Retrospective #116: “A Modifiable Risk Factor”

A Letter to the Editor in my online Lancet subscription contained the comment: “Physical inactivity should be considered as a modifiable risk factor. IMPROVING OF POPULATION HEALTH SHOULD NOT SIMPLY BE MADE THE WORK OF DRUG COMPANIES.” “Bravo!” I say. And this advice is especially apt for OBESITY AND T2 DIABETES too!

But not through exercise! Obesity is also “a modifiable risk factor,” and “improving of population health” – both through weight loss and the concomitant remission of type 2 diabetes – is achievable simply by modifying the macronutrient composition of the diet. It stands to reason, doesn’t it, that if carbohydrates increase the amount of glucose in the blood, particularly among those who have become Insulin Resistant and thus Carbohydrate Intolerant, then reducing the carbs in the diet will reduce the glucose in the blood? I mean, who doesn’t get this?

For our government to ignore this “obvious truth,” with a “one size fits all” prescription in its Dietary Guidelines for Americans, amounts to gross negligence and, for clinicians, medical malpractice on a humongous scale.

I say “concomitant” because remission of type 2 diabetes is a phenomenon that naturally accompanies or follows adoption of a Very Low Carb diet. In 2002, my doctor, who had been trying to get me to lose weight for years, read about a Very Low Carb (20g/day) diet program in the New York Times Sunday magazine. The story, “What If It’s All Been a Big Fat Lie,” was written by the acclaimed science writer Gary Taubes. What attracted my doctor to the story, though, was the photo of the ribeye steak on the cover. As a cardiologist, he hewed to the “company line” to avoid saturated fats. But the visual image got his salivary juices started, so he decided to try the diet himself. He lost 17 pounds in a month and decided to suggest it to me…TO LOSE WEIGHT, NOT TO TREAT MY TYPE 2 DIABETES!

He did suggest, as an afterthought as we walked down the hall of his office to make an appointment for another visit in a month (to monitor me closely), that the low-carb diet “might be good for your [Type 2] diabetes too.” In retrospect, I have to say, how clueless could he be?!!!!! Anyway, he didn’t have to wait a month to see how the dramatic reduction in carbohydrates affected my diabetes; within a day, I had my first hypo. A hypo (hypoglycemia) is a dangerously low blood glucose condition. When I felt the sweating, I went to the newsstand and bought a candy bar. This was perhaps a bit of an overreaction, I admit, but this was my first ever hypo, and I was scared.

Next, after the sweating stopped, I called my doctor. He told me to immediately drop one of the oral anti-diabetic medications he had prescribed for me. Next day late afternoon I had my 2^nd hypo, another candy bar, and called my doctor again. This time he said to cut the other two oral anti-diabetes meds I was on (at maximum doses) in half. I did, but then a few days later, I had my 3^rd hypo. This time my doctor told me to cut both meds in half AGAIN.

I’ve been following a Very Low Carb diet now for 17 years, and I’ve never had another hypo. I eventually titrated off one of the two remaining meds (Micronaise, a sulfonylurea), and lost 170 pounds. I still take Metformin though, to improve insulin sensitivity and suppress unwanted glucose production by my liver.

Along the way, my blood pressure improved from 130/90 to 110/70 on fewer meds. My triglycerides dropped from about 135 to 54 average, and my HDL (good) cholesterol more than doubled from 39 to 84 average. My total cholesterol is under 200 while my latest LDL was 92. And my fasting blood glucoses are usually under 100 and my A1c’s under 5.7% (lowest 5.0%). You would never know I was diagnosed a Type 2 diabetic 33 years ago.

So, obesity is “a modifiable risk factor” and the concomitant benefits of losing weight on a Very Low Carb diet are 1) remission of type 2 diabetes, 2) improved lipid profiles and 2) improved blood pressure. Indeed, “Improving of population health should not simply be made the work of drug companies.” This eloquently stated and obvious truth has been ignored by health-care professionals for many years. But, just as the obvious truth that eating fewer carbs will lower serum glucose levels in the insulin resistant patient, it is also a very effective way to lose weight in the patient whose glucose metabolism is normal. The blood lipid and blood pressure benefits will follow, even where blood glucose regulation is not required, “improving…population health” concomitantly. No Rx required!