb will determine how your blood sugar responds. Just remember: Type 2 Diabetes is a Dietary Disease and YOU are in charge of managing it. Your doctor is there just to monitor your improved blood sugar control and your weight loss.

Monday, December 23, 2019

Retrospective #310: Newly Diagnosed Type 2? What’s Next?

It’s now been 33+ years since I was diagnosed a Type 2 Diabetic (in 1986), so I’ll admit I don’t have a recollection of what happened next. My guess, though, is that what I was told then is not much different from what a newly diagnosed Type 2 or even a Pre-Diabetic is told today. Only the names and classes of drugs have changed.
First, I’m pretty sure I was scared. After all, I was told I had a disease – a life-long, progressive disease – and that it would require medical treatment for the rest of my life. I was also told, I’m sure, that I should lose a lot of weight. That was daunting enough, so I’m pretty sure my doctor didn’t tell me that I would eventually “progress” to injecting insulin and that I would probably die from one of the micro or macrovascular complications of the disease. That was the way it was then, and sadly still is today, if you follow the medical establishment’s treatment protocol.
Of course, losing weight, following my doctor’s recommendations, was my responsibility. Prescribing medications was his. He, like all doctors then and now, was lacking in nutrition training, but probably offered me some “helpful” advice: “eat less and exercise more.” He probably suggested I follow the one-size-fits-all Nutritional Guidelines for Americans’ “eating pattern” to eat a restricted calorie, balanced diet and do some “regular exercise” for 30 minutes a day, 5 days a week. But my doctor knew from long experience with obese Type2 patients that I would fail to lose the weight on that “diet and exercise” program. Not to worry; he had a prescription pad and could write another “script” as my condition worsened. My guess is you are already well familiar with this “establishment treatment protocol” scenario.
Like most doctors, then and now, my doctor was under the mistaken impression that I was obese because I ate too much and didn’t exercise enough. My doctor thought that my obesity led to and was a major contributing factor, perhaps even “the cause,” of my Type 2 diabetes. The truth is: it was the other way around. The underlying condition of my Type 2 diabetes, Insulin Resistance, is what caused my obesity. For an explanation of the mechanism of this metabolic pathway, read “Retrospective #308: What Causes Type 2 Diabetes?” Or a good book: Gary Taubes’s “Why We Get Fat and What to Do About It,” or Volek and Phinney’s “The Art and Science of Low Carbohydrate Eating.”
So, my doctor thought that if I reversed my weight gain, he could slow the rate at which my progressive disease would worsen. And it would be good as well for my general health, blood pressure, etc. My doctor also thought that by prescribing medications to help me control my blood sugar, he would be helping me to control my diabetes and thus likewise “delay the complications.” My doctor, regrettably, was misguided here too, as he was taught to treat diseases by treating the symptoms; my doctor didn’t understand and therefore couldn’t treat the cause of Type 2 diabetes.
The cause, Insulin Resistance, was precipitated when certain of my genes “expressed” themselves after a long history of eating a diet that was too heavily composed of carbohydrates, especially highly processed carbohydrates (including sugars). Since the 1960s, all Americans have been told by the American Heart Association to reduce their intake of fat, in particular saturated fat and dietary cholesterol. In 1977 a Select Congressional Committee issued Dietary Goals, and in 1980 the USDA and HHS jointly produced the first Dietary Guidelines for Americans. In 1990, Congress followed with the Nutrition Facts panel on processed foods. Then and NOW, incredibly, the Nutrition Facts panel calls for a diet of 60% carbohydrates, 10% protein and 30% fat. These ratios are excellent for fattening feed lot livestock for market.
These government interventions were a huge (no pun intended), nation-wide uncontrolled experiment. Now, after half a century, we see that it was a catastrophic failure, leading to an epidemic of obesity and Type 2 Diabetes even in very young children. If you are now a member of this failed low-fat (VERY HIGH CARB) cohort, consider addressing the cause: highly processed carbohydrates.  To avoid “challenging” your “expressed” genes, with the goal of improving your Insulin Sensitivity, consider modifying the macronutrient ratios in your diet. To lower both your weight and your blood sugar, reduce the carbs dramatically, increase the protein slightly, and raise the dietary fat. Get off the livestock fattening program. Start with 20% carbs, 20% protein and 60% fat. Just start with breakfast and see how you feel; perhaps 2 or 3 eggs and 1 or 2 strips of bacon. No toast! No juice! How do you feel? Are you hungry before lunch?

Sunday, December 22, 2019

Retrospective #309: Diabetes Q & A

Q #1: What is Type 2 Diabetes?
Answer: Type 2 Diabetes is a metabolic disorder in which insulin, the glucose transporter in the bloodstream, is blocked on the surface of destination cells, preventing the glucose from being taken up for energy. This condition is called Insulin Resistance. As a result of Insulin Resistance, blood glucose levels become elevated. If untreated, elevated blood glucose eventually causes serious microvascular and macrovascular complications. And, as the disease worsens, the pancreas develops a diminished capacity to make insulin, and insulin replacement therapy is required.
Q #2: How Did I Get Type 2 Diabetes?
Answer: You, along with about half the population of the Western World, were unlucky. First, you have a certain genetic predisposition such that some as yet mostly unknown combination of genes makes them vulnerable to a genetic modification. This is not a “mutation.” Second, you (and I) unwittingly participated in a large uncontrolled government experiment of eating a low-fat, high-carb, dietary pattern and, being genetically predisposed, our genes have “expressed” this modification, causing us to become Insulin Resistant, and thus Carbohydrate Intolerant.
Q #3: What Can I Do If I’m Pre-Diabetic?
Answer: If you’ve been told, or you suspect, that you’re “Pre-Diabetic,” to avoid becoming a Type 2 Diabetic you must change what you eat to reduce, as much as possible, carbohydrates. Carbohydrates are a non-essential macronutrient. There is no minimum requirement for carbs. Carbohydrates include both simple sugars and complex carbohydrates, particularly refined and processed carbohydrates. You must also avoid sugary soft drinks, fruit juices and drinks, and all baked goods, starchy vegetables, cereals, and desserts. This, of course, is difficult to do, but if you do it, it’s a sure and certain way to lose weight without hunger, and besides losing weight, you will avoid developing type 2 diabetes.
Q #4: How Can I Prevent Type 2 Diabetes?
Answer: Easy! Type 2 Diabetes is a dietary disease. If you take charge of what you eat, and seriously restrict your carbohydrate intake, you will avoid developing this disease. Even if you are already somewhat overweight and/or have been told you’re “Pre-Diabetic,” you can reverse Pre-Diabetes and put Insulin Resistance “in remission.” And by continuing to restrict carbohydrates, you will also lose weight rather easily and do it without hunger! As long as you stick to your carbohydrate restriction/reduction, you will remain protected from developing this disease.
Q #5: How Can I Prevent Type 2 Diabetes from Becoming Progressive?
Answer: If you are already a diagnosed Type 2 Diabetic, you must do just one thing: ignore the advice to “eat a balanced diet.” Continuing to eat beaucoup carbs will virtually guarantee that your disease will be progressive. You will become dependent on more and more expensive medications, and possibly become an “insulin dependent type 2” and eventually develop the dreaded complications. The only way to prevent Type 2 Diabetes from becoming progressive is to largely eliminate carbs from your diet: all carbohydrates become glucose in your bloodstream.
Q #6: Can I Reverse Pre-Diabetes or Type 2 Diabetes?
Answer: The only way to reverse Type 2 Diabetes is to largely eliminate carbohydrates from your diet. All carbs become glucose in your blood. If you are Pre-Diabetic or have been diagnosed a Type 2 Diabetic, you have Insulin Resistance and you are therefore Carbohydrate Intolerant. Your body can’t handle carbs any more. So long as you restrict the carbohydrates you eat, your Pre-Diabetes or Type 2 Diabetes will be “in remission.” You’re not cured, but while your disease is in remission, you are not at risk for the microvascular and macrovascular complications.
Q #7: Can I Cure My Type 2 Diabetes?
Answer: No, you can’t. Anyone who uses the word “cure” is misleading you. If you are a Type 2 diabetic, it is because you were genetically predisposed and your genes have “expressed,” i.e., been modified, permanently, as far as anyone knows at this time. That’s history, and you can’t change your genes back to their “normal” expression. However, you can take those genes “out of play” by avoiding all the foods that “express” them: carbohydrates. So long as you eat a diet of fats and protein, as your body was designed to do, your body will adapt. You will have plenty of good energy, healthy food for the heart and brain and every other need the body has, and your blood sugar and insulin levels will decline to “normal.” Your Type 2 Diabetes will be “in remission.”
Q #8: How Can an Overweight Type 2 Lose Weight Safely?
Answer: That’s easy, and you can “kill two birds with one stone.” The most difficult part of any “restricted calorie, balanced” weight loss diet is being hungry all the time. The reason is: most overweight people have Insulin Resistance. So, insulin circulating in your blood, secreted by the pancreas to transport glucose (digested carbs) to your cells, blocks your body from using body fat for energy. Your body thinks, “If you have insulin circulating, so you have carbs in your blood, so you don’t need your precious body-fat reserves.” So, stored fat is “saved” for another day. If you instead restrict carbs, instead of calories, your liver will sense lower blood glucose and blood insulin in the bloodstream, and will start to break down body fat for energy. You will feed on yourself, you will not be hungry, and you will lose weight!
Q #9: Is Being Overweight a Cause of Type 2 Diabetes?
Answer: No, it’s the other way around, and the explanation is simple. When you eat a “balanced” diet, as most weight loss programs and “experts” advocate, glucose from digested carbs is accompanied in the bloodstream by the transporter hormone insulin. The liver, which controls metabolic homeostasis, perceives that since you have dietary carbs available for energy, you don’t need body fat to maintain energy balance. So, the fat stays locked up around your waist. As you develop Insulin Resistance (see #1 above), your serum insulin levels remain high so added, unused  calories from carbs, protein and fat, stored in the liver, are converted by the liver to additional fat stores. You got fat because you’re Insulin Resistant, which means you are either a Type 2 Diabetic or at serious risk of becoming one.
Q #10: Is Being a Type 2 Diabetic like being Gluten or Lactose Intolerant?
Answer: Yes and No. Each involves a food intolerance. Gluten Intolerance means the body is intolerant of the protein portion of the wheat, barley or rye grain. It rapidly results in intestinal distress. Lactose Intolerance means the body is intolerant of foods containing the milk fat lactose, because of the absence of the enzyme lactase to help digest it. Lactose intolerance rapidly results in intestinal distress. Carbohydrate Intolerance, the result of a person developing Insulin Resistance expressed as the metabolic disorder, Type 2 Diabetes, is at first asymptomatic but results in serios long term microvascular and macrovascular complications, usually the eventual cause of death. All three intolerances – gluten, lactose and carbohydrate – are dietary diseases and are best addressed by avoiding the dietary cause.
Q #11: Won’t Eating So Much Fat Make Me Fatter?
Answer: No, unless you eat too many carbs and too much fat. Fat, eaten with or without protein, is filling. You quickly become satiated (satisfied), so eating fat is self-limiting. You will eat less if you eat just meals of energy-dense, full-fat, real foods, moderate protein and minimal carbohydrates. Carbs that have been processed have been depleted of nutrients in processing, including essential fat-soluble vitamins and minerals. Carbs that are eaten to the exclusion of healthy saturated and monounsaturated fats will not satisfy your hunger and will lead to cravings. Eating too many nutrient-deficient processed carbs will lead to overeating carbs, which the liver will convert to body fat via a process called de novo lipogenesis. Eating carbs will make you fat. Think about how livestock is fattened before slaughter.
Q #12: Won’t Eating Saturated Fat Make My Cholesterol Rise?
Answer: Actually, no! Eating a high-fat, low-carb diet will be good for your cholesterol. It will raise your HDL cholesterol (the “good” cholesterol). Mine more than doubled. If your Total Cholesterol (TC), an obsolete value in modern lipidology, rises slightly, it will be because your HDL went up. The formula is TC = HDL + LDL + TG/5. Your LDL cholesterol (the “bad” cholesterol) will probably remain constant, but the LDL particle size and density will improve, from “small dense” to “large fluffy.” And your triglycerides (TG), measured at the same time as your cholesterol, will decline dramatically. Mine dropped by more than two-thirds.
Q #13: Won’t Eating Dietary Cholesterol Block My Arteries?
Answer: Certainly not! Dietary cholesterol, from animal foods like meat, eggs and shrimp, has nothing to do with serum cholesterol (cholesterol in your blood). Cholesterol is an essential compound. It is present in every cell in your body. Your liver makes cholesterol as your body needs it, accounting for about 90 percent of the cholesterol in your body. If you eat less cholesterol, your liver will make more. Cholesterol in the blood actually repairs erosion in the surface layer of your veins caused by inflammation, preventing small, dense oxidized LDL particles from being trapped in the fissures. HDL “clears” LDL, returning it to the liver for disposal.  In December 2014, the Dietary Guidelines Advisory Committee reported that “Dietary cholesterol is no longer a nutrient of concern for overconsumption.”
Q 14: Aren’t Carbohydrates Necessary for Energy?
Answer: No. Carbohydrates, however, are a major source of “quick” energy. They digest quickly, converting primarily to glucose, which is an essential nutrient, in small amounts, for certain organs and tissue. However, because only a small amount of glucose is necessary but because it is essential for certain parts of the body, the body has developed mechanisms and pathways to make glucose from both protein and fat. The liver can make glucose from amino acids that are the breakdown products of protein. And glucose can also be made from the glycerol “backbone” when a triglyceride (fat) molecule is broken down to fatty acids for fuel. Furthermore, the byproducts of this oxidation are ketone bodies which the brain actually prefers to glucose. In the absence of carbs, after a brief period of adjustment, the body does very well on a diet exclusively of fat and protein. Some marathoners prefer fat to carbs for fuel.
Q 15: What About Macronutrient Ratios?
Answer: In 1961, the American Heart Association determined, from epidemiological studies, that dietary saturated fat and cholesterol were a cause of cardiovascular disease (CVD).  In 1977, a U.S Senate Select Committee agreed, and in 1980, the USDA/HHS produced the first Dietary Guidelines for Americans. Food packaging laws followed, resulting in the Nutrition Facts panel on processed and packaged foods. To this day, except for children under the age of 2, the macronutrient ratios on those panels recommend that the entire American population eats a diet consisting of 60% carbohydrate, 10% protein, and 30% fat, and that mostly polyunsaturated fat from vegetable oils like soybean and corn oil. That, in a nutshell, is why half the Western world is now overweight or obese…and has Insulin Resistance.
Q 16: What Is a Low-Carb, High-Fat (LCHF) Diet?
Answer: A Low-Carb, High-Fat (LCHF) diet is designed primarily to lower both blood glucose and blood insulin, thus preventing the onset of Prediabetes or Type 2 Diabetes or reversing Prediabetes due to incipient Insulin Resistance. It also enables the adherent, if needed, to lose weight without hunger. Definitions vary but generally a LCHF diet entails eating less than 50 grams of carbohydrate a day. That’s 10% carbohydrate of a 2,000kcal a day meal plan vs. 300g/day (60%) carbohydrates of the Standard American Diet (SAD) on the Nutrition Facts panel on processed food in the U.S.
Q 17: What is a VLC Ketogenic Diet?
Answer: A VLC Ketogenic Diet is a Very Low Carb Ketogenic Diet in which the adherent eats fewer carbohydrates than in LCHF. Generally, it’s about 5% or between 15 and 30 grams of carbs a day (on a 1200 or 2400kcal/day diet.) Today, I try to eat ≤ 15g/day of carbohydrates to be in a perpetual state of mild ketosis, producing a low level of ketone bodies from the breakdown of my body fat. I find that my body likes this state best. I am always full of energy, get excellent rest, and am never hungry. So long as I adhere to this program, my blood sugars are always <100, and I lose weight.
Q 18: What Foods Must I Strive to Avoid to Stay Healthy?
Answer: Processed carbohydrates, simple sugars and vegetable and seed oils. Carbs include simple sugars, both added and naturally occurring, unfortunately. That means avoiding: fruit, especially fruit juices and fruit drinks; baked goods, cereals, pasta and rice and root vegetables. The more processed the grain or the sugar, the more damage it can cause.  Flour and sugar are not your friends.  Also, avoid inflammatory foods. Vegetable oils, particularly corn and soybean oil, are high in polyunsaturated fats (PUFAs) and are very inflammatory, doubly so if used repeatedly for deep frying.
Q 19: Is Type 2 Diabetes a Lifelong Disease?
Answer: Regrettably, once you get Type 2 Diabetes, you’ll have it for life. Your genes have been modified. However, if you limit the carbs you eat, and avoid processed carbs and sugars, your body will be able to handle it. And when eating Very Low Carb your insulin sensitivity will improve. And your body still produces some insulin, so in response to eating carbs it will produce enough insulin to circulate the glucose and eventually absorb it. Then, after the circulating glucose is absorbed and your blood insulin drops, you will return to burning body fat for energy; your body will be happy, and you will not be hungry. As long as you follow this Way of Eating, your Type 2 Diabetes will be in remission.
Q 20: When I Reach My Goal Weight, What About Maintenance?
Answer:  I have only reached my goal weight once, and I later regained some. In maintenance, you are supposed to keep both carbs and proteins constant and, to stop losing, increase your fat. Increasing fat should be fairly easy. I could snack before dinner on buttered radishes or cream cheese filled celery, or add olive oil or butter to meat and vegetables. For now, I am working on getting back to my goal weight and maintaining my Type 2 diabetes in remission.

Saturday, December 21, 2019

Retrospective #308: What Causes Type 2 Diabetes?

Google “type 2 diabetes” and, in a split second, you get 118,000,000 “results.” The very first “result,” after a brief description of the condition, asks, “What Causes Diabetes?” Their answer to the Google search was, “Usually a combination of things causes [emphasis added by me] type 2 diabetes,” What followed on their list were 6 symptoms, effects and parallel conditions associated with type 2 diabetes, NONE of which is the cause of type 2 diabetes. Only the first named “cause” on the list, “genes,” is relevant in that genes are a precondition, making you susceptible to developing type 2 diabetes, BUT GENES ARE NOT THE CAUSE OF TYPE 2 DIABETES.
Geneticists will tell you the genetic aspect of the origins of Type 2 Diabetes is still in its infancy. Although some genes associated with Type 2 Diabetes have been indentified, no one has yet deciphered the complex combination of genes that have been modified – not mutated – by our EATING A “WESTERN” (“Standard American”) DIET. Certain genes (in those of us who have them) express themselves in a way that compromises the ability of cells to accept glucose. This modified genetic “expression” is called “Insulin Resistance.”
Insulin in the blood, secreted by the pancreas when we eat carbohydrates, carries glucose throughout the body, delivering it to our cells. If glucose can’t enter the cells, because of Insulin Resistance, it continues to circulate. The pancreas releases more insulin to help with the problem, and eventually the pancreas stops working.
An elevated blood sugar (glucose), over time, causes the complications of diabetes. And elevated insulin in the blood signals that there is still glucose (energy primarily from carbs) circulating in the blood so there is no need to burn fat reserves for energy. So, the body keeps our fat in storage, and the liver converts excess  carbohydrates that we eat to fat and adds them to our body’s stores. INSULIN RESISTANCE, resulting in high levels of circulating insulin in the blood, is thus THE CAUSE OF BOTH TYPE 2 DIABETES AND OBESITY, not the other way around. Insulin Resistance causes diabetes, Insulin Resistance causes obesity, and OBESITY is usually a signal that your blood glucose is NOT under control.
What then is the best “treatment” for type 2 diabetes caused by Insulin Resistance? The Googled website I searched listed 18 generalized “risk factors:” 3 are “things you can’t control,” and 11 others are “related to your health and medical history,” things that are epidemiologically associated with those who develop type 2 Diabetes. That may be helpful to you, or to your doctor if he or she is otherwise clueless about whether to diagnose you as “pre-diabetic” or a frank type 2. But let’s face it: they are history, and there’s not much you can do to change your history.
Then the Googled website lists 4 “Other risk factors (that) have to do with your daily habits and lifestyle.” It suggests, “These are the ones you can really do something about.” The site’s advice (amid pop-ups for anti-diabetic drugs): “Take medications and follow your doctor's suggestions to be healthy.” The site’s other suggestions: “Lose weight. Get active. Eat right. Quit smoking.” Okay, but NOT AN EFFECTIVE TREATMENT PLAN FOR INSULIN RESISTANCE.
The best way to think of Insulin Resistance is that your body has become intolerant of dietary – especially processed – carbohydrates, i.e., you are Carbohydrate Intolerant. So, an “eating pattern” that reduces dietary carbohydrates to a minimum, or as few as you are willing to eat, will reduce the levels of both GLUCOSE and INSULIN circulating in your blood. By lowering your blood GLUCOSE, this will 1) minimize your risk of pre-diabetes, frank type 2 diabetes and all the later complications, and by lowering your blood INSULIN, this will 2) enable your body to access your fat stores for energy. You’ll lose weight and, in the bargain, avoid diabetes. WHY DOESN’T YOUR DOCTOR TELL YOU THIS, instead of writing a prescription?
* If you’ve been wondering if you are one of those who is genetically predisposed, there is no laboratory genetic test as yet, but if you are overweight there is a strong likelihood (true, it’s just an “association”) that you have developed a degree of Insulin Resistance sufficient to cause that buildup of body fat. Remember, IT IS INSULIN RESISTANCE THAT CAUSES BOTH OBESITY AND TYPE 2 DIABETES. A good metric to assess this is a waist/hip ratio greater than 1.0. 

Friday, December 20, 2019

Retrospective #307: My Personal Story (N = 1)

In 1986, at age 45, I was diagnosed a Type 2 diabetic. The standard at the time was 2 consecutive fasting blood sugars ≥140mg/dl. In 1997 the standard was lowered to ≥126mg/dl, so I had probably been diabetic for at least 10 years, from age 35. My doctor suspected I might be diabetic because in 1986 I weighed 300 pounds, up from 250 in 1974.
Of course, my doctor told me to lose weight. He also began to treat me with a sulfonylurea (micronase, later glyburide), an oral antidiabetic medication that forced my already stressed pancreas to secrete more insulin whenever I ate carbohydrates, especially simple sugars and highly processed carbs.
I had tried many times to lose weight. My doctor, and his staff nutritionist, a Registered Dietitian (RD) had recommended a “balanced, calorie restricted” diet, and exercise. I was always hungry, but from time to time I did lose weight and always gained it back. Net result: over the years I continued to gain weight, and my diabetes worsened. In the mid 1990s, after I was “maxed out” on glyburide, my doctor prescribed metformin, a new medication (in the U.S.). In a few years I was maxed out on metformin too, and my blood sugars still out of control, so my doctor started me on a third class of diabetes meds. Soon, I feared, I would be injecting insulin once a day or maybe even with each meal.
By 2002, I was the heaviest I had ever been. In fact, at several office visits I had been too heavy to be weighed on the office scale. So, one day in early August, before a scheduled appointment, I stopped at the Fulton Fish Market on the way to work and weighed myself on a commercial scale. I weighed 375 pounds. That was really scary. So, when I walked into the doctor’s office later that day, I was motivated to lose weight.
“Have I got a diet for you!” my doctor greeted me from the nurse’s station as I walked into the office. Serendipity had created a moment where my doctor had a specific recommendation for me, and I was totally receptive. He told me that he had personally tried a diet that he had read about in The New York Times! It was the cover story of July 7, 2002, Sunday Magazine, “What If It's All Been a Big Fat Lie?” written by Gary Taubes, an award-winning science writer. This ground breaking article that was to change many lives, including mine.
My doctor and I were both interested in this diet because we both wanted me to lose weight – a lot of weight. That was his and my primary motivation. But as he walked me down the hall to schedule my next appointment, he put his hand on my shoulder and said, “Dan, this may help your diabetes too.” Boy was that an understatement!
Strictly following this new diet, late in the afternoon of the first day I experienced a “hypo” or hypoglycemic episode – a low blood sugar with “sweats.” I knew something was wrong so I tested my blood and then went to the news stand in the lobby and bought a candy bar…and after 15 minutes, called my doctor. He told me to stop taking the 3rd oral medication, but the next afternoon, I had another hypo. I ate another candy bar and called him again. This time he said to cut the other 2 oral meds in half, and a couple of days later, when I had my 3rd hypo, he told me to cut the meds in half again. In less than a week of strictly following this diet, I was taking just 1/9th the meds as before.
In the next 9 months, I lost 60 pounds and, to avoid low blood sugars, had to eliminate the 5mg of glyburide I was still taking. A few years later, I started cheating (bedtime ice cream) and regained 12 pounds. I rededicated myself to strict adherence and eventually lost well over 100 pounds more. Today, 17 years later, I maintain a 150+ pound weight loss.
But my Type 2 diabetes went into “remission” before I lost a single pound. I’m NOT “cured.” I NEVER will be, but neither is my Type 2 Diabetes still “a progressive disease,” with worsening health, taking expensive oral meds and at risk of injected insulin. Nobody, besides me, was more surprised by these developments than my doctor. We learned that, quite simply, TYPE 2 DIABETES IS A DIETARY DISEASE. And the most effective treatment is to eat Very Low Carb.
* My lipid (cholesterol) profile also improved dramatically: My HDL more than doubled and my triglycerides dropped by 2/3rds. Also, my hsCRP inflammation marker plummeted to <1.0. My blood pressure, of course, is now “normal.”

Thursday, December 19, 2019

Retrospective #306: Type 2 Diabetes, a Dietary Disease

When this post originally appeared in 2015, I published weekly and, after #305, I decided to take a break. In this current “Retrospective Series,” I am rewriting the originals and publishing daily. And I have found a new audience.
From the time #306 first appeared, the landscape has changed dramatically. Atkins, Bernstein, Paleo and Low-carb, High-fat (LCHF) have been replaced by Keto, Fasting (IF, ADF & EF), Autophagy and Carnivory, not to mention Twitter.
The field is now crowed. Diet Doctor, the Dr. Jason Fung Fan Club and The Fasting Method with Megan Ramos are all very good online sites, all advocating effective ways of healthy eating for weight loss and good blood sugar control.
The hiatus (in 2015) gave me an opportunity for introspection. It enabled me to step back and re-examine my purpose and the best methods of achieving them. As my regulars know, I write this column for educational purposes, both mine and the readers.’ I accept no advertising. I have nothing to sell but an idea: Type 2 Diabetes is a Dietary Disease.
in 2011, in Retrospective #114, “My Insulin Dependent Type 2 Pharmacist,” I recalled an offer to write a newspaper column on any subject, without compensation. It was just “content,” or fill between ads, for the publisher.
I accepted and chose to write about Type 2 diabetes because an acquaintance of mine – a registered pharmacist – died, unnecessarily and tragically. It was when I went to buy a glucose meter that I learned that my pharmacist was an insulin-dependent Type 2. He followed “doctor’s orders” – and the advice of the American Heart Association since 1961 and the Dietary Guidelines recommended by our government since 1977 – and his disease progressed to its inevitable conclusion. His death was a waste. It didn’t have to happen. And that’s what I decided to write about it.
With that in mind I have decided to focus my efforts on a large underserved segment of the diabetic population.  I want to explore an aspect of Type 2 Diabetes care that is largely ignored by the medical and pharmaceutical communities, and the press, and therefore little understood by the people: self-management of Type 2 Diabetes.
I am especially interested in reaching what the medical community calls the “treatment-naive” patient, i.e., someone who is newly diagnosed (as Pre-Diabetic or a Type 2 Diabetic) and has never been subject to any “treatment.” Such patients are at a critical juncture, and DENIAL is an extremely tempting option. Typically, the patient is devastated by the news. He or she defaults into a dependent state and accepts their doctor’s ministrations (as we customarily do in healthcare matters). However, a diagnosis of Pre-Diabetes or Type 2 Diabetes is actually a great time to look into what this disease is really all about – to learn what you, the patient, can do about it. Your doctor will probably agree that as a well-informed patient, you CAN self-manage your diabetes care, under your doctor’s watchful eye, of course. 
Self-management of Type 2 Diabetes is a mutually beneficial arrangement. Doctor’s know that Type 2 Diabetes is largely a PATIENT managed disease. They call it “patient-oriented” care, but that leaves the impression that patient care is a collaboration that the DOCTOR manages. I’m sorry, but as far as dispensing dietary advice is concerned, most clinicians, and Certified Diabetes Educators (CDEs) and Registered Dieticians (RDs), if they want to be paid for the advice they dispense, are required to follow the government’s recommendations. And that advice, since 1961 (AHA) and 1977 (DGA) has been dead wrong, almost exactly the opposite to what “healthy eating” advice should be.
So, at this critical juncture, and in the days and months ahead between doctor’s appointments, if YOU decide on self-management, you will follow one of the dietary regimens mentioned above. And at your next office visit your doctor will order tests and monitor (NOT manage), and record, your IMPROVEMENTS in all your important medical markers.
If you default to the dietary advice your doctor and the government offers, you will embark on a path of MEDICAL management (vs. self-management) of your diabetes. After getting your blood sugar under control with drugs, your doctor WILL manage the progressive WORSENING of your condition. You’re thinking, something must be wrong with this “prescription.” Well, your doctor knows that too, but the only arrow he has left is, “More medications could be used.” That’s the road my pharmacist took– progressively worsening disease – and then a slow, premature death.