Glycemic Index vs Glycemic load (Reprinted from Aug 2016)

The ADA site has an interesting study listed. The conclusions state:

No association was observed between glycemic index and SI, fasting insulin, AIR, disposition index, BMI, or waist circumference after adjustment for demographic characteristics or family history of diabetes, energy expenditure, and smoking.

This is a bit hard to accept but I have to question the results. How do they adjust for a family history of diabetes? I get the other categories but how does the American Diabetes Association (ADA) adjust for diabetes? Isn’t this what they are supposed to be figuring out?

Associations observed for digestible carbohydrates and glycemic load, respectively, with SI, insulin secretion, and adiposity (adjusted for demographics and main confounders) were entirely explained by energy intake.

This is true at least in part. The LCHF diet is most just LC and not so much HF. It’s easy to eat meats and miss the high fat sources. The end result of cutting out carbs is a lower energy intake than not dieting. Lower energy intake leads to lower body weights.

So this finding does in fact support a LC diet. It’s easier than counting calories.

Here’s the next interesting point:

In contrast, fiber was associated positively with SI and disposition index and inversely with fasting insulin, BMI, and waist circumference but not with AIR.

Fiber continues to look to be a good thing but if you are not eating a lot of plant roughage then you need to take it in supplement form. I think Dr Atkins recommended psyllium husk. But that would be another BLOG post…

 

Drinking Alcohol (Reprinted from Aug 2016)

This was originally a multi-part series from Aug 2016 where I explored the possibility of drinking beer and doing Low Carb.

Remember the food metabolism curve (Only Three Things in What We Eat)? That graph is only missing one thing. Alcohol.

The conventional wisdom (which seems to be repeated from Atkins) I have heard but now question is whether or not the body only burns alcohol if there are choices between alcohol and other things in the body. Alcohol is the best choice of all for the body in terms of ease of access so I wrongly concluded that the body puts off dealing with proteins, carbs and fats until the alcohol is metabolized.

The Atkins site (Q: Can I drink alcohol now following Atkins 40??) puts it this way:

The body burns alcohol for fuel when alcohol is available. So when it is burning alcohol, your body will not burn fat. This does not stop weight loss; it simply postpones it. Since the alcohol does not get stored as glycogen, you immediately get back into fat burning after the alcohol is used up.

Take careful note. They say that the body won’t burn fat but they don’t mention carbs or protein.

The truth is that the body burns all of the sources as best it can in some blended way. Some are more easily accessed than others and burn more quickly. Some are burned slower but all burn at the same time. Alcohol has it’s own curve for blood concentration (implicitly related to metabolism):

Also, Atkins can’t be right with the word “immediately” since this is such a long and smooth drop. What does make sense is that there are overlapping times when the alcohol level has reached a low enough point that the body has to start drawing energy from the stored energy sources. This isn’t a like a flipped switch at all.

Here’s some information on the interaction of Alcohol and other foods (Science here).

The concomitant ingestion of various foods with alcohol resulted in a decreased area under the blood alcohol concentration curve, a lower peak concentration and an increased time to reach peak. Michaelis-Menten kinetics indicated a decreased alcohol metabolism rate after the ingestion of carbohydrates or fats.

I think everyone who drinks realizes this (at least about carbs). If you eat food you get less drunk for both slower and longer. If you drink on an empty stomach you will get drunk faster but sober up more quickly. (PSA: Use those facts to whatever advantage you personally choose as long as you don’t drive. Find another way to stumble home than your car.)

However, that study does implicitly contradict the claim by Atkins. The study demonstrates that alcohol metabolism is reduced after the ingestion of fats. That implies to me that the body processes both at the same time. At least the dietary portion of the fat is still being burned. It’s not like the body puts the fat off into some corner and says that it won’t burn it until the alcohol is done. It does both at the same time. The alcohol acts slower but so do the other sources (Carbs, proteins and fats) just like they would in any other blended situation.

It is true that the body isn’t burning stored fat during that time, but that’s true of anything that a person eats. The body isn’t burning stored fat if it is getting enough energy from what you are digesting.

In fact the real story may be quite different. Take a look at the pathology of Alcoholic Ketoacidosis – a pretty serious condition (What Is Alcoholic Ketoacidosis?).

Cells need glucose (sugar) and insulin to function properly. Glucose comes from the food you eat, and the pancreas produces insulin. When you drink alcohol, your pancreas may stop producing insulin for a short time. Without insulin, your cells will not be able to use the glucose you consume for energy. To get the energy you need, your body will start to burn fat.

This is directly opposite of what Atkins says. At least for the alcoholic he has reached the point where his body is eating itself up by burning its own fat. That’s the exact goal of Atkins – to burn the body’s fat. The downside is that the blood glucose increases during that time. Note that this seems to take a lot of alcohol over an extended period of time but it does suggest that the alcohol itself does not prevent the body from burning fat.

Craft Beer

My drink of choice is craft beers. I am particularly fond of the higher octane varieties like Southern Tier’s 2X IPA. The nutritional data for that beer is:

Note that the summary below doesn’t get it right since it doesn’t include the alcohol as part of the calorie count.

This can be shown from the math:

Calories from carbs are 4 cal per gm.
Calories from protein are 4 cal per gm.
Calories from far are 9 cal per gm.
Calories from alcohol are 7 cal per gm.

So 12 ozs * .082 (percent alcohol) * 7 (cals per gram) * 28 (grams per oz) = 165 cals from alcohol. Calories from carbs are 21.4 * 4 = 85.6 cals. Cals from Protein are 2 * 3 = 8. This is 250.6, a bit more than the earlier table but close enough.

How Can I Keep Drinking?

So what’s the best strategy for drinking and losing weight/lowering insulin levels? The best approach is the “cut it out approach” but let’s look at the other choices.

First. seems like it would depend upon the type of alcohol. Craft beers, like the 2X IPA, have a pretty good carb count to begin with. That’s partly why they last longer in the body than say Jack Daniel’s Whiskey. Add to that the sheer volume of downing a 12 oz beer vs a 1.5 oz shot. Eating carbs lowers the metabolism of the alcohol and craft beers would have a slower effect than liquor.

Can it be explained by alcohol amounts? A 12 0z craft beer like the 2X IPA at 8.2% alcohol and 12 ozs has about one oz of alcohol in it. Except a person drinks it over an hour instead of 5 seconds it take to down shot.

If the goal is getting drunk then a few shots are a more effective way to get there. If the goal is to enjoy a few drinks over an evening than craft beer is a good choice.

I am convinced that there’s a dual effect of drinking carbolicious drinks like Craft beer with a meal. The carbs in the beer are one effect and the carbs in the food are another and they do add together. The LC treatment says both of these are bad and just cut them out.

If the goal is decreasing Insulin Resistance then it is believed to be helpful to drop the carb consumption. Carbs increase blood glucose levels requiring a quicker insulin response from the body than other sources of food (protein and fats).

The next question is then is it better to drink Craft Beer with dinner or wait a couple of hours and then drink. Certainly delaying alcohol gives the likelihood of drinking less which means less total carbs. Drinking a craft beer every hour or so from 5-11 would mean 5-6 beers which in this case would be 21 grams of carbs per beer. Basically a pretty decent carb load over an evening.

Delaying drinking until a couple of hours then has the effect of less drinking and less carbs combined with the advantage of letting the meal start to digest. If there are carbs in the meal they are then spread out and less bunched together.

So that is what I tried yesterday with success. I started dinner at 5 and ate for a short time. I then waited till 7 and drank beer at 7, 8, and 9 PM. I went to bed at 10 AM and work up at 5 AM to a fantastic blood sugar number of 111.

One thing I have noticed is that Rye Pale Ales do not blow up my Blood Sugar levels like other IPAs (wheat based Ales) do. Not quite sure why.

The carb levels look comparable. Hard to find anything out there on the difference and I’ve never met a diabetic to share the information with. I do remember that My grandfather had a wheat allergy of some sort and could only eat Rye bread due to some unknown digestion problems.

Is there an analogy to bread? The key may lie in the glycemic index/load. According to (The Glycemic Index of Rye Bread):

One slice of rye bread has a glycemic index of 41 and a glycemic load of 5, according to the Linus Pauling Institute at Oregon State University. In contrast, one slice of white bread, made from refined grains, has a GI of 73 and a GL of 10. A high glycemic index is considered 70 or more, and low is 54 or less; a high glycemic load is 20 or more, and low is 10 or less.

So if beer is really just liquid bread and the carb/alcohol numbers are the same, then it makes sense that Rye beer has a lower glycemic index and load over other Pale Ales of similar alcohol and carb counts.

I did a completely unscientific study and measured my BG at 111 and then drank a Rye Pale Ale beer. I then waited an hour and measured my BG and got 114. When I drank the beer I did not take a bolus like I normally would have in the past. I did the same thing a beer without a bolus and an hour later measured my BG at 112. The taste in my mouth tells me that I am out of ketosis. An hour and a half later my BG was 116 and I was solidly in ketosis.

This has been a disappointing year to find Rye Pale Ale. I bought one or two 12 packs and have not seen them at all over the year. Last year I could find Rye of the Tiger and other brands in the local beer distributors but not this year.

Beer can be healthy in moderation.

Mayo Advice #5 – Don’t Stop the Insulin (Repost from Aug 2016)

Here’s where they are totally right and totally wrong at the same time. From the Mayo Clinic site (Avoid weight gain while taking insulin).

Take your insulin only as directed. Don’t skip or reduce your insulin dosages to ward off weight gain. Although you might shed pounds if you take less insulin than prescribed, the risks are serious. Without enough insulin, your blood sugar level will rise — and so will your risk of diabetes complications.

I get what they are saying. If you need insulin to regulate your blood sugar and you go off it then you’ve got serious problems up to death. The thing a diabetic should be watching isn’t the amount you were prescribed. It should be the amount needed to regulate your blood sugar. No more.

My doctor started me out by telling me that I needed to take 40 units of long-lasting insulin. When that led to a high HbA1C number he said that I needed to add meal-time insulin. I wish they would not call it that. So many false things there. He told me to use the 2nd Insulin and use 8 units before every meal. The diabetic nurse told me that was wrong and she had him fix the prescription.

They got me nutritional training and told me to count carbs. Not count as in limit, but to bolus for the amount of grams of carbs in what I was eating. Good advice for high carb meals. Not great when you consider gluconeogenesis. That all got me to a decent point of glucose control but was about 60 units a day (40 of basal and 20 of “meal-time” (fast acting) Insulin. In the last 5 years I have progressed to around 100 units a day (varies by my carb intake). It’s only now that I am getting lower than when I was diagnosed.

I am using less by doing LCHF (really mostly LC) and Intermittent Fasting (IF). Yesterday I used a total of 47 units of Insulin. I will lower my basal (constant) Insulin rate tomorrow to drive my Insulin levels even lower.

 

“Don’t Skip Meals” says the Mayo Clinic (Reprinted from Aug 2016)

The Mayo Clinic website has advice on avoiding weight gain while taking Insulin. Their second point is “Don’t Skip Meals”. They give three reasons to not skip meals.

Don’t try to cut calories by skipping meals. When you skip a meal, your body is less efficient at using energy, and you’re more likely to make poor diet choices at the next mealtime because you’re too hungry. Skipping meals can also cause low blood sugar levels if you don’t adjust your insulin dose.

Let’s think about each of these reasons.

  1. Skipping meals makes your body less efficient at using energy. I guess that’s another way of saying that it lowers your metabolism. Why is a 7 PM to 7 AM fast OK, but a longer fast, say skipping breakfast not OK?
  2. You’re more likely to make poor diet choices at the next mealtime because you’re too hungry. Could be true in some cases but they really don’t explain what a bad diet choice would be.
  3. Skipping meals can also cause low blood sugar levels if you don’t adjust your insulin dose. I suppose they legally have to do that warning for the chronically stupid people out there.

Some of this advice is based on the notion that breakfast is the most important meal of the day. This notion has been recently put to the test as noted in WebMD (Is Breakfast Really Your Most Important Meal?). The data just doesn’t support the necessity to eat breakfast. There may be some benefits to eating breakfast but the clam that you will eat too much at the next meal has now been shown to be false.

It is ironic that they are concerned about the effect of skipping a particular meal on a person’s metabolism but recommend counting (and limiting) calories over a long span of time. It seems inconceivable that missing one meal will mess up someone’s metabolism but living on 1500 calories a day is somehow OK.

The last point about lowering blood sugar and needing to adjust Insulin levels is a double edged sword. The goal of all of this should be to lower blood sugar and reduce Insulin needs. Yes, we need to carefully monitor our blood sugar during fasting periods but we need to do that when we are stuffing ourselves, too. And even more during fasting.

As to the feeling hungry question. I was eating McDonald’s breakfast of 2 breaakfast burritos every day (and even most weekends). When I stopped eating that breakfast (and started skipping breakfast) I was hungry. For a few days. Then I wasn’t hungry any longer. Now I am skipping lunch too and I do get hungry – around 3 PM. That’s about the right time to get hungry since dinner is in a couple of hours.

For me hunger relates to blood sugar levels. I get hungry when my blood sugar is low. That makes perfect sense. Right now I have cut my basal (background) insulin level from 56 units a day down to 26 units a day. That’s at about 10 days into the Intermittent Fasting.

Basically I am taking their warning and following the opposite advice. I am skipping breakfast and lunch but eating a big dinner. I don’t count calories and I eat as much as I want for dinner. I’ve been doing somewhat lower carbs at somewhere around 100 g of carbs a day. I’m still drinking craft beer (several in the evening).

Most of us T2Ds have been on more diets than we can count. I did PhenFen in 1997 and lost 70 lbs in 3 months. Had all the energy in the world. Rollerbladed around my block several times one night. Now I can’t imagine strapping on the blades.

My first diet was at age 16 when I went from the horrible (I thought at the time) weight of 160 lbs to 128 lbs. Everyone told me I look great. Started a viscous cycle of loss then gain exceeding the loss.

I have tried vegan – did that for most of a year. Already mentioned low carb for 18 months (probably the best choice in diets).

This does lead to some good questions. Can a crashed metabolism be started up again? Does our metabolism slow down as we get older?

Right now I weigh the same as I did in 2003 – right before I was diagnosed as T2D. How have I avoided gaining even more weight? I stopped dieting. Other then being generally low carb I just don’t diet any more.

Dietary Control Blood Sugar via Counting Calories (Reprint from Aug 2016)

The Mayo Clinic site we saw earlier recommends counting calories as a way of preventing weight gain when taking Insulin. Sounds good in theory. After all energy out has to match energy in. If you take in more energy than you put out you gain weight. If you take in less energy than you put out then you lose weight.

The only problem is that it is much, much more complicated than that. Here’s what I see as both sides of the question.

Positive Side of Counting Calories

  • Can be reduced to simpler terms, like exchanges.
  • Can eat until we reach our calorie limit and then stop for the day. This produces an extended fasting time which is good.
  • Being aware if how much we eat by logging can show we are eating a lot more calories than we think we are.

Negative Side of Counting Calories

  • Calories don’t take into account the type of calories consumed and their impact on blood sugar control. A packet of white sugar and a piece of lean chicken breast could have the same number of calories but a completely different response in a T2D. We don’t process them at the same rates (previous BLOG post on this).
  • As an example of the type of calories mattering a controlled study was performed which showed the higher protein and lower carbs group had improved insulin sensitivity and cardiometabolic profile in overweight women. So if the advice is to count calories with the goal of restricting calories then the type of calories need to be considered as very important.
  • The type of calories consumed also affected the bounce back after the diet (Study here: Diets with high or low protein content and glycemic index for weight-loss maintenance). Bottom line is higher protein is better.
  • Counting calories is the standard weight watchers approach and thousands of other companies which want to sell you books and meal plans. It doesn’t work in the long run except for getting repeat customers.
  • My own experience is that I still pick up stuff I buy and look at the labels to see what is in them. I don’t eat bread very often and stay away from most carbs and still have way too much weight.
  • Most of the people I know comment on how I never eat. It’s not like I am secretly binging either. I have been on many restricted calorie diets.
  • The Biggest Loser show does the most extreme intervention of restricted calories and exercise possible and many/most of the people gained the weight back. The ones that only had a modest gain were those who worked as trainers.
  • The biggest problem is the reduction in our metabolism that inevitably happens with a restricted calorie diet. This is a long term effect. That is my problem personally and with this sort of diet. In the case of the Biggest Loser show the study concluded:

By the finale, all their metabolisms had significantly slowed down due to the weight loss from diet and exercise routines, and their bodies were not burning enough calories each day to maintain their thinner frames. This was not a surprise to scientists, because studies have previously found that everyone’s metabolism slows down after a diet. But it was shocking that over the next several years, their metabolisms did not recover and return to the normal rate for a person of their size. Instead, their metabolisms became even slower, which caused the pounds to pack back on.

That is the key and the problem with the counting calories form of dieting. Sure you can lose weight but your metabolism drops.

The advice I give my own children is to not go on a diet to lose. Weight. They will gain the weight back and then more when they permanently alter their metabolism.

Insulin and Weight Gain (Reprinted from Aug 2016)

The connection between insulin and weight gain is well understood and acknowledged. From the Mayo Clinic website.

When you take insulin, glucose is able to enter your cells, and glucose levels in your blood drop. This is the desired therapeutic goal. But if you take in more calories than you need to maintain a healthy weight — given your level of activity — your cells will get more glucose than they need. Glucose that your cells don’t use accumulates as fat.

So what is their advice for avoiding this situation? Summarized as

  1. Count Calories
  2. Don’t skip meals
  3. Get aerobic activity
  4. See your doctor about getting on [more] medications
  5. Don’t skip taking your insulin

They pulled out the old tried-and-believed-to-be-true words. That don’t work at all. Nothing makes you feel deprived more than counting your calories. Skipping meals allows your insulin levels to drop. Exercise sounds good in theory but rarely ever gets put into practice. Get more meds which are going to push harder to get the glucose out of the blood into your cells? Sounds like the kind of advice you’d give someone for weight gain, not loss. Finally, don’t go off your insulin for weight loss purposes.

Most of what they say is well-intentioned but completely wrong. All of this explains why we got fat but doesn’t really help us get control of our insulin resistance. Why not tell people that they can skip meals as a way of getting their insulin resistance to improve? Are they so afraid someone will go too low that they don’t want to see people improve their core issue?

Here’s what the advice should be when targeted towards improving insulin resistance.

  1. Don’t count calories. Nothing makes you feel more deprived than counting calories and nothing sets you up for feeling more like a failure. Restricted calorie diets lower your metabolism and you will be worse off for years after the diet since your set point will then be lowered.
  2. Skip meals. At the very least don’t eat just because it’s time to eat. Eat because you are actually hungry. Understand that the fast you did from 7 PM to 7 AM could be stretched out till noon without harming you.
  3. Exercise is always good. If you fast you get more energy and more active naturally. Exercise has lasting effects on blood sugar levels.
  4. Find a doctor who is willing to work with you and explore options that he may not have learned about in medical school. At the very least one that understands what the meds she prescribes to you do and their effects on insulin resistance. At least find a doctor that acknowledges your problem is insulin resistance. (Added List of Low Carb Doctors).
  5. All other things being equal, you can only reduce your insulin needs by lowering your insulin resistance. The goal, therefore, is to figure out how to reduce your insulin usage. Don’t just stop taking insulin and let your insulin levels get really high. I’ve lost a friend recently to DKA so I take this very seriously. She was an undiagnosed T2D but in retrospect she had all of the external markers of a T2D adult.

It might be beneficial to do a post on each of the above treatment points but focus the points on the treatment I am doing now, 18/6 Intermittent Fasting.

Intermittent Fasting (reposted from Aug 2016)

In searching for the solution to Insulin Resistance I ran across the concept of the Intermittent Fast. The guy who’s most prominent in this is Dr. Jason Fung. Here’s Dr Fung’s YouTube channel.

He’s got quite a few videos. One of the better ones is about an half hour long.

The points in the video are:

  1. T2D is reversible – it doesn’t have to be chronic and progressive.
  2. There are examples of people who have stopped being diabetic (via diet, weight loss, etc).
  3. Drugs only treat the symptom not the disease.
  4. T2D is a disease of too much Insulin Resistance.
  5. Treatments are targeted at blood sugar not Insulin Resistance (Metformin being an exception albeit temporary in effect).
  6. The blood sugar isn’t the problem, it is the insulin levels that are the problem.
  7. In 10 years, you are at 100 units of insulin (that’s me).
  8. Never actually treated insulin resistance.
  9. Patients who reversed their disease did so by fixing their insulin resistance.
  10. Giving insulin to a T2D is like giving alcohol to an alcoholic.
  11. Scenario: start insulin, gain 15-20 lbs. Complain to MD who says “go exercise”. It was the insulin which caused the weight gain.
  12. Disease of too much sugar. Cut out the sugar/refined carbs. Stop taking sugar.
  13. Fasting is the most effective way to lower insulin.
  14. LC will lower sugar but not necessarily insulin. Sugar will drop but not necessarily insulin.
  15. Fasting – body will start burning sugar. After that body will start burning fat.
  16. People fast around the world through their entire lives – most major religions.
  17. Insulin levels drop during a fast.  Burn off sugar from your system. Does both at once.
  18. Fasting is not harmful. You don’t enter starvation mode. The metabolism increases during the fast.

Great video. Next post I take a look at my own person experience at this.

 

Only Three Things in What We Eat – Macros 101

There are only three things in what we eat; carbohydrates, protein and fat*. Each of the three have a different effect on the glucose level in our blood (Blood Sugar level). The effect is shown in the following graph.

  • Carbs spike blood sugars to high levels for a short time.
  • Proteins don’t spike blood sugar as high but they are around for a longer time.
  • Fat has the least amount of spike to blood sugar but they have a very long active time.

The curve shows why LCHF works for most people. If you reduce eating carbs and replace them with fat you greatly lower your glucose load and your insulin in the process.

*There is a 4th thing – alcohol. The body burns alcohol quite nicely. In fact, it burns alcohol before anything else (sorta).

Very Low Carbohydrate Studies

This BLOG post will list Low Carbohydrate Diet Studies and will grow with time. New studies will be added to the end of this list.