Scientists now saying carbs, not fat, are to blame for America's ills - latimes.com

Scientists now saying carbs, not fat, are to blame for America's ills - latimes.com

This is a well written article. The author quotes Willett and Hu, from the Harvard School of Public health are very reputable sources. Their research supports glycemic load as a diabetes risk factor.

More thoughts on what I should have presented

Note--this is taken from my email response to someone(on the Nutrition and Metabolism Society  list-serv) wondering how my talk went

I think the effect of advice in the public health/pop culture has to be considered, and peoples conceptions of what people actually eat on a low carb diet are skewed.  We told people to eat less fat and eat carbs instead--instead we just ate more carbs.  People think we eat more of everything or are less physically active, but really what has changed has been carbs.  The NHANES data really support this.  I looked at the USDA consumption data as well, and that really backs it up, http://www.ers.usda.gov/Data/FoodConsumption/.  I really tried to point out that low carb diets do not really result in more fat, or at least more saturated fat consumption, do not result in ketosis, and basically decrease only the carbs in the diet and calories, without overt caloric restriction.  I reviewed  large studies only (I stuck to 6 month + studies, which ended up being in Annals of Internal Medicine, JAMA, or NEJM) even though I know that especially in diabetics the data from smaller studies of shorter duration is great.  I wanted to deflect criticisms.  

I did not get into the arguments that ketosis is safe, we know it is, but getting bogged down in "confusing science" during a one hour presentation when hardly anyone in major LC trials gets to ketosis didn't make sense.  The totality of the data supporting weight loss, and when studied, much better diabetic control, is so compelling, it can speak for itself.   Likewise, I did not discuss metabolic advantage or good and bad calories, but if we believe the reported caloric intake in studies, this is also self evident.  Someone asked about it during my presentation ("What is going on with the low carb diet--It is so much more dramatically more effective than the others ? [I had the weight figure up from the JAMA A to Z trial on the screen].   I did not want to get into is a calorie a calorie ? debate.  I questioned the dietary questioning/pointed out that perhaps a LC diet is lower calorie than the other diets despite reported intakes being similar, but said it is an area of great debate, mentioned the 2nd law of thermodynamics but also reminded people of insulin, glycemic index/load, etc.   It takes a whole lecture to do this  topic justice, if you have people who don't remember their second semester biochemistry in the audience.  By the way, the doctor ( a pediatrician) who asked about ""What is going on with the low carb diet ?" was also one who when I was rushed to get through some data introducing the glycemic index, asked why I didn't spend less time on the rest of the talk and more time on this.  I think his first question was rhetorical and he of course knew how the LC diet was working.  I did point out that the glycemic index is not very intuitive, and even the glycemic loads quoted are not based on real world portion sizes, especially in the case of pasta.  

The other audience response of note was basically--we shouldn't diet--we should instead eat whole, real food, Michael Pollan style.  Nothing is wrong with eating this way.  Everybody nods there head and agrees with M. Pollan--nothing is objectionable.  I don't think it translates into concrete recommendations though.  It would lead to overall lower glycemic load and probably more whole grains, fiber, and maybe less carbs, but people only do maybe 50% of what they tell them (look at the NHANES results--increasing carbs but not decreasing fat or in the large LC trials, carbohydrate intake 30-40% of calories by 6 months).  We are doing well to reduce carbs to 40% of calories and make the ones we eat have a lower glycemic index--but to get there, as in the trials, maybe everybody has to say they are following Atkins, when in fact at six months they are following the Zone diet.  

One last thing I presented was just a bit on the saturated fat idea (pointing out the arbitrary choice of countries in the 7 countries study) and the fact that replacing saturated fat with carbohydrates has a negative effect on cardiac event rates.   I really didn't do the saturated fat topic justice.  There were so many things I wanted to say, and only one CME to put it in.  In retrospect I would have cut a few of the LC intervention studies, Presented USDA consumption data or the NHANES data, but not both, and might not have presented the saturated fat idea.  I might have had time to discuss the glycemic index, insulin, and how LC diets are beneficial and have a metabolic advantage vs a similarly low calorie diet with more carbohydrates.  

In my slide set I had the meat vs plant low carb mortality analysis data--the paper was just a crappy analysis of two decades old observational studies, and taking time to point this out wasn't really necessary in my presentation.  I only included it because I thought people would wonder why I did not discuss this--because the study was picked up in the popular press as "meat kills."  I never realized how much and pre-emptive defense of one's thesis and points goes into deciding what to put into a presentation there is, especially on a relatively controversial topic such as dietary recommendations and different macronutrients.

Post presentation

Overall it went well.  I updated the link to the final version of the slides (includes hidden slides too and final edits).  We have a pretty savvy audience here in Corvallis.  I cannot argue against a varied diet with whole, real foods as Michael Pollan and a few in the audience suggested.  Certainly nothing is wrong with it.  I just don't know how useful the advice is in practice, as opposed to recommending a particular diet to someone who is already obese.  Others pointed out that really maybe the glycemic index is the key.  A moderate carbohydrate diet with whole grains, fruits, and minimally processed foods is probably going to be made up on average with foods with a lower glycemic index.  Teaching people to choose foods based on the glycemic index is not very intuitive though.  Some of the values don't make intuitive sense or are very misleading.  For instance, refined white flour pasta has a low glycemic index, but the glycemic load with a typical serving size is very high.

I think eating like Michael Pollan would want us to can keep a lean person lean, but I think people who are obese with insulin resistance or diabetes are going to need pretty significant weight loss first.  As shown in many studies, this is more likely to occur on a low carbohydrate diet than trying to cut calories and portions on a more balanced diet (though perhaps the comparator diets were not as whole/real foods based as M. Pollan would have us eat).

Slides for my grand rounds on 12/10/2010

Here is the link to the Powerpoint files on MediaFire:
http://www.mediafire.com/?ogxxlzan420bsg4
Hope to see you there on Friday, 12/10/10, conference rooms A/B at 12:30.

Updated handout--More evidence based

Some Surprising But True Facts....
Cutting calories in your diet by decreasing starches and sugars, without adjusting meat, dairy and healthy vegetables and fruits in your diet will raise good cholesterol, lower triglycerides, lower blood pressure, improve blood sugars, and loose weight instead of just cutting calories by cutting fat.



It will be helpful to understand how your food choices can either partially or completely reverse or at least slow down your diabetes or metabolic syndrome—or your diet make them get worse.

1. Knowing that foods are made of different macronutrients: carbohydrates, fats, and proteins.
2. Knowing how the macronutrients affect your blood sugar and then insulin levels. Carbohydrates raise blood sugar and require more insulin to control the blood sugar rise than proteins, and fats do not stimulate insulin or raise blood sugar at all.
3. Knowing the negative effects of too much insulin include the inability to lose stored fat, storing more fat, and possibly an increase in hunger.
4. The problem may be how quickly (and by how much) the carbohydrates we eat raise blood sugar (and thus insulin), called the glycemic index. White rice, potatoes and bread have higher glycemic indexes than brown rice, sweet potatoes and whole grain bread.

No diet will be effective if you are eating too many calories. The reasons why lower carbohydrate diets have been more effective for weight loss and improvements in blood sugar and triglycerides versus similar low fat diets with high carbohydrate contents are an area of much research and the findings are still controversial. I am not necessarily proponent of the Atkins diet, and a fish and plant based Mediterranean diet with 30-45% of calories from carbohydrates may be ideal. I believe though that the most effective diet should be followed when we are trying to reverse obesity and the complications of diabetes and the metabolic syndrome. Lower carbohydrate diets compared to lower fat diets have lead to greater weight loss that is both quicker and sustained for up to two years in studies.

The effect of a lower carbohydrate diet on your cholesterol, or lipids (triglycerides, HDL, and LDL) is complex and surprising to most people. Low carbohydrate diets are usually not any higher in fats than most peoples usual diet. Fat includes saturated fats, monounsaturated, and polyunsaturated fats (depending if you eat mammal or fish protein, nut/avocado intake, and your choice of oils). By decreasing the amount of carbohydrates, your triglycerides will go down, your HDL will increase, and the LDL cholesterol may go up or down. The measured volume of the LDL may increase, but if it does it will be less dense (more buoyant and fluffier, and less likely to lead to artery blockages) with fewer overall number of LDL particles—even if you eat saturated fats.

In many studies, having a low HDL and high triglycerides predicts heart disease much more than a high LDL or total cholesterol level. For many years it has been known that a low carbohydrate diet will improve triglycerides and HDL, but most dieticians and physicians have been reluctant to recommend this dietary change. American Heat Association and Department of Agriculture recommendations have not yet incorporated dietary advice that focus on improvements in HDL or triglycerides. The traditional USDA Food Pyramid has stressed increasing grain and other carbohydrate consumption. This may have been healthy advice if calories were kept stable and saturated fat intake decreased, but Americans have ate the same amount of protein and fat and added approximately 200 calories a day to their diets from carbohydrates. In a years time, this excess calorie intake could add up to 20 lbs in weight. The reasons for not recommending a moderation in our carbohydrate intake likely have more to do with academic culture, and government agricultural policies than an honest interpretation of the science of nutrition, in my opinion and that of many others.

In summary: You should avoid sugars (table sugar and high fructose corn syrup) and refined carbohydrates (rice, bread, and pasta) and fruits and vegetables which are high in carbohydrates or sugar with very little fiber (like potatoes, grapes and watermelons). Decrease your carbohydrates more if you are not losing weight or reaching your blood sugar goals. You must not intentionally overeat or eat when you are not hungry. It is harmful to your health to eat both a high fat and high carbohydrate diet, so be sure you have not taken my advice to mean increasing fats without decreasing carbohydrates. After you have reached your weight loss goal and/or are instructed to cut the doses or stop some of your diabetes medications or insulin, you can add back more healthier, unrefined carbohydrates (like recommended in the South Beach Diet books). You can be sure you are not reversing the helpful metabolism changes you have made by making sure you do not gain weight and checking your blood sugar to be sure it is remaining under control.

WARNINGS FOR DIABETICS:

If you have diabetes and are on insulin or a sulfonylurea, you should know and recognize the symptoms of hypoglycemia (low blood sugar). The pills which stimulate the pancreas to release insulin even with a normal blood sugar are called sulfonylureas (glipizide, glyburide, and glimepiride/Amaryl and metglitinides (repaglinide/Prandin and neglitinide/Starlix). If you are on one of these medications or insulin, your should seek specific advice regarding your risk of developing hypoglycemia and an action plan to prevent it or modify your medications (at times decreasing doses by up to 50% or more depending on your current diet and diabetic controll) before decreasing carbohydrate intake significantly.

If you have diabetes and are on insulin or a sulfonylurea, you should keep your carbohydrates between 50 and 100 grams a day, at least. You should have one small serving of carbohydrates with each meal (one slice of bread, ½ cup of cereal, ½ cup rice, or ½ a medium potato) to be sure you get enough this amount of carbohydrates in addition to the carbohydrates you get in a healthy selection of non-starchy vegetables and less-sweet fruits.

If you are following one of the popular diet books like the Atkins Diet or South Beach Diet, you should begin the programs in the second phase and avoid the extremely low carbohydrate first phases, called “Induction” in the Atkins diet and begin in the “Ongoing Weight Loss” second phase. Your should begin in “Phase 2” of the South Beach diet.

The fist phases of the Atkins or South Beach Diets diet recommend less than 20 grams of carbohydrates a day and would lead to dangerous and unpredictable insulin reactions or hypoglycemic reactions if you are treated with insulin or a sulfonylurea.

Foods can be eating and things you should be doing:

Meat, Eggs, and Tofu Chicken, beef, pork, turkey, venison etc. are all acceptable meats. Eggs that are home raised or vegetarian fed/omega 3 enriched eggs are more beneficial. Only a 15% of people will develop an increase in cholesterol from eating eggs, and even 3 eggs a day, everyday, only raised their LDL by 10-15 mg/dL Fish—any fish is fine, but wild caught and fattier fish may be more beneficial Tofu can be a meat substitute. I like to buy extra firm tofu, press it between two plates to drain the water, and then marinate before cooking. Oils, Fats, and allowed treats Olive oil is probably preferable to canola oil―Avoid most other vegetable oils. Avoid margarines and trans fats. Some baked goods or pancakes made with almond or coconut flour and eggs Nuts― Avoid salty or sweetened varieties because they will stimulate appetite and overeating. Dark chocolate. Butter and cream and other dairy fats can be used in moderation. Cheese—cheeses are fine in moderation

Vegetables green beans, asparagus, broccoli, cauliflower, cabbage, onions, tomatoes, avocados, squash, zucchini, carrots, all kinds of lettuce, etc. Raw carrots and celery are very convenient snacks. Avocados are a very good source of monounsaturated fat. Basically any vegetable except potatoes or corn Fruits Berries are very healthy fruits, high in fiber and nutrients. Blueberries are especially plentiful in the Willamette Valley and can be frozen. Try and eat sweet fruits with less fiber when they are in season or you are more active, generally in the summer. Peaches, plums, grapes, etc. Apples can be eaten anytime of the year and are very filling. Time and water Take the time to enjoy your your food and split your servings into two if you find yourself overeating despite good choices. Drink plenty of water between and with meals. 64 ounces a day is adequate. Supplements Fish oil for most people Vitamin D supplements for most people (1000 to 2000 units a day) A one-a-day multivitamin for most people Calcium supplements for some people

Foods you should try to avoid and things to read:

Group One Foods Generally avoid for maximal metabolic and weight loss benefits. When you do eat them, choose whole grains. Bread―whole grain preferred Pasta―whole wheat preferred Rice―brown or wild rice preferred Potatoes―sweet potatoes are preferable Cereals, hot or cold—choose the highest fiber cereal or old fashioned less processed oatmeal Corn―I consider it nutritionally a starch, not a vegetable. Full sugar/corn syrup sodas, fruit juices, and energy drinks Beer―it is very high in carbohydrates Group Two Foods Avoid if possible―only as very special treats Most desserts, cookies, candy, pancakes, ice cream, and baked goods—in moderation, for obvious reasons Chips, crackers, pretzels, cereals bars—most foods in pre-packaged bags or boxes contain corn syrup or other carbohydrates as the main source of calories. Milk—It contains a lot of carbohydrates and many people drink to excess. Cream or half and half in coffee is fine. Sugary fruit without much fiber―for example watermelons, canned fruit, juices, bananas, and grapes. Group Three Foods Eat in moderation Yogurt—Yogurt is relatively high in carbohydrates compared to fat and protein. Beans― have a significant amount of carbohydrates, but also provide fiber and some protein.

Beginner Books The South Beach Diet, by Anthony Agatston, MD New Atkins for a New You, by Eric Westman, MD Primal Blueprint, by Mark Sisson In Defense of Food, by Michael Pollan Advanced Books Good Calories, Bad Calories, by Gary Taubes. Dr. Bernstein's Diabetes Solution, by Richard K. Bernstein, MD Beginner Web Sites/Blogs www.goodcaloriesgoodinsulin.com my blog www.marksdailyapple.com www.phlaunt.com/diabetes www.phlaunt.com/lowcarb www.low-carbchef.com recipes http://tinyurl.com/veganlowcarb Vegan Low Carber More Advanced Web Sites/Blogs http://tinyurl.com/NYT-Gary-Taubes-Article New York Times Magazine article by Gary Taubes summarizing much of Good Calories, Bad Calories http://tinyurl.com/Rebuttal-of-Gary-Taubes Low fat biased rebuttal of this article by Center for Science in the Public Interest (Nutrition Action) wholehealthsource.blogspot.com www.paleonu.com Paleolithic Nutrition http://tinyurl.com/CarbohydrateRestriction Journal article entitled: Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal My Personal Experience I knew I had to lose weight to avoid diabetes, which runs very strongly in my family. I have cut the carbohydrate calories down in my diet with remarkable improvements. My weight has decreased 30 pounds and I am easily maintaining this. My blood sugar went from 118 to 105. My hemoglobin A1c decreased from 5.8 to 5.3 (a drop of 15 blood sugar points on average). These improvements were in spite of stopping metformin (Glucophage) a medicine which would lower my blood sugar even further. My triglycerides decreased to 135 from 204, my HDL increased to 52 from 46, and my LDL increased to 109 from 74

Faux Spaghetti Recipe (Cabbage)

I have been mentioning at appointments.  I loved making spaghetti.  I used 1/2 Hunts Mushroom Spaghetti sauce and a couples of tomato and a box of Barillo whole wheat pasta.  The problem was I ate 2/3 of the box of pasta.  Now I make the same sauce with the same flavors and much less calories and carbs.  I have been told this is an old Weight Watchers recipe.  I have made variations which also taste great with Worcestershire sauce and thyme/sage or Herbs de Provence instead of a tomato sauce also which taste great.

Cabbage Spaghetti and Meat Sauce
In a large pot
Brown/saute:

• 1 lb of hamburger (80-90% lean approximately)
• 1 or 2 chopped onions
• tablespoon of crushed garlic or 3-4 crushed cloves
• fresh sliced mushrooms if you want

Quarter one cabbage and then slice lengthwise thinly

• Add cabbage to browned and sauteed onions, separating pieces of cabbage if you wish
• Add you favorite pasta sauce--in my case one can of Hunts Mushroom Spaghetti sauce and one large or two smaller cans of tomatoes.  
• 1/2 to one cup of red wine if you want
• Lots of dried basil (tablespoon), some dried oregano (4-5 shakes) , and a bit of celery salt (2-3 shakes) if you want.

Cook for an hour or two in the pot--until the cabbage is fairly soft and of the texture you want, leaving the cover off if there is too much liquid.  

I think it tastes great and "tastes like cabbage if you like cabbage--doesn't taste like cabbage if you don't like cabbage."  My son (5 y/o) even eats it and he thought it was "noodles."  The cabbage bulks up the meal to the point that the sauce is not overly rich.  

Byetta--Is it helpful if you are on a low carb diet?

My uncle recently read my handout and says he is following a primal/low carbohydrate diet for the past 10 days but he has not lost any weight.  He is obese and has diabetes controlled well on Byetta--probably a good but very expensive way to control diabetes!!  In addition giving him some diet reminders and telling him to decrease fruit consumption and maybe even counting carbohydrate grams, his question to me was, "Should I stop Byetta?"

I think Byetta has minimal positive metabolic effects If you are on a low carbohydrate diet and you don't really need the extra kick in the pancreas response to control blood sugars.

Byetta is a great medication when diabetics or pre-diabetics are eating the average diet containing  50-60% calories from carbohydrates though.  

The positive effects that would lead to weight loss though are either not needed or can be regulated without Byetta on a low carb diet.  The positive effects that would lower blood sugar aren't needed if the sugar can be controlled on a low carb diet.  Byetta does increases satiety (delays gastric emptying) and decreases appetite/satiety via the effect on thalamic receptors--but a fat and protein rich meal can also increase satiety and relieve hunger.  

Byetta will make the pancreas more sensitive to blood sugar and cause a much higher and quicker  release of insulin.   By suppressing  glucagon release, Byetta stops glycogen in the liver from breaking down into glucose (and discourages the new storage of glucose as glycogen in the liver).   The greater pancreatic sensitivity to blood sugar (and thus insulin release) that Byetta gives though is helpful if you have a "burnt out" pancreas.  It will lead to a quicker control of blood sugar and the appropriate timing of the insulin release.  This beneficial in those advanced diabetes--those with a "burnt out" pancreas with severe dysfunction.

Byetta may not help much on a low carbohydrate diet if you don't have fairly advanced diabetes.  Unless you really need Byetta to control (by enhancing insulin secretion) even the small rise in blood sugar that occurs with a low carbohydrate diet, it seems plausible that this would lead to higher insulin levels than are needed to decrease blood sugars and prevent the toxicity of high blood sugars.  Higher insulin levels even with a normal blood sugar will lead to less lipolysis (net fat storage).   If you have pre-diabetes or easily controlled diabetes (hemoglobin A1c < 7.5 on Byetta and/or metformin), changing from a conventional high carb diet to a low carb diet will likely lead to at least as much benefit as Byetta.  It is my opinion that Byetta may not improve blood sugars or lead to more weight loss when added to a low carbohydrate diet unless the patient's diabetes is advanced.

I'd welcome comments from patients and doctors on the additive benefits of Byetta to a low carbohydrate diet, if any.

Improved Handout/My "position statement"

Some Surprising But True Facts....

Low carbohydrate diets raise good cholesterol, lower triglycerides, improve blood sugars, and lead to weight loss with less hunger.

Based on my own recent experience and a review of multiple sources of nutritional information, for my patients who have not successfully followed a conventional low fat, calorie restricted diet (like Weight Watchers or the American Heart Association diet) or a relatively high carbohydrate Mediterranean diet, I am recommending a lower carbohydrate, higher fat and moderate protein diet. I am also making this recommendation because you either have high triglycerides/low HDL, have the metabolic syndrome, or have type II diabetes. It will be helpful to understand how your food choices can either partially or completely reverse these problems or make them get worse.

1. 
   
   Knowing that foods are made of different macronutrients: carbohydrates, fats, and proteins.
2. 
   
   Knowing how the macronutrients affect your blood sugar and then insulin levels. Carbohydrates stimulate insulin much more than proteins, and fats do not stimulate insulin or raise blood sugar at all.
3. 
   
   Knowing the negative effects of too much insulin include the inability to lose stored fat, storing more fat, and possibly an increase in hunger.

The effect of a lower carbohydrate diet on your cholesterol, or lipids (triglycerides, HDL, and LDL) is complex and surprising to most people. Low carbohydrate diets are higher in fats, including saturated fat (depending if you eat mammal or fish protein and your choice of oils). Your triglycerides will go down, your HDL will increase, and the LDL cholesterol may go up or down. The measured volume of the LDL may increase, but if it does it will be less dense (more buoyant and fluffier, and less likely to lead to artery blockages) with fewer overall number of LDL particles—even if you eat saturated fats.

When it has been studied, having a low HDL and high triglycerides predicts heart disease much more than a high LDL or total cholesterol level. For many years it has been known that a low carbohydrate diet will improve triglycerides and HDL, but most dieticians and physicians have been reluctant to recommend this dietary change (even though the American Heart Association [AHA] diet may actually lower HDL and raise triglycerides while only lowering the LDL to a very small extent). Instead of recommending a low carbohydrate diet, physicians and nutritionists have recommended weight loss and exercise to improve HDL and triglycerides, even though following the AHA diet generally does not reliably lead to weight loss and adding exercise without dietary changes does very little to affect the lipids. The reasons for not recommending a low carbohydrate diet have more to do with academic culture, and government research policies than an honest interpretation of the science of nutrition, in my opinion and that of many others.

Animal fat is actually a mixture of different forms of fat, and the slight majority of beef fat is actually the healthy monounsaturated fat, not saturated fat. Saturated fat can increase both the HDL cholesterol and LDL cholesterol. It is likely to be neutral in terms of health while on a low carbohydrate diet. Monounsaturated fat, like in olive oil, raises HDL, lowers triglycerides, has little effect on LDL, and it may improve insulin resistance. The Atkins diet allows for a variety of fats while the South Beach diet encourages less saturated fat. Either one is likely to improve your lipid profile and lead to weight loss. You can decide for yourself whether you want to lower saturated fats (animal fat, dairy fat, and coconut oil), but I, among others, believe there is no evidence of harm from saturated fats while on a low carbohydrate diet. Trans fats should always be avoided.

I do not expect my patients to completely avoid all foods listed on page 4, but if you do, you will lose weight very quickly and have very little hunger. Because I realize most people will not avoid all of these foods, I recommend counting carbohydrates for a couple weeks only, just to educate yourself on the carbohydrate content of your food. I recommend using eitherwww.sparkpeople.com or www.fitday.com, and limiting yourself to a total of 30-50 grams of carbohydrates from the non-preferred foods that are in Groups One, Two, or Three listed on page 4. Your total carbohydrates per day using this approach will be about 50-100 grams of carbohydrates including carbs you are not counting from non-starchy (healthy) vegetables and fiber rich fruits like apples and berries listed on page 3. After you have reached your weight loss goal and/or are instructed to cut the doses or stop some of your diabetes medications or insulin, you can add back more healthier, unrefined carbohydrates (like recommended in the South Beach Diet books). You can be sure you are not reversing the helpful metabolism changes you have made by making sure you do not gain weight and checking your blood sugar to be sure it is remaining under control.

In summary: You should avoid sugars (table sugar and high fructose corn syrup) and refined carbohydrates (flour and pasta) and vegetables/grains which are high in carbohydrates with very little fiber (like rice, potatoes, and corn). Decrease your carbohydrates more if you are not losing weight or reaching your blood sugar goals. You must not intentionally overeat or eat when you are not hungry. It is not helpful, and it is harmful to your health to eat both a high fat and high carbohydrate diet, so be sure you have not taken my advice to mean increasing fats without decreasing carbohydrates.

Your particular metabolic tendencies (diabetes, pre-diabetes, high triglycerides or low HDL cholesterol) are based on your genetics and will not change during your lifetime, regardless of weight loss or diet changes. A diet is a short term solution with weight loss alone as a goal, something to endure and then give up. The change I am advocating for you is motivated by more than a short term goal of losing weight and should be maintained for the benefit of your metabolic problems (diabetes, lipids, etc).

WARNINGS FOR DIABETICS:

If you have diabetes and are on insulin or a sulfonylurea, you should know and recognize the symptoms of hypoglycemia (low blood sugar). The pills which stimulate the pancreas to release insulin even with a normal blood sugar are called sulfonylureas (glipizide, glyburide, and glimepiride/Amaryl and metglitinides (repaglinide/Prandin and neglitinide/Starlix). If you are on one of these medications or insulin, your should seek specific advice regarding your risk of developing hypoglycemia and an action plan to prevent it or modify your medications (at times decreasing doses by up to 50% or more) before decreasing carbohydrate intake significantly.

If you have diabetes and are on insulin or a sulfonylurea, you should keep your carbohydrates between 50 and 100 grams a day. You should have one small serving of carbohydrates with each meal (one slice of bread, ½ cup of cereal, ½ cup rice, or ½ a medium potato) to be sure you get enough this amount of carbohydrates in addition to the carbohydrates you get in a healthy selection of non-starchy vegetables and less-sweet fruits.

If you are following one of the popular diet books like the Atkins Diet or South Beach Diet, you should begin the programs in the second phase and avoid the extremely low carbohydrate first phases, called “Induction” in the Atkins diet and begin in the “Ongoing Weight Loss” second phase. Your should begin in “Phase 2” of the South Beach diet. The fist phases of the Atkins or South Beach Diets diet recommend less than 20 grams of carbohydrates a day and would lead to dangerous and unpredictable insulin reactions or hypoglycemic reactions if you are treated with insulin or a sulfonylurea.

WARNINGS FOR PATIENTS WTH KIDNEY PROBLEMS:

If you have kidney disease (chronic renal insufficiency, kidney failure, protein in the urine, elevated creatinine, or low GFR) you should be more cautious about eating an excess amount of protein and remember to drink an adequate amount of water (64 ounces a day). I recommend that you discuss obtaining blood work to check for any worsening kidney function a few weeks after starting on a low carbohydrate diet. The risk of harming your kidneys by the diet is still very low and the harm of a high protein diet to kidney function is controversial. Many kidney specialists no longer recommend protein restriction for most of their patients. However, I would count protein grams for at least a couple weeks to be sure you are not getting more than about 0.4 to 0.5 grams of protein per your pound of weight seems prudent (about 90 grams of protein for a 200 lb person). Six ounces of very lean meat contains about 90 grams of protein. It is probably safe to exclude protein from eggs, vegetables, and beans from this total.

Foods can be eating and things you should be doing:

Meat, Eggs, and Tofu Chicken, beef, pork, venison, elk, duck, turkey, etc. are all acceptable meats. Eggs that are home raised or vegetarian fed/omega 3 enriched eggs are more beneficial Beef bought in bulk from a local ranch is a great value and healthier (more omega 3 fatty acids) than corn/grain fed beef you can get at the grocery store and it can cost as little as $3.50 per pound. Fish--wild salmon, tuna, mackerel, sardines Tofu can be a meat substitute. Buy extra firm tofu, press it between two plates to drain the water, and then marinate before cooking. Oils, Fats, and allowed treats Olive oil―Avoid other vegetable oils. They are not beneficial and may be harmful (even canola oil). Avoid margarines and trans fats. Some baked goods or pancakes made with almond or coconut flour and eggs Nuts― Avoid salty or sweetened varieties because they will stimulate appetite and overeating. Saturated Fats See my discussion of saturated fats on page one of this handouts. You may choose to eat these or not based on your preferences. coconut oil is probably a beneficial fat ghee―clarified butter―is a very useful oil to cook with. It has a high smoking point. butter and cream with veggies and fruits are acceptable Cheese—cheeses are fine in moderation, depending on how much saturated fat you want in your diet.

Vegetables green beans, asparagus, broccoli, cauliflower, cabbage, onions, tomatoes, avocados, squash, zucchini, carrots, all kinds of lettuce, etc. Carrots and celery are very convenient. Avocados are a very good source of monounsaturated fat. Basically any vegetable except potatoes or corn Fruits Berries are definitely the best fruits. Go pick strawberries and eat them in season. Pick blueberries and fill your deep freeze with them (we are in the best area in the country for blueberries). Try and eat sweet fruits when they are in season or you are more active,generally in the summer. Peaches, plums, etc. Apples can be eaten anytime of the year and are very filling. Time and water Take the time to enjoy your your food and split your servings into two if you find yourself overeating despite good choices. Drink plenty of water between and with meals. 64 ounces a day is adequate. Supplements Fish oil for most people (unless you are eating lots of fish or grass-fed red meat) Vitamin D supplements for most people (1000 to 2000 units a day) A one-a-day multivitamin for most people Calcium supplements for some people (if you are eating a diet so low in carbohydrates it is considered ketogenic, like Phase One of the Atkins or South Beach diet, or if you are risk of or have osteoporosis)

Foods you should try to avoid and things to read:

Group One Foods Generally avoid for maximal metabolic and weight loss benefits Bread―whole grain preferred Pasta―whole wheat preferred Rice―brown or wild rice preferred Potatoes―sweet potatoes are preferable Cereals, hot (oatmeal) or cold—very high in carbohydrates, even if “high fiber” Corn―it is a starch, not a vegetable. Full sugar/corn syrup sodas and energy drinks Beer―very high in carbohydrates Group Two Foods Avoid if possible―only as very special treats Milk Chocolate—Very dark chocolate is a better choice. Most desserts, cookies, pancakes, ice cream, and baked goods Milk—It contains a lot of carbohydrates. Cream or half and half in coffee is fine. Sugary fruit without fiber―for example watermelons, canned fruit, juices, bananas, and grapes. Group Three Foods Eat in moderation Yogurt—Yogurt is relatively high in carbohydrates compared to fat and protein. Beans― have a significant amount of carbohydrates, but also provide fiber and some protein.

Beginner Books The South Beach Diet, by Anthony Agatston, MD New Atkins for a New You, by Eric Westman, et al. Primal Blueprint, by Mark Sisson Advanced Books Good Calories, Bad Calories, by Gary Taubes. Beginner Web Sites/Blogs www.marksdailyapple.com www.phlaunt.com/diabetes www.phlaunt.com/lowcarb www.nmsociety.org The Metabolism Society www.low-carbchef.com recipes http://tinyurl.com/veganlowcarb Vegan Low Carber More Advanced Web Sites/Blogs http://tinyurl.com/NYT-Gary-Taubes-Article New York Times Magazine article by Gary Taubes summarizing much of Good Calories, Bad Calories http://tinyurl.com/Rebuttal-of-Gary-Taubes Low fat biased rebuttal of this article by Center for Science in the Public Interest (Nutrition Action) wholehealthsource.blogspot.com www.paleonu.com Paleolithic Nutrition http://tinyurl.com/CarbohydrateRestriction Journal article entitled: Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal My Personal Experience After being inspired by my father who lost 80 pounds (260 lbs to 180 lbs) and cut his insulin from 140 units to none, I knew I had to lose weight. I eat meat, eggs, veggies, fruit, cream, and cheese, and I have lost 25 pounds. My blood sugar went from 118 to 105. My hemoglobin A1c decreased from 5.8 to 5.3 (a drop of 15 blood sugar points on average). These improvements were in spite of stopping metformin (Glucophage) a medicine which would lower my blood sugar even further. My triglycerides decreased to 135 from 204, my HDL increased to 52 from 46, and my LDL increased to 109 from 74. I do not feel hungry and I love the food I am eating.

First Post. Sharing my success and tools

I hope to be discussing and critiquing the research on coconut oil, rice (as opposed to gluten containing grains), a higher protein diet in those with chronic kidney disease (decreased GFR and/or significant proteinuria), and other topics which are poorly understood by patients and physicians.

I am a bit of a novice at the moment in my development of my own diet and dietary recommendations for my patients, but I certainly believe in the power of major dietary changes of our ratios of fat, protein and carbohydrates in those with susceptible metabolisms.  I personally have a family history of very early onset of type II diabetes, gout, and severely high triglycerides.  My current dietary approach is low carbohydrate with no avoidance of saturated fat, but I am open to the evidence.

I have been shocked in the last few months from successes by several patients who have been on Medifast and I have been always mystified by my patients who have lost (and later regained) weight on lower carbohydrate diets which they went on furtively prior to seeing me, without any physician approval.  It seems half of my obese or metabolic syndrome (or worse, diabetic) patients have been on low carb diets and are ashamed of this admission.  I think they quit the diet which made them feel better and they could follow because they had no support and felt that they were doing something wrong.  This all goes back to the fat-cholesterol hypothesis which has become dogma secondary to many factors but not actual good evidence.

So, I feel despite my reservations from years of hearing about fat, that if my overweight, obese, diabetic, and/or dyslipidemic patients have not improved their diet by now on a low fat, calorie restricted diet they are unlikely too.  I have reviewed the literature and looked at my own labs and feel it is reasonable to recommend a much lower carb and much higher fat diet.  I hope I am right, but I do not find any evidence that contradicts this approach and find beneficial changes in short term studies (up to 2 years in duration though now).  I am disappointed that a study powered to find mortality differences between a low carb diet versus a conventional or a low fat diet.  Unfortunately this study will be unlikely to be funded since dietary recommendations are not a profit making venture for any pharmaceutical company.  The government and institutional consensus, per the food pyramid and official recommendations from the American Heart Association, seems to have already decided in 1984 with very little evidence that a low fat diet will decrease deaths and disease, despite contradictory or lack of evidence.

So, this is my initial musing (rant???).