Low Carb Dietitian

Plant-Based vs. Low-Carbohydrate Diets: Presenting the Evidence

07/06/2014

A couple of days ago I received an email from the makers of a soy-based protein bar that began:

"Scientific research continues to show that a plant-based diet is a healthy dietary pattern. In fact, previous versions of the Dietary Guidelines for Americans have emphasized plant-based diets, and the 2015 Dietary Guidelines Advisory Committee appears to be supporting these previous conclusions."

I'd heard this before, after the US Dietary Guidelines Advisory Committee (DGAC) held their third public meeting on the subject this past May. The fourth meeting is scheduled to be held on the 17th and 18th of July, and there's an opportunity to participate online, if you're interested.

It does seem that plant-based diets -- which are usually, although not always, synonymous with vegetarian or vegan diets -- are gaining favor in terms of public perception of their health benefits and sustainability. While I value the contribution vegetables, fruits, and nuts make to our diet, I disagree that most people would benefit from adopting a diet consisting solely of plant foods and have written about this before. And I'm disappointed that low-carbohydrate diets aren't being presented as an alternative at this point, particularly for the many groups of people who would benefit from them.

However, I dislike the confrontational and accusatory messages I've seen from many advocates on both sides in blog posts, comments, and social media sites. I'm passionate about carbohydrate restriction (apparently I'm not supposed to use this phrase to describe myself, but I think it fits), and I get upset when people criticize it and make claims about the superiority of plant-based diets too. But in my opinion, being respectful of the other side -- who are often equally committed to their way of eating -- while letting the evidence in favor of low-carbohydrate diets speak for itself, is the best way to go.

You may have already seen the debate between Dr. Eric Westman and Dr. T Colin Campbell held at the University of Alabama held in the spring of 2013. Both of these men have put many years into researching the effect of diet on various aspects of health. Each strongly believes that his way is the healthiest and most sustainable even though they are quite different. Dr. Campbell's view is that a plant-based, low-protein, low-fat, high-carbohydrate diet provides optimal nutrition, while Dr. Westman favors an eating plan that is very low in carbohydrate, moderate in protein, and high in fat. I encourage you to watch the video if you haven't already, or even if you have. Notice how Dr. Westman seeks to find common ground with statements like "There's more than one way to achieve excellent health," and then goes on to present the large body of evidence --including randomized clinical trials -- supporting carbohydrate restriction for diabetes, metabolic syndrome, and obesity, with early but promising research on ketogenic diets for cancer and neurological disease. I strongly agree with this approach and feel it's what will ultimately allow for more flexibility in the Dietary Guidelines -- specifically, including low-carbohydrate diets as an option.

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Lipid Changes on a Very-Low-Carb Ketogenic Diet: My Own Experience

06/20/2014

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Moscarpone…

I'd like to preface this blog post by apologizing for its length, including links to several long articles. Also, for anyone who doesn't know me, I'm a vocal and enthusiastic supporter of low-carbohydrate diets, but I always strive to be balanced in my writing. I'm very nonconfrontational and don't like "getting into it" with people who disagree with me. However, I expect I'll receive plenty of negative feedback from this article because of the controversial topic.

Cholesterol Results From June 2013 through November 2013

My cholesterol levels have always been higher than average. LDL has ranged from 120s-150s as far back as I can remember, long before I began following a moderately carbohydrate-restricted diet back in 2011. In June of last year, I reported my NMR (Nuclear Magnetic Resonance) LipoProfile results after almost a year of consuming a very-low-carb ketogenic diet (VLCKD) containing less than 50 grams net carb per day. I was very happy with these values and frankly a little surprised that I achieved them while eating delicious, satiating foods.

Lipid Profile from November 2013

In November of last year, I had a standard lipid profile done as part of lab work for my annual physical:

Total Cholesterol: 300
LDL-C: 160
HDL-C: 128
TG: 56

My numbers had increased, but I wasn't terribly concerned about the LDL-C, since on a few occasions it had been nearly that high in the past. Seeing a total cholesterol of 300 was a bit troubling, but I knew it was partially due to having extremely high HDL (Apparently high levels of some types of HDL can also be problematic, although I didn't realize this at the time). Looking back, although I wasn't tracking my intake online regularly back then, I'm pretty sure I was eating the same or perhaps a little more fat than when I had the NMR done five months earlier.

Nutritional Ketosis Experiment

At the beginning of January, I decided to experiment with lowering my carb intake further in order to achieve nutritional ketosis. I didn't want or need to lose weight, but after speaking with a few people who'd reported improved mental focus and energy on minimal carbs and ketone levels between 1.5-3.0, I was intrigued. For the record, I felt great prior to this experiment: no symptoms of adrenal fatigue, excellent blood sugar control, lots of energy, good sleep, etc. But was there a possibility I could feel even better in deep ketosis? I'm a curious type, so I decided to try it for a few months. I had a ketone meter but didn't test very often because the strips are ridiculously expensive. But when I did check prior to this experiment (first thing in the morning, the only time I've ever tested), my ketones ranged between 0.4-1.0 mm.

I began tracking my intake on My Fitness Pal, as many of my clients were doing. I lowered my net carbs to roughly 20 grams per day, although total carbs were often still around 50 grams because I ate a lot of avocados, unsweetened cocoa powder, and high-fiber vegetables like cauliflower. However, my consumption of berries dropped from 1-1.5 cups per day to 5 or 6 every morning at breakfast. I tried to keep protein around 70-80 grams daily (I'm 5'8" and 125 lbs, so this isn't all that low), and I ate more fat in order to maintain rather than lose weight. I never drank bulletproof coffee or added lots of butter or coconut oil to my food. But I did eat a fair amount of cheese, cream cheese, ricotta, and moscarpone, and I began using heavy cream instead of half-and-half in my coffee and tea. I still ate vegetables at every meal, although smaller amounts.

I tested blood ketones a couple of times a week in the morning, and results ranged from 1.2-1.8. After 3 months of eating this way, in all honesty, I didn't feel any different. I still felt great, slept great, etc., but I can't say I had more energy or experienced any cognitive benefits. My weight stayed the same, and my blood sugar control remained good. However, my lipids had definitely changed, and not for the better.

Cholesterol Results from April 2014

I had an NMR drawn at the end of April, and this time I'll admit to being more than a little upset when I saw the results:

I ordered this NMR through a different lab, so there are a few additional labs (mainly VLDL related) that weren't included in the one from June of 2013.

I was really surprised by how much my cholesterol had gone up since the prior test. My first thought was that perhaps my thyroid levels were off. (I have hypothyroidism that was diagnosed shortly before I went low carb, but my levels have been stable for the past few years on desiccated thyroid). However, I didn't feel at all hypothyroid and wasn't scheduled to have my thyroid labs re-checked until summer.

"Why Are You Concerned When You Have Such High HDL-C, Low Triglycerides, and Large, Fluffy LDL-C?"

While I've always been comfortable with higher than ideal cholesterol levels, having an LDL-C over 200 is a different story. The highest value I'd ever seen prior to last December was 158, I believe, about eight years or so ago when I was still following a low-fat, high-carbohydrate diet. But as far back as I can remember, my LDL-C was in the mid 120s to 150s regardless of what I ate, and my total cholesterol was never more than 260. My first NMR was the one last year, so I don't know what my LDL-P values were prior to 2013, but I'm assuming they were above the optimal range, although likely not over 1600. You can see that my LDL and total cholesterol each went up about 100 points and my LDL-P increased by 700 points in a 10-month period. My triglycerides even went up somewhat, although 60 is still pretty low. Although it's my understanding that LDL-C in an NMR is measured directly rather than by using the Friedewald equation (maybe a lipid expert can confirm this), when I plugged my numbers into an online calculator that estimates LDL-C, I got exactly the same number as in the NMR report, 221, for the Friedewald equation and 182 for the Iranian formula (The Iranian formula is believed to be more accurate when triglycerides are over 400 or less than 100).

You may be wondering what LDL-P is, since it's not reported in a standard lipoprotein profile and most doctors don't order it. Dr. Axel Sigurdsson does a great job explaining everything you ever wanted to know about it in his post about LDL-P, but I'll try to give a quick summary. LDL-P is a measurement of the number of LDL (low-density lipoprotein) particles in your blood which carry cholesterol, triglycerides, and another type of fat called phospholipids. According to lipidologists (experts in the field of cholesterol and other lipids), LDL-P is the strongest predictor of risk for cardiovascular disease (CVD) and future cardiac events. Total cholesterol greater than 300 and LDL-C greater than 190 are also associated with significant CVD risk. High levels of LDL-C are prone to oxidation, and oxidized LDL has been linked to the development of arterial plaque and coronary artery disease (CAD). Sometimes people have normal LDL-C and high LDL-P or vice versa (the term for this is discordance), but most people with very high LDL-C have high LDL-P as well. These findings are from recent studies, not decades-old research reported by Ancel Keys.

I want to make it clear that this type of dramatic elevation in LDL-C and LDL-P doesn't occur in most people who adopt a very-low-carb, high-fat diet. I've seen estimates that somewhere between one quarter and one third of low-carbers experience this. I've met and read about several who have. Most people who eat VLCKDs see their cholesterol rise only slightly, not at all, or even decrease, remaining within or near the normal range. I've met plenty of folks like this as well. I've also spoken with people who tell me their LDL cholesterol has always been over 200 and didn't really change after switching to a VLCKD. This is in sharp contrast to what happened to me: going from relatively stable LDL-C between 120s-150s to 221 within a very short period of time.

Of course, many things can affect a person's cholesterol levels, including stress, illness, and injury. Aside from familial hyperlipidemia (FH), there are other genetic disorders of lipid metabolism. Some people's livers produce large amounts of cholesterol (hyper secretors), while others absorb a lot of cholesterol from food (hyper absorbers), and some have both of these issues. My past lipid profiles didn't suggest FH, and I haven't been tested to see whether I have increased hepatic cholesterol production or increased intestinal absorption. I assume I'm probably a hyper secretor, since my levels were higher than average even during my 10 years as a low-fat vegetarian who ate a lot of egg whites but very few yolks or other cholesterol-containing foods.

I do have a family history of heart disease on both sides. My maternal grandfather suffered four heart attacks (the last one fatal), and my maternal grandmother also had coronary artery disease (CAD). My dad's brother has had two heart attacks, and his mother had CVD and died of a stroke. My mom has been on statin therapy since she was diagnosed with CAD ten years ago. (I'm not going to debate the risks vs. benefits of statin therapy in this post, but I'm not a big fan except in certain instances.) You may be wondering what kind of diet my relatives followed. Given that they all grew up and spent their entire lives in Switzerland (with the exception of my mom, who immigrated to the US at age 19), they obviously weren't following the Standard American Diet, but they weren't low-carbers either. My grandfather smoked and had diabetes, and my mom smoked for many years, but my other relatives didn't, and all were moderately active. I've never had a calcium scan or a carotid-intima thickness test(CIMT) to check for atherosclerosis but am looking into having these done. Even if they show no disease at this point, my goal is obviously preventing CAD, heart attack, and stroke in the future.

My NMR results indicate I have the large, pattern A type of LDL with a low number of the more atherogenic small LDL particles (small LDL-P). This is definitely a good thing. However, although I've heard large, fluffy LDL characterized as "harmless" and even "protective," I'm having trouble finding convincing evidence supporting this assertion, especially in the setting of cholesterol levels as markedly elevated as mine. In fact, the authors of the Multi-Ethnic Study of Atherosclerosis (MESA) study summed up their findings as follows:

"Contrary to current opinion, both small and large LDL were significantly associated with subclinical atherosclerosis independent of each other, traditional lipids, and established risk factors, with no association between LDL size and atherosclerosis after accounting for the concentrations of the two subclasses."

Subclinical atherosclerosis is the period when changes are happening in the arteries but the hallmarks of atherosclerosis (i.e., plaque and fatty streaks) haven't developed to the point where the disease can be diagnosed.

It's been pointed out that no studies have been conducted on people following VLCKDs who have very high LDL-C and LDL-P levels, and that's certainly fair to say. However, according to many MDs with expertise and/or personal experience in this area, we really don't know whether CVD risk is lower in low-carbers with cholesterol elevations of this magnitude.

What Do The Experts Say About Very High LDL-C and LDL-P?

I studied lipid metabolism in college as part of the coursework required to become a registered dietitian, but I'll be the first to admit that I have no expertise in that area. I think it's important to listen to the experts in this field since they best understand all of its complexities, including the genetic variations that influence cholesterol levels and the development of CAD. Keep in mind that the physicians listed below are all advocates of carbohydrate restriction to some degree.

Dr. James Underberg is a lipidologist and hypertension specialist in New York City who told me that he has seen similar dramatic increases in total and LDL cholesterol in some of his patients following a carbohydrate-restricted diet. One of the interventions he recommends in these cases is replacing a portion of dietary saturated fat with monounsaturated and polyunsaturated fat sources.

Although technically not a lipid expert, Dr. Rakesh "Rocky" Patel is very familiar with current lipid research as a family doctor in Arizona with hyperlipidemia who treats many people with diabetes and metabolic syndrome. He recommends the CarbNite (cyclical low-carb) method for most of his patients and also follows this approach himself. Back in the fall of 2012, he wrote a fantastic blog post entitled Does LDL-P Matter? in which he described improvement in his carotid intima thickness despite a significant increase in LDL-C and LDL-P after switching to a carbohydrate-restricted diet. When I received my NMR results from April, I asked him if we've learned any more about very high lipids in the context of a VLCKD since he wrote that piece. He responded:

"Not really. It really is an understudied issue. Unfortunately, all the trials in the literature involve the Standard American Diet. Really, I think that before we engage in any discussion regarding cholesterol, one has to establish if atherosclerosis is present in any form. So using testing like CT calcium scoring, carotid intimal thickness testing (CIMT), and genomic scoring (Corus CAD, Cardiodx) becomes imperative and certainly provides context to the lipids."

Dr. Axel Sigurdsson is a cardiologist who practices at a large university hospital as well as a private heart clinic in Iceland. In my opinion, his Doc's Opinion blog provides some of the most balanced, easily understood information about lipids and cardiovascular disease online. I described my experience to him and asked for his thoughts. His response:

"I've seen this lipid response (a very high jump in LDL-C and LDL-P) a number of times in individuals who adopt a low carb/ketogenic diet with relatively high amounts of saturated fat. It seems that a certain percentage of people react in this way. In fact, the lipid response to this type of diet may be genetically determined. Of course, we know that high LDL-C and LDL-P are associated with increased risk of CHD (coronary heart disease). However, nobody really knows what it means in this metabolic situation (nutritional ketosis) and to what degree it is associated with increased risk. Some claim it's not, but I think the evidence is lacking for such a conclusion. On the other hand, we also know that many people with high LDL-C and high LDL-P never have CHD. Of course, you may be one of those people. However, it is difficult to ignore altogether the possibility that high LDL-C and LDL-P may increase the risk of atherosclerotic problems."

Lipidologist Dr. Thomas Dayspring wrote an excellent article about a woman who had an experience similar to mine on a low-carb, high-fat diet, although her case involved weight loss as well. The article is available from his Lecture Pad series, and I highly recommend reading it in its entirety. (You'll have to register to view it, but registration is free). Although it may not always seem like it, he's actually quite supportive of carbohydrate restriction, particularly for people with metabolic syndrome. I didn't discuss my case with him, but here are two quotes from that article:

"We now recognize that the cholesterol usually gains arterial entry as a passenger inside of an apoB-containing lipoprotein (the vast majority of which are LDLs) and the primary factor driving LDL entry into the artery is particle number (LDL-P), not particle cholesterol content (LDL-C)."

"Could the low-carb crowd be outliers and in them we can ignore LDL-C and LDL-P? The advocates of those diets say there is no study showing harm of elevated LDL-P and LDL-C in patients who have eliminated or drastically reduced their insulin resistance and inflammatory markers by low carbing. That is true, but what they want to ignore is that there is no data anywhere that shows they are an exception. Their belief is that by reducing all other atherosclerotic risk factors and normalizing their arterial wall and endothelial biology, that apoB-containing lipoproteins like LDL cannot enter the arterial wall. Although LDL-C and LDL-P in plasma are high, none of the cholesterol content of the apoB particles gains entry into the arterial wall. Is that plausible??? Sure! But is that also erroneous or wishful thinking? Sure? Does one want to bet their CV health or life on a plausible theory? Some do and some do not. Seems to me the first step is to do what this woman did: adjust the nutritional regimen."

He also states that when ketone bodies are present in excess, they can enter the cholesterol synthesis pathway, thereby increasing serum cholesterol levels.

While I agree with Dr. Dayspring on several issues, I disagree with his position (stated in another great article, Understanding the Entire Lipid Profile) that cholesterol-lowering medication is indicated for everyone with LDL-C greater than 190. I think nutritional intervention should be tried first, as it seems to be effective for at least a portion of people willing to do it.

Some of you may have seen spikes in cholesterol similar to mine after being on a low-carbohydrate, high-fat diet for a short period of time or possibly after a few years. You may not be that concerned, and I can understand that given the many positive effects LCHF can have on health, including certain cardiac risk factors. I also think there are still a lot of unanswered questions regarding the risk of elevated cholesterol in the setting of low insulin levels and optimal blood glucose control. But based on the evidence we do have, along with my strong family history of heart disease, I just wasn't comfortable with my numbers. And although I haven't seen this happen in any of my clients yet, I'd definitely recommend some sort of dietary intervention for them if it occurs in the future.

Dietary Changes and NMR Results from June 2014

Over the past two months I made a few small but significant changes to my diet in an effort to lower my cholesterol levels:

1. I cut back on saturated fat, particularly dairy fat and coconut oil, which contain the types of saturated fatty acids with the greatest potential to raise cholesterol.

2. I increased protein back to my previous intake of about 100 grams per day.

3. I doubled my net carb intake from 20 grams to 35-45 grams per day.

4. I began having chia seeds almost every day.

5. I ate sardines 4-5 times a week.

I still eat plenty of saturated fat, including some dairy fat. I drink coffee and tea with half-and-half (only 1 gram of carb in 2 Tbsp), always order Insalate Caprese made with fresh mozzarella at Italian restaurants, and continue to eat eggs cooked in a little butter for breakfast every other day. I still have burrata, ricotta, and moscarpone occasionally and continue eating red meat 3-4 times a week. My total fat intake now ranges from roughly 85-110 grams per day, which is about 50-65% of my total caloric intake. That's still a LCHF diet! And in my case, it's also a mildly ketogenic one, since when I've checked my ketones in the morning (again, I only do this sporadically), they've been 0.4-0.8. Personally, I don't see the need to be in ketosis for my own health; to control my blood glucose, I eat a low-carb diet which just happens to be ketogenic. My weight hasn't changed (which was my goal), energy levels are good, sleep is excellent, etc.

I just received my new NMR results from labs drawn earlier this week:

My LDL-P and LDL-C are still higher than I'd like, but they've dropped considerably in a short period of time. I'm especially impressed by the 44-point drop in my LDL-C. My HDL decreased a bit as well but is still quite high. Considering this occurred in less than two months, I'm pretty happy with these results and hope they continue to improve until they return to the "Above Optimal" to "Borderline" ranges, which I consider normal for me.

As I said at the beginning, I'm a strong proponent of a low-carbohydrate lifestyle. I don't think that's ever going to change. But I feel it's important to look beyond the benefits and address the changes in lipids some people experience that could potentially have adverse effects. This was an n=1 experiment, of course. Remember, most people won't experience extremely high cholesterol levels on a VLCKD. But for me and others who do, I don't believe in shrugging it off and dismissing the results of studies because their subjects weren't following a carb-restricted diet. As a dietitian, I just can't say, "Go ahead and eat as much butter, cream, and bacon as you want. It doesn't matter how high your LDL-C and LDL-P are as long as you're eating low carb and your other markers are low," even if that's what many want to hear. Because we just don't know at this point. Maybe one day there will be evidence demonstrating that VLCKDs are cardioprotective even in the setting of significant hyperlipidemia. I truly hope that's the case. But in the meantime, I'm going to eat a low-carb diet that keeps my lipids in a range I feel more comfortable with.

References

1. Otvos JD, et al. Clinical Implications of Discordance Between LDL Cholesterol and LDL Particle Number. J Clin Lipidol. 2011 Mar-Apr;5(2):105-13
2. El Harchaoui K, et al. Value of low-density lipoprotein particle number and size as predictors of coronary artery disease in apparently healthy men and women: the EPIC-Norfolk Prospective Population Study. J Am Coll Cardiol. 2007 Feb 6;49(5):547-53
3. Cromwell WC, et al. LDL Particle Number and Risk of Future Cardiovascular Disease in the Framingham Offspring Study - Implications for LDL Management J Clin Lipidol. 2007 Dec;1(6):583-92
4. Mora S, et al. LDL particle subclasses, LDL particle size, and carotid atherosclerosis in the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2007 May;192(1):
211-7
5. Waterworth DM, et al. Genetic variants influencing circulating lipid levels and risk of coronary artery disease. Arterioscler Thromb Vasc Biol. 2010 Nov;30(11):2264-76
6. Moriel P, et al. Lipid peroxidation and antioxidants in hyperlipidemia and hypertension. Biol Res. 2000;33(2):105-12
7. Ohlsson L. Dairy products and plasma cholesterol levels. Food Nutr Res. 2010 Aug 19;54
8. Mensink RP, et al. Dietary saturated and trans fatty acids and lipoprotein metabolism. Ann Med. 1994 Dec;26(6):461-4

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Review: KetoDiet App for iPad

06/16/2014

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I'm a firm believer in keeping track of the foods you eat and the nutrition they provide. Many times people believe they're doing everything right but find that their weight, ketones, and blood glucose levels tell a different story. Online tracking apps like My Fitness Pal are helpful, but they weren't designed for people following a low-carbohydrate or ketogenic diet. However, there is an app created specifically for us: KetoDiet App. Some of you may be familiar with Martina's KetoDiet App website, including the blog, which contains fantastic recipes and useful information about healthy, low-carb living.

I love the look and functionality of this app. First of all, it's highly customizable based on your goals for carb intake and weight loss. There are currently over 100 recipes that are beautifully photographed through every step of preparation, and the instructions are very easy to follow. An RSS feed automatically adds new recipes that Martina posts to the website. The app allows you to easily enter your own foods, recipes, and restaurant items, in addition to the KetoDiet recipes. As you add items for the day, the energy (calories), protein, fat, fiber, and electrolytes are tabulated, along with net carbs, which are highlighted in green at the right edge. If you go over your personalized net carb goal (i.e., 30 grams), the color changes from green to red, instantly alerting you. Although the app is called KetoDiet App, you don't necessarily have to be on a ketogenic diet to use it, since you can program in whatever level of carb intake you like.

In my opinion, just about everyone on a low-carb diet would enjoy using this app because of its innovative design, ease of use, reliability, and comprehensive list of mouth-watering recipes. Those of you who read my blog regularly know that I like to be balanced and consider both the positive and negative aspect of everything, but in all honesty, I can't find anything negative to say about this app. I think it's fantastic and, along with the KetoDietApp for iPhone and KetoDietApp book, an excellent value. (Note: The iPhone app is a basic version which does not include the planner and tracker.)

If you haven't already, I highly recommend checking out the KetoDiet App blog and trying out some of the recipes, such as Paleo Greek Meatballs (Soutzoukakia), Cajun Chicken Tacos, and Low Carb Strawberry and Rhubarb Panna Cotta.

Disclosure: Martina provided me with a free copy of KetoDiet App for iPad, but I have received no monetary or other compensation for this review.

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HCG Diet vs. Carbohydrate Restriction for Weight Loss

06/09/2014

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Have you ever cut calories drastically in an attempt to lose weight quickly? I did that repeatedly in my teens, and it never turned out well; I felt hungry and miserable while I was dieting and ended up gaining back all the weight I lost because my appetite was out of control. The promise of rapid weight loss is enticing, particularly for people who have a significant amount to lose. But are the consequences worth it?

In a recent small study that hasn't yet been published, researchers from the Netherlands looked at body composition changes in people losing weight rapidly on a 500-calorie diet for 5 weeks vs. more gradually on a 1250-calorie diet for 12 weeks. Of the roughly 19 lbs lost on average between both groups, at the end of the study, the 500-calorie group had lost almost 3 times as much lean muscle mass as the 1250-calorie group (3.5 lbs vs. 1.3 lbs, respectively). This isn't surprising, since when caloric needs aren't being met, the body uses protein for energy, and muscle mass is broken down to provide amino acids that are essential for survival. After 4 weeks, the numbers looked a little better, which the study authors attribute to improved hydration and glycogen repletion (No mention of how much water weight was regained), but the 500-calorie group was still down about 2 lbs of muscle mass from where they started.

The results of this study made me think about the very-low-calorie HCG diet, which people follow for 3 to 6 weeks at a time, often in several rounds. First popularized in the 1950's by British endocrinologist ATW Simeons, the diet protocol involves taking injections containing HCG, human chorionic gonadotropin -- a hormone produced by pregnant women and approved for use as a fertility treatment -- and restricting calories to 500 per day. (There are also HCG drops, but apparently they contain negligible quantities of the hormone). HCG purportedly has appetite-supressant properties that make subsisting on such low energy intake bearable, and although studies suggest otherwise, many proponents claim it also increases fat burning and weight loss. The HCG diet fell out of favor years ago when researchers reported that the dramatic weight loss of up to a pound a day was due to starvation-level caloric intake rather than the hormone injections. However, within the past few years, there has been a resurgence in its use (thanks in part to the diet being featured on the Dr. Oz show), particularly among anti-aging doctors.

HCG diet lunch, sans melba toast. Repeat for dinner.

The HCG Diet: The Basics

In addition to containing very few calories, the HCG diet is extremely low in fat. The original HCG diet menu below specified the following menu every day, although some updated versions allow people to move some of the foods around to different meals:

Breakfast:
Tea or coffee in any quantity without sugar. Only one tablespoon of milk allowed in 24 hours. Saccharin or stevia may be used.

Lunch:
1. 100 grams of veal, beef, chicken breast, fresh white fish, lobster, crab, or shrimp. All visible fat must be carefully removed before cooking, and the meat must be weighed raw. It must be boiled or grilled without additional fat. Salmon, eel, tuna, herring, dried or pickled fish are not allowed. The chicken breast must be removed from the bird.
2. One type of vegetable only to be chosen from the following: spinach, chard, chicory, beet-greens, green salad, tomatoes, celery, fennel, onions, red radishes, cucumbers, asparagus, cabbage.
3. One breadstick (grissino) or one Melba toast.
4. An apple, orange, or a handful of strawberries or one-half grapefruit.

Dinner:
The same four choices as lunch (above).

This is what dieters are instructed to eat for 4 weeks straight while undergoing HCG injections. Not much to look forward to at mealtimes, which is probably by design in order to prevent overindulging. Characterizing the diet as unappetizing would be an understatement.

The plan provides roughly 55 grams protein, 50 grams carbohydrate, and 9 grams fat. So the macronutrient percentages are about 44% protein, 40% carbohydrate, and 16% fat. 44% of calories from protein sounds like a lot but isn't in this case, and when calories restricted to 500, the protein will be used for energy rather than preservation of muscle mass anyway. After a 6-week break from the diet (I couldn't find any specific dietary guidelines to follow during this period), those who want to lose additional weight often resume the HCG injections and 500-calorie diet for another 4 to 6 weeks.

A Sustainable Alternative to HCG

Doctors recognize that loss of lean mass results in a lower resting metabolic rate. So why are many anti-aging physicians promoting a diet that will, if anything, accelerate the aging process by causing significant muscle loss and other health problems? Some claim that HCG allows people to burn their own body fat for fuel and prevent muscle breakdown, but there is no evidence for this. Studies going as far back as the 1970s indicate that the weight loss achieved on this diet is due to its very low calorie content rather than the HCG injections. (As an aside, I had to laugh at some of the "benefits" claimed on the HCG Doctors Directory site, such as "Improves one's singing voice." Really? And I would like to see clinical evidence that thyroid and adrenal function improve in people consuming 500 calories a day for weeks at a time.)

On the other hand, we have research suggesting that a carbohydrate-restricted diet with adequate calories and protein preserves muscle mass during weight loss, including an analysis of 87 studies that found greater fat loss and better retention of lean mass at lower carbohydrate and higher protein intakes. In addition, carb restriction tends to increase satiety, and most people report enjoying the diet and the wide variety of foods they can eat every day. Many experience rapid weight loss at the beginning, which typically slows down to a more gradual pace after the first week or two. Another benefit of a well-balanced low-carbohydrate way of eating is its suitability for long-term use, both for weight loss and maintenance.

I understand how difficult it is to lose weight and how rewarding it can be to lose rapidly. But it concerns me that there are doctors prescribing a diet so low in calories and nutrients along with hormone injections that were discredited years ago. Rather than encouraging immediate gratification with claims like "Lose up to 30 pounds in a month," why not recommend a sustainable way of eating that not only promotes safe weight loss but is highly pleasurable as well? Carbohydrate restriction has all of these things going for it, and more. In a nutshell, it doesn't feel like being on a diet, and that's one of the primary reasons it works well for so many people.

References:
1. Stein MR, et al. Ineffectiveness of human chorionic gonadotropin in weight reduction: a double-blind study. Am J Clin Nutr. 1976 Sep;29(9):940-8.
2. Rabe T, et al. Risk-benefit analysis of a HCG 500-kcal reducing diet (cura romana) in females.
Geburtshilfe Frauenheilkd. 1987 May;47(5):297-307.
3. Lijesen GK, et al. The effect of human chorionic gonadotropin (HCG) in the treatment of obesity by means of the Simeons therapy: a criteria-based meta-analysis. Br J Clin Pharmacol Sep 1995; 40(3):237-243
4. Volek JS, et al. Comparison of energy-restricted very-low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutr Metab (Lond). 2004 Nov 8;1(1):13
5. Krieger JW, et al. Effects of variation in protein and carbohydrate intake on body mass and composition during energy restriction: a meta-regression. Am J Clin Nutr 83: 260–274, 2006.

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How to Stay Low Carb on a Cruise

05/29/2014

6 Comments

With my friend Emily Maguire, LCHF nutritionist from the UK

Having taken two cruises this year -- Progressive Nation at Sea in February and the Low Carb Cruise last week -- I can tell you that it's very easy to eat delicious food and remain well within your carbohydrate budget during your trip.

When I told people I was speaking on the Low Carb Cruise, many assumed that the passengers would be exclusively low-carbers and only low-carb foods would be offered. But it was actually a regular cruise on Royal Caribbean, and the majority of the people on board were definitely not following a carbohydrate-restricted diet. The ship had all the usual cruise offerings -- from waffles and cereal at breakfast to pasta, potatoes, and an assortment of rich desserts at lunch and dinner.

The number one rule on the Low Carb Cruise was "No Food Police." If people wanted to take a break from their low-carb diets while on vacation, no one was to chastise them or pass judgment in any way. And as far as I could tell, that's exactly what happened. But for those who did want to remain low carb and maintain or possibly even lose weight that week, there were plenty of options, as there always are on any cruise ship.

I'm one of those people who never eats off plan, regardless of the circumstances. But I'm terrible about remembering to take pictures of my food. What can I say -- I'm 47 and not of the Instagram generation, but I'm working on it. Most of the photos below were taken by two other low-carbers on the cruise: Christine Moore (wife of blogger and podcaster Jimmy Moore) and Tommy Runesson, the Swedish blogger who lost 200 lbs after going very low carb back in 2009 and wears a "50%" T-shirt to signify that he's now half the size he used to be. Check out his website, Eat Low Carb High Fat, where he posts pictures of his meals on a daily basis.

Breakfast

Not everyone eats breakfast, of course, but for those who do, there are plenty of choices. Carb count: 2-15 grams

Here's a well-rounded "Protein Power" breakfast plate: bacon, eggs, sausage, cottage cheese, cheese, and honeydew melon
(Photo courtesy of Christine Moore)

This is actually one of my own photos, but it's from the cruise I took in February: salmon, veggies, and cheese

Keto breakfast: meat, cheese, and salmon
(Photo courtesy of Tommy Runesson)

There's also a station where you can order omelets or eggs cooked any way you like. I had sunny-side-up eggs as part of my breakfast several times.

Lunch

Like breakfast, lunch is typically eaten in the buffet area of the ship.
Carb count: 5-15 grams

Burger, cheese, sausage, chicken, and green beans
(Photo courtesy of Tommy Runesson)

Another lunch Tommy put together in the cafeteria. To be honest, I'm not sure exactly what it is, but I know it's LCHF.

Dinner

There are several excellent choices in the elegant dining room, many of which are available every night.
Carb count: 0-25 grams

Salads and Appetizers

Shrimp salad
(Photo courtesy of Tommy Runesson)

Escargot, one of the most popular starters with our group
(Photo courtesy of Tommy Runesson)

Caesar salad. I had this every night.
(Photo courtesy of Christine Moore)

Entree

Steak with Bearnaise sauce
(Photo courtesy of Christine Moore)

Fisherman's Plate: lobster, shrimp, and veggies

Lamb chops: This is Tommy's picture, but I had this entree as well, and it was fantastic.

Dessert

Generally speaking, it's best to stay away from sugar-free desserts if you're very carb sensitive or trying to lose weight. While they may not contain sucrose (sugar), you could end up with a lot of carbohydrates from other ingredients.

Sugar-free chocolate mousse. I'm not sure what type of sweetener it contains. This dessert is most appropriate for someone following a moderate-low-carb diet.
(Photo courtesy of Christine Moore)

Fruit and cheese plate: ideal for the person who still has some room after dinner but wants to keep carbs low.(Photo courtesy of Tommy Runesson)

Here are a few simple tips to stay on track while at sea:

1. Stick to the basics. Order meat, poultry, or seafood, and vegetables. If you're still hungry, you can always order more or make another trip to the buffet. Be aware that sugar is often used as a flavor enhancer in foods that don't taste particularly sweet, including many entrees.
2. Bring your own staple foods. I brought a mixture of cocoa powder and cinnamon to use in coffee and tea, along with unrefined sea salt for my eggs. Several people kept their own heavy cream or grass-fed butter in their cabin refrigerators.
3. Watch the alcohol. Even if you avoid beer and most mixed drinks that contain a lot of carbs, drinking alcoholic beverages can lead to indulging in foods you normally wouldn't eat, along with affecting your blood sugar and potentially impairing your ability to remain in ketosis.
4. Ask for the foods you want. Although there was a large selection of delicious low-carb fare at every meal, I have to admit that I did miss eating avocados and berries, which I never found on the ship. But on the last day of the cruise, I learned that fellow low-carber Glenn Frederich of LC Foods was able to get these items at dinner by requesting them a day in advance. Great information for next year's cruise!

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Five Low-Carb "Superfoods"

05/12/2014

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I'm usually not a fan of the term "superfood." I think it tends to confuse people about which foods are best and how much they should consume. For instance, the ADA's Diabetes Superfoods list includes citrus fruit, whole grains, sweet potatoes, and fat-feee milk. While those items may have beneficial nutrients, their effect on blood glucose levels should instantly disqualify them for consideration on such a list. But I have five favorite foods that I think could be classified as "superfoods." In addition to providing numerous health benefits, they're also very low in carbohydrates and delicious -- an ideal combination.

Cinnamon
This fragrant spice is prized for its strong, distinctive taste and suitability for both sweet and savory dishes. Although research on its ability to improve insulin sensitivity has found mixed results, many people report lower fasting blood glucose levels as a result of taking 1/2 to 1 tsp per day.

Potential benefits:

Lower postprandial blood glucose levels
Improved insulin sensitivity
Decrease in LDL-cholesterol levels
Improvement in liver function, insulin resistance, and inflammation in those with fatty liver

I like adding cinnamon to coffee and tea with a little half-and-half and sweetener. For an exotic main dish, check out Vanessa of Healthy Living How To's recipe for Cinnamon Braised Beef.

References:

1. Magistrell A, et al. Effect of ground cinnamon on postprandial blood glucose concentration in normal-weight and obese adults. J Acad Nut Diet 2012 Nov;112(11):1806-9
2. Ascari F, et al. Cinnamon may have therapeutic benefits on lipid profile, liver enzymes, insulin resistance, and high-sensitivity C-reactive protein in nonalcoholic fatty liver disease patients. Nutr Res 2014 Feb;34(2):143-8.

Cocoa

Chocolate has been getting a lot of good press lately. Of course, we're not talking about Reese's peanut butter cups and Hershey bars; dark chocolate with at least 85% cacao is the type to choose for maximal health benefits with minimal nonfiber carbs.

Potential benefits:

Improved gut health due to its prebiotic properties
Decreased oxidation of LDL cholesterol
Lower risk of cardiovascular disease
Protection from sun damage and overall improvement in skin quality

I like unsweetened chocolate, but it's taken me a while to get to that point. For anyone interested in a low-carb version of one of the most popular candy bars of all time, Carolyn of All Day I Dream About Food has created a sugar-free Chocolate Peanut Butter Cup. And Bill Lagakos of Calories Proper shares an incredibly easy recipe for homemade chocolate at the end of a fantastic blog post about the beneficial effects of chocolate and medium-chain triglycerides on liver health.

References:
1. Tzounis X, et al. Prebiotic evaluation of cocoa-derived flavanols in healthy humans by using a randomized, controlled, double-blind, crossover intervention study. Am J Clin Nutr 2011 Jan; 93(1):62-72 2.West SG, et al. Effects of dark chocolate and cocoa consumption on endothelial function and arterial stiffness in overweight adults. Br J Nutr.2014 Feb;111(4):653-61
3. Ibero-Baraibar I, et al. Oxidized LDL levels decreases after the consumption of ready-to-eat meals supplemented with cocoa extract within a hypo caloric diet Nutr Metab Cardiovasc Dis 2014 Apr; 24(4):416-22
4. Heinrich U, et al. Long-Term Ingestion of High Flavanol Cocoa Provides Photoprotection against UV-Induced Erythema and Improves Skin Condition in Women. J Nutr 2006 Jun;136(6):1565-9

Avocado

Technically a fruit, the avocado contains high levels of healthy monounsaturated fat, and its carbohydrates come primarily from fiber. In addition, avocados are one of the best sources of potassium around and highly satiating due to their high fat and fiber content.

Potential benefits:

Reduced blood glucose levels
Protective effect on liver, kidneys, and pancreas

Antimicrobial activity that could provide an alternative to antibiotic therapy in the future
Inhibition of cancer cell growth

Guacamole is my favorite way to eat avocados, but this Paleo-Stuffed Avocado from Martina at KetoDiet App sounds delicious and contains another low-carb "superfood": sardines.

References:
1. Ezijiofor AN, et al. Hypoglycaemic and tissue-protective effects of the aqueous extract of persea americana seeds on alloxan-induced albino rats. Malays J Med Sci 2013 Oct;20(5):31-9
2.Guzman-Rodriguez JJ, et al. Antibacterial activity of defensin PaDef from avocado fruit (Persea americana var. drymifolia) expressed in endothelial cells against Escherichia coli and Staphylococcus aureus. Biomed Res Int 2013; 2013:986273
3. Ding H, et al. Chemoprotective characteristics of avocado fruit. Semin Cancer Biol 2007 Oct;17(5)386-94

Sardines and Herring

Sardines and herring are generally love-or-hate foods, but those of us who enjoy them definitely have the edge in reaping several health benefits. Their omega-3 fats and low mercury content make them a natural choice for "superfood" status.

Potential benefits:

More favorable omega-6:omega-3 ratio as a result of high DHA and EPA content
Reduced risk of cardiovascular disease
Improvement in bipolar disorder and other forms of depression
Reduced frequency and size of colonic polyps

Fortunately for me, I love both of these. I usually eat sardines about three times a week for breakfast with cucumbers, cherry tomatoes, olive oil, and vinegar. For a fancier presentation, try these Romaine Wedges with Sardines and Caramelized Onions from the Eating Well website.

Reference:

1.Richard D, et al. Infusion of docosahexaenoic acid protects against myocardial infarction.Prostaglandins Leukot Essent Fatty Acids 2014 Apr;90(4):139-43
2. Grosso G, et al. Omega-3 fatty acids and depression: scientific evidence and biological mechanisms. Oxid Med Cell Longev 2014;2014: 313570
3. Hull MA. Omega-3 polyunsaturated fatty acids. Best Pract Res Clin Gastroenterol 2011 Aug 25(4-5):547-54

Eggs
Eggs really are the perfect low-carb choice for any meal. Isn't it nice that one of the healthiest foods around is also one of the most versatile? Of course, we should all be eating the yolk, its most nutritious part. In addition to containing protein of the highest biological value (meaning our body uses it more efficiently than protein from any other source), eggs keep us healthy in several ways.

Potential benefits:

Provide important nutrients like choline (vital for the brain), vitamin K2 (for heart and bone health), and the antioxidants lutein and zeaxanthin (keep eyes healthy and free from macular degeneration)
Raise HDL cholesterol ("good" cholesterol)
Promote a shift from small, dense atherogenic LDL (Pattern B) to larger LDL (Pattern A)

My favorite way to eat eggs is sunny-side-up over sautéed kale with sea salt. I think they'd also be fantastic in this recipe for Eggs Baked in Tomato Sauce.

References:
1. Nasopoulou C, et al. Hen egg yolk lipid fractions with antiatherogenic properties. Anim Sci J 2013 Mar;84(3):264-71
2. Handelman GJ, et al.Lutein and zeaxanthin concentrations in plasma after dietary supplementation with egg yolk. Am J Clin Nutr 1999 Aug;70(2):247-51
3. Fernandez ML. Effects of eggs on plasma lipoproteins in healthy populations. Food Funct 2010 Nov;1(2):156-60

So while we can argue about whether there truly are any "superfoods," I think you can see why I feel the foods above should have a prominent role in your diet. Try to get at least a couple in every day.

8 Comments

Nutritional Management of Metabolic Syndrome

04/26/2014

16 Comments

Metabolic Syndrome:
More Than Just a Risk Factor for Disease

The number of people with metabolic syndrome is increasing, yet those who have it often aren't aware of its significance. Originally identified as Syndrome X by Dr. Gerald Reaven in the 1980s, metabolic syndrome increases risk for cardiovascular disease, heart attack, stroke, and diabetes. It is diagnosed in people who have central obesity (waist circumference >35 inches in women or >40 inches in men) and meet at least two of the following criteria as set forth by the American Heart Association:

fasting blood glucose >100 mg/dL
blood pressure >135/85 mm hg
triglycerides >150 mg/dL
HDL-C < 40 mg/dL in men or <50 mg/dL in women

The majority of people with metabolic syndrome have prediabetes, defined as fasting blood glucose between 100-125 mg/dL and/or hemoglobin A1c between 5.7-6.4%. Interestingly, people with hypertension may have better overall glycemic control as a result of producing large amounts of insulin, but they often develop heart disease at higher rates because of persistent and significant hyperinsulinemia. Unfortunately, it's easier to dismiss concerns about you're health when you're told you "only" have prediabetes.

Insulin resistance is defined as the inability of cells to respond normally to insulin, resulting in higher blood glucose and insulin levels. It's the hallmark of metabolic syndrome. Recently it has been suggested that hyperinsulinemia may be what causes insulin resistance rather than the more commonly held view that insulin resistance leads to increased insulin output and subsequent hyperinsulinemia. Regardless of which occurs first, high levels of serum insulin result in elevated blood pressure, inflammation, and high triglycerides and VLDL cholesterol -- all of which increase the risk for vascular events, i.e., heart attack and stroke. Unfortunately, most people who are diagnosed with prediabetes or metabolic syndrome don't realize that they've already sustained damage. For instance, it's estimated that 50% of people already have heart disease at the time diabetes is diagnosed.

Lifestyle Goals: Is Standard Advice Helpful or Harmful?

The goals of treatment for metabolic syndrome are obvious: weight loss and improvement in blood pressure and lab values. Aside from drug therapy for lipids and blood pressure, what can be done from a nutritional standpoint? Here is the standard advice I found on many highly regarded websites, including the National Heart, Blood, and Lung Institute (NHBLI) site:

Lose Weight
A typical recommendation is to achieve and maintain a BMI of <25, which may not be possible or even desirable for everyone, particularly muscular, large-framed men. The BMI is also meaningless for assessing abdominal girth and body fat vs. muscle. For instance, a man with a BMI of 28 with little body fat and a 32-inch waist is metabolically much healthier than a small-framed man with a BMI of 24, a 38-inch waist, and a considerable amount of visceral fat around his organs. Of course, in people with metabolic syndrome abdominal obesity is a given, but the goal should be decreasing waist circumference rather than BMI.

Follow a Heart-Healthy Diet
It really shouldn't surprise me at this point that the "heart-healthy diet" -- essentially the DASH diet -- so often advised for people with metabolic syndrome isn't the one I'd recommend. From the NHBLI website:

"Fill half your plate with fruits and vegetables. A healthy diet also includes whole grains, fat-free or low-fat dairy products, and protein foods, such as lean meats, poultry without skin, seafood, processed soy products, nuts, seeds, beans, and peas."

Yes, "processed" soy products.

So according to these recommendations, the following meal plan would be ideal:

Breakfast:
Bowl of Raisin Bran cereal with sliced banana and skim milk
V8

Lunch:
Turkey sandwich with low fat mayo on whole grain bread, orange

Snack:
Yoplait Light yogurt with fruit

Dinner:
Tofu, rice, and vegetables with low-sodium teriyaki sauce
Apple

This advice is being given to individuals with metabolic syndrome, who by definition have insulin resistance and hyperinsulinemia with elevated triglycerides, low HDL, and/or impaired fasting glucose. Unless carbohydrate portions are kept very small and fat is added -- neither of which is recommended on a low-fat diet -- these guidelines are likely to exacerbate rather than improve biomarkers and weight. And, let's face it, this plan doesn't sound that appetizing or satiating and would be difficult to sustain for most people.

An Enticing Alternative: Carbohydrate Restriction

On the other hand, research has demonstrated that low-carbohydrate diets do the following:

Reduce postprandial blood glucose and insulin levels
Result in a spontaneous decrease in appetite, which promotes weight loss, leading to lower basal insulin levels
Decrease triglycerides
Increase HDL-C
Decrease blood pressure

Clearly, metabolic syndrome responds extremely well to carbohydrate restriction. Is there any other diet that has shown such impressive results? Some would argue that the Mediterranean Diet has demonstrated health benefits in this population, and there are certainly studies that support this claim. However, if large quantities of fruits, starchy vegetables, and grains are consumed, a Mediterranean diet plan can be as high in carbs as the low-fat plan listed above. Dr. Steve Parker has devised two Mediterranean-based diets that are appropriate for people with Metabolic Syndrome: the Low-Carb Mediterranean Diet and the Ketogenic Mediterranean Diet.

Here's an example of a low-carbohydrate meal plan based on Mediterranean Diet principles:

Breakfast:
Greek yogurt with raspberries and chopped walnuts

Lunch:
Shrimp, tomatoes, and cucumbers with olive oil and basil

Snack:
Mixed nuts or olives

Dinner:
Steak with grilled zucchini, mushrooms, and eggplant
Strawberries with whipped cream

I think that sounds like a pretty enjoyable and sustainable way of eating.

And yet in most papers, on most websites, and among most endocrinologists, carbohydrate restriction isn't even discussed as an option for metabolic syndrome. "Lose weight" seems to be the primary directive, and the recommendation for achieving this is typically a low-fat, low-sodium, high-carb approach. Interestingly, much of the research on hyperinsulinemia and insulin resistance over the past two decades has been published in Diabetes and Diabetes Care, which are journals of the American Diabetes Association, an organization which recently changed its position statement to include low-carbohydrate diets as an option for people with diabetes and prediabetes. I hope other organizations will follow their lead and begin promoting carbohydrate restriction as an option -- or better yet, the best option -- for those with metabolic syndrome.

References:

1. Shanik MH, et al. Insulin resistance and hyperinsulinemia: Is hyperinsulinemia the cart or the horse? Diabetes Care 2008 Feb: 31 Suppl 2: S262-8
2. Reaven GM. Banting lecture 1988: Role of insulin resistance in human disease. Diabetes 1988 Dec;37(12); 1595-607
3. McGavock JM, et al. Cardiac steatosis in diabetes mellitus. Circulation 2007 Sep 4;116(10):1170-5
4. Winhofer Y, et al. Short-term hyperinsulinemia and hyperglycemia increase myocardial lipid content in normal subjects. Diabetes 2012 May;61(5):1210-1216
5. Volek JS, Feinman RD.Carbohydrate restriction improves features of the Metabolic Syndrome. Metabolic Syndrome may be defined by the response to carbohydrate restriction. Nutr Metab(Lond) 2005 ;2:31
6. Castorini CM, et al. The effect of Mediterranean diet on metabolic syndrome and its components. J Am Coll Cardiol 2011 Mar 15:57(11)1299-313

16 Comments

Is a Very-Low-Carb Ketogenic Diet Healthy?

04/07/2014

2 Comments

I recently wrote my first guest blog post for Martina over at the KetoDiet website. I really like Martina's blog -- it's a great mix of beautifully photographed recipes and up-to-date, accurate information on living a very-low-carb lifestyle.

Click here to read my article on the many benefits and few potential drawbacks of very-low-carbohydrate ketogenic diets. While you're there, check out Martina's wonderful recipes, articles, and the KetoDiet iPhone and iPad apps.

2 Comments

Carbohydrate Restriction: An Option for Diabetes Management

04/01/2014

27 Comments

I'm very happy to share the article I recently wrote for Diabetes Self-Management magazine. Like many dietitians and CDEs, I read this publication regularly and think it's a great source of information for people with diabetes. However, I often don't agree with the nutrition articles written by the RDs, as they generally recommend using MyPlate as a foundation for meal planning. I contacted the editor to ask about writing a piece on carbohydrate restriction as an alternative to MyPlate, and somewhat to my surprise, she invited me to write this article. Even better, she made only a few minor changes prior to publishing it, so it's very similar to what I submitted. One thing that wasn't included, though, was a sidebar I created that had a list of resources for people with diabetes, including websites like Blood Sugar 101 and The Low Carb Diabetic and books like The Art and Science of Low Carbohydrate Living and The Rosedale Diet. I think this was likely due to lack of space. But overall, I'm pleased with the way the article turned out, and I hope that many people with diabetes -- as well as dietitians, nurses, CDEs, and doctors -- get a chance to read it and discover that a low-carbohydrate diet can be very safe, effective, and sustainable.

(The document below contains the cover of the March/April issue and my article. If you're interested in the other articles listed on the cover, you'll have to order the magazine from the publisher).

Copyright (c) 2014 Madavor Media
www.DiabetesSelfManagement.com

27 Comments

"Confessions" of a Not-So-Paleo Low-Carb Dietitian

03/27/2014

31 Comments

I love eating the types of natural whole foods my grandparents grew up on: a wide variety of meat and seafood, eggs, cheese, yogurt, fresh vegetables, nuts, and berries. Overall, I consider myself whole-foods based and concerned about food quality. However, for me, avoiding processed food is secondary to keeping carb intake very low, protein and fiber moderate, and fat fairly high, as this controls my blood sugar and makes weight maintenance easier as I age. As I mentioned in a previous post a few months back, I don't really identify as Paleo, Primal, or Ancestral. Carbohydrate restriction has had such a positive impact on my own life and that of countless others. I know many of you follow a Paleo/Primal way of eating, and in many respects I do as well. A typical food day for me is quite whole-foods based, as you can see from my intake yesterday:

Breakfast:
Eggs and kale cooked in coconut oil
Berries with ricotta cheese
Coffee with cream

Lunch:
Arugula with Greek yogurt, avocado, olive oil, and sea salt
Mixed nuts
Hot cocoa tea

Dinner:
Salad made with diced turkey, cucumbers, tomatoes, olive oil, and vinegar
Avocado
Square of unsweetened chocolate
Hot cocoa tea

But there are some decidedly non-Paleo items in my diet and lifestyle as well. Here are my food "confessions," although I don't really like using that term here because it implies I've done something wrong. If any of you can think of a better word, let me know, and I'll change it.

I use saccharin every day.
I mentioned using erythritol when I bake in the post referenced above, and explained that baking is a rare occurrence for me. I do have a cup of coffee and a few cups of sugar-free cocoa tea every day, though, and I use saccharin to sweeten them. But instead of Sweet 'n Low, which contains dextrose (sugar), I use Nectasweet, pure saccharin tablets with no carbohydrates. Saccharin has been around for over 100 years -- it was the original sweetener used by people with diabetes prior to the discovery of insulin -- and there is no evidence whatsoever that it increases cancer risk in humans. Each Nectasweet tablet provides the equivalent sweetening power of 1 teaspoon of sugar, at a cost of only a penny per serving. Yes, stevia comes from a plant and is therefore "natural," but we know less about its long-term safety than we do about saccharin, and it's much more expensive.

Here's my delicious and easy "Hot cocoa tea" recipe:
Pour boiling water over tea bag of choice (I like Rooibos red or vanilla) and let steep 2-3 minutes. Add 1 tsp unsweetened cocoa powder, 1 Nectasweet tablet, and 1 tablespoon heavy cream or half-and-half. Stir and enjoy.

I make my husband low-carb Cheez-its from processed cheese.
I have Laura Westman, Dr. Eric Westman's daughter, to thank for this one. I was telling her that one of my clients had asked about a substitute for crackers. "Have you heard about low-carb Cheez-its?" she asked. "You make them from American cheese, they're super easy, and they taste like the real thing!" Googling "Low-carb Cheez-its" led me to this recipe for Crispy Cheese Crackers. I've never been much of a Cheez-it fan, but I made a batch for my husband. He said they were very good, "pretty close" to the original, and I could make them again sometime, which I've done. That's high praise coming from my extremely finicky (but otherwise wonderful) husband. Yes, American cheese is technically a processed food, but it's not much different from regular cheese in terms of ingredients, and apparently none of them are controversial from a health perspective.

I like Shirataki noodles better than zucchini noodles.
I love zucchini. One of my favorite ways to prepare it is sautéed with mushrooms and onions topped with spicy beef chili. But while some people enjoy substituting zucchini and other vegetables for pasta -- by julienning them manually or using a "Zoodler" or other device intended for this purpose -- I'm not wild about the results. Although I rarely crave pasta the way I imagine some people on low-carb diets do, occasionally I enjoy making low-carb noodle entrees like Thai Chicken and Noodles and Beef Stroganoff. In my opinion, Miracle Noodles are ideal for these dishes and many others. Shirataki (also called glucomannan) comes from the konjac plant, which is native to Japan. It's essentially all fiber and contributes less than 5 calories and 1 carb per serving, yet provides a lot of volume. There's some evidence it may promote weight loss and reduce high cholesterol levels. Maybe it would actually be Paleo approved because it's not really processed other than being ground up and formed into strands before being packed in liquid. At any rate, I enjoy eating these sometimes.
Tip: Rinse Miracle Noodles really well and pan-fry them without oil or other liquid in order to remove as much water as possible. The less water that remains, the better the texture will be.

I use mayo on beef patties.
Conventional mayonnaise is made with soybean oil and a little bit of sugar, although the amount of carbs in a tablespoon is less than zero. Yes, this is the type of oil that's made from GMO soybeans and is high in omega-6 polyunsaturated fatty acids (PUFAs). I'm not saying it's healthy and I don't eat it that often, but if I'm getting a protein-style burger and there's no guacamole around (which is usually the case), I'll top it with mayonnaise without a second thought.

Sometimes I eat nuts roasted in peanut oil, cottonseed oil, etc.
Peanut and seed oils are high in omega-6 PUFAs as well. I usually have raw almonds, macadamias, hazelnuts, and pecans on hand at home. But my husband likes the roasted type, and let's face it: They do taste better. So sometimes I'll grab a few from his stash and eat them instead of the raw nuts. I eat a lot of sardines and salmon -- usually about four fish meals per week -- so I'm definitely getting plenty of omega-3s for balance.

I'm not a fan of Cross-Fit.
In all honesty, I'm about as far from a Cross-Fitter as you can get. I realize not everyone who follows a Paleo diet does Cross-Fit, but enough do to mention it here. I prefer walking and doing Ellen Barrett's Pilates, yoga, and light resistance routines to stay fit and energized. From my understanding of what Cross-Fit entails and online reports of people (particularly women) developing problems when combining it with carbohydrate restriction, it appears that the two aren't compatible.

I reheat food and beverages in the microwave.
I've read articles online cautioning people about the dangers of microwaving food, and at least a few have been from members of the Ancestral community. I need to see convincing evidence for the assertion that microwaving alters food in a different way than occurs in other cooking methods. This article is one of several that explains why microwaving is safe for cooking and reheating foods and beverages when guidelines are followed (i.e., no metal, plastic tubs, etc.).

So now you see the way I truly eat and live. Particularly in the context of my balanced, very-low-carbohydrate diet, I really don't think any of these behaviors will do me any harm. In fact, I hope you can relate to a few of them.