Just Watched: Low-Carb High Fat Diet in Type 1 Diabetes

The origin of this post is that I sent a tweet earlier this week regarding the current crisis in insulin pricing referring to the Banting Diet, which is the precursor of the low-carb high fat diet (or LCHF diet). I sometimes do this (sending unclear messages) assuming that people will figure them out, and usually, that’s not the outcome 🙂 . At least it starts conversation (maybe I do this subconsciously, I don’t know).

In any event, I have been interested in nutrition for a long time and more interested recently (see:Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise) ), as more data is being produced about where our dietary guidelines came from. In the case of diabetes, I have been curious about the ways the medical and other professions counsel patients on diets in ways that may actually increase their risk of diabetes and increase their insulin requirement.

My question, therefore, has been whether the need for insulin could be eliminated in some people and reduced in others, which would blunt the impact of pricing and make living with diabetes more affordable. The other question I have is about the whether reducing the use of specialized insulins for some population would have an added effect, making the pricing power, less powerful.

I’ve read a few papers about this. I don’t feel comfortable doing a literature review myself because these days it’s really hard to interpret papers if hidden biases aren’t known. That and I may be a physician, but I do not know what it is like to live with diabetes. I do know what it is like to live as a former fat person so there is some relevance here for me.

Through the magic of YouTube, Dr. Troy Stapleton (@drtroystapleton) explains his own journey as a person with type 1 diabetes and the LCHF diet. He’s going to to have much more credibility than I and this is a good science-based + authentic overview from a patient perspective. Watch:

A person who produces insulin on this diet is going to have an insulin production curve closer to a person with type 1 diabetes (flat) compared to a person without diabetes (insulin spikes), with the idea that insulin and specifically too much insulin is a requirement for obesity.

#ILN innovating in nutrition, too. #LCHF in Chicago. #ketogenic #ketogenicdiet #lessinsulin

A post shared by Ted Eytan (tedeytan) on

I’m planning to do some more study this summer. At the same time, there are far more experienced researchers, journalists, physicians and scientists engaged in this work, so I’m more interested in dialogue than leadership (they are doing just fine). I always say if there’s a better way to do something, I want to know about it.

This is life in the family medicine revolution (#FMrevolution), where unlimited curiosity reigns in the interest of a person, family, community’s long healthy life. Feel fee to let me know your thoughts in the comments.

How much does it cost to not have a designer? #ILN Day 1-2

2017.05.10 Innovation Learning Network #ILN Chicago IL USA 4625
2017.05.10 Innovation Learning Network #ILN Chicago IL USA 4625 (View on Flickr.com)

This was my conclusion based on a question asked by a colleague which was “How much does it cost to have a designer on your team?” at this year’s first Innovation Learning Network in person meeting. With new streamlined hashtag (#ILN) and twitter handle – @ILNMuse

2017.05.10 Innovation Learning Network #ILN Chicago IL USA 4601
The physicians of Innovation Learning Network – organized with care every year by Lyle Berkowitz, MD (@DrLyleMD) 2017.05.10 Innovation Learning Network #ILN Chicago IL USA 4601 (View on Flickr.com)

It’s seven years later than the last time I was here, when the space was called Gravity Tank (now it’s part of Salesforce) and my photography was not as evolved – only 7 photos back then. And because of the way-back ness of a blog, it’s all here: Mama knows! A week of innovation thinking at AHRQ and GravityTank (Innovation Learning Network).

It almost appears that ILN was a sideline to a busy week back then, but it was a lot more than that. My blogging has also evolved sinc ethen.

This time, more organizations are seeing the value of design and designers and asking critical questions more about “why not have a designer” rather than “why have a designer / design” as part of innovation.

And…through the work of colleague Christi Zuber, RN, PhD candidate (@czuber) we have an understanding of the characteristics of people who achieve success in innovation, in a way that crosses organizational structure, job titles, etc. Check it out in the photos below.

#ILN innovating in nutrition, too. #LCHF in Chicago. #ketogenic #ketogenicdiet #lessinsulin
#ILN innovating in nutrition, too. #LCHF in Chicago. #ketogenic #ketogenicdiet #lessinsulin (View on Flickr.com)

Also check out our delicious low carb, high-fat meal (LCHF) at our dinner with strangers. We know a lot more about nutrition than we did seven years ago. Actually, we know now what we were supposed to know about nutrition 7 years ago. Always good to prototype life and ILN is the place to do it.

Check out this group in 360 degrees, doesn’t learning look great on everyone? (Didn’t have one of these cameras 7 years ago)

Innovation Learning Network #ILN #ILN360 @ILNmuse w @SalesforceIgnite @NorthwesternMed #theta360 – Spherical Image – RICOH THETA

Thanks to our hosts Northwestern Medicine (@NorthwesternMed) and Salesforce (@Salesforce) Ignite as well as to Chris McCarthy (@McCarthyChris) and the team from Hope Lab (@HopeLab), who I hope will read this post and tag themselves in the social networks of their choice 🙂 .

PS, Photos, repeat after me, @CreativeCommons licensed, use as you see fit.

Just Read: Triglycerides and Cardiovascular Disease – American Heart Association Scientific Statement

Yes, all 40+ pages of the American Heart Association’s scientific statement, published in 2011 (the most recent one – citation below), for leisure.

Why?

Triglycerides are that lipid component in our blood that we (or let’s say I) are trained not to pay that much attention to, especially relative to cholesterol (LDL, HDL, etc), and yet its story unlocks a lot of mysteries around nutrition and health (again, for me).

Jumping right in.

  • “It is especially disconcerting that in the United States, mean triglyceride levels have risen since 1976, in concert with the growing epidemic of obesity, insulin resistance (IR), and type 2 diabetes mellitus (T2DM).”
    • As much as we’re fighting LDL, we don’t seem to be winning on this one. Why? And does it matter? (several reasons, and yes)

The dyslipidemic triad and diabetes

High triglyceride levels that accompany either normal or impaired fasting glucose predict the development of Type 2 Diabetes,1and therefore, hypertriglyceridemic states should prompt surveillance to rule out T2DM. In addition, 35% of T2DM adults have fasting triglyceride levels > 200 mg/dL associated with decreased HDL-C and small, dense LDL particles.

Size matters – of LDL particles, that is

LDL particles in patients with DM may be atherogenic even at normal LDL-C concentrations..In addition, hypertriglyceridemia is associated with small, dense, and CE-depleted LDL particles. Thus, individuals with T2DM and mild to moderate hypertriglyceridemia exhibit the pattern B profile of LDL (smaller, denser particles) described by Austin and Krauss; these particles be more susceptible to oxidative modification and catabolism via macrophage scavenger receptors

That’s the not good thing that happens inside blood vessels that causes disease and it’s connected to triglycerides.

In other words (my interpretation), it’s not what triglycerides mean by themselves, it’s the pattern that they are connected to. And therefore, looking at just one number (LDL) has limitations to predict disease. On the other hand, focusing on LDL is easy to do and simple to understand…hence the need for this scientific statement to understand the biology better than most people probably do.

Continuing on.

How we got here. The low-fat diet aka SnackWells USA

The relationship between percent of total fat intake and change in triglyceride and HDL-C concentrations was reported in a meta-analysis of 19 studies published by the Institute of Medicine. In this analysis comparing low-fat, high-CHO diets versus higher-fat diets, for every 5% decrease in total fat, triglyceride level was predicted to increase by 6% and HDL-C to decrease by 2.2%

Overall, optimization of nutrition-related practices can result in a marked triglyceride-lowering effect that ranges between 20% and 50%. These practices include weight loss, reducing simple CHO at the expense of increasing dietary fiber, eliminating industrial-produced trans fatty acids, restricting fructose and SFA, implementing a Mediterranean-style diet, and consuming marine-derived omega-3 PUFA (Table 11). Dietary practices or factors that are associated with elevated triglyceride levels include excess body weight, especially visceral adiposity; simple CHOs, including added sugars and fructose; a high glycemic load; and alcohol.

And the American Heart Association recommended high carbohydrate diets and even candy in the prevention of cardiovascular disease. Oops.

For the biologists/scientists – how carbohydrates may result in higher triglycleride levels and unhealthy lipid profiles

Mechanistically, high CHO intake triggers pancreatic insulin release in response to increased blood glucose. Insulin, in turn, activates sterol regulatory element–binding protein, (SREBP-1c), a transcription factor that regulates fatty acid and triglyceride synthesis. Recently, 2 additional transcription factors, X-box binding protein 1 (XBP1) and CHO response element–binding protein (ChREBP), have been identified as inducers of hepatic lipogenesis in response to ingested CHOs (eg, fructose and glucose) that is independent of insulin.431,432 In contrast, unsaturated fatty acids reduce or inhibit SREBP-1c transcription, thereby reducing hepatic fatty acid synthesis430 and plasma triglycerides.

Using drugs to treat

However, in LIPID, although baseline triglyceride level was not signifi- cantly associated with CVD risk in patients given placebo, each 89-mg/dL decrease in on-treatment triglyceride level in patients given pravastatin significantly decreased CVD risk by 11%, as well as by 14% after adjustment for nonlipid risk factors. However, the lipid-related parameters most strongly associated with CVD risk in LIPID were apo B, LDL-C, and the ratio of TC to HDL-C

Again, the dyslipidemic triad.

Taken together, reductions of 50% or more in triglyceride levels may be attained through intensive therapeutic lifestyle change.

A low fat, high carbohydrate diet increases triglycerides and decreases HDL, the opposite, a higher fat, lower carbohydrate diet reduces triglycerides and increases HDL. For me this explains the non-sequitir of my pathology textbook in medical school stating that high carbohydrate diets are a risk factor for heart disease at the same time high carbohydrate diets were being recommended to prevent heart disease.

A discussion of statins is out of scope here – many many many, many many, articles already cover this.

Andrew Weil, MD’s advice to us in medical school – understand what you’re prescribing to your patients

…I think he may have said that we should try every drug we prescribe to understand its effects (with rationality of course) but human memory can be semi-faulty after so many years…either way it was something of a gift for him to be on faculty at my medical school (University of Arizona) because it promoted an embrace of curiosity that persists to this day, every day.

In any event, I’ve switched to a low carbohydrate diet over the past year. I’m not ready to share my personal health information here, but I will eventually. And my biology is tracking science, as expected, because, well, that’s how science works :).

More to come. In the meantime, here’s a helpful piece on the low-fat diet and what it has done for our health.

Citation: Miller M, Stone NJ, Ballantyne C, Bittner V, Criqui MH, Ginsberg HN, et al. Triglycerides and Cardiovascular Disease. Circulation [Internet]. 2011 [cited 2016 Dec 25];123(20).

Just Read: What should people with diabetics eat? Study of a low-calorie ketogenic diet

Just catching up on my blogging and continuing a closer look at nutrition and health.

This paper discusses a different and emerging approach about diet in people with diabetes, beginning with the declaration that we really don’t know what the optimal diet for people with diabetic is:

The optimal degree of caloric restriction and macronutrient distribution of medical nutritional therapy in T2DM is not well defined.

Traditionally, a low-fat diet has been prescribed, which really is a high-carbohydrate diet that brings with it questions about why feeding carbohydrates to people who are intolerant of them makes sense.

In this intervention, subjects were divided and some were feed a ketogenic (higher fat, lower carbohydrate) diet. In medical school, we’re taught that ketones are a bad thing because of their association with a life-threatening condition known as keto-acidosis. However, in people who have some insulin left, ketones become an alternate fuel from the breakdown of fat.

The diet used here appears to be a little “engineered” compared to what I have read is also done, which is little to no calorie restriction.

And…the results show significant weight loss, glucose control, and as seen in other studies, a significant drop in triglycerides, that other under-emphasized lipid in our training (I’ll post on that later).

Interestingly, I ran across this medical practice based in San Francisco (@VirtaHealth) using this approach to achieve better outcomes in Diabetes. So, I suppose this is becoming a thing. With science attached to it, including its own published intervention trial.

Maybe we are set to really change the way we think about healthy eating….

Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise)

For some reason, I have always had a keen interest in my personal health – I took nutritional sciences courses in college before I went to medical school, something only a few of us pre-med students did.

The curiosity of my medical school pathology textbook warning about high carbohydrate diets and atherosclerosis

To this day, I still remember a curious statement in my Pathology textbook from medical school (and while writing this post, I confirmed that it was there, as of the 2005 Edition). It said:

Risk Factors for Atherosclerosis: Lesser, Uncertain, or Nonquantitated: High carbohydrate intake

I thought that was strange to see in my pathology textbook at the same time my professors were advocating, and all of America were/are being told to indulge in a high carbohydrate diet.

This book, by Nina Techolz (@BigFatSurprise), develops that theme in exquisite detail. On the topic of high carbohydrate diets of the 1990’s she includes this historical context:

Choose “snacks from other food groups such as . . . low-fat cookies, low-fat crackers, . . . unsalted pretzels, hard candy, gum drops, sugar, syrup, honey, jam, jelly, marmalade,” stated a 1995 AHA publication. In short, to avoid fat, people should eat sugar, the AHA advised.

Teicholz, Nina (2014-05-13). The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet (pp. 136-137). Simon & Schuster. Kindle Edition.

I followed up in my own grocery store where in 2016, there are still traces of this diet approach:

The AHA even rode the profit wave of refined carbohydrates from the 1990s onward by charging a hefty fee for the privilege of putting the AHA’s “Heart Healthy” check mark on products …. in 2012, the check mark still appeared on boxes of Honey Nut Cheerios and Quaker Life Cereal Maple and Brown Sugar, which might have healthier-sounding names but are both higher in sugar and carbohydrates than Kellogg’s Frosted Flakes.

Teicholz, Nina (2014-05-13). The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet (p. 137). Simon & Schuster. Kindle Edition.

2016.10.29 Heart Health and Diet 3311
2016 leftover from a bygone era, when high carbohydrate diets were king – 2016.10.29 Heart Health and Diet 3311 (View on Flickr.com)
2016.10.29 Heart Health and Diet 3312
What do you notice about the shape of the cereal bowl and does the evidence support it… 2016.10.29 Heart Health and Diet 3312 (View on Flickr.com)

Does eating fat make you fat?

The answer, according to the book, is probably no.

It’s a very in depth read of the history, personalities, and science behind the diet-heart hypothesis, about what has been thought to make people fat and cause heart disease, and whether the evidence supports it.

The book has been well reviewed and critiqued with lots of surrounding controversy, so I won’t re-cover what Teicholz covers about this, which in a nutshell is

  • many of the studies that we have counted on to tell us what’s right about our diets are flawed
  • there are numerous people involved with long careers dependent on a particular version of diet and health
  • things we take for granted, like the Mediterranean diet, didn’t really exist in the way we think they did
  • the impact of saturated fat, especially when substituted for carbohydrates in the diet, is probably not as dire as we were taught

The part about the people is really important. Teicholz goes in depth into the careers of the most famous food scientists across human history, alive and no longer alive. I now see their names in name-your-article and I have to go back to the book to understand from which perspective/history they are speaking. Otherwise, their conclusions to me are uninterpretable.

A 40 year experiment in low-fat diets, is it over?

I was especially taken by this quote:

No doubt a Cretan or Calabrian peasant might find it ironic that New York socialites and Hollywood movie stars— indeed, nearly all the wealthy peoples on the planet— are now trying to replicate the diet of an impoverished post-war population desperate to improve its lot.

Teicholz, Nina (2014-05-13). The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet (p. 223). Simon & Schuster. Kindle Edition.

..because following this era in Italian history, meat intake tripled, heart disease rates declined, average height increased by 3 inches.

There’s a lot more going on in this dialogue (and I know I’m several years into it) including the recent decision by the British Medical Journal not to retract Teicholz’ 2015 article, which you can read about here.

Suffice it to say, I believe that my Pathology textbook was telling me to be as curious as possible in my medical career…

Addendum, forgot to add this (thanks for the heads up @SDThinkBig & focus on the deep fat and steak part only 🙂 )

Just Read: Listening to Physiology instead of a Wearable for Weight Loss

Comparison Wearable induced vs Physiologic  induced weight loss 161003
Comparison Wearable induced vs Physiologic induced weight loss 161003 (View on Flickr.com)

After reading the study about the impact of (a certain type of) wearable devices on weight loss (See: Just Read: Study – Wearables don’t improve weight loss – can you outrun a bad diet? ) – answer, not much – I also read this study at the same time that focused on exercise and diet in a very different way, and had much different outcomes.

In Mark S, Toit S Du, Noakes TD, et al. A successful lifestyle intervention model replicated in diverse clinical settings. South African Med. J. 2016;106(8):763. Available at: http://www.samj.org.za/index.php/samj/article/view/10136 [Accessed October 2, 2016], a few conventional and unconventional things were tried in a group of willing subjects interested in weight loss:

  1. Behavioral intervention – variable timeframe (conventional)
  2. Caloric restriction until the reaching of weight goal, including fat, sugar, refined cardohydrate restriction (conventional)
  3. NO moderate or vigorous exercise until weight goal achieved (UNconventional)
  4. HIGH fat diet after weight goal achieved (UNconventional>

Foods consumed on the maintenance diet included beef, poultry, fish, eggs, oils, moderate amounts of hard cheeses, and small amounts of nuts, nut butters, seeds and berries.

I can’t determine the actual time to follow-up for the groups, but it looks to be around 2 years, which is the same time as the group in the wearables study. Therefore, I charted the two groups (S1 and S2, for “site 1” and “site 2” in rural practices in British Columbia, Canada) along side the results of the subjects in the wearable study, above (click to enlarge).

Lots of caveats

  • The interventions were different, however both interventions involved manipulation of diet. For the wearables subjects, it was caloric restriction and low-fat (high carbohydrate). For the Canadian subjects it was caloric restriction initially, and then transition to high fat (low carbohydrate).
  • The populations are different, and the starting weights of the subjects makes it hard to compare % weight loss, although to my eyes, they started out pretty close in weight
  • Neither study controlled for diet, meaning there was no comparison group of people who didn’t have their diet manipulated

This is also the part where conflict of interest disclosures are important.

For the wearables article:

Conflict of Interest Disclosures: Dr Jakicic reported receiving an honorarium for serving on the Scientific Advisory Board for Weight Watchers International; serving as principal investigator on a grant to examine the validity of activity monitors awarded to the University of Pittsburgh by Jawbone Inc; and serving as a co-investigator on grants awarded to the University of Pittsburgh by HumanScale, Weight Watchers International, and Ethicon/Covidien. Dr Rogers reported serving as principal investigator on a grant awarded to the University of Pittsburgh by Weight Watchers International. Dr Marcus reported receiving an honorarium for serving on the Scientific Advisory Board for Weight Watchers International. No other disclosures were reported.

For the lifestyle intervention article:

Conflicts of interest. SDT, KN, DC, MM, SVDS and JF have no conflicts of interest to declare. SM is the founder of a sole proprietorship, Approach Analytics, providing analytical support to clinical and public health initiatives. JW is on the Scientic Advisory Board for Atkins Nutritionals Inc. and has accepted honoraria and travel expenses to attend meetings. TN is the author of the books Lore of Running and Waterlogged and co-author of e Real Meal Revolution, Raising Superheroes and Challenging Beliefs. All royalties from the sales of e Real Meal Revolution and Raising Superheroes and related activities are donated to the Noakes Foundation, of which he is the chairman and which funds research on insulin resistance, diabetes and nutrition as directed by its Board of Directors. Money from the sale of other books is donated to the Tim and Marilyn Noakes Sports Science Research Trust, which funds the salary of a senior researcher at the University of Cape Town, South Africa. The research focuses on the study of skeletal muscle in African mammals with some overlap to the study of type 2 diabetes in carnivorous mammals and of the e ects of (scavenged) sugar consumption on free- living (wild) baboons.

The unconventionality of the the intervention is mentioned in the article as something that was hard for others to accept:

Despite the rigour of our quality improvement process, our efforts to communicate the merits of this intervention to health system administrators met with a frustrating lack of uptake. This is not surprising, given that the research literature has many competing ‘solutions’ for the epidemics of obesity and diabetes,[15] many of which are difficult to falsify.[16]

From my understanding of the culture of medicine, something like this written in a scholarly article is usually a vast understatement.

The next several months/years are going to be exciting in this part of health, now that we have a better understanding of physiology and newer tools to (potentially) change our environment and our behavior (maybe).