Glucose, Insulin, & Glucagon in Metabolic Health

Glycemic index is commonly used. In using 10 subjects (presumably on a Standard American diet), it is the measured rate of which foods cause the level of glucose in the blood to rise over a 2-hour period, as compared to the affect of a reference food that is usually pure glucose.

But many question the relevance of the glycemic index. In terms of health, it matters little whether your blood sugar rises over a period of less than or more than 2 hours because the carbs eventually are digested and absorbed. Some argue that an extended and sustained rise of blood sugar is more harmful than a quick boost that goes away quickly. Too much glucose for too long in the blood is toxic — one might say that it’s a heavy load. The body has to deal with the glucose one way or another, either burning it as fuel or storing it as fat.

That is why some prefer glycemic load. It is determined by taking the glycemic index of a food, multiplying it by the net grams of carbohydrate in a standard serving size (e.g., 100 grams), and dividing that by 100. So, it is taking into account the total amount of available carbs in the food. “Glycemic load appears to be a significant factor in dietary programs targeting metabolic syndrome, insulin resistance, and weight loss; studies have shown that sustained spikes in blood sugar and insulin levels may lead to increased diabetes risk[3]” (Glycemic load, Wikipedia). Keep in mind that most Americans have some component of metabolic syndrome: obesity, diabetes, fatty liver, heart disease, etc.

This, of course, ignores satiety. The same serving size of one food won’t be equally satisfying as another food and depending on what it is eaten with as part of a total diet. Neither glycemic index nor glycemic load measures the impact of blood sugar on how much the typical person would eat of a particular food, such as spinach compared to popcorn. Some argue a single serving of potato every day or every other day is healthy for most people, but they don’t take into account that few people would ever only eat one serving of potatoes and eat few if any other carbs for the rest of the day. Even foods with moderate glycemic index and load, if snacked on all day, would keep blood sugars higher than is optimal for long term health. That is the real world impact that gets ignored.

Furthermore, consider the insulin index, which some consider more important than glycemic index or glycemic load. It can be misleading, though, with some foods. Foods high in protein will raise insulin higher than many foods because of gluconeogenesis (protein turned into glucose), but the body only does so to a limited degree and it is an extremely short term spike and then, particularly on a low-carb diet, this is followed by insulin stabilizing at a much lower level. Fatty foods will also kick up insulin levels, although once again not a problem on a low-carb diet. By the way, fat is a complicating factor. Even though fat raises insulin, fatty foods overall have a lower insulin response than non-fatty foods, whether comparing 2% milk and skim milk or a regular cook to a low-fat cookie. This partly has to do with fat moderating the absorption of carbs, but it also has to do with how companies will add sugar to low-fat foods in order to make them taste better.

Anyway, temporary spikes from protein or fat alone are not generally problematic, assuming it’s not part of an otherwise unhealthy diet. Metabolic syndrome is more determined by the sustained increases of insulin, not temporary rises. But the problem with the Standard American diet is that it combines protein and fat with massive amounts of refined carbs, and because many carbs like grains and sugar are addictive this eating pattern is repeated as continuous meals and snacks all day long. There is a reason why, to ignore protein, one can lose weight on both a low-carb diet and a low-fat diet. It’s the combination of the macronutrients in highly processed foods that has such consequences to the metabolic system and, to add to the fire, a high-carb diet is inflammatory as are the industrial seed oils that are used in junk food, fast food, and sadly packaged ‘health foods’.

Still, even these short term spikes can be problematic for diabetics trying to maintain insulin levels. But for non-diabetics, it’s less relevant. As we have glycemic load to show which foods have a sustained rise in blood sugar, we likewise need an insulin load to measure the extended impact of insulin over longer periods. This is particularly important for insulin resistance, as seen in diabetes and what some consider central to metabolic syndrome. It is where the body has to keep raising insulin because the body’s response becomes muted. It’s the constant raising of insulin that causes this muting, not brief occasional spikes.

Also, left out is that blood sugar by itself doesn’t necessarily tell us much. Metabolic syndrome is a disease of insulin, not of blood sugar. But as I said, looking at insulin alone doesn’t necessarily help either. Insulin is a hormone that works with other hormones to maintain the metabolic system. We can only know how an individual is responding, in terms of metabolic health, by measuring the insulin to glucagon ratio. Glucagon can detect diabetes sometimes decades before it otherwise would show up. Any doctor could measure glucagon, although few do.

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Let’s look at a specific food as an example.

Potatoes may seem healthier, but they are still a carbohydrate. Potatoes have a higher glycemic index (high 80s to low 90s) than table sugar (59), although slightly below pure glucose (100). “Sucrose (table sugar) has a GI of 59. It is a disaccharide (two sugar) molecule—it’s made up of one glucose molecule and one fructose molecule. Fructose is processed differently in your body than glucose, and it doesn’t affect your blood sugar as much” (Why Do Potatoes Have a Higher Glycemic Index Than Sugar?). As further comparison, bread has a GI between 40 and 95, depending on the kind.

Likewise, not all potatoes are created equal: “In general, potatoes can range in GI value from 53 to 111, with white potatoes typically showing up lower on the index. Leaving the skin on adds fiber, which can reduce the potato’s effect on glucose. Often, the sweet potato is rated with a GI in the mid-40s.” How they are prepared matters to some degree as well, but that still puts the lowest GI potatoes around the same as table sugar.

The glycemic load, the most important measure, is even worse: “A small study compared the impact 50 grams carbohydrate portion of potatoes versus bread versus pasta had on participant’s blood sugar levels. While clearly none of the foods tested are particularly blood sugar friendly, it’s interesting to note that the potatoes resulted in the most significant rise at the 2 hour mark” (Potatoes and Diabetes: Can You Eat Them?). This also depends on the type of potato with the baked white potato having a high glycemic load of 29 and sweet potatoes around a moderate 19, that is moderate for starchy foods. That is much higher than the glycemic load of bread, from 11 to 16.

The only theoretical advantage to potatoes is resistant starch, but even that is not a net benefit since, “Research has also suggested that increased consumption of potatoes, especially french fries, leads to an increased risk of developing type 2 diabetes.” In case you forgot, type 2 diabetes, like liver disease, are part of metabolic syndrome. So, the basic point is that potatoes don’t contribute to metabolic health and certainly shouldn’t be eaten or at least eaten in extremely small amounts by anyone suffering from any condition of metabolic syndrome.

The author goes on to say that, although it’s true that potatoes have a bit more resistant starch than other high-carb foods, “The problem is that this logic of resistant starch is flawed, similar to the flaws found with the net carb counting method. First, the amount of resistant starch found in a medium potato is about 9 grams, which still leaves around 28 grams of fully digestible carbohydrate available to spike your blood sugar. Resistant starch in and of itself offers health benefits such as improved glycemic control, but in order to eat enough resistant starch (from potatoes, rice, and unripened bananas) you would end up eating an outrageous amount of carbohydrate.”

Let us touch upon the insulin index. Like refined grains, potatoes have a high insulin response. This would vary by kind of potato and preparation method, I’m sure. But interestingly, another factor alters the insulin effect. I mentioned fat above in how it moderates carbohydrate absorption. This is demonstrated by comparing two products that only differ by fat amounts (Forget Calorie Counting; It’s the Insulin Index, Stupid).

A normal potato chips have an insulin index of 45 whereas it’s 51 for 40% reduced-fat potato chips. I don’t know exactly what that means. A low-fat diet can be used to lose weight, but that is a separate issue from the insulin index. Both obesity and high insulin responses contribute to insulin resistance. I guess you could solve this problem by cutting out the potatoes along with most other starchy carbs and then you have nothing to worry about. Potatoes are high insulin response for potatoes, though a bit lower with fat, is still on the higher end of the scale.

The next bit of info comes from an article that seems balanced in the mainstream sense with no particular alternative slant, such as low-carb or vegan. Interestingly, it comes from the Food Revolution Network with their show co-hosted by John Robbins who “was groomed to be the heir to the Baskin-Robbins empire” who left the family business because “He simply didn’t want to devote his life to selling ice cream after realizing it makes people unhealthy.” So, the only bias might be against commercial ice cream.

The author states that, “Potatoes can be a healthy choice for most people…” But… there is always a but: “but three groups might want to minimize their consumption (particularly of white potatoes): pre-diabetics, diabetics, and people who are overweight” (Are Potatoes Healthy? The Surprising Truth About This Controversial Vegetable), and presumably any other condition involving metabolic syndrome/derangement, such as fatty liver. That means anyone who isn’t metabolically healthy should avoid or minimize potatoes in their diet and, as we know, most Americans aren’t metabolically healthy.

On the other hand, “But, in a published in the Journal of the American College of Nutrition in 2014, researchers found that when people followed healthy recipes, they lost weight even while eating five to seven servings of potatoes per week.” So, it’s possible that someone by eating generally healthy, in removing all the common problematic foods, might be able to regain enough metabolic health to eat some starchy foods like potatoes. Still, even then, a serving of potatoes is fairly small. Few people eating potatoes are likely to limit themselves to a single serving, not to mention all the other starchy carbs they are also likely to eat throughout the day.

It goes back to the challenge of modern society. In a few traditional societies, they did eat relatively more carbs as a percentage of their diet. But that is in the context of their diet in general being typically limited and often to an extreme degree with small portions and caloric restriction. That is the key point that goes unspoken. If one is to eat a higher-carb diet or even merely a moderate-carb diet, in any case not low-carb, one should all the more closely follow a traditional diet and lifestyle: pasture-raised animal foods, regular cardio exercise and strength training, etc.

Still, a higher carb diet was rare until the modern era. The highest end of the carbohydrate range of hunter-gather diets at 40% of calories, I like to point out, is what some Western researchers define as part of a ‘low-carb’ diet (Cordain et al, Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-gatherer diets). So, even at the highest amounts for hunter-gatherers, they are still getting most of their energy and nutrients from animal foods. And guess what? Obesity, diabetes, and heart disease is rare among most of these populations — that is as long as they remain on their traditional diets.

The Ketogenic Miracle Cure

Why do we hear so little about the ketogenic diet? At this point, there has probably been thousands of studies done on it going back a century. In the 1920s, it was first demonstrated effective as a medical treatment for epileptic seizures. And since then, it has been studied with numerous other health conditions, especially for weight loss in obesity.

The results are often dramatic. Dr. Terry Wahls, in using a ketogenic diet in a clinical study, was the first to prove that multiple sclerosis could be put into remission. Dr. Dale Bredesen, also through a ketogenic diet in a clinical study, was able to reverse Alzheimer’s which has never before been accomplished, in spite of all the massive funding that has gone into pharmaceuticals.

Dr. Paul Saladino talked with Dr. Chris Palmer about metabolic disorders and psychiatric disorders (Paradigm shiftng treatment of schizophrenia and bipolar with Ketogenic diets. Chris Palmer, MD). Indicating this connection, many antipsychotics and antidepressants affect not only mood but also metabolism, such as weight gain (e.g., see how “a common class of antidepressants works by stimulating activity in the gut and key nerves connected to it rather than the brain as previously believed”; from Michelle McQuigge, New study suggests role of the gut is important in treating depression).

This connection is also seen in how depressives have higher rates of diabetes and diabetics have higher rates of depression, and to emphasize this point those with both conditions tend to have more severe depression. Unsurprisingly, the keto diet has been useful for treating depression.

It likewise has been used to treat other neurocongnitive conditions, including major psychiatric disorders like bipolar disorder and schizophrenia, arguably the same. Lessening of symptoms has been seen with schizophrenics on a keto diet (Chris Palmer, Chronic Schizophrenia Put Into Remission Without Medication). And in one case, 53 years of schizophrenia went entirely into remission and remained in remission for years following. That patient, after doing a keto diet under the care of Dr. Eric Westman in order to lose weight, found she was able to stop taking all psychiatric medications and became independent in no longer needing assistance to do daily tasks.

Now Dr. Stephen Phinney has done the same thing with diabetes, although less surprising as ketogenic research on diabetes goes back several generations. What has been the response from government health officials, non-profit health organizations, and mainstream doctors? A combination of silence and fear-mongering. A revolution in medicine is happening and few seem to be paying attention. But think how many lives could have been saved and improved, if the promising research on the keto diet hadn’t been shut down earlier last century.

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Ketones are fascinating. They are far more than an alternative or, if you prefer, primary fuel in the body. The energy produced is different as well, in being more efficient and cleaner. Furthermore, they don’t merely shift metabolism and can promote effortless fat-loss. Ketones act like master hormones and alter gene expression. This is why they are so powerful in reversing and curing serious diseases. But it isn’t miraculous, as it is entirely natural. This is how the body is supposed to function.

The Mechanisms by Which the Ketone Body D-β-Hydroxybutyrate May Improve the Multiple Cellular Pathologies of Parkinson’s Disease
by Nicholas G. Norwitz, Michele T. Hu, and Kieran Clarke

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What If They Cured Diabetes and No One Noticed?
If the ketogenic diet can reverse diabetes, why isn’t your doctor recommending it?
by Piper Steele

Keto Diet Puts Diabetics in Remission

After Inkinen’s pre-diabetes diagnosis in 2012, he spent the next few years researching the disease and treatments and ultimately teaming up with Stephen Phinney, MD, Ph.D in 2014 to form Virta Health, a research and virtual medical clinic whose mission is to reverse type 2 diabetes.

Phinney has been researching the keto diet and publishing studies on it for over 40 years. But last month, Virta published the results of what may be the most comprehensive study of the diet yet, a two-year intervention tracking 349 people who were divided into two groups. One followed a keto diet, the other followed their usual care for diabetes.

The results are impressive. At the end of two years, the keto group saw incredible improvements: 55% were able to reverse their diabetes and stop all medications except Metformin, and 18.5% were able to achieve remission. That is, they were both officially out of the diabetic range and off of all diabetes medications. Plus they maintained that state for at least one year.

The keto dieters were also able to lose weight (an average of 12% of body weight), reduce their dependence on insulin — dosages dropped 81% — and reduce triglycerides, inflammation and other markers for metabolic syndrome.

By contrast, just 10.5% of the participants in the control group were able to reverse their diabetes, and none was able to achieve full remission.

The control group also gained an average of 5% of their body weight, had a 13% increase in insulin dosages, and saw only modest improvements in triglycerides, inflammation and metabolic syndrome markers.

It’s also worth noting that this research is entirely self-funded — Virta receives its funding from venture capital investors.

“Online Revolt” Infuriates Diabetes Establishment
by Christopher James Clark

Last week, we saw the news that the world’s largest diabetes organizations, including the International Diabetes Federation, the American Diabetes Association, the Chinese Diabetes Society, and Diabetes India, are embracing bariatric surgery as a radical new approach to treating type-2 diabetes. According to these experts, surgery should be the standard protocol for many patients.

At the same time, these experts are becoming increasingly dismissive of diet and lifestyle approaches to reversing type-2 diabetes. The crux of the problem is that “the experts” recommend a low-fat, higher-carbohydrate approach, which simply doesn’t cut the mustard when compared to low-carb, higher-fat approaches.

In the information era, however, the truth always comes out.

Today, The Times is reporting on what they are referring to as “an online revolt by patients.” Diabetes.co.uk, a health organization that opposes the official dietary guidelines for diabetes treatment, launched a study, which included over 120,000 participants, the majority of whom suffer from weight related type-2 diabetes.

These people ate low-carb diets for 10 weeks, in defiance of the UK government’s Eatwell Guidelines, which mimic official US guidelines.

Over 70% of participants lost weight and improved their blood glucose levels.

“The results from the low-carb plan have been impressive and this is a solution that is clearly working for people with type 2 diabetes,” said Arjun Panesar, chief executive officer of diabetes.org.uk

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Ketone bodies mimic the life span extending properties of caloric restriction
by Richard L. Veech Patrick C. Bradshaw Kieran Clarke William Curtis Robert Pawlosky M. Todd King

Aging in man is accompanied by deterioration of a number of systems. Most notable are a gradual increase in blood sugar and blood lipids, increased narrowing of blood vessels, an increase in the incidence of malignancies, the deterioration and loss of elasticity in skin, loss of muscular strength and physiological exercise performance, deterioration of memory and cognitive performance, and in males decreases in erectile function. Many aging‐induced changes, such as the incidence of malignancies in mice 82, the increases in blood glucose and insulin caused by insulin resistance 39, 78, and the muscular weakness have been shown to be decreased by the metabolism of ketone bodies 18, 83, a normal metabolite produced from fatty acids by liver during periods of prolonged fasting or caloric restriction 12.

The unique ability of ketone bodies to supply energy to brain during periods of impairment of glucose metabolism make ketosis an effective treatment for a number of neurological conditions which are currently without effective therapies. Impairment of cognitive function has also been shown to be improved by the metabolism of ketone bodies 84. Additionally, Alzheimer’s disease, the major cause of which is aging 20 can be improved clinically by the induction of mild ketosis in a mouse model of the disease 85 and in humans 86. Ketosis also improves function in Parkinson’s disease 87 which is thought to be largely caused by mitochondrial free radical damage 19, 88. Ketone bodies are also useful in ameliorating the symptoms of amyotrophic lateral sclerosis 89. It is also recognized that ketosis could have important therapeutic applications in a wide variety of other diseases 90 including Glut 1 deficiency, type I diabetes 91, obesity 78, 92, and insulin resistance 20, 39, 93, and diseases of diverse etiology 90.

In addition to ameliorating a number of diseases associated with aging, the general deterioration of cellular systems independent of specific disease seems related to ROS toxicity and the inability to combat it. In contrast increases in life span occur across a number of species with a reduction in function of the IIS pathway and/or an activation of the FOXO transcription factors, inducing expression of the enzymes required for free radical detoxification (Figs. 1 and 2). In C. elegans, these results have been accomplished using RNA interference or mutant animals. Similar changes should be able to be achieved in higher animals, including humans, by the administration of d‐βHB itself or its esters.

In summary, decreased signaling through the insulin/IGF‐1 receptor pathway increases life span. Decreased insulin/IGF‐1 receptor activation leads to a decrease in PIP3, a decrease in the phosphorylation and activity of phosphoinositide‐dependent protein kinase (PDPK1), a decrease in the phosphorylation and activity of AKT, and a subsequent decrease in the phosphorylation of FOXO transcription factors, allowing them to continue to reside in the nucleus and to increase the transcription of the enzymes of the antioxidant pathway.

In mammals, many of these changes can be brought about by the metabolism of ketone bodies. The metabolism of ketones lowers the blood glucose and insulin thus decreasing the activity of the IIS and its attendant changes in the pathway described above. However, in addition ketone bodies act as a natural inhibitor of class I HDACs, inducing FOXO gene expression stimulating the synthesis of antioxidant and metabolic enzymes. An added important factor is that the metabolism of ketone bodies in mammals increases the reducing power of the NADP system providing the thermodynamic drive to destroy oxygen free radicals which are a major cause of the aging process.

A Century of Dietary and Nutritional Trends

At Optimizing Nutrition, there is a freaking long post with a ton of info: Do we need meat from animals? Let me share some of charts showing changes over the past century. As calories have increased, the nutrient content of food has been declining. Also, with vegetable oils and margarine shooting up, animal fat and dietary cholesterol intake has dropped.

Carbs are a bit different. They had increased some in the early 20th century. That was in response to meat consumption having declined in response to Upton Sinclair’s muckraking of the meat industry with his book The Jungle. That was precisely at the time when industrialization had made starchy carbs and added sugar more common. For perspective, read Nina Teicholz account of the massive consumption of animal foods, including nutrient-dense animal fat and organ meats, among Americans in the prior centuries:

“About 175 pounds of meat per person per year! Compare that to the roughly 100 pounds of meat per year that an average adult American eats today. And of that 100 pounds of meat, more than half is poultry—chicken and turkey—whereas until the mid-twentieth century, chicken was considered a luxury meat, on the menu only for special occasions (chickens were valued mainly for their eggs). Subtracting out the poultry factor, we are left with the conclusion that per capita consumption of red meat today is about 40 to 70 pounds per person, according to different sources of government data—in any case far less than what it was a couple of centuries ago.” (The Big Fat Surprise, passage quoted in Malnourished Americans).

What we forget, though, is that low-carb became popular for a number of decades. In the world war era, there was a lot of research on the ketogenic diet. Then around the mid-century, low-carb diets became common and carb intake fell. Atkins didn’t invent the low-carb diet. Science conferences on diet and nutrition, into the 1970s, regularly had speakers on low-carb diets (either Gary Taubes or Nina Teicholz mentions this). It wasn’t until 1980 that the government began seriously promoting the high-carb diet that has afflicted us ever since. Carb intake peaked out around 2000 and dropped a bit after that, but has remained relatively high.

The inflammatory omega-6 fatty acids combined with all the carbs has caused obesity, as part of metabolic syndrome. That goes along with the lack of nutrition that has caused endless hunger as Americans have been eating empty calories. The more crap you eat, the more your body hungers for nutrition. And all that crap is designed to be highly addictive. So, Americans eat and eat, the body hungering for nutrition and not getting it. Under natural conditions, hunger is a beneficial signal to seek out what the body needs. But such things as sugar have become unlinked from nutrient-density.

Unsurprisingly, Americans have been getting sicker and sicker, decade after decade. But on a positive note, recently there is a slight drop in how many carbs Americans are eating. This is particularly seen with added sugar. And it does seem to be making a difference. There is evidence that the diabetes epidemic might finally be reversing. Low-carb diets are becoming popular again, after almost a half century of public amnesia. That is good. Still, the food most American have access to remains low quality and lacking in nutrition.












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Diabetic Confusion

There is been a lot of data coming out about diabetes. Obviously, it gets heavy focus from researchers. Rates have been worsening for the entire 20th century and into the 21st with the majority of the American population now being diabetic, prediabetic, or insulin resistant. But recently, there is some evidence that the rise is finally leveling out, maybe even dipping down a bit.

One could argue that the emerging public debate about and popularity of low-carb diets might finally be having an impact. On the other hand, the data is mixed. Diabetes is getting worse for the young. And it is happening earlier in life. That is the strange part. Type 2 diabetes used to be called adult onset diabetes. Yet this condition, once rare among children and young adults, has become increasingly common. And type 1 diabetes used to be called juvenile diabetes, whereas it is presently found in 42% over the age of 30.

A distinction between these two types is that type 1 diabetes was assumed to be primarily genetic. If that were true, we wouldn’t be seeing the pattern of diabetes increasing the most in type 1. It turns out that we’ve found that both types respond to dietary changes and lifestyle interventions (incidences of type 1 diabetes fell by 60% during WWII because of food scarcity). Many with the genetic predisposition of type 1 diabetes aren’t getting it until late in life, which indicates that what triggers the predisposition might be dependent on other factors.

This confusion can cause further problems. The two types can be mistaken for the other. Children with type 2 diabetes sometimes get misdiagnosed with type 1 and vice versa for adults with type 1. That can harm the patient, since how they are treated is different. Further complicating the situation is the realization that insulin resistance also plays a role in Alzheimher’s, what some are now calling type 3 diabetes.

As with the other two, diet and lifestyle have been proven to improve or even reverse Alzheimer’s symptoms. The same changes that are useful for treating all types of diabetes are also useful for nearly every health condition imaginable. So, despite all the uncertainty and disagreement, we do know this much. A low-carb diet will probably be healthier for anyone. And if you don’t have diabetes, a low-carb diet might help prevent it.

“Simply, we were dumb.”

Dr. Richard David Feinman*: “Whatever else we know or don’t know about Paleo, we know that our ancestors did not get three squares a day, and evolution must have invested far more in ketogenic metabolism than was reflected in our research interests.

“Simply, we were dumb. We’re trying to fix that now.”

Dr. Robert Lustig**: “The thing is I’m a practicing physician and a scientist and for every one patient I took care of and got better ten more would show up in my door. There was no way I was ever going to fix this.

“And the thing that really really bothered me was I learned virtually everything I know about nutrition in college because I majored in nutrition and food science at MIT. And then I went to medical school and they beat it out of me and told me that everything I’d learned was the irrelevant, it had no place in patient care, it wasn’t necessary, and that really all I had to do was focus on calories. I figured these are the clinicians. I’m gonna be closer. I better listen to them and so I practiced that way for like 20 years.

“And then I started doing research because my patients weren’t getting better and I started doing research to try to figure out what’s going on and it like all came rushing back to me, kind of like post-traumatic stress disorder. It’s like, oh my, I knew this stuff back in 1975. So I got pissed off. So I think part of the passion actually is sort of the the being dumbfounded and the anger of what I see going on in medicine today. So I’m glad it translates in a positive way and that people appreciate the passion but I’m just like really ticked off.”

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*”[Dr.] Richard David Feinman is Professor of Cell Biology (Biochemistry) at the State University of New York (SUNY) Downstate Medical Center  in Brooklyn, New York. Dr. Feinman’s original area of research was in protein chemistry and enzyme mechanism, particularly in blood coagulation and related processes.

“Dr. Feinman has worked in several scientific areas including animal behavior and he has had a previous life in the visual arts. His friends consider him a Renaissance Man but he has made peace with the term dilettante.

“His current interest is in nutrition and metabolism, specifically in the area of diet composition and energy balance. Work in this area is stimulated by, and continues to influence, his teaching in the Medical School where he has been a pioneer in incorporating nutrition into the biochemistry curriculum. Dr. Feinman is the founder and former co-Editor-In-Chief (2004-2009) of the journal, Nutrition&Metabolism. Dr. Feinman received his BA from the University of Rochester and he holds a PhD in chemistry from the University of Oregon.” (from bio on his blog)

Dr. Feinman is quoted by Kathryn Goulding in a Paleo Magazine interview for an article on his book Nutrition in Crisis (June/July 20019).

**Dr. Robert Lustig is a Professor of Pediatrics in the Division of Endocrinology at the University of California, San Francisco. He specializes in neuroendocrinology and childhood obesity. He is a leading expert on the obesity, diabetes, and metabolic syndrome epidemics.

His career has included working as a physician, involvement in research (authored 125 peer-reviewed articles and 73 reviews), public speaking (videos of his talks have received millions of views), and authoring books (Fat Chance, Hacking the American Mind, Sugar Has 56 Names, and Obesity Before Birth; also the introduction to John Yudkin’s classic Pure, White and Deadly). He has also been a co-founder, president, director, chairman, member, and consultant of numerous public and private medical, health and dietary task forces, committees, board of directors, institutes, and other organizations.

His focus has been primarily on sugar, not carbohydrates in general. Dr. Feinman has been critical of him on this account. But it appears that he is moving toward the low-carb diet, along with a convergence of his views with those of Gary Taubes. See the discussion on the Ketogenic Forums: Has Lustig moved toward us?

Dr. Lustig is quoted from the below video:

 

Is Diabetes Epidemic Reversing?

“After an almost 20-year increase in the national prevalence and incidence of diagnosed diabetes, an 8-year period of stable prevalence and a decrease in incidence has occurred. […]

“Trends in several risk factors for type 2 diabetes, including intake of added sugar, sugared beverages, total calories, and physical inactivity, peaked in the mid-2000s and either plateaued or decreased thereafter, consistent with the slowing in diabetes incidence.”

New directions in incidence and prevalence of diagnosed diabetes in the USA
by Stephen R Benoit, Israel Hora, Ann L Albright, and Edward W Gregg

American Diabetes Association Changes Its Tune

Over the past decade, ever more mainstream health organizations and government agencies have been slowly reversing their official positions on the dietary intake of carbohydrates, sugar, fat, cholesterol, and salt. This was seen in how the American Heart Association, without acknowledgment, backed off its once strong position about fats that it defended since I think 1961, with the federal government adopting the same position as official policy in 1980. Here we are in 2019, more than a half century later.

Now we see the American Diabetes Association finally coming around as well. And its been a long time coming. When my grandmother was in an assisted living home, the doctors and nurses at the time were following the official ADA position of what were called “consistent carbs”. Basically, this meant diabetics were given a high-carb diet and that was considered perfectly fine, as long as it was consistent so as to manage diabetes with consistent high levels of insulin use. It was freaking insanity in defying common sense.

While my grandmother was still living with my parents, my mother kept her blood sugar under control through diet, until she went to this healthcare facility. After that, her blood sugar was all over the place. The nurses had no comprehension that not all carbohydrates are equal since the glycemic index might be equivalent between a cookie and a carrot, irrespective of glycemic load and ignoring that maybe diabetics should simply be cutting out carbs in general. Instead, they argued that old people should be allowed to enjoy carbs, even if it meant that these nurses were slowly killing their patients and profiting the insulin companies at the same time. My mother was not happy about this callous attitude by these medical ‘professionals’.

Yet here we are. The ADA now says low-carb, high-fat (LCHF) diets aren’t a fad and aren’t dangerous. They go so far as to say they are beneficial for type 2 diabetes. Those not completely ignorant have been saying this for generations. And the research has been accumulating for just as long. The shift in official recommendations that happened in the decades following the 1960s never made sense even according to the research at the time. Many academics and researchers pointed out the lack of evidence in blaming saturated fat and cholesterol. But they were ignored and dismissed, then later attacked, discredited, and silenced by influential and, in some cases, downright charismatic figures (e.g., Ancel Keys) in powerful organizations that became aligned with leading politicians and bureaucrats in key positions. Many careers were destroyed and debate was shut down.

Now those victims of dietary authoritarianism are vindicated, not that this helps all the average folk harmed. There was many decades of bad dietary advice was force onto the American public. This determined official policies and practices of government healthcare programs, school lunch programs, and healthcare providers. Because of the central position of the United States as a geopolitical power during the Cold War, countries all over the world adopted this unhealthy dietary ideology as part of their own official policies.

This also influenced the food system with the government subsidizing high yields of corn and grains to meet the recommendations of these nutritional guidelines. Big ag and big food changed their business models accordingly and put out products that were high in carbs and sugar while low in saturated fat, replacing the latter with unhealthy hydrogenated oils. At least hundreds of millions, if not billions of people, worldwide over multiple generations have suffered a horrible diet, increased sickness, bad medical care, and premature mortality as a result.

Without admitting they were wrong all this time, without apologizing for all the harm they caused, these leading experts and officials are changing their opinion. Better late than never. Mark this date for it is a historic moment.

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A cautiously endorses low-carb nutrition
by Dr. Bret Scher

The central message is one of acceptance and individualization which they sum up by saying:

“Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for people with diabetes. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals.”

While there is definite truth that people have different preferences and metabolic goals, the ADA could risk oversimplification if they stopped there. Fortunately, they get more specific, mentioning the benefits of low-carb:

“For individuals with type 2 diabetes not meeting glycemic targets or for whom reducing glucose-lowering drugs is a priority, reducing overall carbohydrate intake with a low- or very-low-carbohydrate eating pattern is a viable option”

My first question is, who wouldn’t prioritize reducing medications? That should be a given for everyone. Unfortunately, in our pharmaceutically driven medical society, that’s not always the case. But I give kudos to the ADA for mentioning it. I only hope that it will become the new standard, so that next time the ADA can say, “Since reducing or eliminating diabetes medications is a universal goal, we recommend low-cab diets.”

My second question is, what are the glycemic targets? Is it the standard HgbA1c of 7? Or is it time to recognize we can do much better with lifestyle, as opposed to drugs, and set the goal as less than 5.7 for everyone?

After an initial backing of low-carb diets, the guideline then takes a questionable turn.

“As research studies on some low-carbohydrate eating plans generally indicate challenges with long-term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach.”

With Virta Health reporting 83% compliance at 1 year and 74% at 2 years, I would take issue with a blanket statement that compliance is challenging. In fact, any behavioral change has long-term sustainability issues, and carbohydrate restriction may be no different, but it does not deserve to be singled out as particularly difficult. Certainly, if we discuss it with a patient saying “this is difficult to maintain long term,” that has less chance of success than if we say, “All behavior change is difficult, but given the potential health benefits, this is worth committing to for the long-term.” As they say in the beginning of the guide, the words we use matter and we should focus on positive and inspiring messages.

Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report
by Alison B. Evert et al, American Diabetes Association
(also see here)

EATING PATTERNS: Consensus recommendations

  • A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes.
  • Until the evidence surrounding comparative benefits of different eating patterns in specific individuals strengthens, health care providers should focus on the key
    factors that are common among the patterns:
    ○ Emphasize nonstarchy vegetables.
    ○ Minimize added sugars and refined grains.
    ○ Choose whole foods over highly processed foods to the extent possible.
  • Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences.
  • For select adults with type 2 diabetes not meeting glycemic targets or where reducing antiglycemic medications is a priority, reducing overall carbohydrate intake with low- or very lowcarbohydrate eating plans is a viable approach

New Consensus Report Recommends Individualized Eating Plan to Meet Each Person’s Goals, Life Circumstances and Health Status
news release from American Diabetes Association

“‘What can I eat?’ is the number one question asked by people with diabetes and prediabetes when diagnosed. This new Consensus Report reflects the ADA’s continued commitment to evidence-based guidelines that are achievable and meet people where they are and recommends an individualized nutrition plan for every person with diabetes or prediabetes,” said the ADA’s Chief Scientific, Medical and Mission Officer William T. Cefalu, MD. “The importance of this consensus also lies in the fact it was authored by a group of experts who are extremely knowledgeable about numerous eating patterns, including vegan, vegetarian and low carb.”

Nina Teicholz:

Just out: @AmDiabetesAssn guidelines–most comprehensive review to date of Dietary Patterns + diabetes prevention/treatment. What’s new: low-carb recommendations are prominent. (Says low-carb “are among the most studied eating patterns for T2 diabetes.”) […]

This is the key advancement of new @AmDiabetesAssn guidelines. Low carb is no longer “dangerous”‘or “fad”‘but a “viable”‘diet supported by “substantial”‘research and considered best for a number of T2 diabetes outcomes.

Dr. John Owens:

This is an historic day! My case managers and dietitian have been supporting my low-carb recommendations for years, going against ADA guidelines. Now they don’t have to!

Dr. Eric Sodicoff:

Still….They seem a little backward here. Bust out the low carb diet when meds not working?? Really? IMHO-Carb restriction is JOB #1 in diabetes management for use early and always. It is NOT second to medication my treatment protocol.

Starofthesea:

If you go back to the beginning, like back in the 1930’s, the doctors were telling diabetics to stop eating carbohydrates. Then somebody fabricated the cholesterol theory of heart disease and invented a drug called statins. Then suddenly carbs were okay for diabetics.

Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report — American Diabetes Association
from r/ketoscience

lutzlover:

“Eating patterns that replace certain carbohydrate foods with those higher in total fat, however, have demonstrated greater improvements in glycemia and certain CVD risk factors (serum HDL cholesterol [HDL-C] and triglycerides) compared with lower fat diets.”

Yay! Ack that higher fat isn’t deadly.

“The body makes enough cholesterol for physiological and structural functions such that people do not need to obtain cholesterol through foods. Although the DGA concluded that available evidence does not support the recommendation to limit dietary cholesterol for the general population, exact recommendations for dietary cholesterol for other populations, such as people with diabetes, are not as clear (8). Whereas cholesterol intake has correlated with serum cholesterol levels, it has not correlated well with CVD events (65,66). More research is needed regarding the relationship among dietary cholesterol, blood cholesterol, and CVD events in people with diabetes.

Or, in layman’s language: While the data doesn’t support vilifying cholesterol as causing heart attacks, we’re going to keep on searching in hopes we find the answer we want.

dem0n0cracy:

Are protein needs different for people with diabetes and kidney disease?

“Historically, low-protein eating plans were advised to reduce albuminuria and progression of chronic kidney disease in people with DKD, typically with improvements in albuminuria but no clear effect on estimated glomerular filtration rate. In addition, there is some indication that a low-protein eating plan may lead to malnutrition in individuals with DKD (317–321). The average daily level of protein intake for people with diabetes without kidney disease is typically 1–1.5 g/kg body weight/day or 15–20% of total calories (45,146). Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake.

dem0n0cracy:

“The amount of carbohydrate intake required for optimal health in humans is unknown. Although the recommended dietary allowance for carbohydrate for adults without diabetes (19 years and older) is 130 g/day and is determined in part by the brain’s requirement for glucose, this energy requirement can be fulfilled by the body’s metabolic processes, which include glycogenolysis, gluconeogenesis (via metabolism of the glycerol component of fat or gluconeogenic amino acids in protein), and/or ketogenesis in the setting of very low dietary carbohydrate intake (49).”

dem0n0cracy:

Low-carbohydrate (110–112) Emphasizes vegetables low in carbohydrate (such as salad greens, broccoli, cauliflower, cucumber, cabbage, and others); fat from animal foods, oils, butter, and avocado; and protein in the form of meat, poultry, fish, shellfish, eggs, cheese, nuts, and seeds. Some plans include fruit (e.g., berries) and a greater array of nonstarchy vegetables. Avoids starchy and sugary foods such as pasta, rice, potatoes, bread, and sweets. There is no consistent definition of “low” carbohydrate. In this review, a low-carbohydrate eating pattern is defined as reducing carbohydrates to 26–45% of total calories. c A1C reduction c Weight loss c Lowered blood pressure c Increased HDL-C and lowered triglycerides

Very low-carbohydrate (VLC) (110–112) Similar to low-carbohydrate pattern but further limits carbohydrate-containing foods, and meals typically derive more than half of calories from fat. Often has a goal of 20–50 g of nonfiber carbohydrate per day to induce nutritional ketosis. In this review a VLC eating pattern is defined as reducing carbohydrate to ,26% of total calories. c A1C reduction c Weight loss c Lowered blood pressure c Increased HDL-C and lowered triglycerides”

dem0n0cracy:

Low-Carbohydrate or Very Low Carbohydrate Eating Patterns

“Low-carbohydrate eating patterns, especially very low-carbohydrate (VLC) eating patterns, have been shown to reduce A1C and the need for antihyperglycemic medications. These eating patterns are among the most studied eating patterns for type 2 diabetes. One metaanalysis of RCTs that compared lowcarbohydrate eating patterns (defined as #45% of calories from carbohydrate) to high-carbohydrate eating patterns (defined as .45% of calories from carbohydrate) found that A1C benefits were more pronounced in the VLC interventions (where ,26% of calories came from carbohydrate) at 3 and 6 months but not at 12 and 24 months (110).

“Another meta-analysis of RCTs compared a low-carbohydrate eating pattern (defined as ,40% of calories from carbohydrate) to a low-fat eating pattern (defined as ,30% of calories from fat). In trials up to 6 months long, the low-carbohydrate eating pattern improved A1C more, and in trials of varying lengths, lowered triglycerides, raised HDL-C, lowered blood pressure, and resulted in greater reductions in diabetes medication (111). Finally, in another meta-analysis comparing lowcarbohydrate to high-carbohydrate eating patterns, the larger the carbohydrate restriction, the greater the reduction in A1C, though A1C was similar at durations of 1 year and longer for both eating patterns (112). Table 4 provides a quick reference conversion of percentage of calories from carbohydrate to grams of carbohydrate based on number of calories consumed per day.

“Because of theoretical concerns regarding use of VLC eating plans in people with chronic kidney disease, disordered eating patterns, and women who are pregnant, further research is needed before recommendations can be made for these subgroups. Adopting a VLC eating plan can cause diuresis and swiftly reduce blood glucose; therefore, consultation with a knowledgeable practitioner at the onset is necessary to prevent dehydration and reduce insulin and hypoglycemic medications to prevent hypoglycemia.

“No randomized trials were found in people with type 2 diabetes that varied the saturated fat content of the low- or very low-carbohydrate eating patterns to examine effects on glycemia, CVD risk factors, or clinical events. Most of the trials using a carbohydrate-restricted eating pattern did not restrict saturated fat; from the current evidence, this eating pattern does not appear to increase overall cardiovascular risk, but longterm studies with clinical event outcomes are needed (113–117).”

dem0n0cracy:

What is the evidence to support specific eating patterns in the management of type 1 diabetes?

“For adults with type 1 diabetes, no trials met the inclusion criteria for this Consensus Report related to Mediterraneanstyle, vegetarian or vegan, low-fat, low-carbohydrate, DASH, paleo, Ornish, or Pritikin eating patterns. We found limited evidence about the safety and/or effects of fasting on type 1 diabetes (129). A few studies have examined the impact of a VLC eating pattern for adults with type 1 diabetes. One randomized crossover trial with 10 participants examined a VLC eating pattern aiming for 47 g carbohydrate per day without a focus on calorie restriction compared with a higher carbohydrate eating pattern aiming for 225 g carbohydrate per day for 1 week each. Participants following the VLC eating pattern had less glycemic variability, spent more time in euglycemia and less time in hypoglycemia, and required less insulin (130). A single-arm 48-person trial of a VLC eating pattern aimed at a goal of 75 g of carbohydrate or less per day found that weight, A1C, and triglycerides were reduced and HDL-C increased after 3 months, and after 4 years A1C was still lower and HDL-C was still higher than at baseline (131). This evidence suggests that a VLC eating pattern may have potential benefits for adults with type 1 diabetes, but clinical trials of sufficient size and duration are needed to confirm prior findings.”