Saturday, February 29, 2020

Retrospective #378: My New 30-lb Challenge: Project Design

This and every other post in the Retrospective Series was originally published weekly at They are now being republished here, and on Face Book and Twitter, daily, edited mostly for length and format.
As everyone who has ever lost a lot of weight knows, the worst thing you can do is waste the effort by gaining it back. And gaining it back it so much easier than losing it. So, the best defense to avoid gaining it back is a strong offense, i. e., to immediately launch another campaign to lose weight. And that’s just what I’ve done.
I made this decision exactly one week after the conclusion of my recent 10-week, 30-pound challenge, reported on here ad nauseum, in which I lost 31 pounds. Then, in the week after that 10-week challenge, I regained 4 pounds and my FBG average climbed from 80 to 93mg/dl. Ugh! So, my new challenge is to lose the 4 I regained plus 30 more (34 pounds). The length of the new challenge will be 16 weeks, to coincide with my next doctor’s appointment.
For reference, I had previously lost 170 pounds after starting in 2002 to eat Very Low Carb, first on Atkins Induction (20g/day), then later on Bernstein (30g/d). That was also my weight at the conclusion of my Basic Training in the U. S. Army in 1960, 57 years ago. By the end of this Challenge, I should have reached 187 lbs, exactly half the man I was (hehe) when I started Very Low Carb at 375 lbs.  Note: 187 lbs is still in the middle of the “Overweight” range in the BMI chart. I am starting this challenge at 217lbs, my teenage weight (in the 1960s), which is still considered “Obese.”
CHALLENGE DESIGN: To fast 42 hours 2 or 3 alternate days a week, depending on my social calenday. Fasting days could be Tuesday and Thursday or Monday, Wednesday and Friday. Fast from supper one day to lunch 2 days later.
FEASTING DAYS” I will strive to eat about 1,200kcal: 100g of fat, 60g of protein and 15g of carbohydrate. The carbs will actually range up to 30g to accommodate my daily 1 or 2 red wine spritzers, never more.
Breakfast on these days will consist of a 12oz coffee with 1½ oz heavy cream and pure stevia powder. Heavy cream is fat, so any overnight ketosis (if achieved) should continue into the day uninterrupted.
Lunch, if any, or any other food before supper, will be just protein and fat. Examples include a can of Brisling sardines in EVOO, a can of kippered herring in brine, or a hard-boiled egg (or 2). Iced tea sweetened with pure liquid stevia. A mid-afternoon break from gardening: an iced tea and a few spears of dill pickles to restore lost salt and replenish fluids. Before supper, I might snack on celery with anchovy paste or sliced radishes with butter and salt.
Supper on feast days will include a small to medium (not large!) serving of protein, with inherent and added saturated fat, and one serving of a low-carb vegetable, prepared with added fat (butter or olive oil), or a salad. My vegetables include green beans, asparagus, cauliflower, and broccoli. My salads include romaine, mushrooms, hazelnut pieces and grated or shaved cheese tossed in my homemade vinaigrette. My beverage: two red wine spritzers,
This regimen works because, even though this is a low-calorie meal plan for a “feast” day, at no point in the day will I be hungry. That’s because my metabolism is humming along in high gear, burning body fat for energy so long as both my blood sugar and blood insulin levels remain low and stable. I eat this food because I like it. I am not hungry before “breakfast,” but I enjoy my morning coffee. I am also not hungry during the day. I do look forward to a half-hour break from working in the garden – to rest and refresh myself, have a beverage and maybe a bite, and then go back to work.
“FASTING DAYS”: On these days (2 or 3 every week), I will consume about 300kcal/d. I will take my morning pills with the usual 12oz coffee, 1½ oz heavy cream and stevia powder. If I feel dehydrated during the day, I will have just iced tea and a slice (or 3) of pickle; and in the evening, just one red wine spritzer with my pills.
Macronutrients: Coffee w/cream: Fat: 16g (144kcal), Protein: 1.2g (5kcal), Carbs: 1.2g (5kcal); Total: 154kcal. Spritzer (6oz): Carbs: 4.5g (18kcal), Ethyl alcohol: 18g (126kcal); Total: 144kcal. Fasting day total: 298kcal. Say 300kcal/day.
The secret, I think, for the success of this “feast/fast” regimen, is that since I eat VLC, I am already “fat adapted.”

Friday, February 28, 2020

Retrospective #377: My 10-week, 30-lb Challenge: Final Report

Note: This “Final Report” was originally written in early 2017 and reports of my first experience with full day fasting (300kcal/d) to break a weight-loss stall. It is important to note that I was already keto-adapted or “fat-adapted,” meaning I was already eating and continued to eat (on most “feast days”), 15-30 grams of carbs a day. The original goal was to lose 20 pounds in 2 months. Due to early success, the goal was modified to 10 weeks and 30 pounds.
Summary: Primary End Point: Achieved. I lost 31 pounds in 10 weeks. Method: Full-day “fasting” (300kcal/day) – either alternate day or 3-consecutive-day fasting – as an effective way to break a weight-loss plateau if you are keto-adapted at the start. It is easy because you will not be hungry, and it is effective because you lose weight while your metabolism continues to run in “high gear” as you burn your own body fat. When full-day fasting, your fasting blood glucose will fall dramatically (while continuing on Metformin), but not below 60mg/dl, and without hypoglycemia. Essential glucose was provided by glycerol backbone when triglycerides from body fat break down to free fatty acids and from gluconeogenesis when dietary protein breaks down to amino acids. FBG average dropped from 119mg/dl to 81mg/dl (10-week aver). A1c dropped from 5.8% to 5.3%. Total Cholesterol: 201mg/dl; HDL: 74; LDL: 114; TG: 67.
Week 6: Lost 0 lbs. Annoying. I thought I might be in trouble when after my first day of fasting this week I had lost only 1 lb and my FGB was 83. The week before my FBG was 61. I also ate out on Friday (3/17), and while lunch was VLC, supper was 3 Ultras and ad lib peanuts. So, Saturday’s FBG was 107 and my weekly average bumped up to 79 (4.3mmol/L). Still, not bad.
Week 7: Due to the less-than-desired results in Week 6, I decided to try a 3-consecutive-day fast this week (Tue-Wed-Thu). I’m never hungry on fast days, so I thought it would be easy…and it was. No hunger, even on Friday morning. I could have kept it up for longer, easily. I had lots of energy and low but consistent fasting blood sugars (60s & 70s), average 71 mg/dl, and I lost 2 pounds. It was successful so I decided to repeat the 3-day fast the next week.
Week 8: Once again, the 3-day fast was easy. No hunger. Very little thinking about food. When I wasn’t busy with projects, or needed to rest from pushing hard all day, I sat down and read for half an hour. This week I ended the fast with a seminar in NYC that included a talk by Gary Taubes and lunch. I had the salad (with candied walnuts!), a piece of chicken and a spinach side. For supper, I had a petite filet, broccoli rabe side, and a cocktail. FBG this morning was 87! That raised my weekly average to 74mg/dl. I also lost 5 pounds, making my 8-week loss 25.
Week 9: All good things, as they say…slow down. My weight loss continued, but just 1lb, to 26. My FBG average jumped 15 points, to 89mg/dl (range 74 to 101). Explanation (excuse): I spent most of the week in Florida and on the road. It’s hard to stay on track with so many diversions. I cheated. “No dessert,” I said at the Charleston Grill, but then without thinking ate the offered petit fours. Etc. So, with only 8 days remaining in my 10-week, 30-pound challenge, I will need to employ “the nuclear option” again this week: a 3-consecutive-day fast; still 4 pounds to go.
Week 10: It worked, for the 3rd time. I lost 5 pounds, bringing my 10-week weight loss to 31. And my FBG average was 80mg/dl (4.4mmol/L) – higher than expected, due no doubt to the adjustment period the body needs to down regulate from the previous week’s excesses. The 3-day consecutive fast, I discovered, is just as easy as, and more effective than, the Tuesday-Thursday alternate day fast. You just need to be keto-adapted to avoid hunger.
Discussion: As the reader can see, this was a far-from-perfect experiment. It was “real world,” yet the result fully achieved the primary and secondary goals (weight loss and blood sugar control).
Conclusion: If you eat VLC (just 15-30 grams of carbs/day), and you are thus keto-adapted, and you reach a weight loss plateau, you can effectively employ full-day fasting (alternate day or consecutive day) to restart weight loss in a healthy way. I did and I lost 31 pounds in 10 weeks while achieving greatly improved blood glucose control.

Thursday, February 27, 2020

Retrospective #376: “I have gone off carbohydrates almost entirely.”

A couple of days ago (Retrospective #374), I told you the story of a man I met only once, and then only briefly, at a New Year’s Eve party. I was, no doubt, “juiced”, and probably rattled on a bit about my Way of Eating (WOE). I related how I had lost a lot of weight, and otherwise greatly improved my general health, on a Very Low Carb (VLC) diet. I then apparently gave him a card for my website, I honestly expected nothing to come of it.
A few weeks later he emailed me, “I have gone off carbohydrates almost entirely…and lost 10 pounds.” I replied congratulating him on his success and his motivation. I asked, “What was the trigger for you?” He said, “My doctor had me tested for diabetes and suggested I might be pre-diabetic – hence the urgency for weight loss.” I asked, “Why Very Low Carb?” He had doubts, he said, but, “I am hoping I will do myself more good than harm.”
In terms of mental reservation, given the fat phobia most people have learned from bad government guidelines, and from the medical establishment and the media, that was a fair place for him to be; notwithstanding that, however, my casual acquaintance took the next step. In his words, he foreswore “carbohydrates almost entirely.”
I was thrilled for him and pleased that I had at least been a catalyst. It was just serendipity that I had been there (sort of) at that moment to help him point the gun at the right target, CARBOHYDRATES, before pulling the trigger.
My “new friend” had the 3 keys: 1) the motivation, 2) the courage, and 3) the pertinacity to stay with it. All three are critical, but the “catalyst” for him was my bibulous rant on New Year’s Eve. So, what’s your “trigger”?
In my case, way back in 1986, I was diagnosed a Type 2 diabetic. In 2002, 16 years later, I till eating a “balanced” (55-60% carbohydrate) diet as I had been for my whole life. And I had recently gained enough weight that I was too fat to weigh in in the doctor’s office. So, before my next appointment I went to a fish market and stepped on a commercial scale and “discovered” I was 375 pounds! I was shocked. That was my motivation. Then serendipity stepped in for me.
As I opened the door to my doctor’s waiting room, he was standing at the nurse’s station and said, “Dan, have I got a diet for you!!!” Turns out, six weeks earlier my doctor had read the New York Times Sunday magazine cover story: “What If It's All Been a Big Fat Lie,” by award-winning science writer Gary Taubes. He tried the diet Taubes promoted. Lost 17 pounds in 6 weeks, and liked the effect it had on his lipid profile. So, he suggested that I try it too, and I did.
The third factor, your firmness of purpose, or dogged determination, may seem to the uninitiated (or the misled) to be the hardest of the three, but it’s not. After just a few days of adjustment, while you use up the stored glycogen energy in your liver, or immediately if you’re already keto-adapted, you become accustomed to eating mostly protein and fat. You no longer crave carbs because your blood insulin level has dropped enough to allow access to your body’s fat stores. Your body then breaks down that fat when the calories you eat aren’t enough to maintain energy balance.
But your body can’t do this 1) if you eat enough carbs to raise your blood insulin level and/or 2) you eat more food than you need to maintain energy balance. But you won’t, if you listen to your hunger signals, because WHEN YOUR BODY IS BURNING ITS OWN BODY FAT, YOU ARE NOT HUNGRY. Your body is feeding on its own fat stores, so it doesn’t tell you, “I’m hungry. You must feed me with food-by-mouth.” That’s what makes this easy. You won’t be hungry (after I period of adjustment) because your body is content to feed on its own fat stores. And it makes sufficient essential glucose from amino acids (from digested protein) and from the glycerol molecule freed up when body fat (triglycerides) break down. And in the process, it will make ketone bodies, which your brain will love.
So, what’s happening with my “new friend” who lost 40 pounds in two months after “going off carbohydrates almost entirely”? I don’t know, but if he sticks to a Very Low Carbohydrate eating plan, both he and his doctor will be very happy – he a lot healthier and happy with the weight loss and his doctor with that and all his improved lab tests, including his cholesterol panel.  Yours will be too. All you need now is that “trigger.” What will it be for you?

Wednesday, February 26, 2020

Retrospective #375: A New Year’s Eve Conversation, Part 2 of 2

This column and the previous one, from 2017, like every column in the Retrospective series, were originally published weekly. In the Retrospective series they have been edited for size, format and content and are being published daily.
Part 1 of this 2-part series (Retrospective #374) relates how “Bruce” lost weight easily by “going off carbohydrates almost entirely” for two weeks. I met Bruce casually at a New Year’s Eve party and gave him one of my cards. He decided to check out my website, and then to try Very Low Carb (VLC) eating. In our earlier conversation that evening, Bruce told me that he had lost 10 pounds. Our conversation continues here:
Dateline: January 14th (still later the previous evening)
You’re welcome, Bruce. Weight loss was my original motivation (in 2002) for eating VLC because, like yours, my doctor thought that being overweight was a cause of T2DMThey were both wrong, as Gary Taubes and many other experts in physiology and medicine have now exhaustively and conclusively proved. See my Retrospective #5 or Gary Taubes's "Alternative Hypothesis" in "Good Calories-Bad Calories" (2008), a heavy but solid, evidence-based read.
An easier read would be, "What If It's All Been a Big Fat Lie," the New York Times Sunday magazine cover story of July 7, 2002. Google it. My doctor read it, tried the diet himself, and recommended it to me. That's when I got interested in low carb for weight loss. And, incidentally, it started the modern revolution in dietary science that so much of the orthodox profession still continues to dismiss. That's why Taubes, who won the National Science Writers’ Association award 3 times, wrote GC-BC. Sadly, he was to be disappointed by the medical community’s response to his book. 
INSULIN RESISTANCE IS THE CAUSE OF T2DM. IT IS ALSO THE CAUSE OF OBESITY, NOT THE OTHER WAY AROUND.  Insulin is the transporter of glucose in the bloodstream, and so long as there is enough glucose (from carbs) circulating in the blood, insulin levels remains elevated and blocks the alternative fuel, body fat, from breaking down to fatty acids to maintain energy balance. The body saves this fat, a more dense source of energy (9kcal/g vs.4 kcal/g for carbs and protein), for long fasts, including famine and winters (from a Paleolithic/historical perspective).
My current focus in this column is on "Pre-Diabetics," newly diagnosed Type 2s, and those who, like you, have been told they "might be Pre-Diabetic." The medical societies have been very slow to revise standards for diagnosis, but they have been doing it. They just haven't gone nearly far enough. There are many clinicians today who have, however, and many who just may classify you unambiguously as Pre-Diabetic, or even a frank, incipient Type 2 diabetic.
I hope you have a baseline A1c on a recent lab test, because it you stay on your VLC Way of Eating, you will see it drop, perhaps significantly, and perhaps even out of the range of Pre-Diabetic to below 5.7%. That should be your goal.
I also hope you have a baseline metabolic panel or at least a lipid (cholesterol) panel with which to compare your next lab tests. After doing this Way of Eating for awhile, my HDL more than doubled from 39mg/dl to 84mg/dl (comparing 15 average tests for both). And my triglycerides plummeted by two-thirds (from around 150mg/dl average to below 50 average. Both values have stayed there for many years now. My latest cholesterol test: TC 184; HDL 91; LDL 84; TG 46.
BTW, after one day of eating Very Low Carb, I had a hypo and called my doctor. He told me stop taking one diabetic oral med. Later that week he cut the other two in half TWICE, later eliminating one. Now I just take 500mg Metformin.
Dateline: February 29th (6 weeks later)
I emailed Bruce to invite him to another party, our annual Mid-Winter Wing-Ding. He replied:
Hi Dan,
Thanks much for the invitation, but I am in Jensen Beach for January only.
LOST 40 POUNDS [my emphasis] and am taking One-a-Day “Silver” daily.

Tuesday, February 25, 2020

Retrospective #374: A New Year’s Eve Conversation, Part 1 of 2

This column (and the next), from 2017, like every column in the Retrospective series, were originally published weekly. In the Retrospective series they have been edited for size and content and are being published daily.

It all started at a New Year’s Eve party after a New Year’s Eve dinner party. I was pretty well juiced by that point.
Email in my inbox dated January 14th:
Hi Dan,
I met you in the community room [at the] New Years Eve [party]. [We talked)], and [I] was inspired to try to lose weight. Since New Year’s I have gone off carbohydrates almost entirely [my emphasis]. I have lost about 10 pounds to date, but I understand the first 10 pounds are inconsequential. Anyway, this diet naturally has a higher ratio of fat than my previous diet/non-diet. I have been reading your blog at I am hoping I will do myself more good than harm on this diet. Any tips for the beginner?
My reply later that evening:
Hi Bruce,
First of all: Congratulations! 1) on your being motivated and acting on that motivation, and 2) on your actual success. It's true that the first 10 pounds are the quickest to lose, although not necessarily the easiest.
Some people experience hunger (which seems to go away after a couple of days as the glycogen stores in the liver and muscle are used up and you transition to burning fat (breaking down body fat, i.e., triglycerides, into fatty acids and using them for energy and ketones for brain food.). Also, some people feel weakness, which is addressed by making sure you get extra salt (seriously) to compensate for the loss of salt/water weight (half of those 1st 10 pounds).
Depending on how much you eat, and how much you have to lose, you should be able to lose at least 2 pounds a week going forward. At one point (almost 10 years ago), eating 3 meals a day, very low carb, I lost 100 pounds in 50 weeks. 
Thanks for reading my blog. I post every Sunday (at Please keep me posted on your progress, and feel free to ask questions. I'd be happy to connect you to other resources including an on-line forum for Type 2s. Are you, btw, a Type 2, or Pre-Diabetic, or have you been told you have Metabolic Syndrome?
Dan Brown
His reply, still later that evening
Hi Dan,
Thanks for getting back and thanks for the encouragement. My conversation with you on New Year’s Eve inspired me to get started and that I would have a possibility of success. To answer your questions, my doctor had me tested for diabetes and suggested I might be pre-diabetic – hence the urgency for weight loss.
Well, this answer from Bruce put him perfectly in the crosshairs of my new target audience: Pre-Diabetics and those whose doctors have told them, “You might be Pre-Diabetic” or “We’ll have to watch those blood sugars.” At that point they tell you to lose weight (knowing you’ll most likely fail on the dietary advice they give (eat a calorie-restricted, low-saturated fat diet and exercise your ass off). At that point, they’ll start you on a regimen of pills leading, as your disease inevitably progresses on that diet, to injecting insulin).  
Realizing this, I was motivated to elaborate – unsolicited – on my previous reply. Later that evening I wrote to Bruce again, and that message, and his amazing reply to me (six weeks later), will be the subject of my next column. I can hardly wait to tell you! (Spoiler alert: Bruce continued to lose weight, big time!)

Monday, February 24, 2020

Retrospective #373: The “blame the patient” game

When your doctor writes in your file, “patient non-compliant,” let me be clear: I don’t really think that he or she, who is perhaps an internist/cardiologist (like mine) or maybe a family care doctor, is being disingenuous They almost certainly, or for the most part, believe in the advice they have given you. They advised you how to lose weight (exercise more and eat less, of a calorie-restricted balanced diet), they believed you could lose weight.  And when you failed to get the results they expected, eating this a “healthy low-fat diet” (avoiding saturated fat), they concluded it was because you didn’t follow their counsel. So, they deduce, you must have cheated! You were “non-compliant!”
Why do your doctor expect this result? Because the Clinical Practice Guidelines for each of the practice specialties, and the governing medical associations (the AMA, AHA, ADA, etc.), all told them to. That is the result of virtually all of the patient cohorts who were given this advice before you received it. So, the explanation – the reason – must be that it was the patient who failed to follow it…the patient who was non-compliant. That, by the way, is also when the Clinical Practice guidelines tell them to start you on drugs to accomplish what YOU failed to do.
It never occurs to your doctor that it could be the advice they gave you that failed to produce the outcome they (and you) desired. The advice to eat a low saturated fat, low cholesterol diet has now been in place for over half a century – since the time any doctor in practice today went to medical school. The advice was first popularized by the publicity given to the treatment of former President Dwight D. Eisenhower after his first heart attack in 1955. Before he died 14 years later, he was to have 7 myocardial infarctions, 14 cardiac arrests, and at least 1 stroke, but never mind….
The advice to eat a low saturated fat, low cholesterol diet was also strongly espoused by a University of Wisconsin physiologist, Ancel Keys. The bad science, publicized in his “Six Country Analysis” (1955), and later compounded in his “Seven Countries Study” (1958), has since been widely discredited, but never mind….
By January 1961, Keys was on the cover of the then popular Time magazine and had joined the Board of The American Heart Association. And to this day the AHA and the AMA and the ADA still espouses a low saturated fat, low cholesterol diet. The evidence that this advice is faulty – in fact, that it is the virtual opposite of the heart-healthy diet that you should be eating – has existed from “the beginning,” according to a timeline from Diet Heart Publishing.
The evidence supporting a healthy diet has now been well documented in the last 20 years, starting with Gary Taubes’s, 2002 New York Times Sunday Magazine cover story, “What If It’s All Been a Big Fat Lie.” It was followed by three seminal books: 1) Gary Taubes’s “Good-Calories, Bad-Calories”; Nina Teicholz’s, “The Big Fat Surprise”; and Gary Taubes’s, “The Case Against Sugar.” There are many, many others, but these three are among the best.
What got me going on this minor rant was an article in Medscape Medical News in 2017 that described the efforts of scientists to “reprogram” alpha cells in the pancreas to regenerate new beta cells in mice. These are the cells that make insulin until, as in Type 1 diabetes, they are destroyed by an autoimmune disorder. Or they just wear out from overuse due to Insulin Resistance, as in Type 2 diabetes.
What set me off in this article was the suggestion that an artificial pancreas or similar advance “may enable tight glycemic control with minimal patient intervention” (my emphasis). That would be great news for Type 1s, but from my perspective (as a long-term Type 2) it just reinforces the notion that “minimal PATIENT intervention” was the only course of treatment available for Type 2s in the clinical setting, SINCE PATIENTS ARE “NON-COMPLIANT” AND FAIL TO ACHIEVE THE DESIRED OUTCOMES WHEN THEY FOLLOW DOCTOR’S ADVICE. THUS, THE PATIENT IS TO BLAME!
But what if you, the patient, took control of your diet and your metabolic health, and ate a healthy, very low carb, moderate protein, high fat diet, including heart healthy saturated fat, without concern for dietary cholesterol? What if you did this and the outcome was a big weight loss and a lab report with a greatly improved cholesterol panel?
 Or, you could just follow the dietary advice given to President Eisenhower in 1955. Remember that outcome?

Sunday, February 23, 2020

Retrospective #372: My 10-week, 30-lb challenge, 5th week’s Progress Report

Note: This “Retrospective” was originally written in early 2017 and reports of an alternate-day fasting experiment I undertook with the goal of losing 20 pounds in 2 months. This week I upped the stakes. Read on to see how.
I’ve changed the title of the “2-month, 20-pound” Challenge to a “10-Week, 30-Pound” Challenge. The reason is that it quickly became clear to me that I was going to over achieve my goal. This is the new mid-point report.
Another reason is that I have a doctor’s appointment coming up in Week 11, and I wanted to capture both the best A1c and weight loss improvement possible. The challenges will be that, for a large part of the final 2½ weeks, the unique circumstances that gave rise to my beginning this gambit will change: 1) I will not be alone and preparing all my own meals, and 2) I will at times be “on the road” and eating most of my meals in restaurants.
That being said, the necessary adjustments will be good for me. They will allow me to transition to “real life” while at the same time being under the gun to preserve continue the gains. (See how easy it is to undercut one’s confidence and resolve?) Reference: for the Challenge, see Retrospective #368, for the 1st week’s Progress Report, see Retrospective #370, and for the 2nd week’s, see Retrospective #371. Now, back to the new mid-point Progress Report
Week 3: Having gained 1 pound in Week 2 (after losing 11 in Week 1), I was confident the “progress…was not really lost,” and “it [the progress] will show up on the scale this coming week.” Well, I lost 4 pounds in Week 3.
Better yet, my Fasting Blood Glucose (FGB) average dropped again, from 88 (3.8mmol/L) to 86mg/dl (3.7mmol/L). The actual readings were 81, 104, 90, 78, 84, 83 & 79. The 104 was a surprise. It came after a supper of veal kidneys cooked in onions and mushrooms with Marsala wine and a salad of Romaine lettuce, mushrooms, hazel nuts, shredded cheese and my homemade vinaigrette made with white wine vinegar. Go figure! Tonight, I’m having the 2nd half of that kidney dish, with another salad, so we’ll see what happens.
Changes in Week 3: Going forward I’m going to cut my morning coffee from a 16oz mug to a 12oz mug. That should reduce the heavy cream from 2oz to 1½oz. I found that I had swallowed all my supplements with only half a cup and the 2nd half of the cup was just an indulgence. The idea came to me after reading a blogger who was looking for people to join him in a 30-day coffee fast. I like coffee, but I am not addicted to it, and I don’t want to be.
Week 4: Well, it wasn’t the veal kidney and salad supper that gave me that anomalous 104mg/dl FBG (5.8mmol/L) last week. The same supper the 2nd time produced a FBG of 74mg/dl (4.1mmol/L) this morning. Conclusion: anomalies happen. Now, once again, THE BIG NEWS THIS WEEK: MY FBG AVERAGE PLUMMETED AGAIN, FROM 86MG/DL (4.8MMOL/L) TO 77 (4.3). I HAVEN’T SEEN FBGS LIKE THIS EVER! True, on my own initiative, but with the concurrence of my doctor, about a year ago I increased my dose of Metformin from 500mg/day to 1,500. I had read somewhere that 1,500mg was considered a “therapeutic” dose. The inference I drew from that was that a dose of less than 1,500 was not therapeutic. And since I have been a diagnosed type 2 for 30 years, and on a reduced dose of 500mg for the last 15 since beginning VLC, it seemed appropriate to me that my medication should be therapeutic. But I think my doctor never suggested an increase because he thinks my diabetes is already “in good control.” I’m not blaming him. That’s the guidance he gets from the ADA, Medicare, etc.
Week 5: I’m settling into a groove. MY WEIGHT DROPPED BY ANOTHER 2 POUNDS IN WEEK 5, BRINGING THE 5-WEEK TOTAL TO 18 POUNDS. And my weekly average FBG continues to drop. This week I had 3 readings in the low 60s, and MY FGB AVERAGE THIS WEEK DROPPED TO 70 MG/DL (3.9 MMOL/L). Recapping my weekly FBG averages: 119 before starting, then 100, 88, 86, 77 and now 70. I hope they level off now. If not, I’ll cut the Metformin. My goal, though, is a lower A1c, so I am willing to have “low” readings so long as I feel I am in no danger of hypoglycemia.
Conclusion: I can’t believe that I have been so blind in my diabetes self-management for these last 15 years!

Saturday, February 22, 2020

Retrospective #371: My 2-Month, 20-lb Challenge, 2nd week's Progress Report

Note: This “Retrospective” was originally written in early 2017 and reports of an alternate-day fasting experiment I undertook with the goal of losing 20 pounds in 2 months. The early results are quite remarkable. Read on to see how.
When you read this post, I will be 5 weeks into my “2-month, 20-pound challenge,” but I write it after 2 weeks “in.”  The first week I lost 11 pounds and lowered my FBG average by 19 points to 100mg/dl (5.6mmol/L). I did this by strictly following a program of eating 5 Low Carb meals prepared at home by me (2 or more at a time) and then fasting on Tuesdays and Thursdays. Note that in the first week I did not dine out once, as planned.
This week I report on week 2 of the challenge. Based on my FBGs this week, I have also revised the terms, to extend the duration from 8 weeks to 10½ weeks, to coincide with my next doctor’s appointment (4/18). My goal is to get the best A1c possible, lowering it from 5.8% to 5.5%, hopefully lower.  Note, however, that after 8½ weeks I will no longer be preparing my own meals, and my eating pattern will include more “dining out.”
Week 2 began uneventfully, with weight stable and FBGs in the mid-nineties. As the week progressed, my weight and fasting blood glucose (FBG) both dropped until I was down 3 pounds by Friday. I gained one back Saturday and 3 more by Sunday. So, my net for the week was up 1 pound; net for 2 weeks: down 10 pounds.
Saturday was the first day that I ate “out” in almost 2 weeks, and I ate too much (2 meals – albeit “low-carb”), and I drank too much. I don’t regard the 1 lb. gain as much of a setback, though. The progress I made during the week was not really lost. I am confident that it will show up on the scale this coming week.
The big news, and the main reason I am reporting this week, is what happened to my FBG (and presumably my serum insulin). MY FBGS THIS WEEK WERE: 94, 92, 95, 89, 81, 80 & 83. AVERAGE: 88MG/DL (4.9MMOL/L). Recall that in the 1st week my average was 100mg/dl (5.6mmol/L) and in the week before I began the challenge it was 119mg/dl (6.6mmol/L). With FBGs like this week’s, and a stable blood sugar during the day, I think my A1c goal is reachable – if I continue to follow this Very Low Carb Way of Eating…and with a little help from 500mg of Metformin. We’ll see.
Other observations, comments and changes from the original “2-month, 20-pound” challenge:
     Cooking for myself has not been as onerous as I thought it would be. In fact, I’m enjoying it. In the weeks ahead I envision preparing all my meals at home. Since I always make enough for 2 days minimum, that means only cooking 2 or 3 meals a week, since I will be fasting 2 days (at least) every week.
     All day fasting is easy. The first week on the day after a full-day fast I had a “snack” (1H-B egg) or a “light lunch” (2 H-B eggs). This week I did not. And I was not hungry on the fasting day or the day after.
     The quart of heavy cream lasted only 16-17 days. I use it only in coffee, so, alas, I put 2oz/day in my cup.
     I have a new Snack: a few “whole artichoke hearts in water,” and a Light Lunch: ½ can (60g) of “Sell’s Liver Pate.” Also, Bumble Bee is now packing the same wild caught Brisling Sardines as the King Oscar brand, in the same Baltic Sea factory, in EVOO (and Hot Jalapeno Peppers), and at a lower price point. 
     Virtually all my cooked suppers are stove top. I love fish, especially cod and similar species. It’s usually the least costly “wild caught” fish in the case, although it may have been flash-frozen at sea, then thawed by the fishmonger at point of sale. I’m going to check out frozen cod next time I see it. I’m fussy about country of origin.
     My veal supplier has given up, so I need to find a new source for my veal stew and veal kidney recipes.
     I loved the tripe dish I made last weekend. The smallest frozen honeycomb tripe package in the butcher’s case was 2 pounds, so I made it and had it 4 days in a row. I don’t mind eating the same thing multiple days in a row; in fact, if I like a dish I made, I look forward to having it again. (I can’t believe Jason Fung in his “Fructose 3” blog post this week said he couldn’t imagine someone eating tripe 2 days in a row. Jeez!)
The next report will catch up with the lag in reporting; it will be at mid-point (5 weeks into) my new, extended 10½-week challenge. Then, the last report (at 10½ weeks) will have a final weigh-in, and hopefully an A1c and lipid panel. My doctor is very good at reviewing the lab report and mailing it to me the same day his office receives them.

Friday, February 21, 2020

Retrospective #370: My 2-Month, 20-lb Challenge, 1st week’s Progress Report

Note: This “Retrospective” was originally written in early 2017 and reports of an alternate-day fasting experiment I undertook then with the goal of losing 20 pounds in 2 months. As you will see, it was quite remarkable. Read on to see how.

“As you read this, I will be 4 weeks into my 2-month, 20-pound challenge, but I write this after only 1 week “in.” If you don’t know what prompted me to do this, read Retrospective #368 to learn my motivation and other particulars.
The short report: IN THE 1ST WEEK I LOST 11 POUNDS AND LOWERED MY FBG AVERAGE BY 19 POINTS TO 100MG/DL. If you’re overweight (as I am) and prediabetic or a 30-year diagnosed type 2 (as I am), even though theoretically my type 2 diabetes is “in remission,” and that outcome doesn’t pique your interest, you may as well stop reading.
The “challenge” is to stay on my current eating pattern 5 days a week and to fast on the other two. My current eating pattern is coffee with pure stevia powder and a slug of 36% full whipping cream in the morning. Then, only if I am hungry during the day, to eat either a light lunch (smoked herring in brine), a “big” lunch (a small can of brisling sardines in EVOO), or a snack (H-B egg). My main meal (supper) is a stove-top preparation of cod with vegetables or a veal stew. Alternatively, I occasionally make tripe in salsa roja or veal kidney with mushrooms, onions and Marsala.
This week I had cod with tomatoes, green olives and red pepper flakes Sunday and Monday. Then, I bought 2 pounds of tripe and made 4 suppers: Wednesday, Friday, Saturday and Sunday. I fasted on Tuesday and Thursday. On fasting days, besides morning coffee, I had 1 red wine spritzer at “happy” hour; on “feasting” days I had 2 red wine spritzers.
Next week (M, W) I will do different cod preparations (fennel and/or celery in chicken broth). I’ll also make a romaine salad with mushrooms, hazel nut pieces and shaved Pecorino Romano, with my homemade vinaigrette dressing.
During the last week I ate a light lunch (2 H-B eggs) the day after the 1st fast day and a snack (1 H-B egg) after the 2nd fast day. Saturday, I had a small can of pork liver pâté for lunch. There was no other need or occasion to have “lunch” or to snack during the day or after supper all week. Saturday night, after attending a jazz concert, I went “off plan” and stopped at a restaurant on the way home (in February in New York) and had 2 stingers in front of a roaring fire.
And that’s all there was to it, folks. Eleven pounds (okay, half or more of that was water), but the pounds just dropped off after each full day of fasting. My body maintained a high metabolic rate (translation: I felt great and had lots of energy and no hunger or cravings). It did this by transitioning from obtaining energy from the food I ate (S, M, W, F, S) to obtaining energy from breaking down and burning body fat on Tuesday and Thursday.
My perennial goal is to maintain my FBG average below 100mg/dl (and maintain it low and steady during the day). I hope thus to reduce my A1c from the current 5.8% to 5.5% or lower, perhaps as low as 5.0%.
My interim weight goal for this 2-month challenge is to get down to 228 (BMI=32). That’s still considered “obese” in the BMI chart. So, I can’t derive too much satisfaction from the first week. I have to persist and be satisfied with a slower pace going forward, spurred on each week by the 2 days each week of my modified form of full-day fasting.
I know that this is entirely reasonable because several years ago I lost 100 pounds in a year (without full-day fasting) by strictly adhering to a Very Low Carb program (30g/d). But the fasting part is not difficult since you don’t experience hunger or cravings. As I read in a tweet this week from @SBakerMD, “Beat cravings and you win.” He’s right, of course. That’s the beauty of a Very Low Carb diet. By the way, Dr. Baker eats an all-meat (grass-fed) diet (“zero carb”).
So, that’s the 1st week’s progress report. I’ll write another next week (2 weeks “in”). I expect progress to slow a lot, but I am hopeful that my FBG average will drop below 100 and that the weight loss will continue apace.
I fully expect to continue to have a stepped-up metabolism, to feel great and have lots of energy…and no hunger, including on fasting days. Because my body is already “fat adapted,” that is burning fat (body or dietary) at its primary fuel. That is why I’m not hungry ever, and why I feel pumped even (especially?) when I’m full-day fasting.

Thursday, February 20, 2020

Retrospective #369: “759 Secrets for Beating Diabetes”

No joke! “759 Secrets for Beating Diabetes” is the actual title of a Reader’s Digest book. I saw it (on deep discount) while passing through the vestibule of my local Barnes and Noble. Of course, since they were published, the “secrets,” whatever they were, are no longer secret – unless, of course, nobody bought the book! That too is possible.
However, 759 is an awful lot of “secrets” to slog through to learn how to “beat diabetes.” And how would you decide which of 759 “secrets” to try? No one could try them all! Maybe that’s the reason the book didn’t sell well.
To tell you the truth, the book did not pique my interest. I’m just assuming an editor had the idea to amplify on one aspect of the frequently heard advice that “beating diabetes” requires LIFESTYLE CHANGE. And lifestyles are multi-factorial. But 759 factors?
Maybe the editor read somewhere that, since a “CALORIE IN = CALORIE OUT,” the way to beat diabetes was to “MOVE MORE AND EAT LESS” or “DIET AND EXERCISE” or “EAT HEALTHY.” These are all familiar, if erroneous, memes, and all lacking in specificity. So, the editor thinks, let’s tell the folks 759 lifestyle changes! Let the reader pick and choose.
Hey, I lost 170 pounds by just eating, strictly, VERY LOW CARB (VLC). I lost the first 60 on Atkins Induction (20 grams of carbs a day). Then, after a few years of maintaining that loss, I gained 12 pounds back over a summer. So, having just read about Bernstein’s 6-12-12 program, in 50 weeks I lost another 100, and then another 20 pounds later. Bernstein’s program is 30 carb grams a day. Today, 18 years later, at 225 pounds, I am still 150 pounds lighter than when I began.
Back in 2002 when I started to eat Very Low Carb, to avoid hypos in the first week I had to stop taking most of my oral antidiabetic medications. I was maxed out on two and had just started a third. Today, I only take a low dose of Metformin. Along the way my HDL doubled, my triglycerides dropped by 2/3rds and my blood pressure improved on fewer BP meds. My chronic systemic inflammation marker (hsCRP) is <1.0. My A1c’s are consistently in the low 5s.
And the (other) good news is: I’m never hungry or tired. Eating Very Low Carb means my metabolism operates at a high level because, after my body digests the carbs I eat, to maintain energy balance (“homeostasis”), my body transitions to the “fasting” state from the “fed” state and starts breaking down and burning fat that is stored on my body. It can do this because, even though as a type 2 diabetic I do have insulin resistance (IR), my serum INSULIN levels remain low because my serum GLUCOSE levels remain low -- because I eat VERY LOW CARB!
This enables my body to access body fat for energy without slowing down my metabolism. Body fat is stored as triglycerides. A triglyceride molecule breaks down to 3 fatty acid molecules (the main energy source of body fat), plus a glycerol molecule “backbone” which combines with another to make glucose (via gluconeogenesis), and as a by-product, a ketone body. That is why Very Low Carb is called a ketogenic diet. The brain and heart love ketones. I always feel pumped when my body is keto-adapted. I’m at my best. I have all the energy needed “to hunt.”
Imagine this. If our “natural” diet was 55% to 60% carbohydrates, as our government tells us it should be, and we ran out of carbs to eat, for glucose, and couldn’t access fatty acids from our fat stores because of an elevated serum insulin (especially a chronically elevated serum insulin due to “Insulin Resistance”), we’d run out of fuel. Our body’s only fuel sources are glucose (from carbs) or fatty acids (from triglycerides), period.
Our metabolism would then slow down. We’d be sluggish and sleepy and hungry all the time. How then would we be able to hunt in this condition? Not being lean. Without using fatty acids and ketones for fuel? Eating Low Carb is how our forebears survived. They had to be functioning at their best to “bring home the bacon” (to hunt). Think about it.

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!