I'm really pleased with these results. My total LDL-P has dropped by 250 mmol/L and is now  borderline-high, as is my LDL-C, which has further declined from 177 mg/dL last June. My small LDL-P has always been low, but it's now less than 90 mmol/L. 

Elevated LDL-C, LDL-P, Insulin, and Cardiovascular Disease Risk

How important are LDL-C and LDL-P in terms of cardiovascular disease (CVD) risk? It depends who you talk to. I respect the opinions and expertise of the professionals below and believe they all provide valid arguments.

I asked Dr. Thomas Dayspring to review my most recent NMR report. He feels that although my LDL-P has improved, it still places me at greater than average risk for a cardiac event. He said that given my age and the fact that I'm in the latter stages of perimenopause, I should definitely monitor this and other values and make appropriate lifestyle adjustments as needed. Also, there's no arguing that I carry a lot of cholesterol in my HDL particles as well as LDL particles, and this cholesterol is transferred back and forth between all the particles within the bloodstream. He questioned whether the excess cholesterol is due to hyperabsorption, hypersynthesis, increased lipoprotein production and lipidation, or decreased clearance. Without further testing, there's no way to know for certain.

Dr. Dayspring is a very progressive lipidologist, and I highly recommend his LecturePad presentations (sign up for free, and you'll be able to access all content). In Part 1 of Have Cholesterol Measures Outlived Their Usefulness, he explains the reason oatmeal and other whole grain cereals aren't a good choice to increase fiber intake for most people, why triglyceride levels should optimally be less than 100 mg/dL, and the dangers of relying on LDL-cholesterol measurements to evaluate degree of cardiovascular risk. In Part 2,  he discusses the importance of controlling insulin resistance (IR); the interplay between hyperinsulinemia, hyperleptinemia, and appetite; and the benefits of carbohydrate restriction for those with metabolic syndrome: "Dr. Atkins was right." 

Although in my other blog post I referred to an article where he recommended statin therapy for anyone with an LDL-C level greater than 190 mg/dL, more recently, he said: 

"That was written some time ago.  I'd now amend that everyone with moderate to high lifetime risk for CVD events as determined by lipid/lipoproteins, family history, examination (BP, xanthomata) and smoking history - not simply LDL-C by itself."

Dr. Dayspring also provides interesting information in the Cellular Regulation of Sterols lecture series, including the fact that vegans (who consume no animal products and therefore no cholesterol) absorb the same amount of cholesterol  from the gut as do meat eaters and lacto-ovo vegetarians (about 55%, on average), but in their case, it's entirely biliary in nature as a result of the gallbladder releasing hepatic cholesterol into the intestine. Even in non-vegans, most of the cholesterol in the gut comes from the bile rather than the food we eat, which is why limiting egg consumption doesn't make sense as a strategy for lowering cholesterol levels. Even people who absorb more cholesterol than average ("hyper-responders") experience only mild elevations in serum cholesterol concentrations when dietary cholesterol is increased (2).

Ivor Cummins is a chemical engineer known on social media sites as The Fat Emperor and is a prolific blogger on his website of the same name. He's spent a great deal of time studying and writing about the role insulin and a high-carbohydrate diet play in CVD risk. While he agrees with Dr. Dayspring that LDL-P count is important, he feels that the combination of small, dense LDL particles and high insulin levels are the root cause of coronary artery disease (CAD) (3). He also believes maintaining adequate vitamin D3 levels is crucial to cardiovascular health, and I've recently seen him advise people with genetic defects (such as ApoE4) and very elevated LDL-P to replace a portion of saturated fat with monounsaturated fat and long-chain omega-3 fats. In addition to blog posts, he has several great videotaped lectures on his website, including "The Cholesterol Cunundrum."

Dr. Peter Attia is a very-low-carbohydrate, ketogenic diet proponent who believes that elevated  LDL-P values warrant dietary modification, including reduction in saturated fatty acid (SFA) intake. In a recent blog post, he  describes a patient whose LDL-P dropped from 3500 to 1300 as a result of cutting saturated fat intake down to 25 grams per day while remaining on a ketogenic diet. He goes on to say:

"While I believe the population-based guidelines for SFA are not supported by a standard of science I consider acceptable, it does not imply I believe SFA is uniformly safe at all levels for all individuals."

A few years back he wrote a 9-part series of blog posts entitled The Straight Dope on Cholesterol, which received a lot of attention and great feedback. Unfortunately, I've only read the first 2 parts at this point, but I'm hoping to read the entire series soon.

Dr. Spencer Nadolskey is a family physician who promotes a whole foods diet and healthy lifestyle. He's recently done some experimenting with different diets (low-carb and vegan) and reported the changes in his biomarkers with each. He has a very balanced and moderate approach to health and wellness, recognizing the importance of taking people's preferences and individual responses into account when making dietary recommendations.

As I said in my original blog post, most people who follow a low-carbohydrate, high-fat diet don't experience significant elevations in lipids as I did, although it's estimated that at least 25% do. In fact, Dr. Attia states in the blog post I linked to above that even when he was consuming 40% of his calories as saturated fat while following a very-high-calorie ketogenic diet, his biomarkers actually improved. 

Increased vs. Decreased Risk for Cardiovascular Disease

ApoE genotype Apolipoprotein (Apo) E is a regulator of plasma lipid levels. I have two copies of the ApoE3 gene (3,3), which carries a low risk for atherosclerosis and cognitive disorders including Alzheimer's disease (4). Those with the ApoE4 genoptye, who often have elevated cholesterol levels and are at increased risk for developing CAD, dementia, and other diseases, may find the ApoE4 Forums Heart Disease Discussion helpful for information and support.

Family history Regardless of genetic markers, a strong family history of heart disease is another risk factor for a cardiac event. Allthough I don't have the ApoE4 genotype or familial hypercholesterolemia (FH), several of my family members have had CAD.  My mom, who has stable atherosclerosis, has been on a low-dose statin for over 10 years. She is thin, active, and has never had any markers of insulin resistance (her lipid profile is remarkably similar to my own), although she was a long-term smoker before quitting eight years ago.

BMI and waist-to-hip ratio (WHR) My BMI is 19 (under 23 is optimal), and my WHR is 0.7 (less than 0.8 is optimal for women in terms of cardiac risk). 

LDL-P  Larger particles are generally considered less atherogenic than small, dense particles.  I have very low small LDL-P and borderline-high LDL-P. While some would argue that my large LDL-P poses no concern, it's still higher than what's considered optimal. Also, in a study published after my initial blog post, large numbers of small and large LDL particles were both associated with increased CVD risk when compared with medium LDL particles (5). In addition, the MESA study researchers, who investigated CAD risk in more than 5000 people, reported this finding regarding carotid intima thickness (CIMT or IMT), a measure of subclinical atherosclerosis in the walls of the artery:

"Without accounting for LDL subclass correlation, small LDL and smaller LDL size were associated with IMT but large LDL was not. However, after accounting for their inverse correlation, both LDL subclasses showed highly significant and independent associations with IMT, with a greater difference in IMT per large LDL particle compared with small LDL. Smaller LDL size was no longer significant after taking into account the particle concentrations of the two LDL subclasses and risk factors. Thus, small LDL was a strong confounder of the association of large LDL with subclinical atherosclerosis, which may explain the widely-held view that larger LDL size is less atherogenic (6)."

Triglycerides, HDL-C, and HDL-P Low fasting triglycerides, high HDL cholesterol, and a large number of HDL particles are considered cardioprotective. Fortunately, I meet the criteria for all three. However, per Dr.Dayspring, my HDL-C/HDL-P ratio of 67 suggests potential dysfunction:

"In a recent study, individuals with the highest HDL-C/HDL-P ratios (>53) had a significant 1.5-fold increase risk for atherosclerosis progression compared with individuals with the lowest HDL-C/HDL-P ratio (<41) (7)."

However, at this point we don't really know whether my risk is increased, and I'm comfortable with these values but will continue to monitor them.

Interestingly, 4 years ago, when I was following a low-fat diet with at least 50% of calories from carbohydrate, my triglycerides were 55 mg/dL, and my HDL was already quite high at 79 mg/dL.  I think it's  safe to say that I'm not inherently insulin resistant. 

Insulin levels I've had fasting insulin tested three times within the past three years, and each time my level was between 1 and 2 mIU/mL, which is considered very low ("Normal" ranges from 1 to 10 mIU/mL). Researchers have known about the connection between elevated insulin levels and heart disease risk for decades (8), and Ivor Cummins has discussed this extensively on his blog and in his lectures.

Fasting blood glucose, postprandial blood glucose, and A1c Elevated blood glucose, even at prediabetes levels, causes damage to endothelial cells that greatly increases CVD risk (9). My fasting blood glucose levels are consistently in the 80s, and 1-2 hours after eating, I am always under 130 mg/dL. I have an A1c every 6 months, and it has been 5.1-5.2% for the past 3 years. Prior to going low carb, my A1c was 5.6%, and my postprandial blood glucose values were routinely higher than 160 mg/dL.

Age I'll be 49 this year, and as stated above, I'm transitioning into menopause, when changes in hormones, lipids, and body fat distribution increase CVD risk (10).

Low-carbohydrate diets are clearly beneficial for reducing CVD risk in people with metabolic syndrome and type 2 diabetes (11). But what about people with type 1 diabetes or those like me, who don't have IR  but follow a carbohydrate-restricted lifestyle for blood glucose issues, weight control, or simply because they feel better when they eat this way? 

My Diet

I track what I eat in My Fitness Pal most days and have been doing this for over a year. While the nutritional information for the food database isn't completely accurate (as I'm sure anyone who uses it would agree), it does give a good general idea of caloric and macronutrient intake.

Carbohydrates:  I eat 30-45 grams of net carbohydrate per day consistently. Carb sources include nonstarchy vegetables, berries, Greek yogurt, cottage cheese, nuts, and dark chocolate.

Fiber:  My fiber intake is very high, roughly equal to my net carb intake. A typical day includes half a large avocado, 1 cup of blackberries or raspberries, 2-3 oz unsweetened chocolate or cocoa (more than half the carbs come from fiber), 2 Tbsp flaxseed and/or chia seeds, 3-4 oz nuts, and 4-6 cups of nonstarchy vegetables. Fiber helps lower cholesterol levels yet doesn't appear to compromise absorption of fat-soluble vitamins and other nutrients (12).

Total Fat:  According to My Fitness Pal data, my fat intake ranges from 80-100 grams, which is around 50-60% of my caloric intake (I'm usually between 80-90 grams).  Monounsaturated fat accounts for the largest percentage, and primary sources are avocado, olives, nuts, and meat. Eating fatty fish like sardines or salmon 3-4 times a week ensures that I get plenty of long-chain omega-3 polyunsaturated fats, including docosahexaenoic acid (DHA), which is anti-inflammatory and believed to be cardioprotective (13).

Saturated Fat:  I don't deliberately set a limit, but I generally end up consuming 20-30 grams of saturated fat daily. Although I'm  usually on the lower end of that range, this still allows for modest amounts of cheese, half-and-half, coconut oil, butter, and fatty meat.

Protein: I've discovered that I feel best and most energetic with a relatively high protein intake of around 100 grams per day, which is just over 1.75 grams per kilogram body weight. 

Am I in ketosis? I rarely check urine ketones anymore, but when I do they're usually trace or negative. Ketosis has never been my goal (aside from the 3-month experiment I discussed in the prior blog post); keeping blood glucose levels and other biomarkers under control, looking and feeling my best, and eating a healthy, well-balanced diet are what's important to me. However, I realize that for some people, ketosis can be beneficial and desirable.

Further Testing

What about having Coronary Artery Calcium (CAC) scoring, a CIMT, or other tests to rule out subclinical atherosclerosis? According to Dr. Dayspring, CAC testing isn't advisable for women younger than 60, who usually get a zero score even if trouble is brewing. He believes that a CIMT can be useful if done correctly.

Here are his recommendations for further testing in my case, some of which I've already had done. I plan to do the rest within the next year or so.

Sterol synthesis and absorption markers
Omega 3 index
Inflammation markers: MPO, Lp-PLA2, hs-CRP 
Once per lifetime tests: ApoE, MTHFR genotypes and Lp(a) level (I'm negative for ApoE and MTHFR genotypes but haven't had Lp(a) done yet)
Homocysteine (I received a score of 8 on a scale of 4-15 umol/L when last done 2 years ago)
Vitamin D (50 ng/ml as of February 2015, which is considered within the optimal range)  


On Not Taking Sides

I'm a very moderate person. I don't like confrontation and dislike the "us vs. them" mentality. It probably won't come as any surprise that I'm a registered independent and vote Democratic as often as I do Republican (and increasingly frequently  for another party altogether). In addition to the experts listed above, I like and respect the diversity of opinions on this subject that have been voiced by many other knowledgeable people, whether or not they're advocates of carbohydrate restriction.

It's generally agreed within the low-carb community that people have different levels of carbohydrate tolerance. So why is it considered heresy to propose that the same might be true with respect to optimal saturated fat intake?  

As I said earlier, I think we still don't know enough about what kind of risk elevated LDL-P and very high LDL-C carry in the setting of a very-low-carb diet where other markers improve. Because of this, I choose to eat in a way that allows me to enjoy all the benefits of carbohydrate restriction yet keeps my LDL particle number at a level I feel comfortable with. Some may think I've gone too far in making changes to my diet in order to improve my numbers; on the other hand, I'm sure there will be others who feel I haven't gone far enough, since my levels still aren't considered "optimal." I understand both points, but I have to go with my gut on this one. Ultimately, it's up to you to decide what feels right for you given what we currently know and don't know.

References

1. Phinney SD, et al. The transient hypercholesterolemia of major weight loss. Am J Clin Nutr. 1991 Jun;53(6):1404-10.
2. Fernandez ML. Effects of eggs on plasma lipoproteins in healthy populations. Food Funct 2010 Nov;1(2):156-60 
3. Phillips MC. Apolipoprotein E isoforms and lipoprotein metabolism. IUBMB Life. 2014 Sep;66(9):616-23
4. Lamarche B, et al. Fasting insulin and apolipoprotein B levels and low-density lipoprotein particle size as risk factors for ischemic heart disease. JAMA. 1998 Jun 24;279(24):1955-61.
5. Grammer TB, et al. Low-density lipoprotein particle diameter and mortality: the Ludwigshafen Risk and Cardiovascular Health Study. Eur Heart J. 2015 Jan 1;36(1):31-8.
6. 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.
7. Qi Y, et al. Cholesterol-overloaded HDL particles are independently associated with progression of carotid atherosclerosis in a cardiovascular disease-free population: a community-based cohort study. J Am Coll Cardiol. 2015 Feb 3;65(4):355-63.
8. Després JP, et al. Hyperinsulinemia as an independent risk factor for ischemic heart disease. N Engl J Med. 1996 Apr 11;334(15);952-7.
9.Maschirow L, et al. Inflammation, coagulation, endothelial dysfunction and oxidative stress in prediabetes - Biomarkers as a possible tool for early disease detection for rural screening.2015 Mar 6.  pii: S0009-9120(15)00071-5.
10.  El Khoudary SR, et al. Progression Rates of Carotid Intima-media Thickness and Adventitial Diameter during the Menopausal Transition. Menopause (New York, NY). 2013;20(1):8-14.
11. 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. 
12. Ramprasath VR, et al. Consumption of a dietary portfolio of cholesterol lowering foods improves blood lipids without affecting concentrations of fat soluble compounds. Nutrition Journal. 2014;13:101. 
13. Richard D, et al. Infusion of docosahexaenoic acid protects against myocardial infarction.ProstaglandinsLeukot Essent Fatty Acids.2014 Apr;90(4):139-43. 

Over the past few months, several women have contacted me  expressing frustration at being unable to lose weight despite strictly following a LCHF diet. When I ask whether they're including high-fiber plants like brussels sprouts, berries, nuts, and dark chocolate, the response is typically, "I avoid those because they're so high in carbs. I limit my carbs to less than 20 grams total." This is the trend I've noticed lately in the low-carb community: the belief that limiting vegetables and other high-fiber plants in an attempt to keep carbohydrate intake at an absolute minimum (sometimes as low as 10 grams of total carbohydrates per day) long term is the key to losing weight.

Soluble Fiber's Role in Improving Blood Glucose Regulation

A few weeks ago, Martina from the KetoDiet App website wrote an excellent blog post about counting net carbs vs. total carbs for those following a carbohydrate-restricted lifestyle. In the article, she correctly states that insoluble fiber passes through your system without being absorbed, so it should be subtracted from the total carbohydrate count. In addition, Martina explains that, unlike insoluble fiber, soluble fiber does not pass through the colon but rather is fermented into short-chain fatty acids (SCFAs) by our gut bacteria. 

The principal SCFAs are acetate, butyrate, and propionate. Of these, propionate is the only one that can be converted into glucose via gluconeogenesis (1). But would this have any significant effect on postmeal blood glucose given that most fiber is insoluble and only 15-40% of any soluble fiber will be converted to propionate (2)? Take brussels sprouts, for instance, one of the few foods that contains more soluble than insoluble fiber. A 1-cup serving has about 4 grams of soluble fiber. Less than 2 grams will be converted into propionate, and the amount of glucose produced from it via hepatic gluconeogenesis would be quite small, so serum blood glucose levels wouldn't be affected much.

More importantly, as Martina pointed out, De Vadder, et al, recently reported the results of a study on mice suggesting that SCFAs promote intestinal gluconeogenesis (IGN), with propionate acting as substrate and butyrate promoting the expression of genes necessary to induce this process. Compared with control mice fed their normal diet, mice who were fed diets enriched with SCFAs and fructo-oligosaccharides (FOS) experienced lower fasting serum blood glucose levels, improved glucose tolerance, and a significant reduction in the enzyme responsible for hepatic gluconeogenesis (3). Essentially, propionate is converted to glucose, which is used within the intestine, decreasing the amount of glucose produced by the liver, resulting in the above-mentioned benefits. Yes, this was an animal study, but it provides an intriguing explanation for the improvement in blood glucose levels seen in human studies examining the role of dietary fiber (4, 5).

Blood glucose response to fiber-rich food may differ among some people with Type 1 diabetes, whose blood glucose levels can reportedly rise as a result of higher food volume in the stomach or other stimuli, regardless of digestible carbohydrate intake. Dr. Bernstein and others with T1 have suggested such a response (what he calls The Chinese restaurant effect), but I know of no studies confirming this and would appreciate references if anyone has them.

Health Benefits of Fiber and SCFAs

We've known about the benefits of fiber on colon health for decades. Although it's believed these are due in part to insoluble fiber's ability to reduce intestinal transit time so potentially carcinogenic substances in our food spend as little time as possible in our GI tract, more recent research suggests that fiber's chemoprotective effects may be due primarily to the effects of one of the SCFAs, butyrate (6,7), which provides energy and nourishment for the cells of the colon.

In addition, higher fiber intakes may reduce levels of C-reactive protein (CRP) and other inflammatory markers, improve our immune response, and protect the gut from harmful microorganisms that can make us ill (8). In essence, fiber's fermentation to SCFAs helps keep our gut well nourished and working the way it should. 

Increasing High-Fiber Carbohydrate Intake May Be Helpful for Weight Loss

Let's go back to restricting intake to less than 20 grams of total carbohydrates in order to lose weight. When carbohydrate intake is this low, there's a limited number of foods that can be eaten: meat, cheese, fish, eggs, butter, cream, coconut oil, olive oil, and small amounts of greens and other very-low-carb vegetables. Yes, carbohydrate intake may be well below 20 grams of total carbs daily, but depending on portions consumed, calorie/energy intake  may be too high to promote weight loss. A serving of bullet-proof coffee contains 440 calories, zero carbs, zero protein, and zero fiber.

Aside from fiber's beneficial effects on overall health outlined above, consuming at least a moderate amount of fiber can facilitate weight loss, and both insoluble and soluble fiber can be helpful in this regard.

Insoluble fiber passes through the body without being absorbed. It adds volume to meals, but zero calories and zero carbohydrates. In fact, you could almost say that insoluble fiber provides negative calories, in that it may lower the amount of energy derived from fat and protein when all three are consumed at a meal (9).  Most foods are higher in insoluble than soluble fiber, with a few exceptions (Please refer to Martina's fiber chart in the blog post linked to above).

Soluble fiber does contribute calories/energy to the body, but no carbohydrates. The chief benefits provided by soluble fiber are due to its fermentation to the SCFAs acetate, butyrate, and propionate, which have been shown to promote satiety, reduce intake, and and decrease body fat (3,10-11).

Carbohydrate and Fiber: What's Optimal?  

Like carbohydrates, fiber is another substance where across-the-board recommendations can't be made, but I think it's best to aim for at least 20 grams daily, with 1/3 or more from soluble fiber. If you're limiting yourself to less than 20 grams of total carbohydrate, the maximum amount of fiber you can possibly get is 18 grams, and that's only if the carbs come from foods that are more than 90% fiber, such as chia seeds, flaxseed, or avocado. Generally speaking, those who consume diets containing less than 20 grams of total carbohydrate end up with 10 or fewer grams of fiber. Some people reportedly consume less than 5 grams on a consistent basis.

The goal of carbohydrate restriction is to keep blood glucose and insulin levels low, and this can be accomplished without reducing carbs to near-zero levels. I consume around 30-45 grams of fiber daily, and my net carb intake is around 35-50 grams, so my fiber to nonfiber carb ratio is roughly 1:1. This works well for me, but some people do better with 20-30 grams of fiber and slightly lower net carb intake. People with certain GI disorders* may require restriction of certain types and amount of fiber.

How do you get to 30 grams of fiber yet still maintain net carb intake of less than 40 grams? Here's one of the sample menus with recipes that will be included in my upcoming book, The Low Carb Dietitian's Guide to Health and Beauty. 

Sample Low-Carb, High-Fiber Menu

Breakfast:
Cinnamon Flaxseed Pudding*
1 cup blackberries 
Coffee or tea with 2 Tbsp half and half

Lunch:
Insalate Caprese*
1/2 oz dark chocolate (at least 85% cocoa)
Water, tea, or other sugar-free beverage

Snack:
3 celery stalks with 1 Tbsp almond butter

Dinner:
Chicken Curry*
Chocolate Avocado Pudding*
Water, tea, or other sugar-free beverage

Daily totals:
Calories: 1575
Protein: 88 grams 
Total Carbohydrates: 68 grams
Fiber: 31 grams
Insoluble Fiber: 20 grams
Soluble Fiber: 11 grams
Net Carbohydrates: 37 grams
Fat: 108 grams 

Recipes:

Cinnamon Flaxseed Pudding
Number of Servings: 1

Ingredients:
½ cup cottage cheese
2 Tbsp ground flaxseed
½ tsp cinnamon
3 Tbsp chopped toasted pecans
Stevia or other sweetener, if desired

Directions:
Combine all ingredients in small bowl.

Insalate Caprese
Number of Servings: 1

Ingredients:
4 oz fresh mozzarella cheese, sliced into ¼-inch rounds
1 large vine-ripened tomatoes, sliced ¼-inch thick
1/2 cup fresh basil leaves
Coarse sea salt, to taste
2 Tbsp cup extra-virgin olive oil

Directions:
On a plate, alternate mozzarella slice, then tomato slice, followed by basil leaf, and repeat sequence, overlapping each item slightly. Sprinkle salt and drizzle olive oil over top. 

Chicken Curry
Number of Servings: 4

Ingredients:
2 Tbsp coconut oil
1 cup chopped onion
2 tsp sea salt
2 tsp chopped garlic
2 tsp ground ginger
2 tsp coriander
1 tsp turmeric
1 tsp chili powder
4 cups broccoli florets
2 cups snow peas
2 cups mushrooms
½ cup coconut milk
1 lb chicken breast, cut into bite-sized pieces

Directions:
Heat oil in a wok or large saucepan over medium-high heat. Add the onion, then cook and stir until browned. Mix in garlic and spices. Add broccoli, pea pods, and mushrooms. Cook and stir for 1-2 minutes.
Add coconut milk and chicken. Reduce heat to medium and cook for 7 to 8 minutes, until chicken is no longer pink. Stir and remove from heat. Serve immediately.

Chocolate Avocado Pudding
Number of servings: 4

Ingredients:
2 medium very ripe avocados
½ cup unsweetened coconut milk
½ cup unsweetened cocoa powder
1 cup erythritol or other granulated sugar substitute equivalent to sweetness of ¾ cup sugar
2 tsp vanilla extract

Directions:
Cut avocado in half, remove pit, and scrape flesh into food processor or blender. Add coconut milk, cocoa powder, sweetener, and vanilla extract. Process until ingredients are well combined and there are no lumps of avocado. Divide into four dishes and refrigerate at least 30 minutes or until ready to serve.

                                                             
Roasted Brussels Sprouts Recipe

And for anyone who was hoping for a brussels sprouts recipe after seeing the photo and reading about their high soluble fiber content, please check out this delicious side dish, Roasted Brussels Sprouts with Pecans, from Kalyn's Kitchen.
                                                         
A Balanced Low Carb Diet: Eat Plenty of Plants and Animals


If you're consuming less than 20 grams of carbohydrate daily and achieving your weight loss goals, I'm very happy for you. But I would consider adding at least a few grams of high-fiber carbohydrates -- such as vegetables, berries nuts, and dark chocolate -- to optimize overall health and increase your likelihood of long-term success. And if your weight loss has stalled, I definitely recommend increasing your intake of these foods and perhaps decreasing fat and increasing protein intake, depending what you're doing currently. A  sustainable low-carb lifestyle consists of a balance of nutritious animal and plant foods, based on personal tolerance, preferences, and goals. 

                                                                                 * * *
*For those with small-intestinal bacterial overgrowth (SIBO) or other conditions requiring a low-reside diet, such as acute diverticulitis or other inflammatory bowl conditions, the recommendations for fiber intake provided in this article may be contraindicated. Consult your healthcare provider, who can provide guidance or refer you to a dietitian for recommendations.


References

1.Mithieux G, et al. Intestinal glucose metabolism revisited. Diabetes Res Clin Pract. 2014 Sep;105(3):295-301
2. Bergman EN, et al. Energy contributions of volatile fatty acids from the gastrointestinal tract in various species. Physiol Rev. 1990 Apr;70(2):567-90
3. De Vadder F, et al. Microbiota-generated metabolites promote metabolic benefits via gut-brain neural circuits. Cell. 2014 Jan 16;156(1-2):84-96
4. Post, RE, et al. Dietary Fiber for the Treatment of Type 2 Diabetes Mellitus. J Am Board Fam Med Jan-Feb; 25:16-23, 2012 
5. Aller R, et al. Effect of soluble fiber on lipid and glucose intake in healthy subjects: a randomized clinical trial. Diabetes Res Clin Pract. 2004; 65(1): 7-11
6. Cho Y, et al. Colon cancer cell apoptosis is induced by combined exposure to the n-3 fatty acid docosahexaenoic acid and butyrate through promoter methylation. Exp Biol Med (Maywood) 2014;239(3):302-310
7. Fung KY, et al. A review of the potential mechanisms for the lowering of colorectal oncogenesis by butyrate. Br J Nutr. 2012 Sep; 108(5):820-31
8. Levison ME, et al. Effect of Colon Flora and Short-Chain Fatty Acids on Growth In Vitro of Pseudomonas aeruginosa and Enterobacteriaceae. Infect Immun. Jul 1973; 8(1): 30–35
9. Baer DJ et al. Dietary fiber decreases the metabolizable energy content and nutrient digestibility of mixed diets fed to humans. J Nutr. 1997 Apr;127(4):579-86
10.Darzi J, et al. Do SCFA have a role in appetite regulation? Proc Nutr Soc. 2011 Feb;70(1):119-28
11. Lin HV, et al. Butyrate and propionate protect against diet-induced obesity and regulate gut hormones via free fatty acid receptor 3-independent mechanisms. PLoS One. 2012;7(4):e35240

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.

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.

A couple of months ago, I wrote a blog post entitled, Why Are Many Dietitians So Critical of Low-Carbohydrate Diets?  Subsequently, someone asked me  if I thought dietitians were more bothered by the low carb or high fat aspect of a carbohydrate-restricted diet. I said it would really depend on the RD, but because most have been trained and therefore believe that that the brain needs a minimum of 130 grams of carbohydrates per day to function, that would probably be the primary concern. However, I'm starting to rethink that answer, particularly with respect to saturated fat.

My friend and fellow RD and CDE Aglaee Jacob wrote a wonderful article for this month's issue of Today's Dietitian entitled "Coconut Oil: Learn More About this Superfood that Contains Healthful Saturated Fats."  In it, she outlines the many benefits of coconut's medium-chain triglycerides (MCTs) on neurological health, weight, and cardiovascular disease, among other issues. Aglaee previously wrote an article for the same publication on carbohydrate restriction for diabetes management which didn't prompt much of a response from their readership (although her previous article about  a high-fat elimination protocol for gut health didn't sit well with one RD). Apparently, characterizing coconut oil as a "superfood" and explaining the benefits of saturated fats went a little too far for many other dietitians. Aglaee received a message from the Today's Dietitian editor informing her that many RDs were upset by her article, particularly her assertion that saturated fats are not associated with heart disease. The editors are allowing her to publish a response, although they are uneasy about the extent of the criticism. Several other progressive RDs and I have written the editor in support of Aglaee's article and her position, along with providing supporting literature on saturated fats, and I'm confident that her published response will be as clear and convincing as the previous one defending her approach to gut health.

I find it concerning that saturated fats and trans fats are repeatedly lumped together as "bad fats," when their properties and effects on health are very different. The former are natural and most are healthy, depending on the chain length and type, and have been consumed by human beings for thousands of years.  Trans fats, on the other hand, are highly processed, inflammatory, cause unfavorable changes to serum lipids, and frankly our bodies don't know how to deal with them. Unfortunately, many dietitians believe saturated fat contributes to heart disease and must be minimized, if not avoided altogether, despite the lack of evidence in this regard.

It's interesting that Today's Dietitian -- a publication I read and enjoy, as it often provides a lot of great information for RDs -- recently offered a guide from SCAN (Sports, Cardiovascular And Wellness Nutrition Dietetic Practice Group of the Academy of Nutrition & Dietetics) entitled 10 Simple Steps to Make Good Nutrition More Delicious, yet very few dietitians took issue with the fact that this resource is funded by a grant from the makers of Country Crock and I Can't Believe It's Not Butter! margarines.  Although these margarines no longer contain trans fats, they do contain interesterified fats, which are highly processed and, according to early research, may be just as problematic. Natural fats like butter and coconut oil should be discouraged, and we as RDs are supposed to promote these manufacturated fats instead? This doesn't make sense to me.  

For the record, while I'm disappointed in some of the corporate sponsors of Today's Dietitian, I truly appreciate their publishing of Aglaee's forward-thinking articles despite the controversy they ignite. I believe they strive for a balanced approach that will appeal to a broad range of nutrition professionals, which is laudable given the recommendations that come from many of the major health organizations.

When I see dietitians writing columns about low-carb recipes , the overwhelming majority are promoting foods that are low in both carbohydrates and fat.  I'm very happy that some are willing to offer meal planning ideas that limit grains or starches, but the fat content is often unnecessarily low. Egg whites, low-fat cheese, and extra-lean turkey figure prominently in the low-carb recipes I've seen from dietitians online. I will agree that certain people with familial hypercholesterolemia, a relatively rare condition, may need to limit fat intake. Also, for individuals consuming a high-carbohydrate diet, cutting back on saturated fat may be wise. But on a carbohydrate-restricted diet, fat is required as the primary energy source, with saturated and monounsaturated fats being the preferred forms for this purpose. There is a limited amount of protein the body can use effectively, and a very-high-protein, low-carbohydrate, low-fat diet is unsustainable and unhealthy.

I propose that it's time to stop the fat phobia and encourage our patients and clients to eat natural sources of saturated, monounsaturated, and (in smaller quantities) certain polyunsaturated fats in order to optimize rather than jeopardize their health with processed fats that have known and unknown adverse side effects. And the "natural" list includes coconut oil, for all the reasons so eloquently stated by Aglaee in her article.

References:
1. Siri-Tarino P, et al. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr 91:535–546, 2010
2. Lawrence G. Dietary fats and health: dietary recommendations in the context of scientific evidence. Adv Nutr 1;4(3):294-302, 2013
3. Sundram K, et al. Stearic acid-rich interesterified fat and trans-rich fat raise the LDL/HDL ratio and plasma glucose relative to palm olein in humans. Nutr Metab (Lond)15;4:3, 2007

While doing research for one of my Answers.com articles, Defending Your Low-Carb Diet, I found an interesting article on WebMD. I know that much of the information found online is critical of carb restriction, but I was unprepared for the claims made on this website, which is extremely popular and considered a trusted source by many Americans. 

First of all, the article discusses "high-protein, low-carbohydrate diets" and defines "high protein" as 30-50% of caloric intake. Aside from the Stillman diet and perhaps the diets of a few bodybuilders, I don't know of any other popular low-carb plans that recommend more than 30% of calories from protein. On a 2000-calorie diet, 30%  is 150 grams of protein, and 50% is 250 grams. Most low-carb diets are moderate in protein, although some people may consume higher amounts. This article purports to talk about the risks vs. benefits of high-protein, low-carbohydrate diets, but the "benefits" are glossed over, and several of the statements seem to denigrate carb restriction in particular. 

According to Web MD,  high-protein, low-carb diets can cause many health problems:

• Kidney failure  This is untrue in the case of people with healthy kidneys. Although individuals with advanced kidney disease may need to restrict protein, there is no evidence that a high-protein, low-carb diet damages renal function (1).
• High cholesterol  The article states "It is well known that high-protein diets (consisting of red meat, whole dairy products, and other high fat foods) are linked to high cholesterol. Studies have linked high cholesterol levels to an increased risk of developing heart disease, stroke, and cancer."  First off, low-carb diets don't always result in elevated cholesterol levels. And in the vast majority of cases, lipid profiles become more favorable in terms of particle size and number, improved HDL to cholesterol ratio, and lower triglycerides, resulting in less risk of cardiovascular disease and stroke. The exception would be people with familial hypercholesterolemia, who may need to limit dietary fat and cholesterol and replace most foods high in saturated fat with items containing monounsaturated fat like olive oil. With respect to cancer, older and recent research has demonstrated that it is associated with lower rather than higher cholesterol levels (2,3). 
• Osteoporosis  Studies indicate this is not a concern with high protein consumption provided intake of   plants -- ie, nonstarchy vegetables -- is adequate (4).
• Cancer  It's irritating to repeatedly read the assertion that low-carb diets don't provide vitamins, minerals, fiber, and antioxidants. There are loads of micronutrients in animal products, and the vegetables, berries, nuts, and avocado consumed on carbohydrate-restricted diets supply plenty of fiber and antioxidants.
• Unhealthy metabolic state (ketosis)  The information on ketosis in this article was contradictory but predominantly negative. On the one hand, the benefits of ketosis (switching to fat burning, weight loss, reduced appetite) are discussed early in the article, but later:  "During ketosis, the body forms substances known as ketones, which can cause organs to fail and result in gout, kidney stones, or kidney failure." Where is the evidence for this statement?  Children with epilepsy following extremely low-carb ketogenic diets (about 10 grams of carb per day) were found to be at greater risk of developing kidney stones (5), but as far as I know, this hasn't been seen in adults following VLC diets that include nonstarchy vegetables and berries. As far as gout, people who already have the condition will need to continue to monitor their uric acid levels, and they would benefit from eating alkalizing plant foods like vegetables in addition to protein and fat. However, there is no evidence that ketogenic diets cause gout, and because this condition is  related to insulin resistance, outcomes may actually improve on a carb-restricted diet.  Finally, there is no evidence that ketogenic diets cause kidney failure; in fact, preliminary research suggests they may actually reverse kidney damage (6).

In the summary, "Is Low Carb Right for Me?" the writer states that carb restriction is dangerous, particularly for those with heart disease, and that low-carb diets don't allow a high intake of fruits and vegetables. I strongly disagree.  I believe this way of eating is beneficial for people with heart disease for the reasons listed above, as well  as improvements in hyperinsulinemia, hyperglycemia, and hypertension. And there are plenty of plant foods allowed on a low-carb diet. I eat vegetables at every meal, a few servings of nuts a day, berries once a day, and avocado just about every day on my VLC diet. I probably get more vegetables than most people do, along with more fiber and antioxidants. 

Although I guess I shouldn't be surprised, it concerns me that such a highly critical and inaccurate article was published on WebMD.  Perhaps there are even worse articles written on medical sites considered reputable? In my opinion, using scare tactics to discourage people from adopting a carbohydrate-restricted diet is troubling, particularly since this way of eating has had such a positive impact on a significant number of people and has the potential to improve the lives of so many others.

* Although low-carbohydrate diets are safe and healthy for most people, it's important to speak with your doctor prior to adopting a low-carb diet or making other dietary changes.

References:
1. Friedman AN, et al. Comparative effects of low-carbohydrate, high-protein vs. low-fat diets on the kidney. Clin J Am Soc Nephrol. 2012 Jul;7(7):1103-11
2. Kritchevsky SB, et al. Serum cholesterol and cancer risk: an epidemiologic perspective. Annu Rev Nutr. 1992; 12:391-416.
3. Strohmaier S, et al. Total serum cholesterol and caner incidence in the metabolic syndrome and cancer project (ME-CAN).J Epidemiol Community Health 2011; 65:A302 doi:10.1136/jech.2011 
4. Barzel US, et al. Excessive dietary protein can adversely affect bone. J Nutr 128:1051-1053, 1988
5. Sampath A, et al. Kidney stones and the ketogenic diet: risk factors and prevention. J Child Neurol. 2007 April:22(4):375-378
6. Poplawski MM, et al. Reversal of nephropathy by a ketogenic diet. PLoS One 6:1–9, 2011

We just returned from a two-week European vacation and thoroughly enjoyed it! We visited London for the first time and were very impressed by this amazing city that has the energy and culture of New York along with the history and architecture of other European cities. We also spend a few days in Zurich visiting my relatives, as we do whenever we're on the other side of the Atlantic.

In England, my husband and I met up with a UK-based dietitian  named Annette Henry who is currently working on her PhD conducting research on carbohydrate restriction, appetite regulation, and weight loss. We also spent an afternoon with Eddie and Jan Mitchell from The Low Carb Diabetic website. Eddie has Type 2 diabetes and eats a low-carb diet in order to maintain healthy blood glucose levels, weight, and lipids. Jan follows the same way of eating. We had a fantastic time with each of these fellow low-carb advocates and shared a real sense of camaraderie and purpose. 

In terms of carb-friendly dining options, the airlines apparently don't have much of an understanding. Here's a photo of the dinner I was served on the plane. I ordered a "diabetic meal," and this is what it consisted of (carb content approximated):
5 oz grilled chicken breast
1 large roll (30 grams carb)
1 cup white rice (45 grams carb)
1 cup mixed fruit (15 grams carb)
1/2 cup cooked vegetables (5 grams carb)
Mixed salad with fat-free vinaigrette (8 grams carb)

I ask you: Is this meal containing around 100 grams of carbohydrates appropriate for someone with diabetes? I don't even want to think of what my blood sugars levels would have risen to had I eaten the high-carb foods. My husband didn't make a special request for a diabetic meal and was served a nearly identical tray. The difference? He was given regular salad dressing, while I received the fat-free vinaigrette that was higher in carbs!  

Overall, the food in Europe was very good, and it was quite easy to stay very low carb no matter where we ate. I had eggs  and/or bacon with spinach or mushrooms for breakfast, and meat, poultry, fish, or  cheese with vegetables at lunch and dinner. This kept me well under my usual 30-40 grams of carbs for the day, and I often had raw hazelnuts, almonds, and chocolate made with 100% cacao for dessert, as well as tea with cream or half-and-half at or between meals.

One of my favorite meals in Switzerland was Wuerst und Kaese Salat (sausage and cheese salad), which I've loved since childhood. I had this three times in Zurich. It's simply sliced sausage, cheese, lettuce, cucumbers, tomatoes, cabbage, and carrots topped with a cream-based dressing. Delicious, nutrient-dense, filling, and less than 5 grams of digestible carbs! 

I've been following a very-low-carb diet for over a year now, and I truly love this way of eating. I can tell you with 100% honesty that I didn't feel at all deprived throughout our entire vacation because I ate nourishing high fat, moderate protein foods to satiety, along with liberal amounts of delicious fresh vegetables. How could I feel anything but satisfied on such luxurious fare?  

Bottom line: Stay on plan during vacation by choosing low-carb foods unique to the area you're visiting, and enjoy!

Off topic, I posted another article on Answers.com, and this one is a recipe for chili. Not really European, I know. Chili is typically served in the colder months, but I find that it tastes good year-round, and cooking on the range keeps the kitchen from getting too hot.

Easy Low Carb Chili

As someone who tries to read a wide variety of blogs devoted to carb restriction, I often see negative statements about dietitians not understanding the science behind energy balance, hormonal regulation, and blood glucose control.  I frequently get e-mail from people saying something to the effect of, "I didn't know there was such a thing as a low-carb dietitian!"  There are actually several registered dietitians I know of personally who believe in at least moderate carbohydrate restriction and higher fat intake than currently recommended by government health organizations. However, the majority of RDs favor low-fat diets that are inherently higher carb given the relatively narrow protein range of 15-30% that is almost universally agreed upon.  

Why are so many dietitians against low-carb? It's usually one or more of the following beliefs -- some of which I used to share, by the way:

1. They think it's dangerous. Ketosis. Just hearing the word makes most dietitians uneasy. The thought of someone eating fewer than 130 grams of carbohydrates per day is generally considered unhealthy and insufficient to support brain health. Never mind that our ancestors were often in ketosis for long periods of time and many scientists, physicians, athletes, people with diabetes, and others eating low-carb diets use ketones as an alternative energy source with excellent results. There are studies demonstrating that ketone bodies are the preferred fuel for the heart, adrenal cortex,  and other tissues in addition to the brain. Aside from people with Type 1 diabetes who can develop the very dangerous condition of diabetic ketoacidosis from illness coupled with inadequate levels of insulin, levels of ketones do not rise to dangerously high levels in the blood because they are efficiently used for energy by the body.

2.They believe the diet-heart hypothesis. Despite  much  evidence to the contrary, many dietitians think that fat, particularly saturated fat, raises LDL ("bad") cholesterol and increases heart attack risk. 

3. They think the diet is unbalanced.  I've heard the following comments many times: "How do you get enough vitamins and minerals if you don't eat whole grains? And what about the fiber?" A low-carb diet can provide high amounts of all vitamins and minerals (animal products are the best sources, despite what's promoted in the media), as well as adequate fiber from nonstarchy vegetables, berries, nuts, and seeds.

4. They think no one will follow it long term.  Some of my colleagues say that while low-carb diets may help people lose weight, they don't really stick with it and just end up regaining all the weight plus more. Well, for some folks this may be true, but I tend to believe they'd behave the same way after losing weight on any other diet. There are many people who follow a carbohydrate-restricted diet for life and stay healthy doing so, and their experiences shouldn't be discounted just because others end up abandoning it.

Again, these are beliefs held by many, but not all, dietitians. I'm obviously very much in favor of LCHF diets, and there are at least five other RDs I know of who more or less share my view:

Valerie Berkowitz,MS,RD,CDE, and her husband, Dr Keith Berkowitz, worked with Dr. Atkins at the Atkins Center for several years. She offers carbohydrate restriction as an option for her patients and has also written low-carb articles for various magazines.

Algaee Jacob, MS, RD, CDE, is a Paleo dietitian with expertise in digestive health and diabetes management using a low-carb approach. She recently wrote an article on the benefits of low-carb diets for diabetes published by Today's Dietitian -- very encouraging!

Adele Hite, RD, MPH, educated patients about carb restriction while working at the Duke Lifestyle Medical Clinic with Dr. Eric Westman and is currently working on low-carb research and pushing for policy change in the area of nutrition.

Cassie Bjork, RD, LD, is the co-host of the Low Carb Conversations with Jimmy Moore podcast and a proponent of eating lower-carb, higher-fat real foods.

Lily Nichols, RD, CLT, is a whole foods dietitian and Pilates instructor who specializes in digestive health, follows a moderately low-carb diet, and understands the benefits of carb restriction for weight and diabetes.

There are many others out there as well, along with more conventional RDs who don't advise their patients to follow a low-carb diet but don't discourage them if they're achieving good results. I understand the frustration with dietitians not "getting it," but we need to remember  that the women I just listed, myself included, weren't always so favorable toward carb restriction either. There is always hope that more will come over to our side, and I think that's likely to happen if we continue speaking out about the research supporting LCHF and the benefits so many have experienced from adopting this way of eating.