Category Archives: Low-Carb Eating

Is Insulin the Reason You’re Always Hungry?

So easy to over-eat!

So easy to over-eat! Is it the insulin release?

No, insulin probably isn’t the cause of constant hunger, according to Dr. Stephan Guyenet. Dr. G gives 11 points of evidence in support of his conclusion. Read them for yourself. Here are a few:

  • multiple brain-based mechanisms (including non-insulin hormones and neurotransmitters) probably have more influence on hunger than do the pure effect of insulin
  • weight loss reduces insulin levels, yet it gets harder to lose excess weight the more you lose
  • at least one clinical study (in 1996) in young healthy people found that foods with higher insulin responses were linked to greater satiety, not greater hunger
  • billions of people around the world eat high-carb diets yet remain thin

An oft-cited explanation for the success of low-carbohydrate diets involves insulin, specifically the lower insulin levels and reduced insulin resistance seen in low-carb dieters. They often report less trouble with hunger than other dieters.

Here’s the theory. When we eat carbohydrates, the pancreas releases insulin into the bloodstream to keep blood sugar levels from rising too high as we digest the carbohydrates. Insulin drives the bloodstream sugar (glucose) into cells to be used as energy or stored as fat or glycogen. High doses of refined sugars and starches over-stimulate the production of insulin, so blood sugar falls too much, over-shootinging the mark, leading to hypoglycemia, an undeniably strong appetite stimulant. So you go back for more carbohydrate to relieve the hunger induced by low blood sugar. That leads to overeating and weight gain.

Read Dr. Guyenet’s post for reasons why he thinks this explanation of constant or recurring bothersome hunger is wrong or too simplistic. I tend to agree with him on this.

The insulin-hypoglycemia-hunger theory may indeed be at play in a few folks. Twenty ears ago, it was popular to call this “reactive hypoglycemia.” For unclear reasons, I don’t see it that often now. It was always hard to document that hypoglycemia unless it appeared on a glucose tolerance test.

Regardless of the underlying explanation, low-carb diets undoubtedly are very effective in many folks. That’s why I offer one as an option in my Advanced Mediterranean Diet. And low-carbing is what I always recommend to my patients with carbohydrate intolerance: diabetics and prediabetics.

Steve Parker, M.D.

front cover

front cover

Steve Parker MD, Advanced Mediterranean Diet

Two diet books in one

front cover

front cover

Save Time by Microwaving Your Spaghetti Squash

The pale yellow half-squash is cooked. The meaty red sauce is low-carb.

Both of these weighed about 4 pounds (1.8 kg). The pale yellow half-squash is cooked. The meaty red sauce is low-carb.

My wife found this new spaghetti squash cooking method—new to us at least—on a sticker attached to a squash. We tried it and the finished product is the same as if done in the traditional oven baking way. The whole process just takes 15 minutes. Here it is:

Hope you can read it

Hope you can read it

A different squash had a different stuck-on cooking method that involved both microwaving AND oven baking. Why make it so complicated?

It takes no skill at all to make it look like spaghetti pasta

It takes no skill at all to make it look like spaghetti pasta

 

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In the northern hemisphere, the spaghetti squash season is autumn and winter. Purchasing in spring and summer may be iffy. We tried one out of season and it was inedible.

Spaghetti Squash Recipes

Low-Carb Spaghetti Sauce

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Spaghetti Squash Recipes

low-carb diet, spaghetti squash, paleobetic diet, diabetic diet

The yellow spaghetti squash is at the top. It’s related to pumpkins and zucchini.

Many weight-conscious folks are cutting down on carbohydrate consumption. One way to do that is to find lower-carb alternatives to carb-rich items.

An alternative to spaghetti pasta is spaghetti squash. A cup of cooked spaghetti squash has 10 g of carb; a cup of cooked spaghetti has 43 g. The fiber grams are about the same. Numbers are from FitDay.com.

Spaghetti squash is a classic low-carb vegetable. If you’ve never tried it, you should. As vegetables go, it’s one of the largest, heaviest, and most interesting to prepare. Easy, too. The spaghetti squash season is autumn and winter in the northern hemisphere. Purchasing in spring and summer may be iffy.

In my part of the world, supermarket spaghetti squashes weigh between two and five pounds. We cooked a three-pounder (1.4 kg) that yielded five cups; a five-pounder (2.3 kg) gave us 12 cups. A serving size is one, maybe two cups. What you don’t eat immediately stays fresh in the refrigerator for at least several days. Re-heat by microwaving or stir-frying.

Like pasta and potatoes, the squash by itself is bland. It’s a great substrate for sauces or seasonings.

low-carb diet, paleobetic diet, diabetic diet, spaghetti squash

Raw squash cut in half lengthwise

Here’s how we cook it at the Parker Compound. Preheat the oven to 375º F 0r 190º C. Very carefully slice the squash in half lengthwise. Spoon out and discard the guts (seeds and membranes like a pumpkin; it even smells like a pumpkin). Put the halves flat-side down in a pan, then add a half inch (1.3 cm) of water to the pan. Cover with foil and bake until the outer shell (rind) is fairly easily pierced with a paring knife. This will be about 45 minutes for a two-pound squash (0.9 kg); 90 minutes for a four-plus pounder (2.3+ kg). Then turn them over, re-cover with foil, and cook 15 minutes more, until very tender. Remove from the oven and allow them to cool for a few minutes. Then use a fork to pull the strands away from the rind.

Other cooks simplify the process and just place the squash halves flat-side down on a baking sheet and cook for 30-60 minutes. Some leave the seeds in while cooking and spoon them out just before the stranding step.

Or you can save time and microwave it. We can’t tell the difference in the final product.

Now what?

You got options.

Our first experiment was with l0w-carb spaghetti sauce.

paleobetic diet, low-carb diet, diabetic diet, spaghetti squash

Low-carb spaghetti

Next we took three cups squash (710 ml) and mixed in 2 tbsp (30 ml) extra virgin olive oil, 2.5 tbsp (37 ml) chopped parsley, 1/2 tsp (2.5 ml) minced fresh garlic, 1/2 tsp (2.5 ml) salt, and 1/8 tsp (0.6 ml) black pepper.

low-carb diet, diabetic diet, paleobetic diet

Seasoned with parsley, olive oil, garlic, salt, pepper

Finally, we took a cup (240 ml) of the squash and added minced celery (4 inches or 10 cm of stalk), 3 minced black olives, 5/8 oz (18 g) of minced sweet (bell) pepper, 1/2 clove of minced garlic, salt (a dash), and pepper to taste.

paleobetic diet, diabetic diet, low-carb diet, spaghetti squash

Seasoned with sweet peppers, black olives, garlic, celery, and salt

These last two options I consider side dishes. By the way, they taste good either cold or warm. They would go well with a number of entrees, such as steak or salmon.

I’ve read that this squash is good with pesto, or just with salt and butter.

Nutrition facts from FitDay.com:

One cup of cooked spaghetti squash has 75 calories (I’ve seen 42 elsewhere), 10 g of carbohydrate, 2 g of fiber, 8 g of digestible carb, 4 g of fat (predominantly MUFA), minimal protein, and a fair amount of vitamins A, niacin, B6, and C. Plus 8% of your RDA for manganese.

Steve Parker, M.D.

 

Do Low-Carb Diets Cause Death?

Adult life is a battle against gravity. Eventually we all lose.

Adult life is a battle against gravity. Eventually we all lose.

Japanese researchers say low-carb diets are causing premature death. I’m skeptical.

The potentially healthful side effects linked to low-carb eating include reduced weight, higher HDL cholesterol, and lower triglycerides and blood pressure. The Japanese investigators wondered if the improved cardiovascular risk factors seen with low-carb diets actually translate into less heart disease and death.

How Was the Study At Hand Done?

The best way to test long-term health effects of a low-carb diet (or any diet) is to do a randomized controlled trial. You take 20,000 healthy and very similar people—not rodents—and randomize half of them to follow a specific low-carb diet while the other half all eat a standard or control diet. Teach them how to eat, make damn sure they do it, and monitor their health for five, 10, or 20 years. This has never been, and never will be, done in humans. The Nazis may have done it, but it’s not published. In the old days, we could do this study on inmates of insane asylums or prisons.

What we have instead are observational studies in which people voluntarily choose what they’re eating, and we assume they keep eating that way for five or 10+ years. You also assume that folks who choose low-carb diets are very similar to other people at the outset. You depend on regular people to accurately report what and how much they’re eating. You can then estimate how much of their diet is derived from carbohydrate and other macronutrients (protein and fat), then compare health outcomes of those who were in the top 10% of carb eaters with those in the bottom 10%. (We’ve made a lot of assumptions, perhaps too many.)

Of the observational studies the authors reviewed, the majority of the study participants were from the U.S. or Sweden. So any true conclusions may not apply to you if you’re not in those countries. In looking for articles, they found no randomized controlled trials.

The observational studies estimated carb consumption at the outset, but few ever re-checked to see if participants changed their diets. That alone is a problem. I don’t know about you, but I’ve had significant changes in my diet depending on when I was in college and med school, when I was a bachelor versus married, when my income was higher or lower, and when I had young children versus teenagers. But maybe that’s just me.

The researchers looked at all-cause mortality, deaths from cardiovascular disease, and incidence of cardiovascular disease. They don’t bother to define cardiovascular disease. I assume heart attack, strokes, and peripheral vascular disease. (But aren’t aneurysms, deep vein thrombosis, and pulmonary embolism vascular diseases, too?) Wouldn’t you think they’d carefully define their end-points? I would. Since they were going to all this trouble, why not look at cancer deaths, too?

What Did the Investigators Conclude?

Very low-carbohydrate dieters had a 30% higher risk of death from any cause (aka all-cause mortality) compared to very high-carb eaters. The risk of cardiovascular disease incidence or death were not linked with low-carb diets. Nor did they find protection against cardiovascular disease.

Finally, “Given the facts that low-carbohydrate diets are likely unsafe and that calorie restriction has been demonstrated to be effective in weight loss regardless of nutritional composition, it would be prudent not to recommend low-carbohydrate diets for the time being.”

If Low-Carb Dieters Die Prematurely, What Are They Dying From?

The top four causes of death in the U.S. in 2011, in order, were:

  1. heart attacks
  2. cancer
  3. chronic lower respiratory tract disease
  4. stroke

You’ll note that two of those are cardiovascular disease: heart attacks and stroke. So if low-carb diets promote premature death, it’s from cancer, chronic lung disease, or myriad other possibilities. Seventy-five percent of Americans die from one of the top 10 causes. Causes five through 10 are:

  • accidents
  • Alzheimer disease
  • diabetes
  • flu and pneumonia
  • kidney disease
  • suicide

Problem is, no one has ever linked low-carb diets to higher risk of death from any specific disease, whether or not in the top ten. Our researchers don’t mention that. That’s one reason I’m very skeptical about their conclusion. If you’re telling me low-carb diets cause premature death, tell me the cause of death.

Another frustration of mine with this report is that they never specify how many carbohydrates are in this lethal low-carb diet. Is it 20 grams, 100, 150? The typical American eats 250-300 grams of carb a day. If you’re going to sound the alarm against low-carb diets, you need to specify the lowest safe daily carb intake.

For most of my career—like most physicians—I’ve been wary of low-carb diets causing cardiovascular disease. That’s because they can be relatively high in total fat and saturated fat. In 2009, however, I did my own review of the scientific literature and found little evidence of fats causing cardiovascular disease.

If you’re looking for a reason to avoid low-carb diets, you can cite this study and its finding of premature death. I’m not convinced. I’ll turn it around on you and note this study found no evidence that low-carb diets cause cardiovascular disease. The risk of cardiovascular disease had been the traditional reason for physicians to recommend against low-carb diets.

Steve Parker, M.D.

Reference: Noto, Hiroshi et al. Low-Carbohydrate diets and all-cause mortality: A systematic review and meta-analysis of observational studies. PLoS One, 2013; 8(1): e55050

Low-Carb Beats Low-Fat Diet for Weight Loss Without Increase in Heart Disease Risk

…according to an article at MedPageToday.

Many physicians have been reluctant to recommend low-carb diets out of fear that they increase cardiovascular risk. A recent study compared low-carb to low-fat dieting over 12 months and actually found better improvements in cardiovascular disease risk factors on the low-carb diet (max of 40 grams a day).

After 12 months, folks on a low-carbohydrate diet had lost 5.3 kg (11.7 lb), while those on a low-fat diet with similar caloric value had lost 1.8 kg (3.9 lb). Both groups showed lowering of LDL cholesterol, while the low-carbers had better improvements in HDL cholesterol and triglycerides.

DietDoctor Andreas Eenfeldt can add this study to his list of others that show better weight loss with low-carb diets compared to low-fat.

Steve Parker, M.D.

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

Are Low-Carb Diets Safe and Effective for Children?

DietDoctor Andreas Eenfeldt has located three studies that answer in the affirmative. Click through to his blog for details.