 Burrata with heirloom tomatoes, arugula, olives, olive oil 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:
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
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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.  Low carbohydrate diets are often criticized for being high in fat, particularly saturated fat, which is widely believed to raise cholesterol levels and increase risk for heart disease, despite recent and older studies demonstrating that saturated fat is not to blame. However, many lipidologists believe that LDL particle number (lower number is better) and pattern (larger size is better) do correlate with heart disease risk.
My total, HDL, and LDL cholesterol have always been on the high side, even back in 2007 when I was a pesco-vegetarian who threw out egg yolks rather than eating them. The only time my LDL was in the “optimal” range (less than 100) was the year I ate a vegan diet. However, I was also very hungry and sick a lot that year. Recently, someone commented on another blog that “Every low-carb Paleo blogger has nightmarish cholesterol levels," or something very similar. That’s a pretty broad generalization and one I don’t agree with. In many (most?) cases, elevated cholesterol levels are due to something other than diet. And are moderately elevated cholesterol levels always bad anyway? From all the research I've seen, it's inflammation that appears to be at the root of heart disease. In addition, low cholesterol levels have been linked to depression, poor memory, and other health issues. But I was still curious to see what my lipid numbers are like now, 11 months after beginning a very-low-carb, high- fat diet that includes a fairly high percentage of saturated fat. I decided to order an NMR Lipoprofile test so I could get information about particle numbers, size, and pattern, which I've never had measured before, since I believe this is more important than just looking at LDL and HDL. My results: LDL Particle Number LDL-P: 1174 Reference range: Moderate 1000-1299 Borderline High 1300-1599 High >1600 Lipids LDL-C: 124 Reference range: Above optimal 100-129 Borderline 130-159 High >160 HDL-C: 97 Reference range >40 Total cholesterol:226 Reference range <200 Triglycerides: 24 Reference range <150 LDL and HDL particles HDL- P(total): 43.8 Reference range >30.5 Small LDL-P: 103 Reference range <527 LDL size: 21.7 Reference range 20.6-23.0 (Pattern A, Low Cardiovascular Disease Risk) Insulin resistance score LP-IR score: 1 Reference range <45 Honestly, these numbers are better than I’d expected. My HDL has always been good, around 65-70, but it’s increased significantly, while my LDL-C has actually gone down a bit. The particle size and numbers are also very good, as are the triglycerides. I guess I shouldn't really be too surprised given research suggesting that a low-carb-high fat diet results in a less atherogenic lipid profile. My results occurred nearly a year after eating eggs, butter, cream, cheese, and/or coconut oil every single day. Did I also eat a lot of monounsaturated fats in the form of nuts, olives, and avocado on a daily basis and omega-3 fats in fish several times a week? Absolutely -- I eat a lot of all types of fat. But I don’t think the saturated fat has done me any harm; on the contrary, I’ve written before about the benefits of many saturated fats. And limiting my carbs to less than 50 grams a day has resulted in finally normalizing my post-meal blood sugar, which I was unable to do at a moderate low-carb level of 80-100 grams. My weight remains 125 pounds, give or take a pound. So what do I eat? Here’s yesterday's intake and nutrient analysis courtesy of FitDay.com: Breakfast: 4 oz sardines 3 cups spinach with ½ tsp sea salt cooked in 2 tsp coconut oil 1 cup blackberries with 1 oz sour cream and 1/3 cup chopped pecans Green tea Lunch: 1 sliced red bell pepper with Greek yogurt-guacamole dip (1/2 cup 2% Greek yogurt mixed with 2/3 cup guacamole) Chia seed cocoa pudding (1 oz chia seed mixed with ½ cup water, 1 Tbsp cocoa powder, ½ tsp sea salt, ½ tsp cinnamon) Vanilla hazelnut herb tea with 1 tsp half-and-half Dinner: Filet Oscar: 6 oz beef filet, 2 oz crab, 2 Tbsp Bearnaise sauce, 1/2 cup each pea pods and summer squash (pictured above) Water Calories: 1700 Fat: 117 grams (62%) Saturated: 33 grams Polyunsaturated fatty acids(PUFA): 24 grams Monounsaturated fatty acids (MUFA): 60 grams Protein: 97 grams (23%) Carbohydrates: 68 grams (16%) Dietary fiber: 33 grams Effective carbs: 35-51 grams (There are different schools of thought on how to count fiber. If subtracting all fiber from carbohydrate grams, effective carbs are 35 grams; if subtracting half the fiber grams, effective carbs are 51 grams) This is pretty typical intake for me in terms of macronutrient percentage, fiber, and calories. The majority of my fat intake always comes from MUFA and saturated fat, and most of the PUFAs are the omega-3 fatty acids found in seafood. So I'm having great results all around on a low-carb, high-fat, whole foods diet. Everyone is different, of course. I'm not arguing that some people have reported increases in LDL cholesterol after switching to a low-carbohydrate diet, although it seems to occur more often in the initial stages, particularly with folks who lose weight rapidly. But the oft-repeated message that a LCHF approach automatically increases cholesterol and risk for heart disease is not borne out by the research, my n=1 results, and those of many others.  I'll preface this post by saying that it was written with my female readership in mind. Guys, you're welcome to read as well, of course, but I have a feeling most of you will want to pass on this one.
At 46, I'm well into perimenopause and have noticed several changes ranging from amusing to annoying. Almost every woman finds growing older challenging to some extent, be it physically, mentally, and/or emotionally. Many tend to put on weight as they age, and the standard explanation is that our metabolism slows down as we get on in years and decrease our physical activity. But it's more complicated than that, and hormonal regulation plays a very large part. Menopause and perimenopause, the 5-10 year period preceding it, often result in decreased insulin sensitivity, particularly in those predisposed to endocrine imbalances. Recent research indicates that decreasing levels of estrogen lead to insulin resistance and impaired carbohydrate tolerance even among nonobese menopausal women. Weight gain during perimenopause and menopause is an obvious result; it's difficult to ignore your pants getting tighter even if you're not weighing yourself regularly. What many women are less aware of (unless they're testing with a glucometer) are elevated blood sugar levels after eating. While the aging process is inevitable and to some extent dependent on your genes, there are ways to make the transition easier in terms of weight management, loss of muscle mass, and blood sugar control. My advice is to cut back on carbs to a level that allows you to achieve a healthy weight and optimal glycemic levels, keeping in mind that this is highly individualized and may change over time.* Some women at this stage may be able to continue the same moderate-to-high-carb diet they've always consumed without any issues, but after looking into the research and hearing many anecdotal accounts, I know that many are simply not. It saddens me to hear about ladies in their mid-40s to mid-50s eating low-fat diets and continuing to struggle with food cravings and weight. I feel many would benefit from the hunger-reducing, hormone-altering, blood-sugar-stabilizing effects of carb restriction. Another problem women in or approaching menopause often experience is hot flashes, along with sensitivity to temperature changes. Neurosurgeon Dr. Larry Mc Cleary writes in his excellent book, The Brain Trust Program, that the decline in estrogen during this period reduces the action of glucose transporters that deliver glucose to the brain, resulting in release of norepinephrine from the adrenal glands in an attempt to increase blood sugar and provide the brain with energy. He states this process is similar to what children with epilepsy and other seizure disorders experience, although on a much smaller scale. Dr. Mc Cleary recommends a very-low-carbohydrate diet in order to provide the brain with ketones as an alternative source of fuel, thereby eliminating or greatly reducing hot flashes. What types of food, specifically? Meat, fish, poultry, eggs, cheese, nuts, greens, nonstarchy vegetables and small amounts of low-sugar fruits like berries -- exactly what I eat. He also provides a recipe for a "ketogenic cocktail" which contains MCT oil, flaxseed oil, and EPA. I have to say that after 10 months of continuous ketosis/near ketosis, I feel terrific. Blood sugar swings are a thing of the past, my weight is easier to maintain, and energy levels are better than they've been in years. Will this change as I get older and become postmenopausal? Perhaps, but I can honestly say I think eating a very-low-carb diet gives me better odds for keeping things under control. I don't think I've mentioned the importance of exercise in any of my blog posts yet, which is surprising given how important it is in my life. Physical activity is vital it is for feeling good and preserving muscle mass as we age. However, I'm not a cross-fitter, runner, or jogger. I like walking and try to get 30-60 minutes in every day, but I also feel that resistance training, stretching, and strengthening are extremely beneficial. I hate gyms; in fact, I can probably count the times I've worked out in a gym or taken a class on one hand. I prefer working out on in my own home and enjoy routines that make me feel graceful , strong, and energized. Enter Ellen Barrett. Now, Ellen is not a low-carber; judging by her tweets, she may be vegetarian or even vegan. But the way she eats makes no difference to me because she is simply an amazing fitness instructor. Her routines are not only extremely effective at toning, tightening, and increasing energy; they're also very enjoyable, easy to stick with until the end (They range from 30-45 minutes in length), and set to upbeat, fun music. Her enthusiasm, pleasant voice, and genuine smile complement the light weights, Pilates, ballet, yoga, and dance sequences. She always has someone demonstrating the movements at a lower level of intensity for beginners. I love the way Ellen encourages women to really tune in to their bodies and feel graceful and beautiful while exercising. After one of her workouts I feel highly energized, never fatigued. Now, if you love cross-fit or running , that's wonderful -- keep it up! But if you really don't like exercising and aren't big on working out at a gym, I highly recommend getting one or more of Ellen's DVDs.* I own seven (she has even more!), and they're all fantastic. Check out the Amazon descriptions and reviews at the links below: Grace + Gusto Fusion Flow Slim Sculpt Super Fast Body Blast Sleek Sculpt Express Power Fusion Fat Burning Fusion So my advice in a nutshell is to accept aging as a natural part of life but do your best to provide your body with the type of nourishment and activity that gives you the best chance of remaining healthy, strong, mentally engaged, and full of vitality. * Consult your doctor prior to starting a low-carbohydrate diet or engaging in physical activity References: 1.Lindhelm SR, et al. A possible bimodal effect of estrogen on insulin sensitivity in postmenopausal women and the attenuating effect of added progestin. Fertil Steril 1993 Oct:60(4):664-7 2.Whitcroft, et al. Insulin resistance and management of the menopause: a clinical hypothesis in practice. Menopause Int 2011 March:17(1)24-28  Back in August, I wrote about my decision to try lowering my carb intake in an attempt to improve my blood sugar levels. Already eating a low-carb diet (about 30 grams net carbs per meal) and at a healthy weight, I didn't know if following a very-low-carbohydrate ketogenic diet (VLCKD) would have an appreciable effect on my readings or how I'd feel at that level of restriction, but I felt compelled to try it.
Well, after consistently consuming 30-45 grams of net carbs a day for six months, I have only positive things to say about my very-low-carb experience. Not only are my blood sugar readings exactly where they should be -- less than 90 fasting and less than 130 an hour after eating -- but I truly feel healthier, less stressed, and more balanced than ever. I'm hypothyroid, and although my T3 has declined in response to lower carb intake, I feel more energetic and not at all "hypo." Is it the stabilization of blood glucose or being in a mildly ketogenic state that's responsible for my renewed sense of well being? Perhaps a bit of both. There's some interesting research supporting the beneficial effects of ketones on brain health, including depression. I've mentioned several times that the reason I began following a VLCKD in the first place was strictly for blood sugar control. I didn't want or need to lose any weight, and as a diabetes educator, I wanted to try it out to see if I could get my own numbers under control this way. Limiting my carbs to less than 45 grams a day has been surprisingly easy. My diet consists of plenty of fat from avocados, nuts and nut butters, olive oil, cheese, butter, cream, and coconut oil; moderate amounts of fish, chicken, beef, Greek yogurt, and eggs; and at least one serving of nonstarchy vegetables at every meal and a small serving of berries at breakfast. It's truly a rich, satisfying, and luxurious way to eat. Although I've questioned the validity of a low-carb metabolic advantage in the past, I'll admit that I've recently lost a couple of pounds while eating 200-300 more calories daily than before. While I still think calories count, I won't dispute the fact that some people -- although not all -- can consume additional calories and lose weight at very low carbohydrate intakes. After many years of restricting calories, I just didn't think I'd be one of them. While doing research for my ADA low-carb article, I read many studies on carb restriction for diabetes and weight management, but I didn't consider the beneficial effects of ketosis. At the time, I was still consuming close to 100 net grams of carbs a day and wasn't ready to try anything as extreme as a ketogenic diet. But after having looked into the research on VLCKDs and experiencing their effects first hand, I'd like to see more obese and otherwise metabolically challenged people try them. Improved lipid profiles, slowing down of the aging process, and improvements in mood and cognition are just a few of the potential benefits attributed to ketogenic diets, along with weight loss and blood glucose control. In addition to the studies, I've read countless online accounts of how ketosis has changed people's lives for the better. And I plan to continue eating this way indefinitely unless I develop problems, at which point I would make adjustments as needed. That's how I got here in the first place, after all. Now, as enthusiastic as I am about VLCKDs, do I realistically think that all dietitians, nurses, doctors, and other health professionals will come on board in the near future? Probably not, considering most of them think ketosis is unhealthy and that we need at least 130 grams (and preferably a lot more) of carbs at a minimum to support the needs of the central nervous system. But I am cautiously optimistic that the tide is starting to turn as practitioners begin to look at the research and listen to their patients' accounts of success -- or perhaps even test their own postprandial blood sugars. Carb restriction may not be appropriate in every case, but I defy anyone to objectively look at the evidence and deny how beneficial it's been for so many, especially those who have struggled with weight and blood sugar issues for years. References: 1. Murphy P, et al. The antidepressant properties of the ketogenic diet. Biol Psychiatry 2004 Dec 15;56(12):981-3 2.Dashti HM, et al. Beneficial effects of ketogenic diet in obese diabetic subjects. Mol Cell Biochem 2007;302:249-256 3. Dashti HM, et al. Long term effects of a ketogenic diet on obese patients. Exp Clin Cardiol 2004 Fall; 9(3): 200–205 4.Stafstrom CE, et al. The ketogenic diet as a treatment paradigm for neurological disorders. Front Pharmacol 2012;3:59 Disclaimer: The ideas espoused in this blog post are for general information only. Always consult with your physician prior to adopting a low-carbohydrate diet or making any other dietary changes. I'm going to preface this post by saying that I realize there are a number of registered dietitians ( including several whom I consider friends as well as colleagues) who favor intuitive eating for the treatment of obesity and can provide many testimonials as to its effectiveness. I admire their work and do not want to take anything away from the success they have had with this method.
Intuitive Eating is an approach to developing a healthy relationship with food. Created by registered dietitians Evelyn Tribole and Elyse Resch, Intuitive Eating involves listening to your body, becoming attuned to hunger and fullness cues, and consuming a wide variety of foods. No foods or food groups are off limits, and people are encouraged to honor their hunger and eat what they desire, be it berries or brownies, although trying to make primarily nutritious choices is also advised. While Intuitive Eating has proved very successful for many, it's my belief that there are a number of individuals for whom it is not the best choice. One of the "10 principles" outlined on the Intuitive Eating website is "Honor Your Hunger." The description of this principle reads "Keep your body biologically fed with adequate energy and carbohydrates. Otherwise you can trigger a primal drive to overeat." While I agree that adequate (albeit somewhat reduced) energy/caloric intake is crucial to preventing a profound drop in basal metabolic rate, I have a different take on the need for "adequate carbohydrates." In fact, I would argue that in many cases carbohydrates are what may trigger the drive to overeat. The reasons for overeating are complex and involve not only behaviors but also hormones like insulin and leptin, which are highly responsive to the type and quantity of food consumed. There is a growing body of research suggesting that reducing carbohydrate intake may result in improvements in blood sugar control, appetite, and insulin resistance. Leptin also plays a role in appetite and obesity. It is released by fat cells under the direction of insulin, which is produced in largest amounts following carbohydrate intake. Once leptin enters the brain, its effects include appetite reduction, satiety, and an increase in metabolic rate. Interestingly, the obese tend to have higher leptin levels than those of normal weight, which has led researchers to hypothesize that they are resistant to leptin. This theory suggests that leptin resistance prevents the hormone from reaching the brain, confounding one's attempts to regulate intake and facilitate weight loss. In 2004 researchers discovered that elevated triglycerides block the transport of leptin into the brain. Many studies have demonstrated that reducing carbohydrate intake, especially refined carbohydrates, leads to significant decreases in serum triglycerides, and a recent study implicates high carbohydrate intake in the development of leptin resistance and obesity. To be honest, I am not very knowledgeable about leptin and leptin resistance but plan to review more research on this issue, as I find it extremely interesting. While I truly appreciate the philosophy behind the Intuitive Eating approach to making peace with food and accepting a person's genetic body shape, I feel that telling someone that no foods are off limits may not be best for everyone. Advising somebody with impaired blood glucose regulation to eat whatever they feel like eating may result in unstable blood glucose levels. In the leptin-resistant obese, encouraging high intake of trigger foods (which often contain large amounts of the very macronutrient that perpetuates their struggle to modulate intake) may lead to a vicious cycle of overeating, rebound hunger, and overeating again. I am a person for whom an intuitive eating approach would probably not work. I'm extremely regimented, and counting calories every day has allowed me to maintain a 30-lb loss for more than 25 years. Although carbohydrate restriction didn't come into play for me until about a year and a half ago when I began experiencing elevated post-meal blood sugar, limiting carbs has allowed me to see first hand what getting blood glucose levels under control can do. I long ago resigned myself to feeling somewhat hungry at times after dinner when I'd consumed my allotment of calories for the day. I'd adapted to chronic mild caloric restriction (a healthful practice, particularly with respect to longevity) but retained some of the feelings of hunger that accompany it. Once I began following a low carbohydrate diet, I was amazed at the increased satiety I experienced without any change in my total energy consumption, which remains somewhere between 1400-1800 calories every day. I can honestly say that after a meal I simply do not feel hungry anymore. I feel strongly that a low-carbohydrate diet should not be characterized as a "fad diet" that is too difficult to maintain. I have met many people and read hundreds of online accounts of those who have lost weight and maintained their loss long term by following a low-carbohydrate plan which allowed them to regulate their energy intake. In some cases, these losses are 100 pounds or more. The number of people who have achieved excellent blood glucose control on such plans is no less impressive. A low-carbohydrate diet can include many healthy, luxurious, highly palatable and satiating foods; the assertion that it will result in feelings of deprivation is misguided. I personally plan to continue eating low carb for the rest of my life. However, I understand that this lifestyle is not for everyone. I would never tell anyone that they "had to" eat low carb in order to lose weight. There are many people who reach their goals by following a vegetarian or vegan way of eating, and as I stated initially, Intuitive Eating has worked brilliantly for others. I think that's terrific! We are all unique and our responses to food are highly individualized. I realize that the majority of people reading this have had favorable outcomes with carbohydrate restriction, but for the reader who has been unsuccessful with low carb and would like to try an Intuitive Eating approach, I know several dietitians who specialize in this area I could refer you to (use the Contact Me page). My goal as a dietitian is to make sure that people find a way of eating that works best for them in order to achieve their own goals. References: 1. Boden G, et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with Type 2 diabetes. Ann Intern Med. 2005 142:403-411 2.Westman EC, et al. Low carbohydrate nutrition and metabolism. Am J Clin Nutr. Aug 2007; 86(2): 276-284 3. Spreadbury I. Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity. Diabetes Metab Syndr Obes. July 2012; 2012(5):175-189 4. Lopes IM, et al. Effects of Leptin Resistance on Acute Fuel Metabolism after a High Carbohydrate Load in Lean and Overweight Young Men. J Am Col Nutr. Dec 2001; 20(6) 5. Banks WA, et al. Triglycerides induce leptin resistance at the blood-brain barrier. Diabetes.May 2004;53(5):1253-60 6. Hansen, BC. Calorie restriction: Effects on body composition, insulin signaling, and aging. J Nutr. 2001:131, 900S-902S  When I first started this website a little over a year ago, I did so with the intention of discussing low-carb diet research and other low-carb topics. So I want to thank any long-time (well, at least a year!) followers who have stayed with me despite my veering off course now and then. In the beginning I was very green with respect to the benefits carbohydrate restriction as a viable option for blood sugar and weight management (in my training as a dietitian, the Atkins diet was routinely dismissed as unhealthy and unsustainable), and I began spending a lot of time on dozens of low-carb sites, including many with a Paleo/Primal approach. The Paleo diet seemed quite healthy: It was based on whole foods, grass-fed meat, and organic plant foods. However, it contained a lot less dairy and nuts than I was eating and which I continued to consume in fairly large amounts.
In the latter part of 2011, I began adding in some starchy foods like sweet potatoes and rice based on recommendations found on various Paleo sites. Although I'd been consuming 30-35 grams of total carbs per meal at that point with occasional postprandial hyperglycemia, the addition of starchy foods definitely worsened my blood glucose control, particularly after lunch and dinner (for some reason my post-breakfast readings were and are almost always good). Researching other people's online experiences with reintroducing starch reassured me that this was likely a temporary thing that would improve as my body adapted to eating this type of food again. I continued eating the same way and monitoring my blood sugar about three or four times a week. I tried not to get too upset seeing my readings routinely in the 150s-170s and occasionally as high as 200 1 hour after eating, telling myself it would eventually get better. But after 9 months, it never did. Even replacing the starches with an equivalent amount of carbohydrate from fruit or dairy didn't help. Although others may be able to tolerate higher amounts of carbohydrate after a reasonable adjustment period, I had to admit that this wasn't the case for me. I was already eating pretty low carb (about 90-110 grams total or 65-80 grams net), so where to go from there? Obviously, lowering my carb intake was the only thing I could do, short of medication. And since my fasting blood sugar has remained normal, there weren't a lot of pharmalogical options anyway. In researching my ADA article on low carbohydrate diets, I found a study in which many subjects on a very-low-carbohydrate, ketogenic diet (VLCKD) achieved such significant improvements in blood sugar that they were able to greatly reduce or even discontinue their diabetes medication. There is also research on the hormonal benefits of VLCKDs for polycystic ovarian syndrome (PCOS) as well as weight loss. In addition, I found many online anecdotal reports of improved mental clarity and well being with this approach. So I decided to reduce my carb intake further and begin eating a VLCKD containing 40-50 grams of net carbs per day. To be honest, although I've been eating low-carb for about a year and a half, I had some sort of mental block about not wanting to go into ketosis. I'd done enough research to know it wasn't dangerous, but I still resisted the idea on some level. A few months ago I wrote a post stating I didn't think it was necessary for most people. Turns out it may have been just what I needed. Although it's only been 6 days, the results so far are pretty impressive. My highest 1-hour postprandial reading has been 128, but most of the time I'm well below 120, and after 2 hours below 100. I haven't seen numbers like this in such a long time, and I must say it's a welcome change! In addition, I feel great, with more energy and focus but less hunger -- not a surprise given my previous unstable postprandial blood sugar coupled with the appetite suppression of ketosis. I've lost a couple of pounds, which I know is water. I routinely count calories when I eat (again, that dietitian training!), and I'm consuming the same 1500-1800 I've been doing for years, so I don't anticipate losing any additional weight, nor do I want to. I know I'll be perfectly happy eating a very small amount of fruit and avoiding starches entirely (maybe a small bite of dessert once in a while). Not to sound obnoxious, but anyone who knows me personally would say I'm a pretty disciplined eater (sometimes annoyingly so). In addition, I like all kinds of food and look forward to experimenting with very-low-carbohydrate recipes. It's quite apparent to me that eating at a ketogenic level is not only safe but could be very desirable for people with blood sugar or weight management issues. In my previous post, I said, "Starting off at ketogenic levels may provide a psychological benefit due to early rapid weight loss that usually occurs, but there is certainly no indication to remain in perpetual ketosis for weight management purposes." But maybe for some people eating at this level indefinitely is appropriate. The T4 to T3 conversion problem I mentioned in that post most likely is due to cutting calories and losing weight rather than lower carb intake per se, as it occurs with all types of diets. I know that several doctors who follow the same VLCKDs they prescribe for their patients -- including but not limited to Dr. Steve Phinney, Dr. Jeff Volek, Dr. Jay Wortman, and Dr. Richard K. Bernstein -- enjoy this way of eating, remain very healthy, and plan to continue for the foreseeable future. Of course, I still feel people should decide how many carbs they feel comfortable eating based on their blood sugar levels, weight, and most importantly how they feel. I don't think a ketogenic diet (or a nonketogenic low-carb diet, for that matter) is for everyone, and I may ultimately decide it's not the best fit for me. But I'm excited to learn more about the benefits of eating very low carb and will likely be blogging about these sometime soon. *** I will end with my standard advice to always consult with your physician prior to adopting a low-carbohydrate diet or making any other dietary changes. You may also find the following books very helpful: The Art and Science of Low Carbohydrate Living by Dr. Stephen D. Phinney and Dr. Jeff S. Voleck Dr. Bernstein's Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars by Richard K. Bernstein, M.D. References: 1. Yancy WS, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab 2:34, 2005 2. Mavropoulos JC, et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutr Metab 2:35, 2005 3. Manninen AH. Metabolic Effects of the Very-Low-Carbohydrate Diets: Misunderstood "Villains" of Human Metabolism. J Int Soc Sports 1(2)7-11, 2004. Now that I've finally finished my article for the American Diabetes Association, I'd like to start by expressing my sincere appreciation for those who write scholarly articles and books. The time and effort it takes to produce accurate, substantive work is much more than many would expect. So to all the authors of my favorite nutrition books of 2011, thank you so much for the time you put in! My article was only a few pages long and took more hours than I care to admit. Fortunately, doing the research for it provided me with some good ideas for future blogs posts.
I was asked to write the article on a low-carbohydrate diet pattern for blood sugar and weight management in people with diabetes. The amount and type of carbohydrates to prescribe was at my own discretion, and I gave it very careful consideration after reviewing all of the available evidence. Although I've never personally cut carbs to the point necessary to induce ketosis, I was open to the possibility that there was evidence to warrant its use in diabetes and weight management. There has been a lot of research in this area within the past ten years, both short- and long-term studies, and I ended up citing 27 of them in the article. Traditional ketogenic diets are extremely low in carbohydrates (usually 10-15 grams per day) and have been used since the 1920s for the treatment of childhood epilepsy with very impressive results. There is also emerging evidence regarding their use in therapy for certain types of cancer and neurological disorders such as ALS and Parkinson's disease. Ketosis occurs when the body shifts from using glucose to ketone bodies and fatty acids as its primary fuel. The level at which this occurs varies somewhat among different people, but it's generally less than 50 grams per day. The most famous low-carbohydrate ketogenic diet (LCKD) is the Atkins Diet created by cardiologist Dr. Robert Atkins in the early 1970s. It is mainly used for weight loss but occasionally for blood sugar control as well. The plan involves starting off at an "induction phase" of 20 grams of carbohydrates and adding back carbs until reaching a "maintenance" level which is also individualized. Dr. Richard Bernstein, who has lived with Type 1 diabetes for more than 60 years, recommends strictly limiting carbohydates with the goal of achieving normal blood sugar levels. By keeping carbs within 30-35 grams per day and 6-12 grams meal, smaller insulin dosages are needed, resulting in less error in matching carbohydrate intake to insulin and more predictable blood sugars. For people with Type 2 diabetes not taking insulin, very-low-carbohydrate intake prevents post-meal blood glucose spikes. Is there any advantage to a VLCKD vs. a diet that is low in carbs but not low enough to promote ketosis? From the research I've seen, the answer is no with respect to the ketogenic aspect of the diet. The carbohydrate restriction itself is another matter, however. Do Dr. Bernstein and many other people with Type 1 and Type 2 diabetes experience better blood sugar control with carb intake at ketogenic levels? Definitely a very large portion do, but this is due to the diet's effect on blood sugar regulation. For these individuals, the benefits of VLCKDs may very well warrant its use. But for weight management, I just don't think that's the case. Millions of people have lost weight on Atkins or other low-carbohydrate plans, but many have never achieved their personal weight goals, and most have regained at least a portion of the weight back. Although it doesn't work for everyone, I do believe a low-carbohydate diet can help people lose and maintain weight. Starting off at ketogenic levels may provide a psychological benefit due to early rapid weight loss that usually occurs, but there is certainly no indication to remain in perpetual ketosis for weight management purposes. While many low-carb proponents speak of a "metabolic advantage" that occurs with ketosis, characterized as turning your body into a fat-burning machine, I have found no convincing research to support this. It appears that the mechanism responsible for weight loss is a spontaneous reduction in calories due to reduced hunger and greater satiety on both low-carb diets and VLCKDs. And once a person reaches a certain weight, if the caloric intake is too high to promote further loss at this new weight, then weight loss will stall regardless of whether carb intake remains at ketogenic levels or not. There may be another reason for slowed weight loss on a VLCKD. Recently, there have been several posts on various paleo/ancestral blogs regarding problems people have encountered on low-carb diets. I hadn't really been following this issue that closely since I was doing a lot of lit review for the article. But it seems the main issues people have encountered are failing to sustain continued weight loss despite keeping carbs low, an inability to stay warm, and fatigue. These are symptoms of potential thyroid dysfunction (among other things). There is a good amount of research indicating that people may develop problems converting the thyroid hormone thyroxine (T4) to the active hormone triiodothyronine (T3) and instead convert a greater than normal portion to the inactive form, reverse T3 (RT3) at lower carbohydrate intakes, with the effect being more pronounced at ketogenic levels. In certain individuals this may result in lower resting metabolic rate. It's important to note that this does not happen to everyone on VLCKDs, however, and thyroid function is very complex and affected by many factors in addition to carbohydrate and caloric intake. I'm sure I'll probably lose several followers after this post, but I have to be honest and state my true beliefs as a dietitian and fellow low-carber. I've never advocated a ketogenic approach for weight management, and I received some very unpleasant e-mails and comments on another member's Facebook page when I recommended staying above 20 grams of carbs per day. (In that post, I neglected to mention the exceptions of treating epilepsy and possibly cancer and neurological disorders). As an outpatient dietitian in a large hospital, I counsel many people who are not even remotely interested in following a low carbohydrate diet, and that's fine. People can certainly lose weight and even control blood sugar (albeit with larger doses of medication) on a higher carb, lower fat diet. I'll be the first to admit that if I didn't have blood glucose issues I'd be eating more carbs. I truly feel that people should listen to their bodies and eat in a way that works best for them. From a personal standpoint, I tried introducing safe starches to my diet for several weeks after reading about the brilliant Paul Jaminet's Perfect Health Diet and found that I could only tolerate just under 1/2 cup of potato or rice; any more and my blood sugar was well above 140 at the one-hour mark. To me such a small amount just isn't worth the prep time! So these days the majority of my carbs are coming from all kinds of fruit as well as yogurt. My total carb intake for the day is about 90-100 grams (65-75 grams digestible or net carbs), and this works well for me. I'd like you to do what works best for you. If you feel great on a VLCKD and are able to achieve and maintain your goal weight by following this plan, that's wonderful. But please be aware that ketosis isn't necessary to achieve weight loss. As with any diet, it is calories in vs. calories out that determines the ultimate outcome on the scale. If you're wondering what my carbohydrate recommendations were for the article, as a general guideline I advised a starting point of about 85-110 grams of total carbohydrates (60-80 grams net carbs) per day using whole, unprocessed foods. (Interestingly, the Atkins website recommends 75+ net carbs daily, including grains, for lifetime maintenance). I know there will be many very-low-carb enthusiasts who think this is far too high, and I'm also expecting a backlash from other dietitians saying it's way too low, unsafe, unsustainable, lacking in nutrients, and, of course, too high in fat and protein. But I feel good about these recommendations given the research I've reviewed along with my own experience and that of others. You know the lyrics from that old song: You can't please everyone, so you better please yourself. References: 1. Zhou W, et al. The calorically restricted ketogenic diet, an effective alternative therapy for malignant brain cancer. Nutr Metab 2007; 4:5 2. Zhong Z, et al. A ketogenic diet as a potential novel therapeutic intervention in amyotrophic lateral sclerosis. BMC Neurosci 2006: 7:29 3. Johnson CS, et al.: Ketogenic low-carboydrate diets have no metabolic advantage over non-ketogenic low-carbohydate diets. Am J Clin Nutr 2006; 83:1055-1061 4. Martin CK, et al. Change in food cravings, food preferences, and appetite during a low-carbohydrate and low-fat diet. Obesity 2011; 19:1963-19704. 5. Bisschop PH, et al. Isocaloric carbohydrate deprivation induces protein catabolism despite a low T3-syndrome in healthy men. Clin Enocrinol 2001; 54:75-80 |
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