Should Carbohydrate Restriction Be the Default Diet for Diabetes?

Yes….according to a manifesto to be published soon in Nutrition. It may be published already since this post has been sitting in my draft stack for a while. The abstract:

The inability of current recommendations to control the epidemic of diabetes, the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk or general health and the persistent reports of some serious side effects of commonly prescribed diabetic medications, in combination with the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects, point to the need for a reappraisal of dietary guidelines.

The benefits of carbohydrate restriction in diabetes are immediate and well-documented. Concerns about the efficacy and safety are long-term and conjectural rather than data-driven. Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss (although is still best for weight loss) and leads to the reduction or elimination of medication and has never shown side effects comparable to those seen in many drugs.

Low-Carb Spaghetti Squash With Meat Sauce

Low-Carb Spaghetti Squash With Meat Sauce

The lead author is Richard Feinman. Others include Lynda Frassetto, Eric Westman, Jeff Volek, Richard Bernstein, Annika Dahlqvist, Ann Childers, and Jay Wortman, to name a few. Some of them disclose that they have accepted money from the Veronica and Robert C. Atkins Foundation. That doesn’t bother me. I’m familiar with most of the supporting literature they cite, having read it over the last decade. I agree with these guys wholeheartedly.

Read the whole enchilada.

Steve Parker, M.D.

PS: The linked article is preliminary and may undergo minor revision over the coming months.

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A New Artificial Sweetener: Advantame

Lumps of Diabetes

Sugar or advantame?

The U.S. Food and Drug Administration this last spring approved a new artificial sweetener called advantame. The press release calls it a high-intensity sweetener, which is a new term for me. Advantame joins five other artificial sweeteners:  saccharin (e.g., Sweet’N Low), aspartame (Equal and others), acesulfame potassium (Sweet One and others), sucralose (Splenda), and neotame (Newtame).

From the FDA:

High-intensity sweeteners, such as advantame, may be used in place of sugar for a number of reasons, including that they do not contribute calories or only contribute a few calories to the diet. High-intensity sweeteners also generally will not raise blood sugar levels.

Advantame is a free-flowing, water soluble, white crystalline powder that is stable even at higher temperatures, and can be used as a tabletop sweetener as well as in cooking applications. Advantame has been approved for use as a general-purpose sweetener and flavor enhancer and can be used in baked goods, non-alcoholic beverages (including soft drinks), chewing gum, confections and frostings, frozen desserts, gelatins and puddings, jams and jellies, processed fruits and fruit juices, toppings, and syrups.

I haven’t seen it in stores yet.

Steve Parker, M.D.

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Preserve Your Hippocampus With Exercise

MRI scan of brain

MRI scan of brain

The NYT’s Well blog has the details. The brain’s hippocampus is a critical center for memory. Alzheimers disease is associated with a gene called apo-E4. Carriers of that gene who exercise regularly have less shrinkage of the hippocampus than non-exercisers.

To PROVE that regular exercise prevents dementia-related shrinkage of the hippocampus, you’d have to force some folks to exercise and stop others who wanted to exercise. A couple years later, scan their brains and compare the two groups. That study may never be done.

The Mediterranean diet also seems to prevent or forestall dementia.

Steve Parker, M.D.

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Is There a Single Healthiest Diet?

Amby Burfoot has an article that asks, “what is the healthiest diet?”  for the general public. His answer comes from the Journal of Nutrition. Looks like there are four winners. Quoting Mr. Burfoot:

They differ slightly in the degree to which they favor, or disfavor, certain foods and food types, such as the following:

  • The Healthy Eating Index 2010: Considers low-fat dairy products a plus.
  • The Alternative Healthy Eating Index 2010: Considers nuts/legumes a plus, as well as moderate alcohol consumption. Trans fats, sugary beverages, salt, and red meat get a minus.
  • The Alternate Mediterranean Diet: Considers fish, nuts/legumes, and moderate alcohol a plus; red meat, a minus.
  • The DASH Diet: Considers low-fat dairy and nuts/legumes a plus; sugary beverages, salt, and red meat get a minus.

I think the Mediterranean diet has the most and best data to support it.

Steve Parker, M.D.

 

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Prevent Weight Regain With the Mediterranean Diet

Italian seaside tangentially related to this post

Italian seaside tangentially related to this post

Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, no regain of lost weight over the year, on average.

This scientific study is right up my alley. I was excited when I found it. Less excited after I read it.

The Set-Up

This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.)  The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.

Here’s the program:

  1. 20 days of a very-low-carb ketogenic diet, then
  2. 20 days of a low-carbohydrate non-ketogenic diet for stabilization, then
  3. 4 months of a normal caloric Mediterranean diet, then
  4. repeat #1 and #2, then
  5. 6 months of a normal caloric Mediterranean diet

In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).

I found little explanation of period #2 mentioned above, the low-carb non-ketogenic diet. Prescribed macronutrients were 25 or 33% carb, 27 0r 31% protein, 41 or 44% fat, and about 91 g carbohydrate. Prescribed daily calories appear to have averaged 1111.

After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.

Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.

What Did They Find?

Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).

Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.

Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).

Liver and kidney function tests didn’t change.

The authors didn’t give explanations for the drop-outs.

Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned to their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”

Comments

A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.

However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.

Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined  and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.

I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!

There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.

I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).

How much of the success of this protocol is due to the herbal extracts and TISANOREICA? I have no idea.

The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).

The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved  by a variety of diets.

The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.

The authors write:

The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.

I’ve attempted a similar merger with my Low-Carb Mediterranean Diet. Click here for an outline. Another stab at it was the Spanish Ketogenic Mediterranean Diet. And here’s my version of a Ketogenic Mediterranean Diet.

Steve Parker, M.D.

Reference: Paoli, Antonio, et al. Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean Diet and Mediterranean Diet Maintenance Protocol. Nutrients, 5 (2013): 5205-5217. doi: 10.3390/nu5125205

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Filed under ketogenic diet, Mediterranean Diet, Prediabetes, Weight Loss, Weight Regain

Dietary Advice for a 41-Year-Old South Asian With Prediabetes

The CulinaryRx blogger at MedPageToday asked two physicians what diet modifications they’d recommend for a 41-year-old man with prediabetes. (To read the article you may need to do a free sign-up.)

The moderator asked his experts twice whether carbohydrate restriction is important, and never got a straight answer. These experts must not think it’s important since they push legumes, lentils, fruits, and whole grains. Dr. Nadeau said he believes there is no specific diet for folks with diabetes. I almost fell off my chair when I read one comment recommending cookies and sweets, because they’re traditional. They also recommend low glycemic load, nuts, higher protein consumption, vegetables, and “good oils” like olive oil (ghee not mentioned).

Read this blog post for prior comments that include advice from possible clinicians.

I’m confident that Dr. Ronesh Sinha in Silicon Valley, California, would disagree with the advice of MedPageToday’s experts. Dr. Sinha would likely recommend limiting digestible carbohydrates to 50–150 grams/day as the most important dietary step. (I plan on a review of Dr. Sinha’s book here within a few months.)

I’m still looking for clinical studies of various diets for South Asians (aka Indian Asians) with prediabetes and diabetes.

Steve Parker, M.D.

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Would You Get Fat If You Increased Your Daily Calories By 500?

The U.S. adult population in the 1970s ate an average of 2400 calories a day. By the 2000s, our calories were up to 2900.

Putting a face on the statistics

Putting a face on the statistics

What did average adult weight do as we increased daily calories by 500? It increased by 8.6 kg, from 72.2 to 80.6 kg. In U.S. units, that’s a 19 lb gain, from 159 to 178 lb.

Children increased their average intake by 350 cals/day over the same time frame.

If I recall correctly, I’ve seen other research suggesting the daily calorie consumption increase has been more like 150 to 350 per day (lower end for women, higher for men).

Details are in the American Journal of Clinical Nutrition.

The study authors don’t say for sure why we’re eating more, but offhand mention an “obesogenic food environment.” They don’t think decreased physical activity is the cause of our weight gain; we’re fatter because we eat too much.

Steve Parker, M.D.

h/t Ivor Goodbody

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