Type 2 Diabetes, a Dietary Disease #312: Isn’t your Very Low Carb WOE…well, extreme?

A person who is neither Pre-Diabetic nor a clinically diagnosed Type 2 invariably asks me, “Isn’t your Very Low Carb (VLC) eating program…extreme?” In a word my answer is, “yes.” I am highly Insulin Resistant (IR); therefore, I am Carbohydrate Intolerant. Carbs are “poison” for me. However, IR is a relative term; it is on a scale measured in percentage; its inverse (1/IR) is Insulin Sensitivity, a measure of how well your cells take up glucose carried in your blood by insulin. And the degree to which you are Insulin Resistant will determine how many carbohydrates you can safely eat. The determining factor for you will be your degree of IR/Carbohydrate Intolerance.

How does the “treatment-naïve” (untreated) patient with a slightly elevated fasting glucose or hemoglobin A1c determine the degree of IR/Carbohydrate Intolerance they have developed? Well, there are laboratory tests, like the IGTT or Impaired Glucose Tolerance Test. Upon my diagnosis 30 years ago, my GP sent me to an Endo who ordered this 2 hour test in a hospital outpatient setting. It confirmed the GP’s preliminary diagnosis: I had T2DM. At the time (1986), the prevailing clinical standard for an office diagnosis of frank Type 2 Diabetes was 2 consecutive visits with a Fasting Blood Glucose (FBG) ≥ 140mg/dl. In 1996 the standard changed to ≥ 126mg/dl.

There’s also the HOMA2 that I once asked an endocrinologist to do for me. He said he had read about in being used in research but had never ordered it. He did though, for me. It included a fasting serum insulin and gave a 2-part result: Insulin Sensitivity (the inverse of IR) and Beta Cell Function. Beta cells make insulin in the pancreas. I had been eating VLC for years, so my result was remarkably good: Beta cell function = 68.2% and Insulin Sensitivity (IS) = 94.6% (IR = 1.057). This supports the hypothesis that eating VLC (and exercise) increase IS, and that the unstressed pancreas of Type 2s can still possibly create new beta cells. I can only imagine how poor my beta cell function would be today, and how high my IR would be, if I were still eating what “the doctor ordered.”

Today, while the Fasting Blood Glucose test is still in common use, the new diagnostic standard is the A1c test. It measures the percentage of glucose on the surface of your red blood cells. Since red blood cells have an average life of about 3 months, this test is a better measure of the rise and fall of your blood sugar 24/7 for a longer time. It also captures the after-meal spikes which are a better measure of Insulin Resistance/Carbohydrate Intolerance than a simple fasting measurement. Both the A1c and fasting glucose lab tests are “convenient” (inexpensive).

But be careful. This is the point I described in Type 2 Diabetes, a Dietary Disease #306. You are at a juncture. If you leave the matter of “what's next?” entirely up to your “treatment team,” including clinician and RD or CDE, after you fail to lose weight following advice to “eat a balanced diet and exercise,” your clinician will treat your symptom (high blood glucose) by prescribing a pill (or pills) to lower your blood sugar. As such, so long as you continue to eat a balanced diet, the cause of your elevated blood sugars will not be addressed, and your disease will progress! The cause is the Insulin Resistance that has resulted in your becoming Carbohydrate Intolerant and Pre-Diabetic or a Type 2.

This errant course of treatment is in part based on the erroneous belief that being overweight or obese caused your Type 2 Diabetes. That’s one reason your doctor wants you to lose weight. But, in fact, the opposite is true. Read Type 2 Diabetes, a Dietary Disease #308 for an explanation of “What Causes Type 2 Diabetes.” Insulin Resistance is the the actual precipitating cause of Type 2 Diabetes, and it causes obesity. Insulin Resistance, for us who are genetically predisposed, is “expressed” through a diet that is composed of excessive carbohydrates.

So, the only course of “treatment” that treats the cause of Pre-Diabetes or Type 2 Diabetes is one that reduces the carbohydrates in your diet. The government sanctioned dietary pattern (reference the HHS/FDA Nutrition Facts Panel: Footnote 5) is 60% (300g) carbs, 10% (50g) protein and 30% (65g) fat (% by calories, not grams). On a 2,000 kcal/day diet, a Low Carb dietary pattern could be 20% carb, 20% protein, 60% fat; that would be 100 grams of carbohydrate a day. This is not so “extreme,” yet it is only 1/3rd what is recommended, and a 2/3rds reduction. Or even say 10% carb (50g/day), 20% protein and 70% fat. Either plan would be a huge improvement and would almost certainly reverse a Pre-Diabetes condition, putting the condition in “remission,” so long as you continued to eat no more than 100g (or 50g) of carbs a day. Remember, IR is on a scale, and everyone’s varies.

Of course, if you’re “healthy” (i.e. not Pre-Diabetic or a Type 2, and not yet genetically “expressed” but a little thick around the middle), you could probably stay healthy, and lose the extra weight, if you ate 40% carbs, 20% protein and 40% fat. That’s 200 carb g/d and still a 1/3rd reduction from the 300g (60% carb) government plan.

Type 2 Diabetes, A Dietary Disease #311: How Can I Manage My Type 2 Diabetes?

Type 2 Diabetes is a Dietary Disease. Your blood sugar (glucose) rises and falls depending on what you eat. It’s that simple. When you eat carbohydrates, there is a direct and simple relationship to your blood sugar level. It goes up. And when you eat more protein than your body needs, there is, to a lesser extent, a secondary and delayed rise in blood sugar. Fat, the third macronutrient, has virtually no effect on blood sugar.

Carbohydrates – including simple sugars and more “complex” carbs, especially those in packaged foods that have been refined to the point where they are close to simple sugars – will have the most impact on your blood sugar. In contrast, unprocessed, whole vegetables, although also carbohydrates, will digest more slowly. However, all carbohydrates – simple, processed or “whole” (unprocessed) – will become glucose “under the curve” (in your blood) within an hour or two of eating. That’s better than a few minutes, but it’s still an elevated blood sugar.

So, for starters, you need to educate yourself about what carbohydrates are and what foods contain them. Do your homework! And you will need to study the Nutrition Facts panel on processed foods, paying attention to the carbohydrate grams. And don’t forget to check the portion size. It is usually much smaller than you will eat.

You will also need to learn what effect carbs have on your blood sugar. Everyone is different, depending on your degree of Insulin Resistance (IR). (To understand the relationship between IR and blood sugar, see “Type 2 Diabetes, a Dietary Disease #308.” As a frame of reference though, if you fasting blood glucose is not between 70 and 100mg/dl, you have a degree of Insulin Resistance. If it is between 100 and 126mg/dl, you are Pre-Diabetic. If your fasting blood glucose is ≥ 126mg/dl, you are, frankly, a Type 2 Diabetic. How do you know what yours is?

You’re thinking that your doctor will test your fasting blood sugar (or A1c) if he or she suspects you have IR or are Pre-diabetic or Diabetic . True, but he/she can only monitor your Type 2 Diabetes. Remember, Type 2 Diabetes is a Dietary Disease, and only you can manage your diabetes. And to do that you need to buy a meter and test.

First you need to test your blood after an overnight fast. And until you know how your blood sugar responds, you should test both before and after “test” meals. To find out how high your blood sugar spikes, test before and then 1 hour after starting to eat. To find out how close to “normal” it returns, test 2 hours after that meal. If your blood sugar doesn’t drop 2 hours postprandial (after eating) to near where you began, you are Pre-Diabetic. If it isn’t below 140mg/dl, you have Type 2 Diabetes and you have eaten too many carbs in that meal. Blood sugar in a “healthy” (non-insulin resistant) person never goes above 140mg/dl even 1 hour after a big carb load.

You will learn quickly what you should eat and what you shouldn’t. Carbs are hidden everywhere, especially in plain sight. Fruit, unfortunately, is just a simple carbohydrate: sugar (sucrose = glucose + fructose) and water. At least the whole fruit contains a little fiber and pectin, but it is otherwise not much different from a candy bar. Fruit juice is worse. Because it’s liquefied, and thus partially predigested, it is several candy bars at once! It will send your blood glucose through the roof. As will all fruit drinks and all other sugar laden soft drinks.

Bread has a glycemic index of 100, meaning it is the very definition of a high glucose food. The ingredients list of virtually all breads begin with flour (highly processed and 100% carbohydrate), then water, and then always sugar in some form. Even the “sprouted” grains in Ezekiel bread are just sugar. Sprouting or malting is just a method of breaking down the complex grains to simpler sugars. Wiki “malt” or “malting” if you don’t believe me.

Protein digests more slowly than carbohydrates, and has many bodily functions before the excess breakdown products of protein, amino acids, are shunted to the liver for storage. There they cannot be reconstituted as protein; however, the liver can make glucose from them. This secondary process, called gluconeogenesis, is a good thing. The body needs multiple ways to make glucose. Glucose is essential (in small amounts), whereas carbohydrates are not. But the liver of Type 2s makes glucose even when the body doesn’t need it. That’s why clinicians prescribe Metformin to Pre-Diabetics and to Type 2s: to suppress this unwanted glucose production.

So, to take charge of your Pre-Diabetes or Type 2 Diabetes, you need to monitor your blood sugar. And to do that, you have to manage what you eat and eat to the meter.  Test your blood sugar before meals and 1 hour after you eat to see your peak (and 2 hours to see how far it falls). It’ll take time to learn what affects your blood sugar level and by how much. How strictly you follow a Low Carbohydrate Way of Eating (WOE) will determine how your blood sugar responds. But you are in charge. Remember: Type 2 Diabetes is, simply, a Dietary Disease. 

Type 2 Diabetes, A Dietary Disease #310: Newly Diagnosed Type 2? What’s Next?

It’s been 30 years (1986) since I was diagnosed a Type 2 Diabetic, so I’ll admit I don’t have a recollection of what happened next. My guess, though, is that what I was told then is not much different from what a newly diagnosed Type 2 or even a Pre-Diabetic is told today. Only the names and classes of drugs have changed.

First, I’m pretty sure I was scared. After all, I was told I had a disease – a life-long disease – and that it would require ongoing treatment. I was also told, I’m sure, that I should lose a lot of weight and that I would have to begin taking medications on a daily basis. That was daunting enough, so I’m pretty sure my doctor didn’t tell me that my Type 2 Diabetes would be progressive, and that one day I would probably die from its complications. But, that’s the way it was then, and sadly still is today, if you follow the medical establishment’s treatment protocol.

Of course, losing weight was my responsibility. Prescribing medications was my doctor’s. He, who like all doctors then and now was lacking in nutrition training, probably offered me some “helpful” advice: “eat less and exercise more.” He probably suggested I follow the one-size-fits-all Nutritional Guidelines for Americans’ “eating pattern” to eat a restricted calorie, balanced diet and do some “regular exercise” for 30 minutes a day, 5 days a week. But my doctor surely knew from long experience with T2 patients that I would fail to lose the weight on that “diet and exercise” program. Not to worry; he had a pad and could write another “script” as my condition worsened. And if this isn’t familiar to you as a new patient, it will be if you stick with the “established treatment guidelines.”

Unfortunately, my doctor was under the mistaken impression that I was obese because I ate too much and didn’t exercise enough. My doctor thought that my obesity led to and was a major contributing factor, perhaps even the sole cause, for my becoming a Type 2 Diabetic. The truth is it was the other way round. My Type 2 diabetes, or the underlying condition that precipitated the diagnosis, Insulin Resistance, caused my obesity. For a layman’s explanation of the mechanism of this metabolic pathway, read “Type 2 Diabetes, a Dietary Disease #308: Introduction to What Causes Type 2 Diabetes.” Or you can read Gary Taubes’s “Why We Get Fat and What to Do About It,” or Volek and Phinney’s “The Art and Science of Low Carbohydrate Eating.”

So, my doctor thought that if I reversed my weight gain, he could slow the rate at which my progressive disease would worsen. And it would be good as well for my general health, blood pressure, etc. My doctor also thought that by prescribing medications to help me control my blood sugar, he would be helping me to control my diabetes and thus likewise “delay the complications.” My doctor, regrettably, was misguided here too, as he was taught to treat diseases by treating the symptoms; my doctor was not addressing the cause.

The precipitating cause, Insulin Resistance, was “expressed” by certain of my genes from my history of eating a diet that was too heavily composed of carbohydrates, especially highly processed carbohydrates. Since the 1960s, all Americans have been told by the American Heart Association to reduce their intake of fat, in particular saturated fat and dietary cholesterol. In 1977 a Special Congressional Committee began work and in 1980 the USDA and HHS jointly produced the first Dietary Guidelines for Americans. In 1990, Congress followed with the Nutrition Facts panel on processed foods. Then and now, the Nutrition Facts panel calls for a diet of 60% carbohydrates, 10% protein and 30% total fat. Please note these ratios are excellent for fattening livestock.

It was a huge (no pun intended), nation-wide uncontrolled experiment. Now, after 35 years, we see that it was a catastrophic failure, leading to an epidemic of obesity and Type 2 Diabetes even in very young children. If you are now a member of this failed low-fat (VERY HIGH CARB) cohort, consider addressing the cause: highly processed carbohydrates.  To avoid “challenging” your “expressed” genes and to reduce your Insulin Resistance, consider the macronutrient ratios in your diet. To lower both your weight and your blood sugar, you need to substantially reduce the carbs, increase the protein slightly, and raise the dietary fat. Get off the livestock fattening program.  I suggest you start with 20% carbs, 20% protein and 60%* fat. Just start with breakfast and see how you feel; perhaps 2 or 3 eggs and 2 strips of bacon. No toast! No juice! How do you feel? Are you hungry before lunch? Hint: You won't be.

*These are percentages in calories, not grams. And since fat has 9 calories per gram, versus 4 for protein and carbs, that’s less than half as much fat by gram. And fat, as you know, tastes good, and it’s good for you. It also makes you feel full, lose weight, and be full of energy.

Type 2 Diabetes, A Dietary Disease #309: “Type 2 Diabetes Q & A”

Link to #307: Preface: A Personal Story (N = 1)

Link to #308: Introduction to What Causes Type 2 Diabetes

Vignette 1: What is Type 2 Diabetes?

Answer: Type 2 Diabetes is a metabolic disorder in which insulin, the glucose transporter in the bloodstream, is blocked on the surface of destination cells, preventing the glucose from being taken up for energy. This condition is called Insulin Resistance. As a result of Insulin Resistance, circulating glucose levels become elevated. If untreated, elevated blood sugars eventually cause serious microvascular and macrovascular complications. Secondarily, as the disease develops, when more insulin is secreted to help with the take up, the pancreas increasingly has diminished capacity to make insulin and insulin replacement therapy is required.

Vignette 2: How Did I Get Type 2 Diabetes?

Answer: You, along with about half the population of the Western World, were unlucky. First, you have a certain genetic predisposition such that some complex combination of your genes makes them vulnerable to a genetic modification. This is not the same as a “mutation.” Second, you unwittingly participated in a large uncontrolled government experiment of eating a low-fat, high-carb, dietary pattern and, being genetically predisposed, your genes have “expressed” this modification, causing you to become Insulin Resistant, and thus Carbohydrate Intolerant and a Type 2 Diabetic.

Vignette 3: What Can I Do If I’m Pre-Diabetic?

Answer: If you’ve been told, or you suspect, that you’re “Pre-Diabetic,” to avoid becoming a Type 2 Diabetic you must modify your dietary pattern to reduce, as much as possible, carbohydrates. Carbohydrates are a non-essential macronutrient. There is no minimum requirement for carbs. Carbohydrates include both simple sugars and complex carbohydrates, particularly refined and processed carbohydrates. You must also avoid sugary soft drinks, fruit juices and drinks, and all baked goods, starches, cereals, and desserts. That’s anything with flour, sugar (by any name) or starch. This is of course difficult to do, at first, but it’s an easy way to lose weight without hunger, and, if you do it, you will lose weight and you will avoid developing type 2 diabetes.

Vignette 4: How Can I Prevent Type 2 Diabetes?

Answer: Easy! Type 2 Diabetes is a dietary disease. If you take charge of what you eat, and seriously restrict your carbohydrate intake, you will avoid developing this disease. Even if you are already somewhat overweight and/or have been told you are “Pre-Diabetic,” you can reverse your Pre-Diabetes and put your Insulin Resistance in remission. By seriously restricting your carbohydrates, you will also lose weight rather easily and do it without hunger! And as long as you stick to your carbohydrate restriction/reduction, and eat 2 or 3 small meals a day without snacks, you will remain protected from developing this disease.

Vignette 5: How Can I Prevent Type 2 Diabetes From Being Progressive?

Answer: If you are already a diagnosed Type 2 Diabetic, you must do just one thing: ignore the advice to “eat a balanced diet.” Continuing to eat beaucoup carbs will only assure that your disease will be progressive. You will become dependent on more and more medications, possibly become “insulin dependent,” and eventually develop the dreaded complications. The easy way to prevent Type 2 Diabetes from becoming progressive is to eliminate carbohydrates from your diet: all carbohydrates become glucose in your bloodstream. You have Insulin Resistance, and you are Carbohydrate Intolerant. Your body just can’t handle carbohydrates any more.

 Vignette 6: How Can I Reverse Pre-Diabetes or Type 2 Diabetes?

Answer: The only way to reverse Type 2 Diabetes is to largely eliminate carbohydrates from your diet. They all become glucose in your bloodstream. If you are Pre-Diabetic or have been diagnosed a Type 2 Diabetic, you have Insulin Resistance and you have become Carbohydrate Intolerant. Your body can’t handle carbohydrates any more. So long as you continue to restrict the carbohydrates you eat, your Pre-Diabetes or frank Type 2 Diabetes will go into and remain in remission. You’re not cured, but while your disease is in remission, you are not at risk for the microvascular and macrovascular diseases associated with this disease.

Vignette 7: How Can I Cure My Type 2 Diabetes?

Answer: You can’t. People who use the word “cure” are misleading you. You were genetically predisposed and your genes have “expressed,” i.e., already been modified, permanently, as far as anyone knows at this time. That’s history, and you can’t change your genes back to their “normal” expression. However, you can take those genes “out of play” by avoiding the foods that “express” them: carbohydrates. So long as you eat a diet of primarily fats and limited protein, as your body was designed to do, your body will adapt. You will have plenty of good energy, healthy food for the heart and brain and every other need the body has, and your blood sugar and serum insulin levels will decline to “normal.” Your Type 2 Diabetes will be in remission.

Vignette 8: How Can an Overweight Type 2 Lose Weight Safely?

Answer: That’s easy too, and you can “kill two birds with one stone.” The most difficult part of any “restricted calorie, balanced” weight loss program is being hungry all the time. The reason is that when you eat carbs, insulin circulating in your blood, secreted for the purpose of transporting glucose (the digested carbs) to your cells, blocks your body from using body fat for energy. Your body thinks, “If you have carbs to eat, you don’t need to use your precious body-fat reserves.” So your stored fat is “saved” for a famine or for winter. If you instead restrict carbs, instead of calories, you will naturally eat less and your body, sensing lower blood glucose and transporter-hormone insulin in the bloodstream, will break down your body fat for energy. As a result, your body will be fed your broken down body fat. You will not be hungry, and you will lose weight!

Vignette 9: Is Being Overweight a Cause of Type 2 Diabetes?

Answer: No, it’s the other way around, and the explanation is simple. When you eat a “balanced” diet, as most weight loss programs and “experts” advocate, glucose from digested carbs is accompanied in the bloodstream by the transporter hormone insulin. The liver, which controls metabolic homeostasis, perceives that since you have dietary carbs available for energy, you don’t need body fat to maintain energy balance. So, the fat stays locked up around you belly. As you develop Insulin Resistance (see #1 above), your serum insulin levels remain high so added calories from carbs and fat (and unused protein stored in the liver), are converted by the liver to additional fat stores. You got fat because you’re Insulin Resistant, which means you are a Type Diabetic or at very serious risk of becoming one.

Vignette 10: Is Being a Type 2 Diabetic like being Gluten or Lactose Intolerant?

Answer: Yes and No. Each involves food intolerance. Gluten Intolerance means the body is intolerant of the protein portion of the wheat, barley or rye grain. It rapidly results in intestinal distress. Lactose Intolerance means the body is intolerant of foods containing the milk fat lactose because of the absence of the enzyme lactase to help digest it. Lactose intolerance rapidly results in intestinal distress. Carbohydrate Intolerance, the result of a person developing Insulin Resistance expressed as the metabolic disorder, Type 2 Diabetes, results in long term microvascular and macrovascular complications often leading to death. All three intolerances – gluten, lactose and carbohydrate – are dietary diseases and are best addressed by avoiding the dietary cause.

Vignette 11: Won’t Eating So Much Fat Make Me Fatter?

Answer: No, unless you eat too many carbs and too much fat. Fat, eaten with or without limited protein, is filling. You quickly become satiated (satisfied), so eating fat is self-limiting. You will eat less if you eat just energy dense, real foods containing full fat, limited protein and minimal or no carbohydrates. Carbs that have been processed are depleted of nutrients along the way, including essential fat-soluble vitamins and minerals. Carbs that are eaten to the exclusion of healthy fats will not satisfy your hunger and will lead to cravings. Eating excessive nutrient-deficient processed carbs will lead to overeating carbs, which the liver will convert to body fat. Eating carbs will make you fat. Think about how livestock is fattened before slaughter.

Vignette 12: Won’t Eating Saturated Fat Make My Cholesterol Rise?

Answer: Actually, no! Eating a high-fat, low-carb diet will be good for your cholesterol. It will raise your HDL cholesterol (the “good” cholesterol), in some cases, like mine, more than doubling it. If your Total Cholesterol, an obsolete value in modern lipidology, rises slightly, it will be because your HDL went up. The formula: TC = HDL + LDL + TG/5. Your LDL cholesterol (the “bad” cholesterol) will probably remain constant, but their particle size and density will improve, from “small dense” to “large fluffy.” And your triglycerides, measured at the same time as your cholesterol, will decline dramatically. Mine did, dropping by more than two-thirds.

Vignette 13: Won’t Eating Dietary Cholesterol Block My Arteries?

Answer: Absolutely not! Dietary cholesterol, from animal foods like eggs, shrimp and meat, has nothing to do with serum cholesterol (cholesterol in your blood). Cholesterol is an essential compound. It is present in every cell in your body. Your liver makes cholesterol as your body needs it, accounting for about 90 percent of the cholesterol in your body. If you eat less cholesterol, your body will make more. Cholesterol actually repairs erosion in the surface layer of your veins caused by inflammation, preventing small, dense oxidized LDL particles from being trapped. HDL clears LDL, returning it to the liver for disposal.  In 2014 the Dietary Guidelines Advisory Committee said, “Cholesterol as a nutrient is no longer a concern for overconsumption.”

Vignette 14: Aren’t Carbohydrates Necessary for Energy?

Answer: No. Carbohydrates, however, are a major source of “quick” energy, in that they digest quickly, converting primarily to glucose, a necessary and essential nutrient molecule for certain organs and tissue that do not contain ATP, the little energy factories. However, because only a small amount of glucose is necessary but because it is essential for those parts of the body, the body has developed multiple mechanisms and pathways to make glucose from protein and fat. The liver can make glucose from amino acids that are the breakdown products of protein. In addition, glucose can be made from the glycerol molecule which is cut loose when a triglyceride (fat) molecule is oxidized to free up fatty acids for fuel. Furthermore, the byproducts of this oxidation are ketone bodies which the brain actually prefers to glucose. In the absence of carbs, after a period of adjustment, the body does very well on a diet almost exclusively of fat and protein. Some athletes report big improvements: http://eatingacademy.com/how-a-low-carb-diet-affected-my-athletic-performance.

Vignette 15: What About Macronutrient Ratios?

Answer: The three macronutrients, carbohydrates, protein, and fat, were eaten in various ratios by different cultures around the world, until governments got involved. Starting in the mid 20^th century, epidemiological evidence suggested that dietary saturated fat and cholesterol were a cause of coronary artery disease (CAD) and cardiovascular disease (CVD). In 1977, the U.S. government intervened, and in 1980 it produced the first Dietary Guidelines for Americans. The food packaging laws followed, resulting in the Nutrition Facts panel on processed and packaged foods. To this day, the macronutrient distribution on that panel recommends that the entire American populace (except children under the age of 2) eats a diet consisting of 60% carbohydrate, 10% protein, and 30% fat (of that mostly polyunsaturated fat from vegetable oils like soy bean and corn oil). That, in a nutshell, is why almost half the Western world is now overweight or obese…and has Insulin Resistance.

 Vignette 16: What Is a Low-Carb, High-Fat (LCHF) Diet?

Answer: A Low-Carb, High-Fat (LCHF) diet is designed primarily to lower serum insulin and blood glucose, thus preventing and/or reversing the onset of prediabetes or Type 2 Diabetes. It also enables the adherent to lose weight, if needed, without hunger. Secondary outcomes include higher HDL cholesterol and lower LDL cholesterol, triglycerides, and chronic systemic inflammation.  Definitions vary but generally a LCHF diet entails eating less than 50 grams of carbohydrate a day. That’s 10% carbohydrate vs. 300g/day (60%) carbohydrates in the 2,000 kcal Standard American Diet recommended on the Nutrition Facts panel on processed food in the U.S. Even 100g/day (20% carb) would be a very substantial improvement over the Federal Dietary Guidelines.

Vignette 17: What is a VLC Ketogenic Diet?

Answer: A VLC Ketogenic Diet is a Very Low Carb Ketogenic Diet in which the adherent eats fewer carbohydrates than in LCHF. Generally, the carb count is between 15 and 30 grams a day. Thirty grams is the daily total in the Bernstein 6-12-12 Diet designed for diabetics. Twenty grams per day is the amount in the Atkins Diet Induction Phase. I followed Atkins Induction for 9 months in 2002-2003 and lost 60 pounds. I also, within a few days of starting Atkins Induction, found it necessary, to avoid hypos, to eliminate almost all of the oral anti-diabetes medications I had been prescribed. A few years later, I followed the Bernstein’s 6-12-12 program and lost 100 pounds in 50 weeks. Today, I try to eat ≤ 15g/day of carbohydrates to be in a perpetual state of mild ketosis, producing a low level of ketone bodies from the breakdown (catabolism) of my body fat. I find that my body likes this state best. I am always full of energy, get excellent rest, and am never hungry, even after an overnight fast. So long as I adhere to this program, my blood sugars are stellar, and I lose weight.

Vignette 18: What Foods Must I Strive To Avoid To Stay Healthy?

Answer: Foods that contain carbohydrates, obviously. Carbs include simple sugars, both added and naturally occurring, unfortunately. That means fruit, especially fruit juices and fruit drinks, and all sugary drinks. Baked goods, including all breads, pasta and rice.   The more processed the grain or the sugar, the more damage it can cause.  Flours and sugars are not your friends.  Avoiding inflammatory foods is also very helpful.. Some oils are high in PUFA and these are very inflammatory, doubly so if used for frying. Foods that are deep fried in vegetable oils, corn and soy bean oil in particular, are loaded with Advance Glycation End products (AGE’s) that are known to damage your blood vessels and thus cause CVD.

Vignette 19: Is Type 2 Diabetes a Lifelong Disease?

Answer: Regrettably, once you get Type 2 Diabetes, you’ll have it for life. Your genes have been modified. Whenever you eat a lot of carbohydrates, they will express the Insulin Resistance that has caused your Type 2 Diabetes. However, if you eat an absolute minimum amount of carbohydrates, your body will be able to handle it. Unlike in Type 1 Diabetes, your body still produces some insulin, and in response to ingesting carbs it will produce enough insulin to circulate the glucose and eventually see it absorbed. When eating Very Low Carb your insulin sensitivity will improve. Then, when the glucose is absorbed by your cells and your serum insulin drops, you will return to burning fat for energy; your body will be happy, and you will not be hungry. As long as you follow this Way of Eating (WOE), your Type 2 Diabetes will be in remission.

Vignette 20: When I Reach My Goal Weight, What About Maintenance?

Answer: For me this is still a hypothetical question. I have never (yet) reached my goal weight. In theory, according to the scientists I most admire, you are supposed to keep constant, in terms of grams, both carbohydrates and proteins and increase your fat to stop losing and stabilize your weight. I imagine that increasing fat would be fairly easy. I could snack before dinner on buttered radishes or cream cheese filled celery, or add olive oil to meat and vegetables. For now, however, I am working on getting to my goal weight. 

Type 2 Diabetes, a Dietary Disease #308: Introduction to What Causes Type 2 Diabetes

Google “type 2 diabetes” and, in one third of a second, you get 118,000,000 “hits.” On my search the very first, after a brief description of the biological condition, asks, “What Causes Diabetes?” Their answer: “Usually a combination of things cause [emphasis added by me] type 2 diabetes,” What follows is a list of 6 symptoms, effects and parallel conditions associated with type 2 diabetes, none of which is a cause of type 2 diabetes. Only the first “cause” listed, “genes,” is relevant in that it is a precondition, but not a cause of this disease.

I am not a microbiologist or geneticist, but geneticists will tell you the genetic aspect of the science of Type 2 Diabetes is in its infancy. Although some genes associated with Type 2 Diabetes have been identified, no one has yet deciphered the complex combination of genes that have been modified by our Western diet to express themselves in a way that compromises the ability of our cells to accept glucose. This modification is called “insulin resistance.” Insulin carries glucose through the bloodstream, delivering it to cells throughout the body. If glucose can’t enter the cells, it continues to circulate. The pancreas releases still more insulin to solve the problem and eventually (after years) it wears out.

Elevated blood sugar, again over time, causes the complications of diabetes. And elevated insulin in the blood signals that there is glucose (energy primarily from carbs) circulating in the blood so there is no need to burn fat reserves for energy. So the body keeps our fat in storage, and the liver converts excess dietary carbohydrates (and fats) to triglycerides (fat) and adds them to our stores. Insulin resistance, resulting in high levels of circulating insulin in the blood, is thus the cause of diabetes and obesity, not the other way around. IR causes diabetes, IR causes obesity.  And obesity is usually a signal that your blood glucose is not under control.

What then is the “treatment” for type 2 diabetes caused by insulin resistance? The website cited lists 18 generalized “risk factors:” 3 are “things you can’t control,” and 11 others are “related to your health and medical history,” things that are epidemiologically associated with those who develop Type 2 Diabetes. That may be helpful to your doctor if he or she is otherwise clueless about whether to diagnose you as “pre-diabetic” or a frank Type 2. But let’s face it: they are history. There’s not much you can do to change the past.

Then the website lists 4 “Other risk factors (that) have to do with your daily habits and lifestyle.” It suggests, “These are the ones you can really do something about.” The site’s advice (amid pop-ups for anti-diabetic drugs): “Take medications and follow your doctor's suggestions to be healthy.” The site’s suggestions: “Lose weight, Get active, Eat right, Quit smoking.” Not bad advice, but not an effective treatment plan for IR.

The best way to think of Insulin Resistance is that you have become intolerant of dietary carbohydrates, i.e., you are Carbohydrate Intolerant. So, an “eating pattern” that reduces dietary carbohydrates to a minimum, or as few as you are willing to eat, will reduce the levels of both glucose and insulin circulating in your blood. This will, by lowering your blood glucose, 1) minimize your risk of pre-diabetes, frank type 2 diabetes and later complications, and, by lowering your blood insulin, 2) enable your body to access fat stores. You’ll lose weight and, in the bargain, avoid diabetes. Why doesn’t your doctor tell you this, instead of writing a prescription?

* If you’ve been wondering if you are one of those who is genetically predisposed, there is no genetic test as yet, but if you are overweight there is a very strong likelihood (true, just an association) that you have developed a degree of Insulin Resistance sufficient to cause that buildup of adipose tissue (body fat). This is particularly true for those with a waist/hip ratio greater than 1.0.

Type 2 Diabetes, a Dietary Disease #307: A Personal Story (N = 1)

I was diagnosed with type 2 diabetes in 1986. The standard at the time was 2 consecutive fasting blood sugars ≥ 140mg/dl. The standard today is ≥126mg/dl, so I had probably been diabetic for many years. I weighed 300 pounds at that point, up from 250 in 1974. So my doctor told me to lose weight. He also began to treat me with a sulfonylurea, an oral antidiabetic medication that called upon my pancreas to produce more insulin whenever it was presented with simple sugars and other carbohydrates that I had eaten.

I tried many times to lose weight on the “balanced, calorie restricted” diet recommended by my doctor and his staff nutritionist, a registered dietitian (RD). I was always hungry. And from time to time when I did lose weight, I always gained it back. Over the years I continued to gain weight, and my diabetes worsened. In the mid 1990s, after I was “maxed out” on the sulfonylurea (glyburide), my doctor prescribed metformin, a new medication (in the U.S.). In a few more years I was maxed out on that drug too, and my doctor started me on a third class of oral diabetes medication. Soon, I feared, I was going to be injecting insulin directly into my veins.

By August 2002, I was the heaviest I had ever been. In fact, for several previous appointments I had been too heavy to be weighed on my doctor’s office scale. So before my next appointment, I weighed myself (with permission) at the Fulton Fish Market. The commercial scale told me the truth: 375 pounds. That was really scary. When I walked into the doctor’s office later that day, I was motivated to lose weight.

“Have I got a diet for you!” my doctor said as he greeted me from the nurse’s station in the lobby of his office. Serendipity had created a moment where my doctor had a specific recommendation for me, and I was totally receptive to his suggestion. He told me that he had personally tried a diet that he had read about in The New York Times! It was the July 7th Sunday magazine cover story, “What If It's All Been a Big Fat Lie?” by Gary Taubes, an award-winning science writer. This was a ground breaking story that was to change countless lives.

Both my doctor and I were interested in this diet because we both wanted me to lose weight – a lot of weight. But as my doctor walked me down the hall to schedule my next appointment, he put his hand on my shoulder and said, “Dan, this may help your diabetes too.” Boy was that an understatement!

The first day on this new diet, in the late afternoon, I experienced a “hypo” or hypoglycemic episode – a low blood sugar with “sweats.” I knew something was wrong so I tested my blood and then went to the news stand in the lobby and bought a candy bar. I then called my doctor, and he told me to stop taking the 3^rd oral medication. But the next afternoon I had another hypo. I ate another candy bar and called the doctor again. This time he said to cut the other 2 oral meds in half, and the next day, when the scene repeated itself, to cut them in half again. In only a few days of strictly following this diet I was taking just 1/9^th the meds as before.

On this diet, as is manifest, I didn’t need to take all these antidiabetic medications. And in time I was able – correction, I had to eliminate the sulfonylurea completely to avoid hypos. And all this happened before I lost weight. Of course, I did lose a lot of weight on this diet (170 pounds at my lowest), but more importantly my type 2 diabetes went into remission – so long as I continued to stay on this diet. I’m not “cured.” I never will be, but neither is my Type 2 Diabetes still “a progressive disease.” It is, quite simply, A DIETARY DISEASE.

* My lipid profile also improved dramatically: My HDL more than doubled and my triglycerides dropped by 2/3rds. My ratios (TC/HDL and TG/HDL) are now stellar, and my inflammation markers have plummeted. My blood pressure, of course, also improved (on the same meds). And my type 2 diabetes is in total remission!

The Nutrition Debate #306: My New Manifesto: “Type 2 Diabetes, a Dietary Disease”

You may have noticed I took some time off for R & R.  The 305 archived columns, however, saw frequent visits.

The hiatus gave me an opportunity for introspection. It enabled me to re-examine my purposes and the best methods of achieving them. As my visitors know, I d­­o this for eleemosynary purposes. I have no pecuniary interest: no advertising, no dietary supplements to sell, no book to promote; there’s nothing in it for me. I do this, with the help of a great volunteer editor, for purely educational purposes.

As I said in The Nutrition Debate #114, “My Insulin Dependent Type 2 Pharmacist,” I started writing this column because a friend in my community – who was a registered pharmacist – died, unnecessarily and tragically. He was a Type 2 Diabetic. In 1986 when I was first diagnosed a Type 2, he helped me pick out my first blood glucose meter, and he filled my first prescription for an oral anti-diabetic medication.

That’s when my pharmacist told me that he was an insulin-dependent Type 2. He followed his doctor’s orders – and the advice our government has dispensed for half a century – and his disease progressed to its inevitable conclusion. His death was a waste. It didn’t need to happen that way. And that’s my motivation and my message.

With that in mind I have decided to focus my efforts on a large underserved segment of the diabetic population.  I want to explore an aspect of Type 2 Diabetes care that is little understood and generally ignored by the medical and pharmaceutical communities: the self-management of Type 2 Diabetes by the patient and how best to do it.

I am especially interested in reaching what the medical community calls the “treatment-naive” patient, that is, someone who is newly diagnosed (as Pre-Diabetic or Type 2 Diabetic) and has never been subject to any “treatment.” Such patients are at a critical juncture, and denial is an extremely tempting option. Typically, the patient just defaults into a dependent state and accepts their doctor’s ministrations (as we usually do in healthcare matters). However, a diagnosis of Pre-Diabetes or Type 2 Diabetes is actually a great time to look into what this disease is really all about and learn what you, the patient, can do about it. As a well informed patient, you can self-manage your diabetes care under your doctor’s watchful eye and “supervision”? 

Self-management of Type 2 Diabetes is a mutually beneficial arrangement. Doctor’s know that Type 2 Diabetes is largely a patient managed disease. They call it “patient-oriented” care, but that still leaves the impression that patient care is a collaboration that the doctor manages. I’m sorry, but as far as dispensing dietary advice is concerned, most doctors and conventionally educated and certified Registered Dieticians aren’t qualified to manage the care of Type 2 diabetics. So, in the days, weeks and months between doctor’s appointments, you will manage your diabetes care, and at the office visit your doctor will order tests and monitor (not manage) your improvement. Alternatively, if you default to medical management, after initially getting your blood sugar under control with drugs, your doctor will simply manage, and record, the progressive worsening of your condition.

You, the patient, know full well that “doctor’s orders” to “try hard to diet, exercise and lose weight,” aren’t easy to follow and aren’t enough. You’ve seen friends and relatives struggle. Something must be wrong with the “prescription,” you’re thinking. The doctor knows it too, but the only arrow in the quiver of the otherwise uninformed or, sadly, misinformed clinician is, “More medications could be used.” That’s the road my poor pharmacist took, and look what it got him – progressively worsening disease… and then a slow, premature death.

Therefore, the new focus of “The Nutrition Debate” will be “Type 2 Diabetes: A Dietary Disease.” It will begin with this post (#306) by the eponymous title. Then, the next posts will be #307, “Preface, A Personal Story (n = 1),” and then #308, “An Introduction to What Causes Type 2 Diabetes.” The first is my bona fides – my “credentials,” as it were. The second post is an overview of the science, as I see it. These will be followed by #309, “Type 2 Diabetes Q & A: 20 Brief Vignettes,” each fewer than 150 words (4-pages total) in Q & A format.

Further posts will return to the manifesto that drives this new focus: that Type 2 Diabetes is a Dietary Disease. I welcome comments and “debate.” After all, I have taken a very strong position which, as I see it, is irrefutable. Of course, although I consider myself “informed,” mine is just “A Personal Story: n = 1,” and “Your Mileage May Vary (YMMV).”  But, if you read “An Introduction to What Causes Type 2 Diabetes,” it’s difficult for me to see how anyone could look at Type 2 Diabetes in any way other than that Type 2 Diabetes is a Dietary Disease.”