First off, I hope all of you and your families had a wonderful Thanksgiving. Mine was really nice: delicious food and great conversation with family and dear friends.
I've been wanting to write a post like this for some time now. My intention is not to criticize other people's beliefs but rather to explain my own and why I hold them. Looking over a number of "Paleo Thanksgiving" menus prompted me to finally address my ambivalence about Paleo, Primal, Weston A. Price Foundation, and other "real food" ways of eating. I know that several people who read this blog identify with one or more of these ways of eating. Please keep in mind that I strongly favor a whole foods approach over a diet containing processed foods. I'm a proud member of Real Food Dietitians, and I recently became a Primal Docs featured member. However, I think carbohydrate restriction is ultimately more important for people trying to manage diabetes, prediabetes, obesity, metabolic syndrome, and PCOS.
Diabetes, Hyperinsulinemia, and Insulin Resistance
There's a lot of convincing research supporting very-low-carbohydrate diets for people with Type 2 diabetes, metabolic syndrome, and polycystic ovarian syndrome. I'm planning a blog post on insulin resistance and hyperinsulinemia in the near future, but suffice it to say that many, if not most, overweight people have impaired insulin sensitivity, resulting in elevated blood sugar and insulin levels that cause hunger, damage blood vessels and nerves throughout the body, and promote fat storage. Keeping carb intake very low (less than 50 grams per day) will have a beneficial effect on insulin resistance and hyperinsulinemia in virtually everyone, whereas a diet containing twice or three times as much carbohydrate may work for a portion of this population, but most will need to restrict carbohydrates further to lose weight and achieve healthy blood sugar and insulin ranges. In general, the works of Drs. Steve Phinney, Jeff Volek, Eric Westman, Richard Feinman, Michael Eades, Richard K. Bernstein, and other low-carbohydrate researchers are more exciting and convincing to me than authors who classify themselves as Paleo or Primal.
People with Type 1 diabetes or normal weight individuals with blood sugar issues (I'd place myself in the latter category) will also benefit from keeping carbohydrate levels very low. I followed a Primal, moderately low-carb (100 grams or so per day) diet for a while but continued to have postprandial blood sugars over 160 and sometimes as high as 200. Only when I began restricting carbohydrates to 15 or fewer grams per meal did my blood sugar response normalize, and it's remained this way for the past year and a half.
I realize dairy is controversial in the Paleo and Primal community due to its lactose content, insulin-stimulating properties, and potential for allergies, but I personally consume quite a bit of it without any problems. In fact, I have Greek yogurt, cheese, sour cream, and/or cream every day and maintain a healthy weight. While there are certainly people with legitimate reasons to avoid dairy (such as true allergies or hypercalcemia), I think many others will do okay with it. If you have other symptoms that clear up when you eliminate dairy, then obviously you shouldn't eat it.
I understand the WAPF's position on the benefits of raw milk, but I disagree that pasteurized, homogenized dairy products are inherently bad. My parents are from Switzerland and grew up on pasteurized milk products, as did their parents, and continued consuming them throughout their lives. They're now in their 70s, active, and in excellent health, and I know there are many others like them. While raw milk may contain more nutrients and allow for better absorption of fat-soluble vitamins, I think pasteurized milk provides benefits as well.
Here's where I may lose some of my readers (if I haven't lost you already). There was recently a very successful Gluten Summit, and two intelligent MDs, Drs. Davis and Perlmutter, have written books detailing the devastating effects gluten can have on susceptible individuals. But not everyone is gluten sensitive! I avoid grains because of their carb content and I don't really mind not eating them, but there are other low-carbers who consume low-carb bread, wraps, etc., without any problems. Dr. Steve Parker's Low Carbohydrate Mediterranean Diet allows grains for those who tolerate them. The Paleo Thanksgiving yam and sweet potato recipes I saw online contain a lot of carbohydrates. Eating a small amount would be fine, but many people tend to eat larger portions of foods they're told are healthy. I'm not saying that grains are good for you, but to be honest, I'd rather someone with diabetes eat a forkful of stuffing (about 3 grams of carb) than a cup of sweet potatoes (37 grams of carb if plain).
Another controversial area among Paleo/Primal/WAPF devotees is sweeteners. Honey or pure maple syrup is often recommended as an alternative to table sugar. However, these items contain more carbohydrate per serving than sugar does, so they're not a good choice for people with diabetes or insulin resistance. Green leaf stevia is recommended as an option for those who need to limit carbohydrates. But have you tasted stevia? It's got an interesting flavor (reminiscent of anise, in my opinion), but it really doesn't work well as a sweetener for all types of food. I rarely use any sweetener at all, but when I do bake occasionally, I use erythritol, a sugar alcohol that isn't absorbed by the body and tastes very similar to sugar. Some have argued that erythritol is a processed product made from corn, but I think people with issues related to glucose intolerance would be better off consuming it -- or even saccharin -- instead of "natural" sweeteners, including fruit juice. Again, it's best to avoid all types of sweeteners except in limited amounts. I do eat a square of 85-90% cacao dark chocolate a few times a week. It's sweetened with sugar but only has about 2 grams of net carb.
Pastured and/or Organic
As a former vegetarian for ethical reasons, I strongly support raising animals as naturally and humanely as possible. I would prefer to always eat pastured, organic, or naturally raised meat, dairy, and eggs, and most of the time I do, at least at home. But there are many people who can't afford to eat this way on a daily basis. I've written about this before, but I feel even more strongly now that people on limited budgets shouldn't be made to feel that they're jeopardizing their health if they can't buy organic food. I've seen individuals on low-carb forums say that they have to quit eating low carb because it's too expensive. But there are lots of ways to eat low carb without spending a lot of money (also Google "low carb on a budget"). Replacing higher-carb items with conventionally raised animals, eggs, and cheese can have a profound positive effect on blood glucose and insulin levels, as well as weight. And at the end of the day, that's the most important thing.
I hope I didn't offend any of the people I respect yet differ with on this issue, but I wanted to make clear where I stand. If folks with diabetes or weight issues can combine "real food" and low carbohydrate intake, this is ideal. But I'll always place carb restriction as the top priority for them because I truly believe it's the key to improving their health.
1. 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
2. Accurso A, et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutr Metab (Lond) 2008; 5: 9
3. Westman EC, et al. Low Carbohydrate Nutrition and Metabolism. Am J Clin Nutr 2007; 86(2):276-284
4. Mavropolous JC, et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutr Metab (Lond) 2005: 2:35
First of all, I wish each and every one of you a very happy and health Thanksgiving. I have so much to be grateful for, and my loyal and growing readership is definitely something I appreciate more than you can imagine.
This is an odds-and-ends quick post to share some ideas for putting together a wonderful low-carb Thanksgiving dinner and updating you on a few things.
Low Carb Thanksgiving Ideas
If you haven't shopped for your holiday feast yet, no worries -- I haven't either. Check out these sites for incredible low-carb versions of your favorite holiday dishes:
All Day I Dream About Food
CarbSmart Magazine (Monthly subscription highly recommended!)
Mark's Daily Apple
Honestly, looking at all of those pictures and reading the recipes makes me wish it were Thursday already!
Low Carb Dietitian Monthly Newsletter
In response to the many people who have e-mailed me asking to be alerted when I post new blog entries, I've decided to start a monthly newsletter that contains my posts, any low-carb events you might be interested in, and occasional interesting tidbits of information I may not include in my blog articles. If you're interested, please sign up on the LCD home page.
I'm not able to take private clients quite yet but am keeping a list of people interested in working with me starting in January. I hope to have a web page listing my services and rates up within the next couple of weeks, but feel free to contact me in the meantime if you'd like to schedule for January or have any questions.
Have a wonderful and safe Thanksgiving!
About six months ago, I wrote a blog post about the anti-aging effects of carbohydrate restriction and mind-body exercise. I've decided to do a follow-up since I'm turning 47 this week and want to share some additional information on aging that I've learned.
In all honesty, your genes do play a large role in determining the rate at which you age, the degree to which you tend to gain weight, and the types of chronic diseases you're at risk to develop as you get older. It's not fair, but that's the way it is. However, there are so many things we do have control over that affect how we age, particularly what we eat and how much exercise we get. It's empowering to realize how much you can do to look and feel your best! My motto is, do the best you can with what you've got and don't compare yourself to others. A second recommendation would be to not compare your current self to your 20-something self. There's no way to turn back the hands of time, and we shouldn't spend our energy and efforts trying to do so. Focus on the present and the future.
Elevated blood sugar contributes to wrinkled skin and other signs of aging.
Advanced glycation end-products (appropriately abbreviated AGEs) occur when glucose reacts with proteins and fats in the body, forming cross-linkages that accelerate the aging process and contribute to chronic disease. This reaction occurs in everyone, although to a much greater extent in people with uncontrolled diabetes. AGEs are considered largely responsible for the damage to the kidneys, eyes, cardiovascular system, and extremities that occurs when blood glucose levels are high. There is evidence indicating that AGEs also contribute to skin wrinkling, loss of collagen and elasticity, and other signs of aging. Although twin studies have demonstrated that the amount of AGEs circulating in our bloodstream is determined in part by genetics, environmental factors such as smoking and the types of food we eat also play a role. Vitamin B6 may help counteract the effects of AGEs in diabetes complications such as neuropathy, but at this time it's not clear if taking supplements will help prevent skin damage. Research suggests that caloric restriction (CR) can help counteract the effect of AGEs on skin; however, this can cause unwanted effects on the thyroid, including lowering of metabolic rate, in addition to being very hard to sustain without high levels of hunger. Very-low-carbohydrate ketogenic diets (VLCKDs) have been shown to mimic many of the beneficial effect of calorie restriction without the adverse reactions often seen in CR. They also help normalize blood glucose levels, which further reduces AGE levels.
Fat is good for your skin.
Dietary fat gets such a bad rap among many health authorities, so it's great to see research demonstrating its benefits, including healthy skin. Despite what many people have been led to believe, consuming fat --including saturated fat -- can reduce the signs of aging. Researchers in Japan examining the effect of diet on skin in over 1000 women found that those who consumed the highest amount of fat scored best in terms of wrinkling and skin elasticity, provided they also obtained antioxidants in the form of nonstarchy vegetables.
Now, I know there are people who follow a low-fat diet and have great skin. I ate a low-fat diet for many years, and people still thought I looked younger than my age (or at least that's what they told me!) But since I started low-carbing and significantly increased the amount of fat and saturated fat in my diet, I've definitely noticed that the quality of my skin has improved. My pores appears smaller, my skin is very smooth, and I never break out, which was a problem I periodically struggled with in the past. I truly feel that my skin looks better than it has in years. Maybe it's a combination of high fat intake and improved blood glucose control from following a VLCKD?
Exercise is important as we age, but trying to burn off calories by working out harder may be counterproductive to weight loss efforts
We constantly hear that in order to lose weight, we need to burn more calories than we consume. While it is true that a caloric deficit is necessary for weight loss, there are well-controlled studies indicating resting metabolic rate (RMR) often decreases when endurance exercise is performed daily over several weeks, including one on identical twins that found a large variance in RMR changes between different twin pairs but similarity within each pair. Genetics again. While some people may be able to lose weight by increasing their caloric expenditure by ramping up activity, others may lose far less or even maintain by performing the same amount of exercise.
So relying on the Stairmaster that tells you you've burned 500 calories in 45 minutes may give you a false sense of security. If we're unable to increase our metabolism as much as we'd like by doing aerobic exercise, why should we do it? Well, it is undeniably beneficial for our cardiovascular system, which is important, but doing too much may be counterproductive in terms of weight loss. Is there any kind of physical activity that does help prevent weight gain as we age? Resistance or strength training increases muscle mass, which increases RMR. Exercise also improves insulin sensitivity. I'm still doing the Ellen Barrett workouts I referenced in my previous post on aging, and they all have a strength-training component regardless of whether weights are used.
In terms of how to eat when doing resistance training, the classic approach is to have a high-protein meal immediately after working out in order to maximize muscle growth. However, Bill Lagakos over at the Calories Proper website offers an alternative idea: Fuel up with protein prior to working out so that the body has time to break it down into amino acids that will be available at the precise time the body needs them most. I like this approach myself and have always eaten prior to working out, even before reading Bill's great rationale for doing so.
Although losing fat rather than muscle becomes more difficult as we get older, following a very-low-carb diet may be the best way to achieve this. There is evidence that restricting carbohydrates to ketogenic levels (less than 50 grams per day) can preserve lean body mass during weight loss. When three 1800-calorie, low-carbohydrate diets (containing 30 grams, 60 grams, and 100 grams) were compared over a nine-week period, subjects following the 30-gram diet experienced the greatest retention of muscle tissue. For anyone already following a low-carb diet but having trouble losing weight, check out my recent Answers.com article to read about potential causes for your stall.
While it's nice to dream about, there's unfortunately no way to stop the aging process. However, we can at least try to slow it down somewhat and stay as healthy as possible through the transition. And I firmly believe that carbohydrate restriction coupled with right type of exercise can make a world of difference in this regard.
* Consult your doctor prior to starting a low-carbohydrate diet or engaging in physical activity.
1. Gkogkolou P, et al. Advanced glycation end products: Key players in skin aging? Dermatoendocrinol 2012 Jul 1; 4(3):259-70
2. Nagata C, et al. Association of dietary fat, vegetables, and antioxidant micronutrients with skin aging in Japanese women. Br J Nutr 2010 May;103(10):1493-8
3. Bouchard C, et al. The response to exercise with constant energy intake in identical twins. Obes Res 1994, 2(5):400-410
4. Young CM, et al. Effect of body composition and other parameters in obese young men of carbohydrate level of reduction diet. Am J Clin Nutr 1971, 24(3):290-296
While most of my recent posts have focused on the problems with studies, recommendations, and guidelines, I'm happy to say that there has been some very good news on the low-carb front over the past few weeks.
The American Diabetes Association's position paper on nutrition recommendations for people with diabetes
When I initially read this document, I was disappointed by the statement, “Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes.” It was hard to reconcile that first sentence with my knowledge of carb restriction's dramatic effect on blood glucose response. However, upon further reflection, I now view the statements made in this paper as being far more permissive of low carb than in the past. The ADA no longer says that a minimum of 130 grams of carbohydrate daily are required to meet the brain’s energy demands; in fact, they seem to accept the possibility of even very-low-carbohydrate intake, as evidenced by the sentence, “Some published studies comparing lower levels of carbohydrate intake (ranging from 21 grams daily up to 40% of daily energy intake) to higher carbohydrate intake levels indicated improved markers of glycemic control and insulin sensitivity with lower carbohydrate intakes.” So while the ADA also approves vegan, Mediterranean, and low-fat diets for diabetes management, carbohydrate restriction is now considered just as valid an option, which is very encouraging for the doctors, dietitians, and other healthcare providers who take this approach.
Positive portrayal of saturated fat in the British Medical Journal
Although not about carb restriction per se, in this article Dr. Asseem Malhotra explains that the blame for obesity, heart disease, and other health problems has been unfairly placed on saturated fat rather than excessive carbohydrate -- particularly sugar -- intake. Unfortunately, it looks like the full text is no longer available free of charge, so I hope you were able to read it in its entirety last week. It may be available again at some point. If anyone has a link to the full text elsewhere, feel free to leave it in the Comments section.
Diet article in The Consultant
A recent article by John Whyte, MD, in The Consultant comparing various diets is encouraging on several fronts. First, the author correctly describes the Atkins diet as low in carbohydrates and high in fat rather than high in protein. The many benefits of low-carbohydrate diets are discussed, including dramatic weight loss, particularly in the initial phases, improvements in lipid profiles and blood glucose levels, and lower blood pressure. On the downside, low-carb diets are characterized as “fad diets,” and a study linking lower carbohydrate intake to greater all-cause mortality is cited (Of course, that study was observational, the reported carbohydrate intake was fairly high at more than 30% of calories, and there were several limitations of the study, including the use of food frequency questionnaires to assess intake and misinterpretation of data regarding fat intake from animal vs. plant sources). However, the last sentence of the low-carb section sums up Dr. Whyte's overall feelings nicely:
“With these findings, in addition to the benefits of low-carbohydrate diets (not high protein, high fat content) on markers of cardiovascular risk, it is evident that low-carbohydrate diets could be considered in the lifestyle modifications of patients with diabetes.”
SUCCEED study comparing VLCKD vs. low fat diet in people with Type 2 diabetes
Researchers at the Osher Center for Integrative Medicine at the University of California San Francisco are recruiting people across the nation for the SUCCEED study, which will examine the effects of a very-low-carbohydrate ketogenic diet vs. a low-fat, conventional ADA diet on overweight people with Type 2 diabetes. Participants will take classes, have blood pressure checked and labs drawn to measure changes in biomarkers, and receive ongoing support and compensation over an eight-month period of time. You can contact the researchers if you're interested and meet the criteria; however, be prepared for the possibility that you end up being randomized to the low fat rather than low carb group.
I've heard that there will also be further studies investigating the effects of ketogenic diets on cardiovascular disease, cancer, and neurological diseases like Parkinson's and ALS based on favorable early research.
All in all, I’m feeling optimistic about carbohydrate restriction becoming more accepted by doctors and other healthcare providers, governmental organizations, and society in general. However, there's still a lot of work to be done, not the least of which is changing the perception of low carb as a “fad” diet. As we well know, carbohydrate restriction is a way of life that offers long-term blood sugar and weight management via appetite regulation and hormonal control. Nothing faddish about that.
Franziska Spritzler, RD, CDE