Dietary Carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base, by Richard D Feinman et al.

Another Bookmarking post.

From https://dgeneralist.blogspot.co.uk/2013/11/the-low-carb-high-fat-diet.html

The study in question is Dietary Carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base. Here are my comments on the 12 points.

Point 1 is wrong. For ~85% of people who have T2DM, hyper*emia is the salient feature, where * = glucose, TG's, cholesterol, NEFAs, uric acid etc. For ~85% of people who have T2DM, it's a disease of chronic excess.

Ad lib LCHF diet → ↓ Blood glucose & ↓ fasting TG's, but ↑ PP TG's, ↑ LDL-C, ↑ LDL-P & ↑ NEFAs. See Postprandial lipoprotein clearance in type 2 diabetes: fenofibrate effects.
↑ PP TG's is associated with ↑ RR of CHD.
↑ LDL-P is associated with ↑ RR of CHD.
↑ NEFAs are associated with ↑ RR of Sudden Cardiac Death.

Point 2: So? T2DM is a disease of chronic excess. Chronic over-consumption was caused by Food Industry marketing, not carbohydrates.

Point 3 is wrong. A caloric deficit is essential, to reverse liver & pancreas ectopic fat accumulation. See Reversing type 2 diabetes, the lecture explaining T2D progression, and how to treat it.

Point 4 is misleading. Feinman doesn't distinguish between different types of carbohydrates. Starches, especially resistant starches (e.g. Amylose) are beneficial. See Point 11.

Point 5 is moot. Prof. Roy Taylor found that motivation determines adherence. Prof. Roy Taylor's PSMF was adhered to. See Point 3.

Point 6 is correct. Prof. Roy Taylor's PSMF is ~1g Protein/kg Bodyweight, some ω-6 & ω-3 EFAs & veggies for fibre. See Point 3.

Point 7 is misleading. Siri-Tarino et al gave a null result by including low fat studies, also a dairy fat study which had a RR < 1 for increasing intake. Chowdhury et al gave a null result, as some fats have a RR > 1 for increasing intake and some have a RR < 1 for increasing intake.

Point 8 is irrelevant. ↑ Dietary fat → ↑ 2-4 hour PP TG's. See Point 1.

Point 9 is partly correct. Microvascular, yes. Macrovascular, no. See Point 8.

Point 10 is mostly irrelevant. See Point 8.

Point 11 ignores results obtained with high-starch diets, where the starch contains a high proportion of Amylose. See Walter Kempner, MD – Founder of the Rice Diet and From Table to Able: Combating Disabling Diseases with Food.

Point 12 is misleading. The low-carbohydrate part is fine. It's the high-fat part that can cause problems. See Point 8.

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 intake relative to oxidation, causing fasting dyseverythingaemia
(hyperglycaemia, hypercholesterolaemia, hyperNEFAaemia, hypertriglyceridaemia, hyperuricaemia, etc). People who have type 2 diabetes don't have only postprandial hyperglycaemia - they also have postprandial hypertriglyceridaemia. See Lifestyle Intervention Leading to Moderate Weight Loss Normalizes Postprandial Triacylglycerolemia Despite Persisting Obesity. Postprandial hypertriglyceridaemia is atherogenic. See Ultra-high-fat (~80%) diets: The good, the bad and the ugly.

However, because the only tool in the box of someone with type 2 diabetes is a blood glucose meter, their disease looks like one 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 other things 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 until sufficient visceral fat has been lost), does carbohydrate restriction help people with type 2 diabetes.

Negativity is NOT an option!

Oh, wait.

I received a comment on another blog post mentioning Jeffrey M Friedman's commentary Modern science versus the stigma of obesity. I took offence to the following passage:-

"This simplistic notion is at odds with substantial scientific evidence illuminating a precise and powerful biologic system that maintains body weight within a relatively narrow range."

To say that I disagree with the above passage is an understatement of epic proportions. If this is the case, how can Extreme weight loss without surgery happen? This woman went from 265kg (583lb) to 97kg (213lb).

With the right diet, huge amounts of weight & body-fat can be lost and kept off. Lyle McDonald's Rapid Fat Loss solution is a PSMF (Protein-Sparing Modified Fast) that can produce huge weight & body-fat loss. See The Protein-Sparing Modified Fast (PSMF).

Up with this negativity I will not put!

The Protein-Sparing Modified Fast (PSMF)

What's a PSMF?

A standard PSMF is ~1g of protein for every kg bodyweight per day plus lots of green leafy vegetables plus six to ten fish oil capsules per day plus vitamin and mineral supplements plus unlimited water AND NOTHING ELSE. It's a low-carbohydrate and low-fat diet. You may find this quite literally hard to swallow! PSMF may also stand for Protein Strictly , Mother-F***er!

A 100kg person may get to eat ~400kcals per day from protein + ~100kcals per day from incidental carbohydrates and fats = ~500kcals per day.

A well-known PSMF is Lyle McDonald's Rapid Fat Loss Handbook. For more information, see https://forums.lylemcdonald.com/forumdisplay.php?f=7 and Is Rapid Fat Loss Right For You?

To make a PSMF easier to manage (but have a slower rate of weight loss), here are some modifications:-

1) Instead of six to ten fish oil capsules a day, stir ~25g of powdered linseeds into a large glass of drink and swallow the lot. Do this at breakfast-time. ~25g of linseeds contains ~10g of fat (of which ~6g is Alpha-Linolenic Acid, an omega-3 fatty acid) which does the following:-

a) It stimulates the gall-bladder to empty, thus reducing the risk of gallstones.
b) a) usually results in a bowel movement some time later. The ~10g of soluble fibre/fiber in the linseeds + accompanying fluid guarantees regularity.
c) It provides women (but not men) with all of the omega-3 fat they need each day.

Men need to eat either half a 213g tin of wild red salmon per day, or take six to ten fish oil capsules a day, as their bodies don't produce enough DHA from Alpha-Linolenic Acid. See Eicosapentaenoic and docosapentaenoic acids are the principal products of α-linolenic acid metabolism in young men and Extremely Limited Synthesis of Long Chain Polyunsaturates in Adults: Implications for their Dietary Essentiality and use as Supplements

2) Eat about 100g of protein per day. As meat, poultry and fish contains 20-25% protein, this means that you can eat ~1lb of meat, poultry and fish a day. 100g of protein per day is well within the capabilities of your liver and kidneys.

3) Eat about 22g of fat per day. This allows you to choose less lean cuts of meat and poultry, and you can even eat the skin on chicken as long as you factor it into your total fat allowance. It also allows you to use vinaigrette salad dressings or a small knob of butter or a small dollop of real mayonnaise to make your vegetables taste nicer.

4) Eat about 50g of carbohydrate per day. This allows you to eat shed-loads of leafy green vegetables and also an onion. It also allows you to eat a portion of fruit e.g. an apple or a bowl of berries/cherries with Splenda and a small dollop of whipped cream each day.

5) If you do any intense exercise (e.g. HIIT or resistance training with weights), eat an extra 50g of slow-release carbohydrates a couple of hours beforehand, to fuel it.

6) Supplement with 50iu for every kg bodyweight per day of Vitamin D3. Nowadays, many of us spend our lives mostly indoors, and this causes sub-optimal Vitamin D levels. See Vitamin D.

7) Don't get too far away from a toilet. Rapid depletion of muscle and liver glycogen results in rapid shedding of associated water. In addition, the oxidation of fatty acids results in the production of water. A PSMF makes you pee more.

n*CH2 + 3/2*n*O2 = n*CO2 + n*H2O + heat

(Saturated fatty acids are CH3-n*CH2-COOH. For Stearic acid, n=16. ∴ Stearic acid is mostly n*CH2. )


In conclusion:

100g of protein provides 400kcals, 22g of fat provides 200kcals and 50g of carbohydrate provides 200kcals, making a grand total of 800kcals per day. If you weigh over 80lbs but aren't losing weight on 800kcals per day, see your GP as you may have a thyroid problem.

The above diet should avoid the problems of gallstones, constipation, dry skin, dry hair, depression and dietary deficiencies. You get to eat real food and quite a lot of it too, for a fairly rapid fat loss diet.