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…
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.
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.
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.
Great start today
My weight was down 3 lbs from yesterday.
Set a New Basal Rate of .25 units per hour less.
Woke up at 5 AM to a Blood Glucose of 111. Did the bolus to get me from 111 down to 105 (just a few tenths of a unit). Took my number two hours later and it had jumped to 143. Rather than doing a 3 unit bolus I decided to do 2 unit bolus. Will be interesting to see the results I get. Wonder what would have happened if I had not done the few tenths of a unit bolus.
I did a (rare for me) calorie count of my dinner last night. At 1661 calories. Did the percent of calories from various sources and got:
Carbs – 16.9%
That’s a day of counting calories and taking into account the types of calories.
How does the Intermittent Fast work? Here’s another video by Dr. Jason Fung on Intermittent Fasting.
Dr Fung ties together some related points.
Dr Fung’s message really hits home for me. I’ve been looking around for evidence to the contrary. Dr Fung reached his conclusions after years of treating kidney patients the old fashioned way and watching them get sicker.
His key insight is that high levels of Insulin is the problem not the solution to T2D. His second insight is that Intermittent fasting is an effective treatment for T2D.
Dr Fung has videos of patients who have gone from 100 units of Insulin a day down to zero units. Other doctors have case studies as well but there’s something particularly appealing about Dr Fung’s patients. They are older and in declining health due to T2D. They are on 100 units a day or so. Not the easy cases other examples contain.
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.
Here’s the full text of this next piece of advice (Avoid weight gain while taking insulin) from the Mayo Clinic website.
Ask your doctor about other diabetes medications. Some diabetes medications that help regulate blood glucose levels — including metformin (Fortamet, Glucophage, others), exenatide (Byetta), liraglutide (Victoza) and pramlintide (Symlin) — may promote weight loss and enable you to reduce your insulin dosage. Ask your doctor if these or other medications would be appropriate as part of your diabetes treatment plan.
I like the goal – reducing Insulin dosage. When I started Insulin my doctor wanted to take me off Metaglip. Only part of that made sense. The Glipizide part of Metaglip is a Sulfonylurea which stimulates the release of more insulin from the pancreas. But we’ve already determined that too much insulin is the problem. Sulfonylurea drugs also decrease insulin resistance which they would pretty much have to do in order to help the extra insulin work.
The diabetic care nurse knew more about the drug than the doctor did. I was able to convince the doctor to prescribe Metformin which the doctor was convinced could not help since my pancreas (he said) no longer produces insulin. He clearly had the meds mixed up. But he has told me since then that as long as it is working for me (and it is) that he will keep prescribing it.
I was on Byetta (Exenatide) which was getting decent results when the diabetic nurse recommended I go to the “gold standard” of care which is insulin with the pump. The mechanism of Byetta is (wikipedia source).
Byetta has some side effects that bother people enough to get them to stop taking it. It’s a shot, like Insulin, so there’s that inconvenience.
I have no experience with the other classes of drugs but if the drug’s net effect is to increase the level of insulin in your blood then it’s bad. Good that it is reducing your blood sugar. Bad that the insulin is what does the damage.
From what I can tell, Metformin is one of the best and it only gets you half way to normal. So yes, ask your doctor about these drugs but focus on the question of whether or not the drug increases the insulin level in your blood. If so, be skeptical.
Get some aerobic activity can translate into “get off your lazy behind” to some people. I am one of them. Now if I’m more than 100 lbs overweight how easy is it for me to get more exercise? Now suppose I’m eating all three recommended meals and suffering the insulin rise that comes with those meals.
I propose this idea for those who tell me to get more exercise. They need to strap a 120 lb weight on their back and hop on the stair machine or the elliptical. Because that’s what it is like when I get on one of those machines. My pulse rate goes up when I get up to walk to the bathroom. My guess is that my muscle mass is as much as most skinny people. How many of them can walk a mile with a 120 lb weight strapped to them?
I’ve only been on this Intermittent Fasting “diet” for about 10 days but I have a lot more energy. I can’t stay in bed long and I am awake late. I actually cleaned up my kitchen for the first time in 2 years. I cleaned out my living room and hauled a bunch of old bottles to the recycling center today (I am on a week stay-cation with the kids). Most of my house looks like I am no longer a hoarder (a joke not intended to insult those with the real condition).
When I lost 70 lbs back in 1997 I was able to do a lot of physical activity. I rode my bike and roller bladed around the neighborhood (my age at the time was upper 30’s). I long for the day when my body isn’t so pulled down by gravity that I moan to get up.
Benefits of Exercise
It is known that exercise lowers insulin resistance (Acta Med Scand Suppl. 1986;711:55-65. Effects of Exercise on Glucose Tolerance and Insulin Resistance . Brief review and some preliminary results Effects of exercise on glucose tolerance and insulin resistance. Holloszy JO, Schultz J, Kusnierkiewicz J, Hagberg JM, Ehsani AA.). From that page.
Preliminary results are presented in this paper showing that prolonged, strenuous and frequent exercise can also completely normalize GT by decreasing resistance to insulin in some patients with mild non insulin dependent diabetes mellitus (NIDDM) and in some individuals with impaired glucose tolerance (IGT).
What constitutes prolonged, strenuous and frequent exercise? The abstract continues:
The amount of exercise required to normalize GT in such patients appears to be in the range of 25 to 35 km per week of running, or a comparable amount of another form of exercise, performed on a regular basis.
That is 15-21 miles a week. I wonder how many years it would take to work up to that level if exercise? At 4 days a week, that’s running 4-5 miles a day. I am sure there are people who can and do that but really? The level of exercise it would take for a non-mild T2D to reverse their condition is pretty extreme. How many people are able to keep that up over their lifetime without some injury which stops the running?
Add to that their statement:
Exercise appears to be effective in normalizing GT only in patients who still have an adequate capacity to secrete insulin, and in whom insulin resistance is the major cause for abnormal GT.
I wonder how much my pancreas still can make? I guess I will find out as I lower my external Insulin.
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.
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.
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
Negative Side of Counting Calories
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.