I'll preface this post by saying that it was written with my female readership in mind. Guys, you're welcome to read as well, of course, but I have a feeling most of you will want to pass on this one. 

At 46, I'm well into perimenopause and have noticed several changes ranging from amusing to annoying. Almost every woman finds growing older challenging to some extent,  be it physically, mentally, and/or emotionally.  Many tend to put on weight as they age, and the standard explanation is that our metabolism slows down as we get on in years and decrease our physical activity. But it's more complicated than that, and hormonal regulation plays a very large part.

Menopause and perimenopause, the 5-10 year period preceding it, often result in decreased insulin sensitivity, particularly in those predisposed to endocrine imbalances. Recent research indicates that decreasing levels of estrogen lead to insulin resistance and impaired carbohydrate tolerance even among nonobese menopausal women. Weight gain during perimenopause and menopause is  an obvious result; it's difficult to ignore your pants getting tighter even if you're not weighing yourself regularly. What many  women are less aware of (unless they're testing with a glucometer) are elevated blood sugar levels after eating.

While the aging process is inevitable and to some extent dependent on your genes, there are ways to make the transition easier in terms of weight management, loss of muscle mass, and blood sugar control. My advice is to cut back on carbs to a level that allows you to achieve a healthy weight and optimal glycemic levels, keeping in mind that this is highly individualized and may change over time.* Some women at this stage may be able to continue the same moderate-to-high-carb diet they've always consumed without any issues, but after looking into the research and hearing many anecdotal accounts, I know that many are simply not. It saddens me to hear about  ladies in their mid-40s to mid-50s eating low-fat diets and continuing to struggle with food cravings and weight. I feel many would benefit from the hunger-reducing, hormone-altering, blood-sugar-stabilizing effects of carb restriction.

Another problem women in or approaching menopause often experience is hot flashes, along with sensitivity to temperature changes. Neurosurgeon Dr. Larry Mc Cleary writes in his excellent book, The Brain Trust Program, that the decline in estrogen during this period reduces the action of glucose transporters that deliver glucose to the brain, resulting in release of norepinephrine from the adrenal glands in an attempt to increase blood sugar and provide the brain with energy. He states this process is similar to what  children with epilepsy and other seizure disorders experience, although on a much smaller scale. Dr. Mc Cleary recommends a very-low-carbohydrate diet in order to provide the brain with ketones as an alternative source of fuel, thereby eliminating or greatly reducing hot flashes. What types of food, specifically? Meat, fish, poultry, eggs, cheese, nuts, greens, nonstarchy vegetables and small amounts of low-sugar fruits like berries -- exactly what I eat. He also provides a recipe for a "ketogenic cocktail" which contains MCT oil, flaxseed oil, and EPA.

I have to say that after 10 months of continuous ketosis/near ketosis, I feel terrific. Blood sugar swings are a thing of the past, my weight is  easier to maintain, and energy levels are better than they've been in years. Will this change as I get older and become postmenopausal? Perhaps, but I can honestly say I think eating a very-low-carb diet gives me better odds for keeping things under control.

I don't think I've mentioned the importance of exercise in any of my blog posts yet, which is surprising given how important it is in my life. Physical activity is vital it is for feeling good and preserving muscle mass as we age. However, I'm not a cross-fitter, runner, or jogger. I like walking and try to get 30-60 minutes in every day, but I also feel that resistance training, stretching, and strengthening are extremely beneficial. I hate gyms; in fact, I can probably count the times I've worked out in a gym  or taken a class on one hand. I prefer working out on in my own home and enjoy routines that make me feel graceful , strong, and energized. Enter Ellen Barrett.

Now, Ellen is not a low-carber; judging by her tweets, she may be vegetarian  or even vegan. But the way she eats makes no difference to me because she is simply an amazing fitness instructor. Her routines are not only extremely effective at toning, tightening, and increasing energy; they're also very enjoyable, easy to stick with until the end (They range from 30-45 minutes in length), and set to upbeat, fun music. Her enthusiasm, pleasant voice, and genuine smile complement the light weights, Pilates, ballet, yoga, and dance sequences. She always has someone demonstrating the movements at a lower level of intensity for beginners.  I love the way Ellen encourages women to really tune in to their bodies and feel graceful and beautiful while exercising.  After one of her workouts I feel highly energized, never fatigued.  Now, if you  love cross-fit or running , that's wonderful -- keep it up! But if you really don't like exercising and aren't big on working out at a gym, I highly recommend getting one or more of Ellen's DVDs.* I own seven (she has even more!), and they're all fantastic.  Check out the Amazon descriptions and reviews at the links below: 

Grace + Gusto
Fusion Flow
Slim Sculpt
Super Fast Body Blast
Sleek Sculpt Express
Power Fusion
Fat Burning Fusion

So my advice in a nutshell is to accept aging as a natural part of life but do your best to provide your body with the type of nourishment and activity that gives you the best chance of remaining healthy, strong, mentally engaged, and full of vitality.

* Consult your doctor prior to starting a low-carbohydrate diet or engaging in physical activity


References:
1.Lindhelm SR, et al. A possible bimodal effect of estrogen on insulin sensitivity in postmenopausal women and the attenuating effect of added progestin. Fertil Steril 1993 Oct:60(4):664-7 
2.Whitcroft, et al. Insulin resistance and management of the menopause: a clinical hypothesis in practice. Menopause Int 2011 March:17(1)24-28 

Wrong. People with Type 1 and Type 2 diabetes don't require snacks, and anything eaten between meals should contain as few carbohydrates as possible.

I recently joined Pinterest and came across  this link as I was looking  for images to pin to my "Healthy Low Carb Board":  10 Low-Carb Snack Ideas for People with Diabetes.  Looking at the list of foods had me scratching my head. These snacks are low carb? Then I read this:

"'If you need a pick-me-up between meals, a snack with 15-20 grams of carbohydrate is often the answer. For someone with diabetes, it’s important to eat a fiber-filled and nutrient-rich snack to curb the appetite before the next meal,' says Angela Ginn-Meadow, a registered dietitian and a spokesperson for the American Dietetic Association . "

So the person who wrote this article is not an RD but obtained information on snacks for PWDs from a dietitian and spokesperson for the AND (Academy of Nutrition and Dietetics).

As a diabetes educator, the suggestions in this article bother me on a number of levels. First of all, why are we still promoting snacks to people with diabetes? In the days of insulin peaking in the middle of the night and causing overnight lows this was  understandable, but most people are on modern insulins that do not cause this problem.  I know that many dietitians and nutritionists recommend eating every 3-4 hours, but I strongly disagree with that strategy.  First of all, I find that people generally end up eating more if they are snacking or grazing.  If someone eats 2-3 meals a day containing adequate protein and fat, there is no need to snack in between.  Snacks with 15-20 grams of carbohydrate can hardly be called "low carb." I consider an item with less than 5 grams of carb, preferably less, to be low carb. 

There are a number of reasons to avoid carb-containing snacks in people with all types of diabetes. For T2s with insulin resistance, eating carbs between meals causes a rise in blood sugar, resulting in the pancreas needing to produce more insulin, perpetuating hyperinsulinemia and promoting weight gain. Blood sugar is expected to rise after eating; the extent to which it does depends largely on the amount of carbohydrate consumed. Fasting/premeal blood sugar targets differ slightly between the American Diabetes Association (80-130) and American Association of Endocrinologists  (80-110), but the idea is for blood sugar to return to a healthier lower level by the time the next meal comes around. By eating snacks containing more than a minimal amount of carbs, the likelihood of meeting this goal is significantly reduced, and the person ends up well over the target range for most of the day. Snacking on carbs between meals is an equally terrible suggestion for  people with T1 diabetes and people with T2 on mealtime insulin. Bolusing insulin to cover snack carbs places a T1 at risk for hypoglycemia due to stacking doses from the previous and subsequent meal, and foregoing the insulin is certain to spike blood sugar to extremely high levels. 

In my opinion, the only time someone with diabetes should eat carbs in between meals is to treat hypoglycemia, universally defined as blood glucose less than 70. In that case, the treatment is 10-15 grams of rapid-acting carbs, preferably glucose tablets or gel (alternatively 4 oz juice, soda, etc). The snacks in the list above contain some fiber, which would delay recovery and  therefore would not be a good choice.

Although I think carbohydrate restriction is the ideal way to manage diabetes, I know not every person wants to adopt it, and I respect a person's right to make that decision. However, I think promoting "balanced" snacks containing carbs to PWDs is terribly misguided. If truly hungry between meals, a hard-boiled egg, piece of cheese, or a few nuts makes much more sense in terms of maintaining stable blood sugar levels, satiety, and decreasing potential for weight gain.




 

To say my husband has never been a low-carber would be an understatement. Mark's favorite foods include pizza, burritos, and pasta. A typical snack is pretzels right out of the bag. He also has a bit of a sweet tooth and enjoys frozen custard, cookies, and candy. I know, it's difficult to reconcile that with a dietitian wife who promotes and lives a very-low-carb lifestyle, but we make it work :) He's never had to worry about his weight and doesn't have blood sugar issues or other health problems.

 Recently, though, he decided to start cutting back on sugar and refined carbs.  A couple of weeks ago he began a moderate-low-carb diet (about 120-150 grams a day) and replaced his beloved pretzels with almonds, cheese, and beef jerky. I think my success with carbohydrate restriction prompted him to try it for himself.  We're in our mid-forties, and he's seen how energetic and satiated I've been since I adopted low carb (He's also witnessed the vast improvement in my glucometer readings). Needless to say, I'm very happy he's replacing a lot of his carbs with protein and fat sources.

One of his favorite treats at our local farmers market is cinnamon almonds, which are delectable but loaded with sugar. I decided to try making a low-carb version of a recipe I found online.  Verdict:  Mark loved it (The two holes  in the middle are evidence that he couldn't even wait for the pan to cool down)!  These are delicious, very easy to make, and healthy to boot. Win-win for the Spritzlers! 


Low-Carb Cinnamon Almonds

Ingredients

• 1 egg white 
• 1 Tbsp vanilla extract
• 2 cups raw almonds
• Sweetener of choice equal to 2/3 cup sugar (I've found that erythritol works best)
• 1 teaspoon salt
• 1/2 teaspoon ground cinnamon

Directions

• In a large bowl, beat egg white until frothy; beat in vanilla. Add almonds; stir gently to coat. Combine the sugars, salt and cinnamon; add to nut mixture and stir gently to coat.
• Spread evenly into a greased 15-in. x 10-in. x 1-in. baking pan. Bake at 300° for 25-30 minutes or until almonds are crisp, stirring once. Cool. Store in an airtight container.  

Makes about 2 cups. Each 1/4 cup serving has about 7 grams total carbohydrates (vs 16 for the original recipe) and 4 grams fiber, so 3 grams digestible carbs (for those who count digestible/net carbs).

I've been toying with the idea of writing about protein on low-carb diets for a while but until now have resisted due to all the conflicting information I've found on the subject. I decided to address it because I'm often asked how much protein I recommend, and it's a difficult question to answer. Some of the foremost experts on carbohydrate restriction have very different ideas about the optimal amount of dietary protein to consume.

Dr. Rosedale recommends only 0.8-1.0 grams per kilogram of body weight (He has said he sometimes recommends as little as 0.6 g/kg for people with diabetes). Dr. Bernstein is a bit more liberal, allowing his patients as much protein as they would like per meal while cautioning that too much may increase blood glucose levels and lead to weight gain due to increased gluconeogenesis in people with diabetes (It should be noted that he is a fan of small portions of just about everything, including vegetables). Most low-carb research has been conducted with protein intake of 25-30%  of total calories (125-150 grams per day on 2000 calories per day) . Dr. Phinney and Dr. Volek have advised eating  around 1.5 grams protein per kilogram of body weight, and up to 2.5 g/kg for athletes.  Despite having written a best-selling book called Protein Power, Drs. Mike and Mary Eades set protein requirement at a modest 0.6 grams per pound of lean body mass for a moderately active person (about 70 grams protein per day for someone weighing 157 lbs with 24% body fat). 

I've read a lot of research that supports higher protein intake with carbohydrate restriction. It would logically support weight loss/improvement in body composition  due to protein's higher thermic effect (the amount of calories burned from its digestion and processing), satiety factor (higher than fat and carbohydrate),  and ability to promote increased muscle mass.  People attempting to build muscle  via resistance training will benefit by increasing protein intake to support anabolism, particularly on a low-carb diet.

The available research indicates moderate to high protein intake may be beneficial for people with diabetes. In a long-term study of T2's, protein intake of 30% on an 1800-calorie diet (about 135 grams a day), resulted in improvements in blood sugar control and weight.  However, it is unknown whether this is universal among all T2s, and T1s are a different story altogether. Although a recent study found  that significantly higher protein intake at meals does not result in an increase in blood glucose levels in those with T1 diabetes, the anecdotal evidence from many people suggests otherwise. I've had several reports from T1s  about blood glucose spikes after zero-carb high-protein meals.

If you're confused after hearing all of these conflicting recommendations,  you're in good company. I'm a dietitian, and I struggle with making protein recommendations because the ideal amount seems to be so highly individualized.  To me, it seems better to err on the side of getting a little more protein than required versus not enough. My diet  contains a moderate amount of animal protein -- probably 60-65 grams a day -- but I do get a fair amount from plants as well. I eat a lot of nuts and nut butters, and  the several servings of vegetables I consume contain some protein. When I input an average day's intake into FitDay, my total protein is usually close to 100 grams. That comes out to about 1.75 grams/kilogram based on my weight, which is almost double Dr. Rosedale's recommendation. However, my blood sugars remain stable as long as I keep carbs low, and my weight stays exactly where I want it. Based on everything I've read, I wouldn't recommend less than 1 g/kg or more than 2 g/kg ,* but that's obviously a huge range. Some do better at the lower end, while others thrive at the top depending on their fitness goals and unique physiological makeup. As with everything else, I think self-experimentation (monitoring blood sugar and/or weight,  appetite, energy levels, body composition, etc.)  is key to finding the optimal protein intake for you.

* protein g/kg based on current weight if at or near ideal weight.  If overweight or obese, use g/kg ideal weight. There are many charts online, but I use the Hamwi formula:
Men: 106 lbs plus 6 lbs for every inch over 5 feet        (add or subtract 10% for large and small frames, respectively)
Women: 100 lbs plus 5 lbs for every inch over 5 feet  (add or subtract 10% for large and small frames, respectively)

References:
1. Gannon M, et al. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes. 2004 Sep;53(9):2375-82
2. Nielsen J, et al. Low-carbohydrate diet in type 2 diabetes: stable improvements of body weight and glycemic control during 44 months follow-up. Nutr Metab (Lond) 2008; 5:14 
3. Borie-Swinburn C, et al. Effect of dietary protein on postprandial blood glucose in patients with type 1 diabetes. J Hum Nutr Diet.2013 Mar 22. DOI: 10.1111/jhn.12082 

I wanted to let any interested readers know that my article for the ADA’s Diabetes Spectrum is now viewable by all on their website. Two points to keep in mind:

1. This article was heavily edited by the ADA, and I was asked to modify some of my recommendations and add qualifiers to certain statements. I’m also not thrilled with some of the changes they made in terms of verbiage and sentence structure (there are definitely a few awkward phrases), but that’s a minor concern.
   
   
2. I wrote the article over a year ago and realize there are other studies I could have cited as references. This was my first professional article, and I was pretty green in terms of research.
   

While I did have to make some concessions, I’m still very encouraged that the Spectrum editors asked me to write an article favorable to carbohydrate restriction. Slowly but surely, we are making progress!

I can’t publish the article here because the ADA owns it, but you can access it through this link:

http://spectrum.diabetesjournals.org/content/25/4/238.full.pdf+html

Here we go again. A new study appears to link high fat intake to insulin resistance and postmeal blood sugar spikes. All study participants had Type 1 diabetes and were assigned to consume either two low-fat meals and one high-fat dinner or three low-fat meals. Researchers reported that those receiving the high-fat dinner required more insulin (12.6 units vs. 9 units for the low-fat dinner) and that their postprandial blood sugar and insulin levels were higher and stayed high for several hours after eating.

There are a few red flags regarding this study. First of all, the sample size was extremely small (seven people). And this line is revealing:
 "The two dinners received by each subject had identical carbohydrate and protein content but they differed in fat content (10 grams vs. 60 grams)."

Now, the amount of carbs each meal contained wasn't reported (or at least I couldn't find it), but the amount of calories  was. So by doing some math, we can get a ballpark estimate:

The low-fat dinner contained on average about 600 calories, 10 grams of fat (90 calories), and let's say 25% protein (38 grams, 150 calories), which is probably being generous. That would leave approximately 90 grams (360 calories) of carbohydrate to make the 600 calorie total. 

So given the high carbohydrate content of the meal, these results aren't surprising. Fat delays the absorption of carbohydrate and makes accurate dosing of insulin extremely challenging (as CDE Gary Scheiner explains in discussing how to bolus for pizza).  Previous studies have demonstrated the deleterious metabolic effects of consuming a high-fat, high-carbohydrate meal, which include insulin resistance, delayed postprandial hyperglycemia, and elevated triglycerides. 

However, there is research indicating that a high-fat, low-carbohydrate diet does not produce the same response; in fact, it results in lower insulin needs, less insulin resistance, and better postmeal blood sugar and lipid response  in both Type 1 and Type 2 diabetes. And there's enough anecdotal evidence to support these findings many times over.

So this study simply confirms what we already know: The combination of high fat and high carbohydrate is unhealthy. The best chance people with diabetes have of achieving better blood sugar control and decreasing insulin needs is to adopt whatever form of carbohydrate restriction works best for them.

1. Volek JS, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low-fat diet. Lipids 2009 Apr;44(4):297-309.
2.Volek JS, et al. Effects of dietary carbohydrate restriction vs. low-fat diet on flow-mediated dilation. Metabolism
2009 Dec;58(12):1769-77
3. Nielson JV, et al. Low carbohydrate diet int type 1 diabetes, long-term improvement and adherence: a clinical audit. Diabetol Metab Syndr 4: 23, 2012

Back in August, I wrote about my decision to try lowering my carb intake in an attempt to improve my blood sugar levels. Already eating a low-carb diet (about 30 grams net carbs per meal) and at a healthy weight, I didn't know if  following a very-low-carbohydrate ketogenic diet (VLCKD) would have an appreciable effect on my readings or how I'd feel at that level of restriction, but I felt compelled to try it.

Well, after consistently consuming 30-45 grams of net carbs a day for six months, I have only positive things to say about my very-low-carb experience. Not only are my blood sugar readings exactly where they should be -- less than 90 fasting and less than 130 an hour after eating -- but I truly feel healthier,  less stressed, and more balanced than ever. I'm hypothyroid, and although my T3 has declined in response to lower carb intake, I feel more energetic and not at all "hypo." Is it the stabilization of blood glucose or being in a mildly ketogenic state that's responsible for my renewed sense of well being? Perhaps a bit of both. There's some interesting research supporting the beneficial effects of ketones on brain health, including depression.

I've mentioned several times that the reason I began following a VLCKD in the first place was strictly for blood sugar control. I didn't want or need to lose any weight, and as a diabetes educator, I wanted to try it out to see if I could get my own numbers under control this way. Limiting my carbs to less than 45 grams a day has been surprisingly easy. My diet consists of plenty of fat from avocados, nuts and nut butters, olive oil, cheese, butter, cream, and coconut oil; moderate amounts of fish, chicken, beef, Greek yogurt, and eggs; and at least one serving of nonstarchy vegetables at every meal and a small serving of berries at breakfast.  It's truly a rich, satisfying, and luxurious way to eat. Although I've questioned the validity of a low-carb metabolic advantage in the past, I'll admit that I've recently lost a couple of pounds while eating 200-300 more calories daily than before. While I still think calories count, I won't dispute the fact that some people -- although not all -- can consume additional calories and lose weight at very low carbohydrate intakes. After many years of  restricting calories, I just didn't think I'd be one of them.

While doing research for my ADA low-carb article, I read many studies on carb restriction for diabetes and weight management, but I didn't consider the beneficial effects of ketosis. At the time, I was still consuming close to 100 net grams of carbs a day and wasn't ready to try anything as extreme as a ketogenic diet.  But after having looked into the research on VLCKDs and experiencing their effects first hand, I'd like to see more obese and otherwise metabolically challenged people try them. Improved lipid profiles, slowing down of the aging process, and improvements in mood and cognition are just a few of the potential benefits attributed to ketogenic diets, along with weight loss and blood glucose control.  In addition to the studies, I've read countless online accounts of how ketosis has changed people's lives for the better.  And I plan to continue eating this way indefinitely unless I develop problems, at which point I would make adjustments as needed. That's how I got here in the first place, after all.

Now, as enthusiastic as I am about VLCKDs, do I realistically think that all dietitians, nurses, doctors, and other health professionals will come on board in the near future? Probably not, considering most of them think ketosis is unhealthy and that we need at least 130 grams (and preferably a lot more) of carbs at a minimum to support the needs of the central nervous system.  But I am cautiously optimistic that the tide is starting to turn as practitioners begin to look at the research and listen to their patients' accounts of success -- or perhaps even test their own postprandial blood sugars. Carb restriction may not be appropriate in every case, but I defy anyone to objectively look at the evidence and deny how beneficial it's been for so many, especially those who have struggled with weight and blood sugar issues for years.


References:
1. Murphy P, et al. The antidepressant properties of the ketogenic diet. Biol Psychiatry 2004 Dec 15;56(12):981-3
2.Dashti HM, et al. Beneficial effects of ketogenic diet in obese diabetic subjects. Mol Cell Biochem 2007;302:249-256
3. Dashti HM, et al. Long term effects of a ketogenic diet on obese patients. Exp Clin Cardiol 2004 Fall; 9(3): 200–205
4.Stafstrom CE, et al. The ketogenic diet as a treatment paradigm for neurological disorders. Front Pharmacol 2012;3:59


Disclaimer:  The ideas espoused in this blog post are for general information only. Always consult with your physician prior to adopting a low-carbohydrate diet or making any other dietary changes.

Quick update:  My article, "A Low-Carbohydrate, Whole-Foods Approach to Managing Diabetes and Prediabetes" has been published in the Fall/Winter edition of the ADA journal, Diabetes Spectrum!  Unfortunately, you won't be able to view it online for several months unless you're a professional ADA member (or you want to shell out $30 for the privilege), although you can read the first few paragraphs. They do offer open access to all archived articles originally posted at least six months prior. I'll try to post a PDF on this site as well if I'm able to. 

Essentially, I recommended a moderately low-carb diet (100-110 grams total carbs, 80 grams net), as a starting point. While I definitely believe many people would benefit from going lower (in fact, I generally consume slightly less than half this amount of carbs myself), the notion of taking in less than 130 grams  a day is still considered dangerous by many diabetes health professionals, and one of my primary aims was to dispel this myth while recommending a more gradual easing into carbohydrate restriction. Also, for anyone who does read the article, please be aware that it was heavily edited: I was asked to remove some of what I considered important statements and add in content in the form of qualifiers (lots of "however's.") Some of the verbiage is also not my own. Apparently this is what happens to all authors of professional papers, so I can't complain too much. Overall, I think the paper adequately addresses the benefits of, concerns about, and how-to's of low carbohydrate eating.

One other exciting bit of news is that, based on writing this article, I was been asked to speak on a panel at the annual meeting of the American Association of Diabetes Educators (AADE) in August! The name of the panel is "Diabetes Meal Planning," and I believe the other people on the panel will be the dietitians who wrote the Diabetes Spectrum articles  "Rationale for the Use of  a Mediterranean Diet in Diabetes Management" and "Preparing to Prescribe Plant-Based Diets for Diabetes Prevention and Treatment."  While I'm looking forward to this opportunity to promote a way of eating I feel passionately about, I can't deny feeling a little nervous speaking to what will surely be a tough room : doctors, nurses, and dietitians who largely disapprove of low carb (although I'm hoping to find some like-minded practitioners as well).  Fortunately, they're giving me plenty of time to prepare. 

I just wanted to thank all my regular and new readers for your kind words of support in the comments section of my blog and in your e-mails. It's very gratifying to know how many of you enjoy and in some cases learn from my posts :)

I'm going to preface this post by saying that I realize there are a number of registered dietitians ( including several whom I consider friends as well as colleagues) who favor intuitive eating for the treatment of obesity and can provide many testimonials as to its effectiveness.  I admire their work and do not want to take anything away from the success they have had with this method.

Intuitive Eating is an approach to developing a healthy relationship with food. Created by registered dietitians Evelyn Tribole and Elyse Resch, Intuitive Eating involves listening to your body, becoming attuned to hunger and fullness cues, and consuming a wide variety of foods. No foods or food groups are off limits, and people are encouraged to honor their hunger and eat what they desire, be it berries or brownies, although trying to make primarily nutritious choices  is also advised.

While Intuitive Eating has proved very successful for many, it's my belief that there are a number of individuals for whom it is not the best choice. One of the "10 principles" outlined on the Intuitive Eating website is "Honor Your Hunger."  The description of this principle reads "Keep your body biologically fed with adequate energy and carbohydrates. Otherwise you can trigger a primal drive to overeat."  While I agree that  adequate (albeit somewhat reduced) energy/caloric intake is crucial to preventing a profound drop in basal metabolic rate,  I have a different take on the need for "adequate carbohydrates." In fact, I would argue that in many cases carbohydrates are what may trigger the drive to overeat. The reasons for overeating are complex and involve not only behaviors but also hormones like insulin and leptin, which are highly responsive to the type and quantity of food consumed. 

There is a growing body of research suggesting that reducing carbohydrate intake may result in improvements in blood sugar control, appetite, and insulin resistance. Leptin also plays a role in appetite and obesity. It is released by fat cells under the direction of insulin, which is produced in largest amounts following carbohydrate intake. Once leptin enters the brain, its effects include appetite reduction, satiety, and an increase in metabolic rate. Interestingly, the obese tend to have higher leptin levels than those of normal weight, which has led researchers to hypothesize that they are resistant to leptin. This theory suggests that leptin resistance prevents the hormone from reaching the brain, confounding one's attempts to regulate intake and facilitate weight loss. In 2004 researchers discovered that elevated triglycerides block the transport of leptin into the brain.  Many studies have demonstrated that reducing carbohydrate intake, especially refined carbohydrates, leads to significant decreases in serum triglycerides, and a recent study implicates high carbohydrate intake in the development of leptin resistance and obesity. To be honest, I am not very knowledgeable about leptin and leptin resistance but plan to review more research on this issue, as I find it extremely interesting.

While I truly appreciate the philosophy behind the Intuitive Eating approach to making peace with food and accepting a person's genetic body shape, I feel that telling someone that no foods are off  limits may not be best  for everyone. Advising somebody with impaired blood glucose regulation to eat whatever they feel like eating may result in unstable blood glucose levels. In the leptin-resistant obese, encouraging high intake of trigger foods (which often contain large amounts of the very macronutrient that perpetuates their struggle to modulate intake) may lead to a vicious cycle of overeating, rebound hunger, and overeating again.

I am a person for whom an intuitive eating approach would probably not work. I'm extremely regimented, and counting calories  every day has allowed me to maintain a 30-lb loss for more than 25 years. Although carbohydrate restriction didn't come into play for me until about a year and a half ago when I began experiencing elevated post-meal blood sugar, limiting carbs has allowed me to see first hand  what getting blood glucose levels  under control can do.  I long ago resigned myself to feeling somewhat hungry at times after dinner when I'd consumed my allotment of calories for the day.  I'd  adapted to chronic mild caloric restriction (a healthful practice, particularly with respect to longevity) but retained some of the feelings of hunger that accompany it. Once I began following a low carbohydrate diet, I was amazed at the  increased satiety I experienced without any change in my total energy consumption, which remains somewhere between 1400-1800 calories every day. I can honestly say that after a meal I simply do not feel hungry anymore.

I feel strongly that a low-carbohydrate diet should not be characterized as a "fad diet" that is too difficult to maintain. I have met many people and read hundreds of online accounts of those who have lost weight and maintained their loss  long term by following  a low-carbohydrate plan which allowed them to regulate their energy intake. In some cases, these losses are 100 pounds or more. The number of people who have achieved excellent blood glucose control on such plans is no less impressive.  A low-carbohydrate diet can include many healthy, luxurious, highly palatable and satiating foods; the assertion that it will result in feelings of deprivation is misguided. I personally plan to continue eating low carb for the rest of my life. However, I understand that this lifestyle is not for everyone. I would never tell anyone that they "had to" eat low carb in order to lose weight. There are many people who reach their goals by following a vegetarian or vegan way of eating,  and as I stated initially, Intuitive Eating has worked brilliantly for others.  I think that's terrific! We are all unique and our responses to food are highly individualized.

I realize that the majority of people reading this have had favorable outcomes with carbohydrate restriction, but for the reader who has been unsuccessful with low carb and would like to try an Intuitive Eating approach, I know several dietitians who specialize in this area I could refer you to (use the Contact Me page). My goal as a dietitian is to make sure that people find a way of eating that works best for them in order to achieve their own goals.
 


References:

1. Boden G, et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with Type 2 diabetes. Ann Intern Med. 2005 142:403-411
2.Westman EC, et al. Low carbohydrate nutrition and metabolism. Am J Clin Nutr. Aug 2007; 86(2): 276-284
3. Spreadbury I. Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity.  Diabetes Metab Syndr Obes. July 2012; 2012(5):175-189
4. Lopes IM, et al. Effects of Leptin Resistance on Acute Fuel Metabolism after a High Carbohydrate Load in Lean and Overweight Young Men. J Am Col Nutr. Dec 2001; 20(6)
5. Banks WA, et al.  Triglycerides induce leptin resistance at the blood-brain barrier. Diabetes.May 2004;53(5):1253-60
6. Hansen, BC. Calorie restriction: Effects on body composition, insulin signaling, and aging. J Nutr. 2001:131, 900S-902S

When I first started this website a little over a year ago, I did so with the intention of discussing low-carb diet research and other low-carb topics. So I want to thank any long-time (well, at least a year!) followers who have stayed with me despite my veering off course now and then.  In the beginning I was very green with respect to the benefits carbohydrate restriction as a viable option for blood sugar and weight management (in my training as a dietitian, the Atkins diet was routinely dismissed as unhealthy and unsustainable), and I began spending a lot of time on dozens of low-carb sites, including many with a Paleo/Primal approach. The Paleo diet seemed quite healthy:  It was based on whole foods, grass-fed meat, and organic plant foods. However, it contained a lot less dairy and nuts than I was eating and which I continued to consume in fairly large amounts.

In the latter part of 2011, I began adding in some starchy foods like sweet potatoes and rice based on recommendations found on various Paleo sites. Although I'd been consuming 30-35 grams of total carbs per meal at that point with occasional postprandial hyperglycemia, the addition of starchy foods definitely worsened my blood glucose control, particularly after lunch and dinner (for some reason my post-breakfast readings were and are almost always good).  Researching other people's online experiences with reintroducing starch reassured me that this was likely a temporary thing that would improve as my body adapted to eating this type of food again. I continued eating the same way and monitoring my blood sugar about three or four times a week. 

I tried not to get too upset seeing my readings routinely in the 150s-170s and occasionally as high as 200 1 hour after eating, telling myself it would eventually get better. But after 9 months, it never did. Even replacing the starches with an equivalent amount of carbohydrate from fruit or dairy didn't help. Although others may be able to tolerate higher amounts of carbohydrate after a reasonable adjustment period, I had to admit that this wasn't the case for me.  I was already eating pretty low carb (about 90-110 grams total or 65-80 grams net), so where to go from there? Obviously, lowering my carb intake was the only thing I could do, short of medication. And since my fasting blood sugar has remained normal, there weren't a lot of pharmalogical options anyway.

In researching my ADA article on low carbohydrate diets, I found a study in which many subjects on a very-low-carbohydrate, ketogenic diet (VLCKD) achieved such significant improvements in blood sugar that they were able to greatly reduce or even discontinue their diabetes medication. There is also research on the hormonal benefits of VLCKDs for polycystic ovarian syndrome (PCOS) as well as weight loss. In addition, I found  many online anecdotal reports  of improved mental clarity and well being with this approach.  So I decided to reduce my carb intake further and begin eating  a VLCKD containing 40-50 grams of net carbs per day. To be honest, although I've been eating low-carb for about a year and a half, I had some sort of mental block about not wanting to go into ketosis. I'd done enough research to know it wasn't dangerous, but I still resisted the idea on some level. A few months ago I wrote a post stating I didn't think it was necessary for most people. Turns out it may have been just what I needed.

Although it's only been 6 days, the results so far are pretty impressive.  My highest 1-hour postprandial reading has been 128, but most of the time I'm well below 120, and after 2 hours below 100.  I haven't seen numbers like this in such a long time, and I must say it's a welcome change!  In addition, I feel great, with more energy and focus but less 
hunger -- not a  surprise given my previous unstable postprandial blood sugar coupled with the appetite suppression of ketosis.  I've lost a couple of pounds, which I know is water. I routinely count calories when I eat (again, that dietitian training!), and I'm consuming the same 1500-1800 I've been doing for years, so I don't anticipate losing any additional weight, nor do I want to.  I know I'll be perfectly happy eating a very small amount of fruit and avoiding starches entirely (maybe a small bite of dessert once in a while). Not to sound obnoxious, but anyone who knows me personally would say I'm a pretty disciplined eater (sometimes annoyingly so). In addition, I like all kinds of food and look forward to experimenting with very-low-carbohydrate recipes.

It's quite apparent to me that eating at a ketogenic level is not only safe but could be very desirable for people with blood sugar or weight management issues. In my previous post, I said, "Starting off at ketogenic levels may provide a psychological benefit due to early rapid weight loss that usually occurs, but there is certainly no indication to remain in perpetual ketosis for weight management purposes." But maybe for some people eating at this level indefinitely is appropriate. The T4 to T3 conversion problem I mentioned in that post most likely is due to cutting calories and losing weight rather than lower carb intake per se, as it occurs with all types of diets. I know that several doctors who follow the same VLCKDs they prescribe for their patients -- including but not limited to Dr. Steve Phinney, Dr. Jeff Volek, Dr. Jay Wortman, and Dr. Richard K. Bernstein -- enjoy this way of eating, remain very healthy, and plan to continue for the foreseeable future. Of course, I still feel people should decide how many carbs they feel comfortable eating based on their blood sugar levels, weight, and most importantly how they feel. I don't think a ketogenic diet (or a nonketogenic low-carb diet, for that matter)  is for everyone, and I may ultimately decide it's not the best fit for me. But I'm excited to learn more about the benefits of eating very low carb and will likely be blogging about these sometime soon.

***  I will end with my standard advice to always consult with your physician prior to adopting a low-carbohydrate diet or making any other dietary changes. You may also find the following books very helpful:
The Art and Science of Low Carbohydrate Living by Dr. Stephen D. Phinney and Dr. Jeff  S. Voleck
Dr. Bernstein's Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars by Richard K. Bernstein, M.D.


References:
1. Yancy WS, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab 2:34, 2005 
2. Mavropoulos JC, et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutr Metab 2:35, 2005 
3. Manninen AH. Metabolic Effects of the Very-Low-Carbohydrate Diets: Misunderstood "Villains" of Human Metabolism. J Int Soc Sports 1(2)7-11, 2004.