Wednesday, February 19, 2020

Retrospective #368: My 2-Month, 20-Pound Challenge

At the beginning of February 2017, I was in a unique situation. It was of my own making, and it was an opportunity to take sole responsibility for my actions. There were no confounding factors (“excuses”) or impediments to my success (or failure). It was a good test of my intentions and my integrity in taking responsibility for whichever outcome.
The circumstance: I was “home alone” for 2 months. After driving my wife to Florida after Christmas, I flew to Bogotá, Colombia, for 3 weeks to study Spanish. While there I got help translating my 16-page “Folleto” on the cause of Type 2 Diabetes and how to treat it as a dietary disease. I then flew to Aruba to join my wife at our time share for our 25th wedding anniversary, then home to New York for the winter. A week in the hot sun was more than enough for me.
So, to fulfill a commitment I had previously made to Megan Ramos (part of my “integrity test”), the Intensive Dietary Management Program Director and Clinical Educator in Jason Fung’s office in Toronto, and a Facebook friend, I decided to fast for 2 days a week. I selected Tuesdays and Thursdays. On those days I will only take a 16-oz coffee in the morning with stevia and full ounce of heavy cream; then, at night, 1 wine spritzer. Nothing else until the next day. I know this will not be difficult for me because I am not hungry. I am already sufficiently keto-adapted for my body to switch easily from whatever I eat (very-low-carb) to fat-burning to maintain energy balance and a high metabolic rate.
So, I am now cooking for myself. This is something, guys, that will teach you how much you under appreciate that your spouse cooks for you every day, as mine does. Thus, on the remaining 5 days, I will cook supper twice, each time preparing food for 2 days. On the 5th day – once a week – I will go out to dinner. That day may vary each week.
On non-fasting days, I will take the same coffee in the morning. Then, if I feel a “need” to eat something before supper, I have some cans (“tins”) in the pantry: 1) Brisling sardines in EVOO and 2) kippered herring in brine, both of which I love. The sardines, due to the fat (EVOO), are a meal in themselves. The herring, in brine, is more like a snack, but plenty since I will not be hungry. I will use them as a light or late lunch, should I decide to eat something. I will also keep on hand a few hard-boiled eggs from a local farmer if I feel the need for them, sort of like a security blanket.
Then for supper, my main dish will mostly be stove-top preparations of various cod recipes I have, or a veal stew. The cod is wild caught in the North Atlantic and flash-frozen at sea. My recipes incorporate vegetables like onions, celery, cauliflower and fennel. I cook in coconut oil, butter or olive oil and add garlic, green olives, red pepper flakes, sometimes petite cubed canned tomatoes and always lots of salt and fresh ground black pepper.  As an alternate meal, I will sometimes make a veal kidney dish or “tripa en salsa roja,” a Spanish preparation called “callos.”
The veal is from another local farmer. For the stew, I use bacon, mushrooms, and onions and brown the veal cubes in coconut oil before baking. For the kidney dish, I add mushrooms, onions and Marsala wine.  With each of these supper meals, I will drink 2 red-wine spritzers. My house wine is a Spanish Rioja called El Coto.
Just to be clear about this: On my 5 non-fasting days each week, I will take only morning coffee, an occasional “big” lunch (a 3.75 oz. can of sardines + EVOO) or a “light” lunch ( a 3.5 oz can of kippered herring in brine) and the occasional hard-boiled egg or two. Then, supper with 2 wine spritzers. The nutrient breakdown is this:
Fasting days: Calories: 225kcal; Fat: 11g; Pro: 1g; Carbs: 4.75g; Alcohol: 15g
Non-fasting: Calories: 1000-1200kcal; Fat: 45-70g; Pro: 45-85g; Carbs: 15-30g; Alcohol: 30g 
I originally wrote this on Super Bowl Sunday 2017 at 248 pounds (FBG: 104mg/dl). I started the next morning. This “manifesto” was first published on February 19, 2017, three years ago today.
Result (spoiler alert): I lost 31 pounds in 10 weeks, fasting 2 days a week and cooking for myself. My FBG average dropped from 119mg/dl before to 81mg/dl (10-week average). A1c went from 5.8% to 5.3%. Lipid Panel: Total Cholesterol: 201mg/dl; HDL: 74mg/dl; LDL: 114mg/dl; Triglycerides: 67mg/dl. My weight today (3 years later) is 225lbs, plus 8 lbs. in 3 years. I still fast from time to time, sometimes alternate day, sometimes consecutive day. It’s easy when you’re not hungry.

Tuesday, February 18, 2020

Retrospective #367: My Arm’s Length Perspective from Colombia

In February 2016, as I prepared to leave Bogotá, Colombia, after 3 weeks of studying Spanish, a few thoughts related to type 2 diabetes came to mind. Bogotá is a burgeoning city, growing leaps and bounds, transitioning from “a feudal society” (to quote the husband of my teacher) to a modern, invigorating, stimulating place. I loved it, and it’s exciting to see the changes coming about, but also shocking to see the stark contrasts. For grounding and perspective, the husband reminded me that women only gained the right to vote in 1957.
For me personally the most surprising discovery was that the brand new, modern apartment I rented, that had multiple USB connections in every room, has no central heat! Further, there is no hot water in the kitchen – only in the bathroom, supplied by an electric in-line hot water heater for the sink and shower.
At first, I thought that this was a factor of the neighborhood (services are taxed by “estrado”). This method of taxing services by socio-economic status is designed to give preference (“subsidies”) to the less advantaged. Unfortunately, it also results in stagnation and immobility by stigmatizing the poorer neighborhoods.
Later, I discovered that the modern, well-designed apartment of my teacher and her husband (both PhD’s teaching at the National University) also has no central heating and no hot water in the kitchen. ¡Qué sorpresa! They live in an upscale neighborhood in the northern reaches of the city. The “no heat” explanation relates in part to the climate. Bogotá has a moderate climate year-round. It is located close to the equator but at a very high elevation (8,675 feet or 2,644 meters), so temperatures are constant all year round. It never snows.
So this partially explains the central heating issue, but not the lack of kitchen hot water. “How do you wash dishes,” I asked the husband as he did them. “I scrub them well,” he said.  Does that give you perspective?
Type 2 diabetes is similarly just emerging from the dark ages. One hundred and fifty years ago type 2 diabetes was understood as a dietary disease (see Retrospective #1 re: French physiologist Claude Bernard and English undertaker William Banting). It was known as a disease of excessive consumption of carbohydrates and was treated by reducing carbohydrates in the diet. Then, in 1921, Frederick Banting (bizarrely, a distant relation!) discovered how to make insulin in the lab, and since then type 2 diabetes has been treated like type 1 diabetes, a disease of too little insulin.
When our insulin receptor cells resist the uptake of glucose, i.e. they express Insulin Resistance (IR), the pancreas produces more insulin until it eventually wears out. Doctors hasten this catastrophic failure of the pancreas by adding pharmaceuticals, like sulfonylureas (Micronase, glyburide, glipizide, et al.) to push the pancreas to exhaustion. Then, the doctors add injected insulin to the patient’s regimen. This medieval practice, not unlike “bleeding the patient,” is still the Standard of Care of the medical establishment and their government overseers in the United States.
Until recently. We are finally beginning to see a Renaissance. Increasingly type 2 diabetes is being understood again as a disease of Insulin Resistance, resulting in too much insulin. The goal in treating type 2 diabetes should be not only to lower the glucose level in the blood (by diet instead of drugs), but also to lower the insulin level in the blood.
This will occur, and will only occur, when the glucose level lowers, because that is how the body “knows” that it needs to begin to burn fat for fuel (triglycerides, in the form of body fat stored around the “trunk,”) to maintain energy balance and a fully active metabolism. The body, including heart and brain, loves these fatty acids and the ketone bodies that are produced as a side effect of lipolysis (the break-down of triglycerides to fatty acids).
Bogotá is rapidly transforming itself. ¡Ojalá que el mundo de los diabéticos se haga lo mismo! Y pronto.

Monday, February 17, 2020

Retrospective #366: Academy of Nutrition and Dietetics, a Secret Society

Surfing the web a while ago, I came across the Academy of Nutrition and Dietetics (AND). It turns out that for almost 100 years, until 2012, this organization was named the American Dietetic Association, unfortunately sharing the same acronym with the more recognized American Diabetes Association. With my interest piqued, and having a long-time interest in the subject of nutrition, I delved into the membership categories. Here’s where I bumped into my first road block: membership is restricted to only RDNs and other dietetics’ professionals.
Still, being interested in their message, I clicked on their “Advocacy” tab, then “Disease Treatment and Prevention” and finally “Diabetes Prevention Legislation.” I was pleased to see that the AND “has been actively involved in developing and generating support for five pieces of legislation that would help prevent type 2 diabetes.” Great, I thought, let’s have a look. Unfortunately, that was not possible. To see more I was told to “log-in or join.” But, as I am not eligible to join, and therefore can’t log in, the legislation for which they advocate will have to remain secret legislation. Only members of the Academy are eligible to view legislation they advocate to “prevent type 2 diabetes.”
So, I went to Wikipedia. I knew of course that many Wiki sites are written by the searched organization, but I thought I might learn something more about AND, as I would never be eligible to join. Here’s what I learned:
     The Academy "maintains that the only way to lose weight is through a healthy, well-balanced diet and exercise."
     The Academy opposed mandated labeling of "trans fats" on food packaging.
     The Academy has given low ratings to the “high-protein, low-carb” diet known as the Atkins Diet, insisting that the diet is "unhealthy and the weight loss is temporary."
     The Academy maintains that carbohydrates are not responsible for weight gain any more than other calories.
Okay, I no longer needed to see the five pieces of legislation that AND has developed. I know where they’re coming from. But why? What motivates them to be so obtuse? And so backward? I needed to look further into AND.
Here’s what Wikipedia says: “To help better communications with the US government, the Academy of Nutrition and Dietetics has offices in Washington, DC. They also operate their own political action committee. The Academy spent $5.8 million lobbying at the state and national level from 2000–2010.
And “A 1985 report noted the Academy has supported licensing for dispensing nutritional advice,” and “In addition… [has] support[ed] legislation regulating the professional nutrition field in [various] states.”
And finally, the coup de grace: “A 1995 report noted the Academy received funding from companies like McDonald’s, PepsiCo, The Coca-Cola Company, Sara Lee, Abbott Nutrition, General Mills, Kellogg’s, Mars, McNeil Nutritionals, SOYJOY, Truvia, Unilever, and The Sugar Association as corporate sponsorships.
“The Academy also partners with ConAgra Foods, which produces Orville Redenbacher, Slim Jims, Hunt’s Ketchup, SnackPacks, and Hebrew National hot dogs, to maintain the American Dietetic Association/ConAgra Foods, ‘Home Food Safety...It's in Your Hands’ program.” Additionally, “the Academy earns revenue from corporations by selling space at its booth during conventions, doing this for soft drinks and candy makers.”
Wikipedia continues with this trenchant comment from nutrition expert Marion Nestle. She “opined that she believed that as long as the AND partners with the makers of food and beverage products, ‘Its opinions about diet and health will never be believed [to be] independent.’” And, “Public health lawyer Michele Simon, who researches and writes about the food industry and food politics, has voiced similar concerns stating, ‘AND [is] deeply embedded with the food industry, and often communicate[s] messaging that is industry friendly.’"
I guess it’s a good thing for both of us (AND and me) that they won’t let me join their corrupt organization. I would just “rock the boat” or, to use a more apt but mixed metaphor, upset the rotten apple cart.

Sunday, February 16, 2020

Retrospective #365: Look at what’s happening to Medicare!

A 2016 article in the Journal of the American Board of Family Medicine begins, “Clinical practice guidelines abound. The recommendations contained in these guidelines are used not only to make decisions about the care of individual patients but also as practice standards to rate physician ‘quality.’” Did you know that? I have for awhile, and it concerns me. I first became aware of it during the funding cuts in Medicare (+/- $750 billion) during the “negotiations” leading up to the passage of the “Affordable Care Act” or ACA, aka Obamacare.
The Journal article continues, “Thus there is an inevitable aspect of guideline development that makes it subject to value judgments and can be unconsciously colored by intellectual, professional, or financial conflicts of interest.” These include biases such as “decisions colored by tunnel vision (job conditioning), ‘seeing what you want to see’ (confirmation bias), decisions limited to the tools at hand (Maslow’s hammer), or other inclinations that can affect judgment.” That last one especially concerns me. Why? Medicare Payment Reform.
We have all become aware of the movement towards Electronic Health Records (EHR). But did you know that there are financial incentives and disincentives for physician compliance? The EHR program, called Meaningful Use (MU), is now in the process of being itself re-reformed. According to a blog post from Impact Advisors, posted before the final rule was issued, “providers simply wanted to ‘check the box’ in order to reach MU thresholds (and thus avoid ‘adjustments,’ i.e., penalties, foregoing the larger opportunity to improve care.”
EHR was Part 1 of a larger reform program of the Center for Medicare and Medicaid Services (CMS). It is still in place, but Part 2, described as “share data” and Part 3, “improve outcomes,” are now part of a new Medicare Payment program designed to overcome the “noted weaknesses of MU.” Part 1 will be transformed and phased in by stages starting in 2017. Parts 2 and 3, now the Merit-Based Incentive Payment System (MIPS), is part of the Medicare Access and CHIP Reauthorization Act (MACRA) and implementation began in 2019.
Now, according to an AMA email “alert” that I received last fall, CMS has issued its final MACRA rule, detailing the new Merit-Based Incentive Payment System, now called the Quality Payment Program (QPP). In the email, AMA President Andrew Gurman thanked then CMS Acting Administrator Andrew Slavitt for being a “sincere partner” during the process. Gurman was very pleased at the influence the AMA’s comments had that “will allow for a reasonably paced progression into the program so that physicians can learn and adjust…”
He said, “The key elements of the proposed rule that CMS changed based on our recommendations are:”
     Physicians would not have to report in all four MIPS categories to avoid a negative payment adjustment. Instead, the only physicians who “will experience a negative 4% penalty in 2019 [increasing in steps to 9% by 2022] will be those who choose to report no data.”
     Participating in one of 4 options under “Pick Your Pace” will “help the physician avoid penalties.” At the very least if (s)he “chooses to report for only one patient on just one quality measure, one improvement activity, or the 4 required Advancing Care information measures, [(s)he] will avoid a negative payment adjustment.”
     The final rule established a 90-day reporting period, “a significant change over the proposed rule, full calendar-year requirement.” If the physician reports for at least 90 continuous days in 2017, (s)he will be eligible for a positive payment adjustment. This adjustment allows the physician to start later, to have more time to prepare.
     A reduction in the program-wide reporting burden from 11 reporting measures to 4 in 2017 and 5 thereafter.
     “An increase in the low-volume threshold to qualify for exemption from QPP participation.” CMS increased the threshold from $10k to $30k in Medicare payments, but kept the 100 Medicare patients per year limitation. So, your physician has been incentivized to not accept new Medicare patients, and to drop the old ones.
Does this give you a sense of why your relationship with your doctor has changed in recent years? I started this column feeling a bit angry at my doctor. I end it feeling sorry for him. Look what’s happening to Medicare! 

Saturday, February 15, 2020

Retrospective #364: “Prediabetes, in other words, is Diabetes”

This title is in quotes because…I think I cribbed it from Kelley Pounds, an RN, CDE, blogger and diabetes educator whose writings I always find interesting and informative. But, alas, I can’t find that title in her Table of Contents. So, a hat tip to Kelley Pounds. Check out her home page.
The point of the title is that Kelley, and I and many other “activists,” and of late, even some researchers, are urging the public health establishment in the U. S. and world-wide to take a hard look at the current Clinical Guidelines for defining Prediabetes and consider lowering or re-defining it. The implications of doing this are momentous; but likewise, if this is not done, the outcomes will be catastrophic. Consider this December 2016 revelation from the CDC: “Life expectancy for the U. S. population in 2015 was 78.8 years, a decrease of 0.1 years from 2014.” That’s the first DECREASE IN LIFE EXPECTANCY in the U.S. since 1999. Think it’s related to our lifestyle? To our diet?
A ton of evidence associates LIFESTYLE DISEASES with METABOLIC SYNDROME, the major outcomes of which are obesity, Type 2 Diabetes and heart disease. That’s why a Better Standard of Care is needed to address this scourge.
Cardiovascular Disease (CVD), Coronary Heart Disease (CHD), Stroke, Type 2 Diabetes Mellitus (T2DM), Non-alcoholic Fatty Liver Disease (NAFLD), Alzheimer’s Disease, aka Type 3 Diabetes, and even Erectile Dysfunction, plus several types of cancer; A large population study in July 2010 in “Diabetes Care,” shows that “the relative risks of various cancers imparted by diabetes are greatest (about twofold or higher) for cancers of the liver, pancreas, and endometrium, and lesser (about 1.2–1.5 fold) for cancers of the colon and rectum, breast, and bladder.”
A WebMD stub puts it succinctly: “Metabolic syndrome is a collection of symptoms that can lead to diabetes and heart disease. The good news is that metabolic syndrome can be controlled, largely with changes to your lifestyle.” The five related symptoms, first introduced nine years ago to my readers in Retrospective #9, and updated in Retrospectives #78, #334 and #335 are: a Body Mass Index (BMI) ≥30, or large waist circumference (men ≥40 inches, women ≥35 inches); elevated triglycerides (≥150mg/dl), reduced HDL, the “good” cholesterol (men ≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg, and/or use of medications for hypertension) and elevated fasting glucose (≥100 mg/dl, and/or the use of medications for hyperglycemia).
In the U.S. the longstanding criteria for a clinical diagnosis of Type 2 Diabetes Mellitus (T2DM) was two consecutive office visits with a fasting blood sugar ≥140mg/dl (7.8mmol/L). In 1997 that standard was lowered to ≥126mg/dl (7.0mmol/L). In 2002 a definition for Pre-Diabetes was added: an IFG ≥ 100 to 125mg/dl (5.6 to 6.9mmol/L) or an IGT of 140 to 199mg/dl (7.8 to 11.0 mmol/L) two hours after a 75-gram glucose challenge. The WHO uses a higher IFG threshold: ≥110to 125mg/dl (6.1 to 6.9mmol/L).
Later, in the U. S., the HbA1c measurement was added to supplement or in some cases now to supplant the IFG. In the U. S., an HbA1c between 5.7% and 6.4% is considered Pre-Diabetic and ≥6.5% Type 2 Diabetes. Elsewhere in the world, Pre-Diabetes is defined as an “A1c” ratio between 49 and 56mmol/mol and Type 2 Diabetes as ≥58mmol/mol.
For years leading research scientists like Ralph A. DeFronzo and pioneering clinicians like Richard K. Bernstein have called for a lower standard for the diagnosis of incipient Type 2 Diabetes. These men are leading diabetes specialists who have devoted their lives to combating this disease. They are both superstars.
Now, as I reported in #362, the BMJ (British Medical Journal) has published IN 2016 a Chinese meta-analysis done on 1,611,339 people. The lead researcher’s takeaway: “Effective intervention in prediabetes is not just for prevention of diabetes, but also cardiovascular diseases.” The majordomos are starting to connect the dots.
Type 2 Diabetes has to be redefined, as Kelly Pounds and I and DeFronzo and Bernstein would say – indeed have said: “PREDIABETES, IN OTHER WORDS, IS TYPE 2 DIABETES.”
And at the clinical level today, physicians have to revise their Standard of Care and not treat Prediabetes with temporizing measures, e.g., “We’ll have to monitor your blood sugar” (read: to watch your Insulin Resistance worsen as you continue to eat the Standard American Diet. Clinicians need to tell you: “If you are Prediabetic, you are in fact Diabetic. You have Insulin Resistance. You need to change your diet. You are Carbohydrate Intolerant.”

Friday, February 14, 2020

Retrospective #363: Type 2 Diabetes, a Lifestyle Disease

Okay, so which is it? A Dietary Disease or a Lifestyle Disease? It’s both, of course; diet is a part of Lifestyle. But why then is Establishment Medicine comfortable with calling it a Lifestyle Disease and not a Dietary Disease? They would tell you that lifestyle includes such things as doing 175 minutes of exercise a week (which while good for your health, is not necessary) and giving up smoking (which while also good, isn’t relevant to diabetes). Forget the epidemiological studies that show a correlation with Type 2 Diabetes. But remember, “Correlation does not imply causation.”
Exercise is a great habit to have. It builds muscle, keeps you fit, and if you’re a Type 2 or even Prediabetic, it improves your insulin sensitivity. But it’s not necessary to treat Type 2 diabetes. Eating fewer carbs, and thereby secreting less insulin, also improves your insulin sensitivity. “Insulin causes Insulin Resistance,” as Dr. Jason Fung recently blogged.
No, Establishment Medicine probably doesn’t want to call Type 2 a Dietary Disease for a number of reasons:
1)  Some clinicians simply don’t know. I know that’s hard to believe, but I’m afraid it’s true. It’s called “tunnel vision.” See Retrospective #365, “The Dual Pincers of Clinical Practice Guidelines,” this Sunday, for a full explanation.
2)  If you understood that Type 2 Diabetes and Prediabetes are Dietary Diseases, then the logical “treatment” would be a changed diet, not pills and injections… and you could still advocate for exercise and secession of smoking. Ah, but then it would be a less persuasive and perhaps a less effective argument if it was not linked to the avoidance of Type 2 Diabetes. And, if you didn’t have a prescription to write, the patient would feel “cheated.” The patient wants you, oh omnipotent dispenser of scripts, to “cure” this pernicious disease for them.
3)  If Type 2 Diabetes and Prediabetes are acknowledged to be Dietary Diseases, caused by the dietary advice that Government Dictocrats have mandated and the Medical Establishment has peddled for the last 60 years, then your doctor, if he or she were to tell you to change your diet to almost the exact polar opposite of what he or she has been telling you to eat over these many years, they would look pretty silly or just stupid. And the general public, and your doc’s patients in particular, would lose confidence in these omniscient demigods. They’d lose patients too.
4)  The ADA used to say that low carb diets were not safe. Then, the evidence from controlled trials proved them wrong. Then they said they were safe for a limited time only; then the evidence proved that wrong too. Then they said – actually, they’ve said all along – that low carb diets were too difficult to follow. That’s true for some, but certainly not true for many others. Others found them easier to follow than a low-fat, calorie- restricted, “balanced” diet because weight loss, without hunger, was possible. In fact, it was easy. And followers of low-carb, high- fat diets, besides keeping the weight off, had better glucose control and better lipid (cholesterol) profiles!
No, it’s easier to see the patient, take a blood sample, and then tell them (in a phone call or a note with your lab test) that, “Your sugar is a little high; we’ll have to monitor that.” And when you continue to eat the same prescribed “balanced” diet, and exercise as you were told, and your blood sugar goes higher still, the doctor will tell you, as Tom Hanks related to David Letterman in Retrospective #160, “You’ve graduated; you’re now a Type 2 Diabetic.”
Well, what did you expect? You continued to do the same thing and yet you expected a different result? Type 2 Diabetes is a Progressive Disease. Insulin Resistance is a Progressive Condition. Insulin Resistance = Type 2 Diabetes. Insulin Resistance = Carbohydrate Intolerance. The only effective treatment for a Dietary Disease is a different diet.
The only effective treatment of Type 2 Diabetes is a Low Carbohydrate Diet. Not “watching your blood sugar” as it progressively worsens. Not treating this symptom – an elevated blood sugar – with a drug that will force your pancreas to secrete more insulin and thus eventually wear out and die.
Type 1 Diabetes is a disease of too little insulin. Type 2 Diabetes is a disease of too much insulin. The best way to treat your pancreas, and thus save it, is give it a break! Let it secrete less insulin. Eat a low carb diet!

Thursday, February 13, 2020

Retrospective #362:A Stricter Prediabetes Definition

In 2016 a Reuters Health Information article in Medscape Medical News headlined, “Meta-Analysis Backs Stricter Prediabetes Definition.” It reports on a new study in the BMJ (British Medical Journal) that “people with a fasting glucose as low as 100mg/dl (5.6mmol/L) are at increased risk of cardiovascular disease.” It also showed increased CVD risk in individuals with an HbA1c as low as 5.7% (39 mmol/mol). What is significant about this Chinese study is that it is very large (53 studies, comprising 1,611,339 people). The big takeaway: “Effective intervention in prediabetes is not just for prevention of diabetes, but also cardiovascular diseases.”
This isn’t news to my regular readers. I have been saying it forever, most recently in the risk analysis presented in Retrospective #345, “How Diabetic Do You Want to Be? (Part 2). That column was based on the laudatory work of Jenny Ruhl at her website, Blood Sugar 101. Jenny has meticulously collected and provided links to the best research. Her books, “Blood Sugar 101” and “Diet 101,” are awesome too.
Based on the ADA criteria for an Impaired Fasting Glucose (IFG) of 100mg/dl to 125mg/dl (5.6 to 6.9mmol/L), the study found that the association between prediabetes and various co-morbidities is as follows: CVD ↑ 13%; CHD ↑ 10%; Stroke ↑ 6% and All-Cause Mortality ↑ 13%. But the ADA criteria is “contentious,” the authors told Medscape, and “has not been used in other international diabetes management guidelines.” The WHO (World Health Organization), for example, uses a higher cutoff for diagnosing an Impaired Fasting Glucose, 6.1 to 6.9mmol/L (110-125mg/dl), and thus has a higher hazard ratio for “composite cardiovascular disease” of ↑26%.
Similarly, the ADA’s prediabetes criteria for an HbA1c is 39-47mmol/mol (5.7% -- 6.4%), whereas the National Institute for Health and Care Excellence (NICE at Braiain’s NHS) cutoff, 42-47mmol/mol (6.0% -- 6.4%), is different. As a result, CVD relative risks vary from 13% (IFG-ADA) to 26% (IFG-WHO), relative risks for CHD vary from 10% to 18%, and relative risks for stroke vary from 6% to 17%. The authors also argue for the standardization of IFG and IGT (Impaired Glucose Tolerance), and the worldwide incorporation of HbA1c in defining prediabetes.
 But let’s not get lost in the weeds. The bottom line is this: The current cutoffs worldwide for a diagnosis of prediabetes are strongly associated with an increased risk of CVD, CHD, stroke and all-cause mortality. This is in addition to the usual microvascular complications of T2DM of nephropathy (end-stage kidney disease), retinopathy (blindness), and neuropathy (leading to amputations). There is also a similar pattern for dementia (Alzheimer’s).
That’s the message, and that is why I am pleased to see this hue and cry for a stricter and more standardized prediabetes definition. The medical doctor’s response was predictable: “People with diabetes should be followed up and should maintain a healthy lifestyle” (emphasis added by me). And “many drugs prescribed for diabetes may be useful in people with prediabetes (e.g., metformin, acarbose).” The latter is also not news, but it is surprising how many doctors don’t know this and do not routinely employ this intervention in clinical practice.
Then, according to Medscape, the study’s lead author, a research physician, suggests that, “First, we need to develop models for risk stratification in people with prediabetes. Second, we will select higher-risk people with prediabetes to evaluate whether drug treatment can prevent cardiovascular disease in them.” Not a word about diet.
I’m not surprised by this either. Drugs, drugs, drugs. Always treat the symptom (an elevated blood sugar); never treat the cause (Insulin Resistance → Carbohydrate Intolerance). What about “lifestyle modifications” (diet)?
Lifestyle modifications address modifiable risk factors. That means you can do something to reduce your increased risk of cardiovascular disease. You can modify your diet by restricting the amount of carbohydrates you eat and thus lower your blood sugar without drugs. Jenny Ruhl #1: ↓Dietary Carbohydrates = ↓Insulin Resistance = ↓Type 2 Diabetes.

Wednesday, February 12, 2020

Retrospective #361: “Whistlin’ Past the Graveyard”

When I wrote this in mid-December, I had just learned that two people that I thought I was helping are paying no attention to my advice. This news is worse than discouraging. It’s depressing – but not so much for me. I’m trying not to think of myself. I don’t write this stuff for myself. Okay, I do, a little, but I do it primarily for my friends and my faithful readers, and for people who stumble on a column through Google. But it’s especially disheartening to learn that people whose health should be of paramount concern to themare ignoring their health and my advice.
Okay, I’m not a health professional, and I’m certainly not a doctor. I don’t have the opportunity to order blood tests and deliver the bad news to the patient. And then, when they are most vulnerable, tell them to take a pill or even to follow a certain way of eating. But I can’t for the life of me (LOL) figure out why anyone would listen to a doctor in the matter of what to eat. I mean, what in bloody hell do doctors (or RD’s or CDE’s) know about “healthy eating.”
Oh, I forgot. Doctors have been telling us what to eat to prevent heart disease since 1961. In fact, it began after President Eisenhower’s first heart attack in 1955. By January 1961, Ancel Keyes, an epidemiological physiologist, had made it onto the AHA Board of Directors and the cover of Time magazine with the basic advice, then and now, to avoid saturated fat and cholesterol, to eat mostly a plant-based diet primarily with fats from corn and soybean oil.
Then, in 1977, government Dictocrats set the same Dietary Goals and, starting in 1980, updated them every 5 years. This diet, per the Nutrition Facts Label on processed food, was and is, for women, 60% (300g) carbs, 10% (50g) protein and 30% (67g) of the oxidized polyunsaturated vegetable and seed oils (PUFAs) manufactured by the industrial food giant conglomerates supported by the USDA. For men, it’s 375g of carbs, 67g of protein and 83g of fat (PUFA’s).
Now it’s true that in recent years the USDA/HHS/FDA have backed off a little. They no longer limit total fat to 30%, but they insist that to the extent that percentage is increased, you do it with those PUFAs, not the saturated fats from animals. And it’s true that the Dietary Guidelines Advisory Committee told the full panel on December 14, 2014, that “Cholesterol is no longer a nutrient of concern for overconsumption,” eliminating the 300mg per day limitation, but after the full panel held Congressional hearings, the final 2015 Guidelines watered down that recommendation.
There are also lots of news articles appearing now about the benefits of full-fat dairy products like milk and yoghurt. But guess what? Have you tried to find full-fat yoghurt in the grocery store recently? Good luck with that! But what did you expect? Do you think the Government is going to tell you their advice for the last 60 years has been all wrong? Of course not. It’s unthinkable. So, you have to decide for yourself what healthy eating is. Or, listen to me (LOL).
I could even cite myriad scientific reviews questioning – neigh, disparaging the advice to reduce the intake of salt. I’ve cited them over and over again in multiple columns. But, does anyone listen to me? No. Poor, poor little me.
Recently I learned that a friend who needed to lose weight he had gained because of medications he must take – was successful in following the low-carb regimen I recommended. Then, with his wife, he switched to Weight Watchers.
Then another friend, who also has medical issues, on the advice of her physician (who’s vegan), had gone vegetarian. And guess what? She’s tired all the time, and blood tests her doctor ordered showed her to be protein deficient. Quelle surprise! She and her husband, who is in worse shape than she, both have ignored my advice for years.
Okay, I am feeling sorry for myself. But I am also worried for them, and for YOU too – for their health and YOURS. Don’t they realize that is all they have that is important (besides each other)? Don’t YOU realize it?
I just learned a few days ago that another friend died suddenly about a month ago. Maybe this rant is because I’m grieving for him too and for all my other friends and everyone else who is whistling past the graveyard. Thinking about myself, I am in much better health today than I was 20 years ago, or maybe even 50 years ago. And I am still alive and thriving! THIS IS REALLY ABOUT YOU, MY FRIENDS: IT IS YOU WHO ARE WHISTLING PAST THE GRAVEYARD.
February 12th is the scheduled republication date for this column. It will also be the 1st day of the rest of YOUR LIFE.

Tuesday, February 11, 2020

Retrospective #360: Fourteen years ago, I had a relapse (Part 5)

As readers following this series know, I decided to write it after I stumbled on an old misfiled Excel folder detailing my early “carb counting” days from 18 years ago. After regaining 12 pounds of 60 that I had lost on Atkins Induction (20g/d) in 2002, in 2006 I rededicated myself to Dr. Richard K. Bernstein’s 6-12-12 plan for diabetics. Fifty weeks later, with strict adherence and record keeping, I had lost another 96 pounds. When added to the previous 48 (60 – 12), my loss then totaled 144. I would eventually go on to lose a total of 188 pounds, half my original 375.
In the beginning I still ate a lot, but I did not limit calories, fat or protein. I just limited carbs. I had a much larger body to feed then and therefore a lot more organism (and psyche) to satisfy. A person who is used to eating, and gets gratification from eating a lot, needs to acclimate him/herself to this new lifestyle. You need to make a gradual adjustment to smaller meals. And you need to shift gratification from a feeling of being full to a feeling of liking that “lean” feeling and seeing the weight loss as recorded every day and every week.
What surprised me (and amazingly my doctor as well), was how, from Day 1 on strict Atkins Induction, the very low number of carb grams had an immediate effect on my blood sugar readings and on my medications. On Day 1 I had a hypoglycemic episode, and two more that first week. My doctor immediately dropped the 3rd oral anti-diabetic med he had recently started me on and then in successive days that first week, recognizing that I was overmedicated, cut the other two meds, on which I was maxed out, in half twice. In just one week, before weight loss was even noted, I had reduced my diabetes medications by 90% (8/9ths).
Four years in, when I restarted on Bernstein in October 2006, I was still on 5mg Micronase (glyburide, a sulphonylurea or SU) and 500mg of Metformin. I only kept a record of estimated carb grams, I would later add protein, fat, and calories to my records. Still later I added saturated fat, cholesterol, sodium, fiber and simple sugars (mono and disaccharides, both added and naturally occurring). Total sugars were always VERY low.
I kept records in 4-week tables. My goal was simply 30 grams of carbohydrate a day, ala Bernstein’s program. My first 4-week average carb count was 33 grams a day, range 16 to 59, but those were outliers. Most were 20s and 30s. The interesting thing about this month was my fasting blood tests. The fasting average the first week was 139mg/dl. It dropped in weeks 2, 3 and 4 to 107, 104 and 104. But the really interesting result was my late afternoon blood glucose readings. The first week’s average was 85mg/dl. The second week’s average was 78, but by the 3rd and 4th weeks it had dropped to 59 and 56, with 6 out of 7 readings in the last 2 weeks in the 40s.
I WAS OVERMEDICATED, on only 5mg of glyburide (Micronase), while eating VERY LOW CARB! So, in the next 4-week period I stopped the SU for 2 weeks and then added it back at a reduced dose of 2½mg. My late afternoon averages were now 95 and 114mg/dl for the weeks without an SU, and 57 and 81 for the weeks at the reduced dose. My carb gram average for this 4-week period was 31, down from 33, and very close to my goal of 30.
Not bad, considering this period included Thanksgiving… and Christmas was coming. Oh, by the way, I also lost weight during these successive 4-week periods: 10 pounds the 1st, 14 the 2nd, only 1 the 3rd (including a 150-carb binge on Christmas Eve and on Christmas Day another 94g carb binge). Such seasonal indulgences bumped my December carb gram average up to 51 grams a day, but my late afternoon weekly averages held sort of steady (72, 77, 83 & 95) and my evening 2-hr postprandial averages were fine (87, 87, 83 & 95).
In January 2007, I got back to eating according to plan, and my carb average dropped to 32 grams a day. Increasingly, however, my late afternoon readings were again dropping below 70mg/dl (without hypos), with weekly averages went from 85 to 71 to 67 to 68. I WAS STILL OVERMEDICATED. So, I split the tiny pill in half and took just 1.25mg/d.
In March 2007, I stopped the glyburide (Micronase), a sulphonylurea, altogether. SU’s are bad news. They do effectively lower your blood sugars but at a very big price. They deplete the pancreas of beta cells and impair its ability to make more insulin. Eventually, when you can no longer make your own insulin, you must inject it.

Retrospective #359: Fourteen years ago, I had a relapse (Part 4)

In Parts 1, 2 and 3 of this series (#356, #357 and #358), I described how I lost 170 pounds on Very Low Carb diets. I related how it all began after my doctor read “What if It's All Been a Big Fat Lie?” a 2002 NYT Sunday Magazine cover story. He tried the diet to lose weight, and after losing 17 pounds, he suggested I try it, also to lose weight. Unfortunately, my doctor soon regained all his lost weight when he went back to eating “normally.” He would afterwards ask me, “What do you eat?” and “How do you do it?” I said, “It’s no secret.”
He also told me, though, that “It might even help your diabetes.” He was sure right about that. Of course, neither of us knew at the time how much it would help my diabetes, but I you’ve read Parts 1, 2 and 3, you know what happened: my Type 2 Diabetes went into total REMISSION. He would probably say that I was “cured,” because I no longer had any symptoms discoverable by the routine lab tests. I am, however, still a Type 2 diabetic because I have Insulin Resistance. I will, therefore, always be Carbohydrate Intolerant. And that leaves the questions, “What do you eat?” and “How do you do it?” That’s what Parts 4 and 5 are about.
Ten years ago this past summer, after several years of maintaining my weight at about 315 pounds, I relapsed. I regained 12 of the 60 pounds I had lost on Atkins Induction. That’s when, in October 2006, I started on the Bernstein program for diabetics. I built an Excel table to keep track of the carbs I ate.
But Bernstein also requires that you limit protein, since some amino acids (digested protein) are glucogenic (can be made into glucose by the liver). So, after a few months on Bernstein, I built a new table to add protein, and then fat, calories, fasting blood sugars and weight. I used an online program to get the numbers for everything I ate. It took about a half hour a day at the start, then a little less.
I weighed myself daily, but only noted the change weekly. In the beginning, while I was learning the effect that different foods had on my blood sugar, I took a morning fasting blood sugar (FBG) and a 2-hour post prandial. I also took one in late afternoon (usually my daily low reading) and another 2 hours after supper. Now, since I know about carbs, I only weigh-in daily and take a FBG in the morning to get a weekly average.
I kept a detailed food log for a few years, until I learned what I should eat and what I shouldn’t. It was also a good way to show me the price I paid when I ate something that I knew was taboo. It had another effect too. Besides the shame and guilt that I felt, and the disappointment with myself for the “lack of discipline,” it always ruined my averages. If you’re completely honest with yourself, and record everything, the numbers don’t lie. That was probably more devastating than the guilt! You’ve got to be totally honest with yourself. You have to record everything you eat and drink. No rationalizing. No forgetting! And then, you have to face the truth.
After a while, you won’t need to keep records. You figure out what works. You learn, and then you know that eating certain foods will not spike your blood sugar. And others will. You know that eating fat and limited protein with nil carbs, will not leave you hungry. You will also be able to fast easily because YOU WILL NOT BE HUNGRY. When lunchtime rolls around, you will ask yourself, “Am I hungry?” and if the answer is “no,” it will be easy to skip that meal, or eat a smaller meal, without hunger. And, you will lose your “sweet tooth.”
None of this is to say that you will not want to eat something for reasons other than physiological need (hunger). For example, the sight of food is a tremendous stimulus for me. It has been my downfall more times that I can count. Nervous eating, bored eating, habit (mealtimes), social events, social convention, (fellow workers and family members) all present challenges. However, need is the only biological imperative, and real hunger is what drives that need. And if you are in a state of mild ketosis, described as “ketoadapted” or “fat adapted,” your body is content with burning body fat for fuel. You are in energy balance. So, my new mantra is to ask, “Am I hungry?” If the answer is “no,” I try not to eat. But, if I succumb for whatever reason, I try to eat a small meal of just protein and fat.

Sunday, February 9, 2020

Retrospective #358: Fourteen years ago, I had a relapse (Part 3)

When I told my wife that I was writing a series about my weight loss journey since I started Bernstein 14 years ago this fall, she asked me if that was the year that we were in Puerta Vallarta in September. I checked, and it was! What a memory she has! My recollection was a little different…
As I related in Retrospective #357. “Fourteen years ago, I had a relapse (Part 2),” I recalled that my motivation was that I had regained 12 pounds (20%) of the 60 pounds I had lost on Atkins Induction (20g a day of carbs) four years earlier. That was true, but my wife reminded me of a conversation I had had with a Canadian MD I met in the Lazy River in that Mexican resort who told me that I was “IN DENIAL.” What a service that doctor did for me that day!
My wife told me that I came home with renewed resolve to do something about that 12-pound weight gain. Having just read Richard K. Bernstein’s “Diabetes Diet,” I now bought and read his “Diabetes Solution and decided to go for it: eat just 30g of carbs a day. For diabetes meds, I was still on 5mg Glyburide and 500mg of Metformin once a day.
Beginning in October 2006, I started counting carbs daily and taking blood sugar readings again. By November, I had cut back the Glyburide from 5mg to 2½. In late January, I started a 4-week drug trial to reduce it further from 2.5mg to 1.25. And in late February, I started limiting proteins, since so many of their component amino acids are glucogenic, i.e., can be made into glucose by the liver.
Then, on March 17, 2007, I stopped taking Glyburide altogether. By April I was eating just 90g of protein a day (see Retrospective #357 for how I chose this amount). In May, I reduced protein further to 80g/d. I also reduced my fat intake from 110 to 100 to 90g/day. Fifty weeks after starting Bernstein, by September 23, 2007, I had lost 96 pounds, going from 327 to 231. Added to the 48 net (60-12) that I had lost on Atkins Induction, my total weight loss from 375 pounds to 231 on both Very Low Carb diets, was 144 pounds…with more to come.
Remember too (or if you didn’t, read Retrospective #356), starting with the first week on Atkins Induction back in 2002, I had stopped taking all of my oral anti-diabetic medications except 500mg Metformin and 5mg Glyburide.  Now I was only taking 500mg of Metformin, which I was to continue to do for the next 14 years.
With all the weight loss, my blood pressure also improved significantly, on the same and then a reduced “cocktail” of drugs. It went from 130/90 to 110/70 at my lowest weight. Currently it’s 120/75. And my lowest A1c has been 5.0%.
Now, returning back to late 2003, after a year of monthly office visits while monitoring my 60-pound weight loss and maintenance while on Atkins Induction (20g/d), my doctor suggested we change to quarterly office visits. My Total Cholesterol and LDL-C hadn’t changed much. They were both “borderline” by NCEP Guidelines for a “healthy” person. But, based on my still “morbidly obese” status, and Type 2 diabetes, my doctor declared that I was still at “high risk” for cardiovascular disease, so he put me on a statin. He started me on Lipitor, and quickly raised it to the max. My LDL-C (and Total Cholesterol) responded as expected. They both plummeted.
But, prior to my starting statins, on both Atkins Induction and Bernstein, my HDL-D and triglycerides both improved a little. Before starting Atkins, my average HDL-C had been just 39mg/dl and my TGs 143mg/dl. Now, my HDL was 51 average (range 43 to 60) and my triglycerides 84 average (range 36 to 157). As I continued from mid-2004 to mid-2007 on both Lipitor and later a generic statin (Simvastatin), my TC and LDL-C were very, very low (TC: 116 & LDL-C: 48, average of 12 tests); however, SINCE STARTING ON BERNSTEIN, my HDL-C has SOARED and my TGs have PLUMMETED. MY HDL-C AVERAGE WAS NOW 84MG/DL AND MY TRIGLYCERIDES NOW AVERAGED 49MG/DL.
Given the death-from-all-cause benefit of a high HDL-C and low triglycerides, and my total weight loss (by this point 170 pounds), in December 2008 my doctor (on his own accord, without my requesting it!) took me off statins. I have been statin-free now for 12 years. And while my weight has inched up a little, my latest lipid panel was still stellar: Total Cholesterol 184, HDL-C 91, LDL-C 84 and triglycerides 46. How’s them apples?

Saturday, February 8, 2020

Retrospective #357: Fourteen years ago, I had a relapse (Part 2).

As I started to tell in Retrospective #356, fourteen years ago, I had a relapse. I regained 12 of the 60 pounds I had lost over a 9-month period 4 years earlier. I had lost focus. So, I decided, for my health and longevity, that it was time to get serious again and rededicate myself to the principles and practice of Very Low Carb eating.
That summer of 2006, almost 14 years ago, I had also read Dr. Richard K. Bernstein’s book, “The Diabetes Diet.” So, with my renewed resolve, I decided to switch to Bernstein’s Diet Plan for Diabetics. Dr. Bernstein has been a Type 1 Diabetic for most of his 80-odd years and was an engineer before he became an MD, like his wife. As an MD, she had a big blood sugar testing machine in her office, so he used it to develop a strict regimen for “eating to the meter.” After all, he reasoned (as an engineer), if carbs make your blood sugar rise, the best treatment for regulating your blood sugar would be to restrict eating carbs. That makes sense doesn’t it? It’s just common sense!
Bernstein’s credo is that “everyone deserves a normal A1c.” His A1c’s are in the 4s. Being a Type 1, he achieves this by injecting insulin, both long acting (24-hour) and at mealtimes, on a 30g-of-carbs-a-day “diet”. He calls it 6-12-12: 6 grams at breakfast (lower due to the “Dawn Phenomenon”), 12g at lunch and 12g at supper. No snacks. These principles are all explained and well documented in the latest edition of his magnum opus, “The Diabetes Solution.”
Another difference from Atkins Induction (20g/day) is that Bernstein limits protein. When digested, protein breaks down into amino acids, some of which are made into glucose by the liver and thus raise blood sugar. So, to limit excess, unwanted glucose production (called gluconeogenesis), protein needs to be limited. But how much protein should a person eat? In 2006 I studied the question carefully and discovered that opinions vary widely, but the “correct” way is to use a number based on an estimate of “lean body weight.”
Lean Body Weight is the optimal weight for a person, and it is your lean body that needs protein. In 1998 the HHS/NIH adopted the Body Mass Index (BMI) Chart used by WHO, the World Health Organization. Your doctor is required to use this chart to “evaluate” your weight. It is a really gross metric that takes no account of gender, body type, age or cultural environment. It is also a pie-in-the-sky number for almost everyone who will read this post, i.e. people living in a part of the world where food is omnipresent and abundant and where processed food has replaced real food in our lives. Thus, according to the BMI, virtually all of us are now overweight or many of us are obese. Nevertheless, your BMI “normal” weight is what you should use to calculate the amount of protein to eat.
The middle of the “normal” range in the BMI chart for a 5’-10” person (me) is 150 pounds. I still weighed 300 pounds in 2006 – that’s morbidly obese – but 150 lbs still sounded totally ridiculous to me, so, by “mistake,” I chose instead a “goal” weight of 180 pounds for my calculation. And since I was pretty sedentary and did no exercises, I used 0.5 grams of protein per pound (1.1g/kg) of my goal body weight. So, 180 x 0.5 = 90 grams of protein a day. Honestly, though, the grams per pound is also a variable where opinions vary widely, so the number you settle on is up to you. That’s how I started. Note: I was soon able to reduce my protein budget further.
For fat, I followed Bernstein’s dictum: Eat enough to be satisfied. I didn’t avoid saturated fat or cholesterol. I had been convinced by Gary Taubes, and many others since, that the 1977 “Dietary Goals for the United States” and The Dietary Guidelines for Americans, first published in 1980 and then every five years, were A FAILED PUBLIC HEALTH EXPERIMENT. They were in fact THE CAUSE of our obesity and diabetes epidemic. And they certainly weren’t right for anyone who was diabetic, pre-diabetic, or was just a little overweight. It just didn’t make sense.
So, for breakfast, I usually ate 2 fried eggs and 2 strips of bacon, with coffee and whole cream. That’s all. No juice. No bread. No jelly. No fruit and No cereal. Period! No exceptions. I found this small meal very satiating. I was never hungry later in the morning or even at lunch. I usually eat lunch though, out of habit, I suppose. It was sometimes a can of kippered herring in brine, or an avocado with vinaigrette dressing in the cavity, or a can of sardines in EVOO and Jalapeño peppers. Yum. Just protein and fat. And that’s the second meal of the day with virtually no carbs.

Friday, February 7, 2020

Retrospective #356: Fourteen Years Ago, I had a Relapse…

Fourteen years ago, I had a relapse. I regained 12 pounds of the 60 I had lost over a 9-month period 4 years earlier. All I can remember from that misspent summer (I was 65 then) was that I regularly raided the freezer after supper or before bedtime to have a big dish of ice cream. That was all it took.
Four years earlier, in 2002, my doctor had just read “What If It's All Been a Big Fat Lie?” a Sunday Magazine cover story in The New York Times. For years my doctor had been trying, unsuccessfully, to get me to lose weight. And since the diet described in the Times’ story went against the medical establishment’s “Standard of Care,” my doctor was reluctant to recommend it. He had a little paunch (medically speaking, “visceral adiposity”) though, so he decided to try it on himself first…and he lost 17 pounds.
A little later when my doctor suggested that I try this diet – eating just 20 grams of carbohydrate a day) – I decided to give it a shot. I weighed 375 pounds in 2002, and I didn’t think I was going to live that much longer. I was then taking a cocktail of 3 drugs for high blood pressure. In addition, I was taking another cocktail of 3 drugs to “treat” my high blood sugars. I had been diagnosed a Type 2 Diabetic 16 years before.
For Type 2 diabetes, I was taking maximum doses of two classes of oral medications and starting on a third. When the 3rd class of oral meds would eventually fail to control my blood sugar, I would “graduate” to injecting insulin. That is the Clinical Guideline for Type 2s; it is the “Standard of Care” when “diet and exercise” fail. And diet and exercise inevitably WILL fail because the one-size-fits-all diet that doctors prescribe, again according to the “Standard of Care,” is the USDA’s Dietary Guidelines for Americans, which is a low-fat, HIGH-CARB diet!
So, starting on a strict “Very Low Carb” regimen had an immediate effect on my health: I had a “hypo” the very first day. After eating a candy bar and waiting for “the sweats” to subside, I called my doctor. He told me to stop taking the 3rd oral that I had recently begun. But then, the next day I had another hypo. This time he told me to cut the dose of the other 2 meds in half, and before the week was over, I had to cut them both in half again. I hadn’t noticed any weight loss, but in just one week I had eliminated almost all my T2 meds.
I did start to lose weight of course. Remember, that was WHY my doctor had started me on a Very Low Carb diet, not to treat my diabetes.  He was almost as surprised as I was at the “unexpected” effectiveness of the Very Low Carb diet in treating my Type 2 Diabetes. My blood sugar was stable and in control. And over the course of 9 months, I lost the 60 pounds, 1½ pounds a week. And then I retired from work and the weight loss stopped. I didn’t gain any back; I just stopped losing. I don’t recall my state of mind, but I must have kept eating Lower Carb because for three years, until the summer of ‘06, I kept the 60 pounds off, and my blood sugar was stable. No more hypos!
Along the way, with time on my hands (being retired) and being “a little OC” (lol), to be sure that I adhered to the basics of Low Carbohydrate eating, in March 2004 I decided to keep a record of how many carbs I ate. To do this I constructed an Excel table to record for a week everything I ate, every day, and to estimate the carb content only. To do this I used carb counting guides and free on-line services.
The concept was 1) to learn more about carbs and 2) to be accountable to myself – to fully “fess up,” to me alone, everything I put in my mouth. My estimate of food quantities and carb content was crude and approximate. It was just a way to keep daily carb counts, but it had the benefit of keeping me honest.
As I recently discovered when I found a misfiled folder in my directory, I kept these charts on and off from March 2004 until mid-2006, when I went off on that ice cream bender. Fortunately, by that time, I was well connected with an online community that showed me the way forward and provided much needed help and support. In tomorrow’s post I will tell you how I was soon to lose another 100 pounds in just 50 weeks.

Thursday, February 6, 2020

Retrospective #355: “Before and After”

It strikes me as odd that the axiom, “A picture is worth a thousand words,” is barely a hundred years old. It is not surprising, though, that it is attributed to a newspaper editor. As overworked and hackneyed as it is, it is nevertheless true, as these pictures, taken before and after a few years of Very Low Carb eating, testify.

Equally persuasive are simple line charts, with values, as these two, which show respectively my HDL-C and my triglycerides over 35 years, the last 14 of which (2002-2016) were driven by my Very Low Carb Way of Eating.

Lest any doubt remain, this next chart shows that my Total Cholesterol averages over the same time frame were stable, contrary to the perennial declamations of naysayers of the conventional medical persuasion.

Enlarge these charts and look at the numbers, before and after 2002, when I started to eat Very Low Carb.

Wednesday, February 5, 2020

Retrospective #354: Macro and Keto Ratios

While exploring the Very Low Carb world over the years, I became interested in the workings of both Macronutrient Ratios and Ketogenic Ratios. I started with the study of Macronutrient Ratios around 2006 when I thought that “counting carbs” was not enough. I added protein and then fat (and total calories) and adjusted them over the years to where I eventually settled on 75% fat, 20% protein and 5% carbs, on only 1,200 calories by mouth a day. This calculates to a ketogenic ratio of food by mouth of about 2.0. More on that later.
Of course, these Macronutrient ratios account for only ingested food – food and drink that I put in my mouth. But since I strive to eat so few carbs, when I am not eating too many carbs or too much fat (and protein), I am able to add to the calorie burn – when my body requires more to maintain energy balance and remain an active metabolism – by burning body fat. I know that, so long as I eat Very Low Carb, I will have access to these fat calories because my serum insulin levels remain fairly low because there is a correspondingly low level of glucose circulating from carbohydrate (and protein) restriction. I know that my body is not shutting down – or even slowing my metabolism down to compensate for the low calorie intake by mouth – because I feel “pumped” all the time.
This additional body fat burning would imply that my actual Macronutrient Ratios are higher than 75/20/5. It also would imply a higher Ketogenic Ratio, since only fat is being added to the equation, almost all in the numerator.
So, let’s do the numbers. If my daily food intake is 1,200 calories, and the Macronutrient Ratios for food by mouth are 75% fat, 20% protein and 5% carbs, my intake is composed of 100g of fat (900kcal), 60g of protein (240kcal) and 15g of carbs (60kcal). But if my metabolism stays up, that is, is not slowed down by the lower food intake – because the low carb intake allows my body access to its fat storesthen my actual fat contribution, at the cellular level where the nutrients are absorbed, is going to be much higher. How much higher, you ask?
That depends on my metabolic rate. How many calories does my body burn?  That would be the sum of my resting metabolism plus my activity level, when not slowed down by either calorie restriction or from blocked access to body fat stores.
Let’s say, for argument’s sake, that my metabolism chugs along at 2,550kcal/hr. If I am only taking in (by mouth) 100g of fat, 60g of protein and 15g of carbs (1,200kcal total), it is theoretically getting a contribution from body fat of 1,350kcal (2,550 – 1,200 = 1,350kcals), or another 150g of body fat (1,350kcal/9kcal/g = 150g). That substantially changes the Macronutrient Ratio at the cellular level, where the body is actually fed. Check out this chart:
Nutrition & Metabolism
 k/g ratio
Intake orally (food my mouth)
Intake at the cellular level
The formula for ketogenic ratio is derived Wilder and Winter (1922):
K/G ratio = (0.9*FAT+0.46*PRO)/(0.1*FAT+0.54*PRO+1*CHO.) 3.5 is a solid ketogenic ratio.
N.B.: Ideally, I am only burning extra body fat – and sparing protein. My body will use the carbs that I ate, which are going to be oxidized first, when it needs to make glucose for those cells that do not have mitochondria and therefore lack the ability to make ATP. Plus, amino acids from digested protein, not taken up in circulation, will become glucose via gluconeogenesis in the liver. And, the liver will also make glucose from the glycerol backbones of catabolized triglycerides when body fat is broken down and burned. So, fundamentally, the body’s requirement for carbohydrates is zero.