January 27, 2020 · 9:00 AM

What’s the Optimal Diet for Fatty Liver (Hepatic Steatosis)?

Stages of liver damage. Healthy, fatty, liver fibrosis and cirrhosis. Vector illustration

From Dr Bret Scher at DietDoctor:

Fortunately, we have emerging evidence that low-carb and ketogenic diets improve fatty liver while also helping with glycemic control and weight loss, an impressive combination rarely seen with medications. As we reported earlier, studies have shown that carbohydrate restriction changes liver metabolism, stimulating the breakdown of liver fat. Another study mentioned in the same post showed that when children substitute complex forms of starch to replace sugar, they experience reduced amounts of liver fat.

Yet another impressive study found that despite equal weight loss, a low-carb Mediterranean diet was better than a low-fat diet for reversing liver fat and signs of NAFLD. And finally, Virta Health published a subset of its data showing that one year on a ketogenic diet improved non-invasive tests for NAFLD and liver scarring.

Source: Limiting Carbs Likely Better Than Drugs for Fatty Liver — Diet Doctor

Steve Parker, M.D.

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January 26, 2020 · 9:00 AM

1 in 5 U.S. Adolescents Has Prediabetes

ketogenic diet, children

Exercise can prevent prediabetes and T2 diabetes

Stats from JAMA Pediatics:

In the United States, about 1 of 5 adolescents [12-18 y.o.] and 1 of 4 young adults [19-34 y.o.] have prediabetes. The adjusted prevalence of prediabetes is higher in male individuals and in people with obesity. Adolescents and young adults with prediabetes also present an unfavorable cardiometabolic risk profile, putting them both at increased risk of type 2 diabetes and cardiovascular diseases.

Source: Prevalence of Prediabetes Among Adolescents and Young Adults in the United States, 2005-2016. – PubMed – NCBI

I’m doing my part to prevent conversion of prediabetes to type 2 diabetes.

Steve Parker, M.D.

low-carb mediterranean diet

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January 25, 2020 · 9:00 AM

High-Intensity Interval Training May Prevent Dementia

Steve Parker MD

A slow leisurely pace won’t cut it

Dementia is a devastating and expensive development for an individual and his family. Most dementias are progressive and incurable. If it can be prevented, it should be. Exercise is one preventative. But how much and what kind of exercise?

Nine percent of U.S. adults over 65 have dementia. That’s 3.650,000 folks. The initial clue to incipient dementia is usually memory impairment.

From The Globe and Mail:

In 2017, a team led by the lab’s director, Jennifer Heisz, published a five-year study of more than 1,600 adults older than 65 that concluded that genetics and exercise habits contribute roughly equally to the risk of eventually developing dementia. Only one of those two factors is under your control, so researchers around the world have been striving to pin down exactly what sort of workout routine will best nourish your neurons.

Heisz’s latest study, published last month in the journal Applied Physiology, Nutrition, and Metabolism, offers a tentative answer to this much-debated question. Older adults who sweated through 12 weeks of high-intensity interval training improved their performance on a memory test by 30 per cent compared with those who did a more moderate exercise routine.

This was a small study, only about 20 sedentary participants (all over 60 years old) subjected to one of three protocols for twelve weeks, exercising thrice weekly:

  1. Four-minute bouts of vigorous treadmill walking at 90-95% of maximum heart rate, repeated four times, with three minutes easy walking between the high-intensity spells intervals (HIIT)
  2. Walking at 70-75% of max heart rate for 47 minutes (burning the same number of calories as group #1
  3. Thirty minutes of relaxed stretching

Alex Hutchinson’s full article is well worth a couple minutes of your time if you want to avoid dementia.

Source: New study shows the right workout routine can help fight dementia – The Globe and Mail

Most experts agree that diabetes is a risk factor for dementia, and the Mediterranean diet helps prevent it.

Steve Parker, M.D.

low-carb mediterranean diet

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January 24, 2020 · 9:00 AM

Paul Ingraham Cured My PFPS: Patello-Femoral Pain Syndrome

…and Paul’s not even a physician or physical therapist. But he’s a smart guy, writer, and former massage therapist. Click for his article on patello-femoral pain syndrome if interested. I paid about $20 USD for the full article, and it was well worth it. Full disclosure: I don’t know Paul and earn no commission or other compensation for this endorsement.

Photo credit: Steven Paul Parker II

The key to my cure was probably radical rest, or what Paul calls profound rest.

If you have PFPS, I hope you find something useful here.

Regular readers here know I’m a huge proponent of exercise. Unfortunately, exercise can be risky. You can injure yourself. I did that a few years ago when I was getting in shape to climb Humphreys Peak. I accelerated my training program too rapidly and developed patell0-femoral pain syndrome (PFPS).

This is how my right knee felt in 2017:

I’ve developed over the last month some bothersome pain in my right knee. It’s not interfered much with my actual hiking, but I pay for it over the subsequent day or two. I’m starting to think this may put the kibosh on my Humphries Peak trek next month.

The pain is mostly anterior (front part of the knee) and is most noticeable after I’ve been sitting for a while with the bent knee, then get up to walk. The pain improves greatly after walking for a minute or less. It also hurts a bit when I step up on something using my right leg. If I sit with my knee straight (in full extension), it doesn’t hurt when I get up. The joint is neither unusually warm nor swollen. Ibuprofen doesn’t seem to help it.

That episode resolved after I stopped hiking for 3-4 months. But in 2018 I had recurrence of similar pains in my left knee, with no clear precipitant this time. I continued my usual weight-training program and expected another spontaneous resolution. Six months passed…no improvement. That’s when I found Paul Ingraham’s article.

By the way, I’m the one who diagnosed my PFPS. It’s been said that a doctor who diagnoses and treats himself has a fool for a patient. He can’t be adequately objective.

Alternative diagnoses would include patello-femoral osteoarthritis and degenerative meniscus, due to my age (over 60). Diagnosis of the osteoarthritis could be facilitated by knee X-rays: weight-bearing posterior-anterior imaging, weight-bearing lateral view, and sunrise view.

This was my treatment plan for PFPS in early Feb 2019, based on Paul Ingraham’s recommendations. Paul explains how to do various specific exercises below in his article.

  1. Avoid all activities that stress the patella-femoral joint or aggravate pain for at least two weeks, if not longer (2–3 months). Paul calls it “profound rest.” I started this Feb 17. No knee-loading exercise (e.g., leg presses, any kind of squat, deep knee bends) until pain is truly in remission from rest. I quit my usual squats, Bulgarian split-squats, and single-leg Romanian deadlifts.
  2. Consider Motrin (ibuprofen) 400-600 mg three times daily for two weeks (I did 600 mg 3x/day) but usually no help
  3. Consider cold-packs (10–20 mins) when it flares up but usually no help. (I never did this because I couldn’t find my WalMart cold-pack.)
  4. Find a substitute for the squats? E.g., stationary bike? No bike for now: too much stress on patello-femoral joint at this time
  5. Paul’s not big on stretching (quadriceps and hamstring stretches routinely recommended by others). I didn’t stretch.
  6. While recovering, keep leg straight most of the time, even when sitting. Sit less. (I didn’t sit less but did make a huge effort to keep my  affected led fully extended, or at least not bent more that 20 degrees at any time. This necessitated sitting on the edge of my seat at work, and/or lowering the height of the seat. At home relaxing, I’d keep my leg fully extended. I think this was extremely important for my healing. I considered getting a standing desk for home or work but didn’t.)
  7. Start with exercises that keep knees straight. Exercise both lower extremities. As condition improves, can start to add other exercises, very slowly, that allow bent knees. Single-leg RDLs may be a good start (started in Sept 2019). Restart squats, deep knee bends, and leg presses (cycling?) only very late into recovery. Rehab must progress VERY SLOWLY. If an exercise causes more knee pain, back off and work the hips first. Exercise 2–3 times/week. Walking on the flat in moderation is usually OK. Strengthening hip abductors may be helpful.
  8. Hamstring curls via machine or therabands. Curl to 60 degrees, not 120. (I curled to 90 degrees using therabands).
  9. Quadricep setting. (I didn’t do this. Straight-leg raises on your back seem to be similar, which I did.)
  10. Straight-leg raises, on back and side-lying. (Done: 3 sets of 10 reps each side.)
  11. Clam shells. (Done: 3 sets of 10 reps each side.)
  12. Knee lifts? (don’t know what that is; not done).
  13. Consider the following although not from Paul: Hip abductor strengthening: “monster walks” (lateral steps with elastic band around (just proximal to) knees: 1 min x 3 sets. Hip hikes (what’s this?): 2 sets of 20 reps each side.
  14. Consider the following although not from Paul: Quad strengthening: terminal knee extensions with elastic band, 3 sets of 15 reps; leg presses?; semi squat, 3 sets of 10 reps (also recumbent bike?). Also consider stork stance TKE (terminal knee extensions) as alternative to standard TKE.
  15. Paul likes trekking poles for hikers. (I’ve been using these for years; Leki brand.)
  16. Not from Paul: Home physical therapy for six weeks
  17. Not from Paul: Turkish get-ups now or later? Much further into recovery!

Update of Progress on April 4, 2019:

Knee definitely feeling better, probably due to profound rest as above.  On Feb 23, I aggravated knee mildly by sledding in snow with Paul in Care Free – no regrets! Around Feb 26, Sunny got me started on Platinum’s Ortho-Chon Plus, 3 caps twice daily. Per 3 caps: glucosamine sulfate 800 mg, turmeric 380 mg, methylsulfonylmethane 350 mg, berberine HCL 145 mg, Boswellia serrata extract 140 mg, hyaluronic acid 50 mg, cat’s claw 10 mg, total cetylated fatty acids 3 mg. Not sure if these did any good at all; I’m skeptical. Started feeling less pain around Feb 29.

I am not healed or in remission yet. Doing hip exercises twice or once/wk with Therabands: clamshells, straight leg raises, side-lying straight leg raises, hamstring curls.

I had to put hip exercises on hold temporarily on March 28 due to a right low back muscle strain either from the exercises or weed pulling.

Update on Nov 25, 2019:

The PFPS is in remission and has been since July or so. For the last couple months I’ve been doing single-leg Romanian deadlifts and “walking” on elliptical-type aerobic machines at Anytime Fitness—some machines also work the upper limbs, others don’t—which are very easy on my knees. Avoiding treadmill since I have a palpable click in one knee, and treadmill aggravates my degenerative joint disease (DJD in both knees but predominantly left knee).

Next step is to slowly re-introduce exercises that load the knees (particularly the patell0-femoral joint). This is scary but must be done. My quads have atrophied somewhat. Squats? Lunges? Bulgarian split squats?

Steve Parker, M.D.

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January 23, 2020 · 7:00 AM

Both Low- and High-Carb Diets May Kill You

In the research at hand, low-carb was defined as under 40% of calories from carbohydrate, and high-carb was over 70% of calories.

Garlic Naan, a type of flat bread, definitely high-carb

The longevity sweet spot was 50-55% of calories from carbs. You know what? That’s the typical carb percentage in the traditional Mediterranean diet.

If you want to eat low-carb, read more below to identify the possibly healthier substitutions for carbs. Tl;dr version: Eat plant-derived protein and fats.

From a 2018 study in The Lancet Public Health:

Background

Low carbohydrate diets, which restrict carbohydrate in favour of increased protein or fat intake, or both, are a popular weight-loss strategy. However, the long-term effect of carbohydrate restriction on mortality is controversial and could depend on whether dietary carbohydrate is replaced by plant-based or animal-based fat and protein. We aimed to investigate the association between carbohydrate intake and mortality.

Methods

We studied 15 428 adults aged 45–64 years, in four US communities, who completed a dietary questionnaire at enrolment in the Atherosclerosis Risk in Communities (ARIC) study (between 1987 and 1989), and who did not report extreme caloric intake (4200 kcal per day for men and 3600 kcal per day for women). The primary outcome was all-cause mortality. We investigated the association between the percentage of energy from carbohydrate intake and all-cause mortality, accounting for possible non-linear relationships in this cohort. We further examined this association, combining ARIC data with data for carbohydrate intake reported from seven multinational prospective studies in a meta-analysis. Finally, we assessed whether the substitution of animal or plant sources of fat and protein for carbohydrate affected mortality.

Findings

During a median follow-up of 25 years there were 6283 deaths in the ARIC cohort, and there were 40 181 deaths across all cohort studies. In the ARIC cohort, after multivariable adjustment, there was a U-shaped association between the percentage of energy consumed from carbohydrate (mean 48·9%, SD 9·4) and mortality: a percentage of 50–55% energy from carbohydrate was associated with the lowest risk of mortality. In the meta-analysis of all cohorts (432 179 participants), both low carbohydrate consumption (70%) conferred greater mortality risk than did moderate intake, which was consistent with a U-shaped association (pooled hazard ratio 1·20, 95% CI 1·09–1·32 for low carbohydrate consumption; 1·23, 1·11–1·36 for high carbohydrate consumption). However, results varied by the source of macronutrients: mortality increased when carbohydrates were exchanged for animal-derived fat or protein (1·18, 1·08–1·29) and mortality decreased when the substitutions were plant-based (0·82, 0·78–0·87).

Interpretation

Both high and low percentages of carbohydrate diets were associated with increased mortality, with minimal risk observed at 50–55% carbohydrate intake. Low carbohydrate dietary patterns favouring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favoured plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut butter, and whole-grain breads, were associated with lower mortality, suggesting that the source of food notably modifies the association between carbohydrate intake and mortality.

Source: Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis – The Lancet Public Health

Steve Parker, M.D.

PS: These types of studies are often unreliable.

 

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January 22, 2020 · 7:00 AM

Diabetes Drug Dapagliflozin Prevents Worsening Heart Failure and Cardiovascular Deaths

Pulmonary artery arrow is wrong

The amazing thing about this research is that dapagliflozin 10 mg/day seemed to benefit patient who didn’t even have diabetes. Unfortunately, the abstract doesn’t mention how many non-diabetic patients were in the study. As always, you should take news like this with a grain of salt.

Conclusion from the abstract:

Among patients with heart failure and a reduced [left ventricular] ejection fraction [under 40%], the risk of worsening heart failure or death from cardiovascular causes was lower among those who received dapagliflozin than among those who received placebo, regardless of the presence or absence of diabetes.

Source: Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction | NEJM

Steve Parker, M.D.

PS: Your doctor isn’t going to prescribe dapagliflozin for you if you don’t have diabetes. Guess what else helps prevent heart failure and premature cardiac death. The Mediterranean diet.

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January 21, 2020 · 7:00 AM

Dr David Unwin Explains Why He Favors Low-Carb Eating as Best Diet for Type 2 Diabetes

 

diabetic diet, Paleobetic diet, diabetes,

Sunny’s Super Salad

The Diet Doctor website posted a video interview of Dr David Unwin (in the U.K.) discussing his experience with low-carb diets in folks with diabetes (type 2, I assume). If  you’re short on time, just read the transcript. Thanks, Diet Doctor!

I took note of Dr Unwin’s transformation from a run-of-the mill follow-the-herd practitioner to a low-carb advocate. This happened around 2012 when Dr Unwin was 55 years old and on the threshold of retirement. Here it is:

Dr David Unwin speaking: ….There was one particular case I’ve talked about before where there was a patient who – so in 25 years I’d never seen a single person put their [type 2] diabetes into remission, I had not seen it once. I didn’t even really know it was possible.

Dr Bret Scher speaking:  We were not [taught] that it’s possible.

Dr Unwin:  No, my model was that the people with diabetes… It was a chronic deteriorating condition and I could expect that they would deteriorate and I would add drugs and that’s what would be normally going to happen. And then one particular patient wasn’t taking her drugs and she actually went on the low-carb diet and put her diabetes into remission.

But she confronted me with, you know, “Dr. Unwin, surely you know that actually sugar is not a good thing for diabetes.” “Yes, I do.” But then she said, “But you’ve never once in all the years mentioned that really bread was sugar, did you.” And, you know, I never did. I don’t know what my excuse was. So this this lady had done this wonderful thing and she’d also changed her husband’s life as well.

She’d sorted his diabetes out and she’d done it with a low-carb diet and that really made me think I didn’t know much about it. I didn’t know much about it. So I found out what she’d been on… on the low-carb forum of diabetes.co.uk and to my amazement there was 40,000 people on there, all doing this amazing thing. And I was blown away but then I was very sad because the stories of the people online were full of doctors who are critical of these people’s achievements.

***

Dr Unwin: And that original case that showed me you could put into remission; if you could repeat that, how wonderful for people… And when I now – because I think we’ve done 60 patients who put their type 2 diabetes into remission. So I’m able to say with confidence to people, you know, you stand a good chance. In fact I can say that of my patients who take up low-carb, about 45% of them will put their diabetes into remission which is amazing.

At no point does the transcript indicate they’re talking about type 2 diabetes rather than type 1, but that must be the case. Nor does it mention the amount of required carbohydrate restriction. I figure it’s between 20 and 100 grams/day of digestible carbohydrate, depending on one’s metabolic health and how many years of diabetes.

I’ve mentioned Dr Unwin before.

Source: Diet Doctor Podcast #33 – Dr. David Unwin – Diet Doctor

Steve Parker, M.D.

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January 13, 2020 · 7:00 AM

Think Twice Before Heart Artery Stenting or Bypass

Heart attacks and chest pains are linked to blocked arteries in the heart

Doctors are often criticised for over-using coronary artery angioplasty/stenting and coronary artery bypass grafting.

From Stanford Medicine:

Patients with severe but stable heart disease who are treated with medications and lifestyle advice alone are no more at risk of a heart attack or death than those who undergo invasive surgical procedures, according to a large, federally-funded clinical trial led by researchers at the Stanford School of Medicine and New York University’s medical school.

The trial did show, however, that among patients with coronary artery disease who also had symptoms of angina — chest pain caused by restricted blood flow to the heart — treatment with invasive procedures, such as stents or bypass surgery, was more effective at relieving symptoms and improving quality of life. “For patients with severe but stable heart disease who don’t want to undergo these invasive procedures, these results are very reassuring,” said David Maron, MD, clinical professor of medicine and director of preventive cardiology at the Stanford School of Medicine, and co-chair of the trial, called ISCHEMIA, for International Study of Comparative Health Effectiveness with Medical and Invasive Approaches.

***

“Based on our results, we recommend that all patients take medications proven to reduce risk of heart attack, be physically active, eat a healthy diet and quit smoking,” Maron said. “Patients without angina will not see an improvement, but those with angina of any severity will tend to have a greater, lasting improvement in quality of life if they have an invasive heart procedure. They should talk with their physicians to decide whether to undergo revascularization.”

Source: Stents, bypass surgery show no benefit in heart disease mortality rates among stable patients | News Center | Stanford Medicine

Steve Parker, M.D.

PS: The Mediterranean diet is a healthy diet, reduces the risk of heart disease, and you can even lose weight with it!

low-carb mediterranean diet

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January 12, 2020 · 10:10 PM

Not Into Salads? Try This!

Salad and cheese

Jan over at Low Carb Diabetic has a great post on building a salad from the ground up.

“Salads make a nutritious and satisfying meal, whether it’s for lunch or dinner. The best part is that no two salads are exactly the same. There are limitless ways to make salad unique and flavourful. Get some tips for what to add to your next salad….”

Source: The Low Carb Diabetic: Super Salads – Some Tips for Building A Better Salad

Click for my nutritional assessment of various salad greens. Variety is also important.

Steve Parker, M.D.

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January 12, 2020 · 7:00 AM

One Expert’s Anti-Aging Program

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“Darling, think about upping your NMN dose.”

The goal isn’t simply to live longer, but to be vigorous and functional for longer.

David Sinclair is a PhD professor and researcher at Harvard. Harriet Hall, M.D., reviewed his 2019 anti-aging book at Science-Based Medicine. Here’s his current anti-aging regimen as outlined by Dr Hall:

He makes no recommendations for others except “Eat fewer calories”, “Don’t sweat the small stuff”, and “Exercise”.

But he argues that if he does nothing, he will age and die, so he has nothing to lose by trying unproven treatments, and he has personally chosen to do these things:

    • He takes a gram each of NMN [nicotinamide mononucleotide] resveratrol, and metformin daily.
    • He takes vitamin D, vitamin K2, and 83 mg. aspirin.
    • He limits sugar, bread, and pasta intake, doesn’t eat desserts, and avoids eating meat from animals.
    • He skips one meal a day.
    • He gets frequent blood tests to monitor biomarkers; if not optimal, he tries to moderate them with food and exercise.
    • He stays active, goes to the gym, jogs, lifts weights, uses the sauna and then dunks in an ice-cold pool.
    • He doesn’t smoke.
    • He avoids microwaved plastic, excessive UV exposure, X-rays, and CT scans.
    • He tries to keep environmental temperatures on the cool side.
    • He maintains a BMI of 23-25 [click to calculate your BMI].

He plans to fine-tune his regimen as research evolves. He acknowledges “It’s impossible to say if my regimen is working…but it doesn’t seem to be hurting.” He says he feels the same at 50 as he did at 30.

Source: Aging: Is It a Preventable Disease? – Science-Based Medicine

For additional science-based info on anti-aging, see P.D. Mangan’s blog.

Steve Parker, M.D.

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