NOTHING on this site is to be considered personal advice. This site is ONLY intended for educational purposes. Refer to your personal physician regarding ANY health guidelines seen in this blog as everyone is different in their medical needs.

CME slides:

My grand rounds CME slides are now available on Picasa--click the blue box on the top of the right hand column.

Sunday, July 25, 2010

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).
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.
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

  • Cheese—cheeses are fine in moderation, depending on how much saturated fat you want in your diet.

  • 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


  • 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.


  • 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.nmsociety.org The Metabolism Society
www.low-carbchef.com recipes

More Advanced Web Sites/Blogs
www.paleonu.com Paleolithic Nutrition
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.

Monday, July 19, 2010

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???).