Wednesday, 5 June 2013

When the only tool in the box is a hammer...

Everything that needs fixing looks like a nail.

People with diabetes mellitus are issued with blood glucose meters - and nothing else.

For people with type 1 diabetes, that's fine. They lack insulin, so they have to inject insulin in the right amounts & types to keep their blood glucose levels within reasonable limits. Applying Bernstein's Law of small numbers by reducing glycaemic load to a minimum keeps blood glucose levels within reasonable limits (between 3 & 7mmol/L) most of the time. See also The problem with Diabetes.

For people with type 2 diabetes and excessive visceral (belly) fat (~85% of people with type 2 diabetes), that's not fine. Their disease is a disease of chronic excess fuel intake relative to fuel oxidation, causing dyseverythingaemia (hyperglycaemia, hypercholesterolaemia, hypoHDL-cholesterolaemia, hyperNEFAaemia, hypertriglyceridaemia, hyperuricaemia, etc). People who have type 2 diabetes don't have only postprandial hyperglycaemia - they also have postprandial hypertriglyceridaemia. See Postprandial lipoprotein clearance in type 2 diabetes: fenofibrate effects.

However, because the only tool in their box is a blood glucose meter, their disease looks like a disease of only hyperglycaemia. Applying Bernstein's Law of small numbers by reducing carbohydrate intake to a minimum keeps blood glucose levels within reasonable limits, but makes everything else worse if energy from carbohydrates is replaced by energy from fats.

Only if energy from carbohydrates is reduced AND energy from fats isn't increased to compensate (i.e. eat a LCLF PSMF or Modified PSMF), does carbohydrate restriction help people with type 2 diabetes.

26 comments:

the10principles said...

Great analogy! Understanding makes all the difference and if people can understand that diet is still a big part of staying healthy then people with type 2 diabetes can work towards a healthier diet that doesn't include excess fat. Good job to bring awareness to this - which promotes understanding!

Nigel Kinbrum said...

I've tweaked the wording. Is that better?

Kade Storm A.K.A. Hedonist said...

And yet certain parts of the internet sphere are promoting a level of protein phobia that could potentially give those austere vegan diets a run for their money. An example being the link that Charles referenced in one of the other threads about how Protein's giving all these animals metsyn and killing Kenny.

Nigel Kinbrum said...

Sometimes I think that the whole world's gone completely mad, except for me and you....and I'm not too sure about you!

Kade Storm A.K.A. Hedonist said...

Give in to the madness, Nige.

Nigel Kinbrum said...

Oh, gawd! Do I have to?

George Henderson said...

PSMF is the basis of the classic weight loss diets, and I've seen it work well. Using it for diabetes is new to me, but why the hell not? It's just a high-fat diet that uses stored rather than dietary fat.

Nigel Kinbrum said...

Exactly.
I tweaked Lyle McDonald's Rapid Fat Loss Diet to make it a bit less Protein Strictly, Mother-F*cker!

See http://nigeepoo.blogspot.co.uk/2009/01/protein-sparing-modified-fast-psmf.html

OtakuMom2 said...

You've never had T2 diabetes, have you? When the nutritionist told me to follow the food pyramid I used my working brain to determine that it made absolutely no sense to tell someone with an intolernce for carbs to eat them. so I went LCHF, and my numbers have improved greatly.

Nigel Kinbrum said...

My fasting glucose was creeping upwards and it reached 6.8mmol/L. Another 0.2mmol/L and I would have been diagnosed as having T2DM. Luckily for me, I fixed my metabolic problems just in time and dodged the T2DM "bullet". See http://nigeepoo.blogspot.co.uk/2011/02/insulin-resistance-solutions-to.html for how I did it.
So technically, I've never had T2DM. I came within a gnat's whisker of having it.
You say your numbers have improved greatly. Which numbers? Did you lose weight? If you re-read the article above, you'll see that I wrote "but makes everything else worse if energy from carbohydrates is replaced by energy from fats."
If your weight is decreasing, you're in negative energy balance. You therefore didn't replace the energy you previously got from carbohydrates with energy from fat. Therefore, the HF in LCHF is relative, not absolute.
Have you tried any of the things in my insulin resistance article?
Cheers, Nige

OtakuMom2 said...

Not only has my weight gone down, but my a1C went from 6.4 (doctor diagnosed me at 6.4, probably because I had gestational diabetes prior to this and wanted to make sure it was caught early) to 5.8, and my triglycerides went from a high of 315 to 185 and are still dropping. And my energy has gone up greatly -- I have a hill by my house that I used to have to stop on halfway while climbing it, and now I can climb it very easily.

Eating carbs on top of carbs makes no sense to someone who essentially has an intolerance to them. I'm doing well on this diet because I feel better on it. No more heartburn, no more zits, and my feet are not as dry as they used to be. So something has to be working.

Nigel Kinbrum said...

Excellent! You didn't replace the energy from carbs with an equal amount of energy from fat, so you lost weight. There are people (e.g. Gary Taubes) who say that you can exercise as much gluttony as you like on fat & protein and everything will be just fine. Everything won't be just fine. BG & HbA1c will probably be fine, but everything else will be worse, due to excessively-high serum NEFAs.

You haven't done that, so everything got better. If you read more posts here, you'll see that I'm pro-LC & VLC diets. I'm anti-"calories don't count, you can eat as much as you like".

Current advice for diabetics is appalling. I don't agree that diabetics should eat according to the food pyramid. LC & VLC diets are great for controlling BG & HbA1c. I still think that it's worth checking-out the options in my insulin resistance post, as many people are deficient in some important nutrients, due to modern diets & lifestyles.

As I said earlier, I got lucky. 5,000iu/day of Vitamin D3 made a huge difference to my glucose tolerance. My Endo' had trouble believing that my 2 hours post-glucose load BG went from >8mmol/L in 2003 to 3.7mmol/L in 2008. Mind you, he had trouble believing that my lumbar bone density went from -2SD in 2003 to 0SD in 2006 without taking alendronate!

OtakuMom2 said...

Well, actually I did...60% or more of my calories come from fat, which is probably equal to what I was eating in carbs before I started HFLC. The difference is that the fat provides a more stable energy source for me throughout the day, especially since I deal with kids all day long (at home with an almost 5 year old and at work with teenagers/elementary school kids) whereas carbs go in the bloodstream and then quickly disappear.

Nigel Kinbrum said...

You were in negative energy balance, as stable BG & insulin levels meant that you could expend more energy doing things that you couldn't do before (like climbing up & down hills), without experiencing hunger pangs, energy slumps after meals etc. Fats also go in the bloodstream and then disappear, though not as quickly as carbs. See Figs 1 & 3 in http://ajcn.nutrition.org/content/75/3/505.full

Which fuels your body uses at any given instant varies (a bit like what happens in a petrol/electric hybrid car). See http://nigeepoo.blogspot.co.uk/2012/02/its-all-in-days-work-as-measured-in.html

OtakuMom2 said...

You say you're for LC, but the important part of that equation is the HF part of it. I had to switch my fuel in order to feel better because the traditional LFHC diet was not working for me, and in fact made me sicker.

Nigel Kinbrum said...

Why do you say that the HF part is important?
It's the LC part that's important! See http://www.bodyrecomposition.com/fat-loss/do-i-need-to-eat-more-fat-to-burn-fat-qa.html

A PSMF is just protein & a handful of fish oil caps, to provide EFAs & make the gallbladder empty regularly. This is the best diet for T2DM, as it results in the most rapid loss of body-fat. Adding fat to the diet slows the rate of body-fat loss, as the body burns a mixture of dietary fat & body-fat, instead of just body-fat. Adding fat to the diet makes the diet easier to live with. That's the only benefit to raising the fat content. See http://www.bodyrecomposition.com/fat-loss/do-i-need-to-eat-more-fat-to-burn-fat-qa.html

What Lyle McDonald doesn't know about Diet & Nutrition isn't worth knowing. He wrote the reference book on VLC diets, http://www.bodyrecomposition.com/the-ketogenic-diet

Please read the articles on his site. They'll dispel a lot of dietary myths that are promulgated around the internet.

OtakuMom2 said...

I've been losing pretty rapidly on the plan I'm on now (32 pounds since April -- on HCLF I wouldn't have lost this much weight in this amount of time even with exercise). The HF part is important because your body needs an alternate energy source. That with the protein helps you feel hungry, and people on HFLC don't really eat all they want if they're on this diet -- they eat what they're body needs, and they stop. In general, HFLC followers are told not to watch their calorie counts because the body takes care of it on its own.

Nigel Kinbrum said...

If a skinny Kenyan has enough body-fat to fuel his body during a marathon, we less-fit mortals have more than enough body-fat to fuel our activities. That's what not eating carbs does - it makes the body burn fat, whether one eats fat or not.

So yeah. Low-carb diets for the win. Some people's appetite centres in the brain are messed-up, so they can't eat ad-lib and they have to keep an eye on their food intake. Others are lucky and can eat ad-lib. That's why it's wrong to tell all LCHF followers to not watch what they eat, as everyone is different.

CynicalEng said...

Commercial PSMF preparations are more than just protein - 80% protein 19% carbs 1% fats for example. At 500 calories 80% protein is 100g which is enough for most people.

Nigel Kinbrum said...

Commercial PSMFs sound a bit crap, if they're 20% carbs. What sort of carbs? Lyle's Rapid Fat Loss Handbook is a "proper" PSMF.

CynicalEng said...

Maltodextrin typically. They aren't trying to be low carb, just very low calorie and enough protein to stop muscle wastage I guess.

Nigel Kinbrum said...

Sorry about the slow moderation, but I'm away from home. Maltodextrin, eh? Couldn't be much worse.

CynicalEng said...

yep. Some PSMF diet preparations use sugar too, like Optifast as used in Newcastle to reverse T2 diabetes http://www.ncl.ac.uk/magres/research/diabetes/reversal.htm

Calories 160
Protein (g) 14
Carbohydrate (g) 20
Fat (g) 3

Ingredients (French Vanilla): Water, Sugar, Sodium Caseinate (Milk), Calcium Caseinate, Corn Syrup Solids, High Oleic Sunflower Oil

Nigel Kinbrum said...

More sugar than protein? I'm running out of palms. How many of those preparations are consumed each day? I'm guessing three, to make 480kcal/day. 3g of fat/meal is only just enough to stimulate sufficient gall-bladder emptying. Also, no fibre + Ca & no Mg = constipation, or can loads of greens be eaten in addition?

From your link:- "Weight loss averaging 15kg (2 stone 5lb) achieved over 8 weeks..." I wonder how much of the weight lost was fat, how much was LBM & how much was water?

If aspartame/acesulfame K/sucralose had been used instead of sugar, the composition could have been 34g of Protein, 0g of Carbs & 3g of Fat per meal, + carbs & fibre from greens.

CynicalEng said...

Commercial PSMF are nutritionally complete in terms on mins and vits, essential fats etc. That's why they're used in proper medicine settings. The Newcastle people are imaging geeks so looking inside the body at the fat is their thing. 2.6kg of FFM lost, 15.3kg fat.

Nigel Kinbrum said...

That's cheered me up a bit. The results aren't too shabby, either. So, PSMFs for the win, whatever the type.