Diet has always generated passion, and passion in science is an infallible marker of lack of evidence.
That sentence is from a wonderful review of diabetic diet cycles over the last 150 years. It’s by L. Sawyer and E.A.M Gale, published in Diabetologia (2009, vol. 52, pages 1-7, DOI: 10.1007/s00125-008-1203-9). Anyone with a serious interest in diabetic diets will appreciate the funny and philosophical style of the authors.
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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).
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
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.
Filed under Book Reviews
Science-based surgery (usually)Regarding complementary and alternative medicine:
The sciences give a mostly coherent understanding of the world. Mostly coherent. [They do] give an understanding of the possible, the probable, the improbable and the impossible. Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned. Perpetual motion is not considered seriously by any academic physicist; if perpetual motion were an alternative medicine it would be offered at a Center by a Harvard Professor of Medicine.
—Dr. Mark Crislip, infectious disease specialist, at Science-Based Medicine, April 8, 2011
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FITNESS
Sustained physical activity requires that your heart pump blood to the lungs and to the exercising muscles. The muscles extract oxygen, sugar, and other nutrients for use in chemical reactions that enable the muscle to keep moving (contracting). To say that someone is physically fit simply means that the heart easily pumps a large volume of blood and the muscles extract and use nutrients very efficiently. The heart, after all, is just a hollow muscle that pumps blood. If you stimulate your heart muscle through exercise, it will become more powerful and able to pump more blood. Regular sessions of physical activity increase the metabolic efficiency and power of your other muscles, too. There are various degrees of fitness, with professional and Olympic athletes at the extreme upper end.
GETTING STARTED
I’ve had otherwise healthy overweight patients so “out of shape” that walking 20 yards to the mailbox was a real chore. They were tired and panting when they got to the mailbox and had to rest a bit before returning to the house. These folks are habitually sedentary and dramatically overweight. But you need not feel too sorry for them. After starting and maintaining an exercise program, these unfit people achieve the greatest degree of improvement in fitness level. They make more progress, and faster, than those who begin with a greater level of fitness.
The way to achieve aerobic fitness is to regularly challenge your large muscles to perform sustained physical activity. “Regularly” means at least four days a week, if not daily. Left alone, your muscles don’t want to do much other than just get you through your day comfortably, without effort or aching or cramps. You must challenge them to do more, work a bit harder, tolerate a little aching. You’ll know you’re challenging them during exercise when you perceive that mild to moderate effort is required to keep the activity going. You should be mildly short of breath, perhaps even perspiring lightly, yet still able to converse. “Sustained” physical activity means at least 30 minutes in a day. Most people find it a better use of their time to exercise for 30 minutes continuously rather than break it up into five or 10 minutes here and there.
Discontinuous activity (e.g., 10 minutes thrice daily) probably is just as good. If you think about it, there are many easy ways to increase your discontinuous physical activity. Consider taking the stairs instead of the elevator, parking far from the supermarket or workplace doors, walking the golf course instead of riding a cart.
(The exercise model above is “old school,” which isn’t necessarily good or bad. Some newer scientific studies suggest that you can achieve comparable levels of fitness with much less time exercising, if you do it intensely. An example is high-intensity interval training (HIIT). That’s worth a blog post or two by itself. I also leave strength training—also an important aspect of fitness—for another day.)
If you’re starting out in poor shape, you won’t be able to do 30 minutes of any exercise without adverse effects. Don’t even try. The worst thing you could do at this point is injure yourself or have such a horrible experience that you give up entirely. Thirty minutes of daily activity is your goal to achieve over the next four to 12 months. Moderate to high levels of fitness will take you six to 24 months. The most important thing when getting started is to exercise at least a little, five to 10 minutes, on most days of the week. And don’t overdo it in terms of intensity. Start low, go slow. After three months, exercise will be a habit. Prolongation of your exercise sessions will be easy as your amazing body responds gradually to the workload through the process called physical conditioning.
If walking 30 minutes daily is too hard for you at first, try walking just an extra 10 or 20 minutes daily. If you can do that but it’s a bit of a strain, gradually (every two weeks) increase your walking time by five minutes daily until you are up to 30 minutes. Average walking pace is 2 mph (3.2 km/h). Once you can comfortably handle 30 minutes daily, the next step is to increase your walking pace to 3 or 4 mph (4.8–6.4 km/h) for the entire 30 minutes. Four mph (6.4 km/h) is definitely a brisk walk. It’s difficult for many people to sustain over 30 minutes until they work up to it gradually. This is often done by walking at two paces, normal and brisk, during an exercise session. You might walk five minutes at normal pace, then five minutes briskly, alternating every five minutes until the session is over. Every two to four weeks, you can increase the minutes of brisk pace and taper off the normal pace. You’re able to do this easily because your level of fitness is increasing.
I’m asking you to walk briskly (3–4 mph or 4.8–6.4 km/h) for 30 minutes most days of the week. This brisk pace burns roughly 200 calories per session, in case you’re wondering. If you eat a 400-calorie muffin, it provides enough energy for a one-hour brisk walk. If you don’t burn the muffin calories as exercise or basal metabolism, they’ll turn into body fat. (But you’re not eating muffins anymore, are you?!)
If you prefer physical activity other than walking, the general rule is to start slowly and gradually increase your effort (intensity) until you’re up to about 30 minutes of moderate-intensity exercise most days of the week. Start low, go slow.
Filed under Exercise
Certainly, by the last decade of the [20th] century, some lessons had plainly been learned. But it was not yet clear whether the underlying evils which had made possible its catastrophic failures and tragedies—the rise of moral relativism, the decline of personal responsibility, the repudiation of Judeo-Christian values, not least the arrogant belief that men and women could solve all the mysteries of the universe by their own intellects—were in the process of being eradicated. On that would depend the chances of the twenty-first century becoming, by contrast, an age of hope for mankind.
Paul Johson in Modern Times (revised 1991 edition)
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ORIGINS
It all starts with Ancel Keys.
Keys was the leader of the team who put together the Seven Countries Study, which seemed to demonstrate lower rates of coronary heart disease in countries consuming less saturated fat. [Coronary heart disease is the leading cause of death in Western cultures.] He also found that cardiovascular disease rates rose in tandem with blood cholesterol levels. The two countries particularly illustrative of these connections were Italy and Greece, both Mediterranean countries.
The other countries he analyzed in Seven Countries were the United States, Yugoslavia, Japan, Finland, and the Netherlands.
Keys and his wife Margaret, a biochemist, drilled deeper in to the “Mediterranean diet” that was characteristic of Italy, Greece, and other countries on or near the Mediterranean Sea in the 1950s and 1960s. [“Diet” in this context refers to the usual food and drink of a person, not a weight-loss program.] Their efforts culminated in the publication of several best-selling Mediterranean diet books in the 1970s, and Keys’ photo on the cover of Time magazine in 1961.
Thus began the still-popular healthy Mediterranean diet.
Oldways Preservation Trust re-invigorated the Mediterranean diet around 1990, helping the public incorporate Mediterranean diet principals into everyday life. Oldways founder, K. Dun Gifford, passed away within the last year.
DEFINITION
There is no monolithic, immutable, traditional Mediterranean diet. But there are similarities among many of the regional countries that tend to unite them, gastronomically speaking. Greece and southern Italy are particularly influential in this context.
So here are the characteristics of the traditional Mediterranean diet of the mid-20th century:
•It maximizes natural whole foods and minimizes highly processed ones
•Small amounts of red meat
•Less than four eggs per week
•Low to moderate amounts of poultry and fish
•Daily fresh fruit
•Seasonal locally grown foods with minimal processing
•Concentrated sugars only a few times per week
•Wine in low to moderate amounts, and usually taken at mealtimes
•Milk products (mainly cheese and yogurt) in low to moderate amounts
•Olive oil as the predominant fat
•Abundance of foods from plants: vegetables, fruits, beans, potatoes, nuts, seeds, breads and other whole grain products
•Naturally low in saturated fat, trans fats, and cholesterol
•Naturally high in fiber, phytonutrients, vitamins (e.g., folate), antioxidants, and minerals (especially when compared with concentrated, refined starches and sugars in a modern Western diet)
•Naturally high in monounsaturated and polyunsaturated fats, particularly as a replacement for saturated fats
CONTROVERSIES
Keys has been criticized for “cherry-picking” the data that linked saturated fat consumption with increased heart disease. In other words, the allegation is that he used information if it supported his theory, while ignoring data that was contrary or neutral. Subsequent studies indicate a weak link, if any, between saturated fat consumption and heart disease. A list of the pertinent studies de-linking heart disease and saturated fat is at my Advanced Mediterranean Diet Blog.
The Seven Countries Study included only men. It’s practical implications, therefore, may not apply to women.
The traditional Mediterranean diet is increasingly a thing of the past as Mediterranean countries adopt the Western diet characterized by “fast food” and highly processed foods.
FUN FACTS FOR FOOD GEEKS
Ever heard of K rations used by the U.S. military in World War II? Keys invented them. He earned Ph.D.s in biology and physiology. Keys lived to age 100 and was said to be intellectually active through his 97th year.
PS: The Mediterranean diet has too many carbohydrates (55% of total energy) for for most people with diabetes. Hence, the Low-Carb Mediterranean Diet.
References:
Keys, Ancel. Coronary heart disease in seven countries. Circulation, 41, (1970) supplement I: I-1 through I-211.
Keys, Ancel. Seven Countries: A Multivariate Analysis of Death and Coronary Artery Disease. Harvard University Press, 1980.
Oldways website.
Filed under Mediterranean Diet
In the U.S., 24 million people have diabetes, mostly type 2. That’s one in 10 adults. The number for those over 60 is two in 10.
Fifty-seven million have prediabetes; that’s one of every three adults. Most of them are unaware of it.
The American Diabetes Association offers an online diabetes and prediabetes risk assesment. The Centers for Disease Control says one of every three people born in 2000 will develop diabetes. A few risk factors are age over 45, family history of diabetes, sedentary lifestyle, and overweight or obese. Why not recommend the test to someone you know who may be at risk?
Steve Parker, M.D., author of Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet
Filed under Uncategorized
Natchez Eggs is an old family recipe. It’s sort of an egg casserole, good for breakfast. We tend to dust off this recipe when we have house guests—it feeds many people at once, quickly and easily.
It’s not in my new book, Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet. Note my use of both U.S. customary and metric measurements, which I also used in the book. I have no idea how much it costs to ship a book from the U.S. to New Zealand, but the e-book version has no shipping charge.
Ingredients
Cheese, shredded (four-cheese mexican blend), 8 0z (224 g)
Sour cream, 16 oz (448 g)
Green chiles, diced, canned, 8 oz net weight (224g)
Eggs, large, 10 (50 g each)
Preparation
Pre-heat oven to 350°F (175°C). Mix eggs thoroughly in a blender for 3–4 minutes on medium speed, then pour into bowl. Coat a baking dish (9 x13 inches, or 22 x 34 cm) with butter, vegetable oil, PAM or no-stick baking spray. Whisk eggs and sour cream together in bowl. Drain excess water from the chile cans, then spread chiles evenly on the bottom of a dish, then layer the cheese evenly on top. Next, ladle or pour the eggs/sour cream on top. Bake for about 30 minutes, until the eggs are firm, not runny, and you see patches of thin light brown crust.
Makes 12 servings (about 4 oz or 110 g each). Leftovers hold up well in refrigerator for eating over the next few days.
Nutrient Analysis
A serving has 3 grams of digestible carbohydrate, 200 calories, 140 calories from fat, 8 grams of saturated fat, 10 grams of protein, 210 mg cholesterol, 4 grams of carboydrate, 1 gram of fiber.
Options
After you add the cheese layer, sprinkle layer of Hormel Real Crumbled Bacon (4 oz or 112 g) before finishing up with the egg mixture. This adds 33 calories and zero carbs per serving. Or just serve with bacon on the side (my preference). An alternative to the Hormel product is to cook and crumble your own bacon (12 oz or 340 g uncooked weight). Using too much bacon will overwhelm the other flavors. Experiment with different cheeses.
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Filed under Recipes
Michael Pollan is credited with the aphorism, “Eat food. Not too much. Mostly plants.”
Bill Gottlieb interviewed me recently on the topic of prediabetes for a book due out later this year (Bottom Line’s Breakthroughs in Natural Healing 2012). Bill had given me a preparatory list of potential questions, one of which was,”What are the best dietary recommendations? I’m looking for fun, fresh specificity here—along the lines of your book!” Also, “What’s the best way for a person to implement it—specific, practical, small-step actions that would lead to actually changing the diet?”
We didn’t have a chance to get to those in the interview, but here are some of my thoughts:
But “giving up” is not a message people want to hear when contemplating a diet change, even if it’s for their own good. “Avoid” and “cut back on” are not specific. “Forego” works, but is just a euphemism for “give up.” “Eat only God-made foods” might turn off the atheists and agnostics.
Here’s a more marketable catch-phrase that I rather like:
Eat natural food.*
By “natural,” I mean “present in or produced by nature.” This would not include candy bars, potato and corn chips, soda pop, sports drinks, apple pie, bread and other flour products, cookies, etc. That still leaves a lot of different foods to eat, including most of the items on the Low-Carb Mediterranean Diet. Whether modern, mass-produced versions of fruits and vegetables are natural is a debate for another day. I suspect modern corn, for example, is nothing close to the maize cultivated by Native Americans 400 years ago.
Why the asterisk? The exceptions to the “eat natural food” rule are red wine, olive oil, and vinegar. Those are partly natural, partly man-made. (Where do we get vinegar?) The red wine and olive oil are potentially healthful, and many of us like vinegar on our natural salad vegetables.
Eat natural food.
I bet the average person eating the standard American diet would tend to lose excess weight and be healthier by making the switch.
* Exceptions: red wine, olive oil, vinegar
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A cocktail of three common vitamins slowed the rate of brain shrinkage over two years in elderly patients with mild cognitive impairment, according to researchers at the University of Oxford. Less brain shrinkage should translate to better brain functioning. People with diabetes need to know about this since diabetes is associated with age-related cognitive impairment and dementia. The dementia connection is debatable.
As a hospitalist, I see 10 or 20 brain scans every week. A healthy 40-year-old brain nicely fills out the allotted space in the skull. Most 70-year-old brains have an obvious degree of shrinkage. Those with the most shrinkage typically have worse mental functioning, often diagnosed clinically as dementia, or its precursor, mild cognitive impairment (MCI).
The medical term for brain shrinkage is brain atrophy. It reflects loss of brain cells or decrease in brain cell size. I see A LOT of atrophied brains and impaired mental functioning—aka diminished cognition—in the elderly.
Not everybody with atrophy has mental impairment; healthy brains slowly atrophy with age. Alzheimer’s disease patients atrophy quickly; MCI patients atrophy at an intermediate rate. MCI patients converting over the years to Alzheimer’s show a faster rate of atrophy.
Mild cognitive impairment affects 14 to 18% of those over age 70 (five million in the U.S.). Half of these convert to Alzheimer’s disease or another dementia within five years. We desperately need a way to prevent or slow that conversion.
That’s why I was excited to see a research report in which brain atrophy was slowed with three simple daily vitamins: folic acid 800 mcg, B12 500 mcg, and B6 20 mg. (One Centrum vitamin, by comparison, provides folic acid 400 mcg, B12 6 mcg, and B6 2 mg). The investigators will report later on whether the vitamins helped prevent mental decline.
These three vitamins are involved in homocysteine metabolism; they decrease blood levels of homocysteine. Read elsewhere if you want the boring details.
Methodology
Oxford area participants were at least 70 years of age and had mild cognitive impairment but not dementia. Blood homocysteine levels were drawn periodically. Participants were randomized to take either placebo (83 subjects) or the daily vitamins (85 subjects) for two years. MRI scans were done periodically to determine brain volume. Tests of mental functioning were done periodically. More subjects were in the study at the outset but some dropped out and others didn’t have technically adequate MRI scans.
Results
After adjustment for age, the annual rate of brain atrophy was 30% less in the vitamin group compared to placebo.
For the placebo group, the rate of brain atrophy was clearly related to baseline homocysteine levels: higher homocysteine, faster atrophy.
Although the study was not powered to detect an effect of treatment on cognition (findings to be reported separately), in a post hoc analysis, we noted that final cognitive test scores were correlated to the rate of atrophy.
Atrophy appears to be a major determinant of cognitive decline in this population.
There were no significant safety issues and no differences in adverse events between the groups.
The vitamin group lowered homocysteine levels by 32% compared to placebo.
Reduction in brain shrinkage rate was best in those with a higher baseline homocysteine level (over 13 micromol/L); those with the lowest baseline levels (<9.5 micromol/L) showed no effect of vitamin therapy. [In the U.S., 13% of those over 60 have concentrations over 13 micromol/L, whereas the median is 10 micromol/L.]
Comments
Although this is small study, I’m excited about the future clinical implications. The results need to be replicated. I can’t wait to hear from this group regarding the details of mental functioning tests. If preservation of brain function or other practical benefits don’t accompany a slower rate of atrophy , it’s no use taking the vitamins.
A 2008 study found no clinical benefit with a similar vitamin mix in Alzheimer’s patients with mild to moderate disease. In other words, the rate of mental decline was no different than the placebo group. Average homocysteine level was 9.16 micromole/L and fell by 30% during the 18-month-long study. Even those with the highest homocysteine levels showed no benefit. Perhaps B vitamins need to be started much earlier in the disease process to be effective.
The time may come where we screen all 60-year-olds for above-average homocysteine levels, starting them on the vitamin cocktail.
One caveat, however. Ten years ago doctors were quite excited about preventing heart disease events (e.g., heart attacks, cardiac deaths) and strokes in people with high homocysteine levels. We knew that high levels were associated with cardiac events and strokes, and we knew the B vitamins would lower the blood levels. We learned a couple years ago that B vitamin therapy actually didn’t help heart patients or those at high risk for heart disease. Nor do the vitamins prevent strokes. [If you’re a heart patient still taking Foltx, ask your cardiologist if it’s OK to stop it now.]
References:
Smith, David, et al. Homocysteine-lowering by B vitamins slows the rate of accelerated brain atrophy in mild cognitive impairment: A randomized controlled trial. PLoS ONE 5(9): e1244. doi: 10.1371/journal.pone.0012244 [published September 8, 2010]
Aisen, P.S., et al. High-dose B vitamin supplementation and cognitive decline in Alzheimer disease: A randomized controlled trial. Journal of the American Medical Association, 300 (2008): 1,774-1,783.
Filed under Diabetes Complications
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Bible Verse of the Day
Diabetic Mediterranean Diet 