November 18, 2009

Saying Something Over And Over Doesn't Make It True

No, this is not a post about the "eating fat causes heart disease" fantasy, nor is it a post about Going Rogue, but the issue I am going to discuss here shares features with those topics the Low Carb community has been very resistant to confronting.

The issue is this: The very same people who spend hours hunting through overlooked but well-designed published medical research to provide us gems that help us understand metabolism better seem to lose their respect for scientific method as soon as they turn their attention to theories about human prehistory.

People I otherwise respect greatly accept theories about "paleo diets" and the health of early human populations that are either a) based on a very small sample of outdated early 20th century research or b) entirely made up.

It may come as a surprise to some of you that the study of paleontology is a scientific discipline pursued by intelligent, educated scientists using a wide variety of sophisticated tools. These scientists have come up with many findings that tell us a lot about the lifestyles of real "paleo" peoples around the globe.

None of this research is ever cited by the people who have made the so-called "paleo diet" a religious crusade, people who have never taken the time to look into the evidence these myths are based on.

Paleo Fanatics Show Off Their Ignorance

Just this week I read a post on a Low Carb discussion board claiming that the Egyptian mummy that shows evidence of heart disease came from a period "right after the invention of agriculture"--a statement which in off only by about 11,000 years. Agriculture started somewhere around 12,000 BC and the earliest of these mummies are from about 1600 BC.

By the same token, we know a great deal about the lifestyles of hundreds of modern day hunter gatherers painstakingly collected by trained anthropologists who lived with these people for many years. You would never know this from reading the Paleo fantasist's writings, which invariably cite one and only one source, the early 20th century arctic explorer, Vilhjalmur Stefansson.

A recent correspondent went to far as to inform me, based on what he had read on a Paleo fanatic web site, that Stefansson was the only person to ever live with a hunter gatherer culture while speaking their language. This misstatement ignores the work of at least 400 other trained anthropologists who not only did the exact same thing as Stefansson, living with people of pre-industrial cultures all around the world, but in many cases they lived with these people for far longer than the few winter months Stefansson did. They also published more extensively about their observations in writings intended for other anthropologists, not a popular audience, and those writing later in the century were much more aware of the need to see ALL of what was going on in the culture, rather than cherry pick the cultural details that reinforced their personal beliefs and ignore the rest.

So with this in mind, you can see why I find it disturbing that people with a lot of cred in the Low Carb world, including several of the M.D. mega-bestselling authors, continue to parrot Paleo fantasy statements about "our ancestors' diet" or about the diet and lifestyle of modern non-agricultural peoples that have no more basis in science than the idea that eating fat gives people heart attacks.

What Science Knows About Real Paleo Diet and Lifestyle

If you are interested in learning more about what our ancestors really ate, I would highly recommend a new book written by a brilliant Harvard anthropology professor. It opened my eyes to the advances that have occurred in paleontology since I studied it at the University of Chicago in the 1960s when I took my Anthropology degree there.

The book is Catching Fire: How Cooking Made Us Human by Richard Wrangham.

Wrangham's book's very-well documented thesis is that it was the very early discovery of cooking by pre-human hominids which allowed humans to develop the metabolically expensive human brain. His main point is that cooking, because it breaks down starches and proteins, made redundant the long, metabolically expensive digestive tracts found among pre-human hominids and allowed them to atrophy, freeing up the calories no longer needed for 5 hours a day of chewing and round the clock digesting of raw foods to be used to fuel, and grow, our metabolically expensive brains.

But the relevance of this book to our discussions in the online diet community lies not so much in its primary thesis but in the mass of data, derived from extensive research, the author provides about what the historical and anthropological record tells us about what early humans and prehumans ate.

And that research makes it clear that people and "pre-people" eating pre-agricultural diets bear little relationship to the Supermen described in the Paleo Myth invented people ignorant of paleontology and anthropology.

For starters, in most of the many modern era hunter-gatherer societies studied since the late 19th century, it turns out that at least 50% of calories came from gathered, i.e. vegetable, sources not meat, almost always provided by females. And even more importantly, these gathered foods were not made up of leaves which provide very little nutrition, but of starchy foods especially roots, seeds, and tubers.

Wrangham also cites the finding that the Inuit, so beloved by Paleo fantasists, ate more than fat and meat: they savored the raw, full intestines of their prey as well as deer droppings. This suggests the lengths to which humans will go to get the nutrients found from plant-derived sources--and how inadvisable it is to use the Inuit as the model upon which to base your diet.

Nor does research substantiate the idea that the lives of ancient Paleo people were the easy, physically invigorating idylls the Paleo myth describes. Hunting in most environments is an exhausting pursuit that provides marginal sustenance. The usual prey is not an elephant but a few small rodents. In most modern era pre-agricultural societies the sheer volume of food-related labor women are forced to provide is comparable with what was demanded of plantation slaves or the most oppressed factory worker.

The fantasy is that Paleo people lived lives of unparalleled health until they were forced into agriculture and made to live on evil carbs. The reality is that the bones of our "paleo" ancestors show clear signs that they were subject to periodic, severe and crippling famines.

This finding is, of course, reinforced by reports from those who had first contact with modern era hunter gatherers. It is often forgotten that one of the reasons that the earliest French settlers of Canada had so much contact with Native American tribes is that the tribes were starving when Champlain first encountered them, and they came to the French because they offered food.

Wrangham also points out that in modern Africa traditional people's must contend with a long period during the Dry Season when famine is common when game disappears.

I recently read a fascinating biography of a 19th century white child who was raised by Californian Native Americans living a traditional lifestyle, The Blue Tattoo: The Life of Olive Oatman (Women in the West) which made clear what it would be like to live through such a periodic famine. It describes one that occurred in a traditional non-contact Native American society living in SE California. Summary: many children died as did many older adults.

People adopted agriculture because it gave them a much better chance of seeing their children survive. Women probably put a lot of pressure on their men to adopt the agricultural lifestyle because as hard as women work in agricultural societies, their lot in them is far better than those of women in pre-agricultural societies who may have to gather and drag 30 lbs of roots over a range of ten or more miles every single day--before they start cooking dinner for men just returned from hunting.

It is worth remembering that those very few pre-agricultural societies that survived the agricultural revolution--the ones observed by Stefansson and others--were all cultures where people lived in environments where hunting and gathering provided more food than agriculture could--areas with very short (or in the arctic, no) growing seasons, deserts, areas with disease vectors that made settled life fatal, or very rarely, as in Amazonia and New Guinea, tropical areas where nature provided much more food than it does in the temperate zones.

Everywhere else, hunting and gathering was a very hard way to stay alive, and people took to agriculture with the alacrity with which our generation has taken to the computer and for the same reason: because the benefits were undeniable and instantly obvious.

Grain-based agriculture let more children survive to adulthood. Only after its advent did the human population begin to grow at a steady rate, rather than just barely replacing itself.

Grain-based agriculture provides, uniquely in human experience, enough surplus food that some people can put their time into non-calorie producing behaviors, like inventing writing which allows shared knowledge and technology to grow beyond what one person can retain in their memory. It is those grain-provided surplusses that have led to your being able to sit in front of your computer reading this post even if you do it while imagining how much happier you would be if you were "Paleo Man."

Why Does It Matter?

Okay, you might say, maybe the whole Paleo thing is a myth, but why make a big deal about it?

The answer is simple. The minute you support a good idea with made up "facts" and bad science, you invalidate it.

Doctors and nutritionists ignored the Atkins diet because he supported his claims with outdated, discredited studies like the one describing "fat mobilizing substance" and the research that claimed someone lost a huge amount of weight eating ten thousand calories a day of fat. By relying on bad science (and not updating the books to remove it, long after it was known to be bad science) Atkins delayed for a generation the rigorous study of the low carb diet.

We run the risk of doing the same thing to the diet when we argue for it using myths that educated people know to be myths.

What makes it so sad is that there is no need to use myths to make our point. There is plenty of very good science that supports the advantage of cutting down on carbs, eliminating processed foods, and demanding that industry stop polluting our environment with organic chemicals that are damaging our bodies We don't need to argue for our modern dietary improvements by citing imaginary, Eden-dwelling ancestors and misrepresenting their diets to do it.

The truth is, it is irrelevant what ancient people ate 20,000 years ago. Evolution occurs in periods as short as 100 years, so the dietary changes that have taken place in that past 20,000 years have altered our metabolic physiology in thousands of small ways that make us very different physiologically from "paleo" people.

To see an example of this, we need only remember that those of us who are descended from herders can digest milk as adults, while those who did not evolve in cultures with domesticated milk-giving animals are lactose intolerant, like most other adult mammals.

So matter what Paleo peoples ate, those of us who descend from European or Asian stock living in the Temperate Zone can be sure our ancestors' bodies adapted very well to agricultural diets. We are all descended from people who flourished on the energy provided by the stored starchy vegetables and grains that kept them alive through the long cold northern winters when game is very hard to find. Those who did not flourish on those diets did not survive to become anyone's ancestors.

It's Not The Deep Past But The Very Recent Past That Points to The Problems

Rather than imagining the far distant past, we need only look at the very recent past to find much more relevant arguments to support our need for dietary change.

It is the new factors introduced in the past century that we should be focussing the full force of Science on to answer the question of why we have a sudden epidemic of metabolic diseases. Research is turning up a lot of answers, though the corporate-owned media ignore those that point to corporate culpability as the explanation.

The obesity/diabetes epidemic is closely related to the phthalates and other organic molecules that leach from PVC plastics and Bisphenol-A that estrogenize our bodies, the soy proteins that damage our gut linings allowing otherwise benign gluten to get into our blood stream an provoke autoimmune attack, the high fructose corn syrup that turns into intracellular liver fat, the arsenic from coal burning that promotes diabetes, the PCB, pesticide, herbicide and pharmaceutical drugs that are in our water supply and our bodies which all increase insulin resistance.

Let's focus on the real science and make the public aware of the findings of this good science so we can do something about this metabolic epidemic. Until we can heal it, those of us who can't process carbs will have to cut way back on them. But let's leave the myths that reinforce personal belief systems to the churches where they belong. They won't cure what ails us.
UPDATE: Nov 21, 2009:

Check out this fascinating look at Arctic mummies. The link was posted by "Coach Jeff" in the comment section. The book cited is a real eye opener. I will have go get a copy.

Mummies, disease & ancient cultures By Eve Cockburn, Theodore Allen Reyman

Two of the Arctic and Aleutian mummies described here--those of older people--show distinct signs of atherosclerosis. The starved child who died with a tummy full of gravel and hair points out the impact of cyclical starvation on hunter cultures.


November 16, 2009

Portion Size: Your Brain Is Not Your Friend

As we head into the holiday season it's time to reflect on a food-related issue that doesn't get the respect it deserves: portion size.

A study discussed in Science Daily last spring comes up with a fascinating finding about how our minds work--one that explains why we may find ourselves stalled on diets or seeing inexplicable rises in blood sugar. When presented with pictures of the same food in two different portion sizes, people disregard the differences in portion size when estimate calories. Instead, they seem to take a "unit" approach. One plate of food equals one serving.

The description of this study can be read here:

'Shortcuts' Of The Mind Lead To Miscalculations Of Weight And Caloric Intake, Study Finds

All diet strategies that rely on counting anything will fail if you are estimating counts based on a nutritional database but ignoring the fact that the counts apply to a specific portion size.

Because the portion sizes given in nutritional databases are often much smaller than the portions you are likely to find on your plate you may think you are eating a certain food plan while actually eating two or even three times as much food than you think you are.

This tends to be true of all of us, no matter how aware we may think we are about what we are eating. The best way to deal with it, if you are having trouble controlling either your blood sugar or your weight, is to get yourself a digital food scale and start checking the portion size of the portion you are eating against the portion size given in the reference you are using.

You may quickly find the explanation for why your blood sugar is spiking after eating a food that used to work for you or why you have stalled on your diet.

Portion Size Issues Occur With All Macronutrients

The impact of getting clear on actual portion size will be greatest with foods that contain significant amounts of carbohydrate, because these fluffy foods are often the hardest to estimate. The carb counts given in nutritional guides for breads and cakes, for example, universally use a portion size of about 1.5 ounces for a slice of bread and 2 ounces for a muffin, roll, or piece of cake.

Years ago it is possible that someone did sell 2 ounce muffins, but when I went out last year and started weighing baked goods friends brought over I found that the bakery cookies being sold in my town ranged up to 5 ounces each and the coffee shop muffins were often as much as 7 ounces each. Artisanal bread can easily clock in at 3 ounces a slice, too.

Many people with diabetes can tolerate a 10 g serving of carbs. Some, larger people can even tolerate 15 or 20 grams at once. So if you consult your nutritional guide and see that a single chocolate chip cookies is listed at 9 grams, you may easily end up eating "one" five ounce cookie (or even a "small" 2 ounce cookie) without realizing that the database-supplied carb count was based on the size of one boxed ounce chocolate chip cookie which weighs one half of an ounce--15 grams.

The same is true of pasta. Some people with diabetes can eat pasta, because it does digest very slowly and if they have a slow second phase insulin response, it may be enough to mop up the slowly released carbs. But this tends to be true only if you eat a 2 ounce portion of pasta--the portion listed on the box. The portions of pasta sold at restaurants are anywhere from 6 to 8 ounces of pasta. Far too much for anyone to handle, both in terms of carbs and calories--and we haven't even gotten into the issue of sauce. When was the last time you got 6 servings from one can of bottled spaghetti sauce?

But portion size is not only a problem when you eat carbs. When you eat a very low carb diet, excess protein gets converted into glucose by your liver. So if you are eating far more protein than your body needs to repair muscle or provide the small amount of glucose your brain requires, the rest of the protein you eat will turn into glucose in the liver through a process known as "gluconeogenesis."

This happens very slowly--over about 7 hours, but it can be one reason why people eating low carb diets develop rising fasting blood sugars. If you ate a huge protein portion for dinner, after eating a lot of protein at lunch, the cumulative impact of the glucose derived from that protein on your blood sugar may not show up until the middle of the night. Protein shakes pose the same kind of problem, which is why a diet that involves eating large protein shakes for breakfast and lunch may have a very bad impact on your blood sugar, no matter how "low carb" it purports to be.

Meat portions are very hard to estimate. When I started weighing food a few years ago I found I was almost always underestimating meat portions which could easily be twice as heavy as I thought they were. A 300 lb man might be able to lose weight eating a 12 ounce serving of meat at every meal. A 145 lb woman probably can't.

Fat portions matter too if you are trying to lose weight. When you are eating a very low carb diet it is often possible to eat a lot more fat than you could eat on a standard diet and still avoid weight gain. This is because the processes that lead to fat storage tend to be blocked or slowed down when you are in a ketogenic state.

But if you are trying to lose weight eating too much dietary fat will stop weight loss cold, because it is much easier, physiologically, for your body to burn dietary fat than it is to break down the fat stored in your adipose tissue. So if you are eating more fat than you need, you may see weight loss come to a stop. This is especially likely to happen once you have lost 10-20% of your starting weight--a point at which the body's hormone balance becomes one that is much more conservative about releasing stored fat.

The portion sizes of high fat foods are very hard to estimate because they are so dense. The difference between 1 ounce of cheese and 2 ounces is not a lot. Weigh out one portion of peanut butter as listed on the label you will find realize that most of us eat two "portions" any time we eat peanut butter, if not more, without realizing it.

Be Careful What You Put on Your Plate

The study I alluded to at the top of this post has something else to teach us. Because our brains tend to treat whatever is on our plate as "a portion" it's a very good strategy to make sure that you only put onto your plate exactly what you intended to eat. This really comes into play during the upcoming holiday season where food has a way of showing up on your plate almost as if by magic.

Don't kid yourself that you will only eat "a few bites" of a serving of food that ends up on your plate. You'll do much better if you only put on that plate what you intend to eat. If this turns out to be hard to do--and for many of us it is--if you want to eat "a few bites" of some nutritionally horrifying but emotionally satisfying holiday food, ask a close friend or spouse to take the food onto their plate and then only transfer to your plate the "few bites" portion it is safe for you to eat.

I have on occasion had my Sweetie put overly-appealing holiday food gifts into the family safe and had him dole them out to me on a preset schedule. This can make the difference between enjoying a daily 10 gram treat and experiencing a 100 gram metabolic melt-down.

Planning for the Holiday Food Orgy

When it comes to setting the boundaries, it's worth reminding yourself that no one ever gave themselves retinopathy or caused a 30 lb weight gain eating one special high carb high fat high calorie meal. What messes us up is eating that kind of meal over and over again.

Unfortunately, the holidays we celebrate them now, stretch out into a six week period in which "special" holiday meals can appear daily or even two or three times a day for weeks at a time. And this does pose a serious problem for those of us with damaged metabolisms.

Many of us find that the safest strategy is to plan ahead. We choose the specific days or meals where we will eat whatever we decide we are going to let ourselves eat. These are scheduled events, NOT meals we "schedule" on impulse when confronted with a table unexpectedly loaded with tempting delights.

We prepare for those days of holiday excess by eating very carefully for the weeks before they happen. And we know that we will have a tough day after that holiday feast is done--a day when you will be hungrier than usual and will have to exert some very strong will power to avoid making a "one time" indulgence a daily habit.

If you have run into problems in the past at holiday time, being realistic about what is likely to happen, and planning for controlled indulgence, may work out better for you than resolving on complete abstinence and having the unplanned indulgences overwhelm you.

But if you do end up eating more than you intended over the holidays, don't beat yourself up over it. Only people living in caves with no access to the media who have no friends or family--or whose entire circle of family and friends is made entirely of dedicated health nuts-- get through the holidays without a dietary struggle, and only people with very rigid personality struggles win that struggle easily.

If you do run into trouble, you might find this web page helpful:

When Your Crash Off Your Diet

I wrote it years ago for the general dieter, not necessarily someone with diabetes, but you will find that even if you do not produce insulin it may still be helpful. Since I wrote it I have learned more about the hormonal factors that influence hunger, and I now suspect that these other hunger-related hormones play as much of a role as insulin does in producing the rebound hunger you experience when you eat a lot of foods you've been avoiding on a diet.

But the physiological explanation for the phenomena that occur after you crash off a diet are not as important as is learning a strategy that will keep you from turning a one-time food fest into a month, or year-long binge. The strategies I've described in the web page work very well.

Read the article BEFORE you head out into Holiday Food World. This is definitely a situation where preparing yourself before you get into trouble can make it a lot easier to get out of trouble.


November 12, 2009

Effect of The Atkins Diet, Long-term, on Mood

The latest study to compare low fat with low carb diets came up with the finding that long term the Atkins diet caused more mood problems than the low fat diet. This has caused a flurry of posts from LC bloggers and forum participants dissing the study. But I've had a good look at it and I think people are missing some very important things when they dismiss this study outright.

The full text is available online here:

Long-term Effects of a Very Low-Carbohydrate Diet and a Low-Fat Diet on Mood and Cognitive Function. Grant D. Brinkworth et al. Arch Intern Med 2009;169(20):1873-1880.

The most significant finding of this study, which seems to have escaped everyone who has written about it, is that it contradicted the earlier, and very heavily publicized, finding that the low carb diet caused problems with memory and thinking.

This year-long study found Working memory improved by 1 year (P < .001 for time), but speed of processing remained largely unchanged, with no effect of diet composition on either cognitive domain.

So that should put to rest any concerns you might have had about the impact of eating a very low carb diet on your ability to think clearly.

Now let's see what else the study found.

Unlike many studies of supposedly "low carb" diets, this diet was indeed a very low carb diet with a composition that matched that described in the most recent Atkins book. The nutrient breakdown was:
4% of total energy as carbohydrate, 35% as protein, and 61% as fat (20% saturated fat), with the objective to restrict carbohydrate to less than 20 g/d for the first 8 weeks and with an option to increase to less than 40 g/d for the remainder of the study.

This study also limited saturated fat which is not characteristic of classic Atkins, but the direction the Atkins brand has moved into as it has come to copy South Beach. Over the years the original "Atkins" diet was modified several times to incorporate the techniques found in other bestselling low carb diet books, so this shouldn't be a surprise.

In one major characteristic this diet differ from Atkins as described in the book. From the outset, calories were restricted to "approximately 1433 kcal/d for women and 1672 kcal/d for men."

Those who wish to ignore the findings of the study completely have pointed to this limitation as if it discredited the results. However, I do not believe this is fair. For overweight and slightly obese people, the calorie levels used here correspond very closely to what many people who have successfully lost weight on the Atkins diet report eating on the online diet support forums, for example, Low Carb Friends once the "easy pounds" lost in the first month or so are gone.

Atkins dieters almost always stall after the first 6 weeks and those who do not have a lot of weight to lose often find they do have to cut back on calories to continue on with weight loss.

So much for the "Atkins diet" used in the study. But when we look at the "low fat" diet, we see something even more interesting. The "low fat" diet is described as having "46% of total energy as carbohydrate, 24% as protein, and 30% as total fat (<8% saturated fat), with the objective to restrict saturated fat intake to less than 10 g/d for the study duration and with the inclusion of an approved food exchange (equivalent to the energy content of 20 g of carbohydrate) between weeks 9 and 52."

This is a very moderate low fat diet, very different from diets like Ornish. And more significantly, this is a diet that is actually quite low in carbohydrate. Working out the 46% ratio of carbohydrate against the 1433 calorie daily intake for women, we find that a woman on this diet would be eating only 165 grams of carbohydrate a day, NOT the 300 grams a day which is so often recommended by dietitians.

This is not an overwhelming carbohydrate intake for a person who has functioning beta cells. And everyone in this study DID have functioning beta cells, since the study excluded people with diabetes, and also eliminated people with cardiovascular disease--which would have probably got rid of participant with undiagnosed diabetes.

The study found that both groups of dieters lost the same average amount of weight at the end of the year, on average about 30 lbs. This full text of the mood study does not explain what the groups starting weights were. This data is probably available in an earlier publication about the same study that reported the physiological rather than psychological findings of this study. You can find it HERE. Unfortunately, free full text is not available for that study.

This earlier report on this same study found that the Atkins dieters ended up with a higher HDL and lower Triglycerides than the Low Fat group, but also higher LDL, though the particle size of the LDL was not investigated.

It also reports the LC group also seems to have lost more body fat: LC: –11.3 ± 1.5 kg; LF: –9.4 ± 1.2 kg; P = 0.3, though this may not be statistically significant.

The physiological study report also found that "Blood pressure, fasting glucose, insulin, insulin resistance, and C-reactive protein decreased independently of diet composition." This means that the choice of diet did NOT have any impact on these parameters though they improved similarly on both diets.

It is a very significant finding that the two diets ended up producing the same blood sugar outcomes, though this has to be viewed with the knowledge that this was a study that did not include people with diabetes.

So far I see nothing to make me question that this was a decently conducted study that has something to teach us about the impact of these diets on people who, if they had any blood sugar abnormalities had the mild ones described as "pre-diabetes"--a group that includes many people who have insulin resistance, but also who have normal beta cells and hence who will never progress to full fledged diabetes.

So what should we make of the finding that mood deteriorated more in people on the Atkins diet than on the low fat diet?

The first thing I note, before I look at mood, is that as is the case in so many diet studies, the drop out rate was high--41%, And slightly more people in the Low Carb arm dropped out than in the Low Fat arm.

This is not the first time we've seen this happen. The drop out rate of the Atkins dieters was only exceeded, very slightly, by that of the extreme Ornish dieters in the JAMA diet bakeoff published back in 2005. In that study the Atkins compliance rate was considerably lower than that of the dieters eating the conventional Weight Watchers diet, though compliance on all diets deteriorated.

This latest study did not measure compliance, but my guess is that by the end of the study, it wasn't very good because it never is on any diet and there is evidence suggesting that "carb creep" is a huge problem, long term, even for people who believe they are eating low carb diets.

But that high drop out rate, with the higher Atkins drop out rate suggests that people eating the diet were not universally thrilled and the mood indicators that the study presents seem to me to point to why.

The study used standardized questionnaires, which like all psychological tools are very fuzzy in concept, but since mood itself is a very fuzzy concept, there isn't any better way to measure it.

The study design has going for it that it used several different tools to measure mood, not just a single one. These were "the POMS,which measures 6 separate aspects of mood, including tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment, and provides a global score of mood disturbance (total mood disturbance score [TMDS]) that is determined by subtracting the vigor-activity score from the sum of the 5 negative mood factors; (2) the Beck Depression Inventory (BDI) and (3) the Spielberger State-Trait Anxiety Inventory (SAI)."

This link will take you to the graphs describing the findings:

Questionnaire Data

What stands out is that the results of all three measurement tools come out with very similar results. At 8 weeks, all the dieters were considerably happier than when they started their diets. And at 8 weeks, the Low carb dieters were MUCH happier than the low fat dieters according to the Depression-Dejection score, probably because the early weight losses on Atkins are much more dramatic and motivating than the losses on the non-ketogenic diet.

By six months things started to change. Both groups were feeling increased Vigor and Activity at six months, probably because that was the time when they had made most of their weight loss and that weight loss made them feel much better about themselves and more prone to physical activity. But by that point, the measurement tools suggest that the mood of the Atkins dieters is beginning to deteriorate compared to that of the people on the low fat diet.

Anyone who has participated in the online Atkins support groups knows that by 6 months most Atkins dieters have either stalled out completely (usually those who are eating very high calorie intakes in the belief that only carbs matter) or they have gone from dramatic weight losses to losing very, very slowly.

You can see exactly how much real dieters lose on a very low carb diet with the analysis of dozens of real people's posted monthly low carb weight loss experiences you'll find HERE.

Slowing weight loss is characteristic of ALL long term diets no matter what the diet composition, but for the Atkins dieter who saw swift weight loss early on in the diet, the slowdown can be devastating, because most Atkins dieters assume that the extreme changes they have to make in what they eat will be rewarded with huge weight losses like those they experience in the first few weeks. When this doesn't happen, the limitations of the diet are much harder to endure.

Experience in the support group environment reinforces the finding that it is at 6 months into the very low carb diet that people run into serious problems with it. The excitement of eating steak, cheese, and avocados has worn off and unless a person is able to cook and willing to put time into hunting up recipes, the food allowed on the diet can become very boring indeed.

And there is another problem, one that is rarely discussed on the Low Carb support boards:. The early high energy level that enthuses people about the very low carb diet may start to fade out. Some people, in fact, experience thyroid slowing (so-called Euthyroid syndrome) characterized by drops in T3.

My guess is that the finding of this study is real, because it mirrors what I've seen in the support groups. After an initial burst of enthusiasm that lasts about 6 months, a large number of low carb dieters disappear. And even those who lose significant amounts of weight tend to disappear shortly after they stall out for a few months or reach goal, only to show up on the support groups a year later with tales of crashing off the diet and regaining all the lost weight.

Because I did the same thing myself, after 3 years on a very low carb diet, I have a very good appreciation of the process that leads from initial enthusiasm, to depression about the need to eat in a way that is so different from what one might want to eat, and the way that dropping energy levels can lead to giving up entirely.

Since I have diabetes and can't process carbs my choice was NOT to say to heck with it and just live with being fat. But people who don't have diabetes can and do.

So I think the mood issue is real and I think that until it is addressed, people will alway have trouble sticking with a low carb diet, long term, no matter what it's impact on their health if it is too extreme.

And it is that factor of extremeness that I think this study sheds some interesting light on.

If we ignore the issue of "fat" which is really a red herring in these two diets, what we see here is that for people WITHOUT diabetes, there may be a much better outcome in terms of mood with a diet that though it restricts carbs a lot compared to the Standard Diet, doesn't restrict them extremely.

In short, for people who do not have diabetes, a diet of 165 g a day is a huge improvement on one of 300 g a day and may be all that is needed. The women eating that 165 grams of carbs a day did lose the same amount of weight and more importantly, their blood sugar profile and blood pressure did not vary from that of the people eating at much lower levels.

For people WITH diabetes this finding is negated by the fact that few of us can tolerate 165 grams of carbohydrate without seeing very poor blood sugars, ones guaranteed to produce complications.

But what I would take from this study is that it supports the strategy I have been promoting for the past 5 years--one that suggests you cut your carbs down ONLY to the level that gives you safe blood sugars, and no lower.

What that level will be varies from person to person and can only be determined using the strategy described HERE.

More importantly, what this study suggests is that if, like me, you find you can only control your blood sugar by eating at extremely low carbohydrate intake levels--for me it was no more than 50 grams a day with no single meal being higher than 12 g--if you start feeling depressed or rundown, it's time to look into finding a medication that will let you raise your carb intake a bit, but still keep hitting your blood sugar targets without making yourself miserable.

For me, the difference between eating at 100 g a day and 50 g a day is that I can do it, year in and year out, happily. (I'm in year 7 of maintaining a 17% loss of body weight.) But I can only eat 100 g a day using fast acting insulin at some meals.

Not EVERYONE gets depressed or exhausted on a long term low carb diet. The people who stay on these diets for years at a time and write the enthusiastic LC blogs are those who feel better on the diet, not worse. There are quite a few people that match that description, especially among those whose blood sugar is hard to control.

But if you run into problems as your low carb diet hits 8 months, or a year, or two, don't fear turning to medication for help. Insulin, metformin, and for some people Byetta, can make a big difference in how easy it is to control your blood sugar and your weight.

Our goal, after all is health but there is little point in purchasing "health" at the cost of your happiness. If after 6 months of eating a very low carb diet your energy level is low and your mood deteriorating, it's time to start tweaking. Talk to your doctor about adding the safe drugs to your regimen.

Too many people treat using medication as if this were a personal failure. It isn't. The safe medications are is just another set of tools to allow you to live a healthy and happy life.


November 8, 2009

Meaningless Diabetes Days and Months

Diabetes Month is here and World Diabetes day is coming, and I am not about to get all excited about either.

Diabetes month is an excuse for the merchants who profit from diabetes to tout their wares. Though the drug store flyers may announce that it is "Diabetes month", I note that the prices of the diabetes test strips they are highlighting haven't gone down a penny-and are twice what they were in 1998 when I started buying them. This price increase is far greater than inflation. Are you earning twice what you earned in 1998?

Diabetes month is an opportunity for nutritionists to be quoted in the media telling us how if we cut all the fat out of our diets and ate healthy grains we wouldn't have diabetes.

Diabetes month is when you will read how children cause their Type 2 diabetes by being lazy, though it is far more likely that the huge increase in the Type 2 diabetes in levels in children too young to have caused it via eating patterns has almost certainly been caused by prenatal exposure to environmental toxins like Bisphenol-A which occurs in detectable levels in many canned foods and juices and, more importantly, in baby bottles sold as "Bisphenol-A free." Other common promoters of diabetes in children and adults are commonly used herbicides and arsenic which have contaminated our water supply and the SSRIs, routinely fed pregnant women, which research has proven raise insulin resistance and cause obesity.

World Diabetes Day is even more useless. A bunch of folks in the online diabetes community have been wasting their energy campaigning for a "blue doodle" on Google for World Diabetes Day. My response to this is, "Why?" The doodle doesn't convey a single bit of useful information to a single person. Which is the reason that World Diabetes Day bothers me.

Because the only reason to "raise awareness" of diabetes, is if the awareness we were raising included the simple, easily conveyed information that could HELP people control their diabetes. Which is does not.

What is that information? Just this:

Eating Any Kind of Carbohydrate Raises Blood Sugar. Cutting Out Carbs Lowers Blood Sugar Safely and Effectively.

This stupidly simple statement would be enough to help the tens of millions of people with Type 2 diabetes world wide improve their blood sugar. It would be news to a lot of people with Type 1 too.

In fact, it would surprise a lot of doctors who still do not know it is for people with Type 2 to achieve normal blood sugars merely by cutting way back on carbs.

Unfortunately, you will look in vain for any hint of this in any of the activities associated with any of these Diabetes Days, Weeks or Months.

Until they do, these diabetes events will remain what they really are: fund raising opportunities for organizations that have never told people with diabetes the truth about their condition.

If you feel strongly about the importance of these token diabetes events, I would urge you do the following.

Instead of lighting real or virtual candles, how about burning boxes of breakfast cereal labeled "Diabetes Friendly."

Instead of a blue doodle, how about campainging to see the American Diabetes Association explain on its "tight control" web page that lowering carbohydrates will lower blood sugar safely and effectively. The word "Carbohydrate" still does not appear on the ADA's "tight control" page.

Instead of encouraging people to contribute to the large, bloated charities whose track record for doing anything for people with diabetes is abysmal, why not print and distribute as many copies of the "How to Get Your Blood Sugar Under Control flyer" as possible. I have heard from hundreds of people with all kinds of diabetes who tell me that following the instructions on that flyer has dropped their blood sugars from levels producing A1cs as high as 13% to the normal 5% range.

You will find the link to download the flyer in a format using the blood sugar units your country uses at the bottom of THIS PAGE.

I don't want to raise awareness of diabetes. I want to raise awareness of how to CONTROL diabetes.

Until then, all raising awareness about diabetes does is reinforce the tragically flawed beliefs the population has that diabetes is caused by gluttony and sloth and is the punishment people get for overeating.

This is of course not true. If you want ammunition for countering this misinformation you will find it here:

You Did Not Eat Your Way to Diabetes

Diabetes is caused by the fatal combination of specific genes and environmental factors which attack people with those genes. These factors attack people with diabetes genes starting out in the womb and continuing on through life. Dramatic increases in the incidence of diabetes have been associated with a host of chemicals that pollute our environment, including common herbicides and plastics, and widely prescribed psychiatric drugs, many of which are now in trace amounts in our drinking water.

And as we all know by now the high fructose corn syrup, which also invaded our food supply a generation ago, greatly increases insulin resistance because it converts to intracellular liver fat.

The huge increase in the incidence of Type 1 diabetes probably is linked to the invasion of our food supply a generation ago by soy protein, because soy contains substances that damage the lining of the gut and allow food proteins, most notably gluten, to enter the blood stream and provoke antibodies including those that attack the pancreas.

By all means, lets spread "awareness" but let that awareness be of the FACTS. Not the garbled, industry friendly message that the corporate sponsors of these diabetes organizations would prefer the public to hear.


November 4, 2009

Veterans with Moderate CAC Scores DO prevent Heart Attack with Aggressive BG Lowering

A study just published in Diabetes takes a closer look at the notorious Veterans Study. I have blogged before about that study here:

Why Doctors Are Telling Type 2s Not to Lower Blood Sugar And Why They Are Wrong.

The veterans study is one of two studies that found that aggressive blood sugar control did not appear to make any difference in the likelihood of having a heart attack.

But this new analysis of data from the veteran's study found that aggressive lowering of blood sugar did have a dramatic effect on the likelihood of having a heart attack, but only in people who did not already have evidence of severely hardened arteries as measured by CAC heart scans.

The abstract of the new study can be read here.

Intensive Glucose-Lowering Therapy Reduces Cardiovascular Disease Events in Veterans Affairs Diabetes Trial Participants With Lower Calcified Coronary Atherosclerosis Peter D. Reaven et al. Diabetes, November 2009 vol. 58 no. 11 2642-2648. doi: 10.2337/db09-0618

In this study, a subset of the subjects in the veteran's study, 301 type 2 patients, had their degree of artery thickening measured by heart scans, i.e. the coronary artery calcium (CAC) computed tomography test. Participants were then followed over the 7.5-year study for development of cardiovascular end points.

After subjecting their data to an oddball statistical manipulations I won't pretend to understand and hence cannot entirely trust, the researchers came up with the finding that there appears to be a Rubicon of sorts with these heart scan scores.

If patients started the study with CAC scores below 100, aggressive lowering of their blood sugar yielded impressive lowering of their rate of cardiovascular "events." But if they started out with CAC scan values above 100 then aggressively lowering their blood sugar did not change the risk of heart attack.

The actual numbers reported were these:
Among those randomized to intensive treatment, for the subgroup with CAC >100, 11 of 62 individuals had events, while only 1 of 52 individuals with CAC ≤100 had an event.
This suggests that there is a point after which you have permanently damaged your cardiovascular system and that past that point, controlling blood sugar alone won't undo the damage. This makes sense because the CAC scan reports on the amount of calcium deposited in your arteries in the form of plaque, and after you've calcified your arteries past a certain point, they are likely to stay that way.

But if that is your situation, all is not lost. Dr. Davis over at the Heart Scan Blog claims that his patients have improved their CAC scores using interventions that include high dose Vitamin D3, lots of fish oil, Niacin, and cutting out wheat from their diets.

Why fish oil may be so helpful was illuminated by a recently reported study where researchers analyzed plaques removed from people having carotid endarterectomy--the operation where they ream out people's carotid arteries to remove plaques that are preventing blood from getting to their brains.

The researchers report:
All of the fats in the plaques were assessed with mass spectrometry... The plaques of asymptomatic patients [i.e. those having no signs that their brain functions was impaired because of clogged arteries] contained more than twice as much DHA as the symptomatic patients, and about one and a half times as much EPA. Significantly less inflammation was also seen in the carotid atherosclerotic plaques from asymptomatic patients.

You can read more about that study here:

Science News: Fish Oil May Protect Against Stroke From Ruptured Carotid Artery Plaques

Getting back to the veterans study. It is worth remembering that the subjects in the veterans study were mostly elderly people whose blood sugar had been way out of control for many years. If you are recently diagnosed, chances are you have not built up insurmountable levels of plaque in your blood vessels. And if that is true, then lowering your blood sugar aggressively may help prevent heart attack.

It is also worth mentioning that even in studies where aggressive lowering of blood sugar did not prevent heart attack, it did lower the incidence of kidney failure. This alone should make it worth pursuing.

And of course, many of us also have found that lowering our blood sugars very aggressively can prevent or reverse neuropathy.

If your doctor was one who warned you against the "dangers" of lowering blood sugar, make sure to tell your doctor about this latest study--and print out the abstract and take it along. Let the doctor know that one of the major studies being cited as arguing against tight control actually showed aggressive blood sugar lowering caused a dramatic drop in heart attacks in people whose CAC scores were modest when they began the blood sugar lowering.


November 1, 2009

Good News: Risk Equations Seriously Overestimate Heart Attack Risk in Diabetes

Several new studies, two presented at the 2009 IDF World Diabetes Congress and another published in the journal, Diabetes Care, conclude that the Framingham equation used by most doctors to predict your likelihood of developing heart disease even if you have diabetes.

This topic was discussed at the 2009 IDF World Diabetes Congress. You can read very good summaries of two presentations there, one based on ADVANCE data and another on a study done in Greece, in this article:

Heartwire: Current risk equations may overestimate CVD risk in diabetic patients

The IDF presentation which was based on the ADVANCE data reported,
...the Framingham and UKPDS risk equations overestimated four-year CHD risk by as much as almost 300%. [i.e. it predicted three times as many cases of heart disease as were actually diagnosed.]
The IDF presentation which was based on the study of a Greek population reported, according to the Heartwire article,
... that in a five-year study of over 900 diabetic patients in Greece, the Framingham and UKPDS risk equations predicted about a 10% incidence of CHD, whereas the actual incidence was significantly lower, at 6.8%.
You can read the abstract of the study based on Hoorn data which was just published in Diabetes Care here:

Prediction of Coronary Heart Disease Risk in a General, Pre-Diabetic, and Diabetic Population During 10 Years of Follow-up: Accuracy of the Framingham, SCORE, and UKPDS Risk Functions: The Hoorn Study van der Heijden, et al., doi: 10.2337/dc09-0745
Diabetes Care November 2009 vol. 32 no. 11 2094-2098

This study compared the Framingham, UKPDS, and a third formula, SCORE, and concluded
The Framingham and UKPDS prediction models overestimated the risk of first CHD event in all glucose tolerance groups. Overall, the prediction models had a low to moderate discriminatory capacity
. Further analysis revealed that the SCORE equation did the best job of predicting heart disease in people with normal glucose tolerance and that the UKPDS did a slightly better job in the group of people diagnosed with elevated blood sugars, though the UKPDS still overestimated risk in this group too.

The findings of these studies conflicts with the finding published n 2007 of the DECODE study which found the Framingham equation underestimated the risk of heart disease in it's population.

What The Risk Formulas Ignore

After using online calculators to assess my own risk using all three formula cited in the above studies, I noticed that several important parameters are completely missing.

1.The Calculators Rely on Heavily on Cholesterol Ratios However, most interestingly, none of these calculators has factored in statin use or looked at whether long term statin use decreases predicted mortality using any of these risk formulas. My guess is that if they did, you would have heard about it from the drug companies pushing statins.

2.The Calculators Ignore C-Reactive Protein (CRP) Given that there seems to be a strong link between the presence of inflammation as measured by CRP and heart attack, this omission is important.

3.The Calculators Ignore BMI or Other Measures of Obesity. One wonders, again, if this is because they were found NOT to correlate to risk in the studies used to define these formula. This is quite possible, since in my own experience heart disease strikes people of all weights.

Calculate--and Overestimate--Your Own Risk

SCORE uses slightly different formulas for different European populations, but not all appear to be available online. You can find an online SCORE calculator based on data from the UK populations Note that this calculator uses fasting glucose to determine whether someone is diabetic and refuses to calculate risk if they are, because of the assumption--disproven by the research cited above, that everyone with diabetes is very high risk. To use this calculator, use the category that corresponds to your fasting glucose.

SCORE Risk Calculator: UK


The UKPDS calculator can be downloaded here:

UKPDS Risk Engine Download Page


The Framingham calculator can be found here: 10-Year CVD Risk Calculator (Framingham)