Type 2 Diabetes, a Dietary Disease #360: Ten years ago, I had a relapse (Part 5)

As readers following this series know, I decided to write it after I stumbled on an old misfiled Excel folder detailing my early “carb counting” days from 14 years ago. After regaining 12 pounds of 60 that I had lost on Atkins Induction in 2002, in 2006 I rededicated myself to Dr. Richard K. Bernstein’s 6-12-12 plan for diabetics. Fifty weeks later, with strict adherence and record keeping, I had lost another 96 pounds. When added to the previous 48 (60 – 12), my loss then totaled 144. I would eventually go on to lose a total of 170 pounds.

In the beginning I still ate a lot, but I did not limit calories, fat or protein. Just carbs. I had a much larger body to feed then and therefore a lot more organism (and psyche) to satisfy. A person who is used to eating, and receives gratification from eating a lot, needs to acclimate him/herself to this new lifestyle. You need to make a gradual adjustment to smaller meals. And you need to shift gratification from a feeling of being full to a feeling of liking that “lean” feeling and seeing the weight loss as recorded every day and every week.

What surprised me (and amazingly my doctor as well), was how, from Day 1 on strict Atkins Induction, the very low number of carb grams had an immediate effect on my blood sugar readings and on my medications. On Day 1 I had a hypoglycemic episode, and several more that first week. My doctor immediately dropped the 3^rd oral anti-diabetic med he had recently started me on and then in successive days that first week, recognizing that I was overmedicated, cut the other two meds, on which I was maxed out, in half twice. In just one week, before weight loss was even noted, I had reduced my diabetes medications by 90% (8/9^ths).

When I started on Bernstein in October 2006, I was still on 5mg Micronase (glyburide, a sulphonylurea or SU) and 500mg of Metformin. I only kept a record of estimated carb grams, and took 4 took blood sugar readings a day: Fasting, 2 hr postprandial, late afternoon (before Happy Hour) and 2 hours after supper. I would later add protein, fat, and calories to my records. Still later I added saturated fat, cholesterol, sodium, fiber and simple sugars (mono and disaccharides, added and naturally occurring). Total sugars were always VERY low.

I kept records in 4-week tables. My goal was simply 30 grams of carbohydrate a day, ala Bernstein’s program.My first 4-week average carb count was 33 grams a day, range 16 to 59, but those were outliers. Most were 20s and 30s. The interesting thing about this month was my blood tests. The fasting average the first week was 139mg/dl. It dropped in weeks 2, 3 and 4 to 107, 104 and 104. But the really interesting result was my late afternoon blood glucose readings. The first week’s average was 85mg/dl. The second week’s was 78, but by the 3^rd and 4^th weeks it had dropped to 59 and 56, with 6 out of 7 readings in the last 2 weeks in the 40s.

On only 5mg of a SU, while eating VERY LOW CARB, I WAS OVERMEDICATED! So, in the next 4-week period I stopped the SU for 2 weeks and then added it back at a reduced dose of 2½mg. My late afternoon averages were now 95 and 114mg/dl for the weeks without an SU, and 57 and 81 for the weeks at the reduced dose. My carb gram average for this 4 week period was 31, down from 33, and very close to my goal of 30.

Not bad, considering this period included Thanksgiving… and Christmas was coming. Oh, by the way, I also lost weight during these successive 4-week periods: 10 pounds the 1^st, 14 the 2^nd, only 1 the 3^rd (including a 150 carb binge on Christmas Eve and on Christmas Day another 94g carb binge). These and a few more seasonal indulgences bumped the December carb gram average up to 51 grams a day. And my weekly fasting sugar averages increased as well in December (105, 109, 111 & 112), but my late afternoon weekly averages held sort of steady (72, 77, 83 & 95) and my evening 2-hr postprandial averages were fine (87, 87, 83 & 95).

In January, I got back to eating according to plan, and my carb gram average dropped to 32 grams a day. Increasingly, however, my late afternoon readings were again dropping below normal (70-100mg/dl), with weekly averages going from 85 to 71 to 67 to 68. So, in the next 4-week period, my average daily carbs dropped to 23! I took no glyburide in week 3, and starting in week 4 I split the tiny pill in half and took just 1.25mg/day. My late afternoon blood glucose average went from 72 to 77 to 95 and back to 87mg/dl.

On March 17, 2007 (end of week 23 on Bernstein 6-12-12), I stopped the sulphonylurea altogether. SU’s are bad news. They effectively lower your blood sugars but at a very big price. They beat up and deplete the pancreas of beta cells and impair its ability to make insulin. Eventually you must inject insulin as your body loses its ability to produce it. 

Type 2 Diabetes, a Dietary Disease #359: Ten years ago, I had a relapse (Part 4)

In Parts 1, 2 and 3 of this series (#356, #357 and #358), I described how I lost 170 pounds on Very Low Carb diets. I related how it all began after my doctor read “What if It's All Been a Big Fat Lie?,” a 2002 NYT Sunday Magazine cover story. He tried the diet to lose weight. After losing 17 pounds, my doctor suggested I try it, also to lose weight. Unfortunately, my doctor soon regained all his lost weight when he went back to eating “normally.” He would afterwards ask me, “What do you eat?” and “How do you do it?” I said, “It’s no secret.”

He also said though, “It might even help your diabetes.” He was sure right about that. Of course, neither of us knew at the time how much it would help my diabetes, but I you’ve read Parts 1, 2 and 3, you know what happened: my Type 2 Diabetes went into total remission. He would probably say that I was “cured,” because I no longer had any symptoms discoverable by the routine lab tests. I am, however, still a Type 2 diabetic because I have Insulin Resistance. I am Carbohydrate Intolerant. That still leaves the questions, “What do you eat?” and “How do you do it?” That’s what Parts 4 and 5 are about.

Ten years ago this past summer, after several years of maintaining my weight at about 315 pounds, I relapsed. I regained 12 of the 60 pounds I had lost on Atkins Induction. That’s when, in October 2006, I started on the Bernstein program for diabetics. I built an Excel table (Fig.1) to keep track of the carbs I ate.

But Bernstein also requires that you limit protein, since some amino acids (digested protein) are glucogenic (can be made into glucose by the liver). So, after a few months on Bernstein, I built a new table (Fig.2) to add protein, and then fat, calories, blood sugars (4 times a day) and weight. I used an online program to get the numbers for everything I ate. It took about a half hour a day at the start, then a little less with practice.

I weighed myself daily, but only noted the change weekly. In the beginning, while I was learning the effect that different foods had on my blood sugar, I took a morning fasting blood sugar (FBG) and a 2 hour post prandial. I also took one in late afternoon (usually my daily low reading) and another 2 hours after supper. Now, since I know about carbs, I only weigh-in daily and take a FBG in the morning to get a weekly average.

I kept a detailed food log for a few years, until I learned what I could eat and what I couldn’t. It was also a good way to show me the price I paid when I ate something I knew was taboo. It had another effect too. Besides the shame and guilt I felt, and the disappointment with myself for the “lack of discipline,” it always ruined my averages. If you’re completely honest with yourself, and record everything, the numbers don’t lie. That was probably more devastating than the guilt! You’ve got to be totally honest with yourself. You have to record everything you eat and drink. No rationalizing. No forgetting! And then, you have to face the truth.

After a while, you won’t need to keep records. You figure out what works. You learn, and then you know that eating certain foods will not spike your blood sugar. And others will. You know that eating fat and limited protein with nil carbs, will not leave you hungry. You will also be able to fast easily because YOU WILL NOT BE HUNGRY. When lunchtime rolls around, you will ask yourself, “Am I hungry?” and if the answer is “no,” it will be easy to skip that meal, or eat a smaller meal, without hunger. And, you will lose your “sweet tooth.”

None of this is to say that you will not want to eat something for reasons other than real need (hunger). For example, the sight of food is a tremendous stimulus for me. It has been my downfall more times that I can count. Nervous eating, bored eating, habit (mealtimes), social events, social convention, (fellow workers and family members) all present challenges. But, need is the only biological imperative, and real hunger is what drives that need. And if you are in a state of mild ketosis, described as “ketoadapted” (Google it!), your body is content with burning body fat for fuel. So, my new mantra is to ask myself, “Am I hungry?” If the answer is “no,” I try not to eat. But, if I succumb for whatever reason, I eat a small meal of just protein and fat.

Type 2 Diabetes, a Dietary Disease #358: Ten years ago, I had a relapse (Part 3)

When I told my wife that I was writing a series about my weight loss journey since I started Bernstein 10 years ago this fall, she asked me if that was the year we were in Puerta Vallarta in September. I checked and it was. What a memory she has! My recollection was a little different…

As I related in “Ten years ago, I had a relapse (Part 2),” I recalled that my motivation was that I had regained 12 pounds (20%) of the 60 pounds I had lost on Atkins Induction (20g a day of carbs) back in 2002-03. That was true, but my wife reminded me of a conversation I had had with a Canadian MD I met in Mexico who told me that I was “IN DENIAL.” What a service that doctor did for me that day!

I came home with renewed resolve to do something about that 12 pound weight gain. Having just read Richard K. Bernstein’s “Diabetes Diet,” I bought and read his Diabetes Solution  and decided to go for it: eat just 30g of carbs a day. For medications, I was still 5mg Glyburide and 500mg of Metformin a day.

Beginning in October 2006, I started counting carbs and taking blood sugar readings again (see Fig.1  ). By November ( Fig.2), I had cut back the Glyburide from 5mg to 2½. In late January (Fig.3), I started a 4-week drug trial to reduce it further from 2.5mg to 1.25. And in late February (Fig.4), I started limiting proteins, since so many of their component amino acids are glucogenic, i.e., are made into glucose by the liver.

Then, on March 17,^, 2007, I stopped taking Glyburide altogether. By April I was eating just 90g of protein a day (see #357 for how I chose this amount). In May, I reduced protein further to 80g/d. I also reduced my fat intake from 110 to 100 to 90g/day. By September 23, 2007 (Fig.5), 50 weeks after starting Bernstein, I had lost 96 pounds, going from 327 to 231. Added to the 48 net (60-12) that I had lost on Atkins Induction, my total weight loss from 375 pounds to 231 on both Very Low Carb diets, was 144 pounds…with more to come.

Remember too (or if you didn’t, read #356 here), starting with the first week on Atkins Induction back in 2002, I had stopped taking all of my oral anti-diabetic medications except 500mg Metformin and 5mg Glyburide.  Now I was only on 500mg of Metformin, which I was to continue for the next 14 years.

With all the weight loss, my blood pressure also improved significantly, on the same pill “cocktail.” It went from 130/90 to 110/70 at my lowest weight (late 2008). Currently it’s 120/75. And my lowest A1c was 5.4%.

Now, returning back to late 2003, after a year of monthly office visits while monitoring my 60 pound weight loss and maintenance while on Atkins Induction, my doctor suggested we change to quarterly visits. My Total Cholesterol and LDL-C hadn’t changed much. They were both “borderline” by NCEP Guidelines for a “healthy” person. But, based on my still “morbidly obese” status, and Type 2 diabetes, my doctor declared that I was still at “high risk” for cardiovascular disease, so he put me on a statin. He started me on Lipitor, and quickly raised it to the max. My LDL-C (and Total Cholesterol) responded as expected. They plummeted.

But, prior to my starting statins, on both Atkins Induction and Bernstein, my HDL-D and triglycerides both improved a little. Before starting Atkins, my average HDL-C had been just 39mg/dl and my TGs 143mg/dl. Now, my HDL was 51 average (range 43 to 60) and my triglycerides 84 average (range 36 to 157). As I continued from mid-2004 to mid 2007 on both Bernstein and a generic statin, Simvastatin, my TC and LDL-C were very, very low (TC: 116 & LDL-C: 48, average of 12); however, since starting on Bernstein, my HDL-C soared and TGs crashed. My HDL-C average was now 84mg/dl and my TGs averaged 49mg/dl.

Given the death-from-all-cause benefit of a high HDL-C and low triglycerides, and my total weight loss (by this point 170 pounds), on first, Atkins Induction, and then Bernstein, in December 2008 my doctor (on his own!) took me off statins. I have been statin-free now for 8 years. And while my weight has inched up a little, my latest lipid panel was Total Cholesterol 184, HDL-C 91, LDL-C 84 and triglycerides 46. How’s them apples?

Type 2 Diabetes, a Dietary Disease #357: Ten years ago…I had a relapse (Part 2).

As I started to tell you in #356 here, ten years ago this past summer, I had a relapse. I regained 12 of the 60 pounds I had lost over a nine month period 4 years earlier. I had lost focus. So, I decided that it was time to get serious again and rededicate myself to the principles and practice of the Very Low Carb Way of Eating.

That summer of 2006, 10 years ago, I also read Dr. Richard K. Bernstein’s book, “The Diabetes Diet.” So, with my renewed resolve, I decided to switch to Bernstein’s Diet Plan for Diabetics. Dr. Bernstein has been a Type 1 Diabetic for most of his 70-odd years and was an engineer before he became an MD, like his wife. She had a big blood sugar testing machine in her office, so he used it to develop a strict regimen for “eating to the meter.” After all, he reasoned (as an engineer), if carbs make your blood sugar rise, the best treatment for regulating your blood sugar would be to restrict carbs. That makes sense doesn’t it? It’s just common sense!

Bernstein’s credo is that “everyone deserves a normal A1c.” His is in the 4s. Being a Type 1, he achieves this by injecting insulin, both 24-hour and at mealtimes, on a 30g-of-carbs-a-day plan. He calls it 6-12-12: 6 grams at breakfast (lower due to what he calls the “Dawn Phenomenon”), 12g at lunch and 12g at supper. No snacks. These principles are all well documented in the latest edition of his book, “The Diabetes Solution.”

Another difference from Atkins Induction is that Bernstein limits protein. When digested, protein breaks down into amino acids, from which some are made into glucose by the liver and thus raise your blood sugar. So, to limit this unwanted glucose production (called gluconeogenesis), protein needs to be limited. But how much protein should a person eat? In 2006 I studied the question carefully and discovered that opinions vary widely, but the “correct” way is to use a number based on an estimate of ideal, or lean body weight.

Lean Body Weight is the optimal weight for a person, and it is your lean body that needs protein. In 1998 the HHS/NIH adopted the Body Mass Index (BMI) Chart used by WHO, the World Health Organization. Your doctor is required to use this chart to “evaluate” your weight. It is a really gross metric that takes no account of gender, body type, or your cultural environment. It is also a pie-in-the-sky number for almost everyone who will read this post, i.e. people living in a part of the world where food is abundant and where processed food has replaced real food in our lives. Thus, according to the BMI, most of us are now overweight or obese. Nevertheless, your BMI “normal” weight is what you should use to calculate the amount of protein to eat.

The middle of the “normal” range in the BMI chart for a 5’-11” person (me) is 150 pounds. I still weighed 300 pounds in 2006, so that sounded totally ridiculous to me, so, by “mistake,” I chose instead a “goal” weight of 180 pounds for my calculation. And since I was pretty sedentary and did no exercises, I used 0.5 grams of protein per pound (1.1g/kg) of my goal body weight. So, 180 x 0.5 = 90 grams of protein a day. Honestly, though, the grams per pound is also a variable where opinions vary widely, so the number you settle on is up to you. That’s how I started. Note: I was soon to reduce my protein budget further, but not the carbs…yet.

For fat, I followed Bernstein’s dictum: Eat enough to be satisfied. I didn’t avoid saturated fat or cholesterol. I was convinced by Taubes, and others by this point, that the 1977 “Dietary Goals for the United States” and The Dietary Guidelines from 1980 on, every five years thereafter, were a failed Public Health experiment and were in fact the cause of our obesity and diabetes epidemic. And they certainly weren’t the right diet for anyone who was diabetic, pre-diabetic, or had even a touch of Insulin Resistance. It just didn’t make sense.

So, for breakfast, I usually ate 2 fried eggs and 2 strips of bacon, with coffee and whole cream. That’s all. No juice. No bread. No jelly. No fruit and No cereal. Period! No exceptions. I found this small meal very satiating. I wasn’t hungry later in the morning or even at lunch time. I ate something though – out of habit – but it was usually a couple of hard boiled eggs, or later a can of sardines in olive oil or kippered herring in brine. Yum.

Type 2 Diabetes, a Dietary Disease #356: Ten Years Ago, I Had a Relapse…

Ten years ago this past summer, I had a relapse. I regained 12 pounds of the 60 I had lost over a 9 month period 4 years earlier. All I can remember from that misspent summer (I was 65 then) was that I regularly raided the freezer after supper or before bedtime to have a big dish of ice cream. That was all it took.

Four years earlier, my doctor had just read “What If It's All Been a Big Fat Lie?,” the July 7, 2002, Sunday Magazine cover story in The New York Times. For years my doctor had been trying, unsuccessfully, to get me to lose weight. And since the diet described in the Times’ story went against the medical establishment’s “Standard of Practice,” my doctor was reluctant to recommend it. He had a little paunch, though, so he decided to try it on himself first…and he lost 17 pounds.

A little later when my doctor suggested that I try this diet – Atkins Induction (20g of carbohydrate a day) – I decided to give it a shot. I weighed 375 pounds in 2002, and I didn’t think I was going to be healthy or even live that much longer. I was then taking a cocktail of drugs for hypertension (high blood pressure). In addition, I had been diagnosed a Type 2 Diabetic 16 years before, and had probably begun to develop Insulin Resistance a decade before that. Insulin Resistant meant I had become, in stages, Carbohydrate Intolerant .

I was taking maximum doses of two classes of oral antidiabetic medications and starting on a third. When the 3^rd class of meds would eventually fail to control my blood sugar, I would “graduate” to insulin. That is the standard treatment for Type 2s; it is the “Standard of Practice” when “diet and exercise” fail. And diet and exercise inevitably do fail because the one-size-fits-all diet that doctors prescribe, again according to the “Standard of Practice,” is the USDA’s Dietary Guidelines for Americans, a low-fat, high-carb diet!

So, starting on a strict “Very Low Carb” regimen had an immediate effect on my health: I had a “hypo” the very first day. After eating a candy bar and waiting for “the sweats” to subside, I called my doctor. He told me to stop taking the 3^rd oral that I had recently begun. But then, the next day I had another hypo. This time he told me to cut the dose of the other 2 meds in half, and before the week was out I had to cut them both in half again. I hadn’t noticed any weight loss, but in just one week I had eliminated almost all my T2 meds.

I did start to lose weight of course. Remember, that was why my doctor had started my on a Very Low Carb diet.  He was almost as surprised as I was at the “unexpected” effectiveness of the Very Low Carb diet in treating my Type 2 Diabetes. My blood sugar was stable and in control. And over the course of 9 months, I lost the 60 pounds, 1½ pounds a week. And then I retired from work and the weight loss stopped. I didn’t gain any back; I just stopped losing. I don’t recall my state of mind, but I must have kept eating Lower Carb because for three years, until the summer of ‘06, I kept the 60 pounds off, and my blood sugar was stable.

Along the way, with time on my hands (being retired) and being “a little OC” (lol), to be sure that I adhered to the basics of Low Carbohydrate eating, in March 2004 I decided to keep a record of how many carbs I ate. To do this I constructed an Excel table (see this template) to record for a week everything I ate every day and to estimate the carb content only. To do this I used carb counting guides and free on-line services.

The concept was 1) to learn more about carbs and 2) to be accountable to myself – to fully “fess up,” to me alone, everything I put in my mouth. My estimate of food quantities and carb content was crude and approximate. It was just a way to keep daily carb counts, but it had the added benefit of keeping me honest.

As I recently discovered when I found a misfiled folder in my directory, I kept these charts on and off from March 2004 until mid-2006, when I went off on that ice cream bender. Fortunately, by that time, I was well connected with an online community that showed me the way forward and provided much needed help and support. See next week’s post to learn how I was soon to lose another 100 pounds in just 50 weeks.

Type 2 Diabetes, a Dietary Disease #355, Before and After

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

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

Lest any doubt remain, this next chart shows that my Total Cholesterol averages has been stable, contrary to the perennial declamations of naysayers of the conventional medical persuasion.

Type 2 Diabetes, a Dietary Disease #354: Macro and Keto Ratios

While exploring the Very Low Carb world over the years, I have been interested in the workings of both Macronutrient Ratios and Ketogenic Ratios. I started with the study of Macronutrient Ratios soon after I realized that “counting carbs” was not enough. I added protein and then fat (and total calories) and adjusted them over the years to where I have now settled on 75% fat, 20% protein and 5% carbs, on only 1,200 calories a day. This calculates to a ketogenic ratio of about 2.0. More on these values later.

Of course these Macronutrient ratios account for only ingested food – food and drink that I put in my mouth. But since I strive to eat so few carbs, when I am not eating too many carbs or too much fat (and protein), I am able to add to the calorie burn – what my body requires to maintain energy balance and an active metabolism – by burning body fat. I know that I have access to these fat calories because my serum insulin levels remain fairly low because there is a correspondingly low level of glucose circulating from both carbohydrate and protein restriction. I know that my body is not shutting down – or even slowing my metabolism to compensate for the low calorie intake by mouth – because I feel “pumped” all the time.

This additional fat burning would imply that my actual Macronutrient Ratios are higher than 75/20/5. It also would imply a higher Ketogenic Ratio, since only fat is being added to the equation, almost all in the numerator.

So, let’s do the numbers. If my daily food intake is 1,200 calories, and the Macronutrient Ratios are 75% fat, 20% protein and 5% carbs, my intake is composed of 100g of fat (900kcal), 60g of protein (240kcal) and 15g of carbs (60kcal). But if my metabolism stays up, that is, is not slowed down by the lower food intake – because the low carb intake allows my body access to its fat stores – then my actual fat contribution, at the cellular level where the nutrients are absorbed, is going to be much higher. How much higher, you ask?

That depends on my metabolic rate. How many calories does my body burn?  That would be the sum of my resting metabolism plus activity level, when not slowed down by either calorie restriction or from blocked access to fat stores.

Let’s say, for argument’s sake, that my metabolism chugs along at 2,550kcal/hr. If I am only taking in (by mouth) 100g of fat, 60g of protein and 15g of carbs, it is theoretically getting a contribution from body fat of 2,550 – 1,200 = 1,350kcals, or another 150g of body fat (1,350kcal/9kcal/g = 150g). That substantially changes the Macronutrient Ratio at the cellular level, where the body is actually fed. Check out this chart:

Nutrition & Metabolism	kcal	fat(g)	pro(g)	carb(g)	k/g ratio
Intake orally (food my mouth)	1200	100	60	15	2.0
Intake at the cellular level	2550	250	60	15	3.5

The formula for ketogenic ratio is derived from the work of Wilder and Winter (1922):

K/G ratio = (0.9*FAT+0.46*PRO)/(0.1*FAT+0.54*PRO+1*CHO.)

N.B.: Ideally, I am only burning extra body fat – and sparing protein. My body will use the carbs that I ate, which are going to be oxidized first, when it needs to make glucose for those cells that do not have mitochondria and therefore lack the ability to make ATP. Plus, amino acids from digested protein, not taken up in circulation, will become glucose via gluconeogenesis in the liver. And, the liver can also make glucose from the glycerol backbones of catabolized triglycerides when body fat is broken down and burned.