Preventive Medicine 1: Diabetes

Within the past few weeks two good friends suggested topics for this column: Ruby Z. asked for an explanation of the differences between juvenile and adult-type diabetes, and Len K. suggested a discussion on which diseases can truly be prevented by dietary and/or other environmental manipulations. Since they are excellent suggestions, I will deal with both of these issues, which actually overlap in some important ways.

The two main types of diabetes have undergone several changes in nomenclature over the years: juvenile diabetes became insulin-dependent diabetes which then became type 1 diabetes; adult-onset diabetes became non-insulin dependent diabetes which finally became type 2 diabetes.

There were reasons for these changes (for example, although non-insulin dependent diabetes meant that persons with this type of disease did not depend on insulin therapy in order to continue living [unlike the insulin-dependent patients], it seemed confusing since about one-quarter of the so-called non-insulin dependent patients were indeed injecting themselves with insulin). Thus, the American Diabetes Association changed the names of these conditions over the years to minimize confusion.

We will use T1D to denote type 1 diabetes (the old juvenile type) and T2D as the short form for type 2 diabetes (the old adult-onset type). Persons with T1D are typically diagnosed as children at any age through teenage. They usually present with weight loss, increased thirst and urination, fatigue, glucose (sugar) in the urine, but will sometimes first come to medical attention in the emergency room in a semi-comatose or comatose state with a metabolic disorder secondary to the T1D known as diabetic ketoacidosis. Children under the age of two years are more likely to first be seen with this serious condition. Because individuals with T1D have no insulin at all, their blood sugars are sky-high when they are diagnosed.

Insulin, the master metabolic hormone that does much more than merely control blood sugar, is produced in special cells located within the pancreas known as beta cells. In T1D, these beta cells are destroyed by an autoimmune process, likely the result of a genetic susceptibility coupled with exposure to a specific viral infection or some other trigger (researchers have yet to identify the viruses or other infectious agents responsible for setting off the immune cascade). Without insulin, the T1D patients are unable use their blood sugar for energy, and need to switch over to burning fat for this essential process; as a byproduct of this fat-burning, they produce chemicals called ketones which can eventually lead to the ketoacidosis mentioned above.

In T2D, there is no autoimmune destruction of the insulin-producing beta cells; the T2D patients usually have normal or even elevated levels of circulating insulin, so absence of beta cells is not the problem. So, why do they get diabetes?

Most of these T2D individuals have what is labeled as insulin resistance. This is a condition where the cellular targets of insulin action (mainly the liver and muscle cells) require more insulin than is circulating to get the job done. This cellular resistance to insulin action signals the body that it needs more insulin in circulation, thus calling on beta cells to make more. Increased insulin resistance can arise in different ways, for example, certain medical conditions (e.g., testosterone deficiency) and certain drug therapies (for instance, some HIV/AIDS drugs) can cause it, but by far, the most common reason is obesity and associated physical under activity. And this is precisely why we now have an epidemic of T2D.

But wait just a minute, you might say: I know plenty of obese, sedentary people who do not have diabetes—what about them? And further, I know some non-obese adults who became diabetic later in life—what about them? The answers to both of these questions lies in genetic diversity. For the obese non-diabetic, it seems that these people are able to keep up with the increased demand that their bodies make on their beta cells for more insulin, while the obese diabetic cannot keep up, so they have a relative insulin deficiency even though they are still able to produce it.

The non-obese T2D patient appears to have a genetic predisposition towards either increased insulin resistance or (more likely) a defect in the ability of the beta cell in secreting insulin.

Well then, how do we prevent diabetes? For T1D, we do not know. Since it was known to be an immune-based condition, the National Institutes of Health (NIH) funded a large, expensive study which gave small amounts of oral or injected insulin to high-risk relatives of patients with T1D hoping to produce blocking antibodies and “immunize” them against T1D. These tactics failed.

Prevention of T1D is likely 5-10 years away, using information based on either genetic, immunologic or infectious disease findings. For T2D, it is a different story. One needs only maintain proper weight and exercise for just 20 minutes three times per week for the vast majority of Americans who are at risk for T2D. That’s it.

Now please read The Gay Caveman Diet I and II in order to prevent diabetes…

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The Gay Caveman Diet: Part II

Last week we established that obesity has become a global problem and this may be related to the disconnect between the natural or wild-type diet meant for our species and what we eat now. And, as also mentioned last week, experts in nutrition, cardiology and diabetes recommend a diet even farther away from our natural, species-specific menu than what we would eat left to ourselves!

So, let’s see what’s happened in the 30 or so years ending in 2000 since the experts demonized fat and worshiped at the altar of complex carbohydrates:

As you can see, since the mid 70s, the proportion of fat in our diets has dropped significantly and the proportion of carbohydrates has increased significantly (the figure above is for men, but the graph for women is essentially identical). Now look at this graph, concentrating on the top line which shows the overweight plus obese American adults (overweight is defined as a body mass index [BMI] greater than 25; obese is defined as a BMI over 30; go here to quickly and easily calculate your BMI) :

The graphs are practically super-imposable. Think these trends might be related? It certainly does seem that when our dietary carbs began to move from about 41% of our caloric intake to about 49%, we started gaining weight (however, caution must be used because, as noted previously, association does not prove causality). With that being said, I do believe they are related. Why? Well, there are some corroborating points: reducing carbs might lead you to eat less total calories since low carbs and higher protein and fat are more satisfying so you experience less hunger and eat less than on a higher carb diet; for example, see here. And, there are positive metabolic changes that a low carb diet induces. Or, see here. But I digress…

The reason I began writing these two diet-related columns a few weeks ago was that a study published in the New England Journal of Medicine reportedly showed no difference in weight loss from diets containing low vs. high amounts of carbohydrates. In other words, calories are the only things that count. The popular press dutifully reported this (for example, see here and here) with the implication, of course, that the Atkins Diet (or any other low-carb diet) was mere hype and the only thing that counted were the total calories.

Here’s the primary author, Dr. Frank Sacks of Harvard interviewed in the NY Times:“It really does cut through the hype,’’ said Dr. Frank M. Sacks, the study’s lead author and professor of cardiovascular disease prevention at the Harvard School of Public Health. “It gives people lots of flexibility to pick a diet that they can stick with.”

Well, I guess that settles it, eh? You would have imagined that Dr. Sacks rigorously tested the most popular low-carb diets against the standard "balanced" calorie-restricted diets that nutritionists recommend and found them all equal. If you did, you would have been wrong; it is Dr. Sacks who is the party involved in "hype" here, hyping his study which sheds absolutely no light on the question dieters want answered: do low-carb diets work? What Sacks did was use diets where the lowest carb percent was 35% of daily calories, a percent not close to the Atkins’ number which is about 5% on induction (i.e., less than 20 grams of carbs/day for the first two weeks).

What makes this particularly galling is that neither Sacks nor any of the reporters differentiate their “low carbohydrate” diet from Atkins and just leave the implication out there that they tested the Atkins diet or one similar to it. In the Sacks study, he and his colleagues refer to studies that did show the Atkins diet superior to other diets (for example, here in the New England Journal of Medicine and here in the Journal of the American Medical Association), but they do not even hint that the carb content of the successful diets only contained about one-sixth the percent carbs as the lowest carb diet in his study. So, Sacks and the people that reported on his study all grossly misrepresented what was found by what they left out, i.e., the low carb diets tested bore no relationship at all to the Atkins and other very-low carb diets.

Why would they do this? What are their agendas?

Well, here’s what I think: dietitians, nutritionists and their physician fellow-travelers have all heavily invested in a few (purportedly) God-given truths about diet that they have pushed on us for decades. The most sacred tenets of this nutrition religion are:
I. Calories that cometh from any source (be they from fat, carbohydrates or proteins) are the same as they relate to thine weight and metabolism (The Holy Doctrine of the Immutable Calorie)
II. Complex carbohydrates are sacred (The Shrine of St. Pasta of Linguini) and fats are evil (for example, saturated are really Satan-ated fats and must be demonized at every turn) and
III. Raising the proportion of dietary fats and lowering dietary carbs will cause your cholesterol to go dangerously high (The Diet of (af)Firms (affirms what we believe, that is).

And, it turns out that just the opposite occurs with serum lipids when on Atkins.

This sclerotic thinking has helped lead Americans to be fatter than ever. And, the Academic Nutrition/Food Industrial Complex has so much invested in these Eternal Truths that they seem to feel that if they back down at all at this point their credibility will collapse. For example, the American Diabetes Association (ADA) recommends 45-60 grams of carbohydrates per meal. That is, about 600 calories of carbs three times/day, not counting snacks. If followed closely, that could result in more than 60% of calories from carbs (the ADA recommends 55-60% of total calories from carbs).

So what does this all mean? We're going to look at this in two separate parts: losing weight and maintaining weight loss (or normal weight). Maintenance of weight loss has been shown in study after study to be extremely difficult. Whatever method is used to lose weight, the great majority of people gain it back in a year or so: this is the greatest problem faced by dieters with good intentions.

So, I will dispose of the weight-loss part quickly: if you want to lose weight, that is, if you have flipped the switch in your head and agreed with yourself to really do it, use whichever method is most compatible with you. Whether it's the Atkins or South Beach, the Cookie Diet or NutriSystem, Weight Watchers, or even just staying on a 1200 cal/day diet, DO IT! Atkins works best for me, but they ALL work if you apply them with discipline. For maintenance, however, it's the Gay Caveman Diet (I mean Cavewoman too, but caveman is easier than caveperson.

Okay: first the gay angle. Back in the seventies there was a movie based on an off-Broadway show about a party held by a bunch of gay guys in NYC entitled The Boys in the Band. This was a mainstream, successful movie that was very funny, but sad and poignant at the same time. In one scene, one of the characters was verbally going after another, and during the tirade, he mentioned how Harold would starve himself only to eat like crazy at a weekend party. This stuck in my mind. So, here is the strategy for the Gay Caveman’s Diet:

During the week, eat like a caveman ( Loren Cordain's Paleo Diet is the one to look at) and stay away from dairy products, breads, pastas, cakes, cookies, pies, cereals, etc. Eat nuts, meats, fish, veggies, fruits, seeds. And on the weekend, have a slice of pizza, have that bagel, order the key lime pie or chocolate cake for dessert Saturday night....you get the idea. Caveman during the week, but a bit more self-indulgent on the weekend, applying the five-day discipline and two-day indulgence that some in the gay community use.

Now, you needn't be as strict as Dr. Cordain during the week, and you can modify your approach to cavemanism. For example, for a snack during the week before dinner, I have some cheese and pistachios, so overall, my Sunday night through Friday lunchtime is a cross between Atkins and the paleo diet.

And yes...no more daily bagels for breakfast during the week. And use low carb wraps or wheat bread for lunch sandwiches and stay away from Kaiser rolls--during the week. Take a bit from the gays and the cavemen and you may just be able to beat the odds and maintain your weight loss.

Full disclosure: Dr. Mennen has no financial interest in any of the diets, programs or issues mentioned in this column

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The Gay Caveman Diet: Part I

Many Americans—and now, people all over the world—are literally eating themselves to disease and early death. Think for a moment about the people you know who lived or who are now living into their 80s or 90s: was—or is—there a fat one in the group? Probably not, and there’s a good reason for this: the overweight and obese do not usually live that long. You can go here and read an article in the New England Journal of Medicine that lays out the data that show the clear association between excess weight and higher death rates.

Obesity has now overtaken hunger as the number one nutritional problem worldwide. The December 11, 2003 issue of The Economist put it best:

”When the world was a simpler place, the rich were fat, the poor were thin, and right-thinking people worried about how to feed the hungry. Now, in much of the world, the rich are thin, the poor are fat, and right-thinking people are worrying about obesity.”

Why is there now an epidemic of obesity? Simply put (and I know you’ve heard this before) too much energy in (that is, we eat too much) and too little energy out (that is, we do not get enough activity). True enough, but it’s not quite the whole story. While calories in and out are certainly key issues, the types of foods (that is, the ultimate mixture of carbohydrates, proteins and fats, the macronutrients) we eat also play a significant role in setting various switches in our bodies, switches that control rates of metabolism, whether we burn carbs or fats for energy and importantly, our hunger level. So, how do we figure out what the right proportion of macronutrients should be in our diet? What should we eat?

A good place to start would be to consider what our species was built for, or put another way, what were our factory settings?

To answer this question, we turn to the late Ukrainian-American biologist Theodosius Dobzhansky who famously said:

Nothing in biology makes sense except in the light of evolution.

Therefore, if we’re trying to figure out what is natural for our species to eat, we need to look at the environment that we evolved into, the one that shaped us as a species and that we’ve lived in for the greatest time as a species.

Figuring out the proper diet for capuchin monkeys or polar bears or bullfrogs, we need only look at what they eat in their natural environments, be they rainforests, glaciers or Alabama lakes, and extract their wild diet from information gained by observation. However, for our species, Homo sapiens, things aren’t quite so easy. Because of our intelligence, we were able to evolve culturally and move away from the environment and behavior that evolutionary forces set for our genetic and biochemical machinery. The period of our species’ life that occupied more than 99% of our time on Earth was spent as hunter-gatherers, and not as moderns who do their hunting and gathering in supermarkets. Further, it was not even spent as agriculturalists, raising corn, rice or wheat; agriculture is only about 15,000 years old for us, a drop in the bucket compared to the 2.5 million years we spent as hunter-gatherers.

We cannot, however, teleport ourselves back, say, 300,000 or one million years and see what our forbears were eating, so we need to do the next best thing and catalog what modern hunter-gatherers eat and infer our natural diet from those data. Luckily, this has already been done. (Clicking on the link will take you to a site where the original article will automatically download). What these investigators found when they examined the diets of 229 hunter-gatherer tribal societies was a menu vastly different from what organizations such as the US Department of Agriculture, the American Diabetes Association and the American Heart Association recommend. Hunter-gatherers get about 25% of their calories from carbohydrates and about 30% from protein (although variation exists among different tribal societies depending on where they live).

For example, the American Heart Association recommends 15% of energy from protein, 55% from carbohydrates and 30% from fat. It would have been impossible for a hunter-gatherer to achieve this mixture of macronutrients because there is no way in the wild to get concentrated forms of carbohydrate. That ability only came recently, with the advent of agriculture, where we could grow wheat or corn, grind it up, and make tortillas or bread and get a big dose of carbs.

Not only are processed carbs unnatural (defined as coming from anything other than unprocessed fruits, vegetables, grains, nuts or legumes), but so are all dairy products! Cavemen and women did not drink milk, churn butter or produce cheese.

Okay, you may say, I see where you’re going with the caveman bit, but what does gay have to do with anything? For that and whether Dr. Atkins was right or wrong, and how the nutrition establishment reacts to all of this you will have to come back here next week.

Acknowledgement to Bob Hodgen for calling our natural state “factory settings” which I used above

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Those "Health" emails: Is it True What They Say About Bananas?

My old friend Marty P. sent me an email a few weeks ago entitled “Eat Bananas Friends!” I wrote back that it was ultimately a lot of silly stuff, based on half-truths, misreadings of data and leaps of faith that were ultimately a lot like the old test question answer: true; true; not related.

He wrote back and said: "Hey--when you knock something like this, you should be specific." Marty was right...so here's the email and my comments in italics following each nugget:

This is interesting. After reading this, you'll never look at a banana in the same way again.

Bananas contain three natural sugars - sucrose, fructose and glucose combined with fiber. Well, one can say that, more or less, about any fruit. So, while true, the implication is misleading in that it implies something unique about the banana. And, just for completeness sake, fructose seems to be a particularly nasty sugar.

A banana gives an instant, sustained and substantial boost of energy. Research has proven that just two bananas provide enough energy for a strenuous 90-minute workout. So what? Two bananas contain about 200 calories, the same as in about ten Tootsie Rolls (I am not, however, saying Tootsie Rolls are as good as bananas, but our dietary problem in western societies is not a lack of calories, so the bananas are not solving any issue with their calories). But according to this table, a 90 minute strenuous workout (aerobics) for a 150 lb person would burn 1,035 calories! So, this is nonsense.

No wonder the banana is the number one fruit with the world's leading athletes. As Frau Farbissina might say:

"Rilly?"

How do they know this? Where are the data showing a survey of the "world's leading athletes" reporting that they prefer bananas over passion fruit or even the lowly apple? Another unsubstantiated claim.

But energy isn't the only way a banana can help us keep fit. As I mentioned above, too much energy through food is a problem and not a solution. Energy does not keep us fit. Just more silly stuff.

It can also help overcome or prevent a substantial number of illnesses and conditions, making it a must to add to our daily diet.One cannot just make a statement like this without a shred of evidence to support it. I know of no studies which showed that in one group, eating bananas avoided certain diseases which were not avoided to the same degree in another group which did NOT eat bananas. Just nonsense.

Depression: According to a recent survey undertaken by MIND amongst people suffering from depression, many felt much better after eating a banana. Sounds like high science, doesn't it? A survey among people with depression asking them if they felt better after eating bananas? Did they also ask them if they felt better after eating chocolate? Or crab cakes? And what is MIND, anyway? I found two different MIND web sites, one in the UK and one at Harvard. I could not find a survey about bananas and depression on either.

This is because bananas contain tryptophan, a type of protein that the body converts into serotonin, known to make you relax, improve your mood and generally make you feel happier. Boy, this stuff just gets worse and worse. Tryptophan is NOT a protein, but an amino acid (and amino acids, as you will remember from high school biology are the building blocks of proteins); and yes, it is a precursor to serotonin. But bananas, per gram, contain one-one HUNDRETH of the amount of tryptophan in an egg white and one twenty-fifth as much as the same weight of turkey. This amount of dietary tryptophan will not affect your brain serotonin levels.

PMS: Forget the pills - eat a banana. The vitamin B6 it contains regulates blood glucose levels, which can affect your mood. Yes...bananas are a good source of this vitamin, but it will NOT affect your mood by helping to manage you blood sugar.

Anemia: High in iron, bananas can stimulate the production of hemoglobin in the blood and so helps in cases of anemia.Pure nonsense. Bananas do not even make an appearance on this list of non-animal sources of iron.

Blood Pressure: This unique tropical fruit is extremely high in potassium yet low in salt, making it perfect to beat blood pressure. So much so, the Food and Drug Administration has just allowed the banana industry to make official claims for the fruit's ability to reduce the risk of blood pressure and stroke. Not quite. What the FDA says is more like this: “ According to the U.S. Food and Drug Administration (FDA), eating foods rich in potassium and low in sodium may help reduce the risk of high-blood pressure and stroke.” This is from the Chiquita Banana web site. Another leap.

Brain Power: 200 students at a Twickenham (Middlesex) school were helped through their exams this year by eating bananas at breakfast, break, and lunch in a bid to boost their brain power. Research has shown that the potassium-packed fruit can assist learning by making pupils more alert.I searched the web but found no such study anywhere, including the Twickenham schools.

Constipation: High in fiber, including bananas in the diet can help restore normal bowel action, helping to overcome the problem without resorting to laxatives. Fine…it is a good source of fiber like many other fruits and vegetables. Better than some, worse than others.

Hangovers: One of the quickest ways of curing a hangover is to make a banana milkshake, sweetened with honey. The banana calms the stomach and, with the help of the honey, builds up depleted blood sugar levels, while the milk soothes and re-hydrates your system. OK—I think you all get the idea by now. I will dispense with the rest of the silliness in this email (if you really want to read it just google for bananas and depression and you will find the whole thing).

My purpose in writing these columns is to counter the bias of journalists and writers of all stripe who make false and/or misleading health claims because of ignorance, bias, agendas or all three. And, this includes anonymous "health" emails positioned to bring little-known or ignored “facts” to light. However, bananas are indeed an excellent food and should be eaten along with other fruits and vegetables regularly in a varied diet; they are not a "wonder fruit" any more than cherries or apples or cantaloupes. I will have more to say about diet next week.

Next week: The Gay Caveman Diet

The image of the Austin Powers series character Frau Farbissina was obtained at www.webwombat.com.au

© Copyright 2009 Doctor's Weekly Commentary
May not be reproduced whole or in part without citation and/or link to this site