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The table on the left displays my HDL cholesterol for the last 32 years. Okay, I’m a compulsive record keeper, but sometimes that’s a good thing. Anyhow, talk (i.e. advice) is cheap; but lab reports are evidence, and mine are worth taking a look at. There is definitely a ‘takeaway.’
I was 39 years old when I first had an HDL test in 1980. My HDL was 42, just above the border line “bad” of ≤ 40. Eleven years later (on my 50th birthday) my HDL was just 41. Of the first 10 HDLs (blue) recorded, 7 out of 10 were under 40, and the average and mean were both 39. Not good. This is the time in my life when I ruined my metabolism, or rather, by this time I had already ruined it. I was diagnosed a Type 2 in 1986 (using the OLD criteria)!
For the next 16 years I went on eating as before, gaining weight and taking more and more diabetes meds. Before I started on Atkins in September 2002, my baseline HDL was 48. My doctor, an internist/cardiologist, had departed from “the standard of practice” by recommending Atkins. But everything else he had asked me to try in my repeated attempts to lose weight had failed. Because I was a heavily medicated Type 2 diabetic when I started Atkins, he decided to see me every month for the first year. My average HDL for the next 12 months (yellow) was 47. Atkins had no benefit on my HDL. It did, however, have a marked benefit on my weight and blood sugar control. During the first nine months of that year, all on Atkins Induction (20g of carbohydrate a day) I lost 60 pounds and stopped or reduced virtually all of the 3 oral diabetes medications that I had used in ever larger doses over the years.
For the next three years I coasted along, counting carbs and maintaining my weight until the summer of 2006. I regained 12 pounds. It must have been those midnight raids on the freezer. Anyway, after lurking on Dr. Bernstein’s Diabetes Forum and reading his books, I recommitted to losing weight on his Way of Eating. Over the next year I again ate just 20 grams of carbs a day, and I lost 100 pounds. I also got off the last 5mg of micronase (a sulfonylurea), my HDL shot up to 86 and my blood pressure plunged to 110/70 (with no medication changes). My HDL average was 63 (green) for this time period. In the following year I lost another 20 plus pounds, and for the next 2 years my HDLs were all in the 70’s, 80’s and 90’s including a 98.
The rolling average of the last 10 HDL lab reports (red) is now 81. Still, over the last 10 years my HDL average (oldest 10 vs. most recent 10) went from 39 to 81, more than doubling. That’s the hard evidence. My diet is 5% carbohydrate, 25% protein, and 70% fat, including saturated.
Last year, my doctor (who reads this blog looking for tips and “practice pearls” – just kidding doc -- suggested, “Foods that Raise HDL” as a topic for this blog. I thought that was a great idea, so I wrote a column about it (#34) last January. It didn’t occur to me at the time that my doc was curious about the dramatic improvement in my HDL and perhaps looking for a way to improve his own. No kidding, doc. Was it?
The problem is I don’t know what foods raise HDL. So, my answer to the question “What foods raise HDL?” is A VERY LOW CARBOHYDRATE diet – and I mean VERY low carbohydrate (see above). It is this Way of Eating as a whole that has produced the HDL improvement for me.
One thing for sure: there is no “magic bullet,” no pharmacological solution to raising HDL the way there is for lowering LDL. You can’t just write a script to raise HDL, the way you can to lower LDL with a statin. You have to do it by choosing the foods you eat, VERY carefully.
But that’s okay with me. I think individuals (including patients) should take control of their own health. Eat right, avoid as many carbs as possible, and be healthy again. It’s possible, as the evidence in the chart on the left demonstrates. It’s all in your hands now, folks. Just do it!
© Dan Brown 9/23/12
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Sunday, September 23, 2012
The Nutrition Debate #67: HDL Cholesterol and the Very Low Carb Diet
Sunday, September 16, 2012
The Nutrition Debate #66: Fasting Glucose Best Predictor of Diabetes Risk (NOT!)
Okay, this is going to be a rant. Sorry, but I am angry at the current state of the medical community and how it seems to me to perpetuate the status quo at the most elemental and, frankly, idiotic level. A recent example is this headline, “Fasting Glucose Best Predictor of Diabetes Risk,” which appeared in an email from diabetesincontrol.com, a website for medical professionals (free subscription).
The report covers Ajay Gupta MD’s (Imperial College London) presentation at the European Society of Cardiology/World Congress of Cardiology last year. The study was milking another one of those large epidemiological studies (a 19,343 patient “trial”) to find “associations” for the occurrence of “new-onset (T2) diabetes.” It also compared outcomes of pharmacological therapies for hypertension, which explains the “study’s” funding.
This report ticked me off in particular because it is targeted to clinicians with a misleading and patently wrong headline. It reminds me of the report recently that eggs were nearly as bad for you as cigarettes. I have read so many authoritative dismissals of this report that I am embarrassed for the Canadian researchers who produced it. Shame on them for such bad science! And of course, the journalists and editors who also misrepresent findings are to blame too.
But, on a positive note, and the reason for writing this column: YOUR FASTING BLOOD GLUCOSE IS NOT THE BEST PREDICTOR OF DIABETES RISK. Anyone who is informed in this field knows that. I do not see the necessity of citing references for authority as I usually do since this is widely known and accepted in the informed community. Fasting blood glucose as a diagnostic tool is an artifact of the last century. But, just for the record, the diagnosis of Type 2 used to be two consecutive fasting blood glucose tests at or above 126 (+/- ten years earlier ≥ 140). More recently the standard of practice came to include a hemoglobin (Hg) A1c test ≥ 6.5 (formerly 7.0). This test is inexpensive and measures the average serum glucose (from markers on red blood cells over their two to three month life cycle).
The best predictors of diabetes risk today are the indications of Metabolic Syndrome (see The Nutrition Debate #9). And the best diagnostic tool for Type 2 diabetes itself is the GTT, the Glucose Tolerance Test. It tells you if you are glucose (carbohydrate) intolerant as a result of developing insulin resistance. This is a relatively expensive and time consuming test, however, because it takes from 2 to 4 hours to administer. In my case, it was done in a hospital out-patient setting.
There is a much easier way, however, to find out if you are glucose intolerant: measure your one-hour and two-hour postprandial (after meal) blood sugar using a glucometer. See how the Low Carb Dietitian, an RD/CDE, discovered herself to be Pre-Diabetic here in my last column (#65). And learn what she is doing to avert developing full-blown T2.
You may have had an A1c test in addition to a fasting blood glucose at your last checkup. You should keep a record of these to see the trend over time; if the A1c has been rising over the years, now is the time to act. Most practitioners, like the Low Carb Dietitian’s, will not be “concerned” if your A1c is rising but not yet approaching 6.5, BUT YOU SHOULD BE as heart attack risk rises steadily above an A1c of 5.5. Some specialists, such as Dr Richard K. Bernstein, consider an A1c of 5.8 to indicate full-blown Type 2 diabetes.
If your A1c test is higher than the normal range of 4.0 to 4.9 (and if your doctor tested it, he probably suspects it is), you will want to test your blood sugar at home and learn to “eat to the meter.” If your blood sugar rises above 140ml/dl after 1 hour or does not drop back to “normal” (in the low 80s) after 2 hours, you are developing insulin resistance and have become glucose intolerant. YOU ARE PRE-DIABETIC and YOU NEED TO CHANGE YOUR DIET to minimize your intake of carbohydrates to control your blood sugar.
As I said, this is not my usual researched and referenced column. I am rushing it out there because there are so many readers who need to be informed that incipient (“new-onset”) diabetes 1) needs to be recognized and diagnosed early and 2) needs to be seen NOT as a problem with fasting blood glucose but as a problem with postprandial glucose. The way our bodies react to what we eat tells us we have a problem. And the best and least expensive way to find that out for yourself is to test your own blood sugar right before eating and again one and two hours after you have eaten a meal. To do this you will need a glucometer and some test strips. You can get both at Walmart, your local drugstore or buying club (Costco and similar places). The “pearl” here is to know that it is NOT your fasting blood glucose that is the best indicator of diabetes risk; it is your postprandial blood glucose (at 1 and 2 hours after a meal).
As the Diabetes in Control headline that is the title of this column indicates, most of the medical community is hopelessly out of date and behind the times. The solution: TAKE CHARGE of your own health, for your own well being. © Dan Brown 9/16/12
Sunday, September 9, 2012
The Nutrition Debate #65: Introducing the Low Carb Dietitian
Browsing on one of my favorite websites, Dr. Bernstein’s Diabetes Forum, I came across a post by a “newbie” who had “discovered” a blog called Low Carb Dietitian. I clicked on it and read 4 posts that persuaded me there is indeed hope for the salvation of our health care community.
Let me share with you my impressions of this Low Carb Dietitian’s transformative experience. Throughout this post I will quote selectively from 2 posts to provide my readers with a brief digest of where she started, how she evolved and where she is today. And while she is still evolving, and there are a few areas where I think she is still encumbered by her training, it is truly an inspirational transformation. I hope she is not embarrassed by this praise, or defensive about where we still disagree. And to be clear, she does have the “benefit” of formal training and the advantage that she educates herself and her clients full time, whereas I am just an amateur of the n = 1 variety.
This Low Carb Dietitian is Franziska Spritzler, RD, CDE. In her own words, on the About Me tab of her web site, she says,
“I've always had a strong belief in the power of good nutrition. After eight years as a court reporter, I became a dietitian because I wanted to help people improve their health by making dietary changes. Once I began working in the outpatient nutrition setting, I quickly developed a passion for diabetes management. As a certified diabetes educator, my goal is to provide accurate, useful information and support people's efforts to optimize their blood glucose control and achieve a healthy weight.”
That’s all well and good, but that’s not where she started. In her very first post on her blog (7/22/11) she explains,
“My purpose in creating this website is to inform people about healthy low carb living. This site contains information that is likely very different from that which can be found on the websites of other dietitians. However, if you'd told me a year ago that I'd be touting the benefits of a low carb lifestyle, I would have probably said you were crazy!”
Before she “saw the light,” she followed standard establishment public health community diet and nutrition advice.
“I'd been eating a very healthy, semi-vegetarian or pescatarian diet (I consumed dairy, eggs, and fish but no poultry or meat) for many years. Because of genetically high cholesterol, I limited my saturated fat intake, always ordering egg white omelets instead of regular, eschewing butter and choosing trans-fat-free margarines instead, and avoiding cheese and cream sauces. I rarely ate desserts, occasionally having just a bite or two of my husband's cake/ice cream/cheesecake, etc., when we were dining out.”
That’s when this person, who had recently attained both RD and CDE credentials, got the bad news.
“So when I received the results from labs that were done for life insurance purposes back in January of this year [2012], I was speechless. Not only was my LDL ("bad") cholesterol elevated, but my fructosamine (a measure of blood sugar levels over a two-to-three-week period of time) was flagged as high, indicating the potential for diabetes. And my hemoglobin A1c (a measure of blood sugar levels over a two-to-three-month period of time), although still within normal range at 5.5%, was still far higher than would be expected for someone my size who ate the way I did. Now, while these numbers were not outrageously high, as one who works with people who have diabetes or prediabetes every day, they certainly suggested to me that something was not right with my blood glucose metabolism [emphasis added]. I purchased a glucometer and began testing after meals, and discovered my blood sugar levels at one hour were significantly higher than they should be. Within the next few weeks, I saw that the more carbohydrates I ate, the higher the number would go. My fasting blood sugar always remained within normal range, however.”
So, since her education and clinical experience had taught her that “something was not right with (her) blood glucose metabolism,” what did she do? In her own words Franziska Spritzler tells us the incredible tale of what happened next.
“I made an appointment with an endocrinologist, who wasn't overly concerned since my fasting levels were so normal. He did want to retest my A1c, and by that point, it had increased slightly to 5.6%. I cut down on the carbs slightly (not too much, though -- I'd been taught that we need enough carbs to keep our brains and other organs working properly), and then I started doing research online about strategies to control postprandial, or post-meal, blood glucose. It seemed that many people were using low carbohydrate diets with great success in managing their diabetes and postprandial blood sugars. I was skeptical, but once I started reading the available research on carbohydrate restriction, it all started to make complete and perfect sense [emphasis added]. I discovered that that the high carbohydrate, low fat diet I'd been taught to believe was ideal was anything but for many people struggling with diabetes, insulin resistance, obesity, and dyslipidemia. This was quite difficult for me to accept at first, but now that I have, I'm quite excited about the potential to help people struggling with these conditions.”
The inescapable conclusion: Not only did those who educated her in nutrition and nutritional counseling fail her, the endo, the medical specialist she consulted about her blood glucose metabolism, failed to recognize or be “overly concerned” because her fasting levels were normal. He failed to recognize her insulin resistance and her impaired glucose tolerance. Franziska had to take charge of her health and treat herself. Fortunately for her, and for the patients she counsels, she now has the knowledge to act and eat to her meter. And that’s the story of this Low Carb Dietitian.
© Dan Brown 9/9/12
Sunday, September 2, 2012
The Nutrition Debate #64: Very Low Carb Eating: Ten Years Later
In August, 2002, I had been a morbidly obese Type 2 Diabetic for 16 years when my physician, who had tried for years (without success) to get me to lose weight on a “balanced” diet, said “Have I got a diet for you!” At 375 pounds I had been taking progressively more and more oral diabetes medications since my diagnosis in 1986. I was maxed out on a sulphonylurea (20 mg micronase), maxed out on Glucophage (2000mg metformin) and had recently started to take Avandia in failed attempts to control my progressively worsening blood sugar. When Avandia didn’t work, I was then (in 2002) going to be left with only one option: become an insulin dependent T2, injecting both basal and mealtime boluses.
It turns out, though, that my doc had recently read Gary Taubes’s July 7, 2002 cover story “What If It’s All Been a Big Fat Lie?” in the New York Times Magazine, and had decided to try the recommended diet for himself. I think it was the New York strip steak pictured on the cover that got him hooked. He’s an internist and cardiologist and had probably been carefully watching his saturated fat and dietary cholesterol intake for years. Anyhow, the Very Low Carb diet advocated in the cover story worked for him, and he thought it might work for me too. And as he walked me down the hall to schedule a follow-up appointment, he said, “It’ll probably be good for your diabetes too.”
Gary Taubes’s 2002 NYT Magazine cover story was a “game changer” in the world of Very Low Carb eating. It reached his target audience: clinicians, or at least mine. Taubes went on to write “Good Calories – Bad Calories” (“The Diet Delusion” in the UK), but he admitted in an Afterwords to the paperback edition that he considered he had failed to reach as many clinicians as he would have liked. Very Low Carb dieting is a tough sell. It is not the “standard of practice,” and the Public Health Establishment in the US and Britain and almost everywhere else (Sweden excepted) has not waivered much from the Lipid Hypothesis popularized by Ancel Keys about 50 years ago.
Taubes’s cover story touts, indeed lauds the principles behind The Atkins Diet, and that is the diet that my doctor had successfully tried himself, at least from a weight loss perspective. He lost 17 pounds. I don’t know if he did a complete blood chemistry and lipid panel on himself or even if he had been on it long enough to make a difference. But, I give my doctor his due for testing it on himself before departing from the “standard of practice” and recommending it to me.
Of course, within a day or two on strict Atkins Induction (20g carbohydrate a day), as a heavily medicated Type 2 diabetic I was experiencing “hypos” (dangerously low blood sugars). I called my doctor and he told me to stop taking the Avandia. The next day, when I was still having hypos, he said to cut the micronase and metformin in half and a few days later to cut them in half again. After that he saw me monthly for a year to monitor my blood and kidneys and other health markers. In the course of that year I further reduced the micronase from 5mg to 2.5 to 1.25mg and finally phased it out completely. I still take 500 metformin with dinner to suppress gluconeogenesis if (when) I eat too much protein.
In the first 9 months on The Atkins Diet I lost 65 pounds. I then retired from work and kept that weight off for several years. Then I slowly added back about 20 pounds (mostly from eating ice cream before bed, as I recall). By this time I had also been participating in an online diabetes forum, Dr. (Richard K.) Bernstein’s Diabetes Forum to learn all that I could about eating Very Low Carb. I had also read Bernstein’s “Diabetes Diet” and the first edition of his “Diabetes Solution,” so I decided to try his program. It is similar to Atkins but a lot more focused than Atkins was on blood sugar control.
On Bernstein I lost 100 pounds in just under a year (50 weeks). Altogether I lost 170 pounds, settling in at 205 pounds. Today, I have regained some of that weight. Frankly I have been “off the ranch” for long awhile, but I am still much healthier than before. I eat very low carb most of the time and have retained most of the health benefits. My average HDL has more than doubled (from +/- 40 to +/- 84) and my triglyceride average has been cut by more than 2/3rds (from +/- 150 to +/- 42). I try to limit my carbs to about 5% of my diet and my protein to 25%, leaving 70% for fat. I do not limit salt, dietary cholesterol or saturated fat. I eat eggs and bacon and coffee with half and half and Splenda for breakfast, and a can of sardines for lunch. For dinner, it’s just meat and a low carb veggie with lots of butter or tossed in olive oil and roasted. In a restaurant I’ll have a drink (or 2) or two glasses of wine. The only dessert I’ll eat is berries (with cream) on a very special occasion. I love a cheese plate, but it’s just too much food. I always regret if I occasionally order it.
© Dan Brown 9/2/12
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