Paleo and Low-Carb Diets: Much In Common?

My superficial reading of the paleo diet literature led me to think Dr. Loren Cordain was the modern originator of this trend, so I was surprised to find an article on the Stone Age diet and modern degenerative diseases in a 1988 American Journal of Medicine.  Dr. Cordain started writing about the paleo diet around 2000, I think.

What’s So Great About the Paleolithic Lifestyle?

In case you’re not familiar with paleo diet theory, here it is.  The modern human gene pool has changed little over the last 50,000 years or so, having been developed over the previous one or two million years.  Darwins’ concept of Natural Selection suggests that organisms tend to thrive if they adhere to conditions present during their evolutionary development.  In other words, an organism is adapted over time to thrive in certain environments, but not others.

The paleo diet as a healthy way to eat appeals to me.  It’s a lifestyle, really, including lots of physical activity, avoidance of toxins, adequate sleep, etc. 

The Agricultural Revolution (starting about 10,000 years ago) and the Industrial Revolution (onset a couple centuries ago) have produced an environment vastly different from that of our Paleolithic ancestors, different from what Homo sapiens were thriving in for hundreds of thousands of years.  That discordance leads to obesity, type 2 diabetes, atherosclerosis, high blood pressure, and some cancers.  Or so goes the theory.

What’s the Paleolithic Lifestyle? (according to the article)

  • Average life expectancy about half of what we see these days
  • No one universal subsistence diet
  • Food: wild game (lean meat) and uncultivated vegetables and fruits (no dairy or  grain)
  • Protein provided 34% of calories (compared to about 12 in U.S. in 1988)
  • Carbohydrate provided 46% of calories (only a  tad lower than what we eat today)
  • Fat provided 21% of calories (42% today)
  • Little alcohol, but perhaps some on special occasions (honey and wild fruits can undergo natural fermentation) , compared to 7-10% of calories in U.S. today [I didn’t know it was that high]
  • No tobacco
  • More polyunsaturated than saturated fats (we ate more saturated than polyunsaturated fat, at least in 1988)
  • Minimal simple sugar availability except when honey in season
  • Food generally was less calorically dense compared to modern refined, processed foods
  • 100-150 grams of dietary fiber daily, compared to 15-20 g today
  • Two or three times as much calcium as modern Americans
  • Under a gram of sodium daily, compared to our 3 to 7 grams.
  • Much more dietary potassium than we eat
  • High levels of physical fitness, with good strength and stamina characteristic of both sexes at all ages achieved through physical activity

[These points are all debatable, and we may have better data in 2010.]

The article authors point out that recent unacculturated native populations that move to a modern Western lifestyle (and diet) then see much higher rates of obesity, diabetes, atheroslcerosis, high blood pressure, and some cancers.  “Diseases of modern civilization,” they’re called.  Cleave and Yudkin wrote about this in the 1960s and ’70s, focusing more on the refined carbohydrates in industrial societies rather than the entire lifestyle.  I expect Gary Taubes would blame the processed carbs, too. 

Paleo diet proponents agree that grains are not a Paleolithic food.  The word “grain” isn’t in this article.  The authors don’t outline the sources of Paleolithic carbs: tubers and roots, fruits, nuts, and vegetables, I assume.  Legumes and milk are probably out of the question, too.

Low-carb diet and paleo diet advocates often allign themselves, even though this version of the paleo diet doesn’t appear to be very low-carb.  The two share an affinity for natural, whole foods, and an aversion to grains, milk, and legumes.  Otherwise I don’t see much overlap.

ResearchBlogging.orgA 2010 article by Kuipers et al (reference below) sugggests that the East African Paleolithic diet derived, on average, 25-29% of calories from protein, 30-39% from fat, and 39-40% from carbohydrate.  That qualifies as low-carb.  Modern Western percentages for protein, fat, and carb are 15%, 33%, and 50%, respectively.

You can make a good argument that these paleo concepts are healthy: high physical activity, nonsmoking, consumption of natural whole foods while minimizing simple sugars and refined starches.  The paleo community is convinced that grains and legumes are harmful; many others disagree.  Also debatable are the role of dairy, polyunsaturated to saturated fat ratio, low sodium, and high potassium.  Modern diets tend to be high-sodium and low-potassium, which may predispose to high blood pressure and heart trouble—diseases of modern civilization.

For more on the paleo diet and lifestyle, visit Free the Animal, Mark’s Daily Apple, and PaNu

Steve Parker, M.D.

Update December 18, 2010:  I found a reference suggesting that Paleolithic diets may have derived about a third—22 to 40%—of calories from carbohydrate, based on modern hunter-gatherer societies.  See the Cordain reference I added below.

Reference:

Kuipers, R., Luxwolda, M., Janneke Dijck-Brouwer, D., Eaton, S., Crawford, M., Cordain, L., & Muskiet, F. (2010). Estimated macronutrient and fatty acid intakes from an East African Paleolithic diet British Journal of Nutrition, 1-22 DOI: 10.1017/S0007114510002679.  Note that one of the authors is Loren Cordain.  Good discussion of various Paleolithic diets.

Eaton, S., Konner, M., & Shostak, M. (1988). Stone agers in the fast lane: Chronic degenerative diseases in evolutionary perspective The American Journal of Medicine, 84 (4), 739-749 DOI: 10.1016/0002-9343(88)90113-1

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.

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Filed under Carbohydrate, Causes of Diabetes, coronary heart disease, Overweight and Obesity

Diabetic Kidney Disease Diminishing

The U.S. Centers for Disease Control and Prevention recently announced a 35% drop in the rate of end-stage kidney disease caused by diabetes between 1996 and 2007.

End-stage kidney disease by definition requires dialysis (“artificial kidney”) treatments or kidney transplantation to preserve life.  I’ve seen hundreds of dialysis patients.  It’s not a great way to live; avoid it if you can.

Diabetes nevertheless is still responsible for almost half—44%—of all end-stage kidney disease.

The reasons for the reduced rate of this devastating renal complication are unclear.  Possible factors include better control of high blood sugar, high blood pressure, and cholesterol levels.  Increasing usage of the drugs like angiotensin converting enzyme inhibitors and angiotensin-receptor blockers may also play a role.

The University of Maryland Medical Center website offers more information on chronic kidney disease.

Steve Parker, M.D.

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Another Good Reason to Lose the Fat: Stop Urine Leakage

For overweight and obese women, loss of between five and 10% of body weight significantly reduces urine leakage.  According to the research report in a recent Obstetrics & Gynecology journal, weight loss should be the first approach to urine leakage in overweight and obese women.

The other word for urine leakage is incontinence: an involuntary loss of urine.  It’s a major problem that isn’t much talked about.  It’s not exactly dinner-party conversation material.  You can imagine its effect on quality of life.  In the U.S., leakage of urine on at least a weekly basis is reported by one in 10 women and one in 20 men.  It’s more common at higher ages and in women.  Just looking at non-pregnant women, incontinence affects 7% of women aged 20-39, 17% of those aged 40-59, and 23% of women 60-79 years old.

The study at hand involved 338 overweight and obese women: average age 53 (minimum of 30), average body mass index 36, average weight 92 kg (202 lb).  For participation, they had to have at least 10 incontinence episodes per week.  On average, they reported 24 leakage episodes per week (10 stress incontinence, 14 urge incontinence).  All women were given a “self-help incontinence behavioral booklet with instructions for improving bladder control.”  They were randomized to two different weight-loss programs, but I won’t bore you with the details.  The diets were the standard reduced-calorie type.  One diet group had many more meetings than than the other.

The women kept diaries of leakage, and even collected urine soaked pads for weighing.

Results

Eight-five percent of the women completed the 18-month study.

By six months, 89 of the women has lost five to 10% of body weight; 84 lost over 10%.  As expected, when measured at 18 months, only 61 women were in the “five to 10% loss” category; 71 were in the “over 10%” group. 

Greater amounts of weigh loss were linked to fewer episodes of leakage.  Maximal improvement in leakage episodes were seen in the women who lost between five and 10% of body weight, with no additional benefit to greater degrees of weight loss, generally.

Women who lost 5-10% of their body weight were two to four times more likely to achieve at least a 70% reduction in total and urge incontinent episode frequency compared with women who gained weight at 6, 12, and 18 months.

Weight loss works better for stress incontinence than for urge incontinence.

Three of every four women who lost five to 10% of body weight said they were moderately or very satisfied with their improved bladder control.

Bottom Line

Weight loss is usually not a cure for incontinence, but a reasonable management option for overweight and obese women.  It’s going to take loss of five or 10% of body weight.  Other options  include drugs, surgery, Kegel exercises, and just living with it.

Five or 10% weight loss for a 200 pound woman is just 10 or 20 pounds.  That degree of weight loss is also linked to lower risk of diabetes and hypertension: even more reason go for it.  

Does it work for men?  Who knows?

Steve Parker, M.D.

Reference: Wing, R.R., et al.  Program to Reduce Incontinence by Diet and Exercise: Improving urinary incontinence in overweight and obese women through modest weight loss. Obstetrics and Gynecology, 116 (2010): 284-92 PMID: 20664387

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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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THIS Is Why I Love the Mediterranean Diet

Italian researchers reviewed the medical/nutrition literature of the last three years and confirmed that the Mediterranean diet 1) reduces the risk of death, 2) reduces  heart disease illness and death, 3) cuts the risk of getting or dying from cancer, and 4) diminishes the odds of developing dementia, Parkinsons disease, stroke, and mild cognitive impairment.

These same investigators published a similar meta-analysis in 2008, looking at 12 studies.  Over the ensuing three years (as of June, 2010), seven new prospective cohort studies looked at the health benefits of the Mediterranean diet.  The report at hand is a combination of all 19 studies, covering over 2,000,000 participants followed for four to 20 years.  Nine of the 19 Mediterranean diet studies were done in Europe.

The newer studies, in particular, firmed up the diet’s protective effect against stroke, and added protection against mild cognitive impairment.

So What?

The Mediterranean diet: No other way of eating has so much scientific evidence that it’s healthy and worthy of adoption by the general population.  Not the DASH diet, not the “prudent diet,” not the American Heart Association diet, not vegetarian diets, not vegan diets, not raw-food diets, not Esselstyne’s diet, not Ornish’s diet, not Atkins diet, not Oprah’s latest diet, not the Standard American Diet, not the  . . . you name it. 

Not even the Low-Carb Mediterranean Diet.

Just as important, the research shows you don’t have to go full-bore Mediterranean to gain a health and longevity benefit.  Adopting  just a couple Mediterranean diet features yeilds a modest but sigificant gain.  For a list of Mediterranean diet components, visit Oldways or the Advanced Mediterranean Diet website. 

Steve Parker, M.D.

Reference:  Sofi, Francesco, et al.  Accruing evidence about benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.  American Journal of Clinical Nutrition, ePub ahead of print, September 1, 2010.  doi: 10.3945/ajcn.2010.29673

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Filed under coronary heart disease, Health Benefits, Mediterranean Diet

Weight-Loss Drug Meridia Pulled From U.S. Market

MedPageToday reported October 8, 2010, that Abbott is voluntarily removing Meridia from the U.S. market. I had written on October 8 about the higher incidence of stroke and heart attack in Meridia users who had underlying cardiovascular disease.

Meridia, also known as sibutramine, has an estimated 100,000 users in the U.S. Abbott recommends that they stop taking the drug and consult their physicians about other weight-loss programs.

Here are a some options I like:

  1. Advanced Mediterranean Diet
  2. Ketogenic Mediterranean Diet
  3. Low-Carb Mediterranean Diet

This would be a good time for Meridia ex-users to review “Prepare For Weight Loss.”

Steve Parker, M.D.

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Low-Carb Mediterranean Diet PDF Available Now

I finished and posted the PDF of the Low-Carb Mediterranean Diet.  It’s still free.  It will print on the standard 8.5″  x 11″ paper in most U.S. printers.

Also ready is the Grocery Shopping List for the Ketogenic Mediterranean Diet and Low-Carb Mediterranean Diet.  Also free.  You’ll see that very-low-carb eating is much more than bacon, broccoli, and Brie!

Steve Parker, M.D.


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Quote of the Day

The more books one reads, the stupider one becomes.

Mao Tse-Tung, Chinese communist dictator with a lifelong hatred of formal education, as quoted in “Modern Times” by Paul Johnson

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Paleo Diet for Heart Patients With Diabetes and Prediabetes

A Paleolithic diet lowered blood sugar levels better than a control diet in coronary heart disease patients with elevated blood sugars, according to Swedish researchers reporting in 2007.

About half of patients with coronary heart disease have abnormal glucose (blood sugar) metabolism.  Lindeberg and associates wondered if a Paleolithic diet (aka “Old Stone Age,” “caveman,” or ancestral human diet) would lead to improved blood sugar levels in heart patients, compared to healthy, Mediterranean-style, Western diet.

Methodology

Investigators at the University of Lund found enrolled 38 male heart patients—average age 61—patients and randomized them to either a paleo diet or a “consensus” (Mediterranean-like) diet to be followed for 12 weeks.  Average weight was 94 kg.  Nine participants dropped out before completing the study, so results are based on 29 participants.  All subjects had either prediabetes or type 2 diabetes (the majority) but none were taking medications to lower blood sugar.  Baseline hemoglobin A1c’s were around 4.8%.  Average fasting blood sugar was 125 mg/dl (6.9 mmol/l); average sugar two hours after 75 g of oral glucose was 160 mg/dl (8.9 mmol/l).

The paleo diet was based on lean meat, fish, fruits, leafy and cruciferous vegetables, root vegetables (potatoes limited to two or fewer medium-sized per day), eggs, and nuts (no grains, rice, dairy products, salt, or refined fats and sugar). 

The Mediterranean-like diet focused on low-fat dairy, whole grains, vegetables, fruits, potatoes, fatty fish, oils and margarines rich in monounsaturated fatty acids and alpha-linolenic acid. 

Both groups were allowed up to one glass of wine daily.

No effort was made to restrict total caloric intake with a goal of weight loss.

Results

Absolute carbohydrate consumption was 43% lower in the paleo group (134 g versus 231 g), and 23% lower in terms of total calorie consumption (40% versus 52%).  Glycemic load was 47% lower in the paleo group (65 versus 122), mostly reflecting lack of cereal grains.

The paleo group ate significantly more nuts, fruit, and vegetables.  The Mediterranean group ate significantly more cereal grains,oil, margarine, and dairy products.

Glucose control improved by 26% in the paleo group compared to 7% in the consensus group.  The improvement was statisically significant only in the paleo group.  The researchers believe the improvement was independent of energy consumption, glycemic load, and dietary carb/protein/fat percentages.

High fruit consumption inthe paleo group (493 g versus 252 g daily) didn’t seem to impair glucose tolerance. 

Hemoglobin A1c’s did not change or differ significantly between the groups.

Neither group showed a change in insulin sensitivity (HOMA-IR method).

Comments

The authors’ bottom line:

In conclusion, we found marked improvement of glucose tolerance in ischemic heart disease patients with increased blood glucose or diabetes after advice to follow a Palaeolithic [sic] diet compared with a healthy Western diet.  The larger improvement of glucose tolerance in the Palaeolithic group was independent of energy intake and macronutrient composition, which suggests that avoiding Western foods is more important than counting calories, fat, carbohydrate or protein.  The study adds to the notion that healthy diets based on whole-grain cereals and low-fat dairy products are only the second best choice in the prevention and treatment of type 2 diabetes.

This was a small study; I consider it a promising pilot.  Results apply to men only, and perhaps only to Swedish men.  I have no reason to think they wouldn’t apply to women, too.  Who knows about other ethnic groups?

This study and the one I mention below are the only two studies I’ve seen that look at the paleo diet as applied to human diabetics.  If you know of others, please mention in the Comments section. 

The higher fruit consumption of the paleo group didn’t adversely affect glucose control, which is surprising.  Fruit is supposed to raise blood sugar.  At 493 grams a day, men in the paleo group ate almost seven times the average fruit intake of Swedish men (75 g/day).  Perhaps lack of adverse effect on glucose control here reflects that these diabetics and prediabetics were mild cases early in the course of the condition—diabetes tends to worsen over time.

ResearchBlogging.orgPresent day paleo and low-carb advocates share a degree of simpatico, mostly because of carbohydrate restriction—at least to some degree—by paleo dieters.  Both groups favor natural, relatively unprocessed foods.  Note that the average American eats 250-300 g of carbohydrates a day.  Total carb intake in the paleo group was 134 g (40% of calories) versus 231 g (55% of calories) in the Mediterranean-style diet.  Other versions of the paleo diet will yield different numbers, as will individual choices for various fruits and vegetables.  Forty percent of total energy consumption from carbs barely qualifies as low-carb. 

Study participants were mild, diet-controlled diabetics or prediabetics, not representative of the overall diabetic population, most of whom take drugs for it and have much higher hemoglobin A1c’s.

Lindeberg and associates in 2009 published results of a paleo diet versus standard diabetic diet trial in 13 diabetics.  Although a small trial (13 subjects, crossover design), it suggested advantages to the paleo diet in terms of heart disease risk factors and improved hemoglobin A1c.  Most participants were on glucose lowering drugs; none were on insulin.  Glucose levels were under fairly good control at the outset.  Compared to the standard diabetic diet, the Paleo diet yielded lower hemoglobin A1c’s (0.4% lower—absolute difference), lower trigylcerides, lower diastolic blood pressure, lower weight, lower body mass index, lower waist circumference, lower total energy (caloric) intake, and higher HDL cholesterol.  Glucose tolerance was the same for both diets.  Fasting blood sugars tended to decrease more on the Paleo diet, but did not reach statistical significance (p=0.08).

The paleo diet shows promise as a treatment or preventative for prediabetes and type 2 diabetes.  Only time will tell if it’s better than a low-carb Mediterranean diet or other low-carb diets. 

Steve Parker, M.D.

Reference: Lindeberg, S., Jönsson, T., Granfeldt, Y., Borgstrand, E., Soffman, J., Sjöström, K., & Ahrén, B. (2007). A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease Diabetologia, 50 (9), 1795-1807 DOI: 10.1007/s00125-007-0716-y

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Filed under Carbohydrate, coronary heart disease, Dairy Products, Fruits, Glycemic Index and Load, Grains, Mediterranean Diet, nuts

Heart and Stroke Patients: Avoid Weight-Loss Drug Sibutramine (Meridia)

The weight-loss drug sibutramine (Meridia) should be withdrawn from the U.S. market, suggests an editorialist in the September 2, 2010, New England Journal of Medicine.  Based on a clinical study in the same issue, it’s more accurate to conclude that sibutramine shouldn’t be prescribed for people who aren’t supposed to be taking it in the first place.

Sibutramine is sold in the U.S. as Meridia and has been available since 1997.  Judging from the patients I run across, it’s not a very popular drug.  Why not?  It’s expensive and most people don’t lose much weight.

The recent multi-continent SCOUT trial enrolled 9,800 male and female study subjects at least 55 years old (average age 63) who had either:

  1. 1) History of cardiovascular disease (here defined as coronary artery disease, stroke, or peripheral artery disease)
  2. 2) Type 2 diabetes plus one or more of the following: high blood pressure, adverse cholesterol levels, current smoking, or diabetic kidney disease.
  3. Or both of the above (which ended up being 60% of the study population)`.

Here’s a problem from the get-go (“git-go” if you’re from southern U.S.).  For years, Meridia’s manufacturer and the U.S. Food and Drug Administration have told doctors they shouldn’t use the drug in patients with history of cardiovascular disease.  It’s not the scary “black box warning,” but it’s clearly in the package insert of full prescribing information.

Half the subjects were randomized to sibutramine 10 mg/day and the other half to placebo.  All were instructed in diet and exercise aiming for a 600 calorie per day energy deficit.  They should lose about a pound a week if they followed the program.  Average follow-up was 3.4 years.

What Did the Researchers Find?

Forty percent of both drug and placebo users dropped out of the study, a very high rate.

As measured at one year, the sibutramine-users averaged a weight loss of 9.5 pounds (4.3 kg), the majority of which was in the first 6 weeks.  After the first year, they tended to regain a little weight, but kept most of it off.

Death rates were the same for sibutramine and placebo.

Sibutramine users with a history of cardiovascular disease had a 16% increase in non-fatal heart attack and stroke compared to placebo.  To “cause” one heart attack or stroke in a person with known cardiovascular disease, you would have to treat 52 such patients.

Folks in the “diabetes plus risk factor(s)” group who took sibutramine had no increased risk of heart attack or stroke.

So What?

Average weight loss with sibutramine isn’t much.  Nothing new there.  [Your mileage may vary.]

People with cardiovascular disease shouldn’t take sibutramine.  Nothing new there either.

Steve Parker, M.D.

Reference:  James, W. Philip, et al.  Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects.  New England Journal of Medicine, 363 (2010): 905-917.

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Filed under coronary heart disease, Drugs for Diabetes, Overweight and Obesity, Stroke, Weight Loss