Friday, 10 May 2013

Type 2 diabetes: between a rock and a hard place.

About 85% of type 2 diabetics have excessive visceral adiposity (belly fat). This post is about them.
Which is better - the rock or the hard place?


1) The rock:

This is serum glucose. People with type 2 diabetes can measure their own serum glucose. Eating carbohydrates makes serum glucose increase, the rate of increase being proportional to the glycaemic index and the magnitude of the increase being proportional to the grams of carbs consumed. By limiting the intake of dietary carbohydrates, large spikes in serum glucose can be avoided. The occasional spike above 7.8mmol/L (140mg/dL) doesn't hurt. It's spending long periods of time above 7.8mmol/L that's harmful (by glycation).

A low-carb diet (~150g/day of carbohydrate) halves serum glucose fluctuations compared to a higher-carb diet (~300g/day of carbohydrate). A very-low-carb diet (~75g/day of carbohydrate) further halves serum glucose fluctuations compared to the low-carb diet. This seems like an improvement, at first glance.

2) The hard place:

This is the invisible "elephant in the room", as it's not measured by doctors and people with type 2 diabetes can't measure it themselves. It's serum Non-Esterified Fatty Acids, or NEFAs (a.k.a. Free Fatty Acids, or FFAs). Serum NEFAs are high when fasting and fall after eating foods that raise serum insulin (carbs & certain proteins). People with type 2 diabetes and excessive visceral fat (belly fat) have higher-than-normal serum NEFAs due to adipocyte insulin resistance (IR). See Insulin Resistance: Solutions to problems.

Just like with serum glucose, there's nothing wrong with serum NEFAs going up & down. It's chronically-high serum NEFAs that's harmful (except during periods of caloric restriction). See Showing posts sorted by relevance for query NEFA "type 2 diabetes" .

See Fig. 1 in Lack of suppression of circulating free fatty acids and hypercholesterolemia during weight loss on a high-fat, low-carbohydrate diet. On a very-low-carb (less than 50g/day carbs) diet that's not calorie-restricted, serum insulin remains low all of the time. To insulin-haters, that sounds like a good thing. Unfortunately, it means that there is no insulin spike to suppress serum NEFAs by shifting the balance of NEFAs going in/coming out of fat cells. Serum NEFAs stay high all of the time, which is harmful.

Therefore, people who have type 2 diabetes and excessive visceral fat and who are permanently on a very-low-carb diet that's not calorie-restricted are harming themselves.


Charles Grashow said...

so the solution is???

Nigel Kinbrum said...

Temporary very-low-carb diet, while causes of IR are tackled.

Longer-term, low-carb diet.

Praguestepchild said...

I just took a brief look at the first study and it sucks incredible ass:

"All subjects attended weekly group sessions that varied between the 2 treatment conditions only in the type of dietplan prescribed"

"Subjects were told that polyunsaturated fats and monounsaturated fats were healthier sources of dietary fatty acids than were saturated fats, but it was clear that the primary goal was to limit carbohydrate by whatever means were required. Participants were provided a treatment manual, which described the rationale for a low-carbohydrate diet as well as numerous suggestions for meal plans."

And the clincher:

"Healthy, obese adults (n= 32; 22 women, 10 men) were randomly assigned to receive either a carbohydrate-restricted diet..."

16 people on each diet with counseling of what the diet consists of and self-reported results. If that's not real science what is?

Nigel Kinbrum said...

"16 people on each diet with counseling of what the diet consists of and self-reported results. If that's not real science what is?"

The results in Fig, 1 aren't self-reported. That's the only data I'm interested in. Text above tweaked accordingly.

Charles Grashow said...

what should the carb consumption be on the temporary VLC and the long-term LC?

Nigel Kinbrum said...

Unless I'm hallucinating, I'm sure it's mentioned in the paragraph titled "1) The rock:"

Praguestepchild said...

No, those results aren't self-reported, just everything about the people being involved in those two groups was, along with the fact that there was no control group without intervention (or counseling which was the intervention for this 'study' of 32 fatties).

Do you honestly consider this to be science?

Nigel Kinbrum said...

Where Fig. 1 is concerned, yes. It clearly shows the effect of different types of meal on serum insulin & serum FFAs.

I'm not interested in any other aspect of this study.

Wayne Johnson said...

Since certain proteins can spike insulin as much as glucose, might there not be a third alternative to hi-carb or hi-fat: hi-protein?

Nigel Kinbrum said...

Absolutely! However, I'm a bit of a cheapskate and hate spending good money on protein, only to have half of it turned into carbs + a load of nitrogenous waste.

Diana Moon said...

Nigel, another issue with chronically depressed insulin levels is effect on lean body tissue. Insulin being anabolic, doesn't this create muscle waste (and bone loss)?

Nigel Kinbrum said...

Low serum insulin = not anabolic.
High serum cortisol = catabolic.

Diana Moon said...

So...not anabolic doesn't equal catabolic?

I thought it did, since body tissues are always being broken down; they need to be built up.

Nigel Kinbrum said...

Anabolic = building up. Not anabolic = not building up.
Catabolic = breaking down. Not catabolic = not breaking down.
Not building up =/= breaking down.

Diana Moon said...

I'm aware of the meaning of the words, Nigel. Just saying that in the real world, if muscle isn't being repaired by adequate insulin levels (among other things) it will break down. And you will look like shite.

Analogy: letting a house fall apart, as opposed to actively knocking it down.

Nigel Kinbrum said...

The body cycles between anabolism (post-meal absorptive phase) and catabolism (post-meal post-absorptive phase). The overall balance between the two determines overall losses & gains.

Do you have any more eggs that I can teach you to suck? ;-)

Diana Moon said...

"Do you have any more eggs that I can teach you to suck? ;-)"

What does that mean?

Nigel Kinbrum said...

Have you not heard the expression "teaching xxxx (usually granny) how to suck eggs" (meaning "telling someone something that they already know")?

Above, you wrote "I'm aware of the meaning of the words, Nigel." I was teaching you how to suck eggs!

Diana Moon said...

No I haven't heard that expression. And I will continue to suspect that chronically and unnaturally depressed insulin levels are effectively anabolic. But I won't engage with you any further, I'll bring this up to someone who really knows, and who has scientific curiosity.

Nigel Kinbrum said...

"And I will continue to suspect that chronically and unnaturally depressed insulin levels are effectively anabolic."
I think you meant "catabolic".
Sorry for having annoyed you. I'm a nerd. It's what I do.

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

I have a question, but this is about those other 15% who might not have visceral fat. Eh. Actually, this is a hard one to call. I'm under the impression that even if one is low body fat, they could have visceral fat in the belly.

However, for argument's sake, let's assume that the individual doesn't have much belly fat of any sort. How would a low glucose and insulin VLC environment affect this person? Would high serum NEFA be a problem?

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


Although there is a difference between skinny fat and skinny with visceral fat.

Nigel Kinbrum said...

I thought that "skinny-fat" people had little body-fat in the usual places (arms, boobs, love-handles, bum & thighs) but had it mostly in the belly.

What's the difference, in your opinion?

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

To be honest, I am not sure, which is why I asked this question in the first place. I mean, if we see someone with a lean abdominal region, can we be absolutely certain that there isn't fat around the organs? I remember watching that show Embarrassing Bodies. And one of the doctors on the show had a lean physique, and they dedicated one segment of an episode to showing how despite being lean with very little fat around the abdominal region, he carried some 'dangerous fat' beneath the muscle.

Nigel Kinbrum said...

It's a matter of degree. People with few adipocytes in the usual places will accumulate body-fat in the abdominal region. This isn't desirable, as too much fat in the abdominal region causes the problems that I've been blogging about.

So, the doctor with some 'dangerous fat' would have problems if he got a lot fatter.

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

It is a matter of degree. Given that visceral fat is fat around the organs, which is hard to discern from the outside, I always wondered whether individuals with low abdominal fat could still have larger-than-desired levels of fat around their organs. That, I think, seemed to be the case for the doctor in question. Another example of looks being deceiving, especially when it comes to health.

Nigel Kinbrum said...

Something has gone wrong. My reply to Kade is not visible here despite me having received an email notification. His reply to my reply is also not visible to me. My reply must have been visible at some point, for Kade to be able to reply to it!

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Caffie Cat said...

Diabetes drugs are not the answer – most type 2
medications either raise insulin or lower blood sugar (failing
to address the root cause) and many can cause serious side effects

Nigel Kinbrum said...

The same criticism applies to non-calorie-restricted very-low-carb diets, which lower blood glucose but raise serum "everything else" (except HDL-c, which is lowered).