Diabetic Diet: When Low Carb Eating Backfires

Caprese salad: mozzarella cheese, tomatoes, basil, extra virgin olive oil

Healthline has an article by Christina Crowder Anderson, a certified diabetes educator and pediatric registered dietitian nutritionist. It’s worth your time. A snippet:

While I was in my dietetic internship at Duke University, I met a person with diabetes who had morbid obesity and who had participated in Dr. Eric Westman’s “low carb clinic.” They did well on that regimen until they ended up gaining back all the weight plus some, along with a resurgence in their type 2 diabetes.

At that moment, my iron-clad nutrition paradigm started to shift, as the sadness and shame from “diet failure” was palpable. Most individuals would say they “didn’t try hard enough.” But when you meet an actual person and hear their story, you’ll learn there are many factors that play into their success with a specific dietary approach.

Even though I was moved by this experience, my practice philosophies still didn’t change in terms of my recommended dietary approach for type 1 or type 2 diabetes — low carbohydrate. Over the next few years as I worked in a pediatric and adult endocrinology clinic, I steered most patients toward the more severe end of the “low carbohydrate spectrum” and was enthralled by the ability of the low carb approach to produce a flat line continuous glucose monitor (CGM) tracing.

That was, until I worked with 10 young adults in a clinical trial (for my graduate thesis), who chose to participate for a total of 8 months: 3 months on the low carbohydrate diet (60 to 80g day), 2 months of a “washout” period back on their own preferred diet, and another 3 months on the “standard diabetes diet” of >150 g carbs per day.

Source: When Low Carb Eating Backfires for Diabetes

Steve Parker, M.D.

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Stop the Madness: Let’s Resuscitate the U.S. Economy

 

Will we allow coronavirus to destroy the fabric of American life?

I propose a four-point plan to prevent a prolonged economic recession or depression in the U.S. caused by unjustified fear and panic about coronavirus:

  1. Young and middle-aged healthy adults go back to work now.
  2. Young and middle-aged healthy adults and children return to usual social interactions and school, using 6-foot distancing and face masks if desired.
  3. Extreme social distancing for those at risk for serious illness from COVID-19 for the next 2–3 months, then re-evaluate the situation. The goal is NO EXPOSURE  to those who may transmit the virus to them. Protect the medically frail who are over 60, particularly if over 70 or 80.
  4. Continued isolation of COVID-19 cases until they’re no longer infectious.

My presuppositions:

  • A large majority of the COVID-19 deaths and serious illness will be in the elderly (over 60-65) and/or those with risk factors for serious illness, as we’ve seen in Italy, China, and South Korea.
  • Those under 60-65 will have less severe illness and be much less likely to require hospitalization.
  • The pandemic in the U.S. is not going to be as bad as predictions you may have heard or read (e.g., 500,000 to 2.2 million deaths), in part due to actions already taken: isolation of cases, self-quarantine or mandated quarantine, social distancing, education on infection prevention, etc).
  • The recent $2 trillion relief package passed by Congress is unlikely to be very effective, particularly after the bureaucrats, politicians, major banks, and Big Business take their usual lions share. There won’t be much left for little guys like you and me.
  • “Relief packages” passed by politicians are not the answer. Government is more of a problem than a solution.
  • GM and Ford, et al, can’t make 50,000 ventilators in 3–4 weeks. By the time they’re ready, they won’t be needed.
  • The situation is quite fluid and helpful medical information arrives daily. So we need to stay light on our feet and ready to incorporate it.
  • The role of quarantine isn’t clear even now. We need more information. If a nurse treat a COVID-19 patient at the hospital, should she be on quarantine for two weeks or can she keep working? At what point do folks without symptoms start shedding virus that can infect others?
  • We’re seeing a power grab by federal and state governments that is unjustified and unprecedented in our lifetimes. For instance, a Florida pastor was arrested for holding a church service in violation of social distancing. Doesn’t the first amendment to the U.S. Constitution give us the right to peaceably assemble and freely exercise our religion? Once grabbed, government does not readily relinquish power. For more on this issue, read Peter Grant’s April 1 blog post.
  • Behavior of those living in COVID-19 hot spots like New Orleans or New York city may need to be different from those living elsewhere.
  • Extreme social distancing of those at risk or serious illness from COVID-19 may well require them to withdraw from the workforce for several months (or longer), but that’s much less harmful than what is essentially “house arrest” of 80–90% of the population.
  • Our list of conditions that increase serious risk from COVID-19 may well change over time as we learn more.
  • Increased testing to identify those infected with coronavirus will help us devise better containment measures. Containment will also be easier when we can identify—via antibody testing—those who have already been infected and are cured and (hopefully) immune to the current strain of the virus.

The problem with state-mandated or encouraged social distancing is that it’s strangling our economy.

Physicians, virologists, and epidemiologists who are advising our politicians are typically focused on medical aspects of the coronavirus epidemic. Economics is on the back burner, naturally, since that’s not their area of expertise. But the economy matters!

Post-viral apocalypse? Raccoon City?

In the U.S. in February 2020, 165 million people were in the labor force. For the week ended March 21, 2020, the U.S. set a record for unemployment benefits applications: 3.3 million. The very next week, a new record was set: 6.6 million. Economists are predicting a drop in 2nd quarter Gross Domestic Product of at least 20%.

In good times, most folk don’t apprehend the web of connections among various parts of the economy. They will soon find out.

From LexisNexis:

Unemployment has been linked with a number of psychological disorders, particularly anxiety, depression, and substance abuse; dangerous behaviors including suicide and violence toward family members or others also correlate with unemployment. These associations hold true not only in surveys of those already unemployed but also in studies that follow one or several individuals with no psychological difficulties into a period of unemployment. Such findings have been reported from many industrialized nations and, with some minor variations, apply to workers of both sexes and all ages.

Research regarding the consequences of unemployment may be confounded by a commensurate loss of income in subjects being studied. However, some studies try to account for this phenomenon of drop in socioeconomic status. Although an alert health care system may provide some needed assistance, resolution of the problem lies outside the field of medicine.

For example regarding suicide, among the unemployed aged 26 to 64 suicide was two-and-a-half times more likely than those who had jobs. Worldwide, one in five suicides is linked to unemployment. In 2017, suicide was the 10th leading cause of death in the U.S., with over 47,000 victims. At the time of this posting, the U.S. has reported 5,137 deaths from COVID-19.

Bankruptcies and unemployment will lead to an epidemic of despair.

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“Honey, we’ll be able to see the grandkids in few months. It’s just too dangerous right now.”

Additionally, the stock markets in the U.S—S&P 500 and Dow Jones Industrial Average—are already down by 20–30%, depending on the day you check. I wouldn’t be surprised if it drops another 20% or more from here. Imagine how that affects folks approaching retirement, or in it already, who are depending on their 401k’s to live.

Laid-off workers without a paycheck can’t pay their mortgages or car payments or other loans. In most jurisdictions, unemployment benefits are woefully inadequate: in Arizona it’s $240/week. This is a set-up for massive loan defaults. One silver lining: If you have cash, it may soon be buyer’s market for homes and new or used cars.

Panicking is rarely good. Let’s stop.

Expect more from me on Extreme Social Distancing in a future post.

Steve Parker, M.D.

PS: A few other sources that question the mainstream media’s and government narratives…

PPS: The history of the Coronavirus Pandemic will be written in the the next few years. I have not doubt it will look different than what we we’re seeing now.

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Three Ways to Prevent Non-Alcoholic Fatty Liver Disease (NAFLD)

Where does bile come from? The liver.

I found this study a while back. TL;DR: Physical activity, the Mediterranean diet, and legume consumption are linked to lower incidence of liver fat. At least in a Spanish population with metabolic syndrome.

Abstract

Objective

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver morbidity. This condition often is accompanied by obesity, diabetes, and metabolic syndrome (MetS). The aim of this study was to evaluate the connection between lifestyle factors and NAFLD in individuals with MetS.

Methods

A cross-sectional study with 328 participants (55–75 y of age) diagnosed with MetS participating in the PREDIMED-Plus trial was conducted. NAFLD status was evaluated using the non-invasive hepatic steatosis index (HSI). Sociodemographic, clinical, and dietary data were collected. Adherence to the Mediterranean diet (mainly assessed by the consumption of olive oil, nuts, legumes, whole grain foods, fish, vegetables, fruits, and red wine) and physical activity were assessed using validated questionnaires.

Results

Linear regression analyses revealed that HSI values tended to be lower with increasing physical activity tertiles (T2, β = –1.47; 95% confidence interval [CI], –2.73 to –0.20; T3, β = –1.93; 95% CI, –3.22 to –0.65 versus T1, Ptrend = 0.001) and adherence to the Mediterranean diet was inversely associated with HSI values: (moderate adherence β = –0.70; 95% CI, –1.92 to 0.53; high adherence β = –1.57; 95% CI, –3.01 to –0.13 versus lower, Ptrend = 0.041). Higher tertiles of legume consumption were inversely associated with the highest tertile of HSI (T2, relative risk ratio [RRR], 0.45; 95% CI, 0.22–0.92; P = 0.028; T3, RRR, 0.48; 95% CI, 0.24–0.97; P = 0.041 versus T1).

Conclusion

Physical activity, adherence to the Mediterranean diet, and consumption of legumes were inversely associated with a non-invasive marker of NAFLD in individuals with MetS. This data can be useful in implementing precision strategies aimed at the prevention, monitoring, and management of NAFLD.

Source: Influence of lifestyle factors and staple foods from the Mediterranean diet on non-alcoholic fatty liver disease among older individuals with metabolic syndrome features – ScienceDirect

Steve Parker, M.D.

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Paleo Ketogenic Diet Put Crohn’s Disease Into Remission

Have you ever tried to catch a wild rabbit by hand?

The study at hand is an isolated case report, so we can’t get too excited about it. But it does suggest that a “paleolithic ketogenic diet” may be helpful in Crohn’s disease. “Carnivore diet” may be a better description of the treatment.

The problem with case reports is that an individual’s response to intervention may simply reflect placebo effect or spontaneous improvement of the underlying condition, rather than a true response to the treatment applied.

Crohn’s disease is one of two “inflammatory bowel diseases,” the other being ulcerative colitis. Both of these are felt to be autoimmune, meaning the body is attacking its own tissues as if they were foreign invaders, like germs. Crohn’s disease causes abdominal pain, diarrhea (sometimes bloody), bloating, nausea, malnutrition, and other effects. Ulcerative colitis is similar in presentation. I wrote many years ago about a paleo diet improving at least one case of ulcerative colitis.

Moving along….

Hungarian physicians (?) reported a case of a 16-year-old who was diagnosed with Crohn’s disease at age 14 and wasn’t doing well at all despite standard medical therapy. At one point, intestinal surgery was recommended but he (or his parents) declined.

On the paleolithic ketogenic diet, the patient went into remission within months, off medications, and has been in remission for 15 months. The patient’s BMI rose from 17.7 to 19.5.

So, what was this diet?

  • “animal fat, meat, offal and eggs with an approximate 2:1 fat:protein ratio” [is that ratio grams or calories? Not stated]
  • no grains, milk, dairy, refined sugars, vegetable oils, oilseeds (sic), nightshades, and artificial sweeteners
  • honey OK in small amounts
  • poultry OK but discouraged
  • at one point the patient added small amounts of vegetables and fruits but the authors favor “no plants at all”
  • no supplements

The authors mention good ol’ Walter Voegtlin, author of 1975’s The Stone Age Diet. Voegtlin, by the way, was or is a gastroenterologist. Here’s an iconoclastic quote from Voegtlin.

Why did this carnivore diet seem to work? The authors propose it improves the pathological intestinal permeability seen in Crohn’s disease. In short, excessive intestinal permeability allows bad things to enter the bloodstream and wreak havoc.

This is a radical diet compared to the Standard American Diet featuring dairy, grains, industrial seed oils, and ultra-processed foods. As usual, check with your personal physician before making any radical diet change. Odds are, however, your doctor doesn’t know much about this diet and won’t approve.

Steve Parker, M.D.

h/t P.D. Mangan

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Stop the Weight-Loss Drug Lorcaserin: Linked to Cancer

From the U.S. Food and Drug Administration:

ISSUE: FDA has requested that the manufacturer of Belviq, Belviq XR (lorcaserin) voluntarily withdraw the weight-loss drug from the U.S. market because a safety clinical trial shows an increased occurrence of cancer. The drug manufacturer, Eisai Inc,. has submitted a request to voluntarily withdraw the drug. When FDA approved lorcaserin in 2012, we required the drug manufacturer to conduct a clinical trial to evaluate the risk of cardiovascular problems. A range of cancer types was reported, with several different types of cancers occurring more frequently in the lorcaserin group, including pancreatic, colorectal, and lung.

BACKGROUND: In January 2020, FDA announced we were reviewing clinical trial data and alerted the public about a possible risk of cancer associated with lorcaserin based on preliminary analysis of the data.

RECOMMENDATION: PatientsPatients should stop taking lorcaserin and talk to your health professionals about alternative weight-loss medicines and weight management programs.

Source: Belviq, Belviq XR (lorcaserin) by Eisai: Drug Safety Communication – FDA Requests Withdrawal of Weight-Loss Drug | FDA

I never ran across a patient taking it, nor did I ever prescribe it. There are better ways to lose weight.

Steve Parker, M.D.

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The Best Diet to Reverse Non-Alcoholic Fatty Liver Disease (NAFLD)

Stages of liver damage. Healthy, fatty, liver fibrosis, and finally cirrhosis

A recent article in Gastroenterology Clinics suggests this one:

•Prioritize intact starches such as brown rice, quinoa, and steel-cut oats, and limit or avoid refined starches such as white bread and white rice

•Replace some of the CHO [carbohydrate], especially refined CHO, in the diet with additional protein from a mixture of animal or vegetable sources, including chicken, fish, cheese, tofu, and pulses

•Include a variety of bioactive compounds in the diet by consuming fruits, vegetables, coffee, tea, nuts, seeds, and extra virgin olive oil

•Get most fat from unsaturated sources, such as olive oil (ideally extra virgin), rapeseed oil, sunflower oil, safflower oil, canola oil, or nuts and seeds

•Limit or avoid added sugars, whether sucrose, fructose, maltose, maltodextrin, or any syrups. If any of these words appear in the first 3–5 ingredients of any food item, it is best to avoid that item and choose a no-sugar version instead. Examples are yogurts and commercial cereals•In particular, avoid liquid sugar such as carbonated sugary drinks/sodas, lemonade, any juices, smoothies, and added sugar to tea and coffee

Source: Nutrition and Nonalcoholic Fatty Liver Disease – Gastroenterology Clinics

See the article for a typical daily menu. Looks like a Mediterranean diet to me.

Excessive fructose and saturated fatty acid consumption appear to be particularly harmful to the liver.

The authors also seem to endorse exercise: 150 t0 300 minutes per week of moderate- to vigorous intensity aerobics exercise, performed at least thrice weekly.

And all experts recommend loss of excess fat weight.

If you really want to get into the weeds, read about how fat deposits in liver and muscle lead to metabolic inflexibility, resulting in insulin resistance and mitochondrial dysfunction, which alters lipid metabolism, releasing free fatty acids (some of which are lipotoxic), leading to lipotoxic molecules (like ceramides), causing inflammation and fibrosis.

Steve Parker, M.D.

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How Much Calcium Do Your Bones Need?

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That milk mustache is a tell-tale sign she’s not eating pure paleo

I don’t know, and I’m not sure anybody knows.

The biggest concern about inadequate calcium consumption is that your bones will be weak and brittle, leading to fractures.

Dr Harriet Hall at Science Based Medicine reviewed a NEJM article written by Drs Willets and Ludwig on the health effects of milk.

From Dr Hall:

I was surprised to learn that the US recommendations for milk consumption were based on small, flawed studies of calcium balance. Other countries recommend lower levels of calcium intake. The US recommends 1000-1200 mg for adults, the UK 700 mg, and the World Health Organization, 500 mg. Counterintuitively, countries with high milk and calcium intake actually have the highest rates of hip fracture. Clinical trials of calcium for fracture prevention are complicated, because of confounding factors like vitamin D, phosphorous, and adult height. High calcium intake during childhood and adolescence was thought to serve as a way to “bank” calcium, but studies have not supported that hypothesis. In fact, men’s risk of hip fracture increased by 9% for every additional glass of milk consumed during adolescence.

Source: Milk and Health: The Evidence – Science-Based Medicine

Steve Parker, M.D.

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