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: Does Hyperinsulinemia cause obesity, and academic discourse on Twitter (finally)

As I have been reading a lot about nutrition lately (see this post for background: Search Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise), I happened on this article of relevance.

Templeman NM, Skovsø S, Page MM, Lim GE, Johnson JD. A causal role for hyperinsulinemia in obesity. J Endocrinol [Internet]. 2017 Mar 1;232(3):R173–83 discusses experiments in mice with their insulin production modulated to see what happens to their weight.

The content here is relevant because many health professionals (okay, me) are not trained well in the causes of obesity, and the causes are not actually known in all cases. So this is a good review of what’s known about the physiology, plus the experiment itself, which I’ll discuss in a bit.

Social Media as a platform for academic exchange – finally

In some of the work I do, and the work I am doing now, it is a continual source of marvel that some of the most important scholars in a field (you name it) do not have an identity in social media (Do physicians tweet about environmental stewardship in health care?). I give presentations and talks to them about this…and some of them invite me to give them presentations and talks about this (oh, like this one: Dialogue about #hcsm at the 2013 #AAMCJtMtg – Academic Medicine and Social Media).

In this particular space, I think it’s even more critical because from my perspective, even as a physician, it’s not possible to understand the meaning of a published paper without asking questions.


  • This is a slightly controversial topic right now
  • Potential for conflict of interest is everywhere
  • There are groups of scientists working to analyze every piece of literature in this space…and they are finding lots of flaws

Back to this article, then, I was pleased to find that

  • The author included his twitter handle on the piece (@JimJohnsonSci – Hooray)
  • The author entertained conversation about the piece on twitter (but any social network would be fine)

This is a tweet that has a thread connected to it about this study (to see the thread you have to click through to it)

…and the answer is

Notwithstanding, the results of this first study demonstrated for the first time in any mammal that
hyperinsulinemia is required for weight gain.

Hyperbolic proclamations aside from the conversation below, the two things, the paper, and the conversation among scholars, helps put things in their place mentally. It’s not one or the other.

In this case, this piece of data doesn’t unlock next steps in preventing obesity (follow the conversation … ), it’s helpful though.

Bad News/Good News (mostly good news, glass 3/4 full)

The bad news is, with every paper I read, I now need to go find out where the conversation is happening so I can learn. The good news is, the conversation is happening in a place where I can learn.


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).

Just Read: Study – Wearables don’t improve weight loss – can you outrun a bad diet?

I stopped wearing a fitness tracker because it DEmotivated me, by reminding me of the times I was not meeting my activity goals

This is what an attendee said at the recent convening on Making Health Care Measurement Patient-Centered (a proxy for respecting people in health care).

This study published in JAMA a few weeks ago (September, 2016), produced unexpected (and curious) results.

Overweight and obese younger people randomized to receive wearable devices as part of a weight loss program gained back more weight than users who did not receive wearables, after an initial 6 month weight loss.

Both sets of subjects did not have significantly different rates/intensity of physical activity over the 2 year study, and their dietary intake was not statistically significant from each other (calories taken in slightly less for the wearables group at the end). Specifically, the group with the wearable did not exercise more than the group without the wearables.

I was of course curious and decided to look more closely at the data. I produced some charts below.

Here are the things I noticed

  • Subjects were randomized at the very beginning of the study, not at the 6 month mark, when the wearables were initiated. Did they know which group they were in at the beginning and did this shape their behavior?
  • I ask the question above, because the one thing I noticed in charting the data is that the group with the wearables (EWLI – stands for “Enhanced Weight Loss Intervention”), experienced a visible plunge in MVPA: “Nonsupervised moderate-to-vigorous physical activity” even before they got the wearables, that continued well past the time they had the wearables. Overall, though, across the 24 months, there was not found to be a significant difference in physical activity.
  • The subjects were placed on what are essentially high carbohydrate diets with caloric restriction, which remained restricted throughout the 24 months.

Outrunning a bad diet?

I was recently introduced to the work of Tim Noakes (@ProfTimNoakes) (about 5 years behind the rest of the world, but maybe 1-2 years ahead of part of the world) and decided to look more closely at other factors.

Focusing on the diet of the subjects, here’s what it said in the study details (supplemental materials)

All subjects will be prescribed an energy restricted dietary intervention that we have shown to effectively reduce body weight by 8-10% within the initial 6 months of treatment. This will include reducing energy intake to 1200 to 1800 kcal/d based on initial body weight (<200 pounds = 1200 kcal/d; 200 to 250 pounds = 1500 kcal/d; >250 pounds = 1800 kcal/d). Data from our research studies [14, 15] and the National Weight Control Registry [26] indicated that macronutrient composition in the most successful participants consists of 20-30% dietary fat intake, 50-55% carbohydrate intake, and 20-25% protein intake. Therefore, a similar dietary composition will be recommended in this study. However, we do recognize that low carbohydrate/high protein diets are currently popular, have demonstrated some initial efficacy, and some participants may gravitate towards this macronutrient composition, and this will be acceptable provided that total energy intake is within the prescribed range. To facilitate the adoption of the dietary recommendations, individuals will be provided with meal plans (see Appendix B), that will allow them to plan for modifications in their daily and weekly meal plans, and a calorie counter book.

So they were permitted to lower their carbohydrate intake as long as they maintained the same amount of calorie restriction. As a group they did not do this, though. They stuck to their high carbohydrate diets over the long run.

From this paper:

Malhotra A, Noakes T, Phinney S. It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br. J. Sports Med. 2015;49(15):967–8.

Regular physical activity reduces the risk of developing cardiovascular disease, type 2 diabetes, dementia and some cancers by at least 30%. However, physical activity does not promote weight loss.

And there was the September 12, 2016 cover story of Time Magazine:

For all its merits, however, exercise is not an effective way to lose weight, research has shown. In a cruel twist, many people actually gain weight after they start exercising, whether from new muscle mass or a fired up appetite.

This study is about wearables, not exercise, because both groups of people exercised about the same over time.

However, because both groups were on a high-carbohydrate diet throughout the intervention, it’s possible that even if the wearables “worked” (they exercised more), that the results would be the same.

Still pro exercise…

I, like Bob Sallis, MD, who is quoted in the Time magazine article, support exercise for the numerous health benefits it offers – just look up any of my presentations on the topic, oh like this one:

Presentation/Photos: Quantified Community, Population Sensors at WalkHackNight, Transportation Techies

What if listening to a wearable device isn’t as effective as listening to your body? I’m going to post on another approach tomorrow….

Charts from Effect of Wearable Technology on Weight Loss
Charts from “Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss. JAMA. 2016;316(11):1161.” (View on Flickr.com)