Retrospective #165: Obesity is Not the Problem

David Lustig’s 10-year old UCTV YouTube video sensation, “Sugar, the Bitter Truth,” has now been seen 8.5 million times. Here’s a 45 second excerpt I transcribed from “Sugar” that fits in with a theme I’ve been beating the drum about since I published The Nutrition Debate #9, “The Metabolic Syndrome,” almost 9 years ago.

Lustig: “Obesity is not the problem. It never was. They want you to think it’s the problem, but it ain’t the problem. What is the problem? Metabolic Syndrome is the problem. The cluster of diseases that I’ve described to you. That’s where all the money goes. Obesity costs almost nothing. Metabolic Syndrome is 75% of all health care costs today. And there’s the list. [Slide lists: DIABETES, HYPERTENSION, LIPID ABNORMALITIES, CARDIOVASCULAR DISEASE, NON-ALCOHOLIC FATTY LIVER DISEASE, POLYCYSTIC OVARIAN DISEASE, CANCER, DEMENTIA].

What is Metabolic Syndrome? And how is it diagnosed? Most definitions have five “risk factors” in common, with the first always being obesity. It is variously defined as “central obesity,” or a Body Mass Index (BMI) ≥30, or elevated waist circumference (men ≥40 inches, women ≥35 inches). The other four “risk factors” are elevated triglycerides (≥150mg/dl), reduced HDL, the “good” cholesterol (men ≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg, or use of BP medications) and elevated fasting glucose (≥100 mg/dl, or use of medications for hyperglycemia). If you “present” with 4 out of 5, you have Metabolic Syndrome.

The corollary to “obesity is not the problem” is equally riveting: “Everyone’s at risk.” As Lustig explains: “Everyone’s at risk, because everyone is exposed.” That, of course, begs the question: exposed to what?

Dr. Lustig precedes his “obesity is not the problem” mantra with a nice explanation of the implications of the difference between subcutaneous fat (fat near the surface of the skin) and visceral fat (fat around the abdominal organs). The latter is the “bad” type of obesity. He starts with a diagram showing 30% obese and 70% “normal” weight, “and everybody assumes that the problem is this group over here [the 30% obese] because 80% of the obese population is sick in some fashion: type 2 diabetes problems, lipid problems, hypertension, cardiovascular disease, cancer, dementia, non-alcoholic fatty liver disease, polycystic ovarian disease, etc.”

“But,” he continues, “you do the math on this, 80% of 30% [of the 240 million adult population] is 57 million, and it is those 57 million that are bankrupting the country, so it’s the obese person’s fault only, and that’s the way everyone views this. This is wrong. This is a mistake. This is a disaster, actually, ‘cause it’s not correct. Here’s the real story. In fact, 20% of the obese population is completely metabolically normal. They have normal insulin dynamics. They don’t get sick. They die at a completely normal age, cost the taxpayer nothing. They’re just fat.”

“Conversely, up to 40% of the “normal” weight population has the same metabolic dysfunction that the obese do. They’re just normal weight, and so they don’t even know they’re sick until it’s too late; because normal weight people get type 2 diabetes, they get hypertension, they get dyslipidemia, they get cardiovascular disease, they get cancer, they get dementia, etc. etc. And so, when you do the math, that’s another 67 million, and that’s outclassing the 57 million obese, and so the total is 124 million; that’s more than half [the adult population] of America.”

That’s why Dr. Lustig says, “Everyone’s at risk, because everyone is exposed.” Exposed to Metabolic Syndrome! And how do you treat all five risk factors of Metabolic Syndrome? In case you haven’t figured it out yet, the answer is a Low Carbohydrate Way of Eating. No pills, no injections, no surgery. Just a different Way of Eating (WOE).

Okay, you say, I can see how a low-carb Way of Eating can help me lose weight and control my blood glucose. And I can see that as I lose weight, my blood pressure will go down. And maybe I can believe that by eating low-carb, I can lose weight without hunger and without snacks, and even keep the weight off, so long as I continue to eat low-carb. But how can I expect that eating low-carb will cause my triglycerides to go down and my HDL to go up? Well, mine did, dramatically: My HDL average doubled from 39 to 81, and my triglycerides dropped by about two-thirds, from 137 to 49, just by eating Very Low Carb. Of course, scientifically, an N = 1 means nothing, unless that N is you! 

Retrospective #164:The Best Snack?

As a long time (33 year) Type 2 diabetic who, by diet mostly for the last 17 years, has pretty much controlled the disease (and gotten off most of my oral diabetes meds, except Metformin), I have long argued that snacks are unnecessary. If you haven’t eaten a Very Low Carb (VLC) breakfast and a no-carb lunch every day, as I did in the early years, you may doubt this. You may even say it is not credible. But as incredible as it sounds, it is absolutely true. You have to try this Way of Eating (WOE) to discover it for yourself. You will not be hungry between meals.

I do admit to snacking sometimes before supper, though. I like radishes with salt or celery with anchovy paste. Why? Not because of physical hunger or any other known nutritional need. I describe it as habit or nervous eating. I always ask myself if I am hungry before I do it. The answer is always “no,” but I do it anyway. Go figure!

So, in 2013, when I saw a column by the late David Mendoza in the Low Carb Diet News titled, “The Best Snack for Weight Loss and Diabetes, I was interested. Mendoza was a well-respected and widely read blogger who described himself as a “freelance medical writer, advocate, and consultant specializing in diabetes.” He had been a Type 2 diabetic since 1994 and started writing about it online in 1995. So, David Mendoza had credibility with me.

But after I read through his piece about the “best snack,” I felt his credibility was both tarnished and diminished, as I’ll explain. First, I want to point out some of the good stuff. Early on in his blog piece he emphasizes this:

“Unlike some other tasty nuts like cashews, almonds are much lower in carbohydrates, which are the part of our diet that is almost solely responsible for raising our blood sugar level. Nothing else in our diet is more important for managing our diabetes than keeping that level [carbohydrates] in check.”

Mendoza’s point about cashews and carbs is good. Cashews and pistachios (drats; I love them.) are both too high in carbs to be considered part of a healthy diet for Type 2 diabetics. He then goes on to make a pitch for almonds:

“Some other nuts have a somewhat more favorable ratio of those super-healthy monounsaturated to polyunsaturated fats than almonds. But I avoid them as a matter of taste. I can eat macadamia nuts nonstop until the container is empty, but my body gets so full that I can easily put on a few pounds. On the other hand, I don’t particularly appreciate the taste of other healthy nuts like pecans or walnuts.”

I certainly agree with his point about macadamia nuts. They’re also very expensive. (Does anybody know a source for buying macadamia nuts wholesale?) However, as I’ve stated before, for me the only basis for selecting which type of nuts to eat (besides carbs) is their Omega 6 content. In that respect, I disagree with Mendoza. Pecans are marginal at best and walnuts are simply verboten. In my opinion, the very best, excluding again cashews and pistachios because of their high carb content, are macadamia nuts, then hazelnuts (filberts), and then almonds.

Now, to the problem: It turns out, according to Mendoza, “the best snack for weight loss and diabetes” is almonds. And although Mendoza expresses a personal preference for raw almonds (which he keeps in the freezer to give them a little “crunch”), the study he cites is with roasted and salted almonds. The study, however, as Mendoza points out at the end, has a fatal flaw: it was funded by the Almond Board of California. Oh dear…

In the positive, Mendoza said, “A big strength of this study by Purdue University and Australian researchers is that it was randomized and controlled. This is a good-sized study conducted with the standard controls.”

But Mendoza cites 3 problems: 1) the funding source, “…although [the authors] report that they have no conflicts of interest;” 2) “… we still don’t know why the study participants who snacked on almonds didn’t gain weight.”; and 3) “…this was also a short study that couldn’t measure the long-term impact of snacking on almonds.”

Almonds could be my favorite snack too, but the study’s snack size, 1½ ounces (20 almonds) is 250 calories! That’s half a supper meal (for me). How can anyone hope to lose weight eating a 250-calorie snack on a regular basis?

Retrospective #163: So, you think you’re just Pre-diabetic?

This lede in a story in USAToday sets the stage: “Higher blood sugar levels, even those well short of diabetes, seem to raise the risk of developing dementia, a major new study finds. Researchers say it suggests a novel way to try to prevent Alzheimer’s disease -- by keeping glucose at a healthy level” (my emphases). The article was based on a study at the University of Washington, Seattle, and was published in the New England Journal of Medicine.

MedScape Medical News quotes the study’s lead author, saying, “We considered blood glucose levels far into the normal (nondiabetic) range, and even there found an association between higher glucose levels and dementia risk.” “He said the results suggest that the ‘clinical determination of diabetes/not diabetes may miss important associations still there for people who are categorized as not having diabetes’.” That would be the Pre-diabetic.

The Associated Press story quotes Dallas Anderson, a scientist at the National Institute on Aging, the federal agency that paid for the study: “It’s a nice clean pattern -- risk rises as blood sugar does,” Anderson said. “This is part of a larger picture” and “adds evidence that exercising and controlling blood pressure, blood sugar and cholesterol are a viable way to delay or prevent dementia.” The ubiquitous triad: “…blood pressure, blood sugar, and cholesterol.”

The story also quotes a Dr. Crane: “At least for diabetics, the results suggest that good blood-sugar control is important for cognition.” And, for those without diabetes, he said, “It changes how we think about thresholds, how we think about what is normal, what is abnormal.” Is Dr. Crane saying that Pre-diabetic is abnormal? I think he is.

The Gupta Guide at MedPageToday commented, “Nondiabetic patients who developed dementia had a mean blood glucose level of 115mg/dl in the preceding 5 years compared with 100mg/dl in similar patients who did not have dementia. “The higher levels were associated with almost a 20% increase in the hazard for dementia.”

The New York Times take on the story also quoted Dr. Crane: “We found a steadily increasing risk associated with ever-higher blood glucose levels, even in people who didn’t have diabetes. There’s no threshold, no place where the risk doesn’t go up any further or down any further.” The association with dementia kept climbing with higher blood sugar levels and, at the other end of the spectrum, continued to decrease with lover levels.

Another related article from MedPageToday ties blood sugar (A1c) levels to cognitive function NOW, not to the future risk of dementia. The group studied was a population of non-diabetics, aged 50 and up, with BMIs between 25 and 30. Their mean A1c was 5.8%, with a range from 4.3% to 6.5%. The researchers found that “each of the three cognition parameters evaluated was significantly associated with A1c levels…”

That article, “Blood Sugar Tied to Cognitive Function,” added, “‘Lifestyle strategies’ to achieve strict glucose control could prevent age-related cognitive decline, even in individuals with A1c levels currently considered normal…”

So, what’s the takeaway?  What does it mean to change “how we think about thresholds, how we think about what is normal, what is abnormal”? What is considered “normal”? And what is “Pre-diabetic”? From 1979 to 1997 the threshold for Type 2 was two consecutive visits with a fasting blood glucose of ≥140mg/dl. In 1997, the threshold for a diagnosis was changed to ≥126mg/dl, and in 2010 the ADA added A1c standards, with an A1c of 6.5% for diabetes (with a “treatment goal” of 7.0%!!!), and an A1Cs of 5.7--6.4% for Pre-diabetes.

Richard K. Bernstein, consider 5.7% to be a full-blown Type 2 diabetes. Another MD, Dr. Ralph DeFronzo, in his Banting lecture at the 2008 ADA convention, said that “By both pathophysiological and clinical standpoints, these Pre-diabetic individuals with IGT [Impaired Glucose Tolerance] should be considered to have Type 2 diabetes.”

Statistically, you are 7-10 years away from diabetes and your heart disease risk is already rising. It has been more than 20 years since the diabetes threshold has been revised. Shouldn’t it be revised again NOW, and shouldn’t we all adopt “‘lifestyle strategies’ to achieve strict glucose control” and thus potentially “prevent [CVD, pancreatic cancer, and] age-related cognitive decline, even in those individuals with A1c levels currently considered normal…?”

Retrospective #162: The ADA’s Glycemic, Blood Pressure and Lipid Goals

When it was issued by the ADA in 2013, I was thrilled by their Position Paper, “Nutrition Therapy Recommendations for the Management of Adults with Diabetes.” It announced that “there is not a ‘one-size-fits-all’ eating pattern for adults with diabetes.” Importantly, the ADA said the nutrition recommendations were written at the request of the ADA Executive Committee, which has approved the final document.”

However, there is only so much one committee can do to turn the Titanic. This is an apt metaphor because we who have adopted a Western Diet are all in the same boat. If we stay on our present course, i.e., if we continue to eat the Standard American Diet (SAD) that we have been told to eat ever since the diet/heart hypothesis was first promulgated in the 1950s, we are going to die from one of the diet-related diseases of Western Civilization.

Think back - Ancel Keys made the board of the American Heart Association and the cover of Time magazine in 1961. In 1977, George McGovern’s Senate Select Committee’s staff produced the Dietary Goals of the United States. To say that Keys and McGovern were misguided would be an understatement of, well, Titanic proportions. They will be remembered as the principal enablers of the corrupt cabal of agribusiness, big pharma, and self-serving professionals in the medical societies and government agencies who continue to perpetuate this mess.

The ADA nutrition therapy committee was made up entirely of MSs, MPHs and PhDs who were all also RDs and/or CDEs. They represent just one voice in the ADA, on the nutrition therapy side. Their goal, it seems to me, was both admirable and realistic: increased flexibility to help patients by “individualizing” the therapeutic approach. It was a brilliant ‘workaround’ for the proscription on low-carb diets in previous iterations: low-carb nutrition therapy was first deemed “safe” for one year in 2008 and then later, for two years. Now, the time limit has been eliminated

So, with that as preface, what outcomes does the ADA think can be expected? What goals do they set their sights on achieving? How aspirational can they seem to be without appearing unreasonable? What goals do they set for glycemic control, and blood pressure and lipid improvements? The answer, sadly, is abysmal. But don’t blame the nutritoin committee. That was, as it should be, beyond the purview of their recommendations. Who then?

The ADA’s doctors. The goals the ADA hopes to achieve for the management of adults with diabetes are as follows:

1.        Attain individualized glycemic, blood pressure, and lipid goals. General recommended goals from the ADA for these markers are as follows:

·         A1C < 7%

·         Blood pressure < 140/80mmHg

·         LDL cholesterol < 100 mg/dl

·         Triglycerides < 150 mg/dl

·         HDL > 40mg/dl for men; > 50mg/dl for women

2.        Achieve and maintain body weight goals

3.        Delay or prevent complications of diabetes

And because of the recommended SAD, the ADA’s recommendations allow for even less ambitious goals “…based on age, duration of diabetes, health history and other present health conditions” than these already very lax goals.

So, the Titanic continues to sail on while “the band [the medical doctors] plays on.” By issuing new nutrition therapy recommendations, the RDs and CDEs “rearrange the deck chairs” – but will this make a difference or will it just be a futile exercise as our state of health continues to sink? Or, as individuals, can we “jump ship” and aspire to higher goals to control our diabetes (and blood pressure and blood lipids), “…through diet, mostly.” Yes, we can!

If you do work to control your type 2 diabetes “…through diet, mostly,” you can reasonably expect to “achieve and maintain body weight goals” and “delay or prevent complication of diabetes.” And you can achieve splendid lipids!

I have achieved and maintain a much higher health profile with a Very Low Carb Way of Eating (WOE): 75% fat, 20% protein and 5% carbohydrate. Triglycerides are particularly influenced by dietary carbs. My Trig/HDL ratio is 0.57, indicating a very low risk of CVD. Does you doc check this ratio for you? If not, he or she really should.

Retrospective #161: Why Go to the Doctor?

Why go to the doctor, seriously. When my doctor of 21 years died in 2012 (the one I eulogized in Retrospective #95), my medical records were transferred to the internist/cardiologist who used to ‘cover’ for him. At my first appointment, after the physical/history, the doctor asked me what he could do for me. I said I would like to be seen 3 or 4 times a year, to which he replied, to my surprise, that that didn’t seem necessary to him.

What did this tell me? It told me that, from his review, that I was a fairly “healthy specimen” compared to the rest of his patients. I think his view of me was also influenced by my comment that I thought my previous doctor, of whom I was very fond – he saved my life, I used to tell him – had perhaps “milked the system” to help “pay the rent.” I say this about others too, like my auto mechanic: I know I am helping him make his boat payments.

What this also told me was that my desire to be seen 3 or 4 times a year was driven by me – that it was not “medically necessary.” Of course, my desire was influenced by the fact that I am on Medicare and have good supplemental coverage. The result is that, I have no co-pays and a low annual deductible. So, I have “no skin in the game” and can see a doctor as often as I want. I think this is a lousy way to pay for medical care, but it is what it is.

My desire to be seen 3 or 4 times a year also provides insight into what motivates me. Now, no offense intended, doc (I think he reads the column sometimes, and certainly will read one titled “Why Go to the Doctor?”). But I don’t go to see him for his personality. Although his is great; he is always positive, conversational, jaunty, indeed, almost bubbly. And, interestingly, besides being board certified in his specialties, he holds a PhD. How cool is that!

What reason do I have for more than, say, an annual or semi-annual visit? The answer is to monitor the metrics that I use to track my diabetic health. I put the emphasis on “that I use” because the metrics that I use are very different from the ones my doctor uses. I just want to point out and stress that, if you do the same, that is, rely on the standards that your doctor uses, you do so at great risk to your health. I’m sorry, doc, but that’s the truth, folks.

Understanding this point is crucial to the Type 2 diabetic who is taking responsibility for his or her own healthcare and who has chosen to do it “through diet…mostly,” in the words of David Letterman in his 2013 conversation o with Tom Hanks (See Retrospective #160 below). If you leave it to your doctor, you will learn that Type 2 diabetes is a “progressive” disease, and you will be monitored at annual or semi-annual appointments until you “graduate” to being diagnosed a Type 2. Then you will be prescribed, progressively, oral or injected medications. Congratulations!

So, to repeat, if you leave the evaluation of the measurement of your health to your doctor, most of them will rely almost entirely on the standards which they must follow to assure that you’re covered and they get paid by your insurance company. If you do this, you will, in my opinion, be poorly served. That’s a bit strong, but it’s the truth.

Bottom line: the reason I want to see my doctor 3 or 4 times a year is for a LAB REPORT. And until I have him trained (sorry, Doc) in what I am interested in knowing each time I go, knowing what my insurance will cover, I usually have to ask for what I want tested. Of course, his office weighs me and takes my blood pressure, as I do at home. I also test my fasting blood glucose daily, for discipline and as a reminder and a check on what I eat. It’s the other blood tests that I want: the metabolic panel, the A1c, the C-reactive protein (chronic systemic inflammation), electrolytes, and once-a-year thyroid tests and kidney function tests (eGFR, urea nitrogen and creatinine).

Last week a copy of my most recent tests arrived in the mail. My doctor is good about that; I don’t have to request it, and the lab report is accompanied by an evaluation letter. That’s nice. My blood pressure, by the way, was 110/70 (on meds). My lipid panel: Total Cholesterol = 186; HDL = 80; LDL = 92; triglycerides = 56; Non-HDL = 106; A1c = 5.5. Fasting glucose was 102mg/dL. I don’t know how that happened. It was 93mg/dL before I left home.

With lab reports like this, going to the doctor 3 or 4 times a year is something I look forward to. I think my doctor does too. From my perspective, it motivational. From his, it’s not having to badger and cajole me. It’s a pleasure.

Retrospective #160: Letterman to Hanks: “…through diet, mostly.”

On the David Letterman show in late 2013, Tom Hanks blurted out that his doctor had told him that after 20 years of having high-normal blood sugars, “You’ve graduated. You’ve got Type 2 diabetes, young man.” All the media coverage the next day was about how Hanks had “performed an important role in raising awareness.” All I heard everywhere was banal generalities about how a “regular guy,” who “doesn’t appear to lead an unhealthy lifestyle,” can develop Type 2 diabetes. And that “Diabetes is a very treatable disease with good guidelines for effective treatment.” Really? Don’t get me started on those “good guidelines,” but that’s another story.”

Nobody in the press – medical or lay – covered the most important utterance in the Letterman interview. It was Letterman’s response to Hank’s, “It’s treatable…” Letterman said, “…through diet, mostly.” Letterman then added, “I suffer from high blood sugar – had to go on a special diet myself.” LETTERMAN GOT IT RIGHT, AND NOBODY COVERED IT. Nobody reported that Letterman’s doctor had told him, if he did treat it “right,” “through diet mostly, he would get back to his high school weight and essentially be healthy and would not have Type 2 diabetes.”

In a BBC interview, Hanks said that he “gets regular exercise, eats right, takes certain medications, and, so far, feels fine.” It sounds to me like he’s making the same mistake as Paula Deen. They’re both leaving the control of their diabetes health in the hands of a medical practitioner.  Tom Hanks (and Paula Deen) should listen to David Letterman instead: Type 2 diabetes is “controllable…through diet, mostly.”

But I don’t think either of them will listen to Dave, or me either. If Hanks had high blood sugars for 20 years and hadn’t figured out what to do about, I don’t expect he will now. But I was in a similar – actually, identical situation for the first 16 years after my Type 2 diagnosis in 1986. Of course, I know better now, and that’s why I work hard today to try to persuade others If you are Pre-diabetic, you don’t have to develop full-blown Type 2 diabetes; you can TREAT it… through diet, mostly. But if you do develop it, you can CONTROL it “…through diet, mostly.

I know I’m “beating a dead horse.” I persist because I know it’s hard not to, by default, leave your health care in the hands of your doctor. We presume that doctors know what’s best for us. Unfortunately, though, that’s not always the case, especially with respect to nutrition. They’re not educated in nutrition. They know that, but they also know that, in order to gain and hold your trust, they must preserve and maintain the appearance of omniscience.

They are constrained by a multitude of factors. Most older doctors were trained in the era of Ancel Keys’s diet/heart hypothesis in which they were taught that saturated fat and dietary cholesterol were “killers.” How can they now do a 180 degree turn and tell you that saturated fat is good for you and that, in the words of Ancel Keys himself later in life, “cholesterol in the diet doesn't matter at all unless you happen to be a chicken or a rabbit.”

They are also constrained by the standards of practice of their medical specialty. It takes a long time for research findings to influence clinical practice through updated guidelines. Not to follow those standards would risk professional sanction and possible loss of license. They are also constrained by the reimbursement rules of Medicare and the insurance companies; they are constrained by limited time with patients and limited time for continuing education. And, sadly, they and their medical associations are so influenced by the big pharmaceutical companies that conflicts of interest are pervasive. So, it’s tough to be a doctor these days, but from the patient’s point of view, there’s a workaround: SELF-CARE. YOU can decide what to eat and not eat.

If type 2 diabetes is controllable… through diet, mostly, Tom Hanks can do as David Letterman did and “go on a special diet” himself. Wake up, Tom! Take responsibility for your own health. Take charge of your own nutrition. Stop being in denial. You’re carbohydrate intolerant, Tom. For whatever reason, including a combination of genetic predisposition and past eating patterns, over many years you developed Insulin Resistance. Insulin Resistance = Carbohydrate Intolerance. Accept it, Tom. Don’t act like a victim. Show some character. Show me some grit, Tom.  Show the world that you can be a positive role model. Show us you’re a good man, Tom, like old James Ryan…

Retrospective #159: While Rome Burns, the GACD fiddles and the Chinese nap

Please excuse me if once in a while I tear into a rant. I get frustrated and then very cynical with some of the things I read. I also know that, individually, I have so little power to influence outcomes beyond my own…and, if I’m lucky, a few others. But I still have to get some things off my chest. So, the best thing for me to do is to write about it. What set me off this time was a piece in The Lancet, “Funding: Global Alliance for Chronic Diseases tackles diabetes.”

Here’s what the report said: “To meet the challenge in emerging economies, the Global Alliance for Chronic Diseases (GACD) has launched a call for research proposals to prevent and treat Type 2 diabetes. The GACD is an alliance of some of the world’s biggest publicly funded research organizations, ranging from the UK’s Medical Research Council to China’s Ministr­­y of Health and the European Commission.” Okay, that’s benign enough; it’s an employment program for writers and government scientists, a kind of job security. Here’s what set me off:

“Refreshingly, GACD members have realized that the science of Type 2 diabetes is well understood; this is no high-spending, high-tech initiative but a strict focus on implementation of existing policies, present knowledge, and proven interventions.” It is reading arrogant bull$#%& like this, I think, that gives me high blood pressure. LOL.

So, these government bureaucrats, who know all about how to treat Type 2 diabetes, are going to disseminate their message to “low-income and middle-income countries, such as China, India, and South Africa where the biggest emerging problems are to be found, but where success might pay the highest dividends.” That’s just great!!! The developed world, where this Type 2 diabetes problem arose as a result of modern methods of processing and manufacture of the very “foods” that made us sick, is now going to fix the problem. Sell the problem, and then sell the solution!

Boy, that’s irony for you, but the author doesn’t see it that way. He’s “refreshed.” It doesn’t occur to him that existing policies and present knowledge have not led to proven interventions. They have produced the growing and out-of-control epidemic of not only Type 2 diabetes, but obesity (an outcome, NOT a cause of T2DM), dyslipidemia (i.e. low HDL, high triglycerides, and Pattern ‘B’ LDL particles), and hypertension, all aka Metabolic Syndrome.

Okay, Ivory Tower researchers live in a special world – a world in which a primary duty is to write and “call for research proposals” from other “publically funded research organizations.” They are isolated from the real people-populated world in which we mere mortals spread the word about the most effective intervention “to prevent and treat Type 2 diabetes” - Eat Real Food.” Now that would be “refreshing.” ­­­­­But where’s the money? No drugs to market. No processed foods to manufacture and sell. Simply small-scale farming – just like they already do now in low-income and middle-income countries like China, India and South Africa!

So, the best thing that “developed” countries can do is stay the hell out of the management of Type 2 diabetes in the underdeveloped and developing world until they get the message right. I’m not hopeful, though. This is not likely to happen so long as Agribusiness is so thoroughly insinuated in the interstitial tissue of our nation’s and the world’s advisory and regulatory bodies. I do not soon see an end to their insidious and pernicious influence.

My favorite news flash, though, came from Diabetes in Control: “Afternoon Napping Tied to Increased Risk for Diabetes.” It begins, “Since afternoon napping is very common in China, Fang et al. conducted a study to determine if the duration of a person’s nap affected their risk for developing diabetes or an impaired fasting blood glucose.” Their conclusion: “Napping duration was associated in a dose-dependent manner with IFG and DM.” “This finding suggests that longer nap duration may represent a novel risk factor for DM and higher blood glucose levels.”

Perhaps the Chinese scientists will now apply for a grant to determine if the outcome observed by Fang et. al. can be attributed causally to the blood glucose crash (and resulting longer naps), after eating a bowl of overcooked white rice, by some of the 27,009 participants. Maybe the researchers will “refreshingly” (?) discover Insulin Resistance (IR). Whew!

Retrospective #158: Demolishing the Saturated Fat Bogeyman

“It is time to bust the myth of the role of saturated fat in heart disease and wind back the harms of dietary advice that has contributed to obesity.” The ground shook and a tsunami rolled around the world. Ripples were even felt in the mainstream when this commissioned, peer-reviewed and foot-noted “Observations” statement by the now famous British cardiologist Aseem Malhotra appeared in the October 22, 2013 BMJ (British Medical Journal).

Dr. Malhotra reminded us that, “Saturated fat has been demonized ever since Ancel Keys’s landmark ‘seven countries’ study in 1970. This concluded that a correlation existed between the incidence of coronary heart disease and total cholesterol concentrations, which then correlated with the proportion of energy provided by saturated fat. But correlation is not causation; and Keys cherry-picked his data. Nevertheless, we were advised to cut fat intake to 30% of total energy and saturated fat to 10%.” That was and still is a core recommendation incorporated into the “Dietary Guidelines for Americans” from its inception in 1980 to this day. It has been immutable dogma.

“The mantra that saturated fat must be removed to reduce the risk of cardiovascular disease has dominated dietary advice and guidelines for almost four decades,” Dr. Malhotra continues. “Yet scientific evidence shows that this advice has, paradoxically, increased our cardiovascular risks. Furthermore, the government’s obsession with levels of total cholesterol, which has led to the overmedication of millions of people with statins, has diverted our attention from the more egregious risk factor of atherogenic dyslipidemia.” Translation: Low HDL and high triglycerides, plus “small-dense” LDL lipoprotein particles (Pattern B LDL) accompanied by systemic inflammation.

To explain how that comes about, Dr. Malhotra continued, “The aspect of dietary saturated fat that is believed to have the greatest influence on cardiovascular risk is elevated concentrations of low density lipoprotein (LDL) cholesterol. Yet the reduction in LDL cholesterol from reducing saturated fat intake seems to be specific to large, buoyant (type A) LDL particles, when in fact it is the small, dense (type B) particles (responsive to carbohydrate intake) that are implicated in cardiovascular disease.” Translation: Reduced saturated fat intake = fewer large buoyant (type A) LDL particles; Increased carbohydrate intake = more small dense (type B) LDL particles.

“In previous generations cardiovascular disease existed largely in isolation,” he said. “Now two thirds of people admitted to hospital with a diagnosis of acute myocardial infarction really have metabolic syndrome – but 75% of these patients have completely normal total cholesterol concentrations. Maybe this is because total cholesterol isn’t really the problem,” he suggests. Metabolic Syndrome is “the cluster of hypertension, dysglycemia, raised triglycerides, low HDL, and increased waist circumference.” Do these sound familiar? Do they apply to you?

Dr. Malhotra reminds us that, “The notoriety of fat is based on its higher energy content per gram in comparison with protein and carbohydrate,” but he cites Richard Feinman and Eugene Fine’s work on “metabolic advantage” to show that “different diet compositions showed that the body did not metabolize different macronutrients in the same way.” “The ‘calorie is not a calorie’ theory has been further substantiated,” he adds, “by a recent JAMA study showing that a low fat diet resulted in the greatest decrease in energy expenditure, an unhealthy lipid pattern, and increased insulin resistance in comparison with a low carbohydrate and low glycemic index diet.”

So, will this message resonate? Were there aftershocks? Sure, the Diet Doctor featured it. Then, the latimes.com had a piece and the BBC Health News featured it, and they also had a morning show video segment. Early tremors were registered everywhere.  Maybe it will resonate this time, if enough people hear it, over and over and over…

 The title of Dr. Malhotra’s BMJ piece shouts, “Saturated Fat is not the major issue.”  The sub-title, “Let’s bust the myth of its role in heart disease…” Bravo! Switching metaphors, this stake to the heart will help. But ‘SFAs = bad’ is an undead concept that will persist to eat away at our health, like a zombie apocalypse. Just wait for the 2020 Guidelines, and you will see how intransigent the Dietary Guidelines continue to be in the face of all the evidence. Being charged with protecting the health of Americans for the last 40 years, it is hard to admit you’ve been wrong.

Retrospective #157: The ADA’s Problematic Position on Dietary Fat

Having just sung the praises of the American Diabetes Association’s Position Paper on nutrition therapy, it is unfortunately still necessary to have to criticize their unbending adherence to the Establishment’s wisdom with respect to saturated fatty acids (SFAs), aka saturated fats. They dodge the issue. Instead of saying “the evidence is inconclusive…so goals should be individualized,” as they did with Macronutrient distribution, they say: “Due to a lack of research in this area (?!!), people with diabetes should follow the guidelines for the general population.” That would be the Dietary Guidelines for Americans. What a cop-out!

But the ADA did say in this Position Paper on “recommended eating patterns for adults with Type 2 diabetes”:

“It is the position of the American Diabetes Association (ADA) that there is not a ‘one-size-fits-all’ eating pattern for individuals with diabetes.” That was enough for me, then. We have all suffered from the ADA’s intransigence. Many, like myself, have had the n=1 experience of losing weight easily, without hunger or cravings, and having their Metabolic Syndrome disappear on a Very Low Carb (VLC) diet. And we did it all without the approval, and occasionally with outright hostility, from our doctors, from our family, and from the “dietary authorities.”

For this Type 2 diabetic, as my weight dropped, so did my blood pressure, from 130/90 to 110/70 (on fewer meds). And while my LDL cholesterol particle number didn’t go down, the particles changed from “small-dense” (Pattern B) to “large-buoyant” (Pattern A), making it less likely that they could get stuck in any erosion in the endothelial layer of my arteries. Such erosion, by the way, is caused by inflammation, but on this VLC Way of Eating, my C-Reactive Protein test, a blood marker for chronic systematic inflammation, is often below 1.0, the level generally considered “ideal” for cardiovascular risk.

Cholesterol in the blood attempts to repair the eroded, “small-dense” LDL particle-filled arteries by creating plaque. That’s why cholesterol is blamed for plaque, but it’s like blaming the fireman for putting out the fire. Statins are thought to work by stabilizing plaque, but what prevents plaque formation? Answer: Low systemic inflammation, large-buoyant LDL particles, and high HDL to carry excess LDL particles away from the heart and back to the liver. This is a much better way to mediate CVD risk, and it is attainable by eating Very Low Carb.

The ADA now recognizes that Low Carb eating is “healthful,” but they still tow the line of the AHA, AMA, HHS and the USDA with respect to which fats are healthful. Everyone says that MUFAs (monounsaturated fats like olive oil) are healthful, and the dietary authorities now admit that trans fats (artificially saturated vegetable oils) are deadly; but they still insist that naturally saturated animal fats, are unhealthful. And that PUFAs (highly processed, inflammatory polyunsaturated fats (e.g. soybean oil. Corn oil, etc.) are healthful!!!

Naturally occurring saturated fats found in animal products and artificially saturated manufactured TRANS fats are totally dissimilar in structure and effect on the body’s cells. Conflating them is an egregious misrepresentation.  

The ADA’s position on SFAs leads them inexorably to advocating one “eating pattern” in particular, the Mediterranean diet. That’s okay IF YOU’RE NOT A TYPE 2 DIABETIC OR PRE-DIABETIC. If you can keep a healthy metabolism eating “abundant plant food (fruits, vegetables, breads, other forms of cereals, beans, nuts and seeds),” good for you. You’re very lucky, and I’m jealous. Note however to the ADA and to my readers: TYPE 2 DIABETICS AND PRE-DIABETICS CAN’T EAT A MEDITERRANEAN STYLE DIET AND BE HEALTHY. But for those who can, by all means eat “fruit as the typical daily dessert and concentrated sugars and honey consumed only for special occasions,” and “olive oil as the principal source of daily lipids, dairy products (mainly cheese and yoghurt) consumed in low to moderate amounts,” etc. Of course, it allows only very limited amounts of red meat and eggs and thus is definitely skewed away from dietary cholesterol and saturated fats – all misguided, unnecessary, and in fact, unwise – especially for the metabolically compromised, AS TYPE 2 DIABETICS (AND PRE-DIABETICS) ALL ARE.

So, what will be the next canon of “healthy nutrition” orthodoxy to fall? Will it be saturated fat? Let’s hope so.

Retrospective #156: The New (2013) ADA Nutritional Guidelines: Some Misgivings

My last column, “Cowabunga, the ADA Makes the Turn,” was my overview of the ADA’s groundbreaking move in 2013 to a patient-oriented approach, allowing Low Carb as healthy eating for Type 2 diabetics. Their new Position Paper, “Nutrition Therapy Recommendations for the Management of Adults with Diabetes,” was truly refreshing; it was completely devoid of evidence of “industry support,” which plagues virtually every other dietary prescription coming out of government and public health/medical organizations (e.g., AHA or AMA) or “public interest” groups.

That Position Paper was in strong contrast with the “Dietary Guidelines for Americans, 2010,” which has hardly varied from its inception in 1980. The 1980 cover states in boldface: EAT LESS FAT, SATURATED FAT, AND CHOLESTEROL. Its predecessor document, the 1977 “Dietary Goals for the United States,” was not prepared by scientists but by the staff of the Senate Select Committee headed by Senator George McGovern (from South Dakota) and aimed to promote the corn and soybean-based Agribusiness industry. If you want to get your hackles up, read the “Illustrated History of Heart Disease 1825-2015,” a diet-heart “timeline” by Diet Heart Publishing.

While I am obviously very pleased that the American Diabetes Association (ADA) has turned the corner on “nutritional therapy,” I would still pick a quarrel here and there. Their glycemic, blood pressure and lipid goals, for example, are unambitious in the extreme: They adhere to the “general recommended goals of the ADA for these markers.” Okay, they didn’t want to pick a quarrel there; the report was prepared by nutritionists, not MDs.

 And while this document was written by, for and from the perspective of the Medical Nutrition Therapist (MNT), it acknowledges that “a large percentage of people with diabetes do not receive any structured diabetes education and/or nutrition therapy” and that “in addition to MNT provided by an RD, diabetes self-management education and support are critical elements of care for all people with diabetes and are necessary to improve outcomes in a disease that is largely self-managed.” This point is very important in two respects: Too few Type 2 diabetics take responsibility for self-education or self-care. Most Type 2 diabetics just let their doctor (who is generally clueless in nutrition) take care of their diabetes; he takes their blood, writes a script and tells them to lose weight.                  

The second reason is that most RDs and CDEs haven’t got a clue either; they still espouse the one-size-fits-all dietary advice in the Dietary Guidelines for Americans prescribed for the whole population, diabetics included – a restricted-calorie, low-fat, and thus high-carb diet – which is very bad for the general population (raising their risk for CVD and diabetes) but disastrous advice for Type 2 diabetics. So, hopefully, these new recommendations will have some impact on RDs and CDEs, and thus on the clinical practice of nutrition therapy. I hope so, anyway.

Achieving and maintaining body weight goals and delaying or preventing complications of diabetes are other stated goals, and they say, “due to the progressive nature of Type 2 diabetes, nutrition and physical activity interventions alone (i.e. without pharmacotherapy) are generally not adequately effective in maintaining persistent glycemic control over time for many individuals.”  I have discovered, however, that nutritional therapy alone, without pharmacotherapy or physical activity, is sufficient IN AND OF ITSELF to put Type 2 diabetes in total remission!

Anyway, achieving and maintaining body weight goals and delaying or preventing complications of diabetes are very important goals and highly desirous. The report states further, “More than three out of every four adults with diabetes are at least overweight, and nearly half of individuals with diabetes are obese.” And, “Among the studies reviewed, the most consistently reported significant changes of reducing excess body weight on cardio vascular risk factors were an increase in HDL cholesterol, a decrease in triglycerides, and a decrease in blood pressure.” Bravo!

The ADA Position Paper does address the macronutrients individually, as well as various micronutrients, vitamins and minerals. It also expresses a “bias” (with reasons) for the Mediterranean Diet. I will delve into this and other aspects of this important new blueprint into the frontier of “nutrition therapy” in upcoming columns. Stay tuned. It will be interesting.

Retrospective #155: Cowabunga, the ADA makes the turn

In 2013, for the first time in 5 years, the American Diabetes Association (ADA) issued new nutritional guidelines for adults with Type 2 diabetes. They were revolutionary, and I was ecstatic. The implications of this shift were great.

The changes were summed up by Miriam Tucker in a Medscape Alert. Her lede was, “New nutritional guidelines …focus on overall eating patterns and patient preference, rather than any particular dietary prescription.” “The authors intentionally avoided using the word diet,” lead author Alison Evert told Medscape Medical News.

“Throughout the document, we refer to 'eating plans' or 'eating patterns' rather than 'diet,'” Evert, MS, RD, CDE, told Medscape. “We want to work with patients and help them achieve individual health goals. A variety of eating patterns can help, and people are more likely to follow an eating plan that speaks to them," she said. Boy is that true! “Doctors and dietitians have long recognized that ‘diets’ work best if you, the patient, like them.” To which I add, “And you are more likely to stick to it if you can lose weight and feel great without hunger and cravings!”

“Indeed, the new evidence-based position statement…reviews the evidence for several popular eating plans, including Mediterranean style, vegetarian, low fat, low carbohydrate, and Dietary Approaches to Stop Hypertension (DASH), but does not recommend any specific one.” "Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals [my emphasis] should be considered when recommending one eating pattern over another," they said. To me this means that for Type 2s, Low Carb is best.

Remember, it was only a few decades ago that Robert Atkins, MD, was scoffed at and ridiculed. And it’s been only 17 years since Gary Taubes’s seminal piece in The New York Times, “What If It’s All Been a Big Fat Lie?” Then, after years of ‘anecdotal reports’ of the success of Low Carb eating on both weight loss and “metabolic goals,” in 2010 the ADA allowed that low carb dieting could be tried for a year, but the long-term safety of low carb eating was unknown. And then last year the ADA allowed Low Carb, maybe for two years… Well, they’ve decided now, folks: Low Carb is safe! YOU can now pick the eating plan that works best for you, and the ADA says, “…we want to work with patients and help them achieve (their) individual health goals” because “nutrition therapy is a core tenet of diabetes management.” Note: Nutrition is “core” and you can now choose the eating plan that works best for you.

Of course, to get to this point the ADA had to construct a giant ‘workaround.’ Here’s how they did it. Starting with their 2008 guidelines, and in recognition of the growing controversy around macronutrient proportions (e.g., low-fat, high-carb vs. low-carb, high-fat), they ducked. It was a beautiful finesse. With respect to the guidelines for each macronutrient – dietary fat, protein and carbohydrate – they said “the evidence is inconclusive…therefore, goals should be individualized.” That’s very convenient and a brilliant way to transition to the 2013 ADA guidelines.

They now say, “It is the position of the American Diabetes Association (ADA) that there is not a “one-size-fits-all” eating pattern for individuals with diabetes.” The only caveat is your eating pattern should consist of “nutrient dense foods in appropriate portion sizes to improve overall health.” Otherwise, choose your eating plan “based on personal preferences and metabolic goals. So, if you’re a “woke” Type 2, your eating pattern should be Low Carb!

It further urges “that each person with diabetes be actively engaged in self-management, education and treatment planning with his or her health care provider” since “for many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat.” They got that right! And then this: “Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management.” And this: “Monitoring carbohydrate amounts is a useful strategy for improving postprandial glucose control. Evidence exists that both the quantity and type of carbohydrates in a food influence blood glucose level, and total amount of carbohydrate eaten is the primary predictor of glycemic response.” Type 2s knows this, but I didn’t expect to hear it from the ADA. “Congratulations, ADA!” This is a patient-centered manifesto!

Retrospective #154: Salt, Sugar and Fat

When it was published in 2013, I resisted commenting on Michael Moss’s eBook, Salt Sugar Fat: How the Food Giants Hooked Us. I did not want to be negative. Mr. Moss, a New York Times investigative reporter since 2000, had made a career out of sensationalizing popular causes, even when the idea was a myth. Lumping together salt, sugar and fat as an unhealthy agglomeration is just one of those myths. I get curmudgeonly just thinking about it.

So, when The Lancet, a peer-reviewed medical journal, later published a “Perspective” titled “Salt, Sugar and Fat or branding, marketing, and promotion,” by Dariush Mozaffarian, it caught my attention. Mozaffarian is a cardiologist and epidemiologist at the Harvard School of Public Health. I hoped and assumed, therefore, that his take would be “informed” and “professional,” vs. a rant such as I might have written, and it was. Dr. Mozaffarian’s “perspective” is well-reasoned, balanced and, to my delight, in the end, also negative, at least in the areas of interest to me.

According to Mozaffarian, Moss “shines” and “the text sparkles” as he “argues that the food industry manipulates and is deeply dependent on these three ingredients to create maximally alluring, addictive products that drive overconsumption, obesity and other chronic diseases. Moss “deftly walks us through these fascinating stories, yet he seems to miss his own point.” Mozaffarian concludes, “Salt Sugar Fat is, however, unconvincing when Moss attempts to link these fascinating stories and products…back to salt, sugar and fat.”

Mozaffarian allows that the case made by Moss for salt is “reasonable,” but that “a central tenet – that fat content in foods induces overconsumption and poor health – has been disproven by prospective studies and randomized trials.” Hallelujah, I say! “Yet this folklore is repeatedly asserted,” Mozaffarian continues, “overlooking the evidence that both the total fat content of foods and the overall fat content of the diet has little, if any, influence on major diseases, including type 2 diabetes, heart disease, or cancers” AMEN! Would that this message were broadcast on a continuous loop over the air. Drumbeaters and axe grinders like me would have to find other ‘work,’ or go fishing.

Dr. Mozaffarian’s indictment of the 3^rd member of this cabal, sugar, starts off a bit timidly, by today’s standard: “All refined carbohydrates – whether white bread, white rice, breakfast cereals, or packaged foods containing these refined grains, cereals, and starches – have LARGELY INDISTINGUISHABLE METABOLIC HARMS AS SUGARS.” “Whereas sugars in liquid form are most obesogenic, there is only limited reliable evidence to suggest that sugars in foods are any worse for health than other refined carbohydrates and starches – all are detrimental.”  Mozaffarian asserts, “This key issue is only mentioned by Moss in the first chapter, then seems to be promptly forgotten.”

Nevertheless, “the focus on how diet affects obesity and its complications, including diabetes,” was the impetus for this eBook. “People have recognized for millennia that overeating leads to weight gain,” Mozaffarian says, but then he brightens my day with this follow-up: “Yet, this was historically attributed to weakness of individual will.” But, Dr Mozaffarian the epidemiologist notes, “Obesity’s remarkable and rapid contemporary rise across diverse races, social classes, cultures and nations – including perhaps most influential of all, in children – has created a new awareness that external influences on dietary choices are likely powerful and widespread…”

Here is the common thread that links Moss and Mozaffarian: “external influences on dietary choices,” but here is also where they depart. Mozaffarian concludes: “Throughout Salt Sugar Fat, Moss attempts to indict these three ingredients as principal forces behind product development and sales, Yet, time and again, the stories reveal the true drivers of the success of individual products and our modern overconsumption: the immense and pervasive power of modern advertising and promotion.”  Mozaffarian cites how Coca Cola came to dominate globally with its systematic, data-driven strategy to infiltrate life’s “special moments” and create early brand adopters.

“Ultimately, the irony is that in trying to bring everything back to these three ingredients- whether related to food formulations, product success, or health – Salt Sugar Fat sensationalizes their true role.

The real story for me is how the Harvard School of Public Health got it right. Props to Mozaffarian and Harvard!

Retrospective #153: “Salt: friend of foe?”

A 2013 Lancet article (Vol. 381, Issue 9880), “Salt: friend or foe?” revisited a perennial conundrum. It began:

“Dietary guidelines advise against the consumption of too much salt. A high intake of sodium causes raised blood pressure – an established risk factor for heart disease, stroke and kidney disease. But how much salt is too much? And could a very low salt intake also be detrimental?”

What was the impetus for this foray into the controversial effects of salt consumption on health outcomes? Answer: A Report, “Sodium Intake in Populations: Assessment of Evidence” from the Institute of Medicine’s (IOM) “Committee on the Consequences of Sodium Reduction in Populations.” The Centers for Disease Control and Prevention (CDC) asked IOM to do the study since IOM “serves as adviser to the nation to improve health.” Hmmm.

The key words for me in the quote above are “Dietary guidelines.” They are obviously a reference to the then most recent “2010 Dietary Guidelines for Americans.” In those Guidelines, the authors at the USDA/HHS call for the general population to have “a goal of reducing sodium intake to less than 2,300mg/day, and further reducing intake to 1,500mg/day” among VERY LARGE population subgroups including everyone 51 years old and older, all people who have hypertension, diabetes, or chronic kidney disease, and all African Americans.  The American Heart Association (AHA) “even advises that everyone adheres to the 1,500mg/day limit, irrespective of age or race.”

What are the “implications for population-based efforts” at dietary guidelines for sodium consumption? According to the IOM, the “assessment of evidence” of “sodium intake in populations,” is as follows:

·         The available evidence on associations between sodium intake and direct health outcomes is consistent with population-based efforts to lower excessive dietary sodium intakes.

·         The evidence on health outcomes is not consistent with efforts that encourage lowering of dietary sodium in the general population to 1,500mg/day.

·         There is no evidence on health outcomes to support treating population subgroups differently from the general U.S. population.

I have no quarrel with the first conclusion but the second conclusion is really troubling. Lowering dietary sodium in the general population to 1,500mg/day, as the AHA purportedly recommends, is not consistent with the evidence. This is a principal conclusion from a distinguished committee at the Institute of Medicine. What do they say?

“…(T)he committee concludes that the evidence supports a positive relationship between higher levels of sodium intake and risk of CVD. This is consistent with existing evidence on blood pressure as a surrogate indicator of CVD and stroke risk for the general population. The committee also concludes that studies on health outcomes are inconsistent in quality and insufficient in quantity to determine that sodium intakes below 2,300mg/day either increase or decrease the risk of heart disease, stroke, or all-cause mortality in the general U.S. population.”

Wow. But how about those “special population” subgroups that taken in their entirely make up a majority of the adult population of the United States. Is there really “no evidence to support treating population subgroups differently…”? Here’s what the IOM committee, examining this specific question, said about that:

“The committee found no evidence for benefit and some evidence suggesting risk of adverse health outcomes associated with sodium intake levels in ranges approximately 1,500 to 2,300mg/day among those with diabetes, kidney disease, or CVD. Further, the evidence on both the benefit and harm is not strong enough to indicate that these subgroups should be treated differently than the general U.S. population. Thus, the evidence on direct health outcomes does not support recommendations to lower sodium intake within these subgroups to…1,500mg/day.”

Okay, you say this is just an internecine quarrel between government/medical entities, pitting the medical (AHA), public health (HHS) and Agribusiness (USDA) establishments against the less influential CDC and IOM. In fact, if I hadn’t told you abut this Lancet article on an obscure IOM report here, it is not likely you would have read about it anywhere else. IOM and CDC don’t get much notice in the popular press with respect to American dietary choices.

However, there has been plenty of talk in the blogosphere. My post #74, “No Added Salt? Why?,” had 5 links to good sources on salt in the diet:1) to Gary Taubes’s “The (Political) Science of Salt” from 1998 and 2) to Taubes’s 2012 NYT op-ed “Salt, We Misjudged You”; 3) to a stunning 2011 article in Diabetes Care about a University of Melbourne study; 4) to a Chris Kresser article, “The Dangers of Salt Restriction” about a 2011 study reported in JAMA; and 5) to the Drs. Michael and Mary Dan Eades recommendations in their seminal book, “Protein Power.”

Retrospective #152: Set Point Theory

My current interest in Set Point Theory was spurred by my own (n=1) experience. I’ve been working on losing weight (as always) and recently reached another weight loss “plateau.” I eat a Very Low Carb Ketogenic Diet, and for the last two weeks my weight hasn’t changed. It goes up or down a pound or two (of water weight) daily, but the scale has not gone lower from week to week. We’ve all been frustrated by this experience and wonder “why?”

Many people are acquainted with the scientific concept that, as we attempt to eat a restricted-calorie, balanced diet, as recommended by mainstream medicine, our metabolism “adjusts” (slows down).  Our body senses that we are in “semi-starvation mode,” and hormonal changes beyond our conscious control initiate this change. Our body decides, independently of our intention, to conserve (use less) energy as a survival mechanism. That is why it is so hard to lose weight. Our body fights us “tooth and nail” to maintain our weight. And our body wins every time.

Until recently, my own experience has been that this “slowing down mechanism” doesn’t apply to me.  I find that my energy level is elevated when I diet. The reason is that all of my weight loss (170 pounds during my initial loss) was attributable to Very Low Carb (VLC) eating in which low serum insulin, a consequence of eating Very Low Carb, allowed my body to access body fat for energy. The body got the “low insulin” signal from the absence of carbs in my diet for energy. On that signal, it mobilized the breakdown of body fat to maintain my energy balance.

And since I had plenty of fat in “storage,” and my survival was not threatened, my metabolism didn’t slow down!

My body was not being starved because it got all the nutrients it needed from the reduced level of protein and fat that I ate plus the body fat it needed to supplement my energy needs – so long as I ate Very Low Carb.

I also try to avoid all grains and as much fructose and “vegetable” (seed and legume) oils as I can, to avoid harm. When I do, my body is “happy,” and I “feel great,” and I lose weight. So, why has my weight plateaued?

My wife related how she remembered this subject when she was low-carbing “before Atkins.” (I wonder if she realizes how much she is dating herself.) Her response over breakfast today was, “Be patient, it (weight loss) will start up again,” and “You may just need to ‘jump start’ it by fasting” to create a little “calorie confusion.” Hmmm…

That comment reminded me of a diet called “The 8-hour Diet,” in which you eat all your food in any day within an 8-hour “window.” The theory is that gives your body a chance to get into “fasting” mode for 16 hours a day, when it will burn body fat for energy. I like this idea but how it relates here is that the author suggests doing it only 3 times a week. That would certainly create a state of “calorie confusion,” wouldn’t it?

That idea led me to a New Year’s Resolution idea from a few years ago from the now deceased blogger David Mendoza. His suggested “weight loss tip” was that whenever your weight drifts above “target,” you skip dinner that day. That’s not as hard as it sounds because you’re not hungry on a VLCKD. In fact, I did it recently two days in a row. I actually ate only breakfast for two days and my weight dropped like a stone.

So, the common thread of all these ramblings and ruminations is: Fasting, so long as you are in fat burning mode (in ketosis) to begin with, and thus not experiencing hunger or any mysterious drives or cravings, is an effective way to jump start weight loss again.

The inescapable conclusion, however, is that set-points can even set in when you are ketogenic. Your body gets “happy.” Homeostasis (energy balance) has many under-understood aspects.

Perhaps J. Stanton at gnolls.org said it best: "It's tempting to talk about ‘set point’ and leave the discussion there — but as I've said before, ‘A set point is just a homeostasis we don't understand.’” The trillions of cells in our bodies each have metabolic requirements for macro- and micro-nutrients, as well as a functional hormonal environment -- in the words of the great mid-19^th century French physiologist Clause Bernard, the “milieu intérieur.” So, to answer the “why” of those pesky set points stalls, try “calorie confusion,” using a mix of intermittent fasting protocols.