Diabetes "Crash" Cures: VLCal vs. VLCarb
In light of my post earlier today regarding treating diabetes, I thought I'd bump this post from around a year ago that compared the impact of acute caloric deficit to acute carbohydrate restriction. If the results don't give one pause regarding low carb always being the best and forevermore necessary diet for diabetics, it's probably hopeless ... but I'll keep trying :-)
Original Publication Date: 7/4/2011
As I was looking at the results from the VLCal diet that "cured" diabetes, I was reminded of the discussion of "curing" vs. remission of diabetes over at Dr. Davis' Heart Scan blog. At the time I couldn't recall the thread in which it had occurred but just now stumbled across it. The post was entitled The Westman Diet. Westman being Dr. Eric Westman of Duke University whom most of my readers are probably rather familiar with.
Original Publication Date: 7/4/2011
As I was looking at the results from the VLCal diet that "cured" diabetes, I was reminded of the discussion of "curing" vs. remission of diabetes over at Dr. Davis' Heart Scan blog. At the time I couldn't recall the thread in which it had occurred but just now stumbled across it. The post was entitled The Westman Diet. Westman being Dr. Eric Westman of Duke University whom most of my readers are probably rather familiar with.
In that post Davis cites the following study:
The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus
mnjjjjjjjjjjjjjj <- low carb house carnivore input
After 6 months, average weight loss was 24.4 lbs, BMI was reduced from 37.8 to 34.4. At the end of the study, 95% of participants on this severe carbohydrate restriction reduced or eliminated their diabetes medications.
I'll give props to Wheat Belly here for calling the LCKD (low carb ketogenic diet) severe, but the other claim is highly exaggerated and downright misleading. I'll have a few comments in this regard after the analysis. It struck me that this was a good study to compare the effectiveness of a very low carb diet -- you know, the one that allows one to control their blood sugars with moderate carb restriction or without going hungry eating a bunch of fat -- with the VLCal diet recently in the news. I discussed VLCal diet here and here, and here's the original study:
Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol
The time frames for the two studies are similar enough to be comparable. In VLCal study assessments were done at 8 weeks and 20 weeks (8 + 12 week followup), while in VLCarb assessments were made at 12 and 24 weeks. The VLCarb study was a bit bigger, but in the end we're comparing 11 subjects VLCal to 21 "completers" of the VLCarb study.
Now unfortunately, the VLCarb (hereafter the ketos) group does seem to start out as "more diabetic" than the VLCal group (hereafter the crashers), 8 of the 21 completers (38%) were taking insulin at baseline. We don't have the numbers for the 13 subjects who were not on insulin at the start of the study, but all but one of these was on some diabetes medication at the start of the study. However, inasmuch as the inclusion of insulin dependent diabetics in the group may have skewed certain parameters higher overall, and mitigated the degree of recovery possible, the inclusion of 6 subjects (29%) taking insulin initially still getting some sort of "pharmaceutical assistance" for their glycemic control, of which 4 were still taking the insulin (19%), in the numbers would work in this study's favor compared to the unmedicated crashers. Lastly, the ketos were given a glucose-lowering supplement regime of vanadyl sulfate 200 mcg/day, chromium dicotinate glycinate 600 mcg/day, alpha-lipoic acid 200 mg/day -- a supplement mix known to impact blood glucose according to a paper cited in the study.
Unless the non-insulin taking subgroup of ketos ends up being a little lighter, we're left with one additional variable that could be at play in that the ketos were significantly more obese than the crashers. Only Westman et.al. included racial makeup of the study group (included 5 African Americans, 14 white), the ketos were two-thirds female, compared to the crashers being mostly (80%) male. OK ... all of those qualifiers aside .... I've summarized the parameters assessed in common in the table below (in the interests of time I ignored the lipids).
Now, let's keep in mind also that the ketos were on their "severe" diet for the full 24 weeks. Basically Atkins Induction with a few nuts thrown in. We are not given dietary intake data (or I may have missed it and I'm too lazy to look back) but probably they consumed somewhere in the 1200-1400 cal/day range - likely less in the first half of the study when they lost more weight. So unlike some other studies, the carbs were kept low for a fairly extended time. The crashers, OTOH, were evaluated after 8 weeks and sent home with advice on healthy eating and portion control.
Now the ketos did start off heavier and more diabetic, but also note that at 12 weeks in, they match up surprisingly similarly with the baseline crashers. Only the ketos, did not lose much more weight (2.8 kg) in the second 12 weeks. If carb restriction were a superior "cure" shouldn't the still-losing-weight (albeit more slowly) low carbers have seen additional improvements over 12 weeks compared to the no-longer-crashers, now consuming a "normal diet" (presumably in a 2000 cal + range and likely 40-50% carb) and gaining slightly? But we don't see this. Which, frankly, I am very surprised by, and I believe the researchers were too!
The ultiimate (24 and 20 week) net weight loss was comparable between the two studies just under 25 lbs. Yet the crashers, even after a "recovery" period, seem to have fared much better even by relative standards. But surely this was due to the fact that such a low calorie diet is by virtue low carb. Well, the crashers were getting roughly 60g carb/day (perhaps 70g if you add in the veggies), while the ketoss got <20g. I don't care if it's still low carb, the crashers consumed 3 times the carbs of the ketos. And yet, WITHIN ONE WEEK, their fasting glucose went down almost to the level at the end of 8 weeks of the diet ... and it only crept back up ever so slightly after 12 weeks of eating more carbs and enough calories to gain an average of about 7 lbs. Oh ... and none were taking any pharmaceuticals or supplements to assist in this. And they passed an oral glucose challenge and had normal insulin secretion as assessed. Things I think Westman and company are a bit hesitant to even try.
If we're going to talk cure folks, this study CANNOT go ignored and it cannot be dismissed either. Any way you look at it, even extreme carbohydrate restriction did not produce results in 6 months even remotely rivaling those Lim et.al. achieved with their crashers in 2 months. My readers soon learn that I'm SO not a fan of "crash diets", but these results are impressive. Of course we don't know if the results would last even if they maintained the weight loss, but if I had a choice between taking diabetes drugs every day for the rest of my life vs. going a little hungry for a couple of months for a few more years free of having to do so, I'd give serious thought to that sacrifice.
So now let's get back to Dr. Wheat Belly Davis for a moment, shall we? He proclaimed that VLC "cured" diabetes based on the amazing fact that 95% of the keto diet participants either reduced or eliminated their medications. True, but let's take a look at what that meant, and compare it to the other diet group in Westman's study - the low GI diet. The med changes are in this table. Let's look at the attrition for a moment and the differentials between the groups in Westman's study. For the low carb group, they started out randomly assigning 48 subjects to this group, to which 10 said no thanks so they started out with 38. Of those, 21 completed the study. It just so happens that 20 of those completers were taking some diabetes medication at the inception of the study. Of the 49 assigned the low GI route, only 3 said no thanks so the initial group was larger (46) of which 29 completed. So it is rather odd to me that we had only 3 insulin-only takers in the larger group of 29 GI completers (10%) vs. 8 insulin and/or insulin + takers of the 21 KD completers (38%). Looking at the med table, it seems the "other than insulin" meds were changed less than insulin. This skews a blanket statement of reduction in medications dramatically in the KD favor.
Now one would think that Dr. Davis would see the headline about a cure for diabetes and jump for joy right? After all, hhe has been wondering why nobody else is trying to cure it for a year now. In the comments on the Westman thread, he did later state, referring to his and LC'er diabetes: "I use the term 'cure' loosely. "Latent" would be a better term. " Considering the results of Lim et.al., small study size and short follow-up and all that, should he be out front and center trying to cure his patients? Just saying ....
"mnjjjjjjjjjjjjjj <- low carb house carnivore input". What on earth can it possibly mean?
I've known several people who did realy well over a really long period of time [say...20 yrs and counting] using a method that basically goes like this "Fast until undeniable physical hunger, eat whatever sounds good, eat only to the point of no longer feeling "hunger" [not to be confused with "full" or "satisfied"] then fast again and so on and so forth.
So basically just go ahead and sit a hair to the left of hunger for...ever.
Which is probably great for them metabolically but in terms of practical application I think it might be a bit of a problem because people get just a little irritable under those circumstances and my children and husband do not want me to sprout fangs and claws on a regular basis under the slightest stress or if my next meal has to be delayed for some reason.
It's at the beginning tho...
I've read some posts and yours too about this and I'm wondering should I put her on a low kcal diet sub 1000 kcals/day, controlling carb intake or put her on a similar diet 600 kcal/day only with vegetables ?
Do you have suggestions, what would you do in my place ?
I'm kinda desperate...
To what degree they can repair themselves is anyones guess.
Ultra low calorie should be more effective than high a calorie ketogenic diet for this however I would still completely avoid as many carbs ( and probably protein aswell )on low calorie as possible, there aint gonna be anything good about spiking your blood sugar when you have severe insulin resistance.
@Kindke: There's no science, that I see, behind the notion of using a "fat fast" to treat insulin resistance. This seems to be what you're suggesting. I'd probably use an insulin sensitizing med or inject insulin to prevent whatever sugar spikes I was subjecting my body to. The high fat content of a VLC diet seems to work against the beta cells in the long run.
I would expect that to utilize both plans for their optimal results with a nod to the practical aspect that people who are hungry and uncomfortable all day every day or who are trying to lose weight while eating high carb and having cravings are likely to be noncompliant.
It's the conundrum that higher carb ratio at lower volume may very well be optimal but higher carb ratio makes lower volume problematic unless a person is already very insulin sensitive.
The people I have known who practice this style of eating have never been significantly over weight and their portions of food look like childrens portions. Sure, they eat three bites of ordinary pizza. So could anyone...right? So why don't they? If three bites is enough [and their good health suggests that it is] then why is an overweight person dissatisfied after three SLICES.
I think a lot of people will be satisfied to stop short of "optimal" if they can be at their desired weight and eat ad libitum with limitations only on their upper limit of carb consumption.
That's my amatuer best guess anyway.
Mention Weight Watchers and it's like waving a red flag. But that is exactly the message that people live with, and lose weight with, on WW: you can eat anything you want, within your daily calorie limit (those bites of pizza are fewer calories than slices). With WW, calories are 'points plus.'
You CAN eat three slices of pizza, if you are willing to live with the consequences the rest of the day. That is, you eat less of other things, and if you are hungry, you can 'fill up' on vegetables (sans fats).
People eat 'ad libitum' of vegetables and fruits (called free foods) with limitations on their upper limit of fat consumption (proteins aren't free, probably because they contain fat).
Fatty meats (all you can eat). Fruits and vegetables (all you can eat). Your choice.
According to the Atkins website, if it's not working for ya, look at the calories.
If we assume people's calorie totals are remaining the same then it's a safe bet that post Atkins weight loss OR WW or "insert method here" ALL utilise the portion control without calling it that. Maintainance mashed potatos might look like 1/3 C once or twice a week. People are so pleased to be able to have them again at all they maybe forget that they used to eat a large bowl at one sitting? Ditto fats on a fat restricting diet. Oh yay now I can have butter on my potatos! Forget that I used to dissolve an entire stick into my serving. Etc and so forth.
I think the fasting could also add further appetite suppression once the carbohydrate is elevated. I have always found fasting to be suppressive, never ever caused me to chow down uncontrollably. I mean, sure maybe if I was lost in the woods for 3 days but I'm talking about hours not days.
Amen to that.
WW asks you to count points plus (calories). If you don't wanna, and you're not gonna, but you lose weight anyway, using wiser food choices, fine. No one checks your urine, reads your food diary.
But IF perchance you do use the tools and you do count to see what you actually put in your mouth, at some point, you not only hold up a pair of jeans that would fall off your hips today. You also have to admit, 'Wow, I started this program eating THIS much and now I eat way less... how'd I ever eat that much in a day?'
How about them apples...lol!
But it does follow if I sit and think about it. Assume that a person was fasting to true hunger then eating only to the point of satisfying "hunger". That hair to the left moment again. We are totally in 3 bites territory again.
So then say you have got a big yen for apple pie and it's a binge food for you and you are afraid that you will "cave" for apple pie and it's not very nutritious and so on and so forth.
Enter mental anguish and binge cycle presumably.
This theory instructs a person having that problem to use apple pie for their whole "meal" at every period of eating for days on end if necessary until it loses its shine and doesn't call your name anymore. Eventually the apple pie is supposed to revolt you until you go without eating it for awhile. Theory instructs that concern over nutrition can do more harm than good in thinking an obese or disordered eater will suffer irreversible damage going without "balanced" meals for a few days to get over a craving.
I've never tried it so I can't give a thumbs up or down but based on the info I'm seeing re whole health source etc it looks like it might very well bear further investigation.
That eating philosophy is also very critical of any system that places artificial boundaries around any kind of food for two reasons...
1 it creates food obsession and
2 it gives license to eat outside of hunger [example Atkins gives 20 grams carb during induction or WW gives "points"...so then people are still free to eat when they are not hungry provided they do not exceed those boundary lines]
I think there's probably something to that.
Ah, there's always something, eh?
One difference, I guess, would be that WW doesn't bother to critique your reasons for eating. Only for OVEReating. The boundary lines are there for a reason: when you exceed them, you gain weight. If weight weren't the issue, would you be at WW? (I'm guessing not.)
Eating when not hungry is something discussed at WW meetings; because eating is something people do to soothe themselves when stressed, when bored, when in a group and wanting to particpate... Yep, if you obey the boundaries (calorie-wise), you're still good to go, eating that pizza SLICE. It's beer night, they're your buddies, you ate at home, you've got some points plus left. You're OK.
Food obsession? Can't help with that. We face food choices every day. Some of us are more 'foodie' than others.
BigWhiskey are you asking me what the Optifast formula is?
Y'know Jim, I think many of us have a distorted impression of the satiating ability of carbs from the context of the SAD. French fries are not very satiating, potato chips even less so. And in the end the fat that one might consume dipping that chip doesn't add much. Potatoes OTOH are, especially after not eating them for a long time. In my diet/ED days, I could eat an entire box of instant oatmeal packs. These days I make a small bowl of steel cut oats and often can't even finish it.
The notion of "free foods" is misguided when we think about it. It implies that eating such foods is exempt from the reasons for eating it -- e.g. genuine hunger.
I wonder if it would have made it possible to do the low cal with much less discomfort? I also wonder if the action of having the insulin go up and donwn as it's meant to contributes anything metabilically significant to the good outcome of curing the t2 diabetic?
They really should clear these things with me before they design their studies.
One benefit of 'free foods' is that you can eat them to 'fill up' when you are hungry, having already eaten your 'points plus quota' of foods for the day. They are discussed in the context of hunger - when you are hungry, reach for veggies or fruits!
I can see that this is about hunger and optimality, etc.
If we are talking about losing weight, then the CA/CO balance is still addressed with a 'points plus' allowance. You have a limit that you don't HAVE to meet. You just can't exceed that limit (given your age, height, lbs., etc., the limit is set for you in the beginning, then adjusted downwards as you lose weight).
This limit has 'wiggle room'; it's unlikely that the calories in fruits and vegetables are going to take you out of a margin allowed with that limit. It's possible that you can eat too many apples, too many broccoli spears, etc., but not likely. If that happens, to the extent that you exceed your calorie limit, then you gain weight. It does happen - it means a sit-down with the WW group leader to talk about what you eat and how much.
The weekly weigh-in keeps this from getting out of control. Tracking food (food logs) is one of the tools that help figure it out.
It's still calories in/calories out. To the extent that physical activities also have points plus values.
The combination of food intake and physical activity and sense of well-being adds up to optimality, and ends up being individual. If you think that a prescription would eliminate ever feeling hungry, guess again. WW knows that, which is why, if you're hungry, you can have 'free foods' that aren't going to put a dent in your weight loss progress. They will satisfy your hunger (there's variety there, too) but not push you into a zone where you gain weight.
I'm not trying to 'sell WW,' just to explain the concepts. Which are not hidden, nothing strange, just calories in, calories out!
Low-carb, low-cal? Sounds like the Dukan diet to me.
I understand the concepts and I understand that they use calorie sparse foods as a crutch that probably won't add enough calories to make a difference one way or the other.
My question is why would a person who has 10-30-100-300 pounds of stored calories on their body feel hunger...ever? If CA/CO is strictly THE relevant factor then a person who is out of energy balance should not experience hunger until their stores have been emtptied and they have returned to balance.
The fact that they need the crutch at all strongly implies to me that something is very wrong with that hypothesis as a standalone.
Looking at this dispassionately I see what people say food is used for...emotion, social, pleasure, etc...and I think that even further argues that CA/CO is not sufficient. Those calories have to be DOING something in order for them to have a use outside of fueling your body.
Example: There is no equivilent of an "obese" breather or an over breather. We adequately understand what the mechanism of breathing is.
If food does more to your body than feed it then the other areas are relevant to the question of "why" a person would use food in excess even to the detriment of the body.
If those "why's" are chemical in nature [and I'd be inclined to think that even "emotional" things are chemical at foundation] then the problem can't be solved without addressing the chemistry.
Perhaps because our metabolisms and all the regulatory compensations were "wired" for an environment where humans didn't gain more than, say, 20-30 lbs EXCESS fat. Obesity is the normal fat stores + a little extra + MORE. So the body sees losing 20-30 lbs and says -- STOP! -- I've got none more left?? Makes sense to me.
First, I prefer the words 'margin' or 'cushion' to 'crutch,' when talking about the WW solution to feeling hungry, which is: eat free veggies and fruits.
WW addresses those 'emotional things' that you feel are chemical. That's the weekly meeting and much depends on the synergy of the group and the leader. If you don't find that synergy working for you, you find another meeting/leader. This approach is actually successful: support, skills, sharing.
BUT if your hunger can't be adjusted with diet, attitude, diet tips and tricks (every diet has them), then a doctor CAN prescribe something for alleviating hunger (ah, college days, and the black market pills we used to take - to study, of course!) My own opinion, not WW!
I have known women to deliver a 7+ pound infant on a 21 pound weight gain eating ad libitum with weight loss obviously almost immediate.
I have also seen people gain 50 pounds and deliver a 4 pound infant and still be at or near their post partum weight two years later.
I agree that a persons body might have a stop loss mechanism but what drove it to gain in the first place?
It's a crutch. No different than the iced splenda laden mocha latte clutched in the hot little fist of a low carber who is still craving. I'm not a fan of sanitizing terminology and find it self defeating behavior but I'll do it henceforth if it really matters to you.
Use of the word "margin" bothers me because it implies that the overweight person might "need" more calories than allotted in their dietary plan and thus...a margin for "error" is established with healthy minimal cal foods.
Which is fine if there actually IS an error...but if we are defending CA/CO then there definitely is not and the practice is attempting to minimise the damage of still disordered eating.
A person shouldn't NEED "support" to eat the amount of calories that they need UNLESS there is more to the equation than the CA/CO theory can account for.
I'm totally in agreement that GT has overshot and misinterpretted and/or deliberately misrepresented and I'm shocked it ever got past an editor but he did make a good point in asking the question WHY does the overweight person over eat, feel dissatisfied, and eat outside of hunger. He's right in saying that "because they do" isn't an answer.
People who never ever carry excess weight eat whenever they want as much as they want. I've known a lot of them and assumed I was one of them for a long time. Until pregnancy it did seem to be so. To be fair I don't carry A LOT of excess post partum but I did lose that golden ability to just...eat...and never have to consider my weight at all. It never took "choices" or support or wisdom or excercise or anything else before and still doesn't for nearly all of the people I have known who are naturally at their right weight.
I don't think it's because the idea is that they might 'need' more. It's that they are allowed more, without disturbing a somewhat larger limit.
When that craving for Aunt Bea's special brownies hits, at the family barbecue, EVEN after you have eaten plenty and know you're THIS close to your limit, you feel that as 'hunger' which - with free veggies and fruits (you can usually find them at a group meal) - you can satisfy. Is a craving really hunger?
Sometimes, I just want to seize the moment - grab that brownie, just because Aunt Bea made it for me when I was 8 and it was the best brownie I ever had. (WW advice: when it turns out to NOT live up to memory, put it down. Not so easy to do. That's a habit, mindfully eating, that can change.)
Actually, they do need support if it a 'deprivation' issue (I was deprived, I hate feeling deprived, it makes me feel sad that I'm deprived...) or any other emotional connection. Food has emotional connections for people.
Ask any low-carb board member - who goes to the board for support! (I ate a piece of bread. I'm up 2 pounds this morning. Is it water weight? And by the way, here's my recipe for mock macaroni and cheese, using cauliflower - read: comfort food...)
For the record, I have never met a person like that. I don't think I've led a particularly sheltered existence, either.
Not even a good example: my niece is probably a size 0 or 1, and SHE doesn't eat anything she wants, whenever she wants. She actually watches her diet, despite having a very slender frame and almost no hips. That is not the norm. But people like my niece do make good runway models - who also watch what they eat - or athletes.
The story that 'other people don't have to watch what they eat' and yet they never gain weight - I don't buy it. If you want to be a slender person, live like a slender person. That is, eat less and move more to get out of the present overweight state, and then, once at your goal, don't go back to your old eating habits and move less.
OK. Try that.
I'd be very surprised if you didn't put weight back on. The problem of obesity is not that we can't lose weight. We do. But then we put it back on. Repeat. Over and over again. Another WW message, which is just WW pointing out the obvious.
Being adequately fed isn't deprivation. What are people who feel deprived being deprived of exactly?
Don't even get me started on low carb diet message/support boards and their plethora of food recreations.
And I always go back to my baseline weight 110ish and stay there.
My point is not that they can eat ANY amount of calories consequence free but that they can eat any amount that they WANT.
I have seen first hand and even from inside myself [ultimate first hand?] how extremely disinteresting any food is when you aren't hungry and your body is functioning correctly.
Calorie restriction does work [and in the case of the diabetic study quite extreme restriction looks to have worked very well] but I strongly suspect it's only necessary because something that should be in place isn't doing it's job.
I'd love to know what that was and whether it can be fixed and by what means. After all it wasn't so long ago that people thought beta cell function couldn't be restorred once it was lost past a certain point. Poof...that got blown out of the water.
Personally I have never experienced excess hunger exactly...more like a lack of satiation. If I took that brownie for example. It's not that it would just taste so good I'd want to prolong the experience by eating the whole pan. Not at all. It's like it's NOT satisfying. Satisfaction seems like it's always just a few more bites away.
Like a bug bite...no matter how much you scratch it...it's still annoying and on your mind. Something is wrong with that. I doubt it's the carbs specifically. Low carb makes the untasted brownie uninteresting. Eating one is a different story. So it's obviously not a cure but a very effective crutch. I'd imagine that the more people play around with low carb recreation food the less well it would work for them and it's not because of the carbs.
When I was talking about deprivation, I was still referring to people who feel that being denied something is deprivation. Food included. It's painful, bringing up an emotional reaction that is not necessarily appropriate, but it is THEIR emotional reaction. Until they deal with it, dieting to lose weight is going to hit them in an emotional place.
'Low carb makes the untasted brownie uninteresting.'
In my case, I wish that were so! I finally have a diet in which NOTHING is off limits, as long as I stay within my calorie limit. So the untasted brownie, which looked deliciously forbidden, is not off limits. By not being 'off limits,' it also doesn't have that appeal of the forbidden and is less appetizing in itself. Attach some memories, though, that you want to relive, and it gets a little boost (Aunt Bea's delicious brownies - are they still delicious?) Body functioning correctly. There's still my mind. My emotions. My bug bite.
'Something is wrong with that.' I agree something is wrong with that, when thinking about food takes over, it becomes THE central focus. I'm not a big fan of Geneen Roth, but there are psychologists and therapists who deal with this. The bottom line probably is 'Get a life.' Take the focus away by purposefully putting it somewhere else. My favorite day is one in which I forget to eat.
'My point is not that they can eat ANY amount of calories consequence free but that they can eat any amount that they WANT'
Yep. It's the WANT. They don't tend to overdo that WANT, though. They WANT and then they pass up things that others think are irresistible. My niece, the size 0, may eat a 5 guys burger and someone can notice that and say, 'Look at how much she eats and how skinny she is...' But they didn't go to the movie theater with us: I and my kids had large buttery popcorn (the buckets were the size of, er, buckets) and she had: a diet coke.
Everyone has choices.
What isn't doing its job is the environment. In the wild our appetites would only be for that which is hard-to-get, and we've made the hard-to-get things into the most common things. I don't know any thin person over 40 who isn't abstemious.
"BigWhiskey are you asking me what the Optifast formula is?"
"What isn't doing its job is the environment. In the wild our appetites would only be for that which is hard-to-get, and we've made the hard-to-get things into the most common things. I don't know any thin person over 40 who isn't abstemious"
Terrific comment, Jim.
There seems to be an assumption in this discussion that hunger (over and above levels that would result in weight maintenance) is inherently problematic, even pathological. This makes no sense from an evolutionary point of view.
There would have been clear selection advantages to carrying some energy reserves (e.g. getting through tough winters). The point at which hunger gets 'pathological' is where the reproductive fitness of the eater is compromised by their hunger levels, and subsequent level of fatness. I'm not sure how we could quantify that exactly, but I have no doubt that it sits some number of pounds north of "having a rippling six pack" territory!
So, while hunger IS a problem for the obese (and ought to be addressed directly by 'metabolic repair' measures), hunger for the lean is a perfectly natural and healthy sensation IMO. Trying to 'trick' our way out of natural hunger (e.g. taking appetite suppressants, going into ketosis, eating monstrous amounts of fibrous veggies etc.) might be where the pathology actually resides!
But now I'm not so sure which is why I bring it up for clarification at all.
I actually usually feel really well and NOT crave prone in a fasted state. Now that I am seeing some strong evidence that low carb is the cheap third cousin of actual fasting in that it mimics SOME of the metabolic benefits but obviously not all.
My questions re the healthfullness of low carb have mostly been related to certain things like having to go out of your way to get certain nutrients and the strong admonition not to do it while pregnant or nursing. Not because it doesn't work or because I don't feel well while doing it.
I might give it a shot and vote to heck with macro ratios entirely. If it doesn't produce the same or better results I can always go back to what does work.
Still the fasting aspect does make me pause in thinking that maybe typical diet frequency is too often. I'm thinking ideally I'd start out with the fast from my current diet rather than go out...deliberately carb load..then wait to see if it makes me hungry. No...let the fast do it's job then just eat to the point of no longer being hungry. I'm curious enough to see if it produces any changes. Maybe I'll keep a log if/when I actually do it.
This is my struggle, as much as I am now coming through my carb phobia, its really hard to get it into my brain that cheese does have a lot of calories, and it is not 'free food'. I'm having to try so hard not to jump back on the same bandwagon that is encouraging unhealthy habits. Its even funnier, in a way, that I have to fight the urge to eat blocks of cheese, as I couldn't stand the stuff when I was a teen. I actually hated the taste.
"If I eat anyway, I'm usually more hungry the rest of the day"
Yes, agree. Eating outside of hunger makes me hungry no matter what I eat.
I don't get that many LC'ers can't wrap their heads around that they will burn less (net) body fat the more dietary fat/calories they eat. I believe that the fat-fear most still have the first time they try Atkins -- rather than once they've been "educated" -- contributes to the success of that first time b/c the person eats a lot fewer calories.
Yeah Jenna, cheese really is a killer. As I've been upping my carbs I've deliberately cut back on fat consumption. Added fats are my easiest to control, but also the cheese. Snacking on a slice of cheese was not uncommon. That's the easy kind. Cutting off a block or a wedge? Harder to portion. It's so easy to eat 200 cals thinking that was 100. I try to use cheese as a condiment these days.
I think we become prone to "deprivation" the more accustomed we are to surfeit. For example, I visited Russia in 1990 right after the coup - the very definition of a deprived environment. A depressing dreary environment devoid of color and extras. In striking up a conversation with an English-speaking woman, obviously a member of the elite who had visited the USA, she told me she really missed....peanut M&Ms! She spoke of them as if they were a huge delicacy, like you and I would speak of the best Belgian or French chocolates.
The first thing I did when I went home was buy a little bag of them....they really were delicious. I can still taste them now, 21 years later.
2. The greatest meal I ever had was in the middle of a miserable hike. It was wet, muddy and rocky. I decided to stop and eat an apple, which was small, watery and sour. Best apple I ever tasted.
3. The very thought of certain foods is enough to make me salivate. Others....meh. I wonder if my environment was entirely composed of "meh" foods I'd be conditioned to eat less and feel deprived less.
4. Is our entire environment essentially set up to create feelings of deprivation? I'm not suggesting a conspiracy, just that it evolved that way. Some folks are simply resistant to that environment, some folks (like me) are very affected by it.
5. I agree with you about dieting causing obesity. I suspect that if I had never gone on a diet when I was 14, 5'5", 140 pounds, I'd never have gone on this horrible odyssey. At that weight I was only 10 - 15 pounds overweight. I could have lost it in 6 months by slow ELMM. Instead I went on a variety of crazy diets and 42 years later, I'm still struggling. Oh well, it's the process....
2) With such a small sample size, it's impossible to eliminate idiosyncracies of the dieters. As you point out, the keto group was almost all female! It is crazy, to compare weight loss efficacy between females and males. Males almost always lose faster than females, it's that whole endocrine thing.
The keto group as you also point out was fatter and more diabetic.
3) Last but not least no one is arguing that a keto diet is better than a VLCal diet. A VLCal diet is extremely efficient at reducing insulin levels and causing weight loss - duh, no energy coming in from the diet, PLUS you benefit from a similar carbohydrate restriction. A VLCal diet is like a keto diet, except better because in addition to relatively low carb the VLCal diet also is low fat so the dieter is forced to use their stored body fat to fuel basic metabolic processes.
The real interesting question would be to compare an isocaloric keto diet to a "balanced" diet.
Would that be equal, for the diabetic participants? My guess, not a chance. The keto would be clearly superior to reduce insulin and diabetic parameters and also weight.
4) Note that the dieters on keto spontaneously reduced calories. All those improvements in their insulin and FBS - pure natural. THey are eating as much as they WANT.
Can the people starving to death on 600 calorie per day say the same thing? Their insulin and FBS may be lower... but they are starving to death. This is not a diet that can be continued forever. If they try they will die of starvation complications like heart failure from wasted muscle tissue.
A study like this is useless for clinical purposes, because it tests a diet intervention which is ultimately impractical and impossible to follow long term. People can NOT continue to eat 600 calories per day. When these people try to increase their calories sooner or later, what on earth do they do? Does their diabetes magically go away?
Nobody is saying that one should continue to eat 600 cal/day. Indeed in the study they only did it for 8 weeks then there was a 12 week followup where they clearly ate more (regained a bit).
Last but not least no one is arguing that a keto diet is better than a VLCal diet.
Oh c'mon! That's exactly what proponents of LCarb diets are saying. Since Atkins himself!
No obese person is "starving to death" eating 600 cals/day for a couple of months. At just slightly overweight I ate not much more for several months more than that in my late teens.
I don't know that it matters much the composition of the diet at those levels so long as protein is spared.
I'm not saying that this is a perfect comparison or the results of this one small study (the ketos) presents some final answer, but the results are pretty impressive. NO medications, 8 weeks VLCal and 70% remaining diabetes free despite a slight regain 3 months after returning to a normal diet? I can't shrug that off.
I should clarify what I mean by "better", as there are multiple definitions of this word pertaining to dieting.
There is "better" in terms of absolute efficacy in a clinical trial. This is one way of defining "better". In this type of "better" a nearly starvation diet is clearly going to be more efficacious for diabetes and weight loss than a diet with food in it (a ketogenic ad lib diet). If you are eating slightly more than NOTHING, then yes, your type 2 diabetes will improve a lot and you will lose a lot of weight.
There is "better" in terms of real world application - is this something we can do every day forever? Is this something that is a realistic prescription for a patient?
In that case, the very low calorie diet is NOT better than a ketogenic diet. It is impossible to eat 600 calories long term, it is impossible to even eat 1200 calories long term. All people will eventually end up eating enough calories to stop feeling hungry.
What makes the glucose metabolism correcting diet - ketogenic, very low carb diet - so much "better" is that people with glucose metabolism disorders SPONTANEOUSLY reduce their calories, and their diabetic parameters improve all by themselves. The person can keep eating this diet forever and ever and stay healthy.
It really doesn't matter that starvation or semistarvation is "better" than ketosis. You can not keep it up forever, sooner or later you need to increase calories to a healthy level.
So then the question becomes, do you add in calories from FAT (and maintain a very low carb diet, because at 600 calories per day you are already low carbing even if you are eating 65% carbs)... or do you maintain your percentages and add in carbs primarily? WHat do you think is going to be better for an obese diabetic? I strongly suspect the fat addition with no further addition from carbs would be the best idea.
It should be noted that at 600 calories per day it is certain these severely obese people are in ketosis anyway - there is no way to stay alive unless the rest of the calories are coming from body fat, which means ketosis.
If an obese person eats 600 calories per day for months on end, they will surely run into protein deficiency and possibly suffer heart failure. This has happened many times when crazy scientists try to starve fat people ("well they're fat, we can just not feed them and they will be okay lulz!")
Many people starve themselves for months on end. Anorexics do it without any body fat. Many anorexics die of heart failure, but not all do. Just because some obese people manage to live months on 600 calories / day does not mean it is a good idea. I can also drive 100 miles an hour on the highway - surviving this doesn't make it a good idea or mean it is safe to do.
All people need to eat more than 600 calories per day. If you try to do this for a very long time you are flirting with death even if you are fat.
Obesity is an abnormal disease state and contrary to what one might think they can not tolerate prolonged food shortage better than a person who is at a relatively normal weight.
There are several reasons for this.
The first reason is that the obese person is in an abnormal hypermetabolic, hyperanabolic state. Obesity is not normal. It is a result of hyperinsulinemia and it is a disease. If you abruptly remove the food supply of a fat person they will struggle to meet their metabolic needs and can not oxidize fat enough to fuel metabolic processes. This taxes their protein reserves (via more glucose syntehsis) which need to be shunted into maintaining cardiac muscle. This accelerates the wasting of cardiac tissue.
Second, the obese person is not capable of becoming hypoleptinemic.
Hypoleptinemia is life saving during real starvation, and one of the things it does is it shunts protein anabolism away from skeletal tissue and toward cardiac tissue. This is one of many reasons people can be skin and bones but still live - the whole metabolism changes to keep you alive when leptin is low, and one thing it does is bolster cardiac tissue at the expense of skeletal muscle. (note, this effect of low leptin to promote skeletal muscle wasting is why post obese people look sickly and have diminished muscle tone - chronic low leptin makes it very difficult to maintain muscle mass as it is very expensive metabolically to do so).
Since obesity is an abnormal disease process , a pathological accumulation of fat tissue, the obese person can NOT drop their leptin enough in starvation due to their hypertrophic fat tissue. As a result their cardiac muscle is especially vulnerable to wasting when the food intake is diminished. They are incapable of accessing this very vital starvation adaptation mechanism: shunting protein into cardiac muscle.
This study of the leptin deficient mouse shows that left ventricular hypertrophy is a sign of leptin deficiency. In normal physiology, low leptin merely helps protect the heart from starvation. In pathological contential leptin deficiency where there is ample access to food, or in disrupted leptin signalling as in some types of obesity, then cardiac hypertrophy occurs.
" Conclusions— Together these data show that the effect of leptin on LV remodeling is not attributable to weight loss alone, indicating that leptin has antihypertrophic effects on the heart, either directly or through a leptin-regulated neurohumoral pathway. Disruption of leptin signaling may represent a novel mechanism in LVH and related cardiovascular disorders. "
At 600 calories per day, an obese person is very at risk for heart failure.
>, a pathological accumulation of fat tissue
Uncontrollable disease process has been proven in a few people yes.
Surely not in enough people that one can state without qualification "... obesity is an ..." as if this applied to all obesity
> much more susceptible to starvation induced
> heart failure than a person with normal
Is there proof (not clues and indications and signs and portents, but proof) of this in humans? controlled studies in humans
I will be VERY impressed if this has been proven by studies in humans.
I would think that for the hyperobese it's very, VERy hard to separate out dieting effects from underlying effects of the obesity or the original cause of the obesity. If a bunch of such people died of heart failure, what caused it - the diet or the obesity? Absent controlled studies (the ones I can think of would probably be unethical) it would take some pretty fancy scientific and logical-deduction-footwork to segregate the 2 things.
I've read about many hyperobese living on minimal calories for months on end without heart problems - the after-diet health problems had started well before the diets for the most part.
I really hope the answer consists of citations of human studies, with no references to Italians, Teutons & lovers of monkeys.
“Obesity is an abnormal disease state and contrary to what one might think they can not tolerate prolonged food shortage better than a person who is at a relatively normal weight.”
The thought you bring up here has been bothering me since I interviewed a survivor of a NAZI concentration camp about fifteen years ago. She said (without me asking specifically): “The fat people generally fared worse than normal weight or even very lean people. Many of them soon became very ill and often died while still being fat.” I have since tried to find scientific support for her observation (which I simply have to believe, for she was a very clever old lady, without any bias or even interest in nurtrition), but I have found exactly nothing.
@Woo: I'm sorry but you can't equate a PSMF for 8 weeks with starvation. Nobody is saying 600 cal/day forever ... not even in this study! 70% remained free of diabetes a full 3 months after resuming a "normal" diet.
Yes, the two groups are less than perfectly matched ... I pointed that out. But we also see that Westman's results are far less than the glorified reporting would have you believe. As for the long haul, we already see that from 3 to 6 months the improvements were already muted. There's no reason to believe they continue to improve in the long haul.
I'm in agreement with Sanjeev here. I do not view obesity as "is an abnormal disease process, a pathological accumulation of fat tissue" in the large majority of the obese these days that's simply not true. Genetically a very small percentage - perhaps 2-3% or even less - of humans have metabolic defects that cause obesity. The epidemic we're seeing is due to environmental factors. It cannot be explained by some mass mutation of human population in certain countries and, frankly, proportionally more in certain US states than others.
Furthermore, what is this distinction you are making between (a) environmental factors, and (b) environmental factors (interacting with genetic factors)? I ask this because genes can only be expressed in an environment. Environment cannot act upon, or give rise to, metabolism in the absence of genes.
I don't know what are the environmental factors (to which the obesity epidemic is due) that you have in mind. But as they cannot be operating exclusively of genes, then the underlying causes of all metabolism, including obesity, must necessarily lie in genes operating in environments.
And I do wonder which are the defective genotypes? Yes, there are many individual variations in genotypes.
But whether you choose to characterise any given genotype as giving rise to (a) a "defect" of metabolism or (b) a "difference" in metabolism is largely a matter of personal taste.
You have in mind an arbitrary subset of 2-3% or less of obese people whose genes are defective. I am however entirely at liberty to say (as is Wooo) that all of the people who suffer obesity (under the environmental factors you have in mind) have defective metabolisms. After all, most people are not obese, even though they are subject to the same environmental factors as the obese people.
I could of course just say that the genotypes of the obese people are different, rather than defective. But it would not change the fact that the obesity is caused by interaction between genotype and environment.
At the end of the day, the obese people and the thin people may need different environments.
Is the fact that many of them became ill related to their being fat? Did many of the normal weight people become very ill? ('generally fared worse' doesn't tell me much, and one source of its subjective nature may be the high visibility of fat people - you can't miss them, so you pay more attention!)
What really strikes me about this one (just one, after all) comment is that I read an observation (a comment, just one, after all) years ago, when reading about how the British humor writer, P.G. Wodehouse, was sent to a civilian internment camp in Toszek, Poland. Wodehouse was criticized for sounding cavalier about his experience, even accused of 'collaborating with the enemy.' His was not a concentration camp, though. It was merely a prison. What I recall reading was that the prisoners lost weight (eating potatoes, I believe) and the fat prisoners got healthier as they lost weight. I think this observation contributed to the feeling that Wodehouse was sugar-coating the prison experience, and so absolving the Nazis, somehow, of doing terrible things.
Being slightly overweight seems to make you live longer than being "normal" or "skinny"!!!
See for example these texts:
but you neglected the qualifier (PubMed - not NYT reporter)
". . . but this protection effect is concentrated in black men, older adults, and people in the lowest income stratum."
Are you covered by this qualifier?
When my Mom had in patient physical therapy for her knee replacement, the facility was housed within a nursing home. I got lost many times going to visit her and was in the general areas quite a bit. I dunno what it means that there were no obese and few even overweight people there. Either they live longer cuz the bigger people die off before they deteriorate, or thinner people deteriorate to need assisted living more. Or ... just an anecdotal observation that doesn't mean a heckuvahlot.
Keep up the great writing.
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"Any way you look at it, even extreme carbohydrate restriction did not produce results in 6 months even remotely rivaling those Lim et.al. achieved with their crashers in 2 months."
HbA1c went down 1.4 points in the keto and 1.2 points for the low cal.
Insulin went down 6 points for the keto and 7 for the low cal.
Weight went down 11kg for the keto and 12kg for the low cal (some of this is probably lean mass).
Only FBG was much lower in the low cal group. And that number is odd indeed but as you stated, the keto subjects started out more diabetic.
But another point is that the low cal folks could never sustain such a low calories intake. And for sure they were losing lean mass. The keto group more than likely did not. According ot the work of Volek, keto diets are protein sparing. This means the keto gorup could continue to eat as they were without any negative consequences.
The low cal folks DIDN'T sustain such low calories. You did NOT read.
My point is that you exaggerated. You used the words "...even remotely rivaling..." The keto subjects results DID rival the low cal folks in weight loss, HbA1c and insulin. And they started out more diabetic and this matters and matters a lot.
Perhaps the meds interfered in some way and/or did not contribute to the benefit of a keto diet. What are the side effects of the meds? You don't discuss this. But the meds are beside the point.
I read the low cal subjects their cals went up as as their cals - and carbs - went up and their measurements began to decline.
You side stepped my point on lean mass loss I see. Did the study look at ONLY weight loss? We both know that wieght loss can occur from BOTH fat and muscle mass. Keto diets spare lean mass. Low cal diets hasten lean mass loss.
And the TOTAL carb intake before and after matters. It doesn't matter than the low cal subjects ate more carbs than the keto subjects. What matters is the difference in carb intake of the low cal subjects before they entered the study and during.
I'd appreciate it if you could post the full citation of the study if convienient for you.
As to my tone? Well, it is clear you didn't read my post, or didn't read it carefully because you would not have made the ignorant comment about the sustainability of the crash diet. It is not sustainable. It is not intended to be sustained. It was discontinued after 8 weeks.
As regards lean mass, you and I both know that any lean mass retention on a reducing diet is a function of adequate protein content. There is absolutely NOTHING that says that a low fat diet has to be low protein and it is very easy to construct a high protein, high carb (by %) reducing diet from real whole foods when one centers it around seafood and legumes. In your industry you should be well aware that lean mass is mostly influenced by exercise (and type) in the presence of adequate protein.
As to my attitude? LOL. Your attitude on that mega FB thread that landed you here was far worse of what you wish to see my readers spared from. My time is precious and you waste it and therefore disrespect me, each and every time you ask and badger for information that has already been provided to you.
I am not going to bother to look for it. I am busy. But a reader linked to a study where resistance training + PSMF of 800 cal/day led to significant fat loss with little to no loss of lean mass.
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