Category Archives: Book Reviews

Book Review: The Dukan Diet

With a suspicion that the Dukan Diet may be the next diet fad in the U.S., I read The Dukan Diet: 2 Steps to Lose the Weight, 2 Steps to Keep It Off Forever by Pierre Dukan (2011, first American edition).  On Amazon.com’s rating system, I give it two stars.

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Think of Dukan as a Low-Fat Atkins Diet.

The Dukan Diet is apparently very popular in Europe.  It’s comprised of four phases. The Attack Phase, also called “Pure Protein,” lasts usually two to seven days.  Eat all you want from the protein-rich food list, mostly skinless chicken, low-fat meat, fish, and nonfat dairy.  No carbs at all except for the dairy.  The Cruise Phase is next: Alternate Pure Protein days with proteins and non-starchy vegetables until you’re at your goal weight.  Eat all you want from the low-carb veggie list.  Consolidation Phase lasts five days for every pound lost.  Eat more variety but limited quantities: two slices of whole grain bread, one portion each of fruit and cheese daily, one or two servings of starchy carbs (e.g., legumes, flour, cereals), plus two “celebration meals” a week, carefully defined.  Proteins and low-carb veggies are still unlimited.  Finally, the Permanent Stabilization Phase is lifelong and similar to Consolidation Phase, but requires one Pure Protein day per week, such as Thursdays.  Also, take no stairs or elevators.  All phases include prescribed servings of oat bran.

During the active weight loss phases, this diet is low-fat, low-carb, and high-protein. You don’t have to count carb grams, fat grams, or calories.  Presumably, Dr. Dukan has done all that for you, although he never shares the average calories consumed nor the macronutrient breakdown (i.e., what percentage of calories are derived from protein, fat, or carbs). The latter two phases are still very low-fat but allow a bit more carbs.

I liked this book more than I expected.  It’s obvious the author has copious experience with dieters, especially women.  The writing is clear.  He’s a serious, earnest man, not a charlatan.  Although some will criticize the book’s repetitiveness, it’s a proven educational technique.  For weight management, Dr. Dukan and I agree that 1) weighing daily is good, 2) abstinence from sugar rarely eliminates the longing for sweets, 3) artificial no-calorie sweeteners are OK, 4) the 4-7 pound weight loss in Attack Phase is mostly water, not fat, 5) discipline and willpower are important, 6) after losing weight, you’ll regain it if you ever return to your old ways, and 7) a realistic weight goal is essential. 

Dr. Dukan recommends at least 20-30 minutes a day of walking.  He provides little information on resistance training, although increasing evidence supports it as a great weight control measure.  I wish he’d mentioned high intensity interval training (HIIT).

The book contains numerous recipes, including a week of menus for the Attack Phase.  Disappointingly, none of the recipes include nutritional analysis.

You’ll find an index.  It doesn’t list glycogen.  Insulin, a primary fat-storage hormone, is mentioned on only one page, one sentence.

This is one fat-phobic diet.  In Dr. Dukan’s view, “fat in food is the overweight person’s most deadly enemy.”  All fat consumption contributes to fatness, and animal fats “pose a potential threat to the heart.”  It seems Dr. Dukan never got the memo that total and saturated fat content of foods have little, if anything, to do with heart or other cardiovascular disease. While criticizing Dr. Atkins’ diet for demonizing carbohydrates, Dr. Dukan demonizes fats.  Yet Dr. Dukan does all he can to banish both carbohydrates and fats from his weight loss phases. 

Dr. Dukan makes several erroneous statements, including 1) all food is made up of only three nutrients, 2) all alcoholic beverages are high in carbohydrates, 3) all shellfish are carbohydrate-free, 4) he implies that when dieting or fasting, we convert much of our fat into glucose, 5) there are no indispensable fats, 6) fat is bad for the cardiovascular system, 7) vinegar is the only food containing sour taste, 8) fruit is the only natural food containing rapid-assimilation sugars, 9) “Anyone who loses and regains weight several times becomes immune to dieting,” 10) weight loss releases into the bloodstream artery-toxic fat and cholesterol, 11) many overweight folks are unusually good at extracting calories from food, 12) some people can gain weight even while they sleep, 13) exercise is vitally important for losing weight, and 14) the Atkins diet raises triglycerides and cholesterol levels dangerously.

Will the diet work?  I’m sure many have lost weight with it and kept it off.  It does, after all, limit two of the major causes of excess weight: sugars and refined starches. 

In considering rating this book two or three stars, I asked myself if I’d recommend it to one of my patients looking to lose weight.  Initially I had concern that the diet may be deficient in essential fatty acids since it’s so fat-phobic.  “Essential” means necessary for life and health.  Then I figured that the body’s own fat stores would provide adequate essential fatty acids, at least in the first two phases.  The later stages, I’m not so sure.  Carefully choosing specific foods would eliminate the risk, but how many people know how to do that?  Separate from that potential drawback, there are other diets that are better for the non-diabetic population, such as The New Atkins Diet for a New You, Protein Power, the Ketogenic Mediterranean Diet (free on the Internet), and The New Sonoma Diet.  You’ll have no risk of fatty acid deficiency with those.

For people with diabetes or prediabetes, I like Atkins Diabetes Revolution, Dr. Bernstein’s Diabetes Solution, and, of course, Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet.

 If you limit carbs, there’s just no need for fat-phobia.

Steve Parker, M.D.

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Book Review: Carbohydrates Can Kill

I recently read Carbohydrates Can Kill, by Robert K. Su, M.D., written in 2009.  Per Amazon.com’s rating system, I give it four stars ( I like it).

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Many developed Western societies have a love affair with carbohydrates, particularly concentrated sugars and highly processed grains and starches.  The U.S. is a good example.  Our skyrocketing rates of overweight and obesity (68% of adults) are testament to that.  Obesity is strongly linked to cancer, high blood pressure, heart attacks, diabetes, strokes, and premature death.  It’s not too much of a stretch to blame carbohydrates for at least a portion of these diseases and others.  Dr. Robert Su thoroughly reviews these connections in Carbohydrates Can Kill.

Blissfully unaware of his prediabetes

Blocked heart arteries are the No.1 cause of death in developed countries.  A growing trend among the experts is to abandon the theory that total and saturated fats cause heart disease, pointing instead to excessive consumption of sugars and processed grains and other starches.  Dr. Su makes a fairly convincing case for the carbohydrate theory of heart disease.  He’s also convinced that carbs cause high blood pressure, dementia, many cancers, diabetes, overweight, perhaps even most diseases. 

This book addresses overweight, adverse health effects of obesity, nutrition and digestion in detail, and numerous scientific studies supporting his ideas.

One of the most interesting things to me was Dr. Su’s personal medical story.  At age 62, he found himself 40 pounds (18 kg) overweight, blood pressure 205/63, and having apparent reversible heart pains (angina) when stressed or exercising.  The combination of salt restriction and exercise didn’t help.  Reducing carbs to 60-70 g/day and continued exercise (walking and stair-climbing) did the trick, helping him lose 30 pounds and controlling angina and high blood pressure.  I expected him at any time to reveal he had a heart attack, stroke, or heart bypass surgery, but he dodged those bullets.  His problems at 62 were a wake-up call.  He didn’t want to end up prematurely dead or disabled, a burden to his family and unable to spend quality time with them.  So he undertook major lifestyle changes.  Very inspirational. 

In addition to a medical degree, Dr. Su has a degree in pharmacy.  He knew he’d be put on multiple drugs if he went to a doctor for treatment of his symptoms.  Like me, he’s wary of drug side effects and wanted to avoid them, opting for diet and exercise instead.  He gambled and won.  I’m sure at least a few others would not be so lucky.

Dr. Su cites evidence that high blood sugars cause inflammation, which can predispose to cancer.  Diabetics do indeed have a higher risk of certain cancers, yet he didn’t mention that diabetics have a lower risk of prostate cancer. 

Dr. Su is anti-alcohol.  The studies are mixed on the overall health effects of alcohol, but the bulk of the studies link low-to-moderate consumption of alcohol with less cardiovascular disease and longer lifespan.  Clearly, heavy drinking can be lethal.

Like all books, CCK isn’t perfect.  First, it could have used better editing to eliminate grammatical errors and wordiness.  Next, I suspect Dr. Su is getting a little ahead of the science when he states that “….most diseases, if not all, are directly or indirectly caused by too much blood sugar.”  If carbohydrates are so deadly (mediated via high blood sugar), why do the Kitavan’s of Melanesia have such low rates of heart attack, stroke, overweight, and diabetes, despite a diet deriving 69% of total calories from carbohydrates?  (Calories from carbohydrates in the U.S. are about 50% of the total.)  Granted, Kitavan’s carbs are mostly unrefined.  Could the Kitavans be genetically protected from carb toxicity? 

So, what do we do if carboydrates are so dangerous?  Dr. Su recommends limiting carb consumption to a maximum of 100 grams a day.  (By way of reference, average U.S. carb consumption is 250 grams a day.)  Simple sugars and highly processed grains and starches should be avoided.  Additionally, he recommends a yearly glucose tolerance test to determine fasting blood sugar, then blood sugar readings every 15-20 minutes after an unspecified meal for two or three hours.  I wonder if a single hemoglobin A1c blood test would suffice.  I agree with Dr. Su that fasting blood sugars should be under 110 mg/dl (6.1 mmol/l)—if not lower—and all blood sugars after meals under 150 mg/dl (8.3 mmol/l).

Dr. Su is a tireless advocate for carbohydrate-restricted eating.  Visit his website: carbohydratescankill.com.  If his diet and exercise ideas were widely adopted in the U.S., we’d be a healthier country.  This book is a worthy read for anyone with overweight, obesity, diabetes, prediabetes, or otherwise enamored of concentrated sugars and highly processed grains and other starches.  Note that one of every three U.S. adults has prediabetes, including half of all those over 65, and most of them are unaware.

Steve Parker, M.D.

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Book Review: Secrets of a Healthy Diet: What to Eat, What to Avoid, and What to Stop Worrying About

I recently read Secrets for a Healthy Diet: What to Eat, What to Avoid, and What to Stop Worrying About by Monica Reinagel (2011).  It’s aimed at the general public rather than people with diabetes or overweight.  I give it five stars on Amazon’s rating system (I love it). 

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This indispensible book cuts through the malarky of nearly all recent nutrition fads, sharing with us the science-based nutrition ideas that prevent disease and prolong life.  If you’re eating the Standard American Diet (SAD), you need this book.  The author gives highly practical suggestions on how to make your diet healthier immediately. 

In short, Ms. Reinagel focuses on minimally processed, whole foods, and preparing your own meals.  But there’s so much more here.  As you might expect, the Mediterranean diet was discussed very favorably.

I’ve been following Monica Reinagel’s nutrition writing carefully for the last three years.  She knows the nutrition science literature as well as anyone, if not better.

The book starts with an unusually detailed table of contents that helps you find what you’re interested in without wasting time.

As promised by the subtitle, the author tells you what you DON’T need to worry about.  Is mercury in fish a problem?  What about bisphenol-A in plastic containers and canned foods?  Does red meat cause cancer?  Is pesticide residue on our food a problem?  Is salt a killer?  

I stay up to date on nutrition much more than the average physician, but the author introduced me to several new concepts, such as hemp milk, oat milk, and the idea that “pregnant women and small children should avoid cured meats altogether.”  I was particularly interested in her thoughts on the intersection of nutrition and exercise since I recently started an exercise program called Core Performance.

She successfully debunks many nutrition myths, such as 1) the need to eat every 2-3 hours, 2) saturated fat is bad for your heart and arteries, 3) eggs are bad for you (too much cholesterol, you know), 4) grain products are essential for health.

Any deficiencies in the book?  The font size is on the small side for people over 45.  On page 150, vitamin K is confused with vitamin D – undoubtedly a simple misprint.  No mention of the raw milk controversy.  When discussing potassium chloride as a salt substitute, she doesn’t mention the potential risk to people with kidney impairment or taking certain fluid pills. Tips on how to select fresh fish would have been helpful.

In summary, this is a great book for anyone wanting to get healthier via nutrition, but who’s confused by all the recent controversies.  The book is without peer.  If everything you learned about healthy eating was acquired over 10 years ago, you’re way out of date and need this book.  I hope the author does an updated edition every five years or so.

Steve Parker, M.D., author of Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet and The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer.

Disclosure: Other than a free advance review copy of the book from the publisher, I received nothing of value for writing this review.

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Book Review: Why We Get Fat

Gary Taubes’s new book, Why We Get Fat: And What To Do About It, comes on the market later this month.  I give it five stars per Amazon.com’s ranking system (I love it).

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At the start of my medical career over two decades ago, many of my overweight patients were convinced they had a hormone problem causing it.  I carefully explained that’s rarely the case.  As it turns out, I may have been wrong.  And the hormone is insulin.

Mr. Taubes wrote this long-awaited book for two reasons: 1) to make the ideas in his 2007 masterpiece (Good Calories, Bad Calories) more accessible to the public, and 2) to speed up the process of changing conventional wisdom on overweight.  GCBC was the equivalent of a college-level course on nutrition, genetics, history, politics, science, physiology, and biochemistry. Many nutrition science geeks loved it while recognizing it was too difficult for the average person to digest.

Paradigm Shift

The author hopes to convince us that “We don’t get fat because we overeat; we overeat because we’re getting fat.”  We need to think of obesity as a disorder of excess fat accumulation, then ask why the fat tissue isn’t regulated properly.  A limited number of hormones and enzymes regulate fat storage; what’s the problem with them?

Mr. Taubes makes a great effort convince you the old “energy balance equation” doesn’t apply to fat storage.  You remember the equation: eat too many calories and you get fat, or fail to burn up enough calories with metabolism and exercise, and you get fat.  To lose fat, eat less and exercise more.  He prefers to call it the “calories-in/calories-out” theory.  He admits it has at least a little validity.  Problem is, the theory seems to have an awfully high failure rate when applied to weight management over the long run.  We’ve operated under that theory for the last half century, but keep getting fatter and fatter.  So the theory must be wrong on the face of it, right?  Is there a better one?

So, Why DO We Get Fat?

Here is Taubes’s explanation.  The hormone in charge of fat strorage is insulin; it works to make us fatter, building fat tissue.  If you’ve got too much fat, you must have too much insulin action.  And what drives insulin secretion from your pancreas?  Dietary carbohydrates, especially refined carbs such as sugars, flour, cereal grains, starchy vegetables (e.g., corn, beans, rice, potatoes), liquid carbs.  These are the “fattening carbs.”  Dozens of enzymes and hormones are at play either depositing fat into tissue, or mobilizing the fat to be used as energy.  It’s an active process going on continously.  Any regulatory derangement that favors fat accumulation will CAUSE gluttony (overeating) or sloth (inactivity).  So it’s not your fault. 

What To Do About It

Cut back on carb consumption to lower your fat-producing insulin levels, and you turn fat accumulation into fat mobilization.

Before you write off Taubes as a fly-by-night crackpot, be aware that he’s received three Science-in-Society Journalism Awards from the National Association of Science Writers.  He’s a respected, professional science writer.  Having read two of his books, it’s clear to me he’s very intelligent.  If he’s got a hidden agenda, it’s well hidden.

One example  illustrates how hormones control growth of tissues, including fat tissue.  Consider the transformation of a skinny 11-year-old girl into a voluptuous woman of 18. Various hormones make her grow and accumulate fat in the places we now see curves.  The hormones make her eat more, and they control the final product.  The girl has no choice.  Same with our adult fat tissue, but with different hormones. If some derangement is making us grow fatter, it’s going to make us more sedentary (so more energy can be diverted to fat tissue) or make us overeat, or both.  We can’t fight it.  At not least very well, as you can readily appreciate if look at the people around you at any American shopping mall.

This’N’That

Taubes’s writing is clear and persuasive.  He doesn’t beat you over the head with his conclusions. He lays out a logical series of facts and potential connections and explanations, helping you eventually see things his way.  If insulin controls fat storage by building and maintaining fat tissue, and if carboydrates drive insulin secretion, then the way to reduce overweight and obesity is carbohydrate-restricted eating, especially avoiding the fattening carbohydrates.  I’m sure that’s true for many folks, perhaps even a majority.

If you’re overweight and skeptical about this approach, you could try out a very-low-carb diet for a couple weeks or a month at little expense and risk (but not zero risk).  If Mr. Taubes and I are right, there’s a good chance you’ll lose weight.  At the back of the book is a university-affiliated low-carb eating plan.

If cutting carb consumption is so critical for long-term weight control, why is it that so many different diets—with no focus on carb restriction—seem to work, if only for the short run?  Taubes suggests it’s because nearly all diets reduce carb consumption to some degree, including the fattening carbs.  If you reduce your total daily calories by 500, for example, many of those calories will be from carbs.  Simply deciding to “eat healthy” works for some people: stopping soda pop, candy bars, cookies, desserts, beer, etc.  That cuts a lot of fattening carbs right there.

Losing excess weight or controlling weight by avoiding carbohydrates was the conventional wisdom prior to 1960, as documented by Mr. Taubes.  Low-carb diets for obesity date back almost 200 years.  The author attributes many of his ideas to German internist Gustav von Bergmann (1908).   

Taubes discusses the Paleolithic diet, mentioning that the average paleo diet derived about a third of total calories from carbohdyrates (compared to the standard American diet’s 55% of calories from carb).  My prior literature review  found 40-45% of paleo diet calories from carbohydrate.  I’m not sure who’s right.

Minor Bone of Contention RE: Coronary Heart Disease

Mr. Taubes provides numerous scientific references to back his assertions.  I checked out one in particular because it didn’t sound right.  Some background first. 

Reducing our total fat and saturated fat consumption over the last 40 years was supposed to lower our LDL cholesterol, thereby reducing the burden of coronary heart disease, which causes heart attacks.  Instead, we’ve experienced the obesity epidemic as those fats were replaced by carbohydrates.  Taubes mentions a 2009 medical journal article by Kuklina et al, in which Taubes says Kuklina points out the number of heart attacks has not decreased as we’ve made these diet changes.  Kuklina et al don’t say that.  In fact, age-standardized heart attack rates have decreased in the U.S. during the last decade. 

Furthermore, autopsy data document a reduced prevalence of anatomic coronary heart disease in people aged 20-59 from 1979 to 1994, but no change in prevalence for those over 60. The incidence of coronary heart disease decreased in the U.S. from 1971 to 1998 (the latest reliable data).  Death rates from heart disease and stroke have been decreasing steadily over the last 40 years in the U.S.; coronary heart disease death rates are down by 50%.  I do agree with Taubes that we shouldn’t credit those improvements to reduced total and saturated fat consumption.  [Reduced trans fat consumption may play a role, but that’s off-topic.] 

I think Mr. Taubes would like to believe that coronary artery disease is either more severe or unchanged in the last few decades because of low-fat, high-carb eating.  That would fit nicely with some of his theories, but it’s not the case.  Coronary artery disease is better now thanks to a variety of factors, but probably not diet (setting aside the trans-fat issue).

Going Forward

Low-carb dieting was vilified over the last half century partly out of concern that the accompanying high fat consumption would cause premature heart attacks, strokes, and death.  We know now that total dietary fat and saturated fat have little to do with coronary heart disease and atherosclerosis (hardening of the arteries), which sets the stage for a resurgence of low-carb eating.  

I advocate Mediterranean-style eating as the healthiest, in general.  It’s linked with prolonged life and lower risk of heart disease, stroke, dementia, diabetes, and cancer.  On the other hand, obesity is a strong risk factor for premature death and development of heart disease, stroke, diabetes, and cancer.  If consistent low-carb eating cures the obesity, is it healthier than the Mediterranean diet?  Maybe so.  Would a combination of low-carb and Mediterranean be better?  Maybe so.  I’m certain Mr. Taubes would welcome a decades-long interventional study comparing low-carb with the Mediterranean diet.  But that’s probably not going to happen in our lifetimes. 

Gary Taubes rejects the calories-in/calories-out theory of overweight that hasn’t done a very good job for us over the last 40 years.  Taubes’s alternative ideas deserve serious consideration.

Steve Parker, M.D.

Update December 18, 2010: I found Mr. Taubes’s reference for stating that Paleolithic diets provide about a third of calories from carbohydrate (22-40%), based on modern hunter-gatherer societies).  See References below.   

References:
Coronary heart disease autopsy data:  American Journal of Medicine, 110 (2001): 267-273.
Reduced heart attacks:  Circulation, 12 (2010): 1,322-1,328.
Reduced incidence of coronary heart disease:  www.UpToDate.com, topic: “Epidemiology of Coronary Heart Disease,” accessed December 11, 2010.
Death rates for coronary heart disease:  Journal of the American Medical Association, 294 (2005): 1,255-1,259.

Cordain, L., et al.  Plant-animal subsistance ratios and macronutrient energy estimations in worldwide hunter-gatherer dietsAmerican Journal of Clinical Nutrition, 71 (2000): 682-692.

Disclosure:  I don’t know Gary Taubes.  I requested from the publisher and received a free advance review copy of the book.  Otherwise I received nothing of value for this review.

Disclaimer:   All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Update April 22, 2013

As mentioned above, WWGF was based on Taubes’ 2007 book, Good Calories, Bad Calories. You may be interested in a highly critical review of GCBC by Seth at The Science of Nutrition.

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Atkins Diet for Diabetes: Lively Debate

HeartWire at TheHeart.Org on October 18, 2010, posted an article about use of the Atkins diet for people with diabetes.  You might enjoy the ongoing lively debate among (mostly) physicians and researchers.

My review of Atkins Diabetes Revolution summarizes my thoughts.

Steve Parker, M.D.

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2002 Atkins Diet at a Glance

Dr. Robert C. Atkins is the modern popularizer of low-carb dieting.  He was neither the first nor only low-carb advocate of the 20th century, but certainly the most influential in modern history in terms of followers.  His Dr. Atkins Diet Revolution was published in 1972 and sold millions of copies. 

Sir Isaac Newton wrote in 1676: “If I have seen further, it is by standing on the shoulders of giants.”  Twentieth century giants for Dr. Atkins include Frank Evans, Blake Donaldson (the original paleo diet guru?), Per Hansen, Alfred Pennington, and John Yudkin.  Most of these were physicians, by the way.  William Banting preceeded them, in the 19th century.

Dr. Atkins New Diet Revolution, published in 2002, was a huge seller then and maintains a respectable sales volume even now.  My impression is that Atkins Nutritionals, Inc., has replaced it with The New Atkins for a New You, which I reviewed last spring.  Enough people still follow DANDR that I need to stay familiar with it.  Here’s my brief summary of the phases.

Induction or Phase 1

  • Limit carbs to 20 g of “net carbs” daily for a minimum of two weeks.
  • “Net carbs” is the total carb count in grams, minus the fiber grams.
  • 3 cups of salad greens daily with olive oil/vingar or lemon juice OR 2 cups of salad greens and one cup of non-starchy cooked vegetables (e.g., broccoli or zucchini).
  • May also eat 3–4 ounces of aged cheese, a handful of olives, and half an avocado daily.

Ongoing Weight Loss (OWL) or Phase 2

  • Deliberate slowing of weight loss.
  • Gradually add back nutrient-rich carbs.
  • Increase net carbs weekly by just 5 g, by eating more veggies, nuts, seeds, even berries (this is where the “carb ladder” comes into play, adding carb groups in a specific order).
  • Some dieters can even add small amounts of beans and fruits other than berries, until weight loss stalls.  At that point, you drop back 5 g net carbs, to your Critical Carbohydrate Level for Losing (CCLL).

Pre-maintenance or Phase 3

  • Begins 5 or 10 pounds before reaching your weight goal.
  • Weight loss slows even more, taking at least 2 months to lose that last 10 pounds.
  • Can now add some starchy veggies like sweet potatoes, peas, whole grains.
  • If weight loss stops before goal, drop back down by 5-10 g net carbs, to your revised CCLL.

Lifetime Maintenance or Phase 4

  • Starts when you’ve been at goal weight for one month.
  • No more junk food, ever.
  • Stay vigilant for excessive carbs.  You may never be able to go back to whole grains or higher-carb fruits and vegetables.

Steve Parker, M.D.

PS: Gary Taubes reviews the history of low-carb diets in his masterpiece, Good Calories, Bad Calories.

Sir Isaac Newton
Head and shoulders portrait of man in black with shoulder-length gray hair, a large sharp nose, and an abstracted gaze

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Book Review: Diabetes Solution – The Complete Guide to Achieving Normal Blood Sugars

Here’s my review of Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars, published in 2007.  Per Amazon.com’s rating scale, I give it five stars (I love it).  

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Dr. Richard K. Bernstein gives away thousands of dollars’ worth of medical advice in this masterpiece, Diabetes Solution.  It’s a summation of his entire medical career and a gift to the diabetes community.  

The book starts off with some incredible testimonials: reversal of diabetic nerve damage, eye damage, and erectile dysfunction.  They’re a bit off-putting to a skeptic like me, like an infomercial.  Dr. Bernstein is either lying about these or he’s not; I believe him.  His strongest testimonial is his own.  He’s been a type 1 diabetic most of his life, having acquired the disease at a time when most type 1’s never saw 55 candles on a birthday cake.  He’s in his mid-70s now and still working vigorously.  

I only found one obvious error and assume it’s a misprint. He writes that 95% of people born today in the U.S. will eventually develop diabetes.  That’s preposterous.  The U.S. Centers for Disease Control predicts that one in three born in 2000 will be diagnosed.  

Dr. Bernstein delivers lots of facts that I can neither confirm nor refute.  He’s a full-time diabetologist; I am not.  

"Put down the bread and no one will get hurt!"

  

The central problem in type 1 diabetes is that, due to a lack of insulin,  ingested carbohydrates lead to spikes (elevations) in blood sugar.  The sugar elevations themselves are toxic.  The usual insulin injections are not good imitators of a healthy pancreas gland. So Dr. Bernstein is an advocate of low-carb eating (about 30 g daily compared to the usual American 250-300 g).  He says the available insulins CAN handle the glucose produced by a high-protein meal.  

Dr. B reminds us that insulin is the main fat-building hormone, which is one reason diabetics gain weight when they start insulin, and why type 2 diabetics with insulin resistance (and high blood insulin levels) are overweight and have trouble losing weight.  You can have resistance to insulin’s blood sugar lowering action yet no resistance to its fat-building (fat-storing) action.  Insulin also stimulates hunger, so insulin-resistant diabetics are often hungry.  

“Carbohydrate counting” is a popular method for determining a dose of injected insulin.  Dr. B says the gram counts on most foods are only a rough estimate—far too rough.  He minimizes the error by minimizing the input (ingested carbs).  From his days as an engineer, he notes “small inputs, small mistakes.”  

Dr. B also cites problems with the absorption of injected insulin.  Absorption is variable: the larger the dose, the greater the variability.  So don’t eat a lot of carbs that require a large insulin dose.  For adult type 1 diabetics, his recommended rapid-acting insulins doses are usually three to five units.  If a dose larger than seven units is needed, split it into different sites.  

He recommends diabetics aim for normal glucoses (90 mg/dl or less) almost all the time, and hemoglobin A1c of 5% or less.  This is extremely tight control, tighter than any expert panel recommends.  He says this is the best way to avoid the serious complications of diabetes.   

Here’s a smattering of “facts” in the book that made an impact on me, a physician practicing internal medicine for over two decades.  I want to remember them, incorporate into my practice, or research further to confirm:  

  • Hemoglobin A1c of 5% equals an average blood sugar of 100 mg/dl (5.56 mmol/l).  For each one % higher, average glucose is 40 mg/dl (2.22  mmol/l) higher.
  • He’s against any drugs that overstimulate (“burn out”) the remaining pancreas function in type 2 diabetics: sulfonylureas, meglitinides, “phenylalanine derivatives”.  Pancreas-provoking agents cause hypoglycemia and destroy beta cell function.
  • The insulin sensitizers are metformin and thiazolidinediones.  He likes these.
  • Blood sugar normalization in type 2 diabetes and early-stage type 1 can help restore beta cell function.
  • He often speaks of preserving beta cell function.
  • He believes in “insulin-mimetic agents” like alpha lipoic acid (especially R-ALA, and take biotin with either form) and evening primrose oil.  These  are no substitute for insulin injections but allow for lower insulin doses.  ALA and evening primrose oil don’t promote fat storage like insulin does.
  • He says many cardiologists take ALA for its antioxidant properties [news to me]
  • He says rosiglitazone works within two hours [news to me] but later admits it may take 12 weeks to see maximal benefit
  • One of his goals is to preserve beta cell function if at all possible
  • He prefers rosiglitazone over pioglitazone due to fewer drug interactions
  • “Americans are fat largely because of sugar, starches, and other high-carbohydrate foods.”
  • He’s convinced that people who crave carbohydrates have inherited the problem, which also predisposes to insulin resistance and type 2 diabetes.  Low-carb diets decrease the cravings for many, in his experience.
  • In small amounts, alcohol is relatively harmless: dry wine, beer, spirits.  Very few doctors have the courage to say this.
  • If you’re in a restaurant, you can use urine sugar test strips and saliva to test for presence of sugar or flour in food
  • A rule of thumb: one gram of carbohydrate will raise blood sugar about 5 mg/dl (0.28  mmol/l) or less for most diabetic adults weighing 140 lb (64  kg) and about 2.5 mg/dl (0.139 mmol/l) in a 280-pounder (127  kg).  This must refer to type 1 diabetics or a type 2 with little residual pancreas beta cell function; variable degrees of insulin resistance and beta cell reserve in many type 2s would make this formula unreliable.
  • Be wary of maltodextrin in Splenda: it does raise blood sugar.
  • Much new to me in his section on artificial sweeteners.  Be wary of them.
  • He avoids all grains, breads, crackers, barley, oats, rice, and pasta.
  • Most diet sodas are OK.
  • Coffees with 1-2 tsp milk is OK.  Cream is OK.
  • He eats NO fruit and recommends against it.
  • He avoids beets, corn, potatoes, and beans. A slice of tomato in one cup of salad is OK.  A small amount of onion is OK.
  • String beans and snow peas are OK.
  • Cooked vegetables tend to raise blood sugar more rapidly than raw.
  • Use “Equal” aspartame tabs as a sweetener.  Don’t use “powdered” Splenda.
  • Avoid nuts: too easy to overeat.
  • For desert: sugar-free Jell-O Brand Gelatin.
  • Yogurt?  Plain, whole milk, unsweetened.  Flavor with cinnamon, Da Vinci syrups, baking flavor extracts, stevia or Equal.
  • Avoid balsamic vinegar.
  • Need fiber?  Bran crackers or soybean products.
  • “Ideally, your blood sugar should be the same after eating as it was before.”  85 mg/dl (4.72  mmol/l) is his usual goal.  If blood sugar rises by more than 10 mg/dl (0.56 mmol/l) after a meal, either the meal has to be changed or medication changed.
  • Protein is a source of glucose: keep protein amounts at meals constant from day to day, especially if taking glucose-lowering drugs.
  • The lowest-carb meal of the day should be breakafast.  Why?  Dawn phenomenon.
  • He promotes strenuous, prolonged exercise, especially weight training (extensive discussion and instruction in book).
  • Many diabetics on insulin need dose adjustments in 1/2 and 1/4 unit increments [news to me: if I ordered 4 and 1/4 units of insulin at the hospital, the nurses would laugh].
  • Typical rapid-acting insulin doses for his adult type 1 patients are 3-5 units.  The “industrial doses” of insulin seen or recommended by many physicians reflect diets too high in carbohydrate.
  • He says Lantus only acts for nine hours (nighttime injection) or 18 hours (AM injection).
  • He doesn’t like mixed insulins (e.g., 70/30).
  • Humalog and Novolog are more potent than regular insulin, so the dose is about 2/3 of the regular insulin dose
  • “Only a few of the 20 available [home glucose monitoring] machines are suitably accurate for our purposes.”  “None are suitably accurate or precise above 200 mg/dl [11.11 mmol/l].”
  • Vitamin C in doses over 250 mg interferes with fingertip glucose monitors.  Later he says doses over 500 mg cause falsely low readings.
  • He prefers regular insulin (45 minutes before meal) over Novolog and Humalog, because of its five-hour duration of action.
  • Insulin users need to check glucose levels hourly while driving.
  • His personal basal insulin is 3 units Lantus twice daily.
  • He urges use of glucose (e.g., Dextrotabs) to correct hypoglycemia.
  • He says hypoglycemia is rare on his regimen.
  • He has an entire chapter on gastroparesis.

Dr. Bernstein’s recommended eating program in a nutshell:  

  • Some similarities to the Atkins diet, which he never mentions.
  • No simple sugars or “fast-acting” carbs like bread and potatoes, because even type 2s have impaired or nonexistent phase 1 insulin response.
  • Limit carbs to an amount that will work with your injected insulin or your remaining phase 2 insulin response, if any.
  • “Stop eating when you no longer feel hungry, not when you’re stuffed.”
  • Follow a predetermined meal plan (each meal: same grams of carb and ounces of protein)
  • Six g (or less) of carbs at breakfast, 12 g (or less) at lunch and evening meal.  So his patients count carb grams and protein ounces.
  • Supplements are not required IF glucoses are controlled and eating a variety of veggies.  Otherwise you may need B-complex or multivitamin/multimineral supplement.
  • Recipes are provided.

His has four basic drug treatment plans, tailored to the individual.  They are outlined in the book.  Dr. B provides detailed notes on what he does with his personal patients.  

Overall impressions:  

  • Too complicated for most, and they won’t give up higher carb consumption.  It requires a high degree of committment and discipline.  In fact, I’ve never had a patient tell me they were on the Bernstein program.
  • If I had type 1 diabetes, I might well follow his plan or the Low-Carb Mediterranean Diet, NOT the high-carb diet recommended by the ADA and many dietitians.
  • And if I had type 2 diabetes?  Low-Carb Mediterranean Diet first, Diabetes Solution as second choice.
  • If one can get his hemoglobins A1c down to 5% with other methods, would that be just as good?  Dr. B would argue that all other methods have blood sugar swings that are too wide.
  • Many new ideas and techniques here, at least to me.
  • He pretty much reveals his entire program here, which is priceless.
  • I’m not sure this plan will work unless the patient’s treating physician is on-board.
  • His personal testimony and breadth of knowledge are very persuasive. 

Steve Parker, M.D.  

Disclosure:  I was given nothing of value by Dr. Bernstein or his publisher in return for this review.

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Filed under Book Reviews, Carbohydrate, Drugs for Diabetes, Protein

Book Review: The New Atkins for a New You

Here’s my review of The New Atkins for  a New You, a weight-loss book by Dr. Eric Westman, Dr. Stephen Phinney, and Dr. Jeff Volek released a week ago.  The copyright holder is Atkins Nutritionals, Inc.  Under Amazon.com’s five-star rating system, I give it four stars (“I like it”).  

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The most exciting nutritional medicine development in recent memory is the fact that saturated fat consumption is not a significant cause of heart disease and premature death. The same goes for for total fat and cholesterol.  When enough physicians, nutritionists, and dietitians learn this, low-carb eating will take off like a rocket.

For those unfamiliar with the Atkins diet, it is designed for weight loss via high fat consumption and major carbohydrate restriction.  Protein intake is a bit higher than average.  As long as carbohydrates (carbs) are kept low, other foods are mostly unlimited.  Atkins has four phases.  As you graduate from one phase tothe next, more carbs are allowed, adding some carb sources before others (the Carb Ladder). 

Atkins has been around for years.  It’s not just a weight-loss diet; it’s a lifetime way of eating.

Doctors Westman, Phinney, and Volek are leaders in low-carb nutritional science.  The last time Atkins peaked (2003), we didn’t have the scientific studies backing up safety of the diet.  Now we do, in large part thanks to these guys. 

Physicians see beaucoup patients with overweight-related medical conditions.  We’re not going to recommend a diet that causes heart attacks, strokes, and other major medical complications.  Published research over the last eight years has established the relative safety of very low-carb diets, particularly Atkins.  Low-carb diets may even be healthier than the low-fat, high-carb diet that has been recommended by U.S. public health authorities for the last forty years.  Come to think of it, our current obesity and diabetes epidemics started around that same time.

The book covers nutrition basics, day-to-day practical application of Atkins eating, recipes and detailed meal plans, and the science behind the program.    

What’s New Since Dr. Atkins’ 2002 Book?

  • adaptations for vegetarians and vegans
  • adaptations for Latinos
  • coffee is now OK
  • introduction of the term “foundation vegetables” and almost doubling the amount of vegetables allowed in Phase 1: “approximately six cups of salad and up to two cups of cooked vegetables, depending upon the ones you select”
  • more flexility, such as the option to skip Phase 1 (induction)
  • focus on adequate protein intake, based on your height
  • emphasis on getting enough omega-3 fatty acids
  • no emphasis on supplements and low-carb products sold by Atkins Nutritionals,Inc.
  • diet journals—a personal record of your weight-loss journey—are recommended
  • eliminate or minimize “induction flu” and constipation (in Phase 1) by eating at least 1/2 teaspoon of salt daily [I’m skeptical.]
  • discussion of the trendy omega-6/omega-3 fatty acid ratio
  • favor monounsaturated fatty acids (e.g., olive oil, canola oil) over certain polyunsaturated fats, as in oils from corn, soybeans, sunflower, cottonseed, and peanuts
  • no mention of testing urine for ketosis
  • more discussion of psychological aspects of weight

The lack of ads for Atkins Nutritionals products is welcome and refreshing.  Too many of the official Atkins books read like infomercials, which diminishes credibility.

A vegetarian or vegan “Atkins diet” is just not something I can visualize.

What Could Have Been Done Better?

  • no specific amounts given for these recommended supplements: calcium, vitamin D, omega-3 fats, multivitamin, magnesium and other minerals (except “no iron”).  [Is the idea to encourage a visit the official Atkins website?]
  • little guidance for physicians who are to advise diabetics doing Atkins.  Few physicians are familiar enough with the program to make the necessary changes in particular diabetic medications.
  • little discussion of the constipation and leg cramps that often accompany very low-carb diets
  • the hype on the cover: “How would you like to LOSE UP TO 15 POUNDS IN TWO WEEKS!”  [To their credit, the authors note that such results are not typical.]
  • nearly all the measurements are U.S. Customary.  Metric users are out of luck.
  • four phases seem a bit much.  The beauty of Atkins Phase 1 is its simplicity. 

My favorite sentence: “White flour is better suited to glue for kindergarten art projects than to nutrition.”

My least favorite sentence: “We can’t stress strongly enough that the best diet for you is one composed of foods you love.”  I love apple pie and Cinnabon cinnamon rolls, but they won’t help me manage my weight.

The only error I found worth mentioning is minor.  The authors state that the American Heart Association recommends consumption of fish three times a week. The official policy is still “at least twice weekly.”

The book is very practical and easily understood by average people.  Most will skip the science chapters at the end.  I know the basic Atkins program works at least short-term; many of my patients have done it.

In summary, the book has nearly everything you need to be successful with the Atkins diet. 

As far as I know, there are no comprehensive long-term studies (e.g., 10+ years) regarding health outcomes of Atkins-style eating.  In other words, does Atkins have any effect on longevity, cancer, heart attacks, strokes, etc.?  But very few of the popular diets have these data either.  The best researched ways of eating in this respect are the Mediterranean diet and vegetarian diets.

Steve Parker, M.D.

Disclosure:  I was given nothing of value for this review by the authors, publisher, or Atkins Nutritionals, Inc.  I wrote it for the benefit of my patients and readers.

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Filed under Book Reviews, Carbohydrate, Fat in Diet, ketogenic diet, Weight Loss

Book Review: Cheating Destiny – Living With Diabetes, America’s Biggest Epidemic

I read James Hirsch’s book in 2006 but never got around to reviewing it.  Better late than never?  I give it four stars per Amazon.com’s rating system: “I like it.”

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Cheating Destiny: Living With Diabetes, America's Biggest EpidemicIf you have diabetes or love someone who is afflicted by diabetes, you’ll benefit from this book. It’s an insider’s view into the world of diabetes, with a predominant focus on type 1 rather than type 2.  Both are covered well.

Look elsewhere for a “how-to” book on managing diabetes.  Cheating Destiny is about emotions, coping strategies, public policy, and history.  Although I’ve been treating diabetes for over two decades, Mr. Hirsch taught me a thing or two.  For instance, did you know . . . that some people with diabetes are offended if you call them diabetics? (They prefer “people with diabetes.”)  That diabetes was considered shameful years ago?  That even the preeminent Joslin Diabetes Clinic loses money and has to be supported by private donations?  That the founder of d-Life TV was a patient of the iconoclastic Dr. Richard Bernstein?  About the exciting story of the discovery of insulin by Fred Banting and Charles Best in 1922?   

The author himself has type 1 diabetes.  The heart-wrenching story of his son’s diagnosis at age 3 showcases Mr. Hirsch’s considerable writing skills. 

To counter the sad and frustrating aspects of diabetes, the book is peppered with  funny anecdotes.  Did you ever duck in to a private booth at a girlie peep show to inject insulin?  Mr. Hirsch has!  [It’s not what you think.]

One undercurrent of the book I take issue with is the implication that the medical profession somehow perpetuates diabetes or purposefully provides inadequate care, because that’s where the money is.  Why work hard to cure diabetes or prevent complications when the profession makes money off the disease and it’s complications?  I don’t see it that way at all.  It is true, however, that preventive care and cognitive medical services (as opposed to invasive procedures) are poorly funded by insurance.  That’s an economic and political problem, not an ethical one in physicians and researchers.
 
Full disclosure:  My defunct outpatient medical practice is mentioned in chapter five.  The author outlines my efforts to provide conscientious care to people with diabetes – mostly type 2 – despite poor funding from insurers (primarily Medicare in my practice at the time).  Poor pay for cognitive services forced me to close my office.  I found Mr. Hirsch to be a thorough and accurate researcher.

[I’m a hospitalist and health blogger now.]

Other highlights of the book are discussions of Dr. Elliott Joslin, an overweight Southern black woman (the Diabetes Queen), intimate details about the type 1 diabetes experience from the patient and family perspective, Dr. Richard Bernstein, insulin pumps, islet cell transplants, origins of the Juvenile Diabetes Research Foundation, Douglas Melton and stem cell research, research rivalries and funding, and inspirational survivor tales.

Mr. Hirsch rightfully criticizes many aspects of the health and medical fields with regards to diabetes.  Thankfully, he never suggests a sweeping government take-over of the healthcare industry.  He urges diabetics – people with diabetes – to take care of their own disease and demand improvements in the current system.

The U.S. already has 24 million people with diabetes and another 54 million with prediabetes.  Approximately one of every three persons born in the U.S. in 2000 will develop diabetes in his or her lifetime, according to the Centers for Disease Control and Prevention.

I agree with Mr. Hirsch that diabetes is “the country’s leading public health crisis,” driven by obesity and the aging of the population.”  This book will help alleviate the damages. 

Steve Parker, M.D.

Disclosure:  I bought this book at Amazon.com.  I was not paid to review it.

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