Tag Archives: low carb diet

Improve Metabolic Syndrome with Paleolithic Diet

Posted on October 26, 2015 | Comments Off on Improve Metabolic Syndrome with Paleolithic Diet

…according to an article at American Journal of Clinical Nutrition.

shutterstock_268538780

 

“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. You can lower your risk of these conditions by reversing your metabolic syndrome.

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)
  • fasting blood glucose over 100 mg/dl (5.55 mmol/l)

I don’t plan on reading the full text of the report because it’s a meta-analysis and I’ve likely reviewed the four component studies already at my Paleo Diabetic blog. Here are the results:

Four RCTs [randomized controlled trials] that involved 159 participants were included. The 4 control diets were based on distinct national nutrition guidelines but were broadly similar. Paleolithic nutrition resulted in greater short-term improvements than did the control diets (random-effects model) for waist circumference (mean difference: −2.38 cm; 95% CI: −4.73, −0.04 cm), triglycerides (−0.40 mmol/L; 95% CI: −0.76, −0.04 mmol/L), systolic blood pressure (−3.64 mm Hg; 95% CI: −7.36, 0.08 mm Hg), diastolic blood pressure (−2.48 mm Hg; 95% CI: −4.98, 0.02 mm Hg), HDL cholesterol (0.12 mmol/L; 95% CI: −0.03, 0.28 mmol/L), and fasting blood sugar (−0.16 mmol/L; 95% CI: −0.44, 0.11 mmol/L). The quality of the evidence for each of the 5 metabolic components was moderate. The home-delivery (n = 1) and dietary recommendation (n = 3) RCTs showed similar effects with the exception of greater improvements in triglycerides relative to the control with the home delivery. None of the RCTs evaluated an improvement in quality of life.

Ways to improve or cure metabolic syndrome include the paleo diet, Mediterranean diet, low-carb diets, ketogenic diets, and exercise. Losing excess fat weight with any reasonable diet would probably work. Enhance effectiveness with exercise.

Steve Parker, M.D.

Reference:Eric W Manheimer,  Esther J van Zuuren, Zbys Fedorowicz, and Hanno Pijl. Paleolithic nutrition for metabolic syndrome: systematic review and meta-analysis. AJCN. First published August 12, 2015, doi: 10.3945/​ajcn.115.113613

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Book Review: “Stop the Clock: The Optimal Anti-Aging Strategy”

Posted on August 31, 2015 | Comments Off on Book Review: “Stop the Clock: The Optimal Anti-Aging Strategy”
dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“I wish we could have read PD Mangan’s book thirty years ago!”

I read P.D. Mangan’s 2015 book, Stop the Clock: The Optimal Anti-Aging Strategy. I give it five stars in Amazon’s rating system. High recommended.

♦   ♦   ♦

I approached this book with trepidation. I like PD Mangan even though I’ve never met him. We’ve interacted on Twitter and at our blogs. You can tell from his blogging that he’s very intelligent. I don’t know his educational background but wouldn’t be surprised if he has a doctorate degree. My apprehension about the book is that I was concerned it would be brimming with malarkey and scams. Fortunately, that’s not the case at all.

Twin studies have established that 25% of longevity is genetic. That leaves a lot of lifestyle factors for us to manipulate.

I’m not familiar with the anti-aging scientific literature and don’t expect it will ever be something I’ll spend much time on. But it’s an important topic. I’ll listen to what other smart analysts—like Mr. Mangan—have to say about it.

It’s quite difficult to do rigorous testing of anti-aging strategies on free-living humans. So the best studies we have were done with worms, rodents, and monkeys; the findings may or may not apply to us. For example, long-term calorie restriction—about 30% below expected energy needs—is known to prolong life span in certain worms and rodents, with mixed results in rhesus monkeys. It’s the rare person who would follow such a low-calorie diet for years as an experiment. I doubt I would do it even if proven to give me an extra five years of life. I like to eat.

There are several prominent theories of how and why animals age. The author thinks the major factors are:

  1. oxidative stress
  2. inflammation
  3. a decline in autophagy (perhaps most important)

An effective anti-aging program should address these issues.

In the anti-aging chapter of his book, The South Asian Health Solution, internist Ronesh Sinha says that “Lifestyle practices that reduce excess inflammation in the body will help delay the aging process.” Dr. Sinha is a huge exercise advocate and low-carb diet proponent.

Mr. Mangan makes a convincing argument that a good way to forestall aging is to apply hormetic stress. Hormesis is a phenomenon whereby a beneficial effect (e.g., improved health, stress tolerance, growth, or longevity) results from exposure to low doses of an agent or activity that is otherwise toxic or lethal when given at higher doses.

Needs a bit more hormetic stress

Needs a bit more hormetic stress

In case you’re not familiar with hormesis, here’s a major example. Lack of regular exercise leads is linked to premature death from heart disease and cancer. Starting and maintaining an exercise program leads to greater resistance to injury and disease and longer life span. On the other hand, too much exercise is harmful to health and longevity. We see that in professional athletes and excessive marathon runners. Something about exercise—in the right amount—enhances the body’s intrinsic repair mechanisms. That’s the hormetic effect of exercise; one mechanism is by turning on autophagy.

Autophagy is the body’s natural process for breaking down and removing or recycling worn-out cellular structures. This wearing-out occurs daily and at all ages.

If you’re thinking Mr. Mangan recommends exercise as an anti-aging strategy, you’re exactly right. Especially resistance training and high intensity training. His specific recommendations are perfectly in line with what I tell my patients.

Calorie restriction is another form of hormesis; the body reacts by up-regulating stress defense mechanisms. As a substitute for calorie restriction, the author recommends intermittent fasting. Intermittent fasting increases insulin sensitivity, which leads to enhanced autophagy. Fasting seems perfectly reasonable if you think about it, which very few do. Many of us eat every three or four hours while awake, whether a meal or a snack. If you think about it, that’s not a pattern that would be supported by evolution. In the Paleolithic era, we often must have gone 12–16 hours or even several days without food. Hominins without the resiliency to do that would have died off and not passed their genes down to us.

Steve Parker MD, Advanced Mediterranean DIet

Naturally low-carb Caprese salad: mozzarella cheese, tomatoes, basil, extra virgin olive oil

Another anti-aging trick is a low-carb diet, defined as under 130 grams/day, or under 20% of total calories. It may work via insulin signaling and weight control.

Glutathione within our cells is a tripeptide antioxidant critical for clearing harmful reactive oxygen species (free radicals). We need adequate glutathione to prevent or slow aging. Cysteine is the peptide that tends to limit our body’s production of glutathione. We increase our cysteine supply either through autophagy (which recycles protein peptides) or diet. Dietary sources of cysteine are proteins, especially from animal sources. Whey protein supplements and over-the-counter n-acetyl cysteine are other sources. Fasting is another trick that increases cysteine availability via autophagic recyling.

I don’t recall the author ever mentioning it, but if you hope to maximize longevity, don’t smoke. Even if it has hormetic effects. Maybe that goes without saying in 2015.

When I read a book like this, I always run across tidbits of information that I want to remember. Here are some:

  • those of us in the top third of muscular strength have a 40% lower risk of cancer (NB: you increase your strength through resistance training not aerobics)
  • exercise helps prevent cognitive decline and dementia, at least partially via enhanced autophagy
  • exercise increases brain volume (in preparing to do this review I learned that our brains after age 65 lose 7 cubic centimeters of volume yearly)
  • optimal BMI may be 20 or 21, not the 18.5-25 you’ll see elsewhere (higher BMI due to muscle mass rather than fat should not be a problem)
  • Scientist Cynthia Kenyon: “Sugar is the new tobacco.” (in terms of aging)
  • phytochemicals (from plants, by definition) activate AMPK, a cellular energy sensor that improves stress defense mechanisms and increases metabolic efficiency
  • curcumin (from the spice turmeric) activates AMPK
  • coffee promotes autophagy
  • he does not favor HGH supplementation
  • in the author’s style of intermittent fasting, you’re not reducing overall calorie intake, just bunching your calories together over a shorter time frame (e.g., all 2,500 calories over 6-8 hours instead of spread over 24)
  • mouse studies suggest that intermittent fasting could reduce risk of Alzheimer’s disease and Parkinsons disease
  • consider phytochemical supplements: curcumin, resveratrol, green tea extract
  • calorie-restriction mimetics include resveratrol, curcumin, nicotinamide, EGCG, and hydroxycitrate
  • supplemental resveratrol at 150 mg/day improved memory and cognition in humans

The author provides very specific anti-aging recommendations that could be followed by just about anyone. Read the book for details. Scientists are working feverishly to develop more effective anti-aging techniques. I look forward to a second edition of this book in three to five years.

Steve Parker, M.D.

PS: People with certain medical conditions, such as diabetics taking drugs that can cause hypoglycemia, should not do intermittent fasting without the blessing of their personal physician. If you have any question about your ability to fast safely, check with your doctor.

PPS: If you need to lose weight on a low-carb diet, consider my Advanced Mediterranean Diet or Ketogenic Mediterranean Diet.

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What Really Was William Banting’s Diet?

Posted on April 26, 2015 | 2 comments
Banting thought salmon was too fatty

Banting eschewed salmon (too fatty?)

I’ve been reading about Banting’s diet for at least five years. Thanks to Tim Noakes in South Africa, it’s seeing a mini-surge in popularity. William Banting published his Letter on Corpulence in 1863. Eating like him to lose weight is sometimes referred to as “Banting.” It’s one form of a low-carb diet and considered a precursor to the Atkins diet.

Form your own opinion of what William Banting may have eaten by reading these:

In terms of macronutrient calories, here’s my rough back-of-the-envelope synthesis of Banting’s diet:

  • 20–25% carbohydrate
  • 25% protein
  • 20–25% fat
  • 25% alcohol
  • 1800–2000 total calories

For the 200 lb (91 kg) man that Banting was, 2000 calories would almost certainly have been a calorie-restricted diet. Leigh estimated he was eating at least 2800 cals/day at baseline before losing weight. I don’t doubt that.

In summary, Banting drank a lot of alcohol (even more than on the Ketogenic Mediterranean Diet), and ate fairly low-fat, moderately carb-restricted, and relatively high protein. In other words: low cal, low carb, low fat, high protein, high alcohol.

His weight loss, assuming it wasn’t a hoax, came from calorie restriction. Something about that combination of macronutrients apparently allowed him to stick with the program and maintain a 50-lb weight loss. Protein is particularly satiating. Your mileage may vary.

I’m concerned that 25% of calories from alcohol would displace more healthful micronutrients.

Steve Parker, M.D.

PS: William Banting was a distant relative of Frederick Banting, the co-discoverer of insulin in 1921.

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How Many Years Does Obesity Cut From Lifespan?

Posted on April 20, 2015 | Comments Off on How Many Years Does Obesity Cut From Lifespan?
Are you tired of this stock photo yet?

Are you tired of this stock photo yet?

MedPageToday has the details. A quote:

In a computer modeling study, very obese men lost just over 8 years of life compared with normal-weight men, and very obese women lost as many as 6 years, Steven Grover, PhD, of McGill University, and colleagues reported online in the Lancet Diabetes and Endocrinology.

They also found that very obese men and women (defined as a body mass index [BMI] of 35 and higher) lost about 19 years of healthy life, defined as living free of chronic disease such as diabetes and cardiovascular disease.

Note that “very obese” in this context has a specific definition: body mass index 35 or higher. Calculate yours.

The number of life years lost to obesity and disease were highest for those who were very obese in young adulthood and presumably stayed obese for years. In other words, becoming very obese at age 60 is not as dangerous as at 25.

I first got interested in weight loss in the 1990s when I had an office-based primary care medical practice. It was obvious that many of the medical problems I was treating were related to years of obesity. Believe me, you’re much better off preventing those problems via diet and exercise.

In the 1990’s, both Dr. Dean Ornish’s vegetarian diet and Dr. Robert Atkins low-carb diet were very popular, and you couldn’t find any two diets that were more polar opposites. And do you remember Susan Powter and her “Stop the Insanity” diet? My desire to lead my patients onto the right path resulted in the first edition of my Advanced Mediterranean Diet.

Click for The Lancet study abstract.

Steve Parker, M.D.

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Brian Burgers With Brussels Sprouts, Tomato, and Pistachios

Posted on April 6, 2015 | Comments Off on Brian Burgers With Brussels Sprouts, Tomato, and Pistachios
diabetic diet, low-carb diet, paleobetic diet

Brian burger and bacon Brussels sprouts

Here’s another meal recipe from my stepson. We put it together originally for a low-carb diet, such as the Ketogenic Mediterranean Diet. But since I provide the nutritional analysis below, it also works with the Advanced Mediterranean Diet.

This makes three servings. You’ll want to make the Bacon Brussels Sprouts to serve with other meals, so I’ve provided an additional nutritional analysis for those alone. Enjoy!

Ingredients:

13 oz (370 g) ground beef, 85% lean

1/2 tbsp (7.5 ml) Tessemae’s All Natural Dressing-Marinade-Dip “Southwest Ranch,” or A1 Steak Sauce or balsamic vinaigrette or AMD vinaigrette (Brian recommends the Tessemae’s Dressing)

1.7 oz (50 g) onion, diced coarse or fine

1 garlic clove, diced

1/8 tsp (0.5 ml) paprika

1–2 pinches of salt (pinch = 1/16 tsp)

pepper to taste (a pinch or 2?)

1/4 tsp (1.2 ml) dried rosemary, crumbled or crushed

1/2 large egg, whisked to blend white and yolk

3 oz (85 g) lettuce

1 lb (450 g) Brussels sprouts (cut and discard bases if desired, probably doesn’t matter),   shredded

8 oz (225 g) bacon (6.5 regular (not thick) 8-inch strips), diced

3 tbsp (45 ml) water

1.5 large tomatoes, sliced

4.5 oz pistachio nuts

diabetic diet, paleobetic diet, low-carb diet

Prepping the bacon; use a sharp knife

Instructions:

First cook the bacon in a pan over medium–high heat until done. Don’t discard the grease.

Next do your Brussels sprouts prep (shredding). It will take a few minutes to shred it with a knife. Set those aside.

diabetic diet, paleobetic diet, low-carb diet

Brian slaving away. Thanks, dude!

Start on the burgers now. Place the ground beef in a bowl then add your chosen sauce or vinaigrette, onion, egg, garlic, paprika, rosemary, salt, and pepper. Mix thoroughly by hand. Divide the mess into three patties of equal size. Fry or grill over medium heat until done, about 10 minutes.

diabetic diet, paleobetic diet, low-carb diet

Steaming in progress

As soon as the burgers are plopped on the heat, start steaming the shredded sprouts thusly. Take a pan with a lid, add 3 tbsp (45 ml) of the bacon grease and the 3 tbsp of water, then heat that up for a minute or two over medium to high heat. Then throw in the shredded sprouts, salt and pepper to taste (probably unnecessary), and cover with a lid. Immediately reduce heat to medium and cook for 4–6 minutes. The sprouts will soften up as they cook. Gently shake the pot every minute while steaming to prevent contents from sticking to the pan. If necessary, remove the lid and stir while cooking, but this may increase your cooking time since you release hot steam whenever you remove the lid. When the sprouts are done, remove from heat and add the remaining bacon and bacon grease, then blend.

Bacon has been added and blended after the sprouts are cooked

Bacon has been added and blended in after the sprouts are cooked

Serve the burger on a bed of lettuce (1 0z). Enjoy tomato and pistachios on the side. Serving sizes are below.

Number of Servings: 3 (one burger patty, 1 oz (30 g) lettuce, 1 cup (240 ml) of sprouts, 1/2 tomato or a third of all the slices, 1.5 oz (40 g) pistachio nuts)

Advanced Mediterranean Diet boxes: 2 veggies, 1 protein, 4 fats

Nutritional Analysis per Serving:

58% fat

17% carbohydrate

25% protein

740 calories

32 g carbohydrate

12 g fiber

20 g digestible carbohydrate

827 mg sodium

1,802 mg potassium

Prominent features: Rich in fiber, protein, vitamin B6, B12, C, copper, iron, manganese, niacin, pantothenic acid, phosphorus, riboflavin, selenium, thiamine, and zinc.

Nutritional Analysis for Bacon Brussels Sprouts: (1 cup, no added salt):

Advanced Mediterranean Diet boxes: 1 veggie, 1 fat, 1/4 protein

47% fat

28% carbohydrate

26% protein

180 calories

14 g carbohydrate

6 g fiber

8 g digestible carbohydrate

530 mg sodium

709 mg potassium

Prominent features: mucho vitamin C.

diabetic diet, paleobetic diet, low-carb diet

Brian likes his burger wrapped in 2 oz of lettuce

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Book Review: The Low Carb Dietitian’s Guide to Health and Beauty, by Franziska Spritzler

Posted on February 18, 2015 | 1 comment
247 pages

247 pages

I just finished The Low Carb Dietitian’s Guide to Health and Beauty,
written by Franziska Spritzler, RD, CDE, and published last month. CDE, but the way, means Certified Diabetes Educator. Per Amazon’s rating system, I give it five stars (I love it).

*   *   *

This valuable addition to the low-carb literature is unique: No other book covers the beauty and health aspects of low-carb eating specifically in women.

I’m a strong proponent of carbohydrate-restricted eating for weight management and cure or control of certain medical conditions. The great advantages of low-carbing for weight loss are 1) suppression of hunger, and 2) proven greater efficacy compared to other types of dieting. Nevertheless, I wasn’t aware that this way of eating also had potential benefits in terms of beauty maintenance or improvement. The author persuasively makes that case in this ground-breaking book.

Just because she has RD (registered dietitian) behind her name doesn’t mean you just have to take her word for it. Franziska gives us references to the scientific literature if you want to check it out yourself.

The author focuses on health and beauty; the weight loss happens naturally with low-carb eating. That’s a helpful “side effect” since 2/3 of women in the U.S. are overweight or obese.

She covers all the basics of low-carb eating, including the rationale, potential side effects and how to prevent or deal with them, the science of “good fats,” the importance of plant-derived foods and fiber, info on artificial sweeteners, and management of weight-loss stalls.

Then Franziska does something else unique and very helpful. She offers three different eating plans along with a simple test to help determine which is the best for you. The options are 1) low-carbohydrate diet, 2) high-fiber, moderate saturated fat, low-carb diet, and 3) intermittent fasting low-carb diet with weekly treat meal. You can dig right in with a week’s worth of easy meals made from readily available ingredients.

It was interesting for me to learn that the author ate vegan-style and then pescetarian for awhile. In 2011 she was eating the usual doctor-recommended “healthy” low-fat high-fiber diet when life insurance blood work indicated she had prediabetes. So she cut her daily dietary carbs from 150 grams to 50 or less, with subsequent return of the labs to normal ranges.

I only had a few quibbles with the book. For instance, there’s no index, but that’s mitigated by a very detailed table of contents. The font size is on the small side for my 60-year-old eyes. If either of those issues bother you, get the ebook version. “Net carbs” are mentioned briefly before they are defined, which might confuse folks new to low-carbing.

A particular feature that appealed to me is the vegetarian meal options. Low-carb eating is often criticized as being meat-centric. Franziska shows it doesn’t have to be.

I also appreciate that she provides the net carb grams and calorie counts for her meal plans and recipes. All diabetics and many prediabetics need to know the carb grams. Calorie counts come in handy when analyzing the cause of a weight loss stall. Yes, calories still count in weight management.

I don’t think it’s giving too much away to say that the author’s top low-carb beauty foods are avocados, berries, cinnamon, cocoa/dark chocolate, fatty fish, flaxseed, full-fat dairy, green tea, nuts, olives/olive oil, and non-starchy vegetables. I was skeptical at the start of the beauty foods chapter, but Franziska’s scientific references support her recommendations. I’m already eating most of these foods. Now I’m going to try green tea and ground flaxseed (e.g., her flaxseed bread recipe).

The author will also get you going on exercise. I heartily agree with her that exercise is truly a fountain of youth.

Menopausal? The author has your special challenges covered.

If you’re curious about the paleo diet, note that only about a quarter of these recipes are pure paleo. Dairy products disqualify many of them.

Here are a just a few tidbits I picked up, to help me remember them:

  • a blood test called fructosamine reflects blood sugar levels over the previous three weeks
  • you’ll have less wrinkles if you can reduce the advanced glycation end-products (AGEs) in your skin
  • Japanese women on the highest-fat diets have less wrinkling and better skin elasticity
  • soluble fiber from plants helps to reduce appetite, improves blood sugar control, and helps with weight regulation (see her table of high-fiber plants, including soluble and insoluble fiber)
  • seitan is a meat substitute for vegetarians
  • erythritol (an artificial sweetener) may have less gastrointestinal effects (gas, bloating, diarrhea) than many other artificial sweeteners
  • maltitol (another artificial sweetener in the sugar alcohols class) tends to increase blood sugar more than the other sugar alcohols
  • I’m going to try her “sardines mashed with avocados” recipe (Alton Brown popularized sardine-avocado sandwiches, so it’s not as bizarre as it sounds!)

I wouldn’t be surprised if Franziska’s recommendations help men as well as women keep or regain their youthfulness.

Steve Parker, M.D.

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Recipe: Natchez Eggs

Posted on January 21, 2015 | Comments Off on Recipe: Natchez Eggs
kk

This particular batch contained Bacon Bits

Natchez Eggs is an old family recipe.  It’s sort of an egg casserole, good for breakfast.  We tend to dust off this recipe when we have house guests—it feeds many people at once, quickly and easily.

It’s not in The Advanced Mediterranean Diet (2nd Edition) or KMD: Ketogenic Mediterranean Diet, although it’s compatible with both of those.

Note my use of both U.S. customary and metric measurements, which I also use in the books. I have no idea how much it costs to ship a book from the U.S. to New Zealand, but the e-book versions (AMD or KMD) have no shipping charges.

The low carbohydrate content of this dish is a bonus if you have diabetes, prediabetes, or metabolic syndrome.

kk

Note the light brown crust which tells you it’s probably finished cooking

Ingredients

Cheese, shredded (four-cheese mexican blend), 8 0z (224 g)
Sour cream, 16 oz (448 g)
Green chiles, diced, canned, 8 oz net weight (224g)
Eggs, large, 10 (50 g each)

Preparation

Pre-heat oven to 350°F (175°C).  Mix eggs thoroughly in a blender for 3–4 minutes on medium speed, then pour into bowl.  Coat a baking dish (9 x13 inches, or 22 x 34 cm) with butter, vegetable oil, PAM or no-stick baking spray.  Whisk eggs and sour cream together in bowl.  Drain excess water from the chile cans, then spread chiles evenly on the bottom of a dish, then layer the cheese evenly on top.  Next, ladle or pour the eggs/sour cream on top.  Bake for about 30 minutes, until the eggs are firm, not runny, and you see patches of thin light brown crust.

Number of Servings

12 servings of 4 oz or 110 g each.  Leftovers hold up well in refrigerator for eating over the next few days.

Nutrient Analysis

A serving has 3 grams of digestible carbohydrate, 200 calories, 140 calories from fat, 8 grams of saturated fat, 10 grams of protein, 210 mg cholesterol, 4 grams of carboydrate, 1 gram of fiber (so only 3 grams of digestible carb).

Advanced Mediterranean Diet boxes: 1 fat and 1/2 protein

Options

After you add the cheese layer, sprinkle layer of  Hormel Real Crumbled Bacon (4 oz or 112 g) before finishing up with the  egg mixture.  This adds 33 calories and zero carbs per serving.  Or just serve with bacon on the side (my preference).  An alternative to the Hormel product is to cook and crumble your own bacon (12 oz or 340 g uncooked weight).  Using too much bacon will overwhelm the other flavors.  Experiment with different cheeses.

You can also tweak it if you wish with additional ingredients such as diced bell peppers or chopped green onions (chives). I wouldn’t add more than one ingredient per batch. I wonder if small chunks of broccoli would work.

Steve Parker, M.D.

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Do Low-Carb Diets Cause Death?

Posted on December 5, 2014 | 1 comment
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

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

Posted on September 3, 2014 | Comments Off on 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.

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Mediterranean Diet Helps With Maintenance of Weight Loss After Ketogenic Diet

Posted on May 28, 2014 | Comments Off on 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

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Posted in Diet Reviews, Ketogenic Mediterranean Diet, Low-Carb Eating, Low-Carb Mediterranean Diet, Overweight & Obesity, Weight Loss, Weight Regain

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