Tag Archives: prediabetes

Mediterranean Diet Helps With Maintenance of Weight Loss After Ketogenic Diet

Italian seaside tangentially related to this post

Italian seaside tangentially related to this post

Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, no regain of lost weight over the year, on average.

This scientific study is right up my alley. I was excited when I found it. Less excited after I read it.

The Set-Up

This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.)  The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.

Here’s the program:

  1. 20 days of a very-low-carb ketogenic diet, then
  2. 20 days of a low-carbohydrate non-ketogenic diet for stabilization, then
  3. 4 months of a normal caloric Mediterranean diet, then
  4. repeat #1 and #2, then
  5. 6 months of a normal caloric Mediterranean diet

In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).

I found little explanation of period #2 mentioned above, the low-carb non-ketogenic diet. Prescribed macronutrients were 25 or 33% carb, 27 0r 31% protein, 41 or 44% fat, and about 91 g carbohydrate. Prescribed daily calories appear to have averaged 1111.

After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.

Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.

What Did They Find?

Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).

Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.

Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).

Liver and kidney function tests didn’t change.

The authors didn’t give explanations for the drop-outs.

Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned tho their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”

Comments

A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.

However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.

Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined  and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.

I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!

There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.

I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).

How much of the success of this protocol is due to the herbal extracts and TISANOREICA, I have no idea.

The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).

The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved  by a variety of diets.

The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.

The authors write:

The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.

I’ve attempted a similar merger with my Low-Carb Mediterranean Diet. Click here for an outline. Another stab at it was the Spanish Ketogenic Mediterranean Diet. And here’s my version of a Ketogenic Mediterranean Diet.

Steve Parker, M.D.

Reference: Paoli, Antonio, et al. Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean Diet and Mediterranean Diet Maintenance Protocol. Nutrients, 5 (2013): 5205-5217. doi: 10.3390/nu5125205

Metabolic Syndrome: A Thumbnail Sketch

metabolic syndrome, low-carb diet, diabetes, prediabetes

He’s at high risk for metabolic syndrome

“Metabolic syndrome” may be a new term for you. It’s a collection of clinical features that are associated with increased future risk of type 2 diabetes and atherosclerotic complications such as heart attack and stroke. One in six Americans has metabolic syndrome. Diagnosis requires at least three of the following five conditions:

  • high blood pressure (130/85 or higher, or using a high blood pressure medication)
  • low HDL cholesterol:  under 40 mg/dl (1.03 mmol/l) in a man, under 50 mg/dl (1.28 mmol/l) in a women (or either sex taking a cholesterol-lowering drug)
  • triglycerides over 150 mg/dl (1.70 mmol/l) (or taking a cholesterol-lowering drug)
  • abdominal fat:  waist circumference 40 inches (102 cm) or greater in a man, 35 inches (89 cm) or greater in a woman
  • fasting blood glucose over 100 mg/dl (5.55 mmol/l)

What To Do About It

Metabolic syndrome and simple excess weight often involve impaired carbohydrate metabolism. Over time, excessive carbohydrate consumption can turn overweight and metabolic syndrome into prediabetes, then type 2 diabetes.  Carbohydrate restriction directly addresses impaired carbohydrate metabolism naturally. When my patients have metabolic syndrome, some of my recommendations are:

  • weight loss, often via a low-carb diet (but most any reasonable diet may also work)
  • carbohydrate-restricted diet if blood sugars or triglycerides are elevated
  • regular exercise, a combination of strength and aerobic training

If these are effective, the patient can often avoid costly drugs and their potential adverse effects.

Ask your doctor what she thinks.

Steve Parker, M.D.

Prediabetes Is a Risk for Heart Disease

…according to an article at MedPageToday. What to do about it? See Conquer Diabetes and Prediabetes, if nothing else.

Small Study Shows Improved Diabetes and Prediabetes With Biggest Loser Plan

“One more rep then I’m outa here!”

Do you wonder how much exercise it takes to lose a lot of weight quickly?  Read on.

TV’s “The Biggest Loser” weight-loss program works great for overweight diabetics and prediabetics, according to an article May 30, 2012, in MedPage Today.  Some quotes:

For example, one man with a hemoglobin A1c (HbA1c) of 9.1 [poor control of diabetes], a body mass index (BMI) of 51 [very fat], and who needed six insulin injections a day as well as other multiple prescriptions was off all medication by week 3, said Robert Huizenga, MD, the medical advisor for the TV show.

In addition, the mean percentage of weight loss of the 35 contestants in the study was 3.7% at week 1, 14.3% at week 5, and 31.9% at week 24…

The exercise regimen for those appearing on “The Biggest Loser” comprised about 4 hours of daily exercise: 1 hour of intense resistance training, 1 hour of intense aerobics, and 2 hours of moderate aerobics.

Caloric intake was at least 70% of the estimated resting daily energy expenditure, Huizenga said.

At the end of the program, participants are told to exercise for 90 minutes a day for the rest of their lives. Huizenga said he is often told by those listening to him that a daily 90-minute exercise regimen is impossible because everyone has such busy lives.

“I have a job and I work out from 90 to 100 minutes per day,” he said. “It’s about setting priorities. Time is not the issue; priorities are the issue.”

Of the 35 participants in this study, six had diabetes and 12 had prediabetes.  This is a small pilot study, then.  I bet the results would be reproducible on a larger scale IF all conditions of the TV program are in place.  Of course, that’s not very realistic.  A chance to win $250,000 (USD) is strong motivation for lifestyle change.  Can you see yourself exercising for four hours a day?

Steve Parker, M.D.

PS: Although not mentioned in the article, these must have been type 2 diabetics, not type 1.

Spanish Ketogenic Mediterranean Diet

Ever heard of the Spanish Ketogenic Mediterranean Diet? It looks like a low-carb quasi-Mediterranean diet.

Researchers with the University of Cordoba in Spain studied 40 subjects eating a low-carb “Mediterranean” diet for 12 weeks. The results were strikingly positive.

Methodology

A medical weight loss clinic was the source of 40 overweight subjects, 22 males and 19 females, average age 38, average body mass index 36.5, average weight 108.6 kg (239 lb). These folks were interested in losing weight, and were not paid to participate.

Nine subjects were not included in the final analysis due to poor compliance with the study protocol (3), the diet was too expensive (1), a traumatic car wreck (1), or were simply lost to follow-up (4). So all the data are pooled from the 31 subjects who completed the study.

Blood from all subjects was drawn just before the study began and again after 12 weeks of the diet.

Study diet: Low-carbohydrate, high in protein [and probably fat, too], unlimited in calories. Olive oil was the main source of fat (at least 30 ml daily). Maximum of 30 grams of carbohydrates daily as green vegetables and salad. 200-400 ml daily of red wine. The authors write:

Participants were permitted 3 portions (200 g/portion) of vegetables daily: 2 portions of salad vegetables (such as alfalfa sprouts, lettuce, escarole, endive, mushrooms, radicchio, radishes, parsley, peppers, chicory, spinach, cucumber, chard and celery), and 1 portion of low-carbohydrate vegetables (such as broccoli, cauliflower, cabbage, artichoke, eggplant, squash, tomato and onion). 3 portions of salad vegetables were allowed only if the portion of low-carbohydrate vegetables were not consumed. Salad dressing allowed were: garlic, olive oil, vinegar, lemon juice, salt, herbs and spices.

The minimum 30 ml of olive oil were distributed unless in 10 ml per principal meal (breakfast, lunch and dinner). Red wine (200–400 ml a day) was distributed in 100–200 ml per lunch and dinner. The protein block was divided in “fish block” and “no fish block”. The “fish block” included all the types of fish except larger, longer-living predators (swordfish and shark). The “no fish block” included meat, fowl, eggs, shellfish and cheese. Both protein blocks were not mixed in the same day and were consumed individually during its day on the condition that at least 4 days of the week were for the “fish block”.

Trans fats (margarines and their derivatives) and processed meats with added sugar were not allowed.

Vitamin and mineral supplements were given.

Subjects measured their ketosis state every morning with urine ketone strips.

Results (averaged)

  • Body weight fell from 108.6 kg (239 lb) to 94.5 kg (209 lb), or 2.5 pounds per week
  • Body mass index fell from 36.5 to 31.8
  • Systolic blood pressure fell from126 to 109 mmHg
  • Diastolic blood pressure fell from 85 to 75 mmHg
  • Total cholesterol fell from 208 to 187 mg/dl
  • LDL chol fell from 115 to 106 mg/dl
  • HDL chol rose from 50 to 55 mg/dl
  • Fasting glucose dropped from 110 to 93 mg/dl
  • Triglycerides fell from 219 to 114 mg/dl
  • No significant differences in male and female subjects
  • No adverse reactions are mentioned

Researchers’ Conclusions

The SKMD [Spanish Ketogenic Mediterranean Diet] is safe, an effective way of losing weight, promoting non-atherogenic lipid profiles, lowering blood pressure and improving fasting blood glucose levels. Future research should include a larger sample size, a longer term use and a comparison with other ketogenic diets.

My Comments

The researchers called this diet “Mediterranean” based on olive oil, red wine, fish, and vegetables.

What’s “Not Mediterranean” is the paucity of carbohydrates (including whole grains); lack of yogurt, nuts, and legumes; and the high meat/protein intake.

The emphasis on olive oil, red wine, and fish could make this healthier than other ketogenic diets.

Ketogenic diets are notorious for high drop-out rates compared to other diets. But several studies suggest greater short-term weight loss for people who stick with it. Efficacy and superiority are little different from other diets as measured at one year out.

Many of the metabolic improvements seen here might be duplicated with loss of 30 pounds (13.6 kg) over 12 weeks using any reasonable diet.

Average fasting blood sugars in these subjects was 109 mg/dl. Although not mentioned by the authors, this is in the prediabetes range. The diet reduced average fasting blood sugar to 93, which would mean resolution of prediabetes. Dropping body mass index from 36 to 32 by any method would tend to cure prediabetes.

Elevated blood sugar is one component of the “metabolic syndrome.” Metabolic syndrome was recently shown to be reversible with a Mediterranean diet supplemented with nuts.

If you’re thinking about doing something like this, get more information and be sure to get your doctor’s approval first.

My Ketogenic Mediterranean Diet has much in common with the study at hand. One of several major differences is that it’s user-friendly and ready to implement as soon as you have your physician’s clearance. It’s posted at the Diabetic Mediterranean Diet Blog.

Steve Parker, M.D.

Addendum:

In April, 2008, had a delightful conversation with Jimmy Moore, of Livin’ La Vida Low-Carb fame regarding this study. I reviewed this article in preparation.  It struck me that the Spanish Ketogenic Mediterranean Diet is probably higher in protein and lower in fat than many other ketogenic weight-loss diets. Since fish is emphasized over other animal-derived foods, it’s likely also lower in saturated fat. (In low-carb diets, carbohydrates are substituted with either fats or proteins.)

References and Additional Reading:

Perez-Guisado, J., Munoz-Serrano, A., and Alonso-Moraga, A. Spanish Ketogenic Mediterranean diet: a healthy cardiovascular diet for weight loss. Nutrition Journal, 2008, 7:30. doi:10.1186/1475-2891-7-30 I like the idea behind Nutrition Journal. From the publisher’s website:

Nutrition Journal aims to encourage scientists and physicians of all fields to publish results that challenge current models, tenets or dogmas. The journal invites scientists and physicians to submit work that illustrates how commonly used methods and techniques are unsuitable for studying a particular phenomenon. Nutrition Journal strongly promotes and invites the publication of clinical trials that fall short of demonstrating an improvement over current treatments. The aim of the journal is to provide scientists and physicians with responsible and balanced information in order to improve experimental designs and clinical decisions.

With the advent of the Internet, has dawned a new way to exchange information and to publish biomedical journals. BioMed Central has been a pioneer in online publishing with Nutrition Journal being one of its many journals. Publication in Nutrition Journal offers many advantages over traditional paper publications; the journal offers free access to its articles; high quality and rapid peer-review; immediate publication; and most importantly, universal access to its content from virtually any place in the world.

Bravata, D.M., et al. Efficacy and safety of low-carbohydrate diets: a systematic review. Journal of the American Medical Association, 289 (2003): 1,837-1,850.

Gardner, C.D., et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. Journal of the American Medical Association, 297 (2007): 696-677.

Stern, L., et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Annals of Internal Medicine, 140 (2004): 778-785.

Shai, Iris, et al. Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet. New England Journal of Medicine, 359 (2008): 229-241.

Prevalence Figures for Diabetes and Prediabetes

In January of 2011, the U.S. Centers for Disease Control and Prevention released the latest estimates for prevalence of diabetes and prediabetes. The situation is worse than it was in 2008, the last figures available.

  • Nearly 27% of American adults age 65 or older have diabetes (overwhelmingly type 2)
  • Half of Americans 65 and older have prediabetes
  • 11% of U.S. adults (nearly 26 million) have diabetes (overwhelmingly type 2)
  • 35% of adults (79 million) have prediabetes, and most of those affected don’t know it

The CDC estimates that one of every three U.S. adults could have diabetes by 2050 if present trends continue.

The press release from the CDC mentions that physical activity and avoidance of overweight will prevent some cases of diabetes. I believe that limiting consumption of refined carbohydrates like sugar and flour would also help.

Those who already have diabetes and prediabetes should consider carbohydrate-restricted Mediterranean-style eating, as in Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet.

Steve Parker, M.D.

173 Years of U.S. Sugar Consumption

Thanks to Dr. Stephan Guyenet and Jeremy Landen for this sugar consumption graph.  I’d never seen one going this far back in time. 

 Dr. Guyenet writes:
It’s a remarkably straight line, increasing steadily from 6.3 pounds per person per year in 1822 to a maximum of 107.7 lb/person/year in 1999.  Wrap your brain around this: in 1822, we ate the amount of added sugar in one 12 ounce can of soda every five days, while today we eat that much sugar every seven hours.
The U.S. Department of Agriculture estimates that added sugars provide 17% of the total calories in the average American diet.  A typical carbonated soda contain the equivalent of 10 tsp (50 ml) of sugar.  The average U.S. adult eats 30 tsp  (150 ml) daily of added sweeteners and sugars.
 
Note that added sugars overwhelmingly supply only one nutrient: pure carbohdyrate without vitamins, minerals, protein, fat, antioxidants, etc.
 
Do you think sugar consumption has anything to do with diseases of affluence, also known as diseases of modern civilization?  I do.
 
Was our pancreas designed to handle this much sugar?  Apparently not, judging from skyrocketing rates of diabetes and prediabetes.
 

Book Review: The Blood Sugar Solution

I just finished reading the No.1 book at Amazon.com, The Blood Sugar Solution: The UltraHealthy Progam for Losing Weight, Preventing Disease, and Feeling Great Now!  Published in 2012, the author is Dr. Mark Hyman. I give it three stars per Amazon’s rating system (“It’s OK”).  Actually, I came close to giving it two stars, but was afraid the review would have been censored at the Amazon site.

♦   ♦   ♦

The book’s promotional blurbs by the likes of Dr. Oz, Dr. Dean Ornish, and Deepak Chopra predisposed me to dislike this book.  But it’s not as bad as I thought it’d be.

The good parts first.  Dr. Hyman favors the Mediterranean diet, strength training, and high-intensity interval training.  His recommended way of eating is an improvement over the standard American diet, improving prospects for health and longevity.  His dietary approach to insulin-resistant overweight/obesity and type 2 diabetes includes 1) avoidance of sugar, flour, processed foods, 2) preparation of your own meals from natural, whole food, and 3) keeping glycemic loads low.  All well and good for weight loss and blood sugar control.  It’s not a vegetarian diet.

The author proposes a new trade-marked medical condition: diabesity. It refers to insulin resistance in association with (usually) overweight, obesity, and/or type 2 diabetes mellitus.  Dr. Hyman says half of Americans have this brand-new disorder, and he has the cure.  If you don’t have overt diabetes or prediabetes, you’ll have to get your insulin levels measured to see if you have diabesity.

He reiterates many current politically correct fads, such as grass-fed/pastured beef, organic food, detoxification, and strict avoidance of all man-made chemicals, notwithstanding the relative lack of scientific evidence supporting many of these positions.

Dr. Hyman bills himself as a scientist, but his biography in the book doesn’t support that label.  Shoot, I’ve got a degree in zoology, but I’m a practicing physician, not a scientist.

The author thinks there are only six causes of all disease: single-gene genetic disorders, poor diet, chonic stress, microbes, toxins, and allergens.  Hmmm… None of those explain hypothyroidism, rheumatoid arthritis, systemic lupus erythematosis, tinnitus, migraines, irritable bowel syndrome, Parkinsons disease, chronic fatigue syndrome, or multiple sclerosis, to name a few that don’t fit his paradigm.

Dr. Hyman makes a number of claims that are just plain wrong.  Here are some:
  – Over 80% of Americans are deficient in vitamin D
  – Lack of fiber contributes to cancer
  – High C-reactive protein (in blood) is linked to a 1,700% increased probability of developing diabetes
  – Processed, factory-made foods have no nutrients
  – We must take nutritional supplements

Furthermore, he recommends a minimum of 11 and perhaps as many as 16 different supplements even though the supportive science is weak or nonexistent.  Is he selling supplements?

After easily finding these bloopers, I started questioning many other of the author’s statements.   

I was very troubled by the apparent lack of warning about hypoglycemia (low blood sugar).  Many folks with diabetes will be reading this book.  They could experience hypoglycemia on this diet if they’re taking certain diabetes drugs: insulin, sulfonylureas, meglitinides, pramlintide plus insulin, exenatide plus sulfonylurea, and possibly thiazolidinediones, to name a few instances.

If you don’t have diabetes but do need to lose weight, this book may help.  If you have diabetes, strongly consider an alternative such as Dr. Bernstein’s Diabetes Solution or my Conquer Diabetes and Prediabetes.

In the interest of brevity, I’ll not comment on Dr. Hyman’s substitution of time-tested science-based medicine with his own “Functional Medicine.”

Steve Parker, M.D.