diabetes Archives - Macro Four

Type 2 Diabetes: Beyond Remission to a Cure

Disclaimer: This post is not medical advice. At all times you should consult with your trusted health professionals. It is a self-reported case study with discussion of type 2 diabetes pathology, much of which is unsettled.

Foreword

About 500 million people have Type 2 Diabetes (T2DM), so it is likely that this case study will be useful for more than one person who is like me, and may have some use for a good many others. If you have T2DM or pre-diabetes, I hope that is you.

To the best of my knowledge, there isn’t a more detailed long-term case history with results and analysis of a cure of T2DM than in this blog. If there is, please let me know as I want to read it and learn. I’ve documented this truthfully with my lab results and tried to avoid my bias and enthusiasm for what worked for me and why.

If you are a clinician then there may be insights from my case to help the growing number of people who have achieved remission, but now wish to progress even further towards a completely normal metabolism.

Among other things, I think my success is because I took a metabolic health approach to my problem. This is a long post so I will put that detail in a separate ‘how-to/ what I did’ post, which needs to include metabolic testing and body composition. In full disclosure, convinced of the value of a metabolic approach, I now do work for Metabolic Health Solutions (MHS) after being a client.

I’d love your comments, improvement suggestions, or notification of any errors. Leave a comment here or have a discussion with me on Twitter.

My Type 2 Diabetes is Cured

It’s been about three years since my last post and my original one seeking to go beyond remission to a cure for T2DM. You might review these if you are unfamiliar with them. I have achieved my goal of curing T2DM with the proof of that coming about a year ago now, but I’ve taken my time to publish this as I wanted to get my ducks in a row.

When I say ‘cured’ what do I mean? Firstly, I have a non-(pre)-diabetic HbA1c that is now consistently less than 5%. That is better than most of the non-(pre)-diabetic population. Secondly, washed out of all medication, I passed a gold standard Oral Glucose Tolerance Test (OGTT) with a non-(pre-)diabetic result. There are no diagnostic criteria to say that I have either T2DM or pre-diabetes.

I challenge the belief that T2DM is a chronic progressive disease that has no cure, even though diabetes charities only allow you to be in remission (never cured). I challenge that T2DM is purely an unlucky genetic lottery. While genetics play their part in susceptibility, T2DM is an arbitrary diagnosis point of a condition that is actually a metabolic spectrum you are already on.

Without doubt, I have moved down that spectrum to be almost completely healthy. I don’t doubt that if I went back to the diet and lifestyle that led to it, it would come back, just as it develops in someone afresh. If I maintain a truly metabolically healthy lifestyle, I have every expectation that it will not.

T2DM as Metabolic Disease

To cure a disease, you’d better understand it’s nature. T2DM most likely starts with poor fat oxidation. If you are unable to use your body fat effectively for energy, it accumulates. Too much where it should be, then spilling to where it should not be. That includes in your liver, your adipocytes (fat cells), and in your pancreas. De Novo Lipogenesis (DNL or fat production from carbs) may be increased, exacerbating this process by depositing more fat in the liver which causes or aggravates Non-Alcoholic Fatty Liver Disease (NAFLD). One strong theory is that this fat spills over into the pancreas becoming T2DM (1). Dyslipidemia and inflammation from that are likely to be causal for cardiovascular disease (CVD). While the exact order and causation may be debated, one useful view of how all of these major conditions are linked from the same root cause is shown in Figure 1 below (2).

Figure 1. From Obesity to NAFLD to T2DM to CVD

T2DM development is not completely understood, but in effect, because your metabolism is broken, insulin rises to high levels (hyperinsulinemia) often even without eating. Worsening insulin resistance means that more insulin is needed to hold blood glucose at desired levels. The same amount of insulin no longer produces the same lowering of glucose. As it’s governed by a control system, our pancreas obliges and puts out more insulin to try to keep blood glucose controlled. Eventually, our insulin-producing beta cells can not produce enough insulin and we get an Impaired Glucose Tolerance (IGT). When blood glucose rises past an arbitrary point, T2DM is diagnosed, however, you can see there is already a problem. Even if you’ve been to your doctor and told: “Everything is OK with your blood glucose, you don’t have (pre)-diabetes.”, you may have ‘diabetes in situ’ (3) or metabolic syndrome.

Blood glucose can be managed with lifestyle and medication but this almost certainly continues as a chronic progressive disease. It continues to rise and insulin production falls further and eventually, injected (exogenous) insulin may be needed. Unfortunately, high insulin and high blood glucose cause diabetic complications, some of which we see above. Along with CVD, you can risk blindness, kidney disease, and poor circulation with nerve damage that leads to amputation.

The T2DM Spectrum

This diagram from doctors Kushner & Johnson’s article (4) illustrates this kind of progression which occurs over many years. In my case, it was over about a decade- perhaps more.

Figure 2. The Progression of Type 2 Diabetes

This picture exposes that we have created a problem because we have a binary view T2DM. “You have it or you don’t.” this leads people to think “You have the bad genes or you don’t” or some other factor. While computer numbers are binary, metabolic processes rarely are. If fact, the very existence of pre-diabetes (which precedes T2DM and can also be reversed and prevented from proceeding to T2DM) shouts out to us that T2DM is not a binary condition.

Instead, we should view T2DM as a condition of extended metabolic illness where everyone is on its spectrum. Consistent with Kushner & Johnson’s view, and while not really new, I propose Figure 3 showing T2DM on a spectrum.

Figure 3. The T2DM Spectrum. Where are you on this?

Accepting that spectrum is reversible, then we need to find the things that will move us left. You will note that in figure 1, I have added “poor fat oxidation and poor metabolic flexibility”. That corresponds with figure 2’s meal size, composition, timing, and low activity. If that is driving the process, it’s no surprise then that changing meal size, composition, timing, and activity to achieve better fat oxidation and metabolic flexibility would be a great place to start to move left. High insulin is a major problem, so continuing to keep that as low as possible also seems wise.

T2DM as Insulin Resistance of the Pancreas

The latest research into diabetes indicates that a problem of T2DM may be insulin resistance of the pancreas itself. This leads to the related problem that alpha cells that make glucagon (the hormone that makes your body produce glucose) make too much of that (5) because they do not react properly to high insulin, so the liver overproduces glucose.

This seemed to be my main problem. My glucose was low most of the time, but would still be high in the morning even before I’d eaten. This had improved but appeared to be why my HbA1c wouldn’t drop below my target of 5.1%. Instead it hovered around 5.6%.

Let’s summarise some important points from this discussion of T2DM.

T2DM is characterised by hyperinsulinemia, with insulin resistance affecting tissues in the body differently, including, but not limited to, muscle, kidneys, liver, and (it seems) the pancreas itself.
Both insulin and blood glucose levels are high. Both will be exacerbated by lifestyle and in particular by foods that raise blood glucose and promote insulin secretion.
While the focus is often on the problems with the insulin-producing beta cells, both the alpha and beta cells do not function normally. Especially if there is no severe damage to them, this may be reversible. Even if there is some damage, it might be possible to regain function or possibly repair them.
T2DM is actually a spectrum condition that has hyperinsulinemia and insulin resistance to varying degrees. Before pre-diabetes, we have “sub-clinical diabetes” or T2DM that has not yet passed its clinical diagnosis points. You may also hear this called ‘diabetes in situ’.
Reversal can target hyperinsulinemia by lowering insulin and improving insulin sensitivity (reducing insulin resistance) until we have moved to the left, subject to any lasting damage to tissues and organs which then may or may not heal over time.
If we just try to control blood glucose without addressing high insulin, we have a chronic progressive disease. We can ‘rob Peter (increase insulin) to pay Paul (reduce glucose)’. This is, unfortunately, often the outcome of standard diabetes management.
If insulin resistance and hyperinsulinemia are the real problem, making the pancreas produce more insulin or supplementing insulin to keep it high by injecting it, is unlikely to fix the problem.
Striving for excellent metabolic health, by moving to the left in figure 3, appears to be the real goal for a cure.

Moving Towards a Cure

One interesting aspect of my case is that it was almost only a diet approach for the first years. I did little exercise and was on a fairly small dose of metformin (500mg) for most of the time. This means my case study largely isolates diet (with a small metformin dose) from other factors like exercise.

It was a low carbohydrate approach which has the advantage of also minimising the insulin my pancreas produces. This is because carbohydrates stimulate insulin the most, then protein (but also much less in the near absence of carbohydrates) and fat the least. Logically too, if I had a pancreas overworked from six years of being unable to keep up with insulin production, it makes sense to give it a holiday from that.

After 18 months (see my 18-month post), I had markedly better health. My HbA1c was consistently below 6%, but I wanted it lower than 5.1%. My weight was now about 96kg, but I wanted to be around 80kg. Both seemed to be stuck. I toyed with options like keto (higher fat), exercise (but what kind?) and further intermittent fasting as discussed in my previous 18-month post.

I did persist for about another 10 months with just diet. Strictly two meals a day (16:8 fasting). I tried more keto but my blood glucose and weight did not seem to shift. Control chart theory (and common sense) indicated that if I wanted my system to change, I needed to do something different.

Metabolic testing from MHS (the subject of my next post) showed that my metabolism was far from optimal and this provided evidence for the lifestyle interventions. With my doctor’s support, I also increased my metformin dose.

Inflammatory Hysteresis

Inflammation can be caused by high blood glucose and high insulin. Neither my blood glucose nor (fasting) insulin was springing back to a level normal for the general population. Why was that and how could I shift it?

Nick Paterson who writes this blog from Finland, coined the term ‘inflammatory hysteresis’ to describe a phenomenon he saw in his own journey and people he worked with. Hysteresis is an engineering term and it made some sense to me so what does it mean?

Take a paperclip and straighten it out. Now deform the straight end slightly with a bit of pressure then let go. The clip springs back a bit like a spring. If you flex it much further, it will stay bent and if you deform it further in the same direction it will not return to the original position. It will bend further until it breaks. The inability of a system to return to normal shows that a system can hold a different persistent state. Simplistically, this is hysteresis. To straighten the clip, we need to actively deform it in the opposite direction to take it past its normal position.

The bent spring is a pretty good analogy for diabetes. You have bent your metabolism and pancreas so far that it will not snap back to normal. Hopefully, it’s not permanently damaged, but you need to ‘bend’ in the opposite direction so that it might settle back to normal again.

Increasing Metformin

Diet and exercise interventions are tools, but could I somehow bend my metabolism further? Nick was doing an experiment with metformin to see if that could help. I also remembered the comment in my previous post from Dr Lance De Foa about metformin.

Most doctors would not prescribe metformin for T2DM with an HbA1c of about 5.6% if it is only to manage blood glucose. At 5.6% blood glucose is already non-diabetic and metformin will likely not lower it much further.

Clinical practice might need to be rethought for T2DM in remission. Metformin should improve insulin resistance and reduce gluconeogenesis (caused by my alpha cells) to promote further recovery ‘bending the spring’ a bit further using medication. Patients may have a goal to be medication free (I did), but metformin is not the same as insulin or sulphonylureas which may make T2DM progression worse (6) and increase the risk of cancer (7) and CVD (8). In fact, metformin is likely to improve those risks and others (9).

Changes

At about month 58 in figure 3, I began deeper fasting, resistance training, and I took my increased metformin dose. It worked almost like magic. Over the next year, my HbA1c crashed through the 5.1% barrier to 4.6%, my weight dropped 18kg to 78kg, and my fasting insulin dropped from about 12 to 6.

Figure 4. My T2DM reversal from Uncontrolled to a Cure

These were great results, but could I say I was cured? A great HbA1c on a low carbohydrate diet is often dismissed because you have just ‘hidden the problem’ by avoiding carbohydrates, however, my fasting insulin had also fallen from 26 to 6. On a low carbohydrate diet it turns out that for me HbA1c (in %), is a pretty good proxy for fasting glucose (in mmol/L) so this would indicate that my HOMA-IR (insulin resistance) had fallen from about 6.7 to 1.3. Generally, between 0.5 to 1.5 is regarded as the healthy range but this was when my pancreas was not being worked hard (during fasting).

My Pancreas at Wide Open Throttle

The gold standard test for diabetes is an Oral Glucose Tolerance Test (10). I decided to do this in month 89. You can see my preparation and the test results I took alongside the lab measurements on Twitter, which was tweeted in real-time. I ceased taking metformin for two weeks prior so that it was not a factor affecting the result. The official result confirmed that I was neither diabetic nor pre-diabetic.

Figure 5. OGTT and Other Laboratory Results, December 2019

The C-Peptide result shows that my pancreas still produces adequate insulin despite six years of quite bad T2DM. It was almost in the middle of the normal range. My HbA1c was 4.6% so it was below the population average of about 5.1%. Everything looks pretty good but the pass or fail isn’t really enough to assess where I am on the T2DM spectrum. Metabolism testing was also good (to be the subject of another post). To assess further we need a little detective work and this paper (11), particularly figure one in it, as provides us with a useful yardstick. Here is that figure reproduced with my results added to it in yellow.

Figure 4. Oral Glucose Tolerance Tests & Metabolic Health

Analysing my Oral Glucose Tolerance Test

Analysing the insulin, it’s a shame that I don’t have a 30-minute insulin value to compare (it was not part of the standard test that is done in Australia) but otherwise, the insulin response is fairly close to the average value for an insulin sensitive person with normal glucose tolerance.

Looking at the glucose curve, we can see that while I passed the test threshold at 2 hours, the peak is higher than would be expected for an insulin sensitive person with normal glucose tolerance. I speculate that for some reason (that may or may not be damage to my pancreas from T2DM) my first phase insulin response is still slow or low which leads to an excessive glucose peak. This might have been seen if I had an insulin measurement at 30 minutes.

What does that mean for me? Probably that it is best to still avoid food that is like 75g of glucose in one hit. Slow, complex carbs should not be as bad. Aren’t we all told to do that anyway to avoid T2DM? I’ll still generally restrict carbohydrates in my diet until I can see this improve too. It’s easy for me to repeat this test yearly myself to see how the glucose peak changes.

This may be due to a (genetic?) metabolic abnormality that I have always had or developed as I aged. If so it may be the reason I was more susceptible to developing diabetes (12). It is also possible that this is just the last thing needed to fixed before becoming completely normal. Interesting questions for me and perhaps for others.

We know from Prof. Roy Taylor’s work that first phase insulin response can improve with effective reversal or remission and this is more likely if you reverse T2DM after less than six years. It may be that six years of diabetes has left my first phase response more damaged. If that’s the case, maybe it can’t be improved or fixed, but then that’s what they’ve told us about T2DM for decades and so far ‘they’ haven’t been right for me.

There is also another possible explanation. These were the first substantial carbohydrates that I had eaten for 3.5 years. The OGTT protocol requires that you eat 150g of carbs a day for three days. I did that for four days but I cannot rule out that I might actually need longer to adapt given my very long time without them. It is fairly uncharted territory, but if anyone knows of a study that resolves this possibility or can otherwise explain this, then let me know.

“Just Losing Weight Cured You.”

I have been told this by some folks on social media. Usually, they don’t like low carb diets and/or fasting and think that a caloric deficit and weight loss are all that is needed. It’s sometimes from some who really should know better.

At 78kg down from 109kg it’s clear that I have healthier adipose tissue but there are also obese people that don’t have T2DM and thin people that do. If you consider that and now appreciate the complexity of T2DM a bit better, then you will know that saying that T2DM reversal is purely about weight loss is an oversimplification. It is as wrong as saying that weight loss has nothing to do with it. I note:

We’ve been telling people with T2DM to lose weight for decades. It hasn’t made much difference to the remission rate. Most health professionals don’t even bother to try with patients because losing weight is hard if you are unable to utilise your body fat- which is likely to be why the whole problem started. They just put them straight onto medication.
How do thin people with T2DM reverse it if excess body mass is wholly causative and remission is achieved just by losing 15kg? The answer is that they do this with a metabolic diet and don’t try to lose weight unhealthily to reverse it like this poor fellow (13).
Specifically, though, diabetes is most believed to be exacerbated by ectopic and visceral fat accumulation around and in the liver and pancreas (14). Liver fat may be reduced without a significant change in weight (15).
Metabolism is complex. A recent review (16) of the evidence supports that the relationship between weight loss and glycaemia (hence remission) is not as straightforward as might first be thought.
My particular case shows that weight loss is not the only thing happening in remission if therapy is sustained. For me, a very modest weight loss of about 1.5kg dropped my fasting insulin from 26 to 12. Insulin resistance was more than halved and there was no exercise to confound this! That is easily seen between months 38 and 51 in figure 3.

For the sake of people with T2DM, we need to challenge the “it’s just weight loss” paradigm, not the least because it just has not worked as a goal in itself for remission for 40 years or more. A good approach instead is a focus on overall metabolic health. That means healthy adipose tissue, healthy mitochondria, visceral fat reduction, metabolic flexibility, improved fat oxidation, increased muscle mass, total fat mass reduction and (naturally) involves weight loss.

What I Have Learned

Reflecting on my journey:

Diet is the primary intervention for T2DM, but metabolic health, which can include sleep, sunlight, exercise, and supplements (sometimes medications), is the real aim. Nonetheless, while it’s not all about diet, a low carb/ keto diet (with intermittent fasting) is a powerful metabolic tool.
Even if a dietary guidelines diet is healthy for everyone already healthy, it is an inappropriate diet for someone with T2DM wishing to be in remission or cured. It is unlikely to therapeutically address the underlying pathology, but also how could any health professional recommend an eating pattern to achieve remission that has no evidence for delivering remission?
It’s not all about weight loss. Your metabolism is complicated and T2DM puts you at the far end of a spectrum of a metabolic problem. That said, significant weight loss is a likely part of the journey if you are overweight or obese with T2DM. Losing excess fat mass improves your metabolic health, but the relationship is complex because sustained weight loss is also an outcome from an improved metabolism.
It’s much more about lowering insulin than managing glucose but we manage best what we measure. It’s easy to measure blood glucose and as it’s associated with complications so it’s the therapeutic goal, but it is not the only or best therapeutic goal. A focus on blood glucose has allowed us to mistreat T2DM with exogenous insulin, sulphonylureas, and now SGLT2’s (which are better but still not great). Evidence shows that a therapeutic diet can obviate or reduce the need for medications for many people.
Patience and persistence are important. It took me 3.5 years to reverse my metabolism to a non-(pre)-diabetic state after a decade of NAFLD and 6 years of poorly controlled T2DM. If one of the factors in reversal and cure is simply time, that’s unlikely to happen if you can’t sustain the therapeutic lifestyle needed and go back too early to a diet that may actually have caused progression. If I had tried to cure my T2DM using shakes for rapid weight loss, followed by a high carb dietary guidelines eating pattern, the result would likely have been quite suboptimal.

From here I’m going to continue my health journey. My weight hovers between 78kg and 82kg quite reliably. It’s unlikely that a decade of fatty liver and six years of poorly controlled T2DM has left me with no problems or health risks, but I’m a hell of a lot better than I would have been with a decade of T2DM.

Research Reflections

Everyone should think about where they are on the T2DM Spectrum. I would hope if you have T2DM and are not in remission, you might now be inspired you to set that as a goal. If you are in remission, I hope it would show you there is a further path to travel, but that is also true whether you are pre-diabetic or have insulin resistance or metabolic syndrome.

For self-managing patients and clinicians, I think there are a few concepts here (and also in my next post) useful to continue to assess progress and work beyond remission.

Of course, my case can’t prove repeatability for someone else; however, it’s a more useful scientific resource than me filling in a lifestyle (food frequency) questionnaire only to have it mixed with 100,000 others, so you can look for an association with the foods to eat for a T2DM cure!

Maybe you can dismiss it as an anecdote and close your browser tab? I hope not as wisdom suggests an n=1 helps you understand a disease. Noting that I had diet as the main intervention for the first years, I think my case provides some interesting separation of the effects of those interventions for you to ponder.

I expect there are a few hypotheses in this post worth testing. 4.5 years is a long time to live without carbs and I’d like to put a few back at some point and expect I will after seeing my one hour OGTT normalise and HOMA-IR improve further. It’d be nice that if repeatable, the process heal can be sped up for others.

CONCLUSION

What is a cure for T2DM? I think it’s about getting the best metabolic health you can with a damaged pancreas (alpha & beta cells) and clearly, that is partly about restoring a healthy adipose system with reduced visceral and ectopic fat. Normoglycaemia and normoinsulinemia are surely pre-requisites for that. Diet, exercise, sleep, and medications/ supplements are the lever to get there, but time is also a factor.

You may not be able to reverse damage to your pancreas, however understanding the damage and eating (carbs) to the limitation of that can see you otherwise healthy for life and sets up the conditions that might give the best chance of pancreatic improvement. Even if you are fully reversed, you may be more susceptible to redeveloping but that does not mean you aren’t cured.

I note if you are cured of malaria, you still don’t get immunity from it and you can be more susceptible to worse disease the next time. It is my view that carbs are causal of T2DM (necessary but not sufficient) and no one has invented a vaccine against eating highly refined carbohydrates. In fact, it may be that the high carb diet many are eating is not a natural diet for humans and may be the cause of the problem.

Being cured is not the same as immunity. Setting the bar that you must be able to ‘eat carbs like everyone else again’ to be cured is subjective & clinically irrelevant unless doughnuts are clinically important. I’ll certainly not be eating them until the doughnut vaccine is developed. Good luck with that!

References

(1) Taylor R. Type 2 diabetes: etiology and reversibility. Diabetes Care. 2013 Apr;36(4):1047-55. doi: 10.2337/dc12-1805. PMID: 23520370; PMCID: PMC3609491.

(2) Lomanaco, R. & Cusi, N., Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?, Chapter 21, Evidence-based Management of Diabetes

(3) Joseph R. Kraft, M.D., Detection of Diabetes Mellitus In Situ (Occult Diabetes), Laboratory Medicine, Volume 6, Issue 2, 1 February 1975, Pages 10–22, https://doi.org/10.1093/labmed/6.2.10

(4) Johnson, JD & Kushner, JA. Endogenous insulin: its role in the initiation, progression and management of diabetes, The Endocrinologist, ISSUE 129 AUTUMN 2018

(5) Muhmmad Omar-Hmeadi, Per-Eric Lund, Nikhil R. Gandasi, Anders Tengholm, Sebastian Barg. Paracrine control of α-cell glucagon exocytosis is compromised in human type-2 diabetes. Nature Communications, 2020; 11 (1) DOI: 10.1038/s41467-020-15717-8

(6) Genuth S. Should sulfonylureas remain an acceptable first-line add-on to metformin therapy in patients with type 2 diabetes? No, it’s time to move on! Diabetes Care. 2015 Jan;38(1):170-5. doi: 10.2337/dc14-0565. PMID: 25538314.

(7) Bowker SL, Majumdar SR, Veugelers P, Johnson JA. Increased cancer-related mortality for patients with type 2 diabetes who use sulfonylureas or insulin. Diabetes Care. 2006 Feb;29(2):254-8. doi: 10.2337/diacare.29.02.06.dc05-1558. PMID: 16443869.

(8) O’Brien MJ, Karam SL, Wallia A, et al. Association of Second-line Antidiabetic Medications With Cardiovascular Events Among Insured Adults With Type 2 Diabetes. JAMA Netw Open. 2018;1(8):e186125. doi:10.1001/jamanetworkopen.2018.6125

(9) Campbell JM, Bellman SM, Stephenson MD, Lisy K. Metformin reduces all-cause mortality and diseases of ageing independent of its effect on diabetes control: A systematic review and meta-analysis. Ageing Res Rev. 2017 Nov;40:31-44. doi: 10.1016/j.arr.2017.08.003. Epub 2017 Aug 10. PMID: 28802803.

(10) Phillips, PJ,. Oral glucose tolerance testing, Emergency Care, Volume 41, No.6, June 2012 Pages 391-393

(11) Wang, Q., Jokelainen, J., Auvinen, J. et al. Insulin resistance and systemic metabolic changes in oral glucose tolerance test in 5340 individuals: an interventional study. BMC Med 17, 217 (2019). https://doi.org/10.1186/s12916-019-1440-4

(12) Gerich JE. Is reduced first-phase insulin release the earliest detectable abnormality in individuals destined to develop type 2 diabetes? Diabetes. 2002 Feb;51 Suppl 1:S117-21. doi: 10.2337/diabetes.51.2007.s117. PMID: 11815469.

(13) Odhaib S A, Mansour A A (June 03, 2019) A Patient Loses 18 kg and Type 2 Diabetes Mellitus: The Challenge of Complete Remission. Cureus 11(6): e4817. doi:10.7759/cureus.4817

(14) Sattar N, Gill JM. Type 2 diabetes as a disease of ectopic fat? BMC Med. 2014 Aug 26;12:123. doi: 10.1186/s12916-014-0123-4. PMID: 25159817; PMCID: PMC4143560.

(15) A. Mardinoglu, H. Wu, E. Bjornson, C. Zhang, A. Hakkarainen, S.M. Rasanen, S. Lee, R.M. Mancina, M. Bergentall, K.H. Pietilainen, S. Soderlund, N. Matikainen, M. Stahlman, P.O. Bergh, M. Adiels, B.D. Piening, M. Graner, N. Lundbom, K.J. Williams, S. Romeo, J. Nielsen, M. Snyder, M. Uhlen, G. Bergstrom, R. Perkins, H.U. Marschall, F. Backhed, M.R. Taskinen, J. Boren
An integrated understanding of the rapid metabolic benefits of a carbohydrate-restricted diet on hepatic steatosis in humans, Cell Metabolism., 27 (3) (2018), pp. 559-571

(16) Fridman M, Lucas ME, Paprocki Y, Dang-Tan T, Iyer NN. Impact of Weight Change in Adults with Type 2 Diabetes Mellitus: A Literature Review and Critical Analysis. Clinicoecon Outcomes Res. 2020;12:555-566. Published 2020 Sep 29. doi:10.2147/CEOR.S266873

Engineering a Cure for Type 2 Diabetes: 18 Months

Eighteen Months of Low Carb

Dietitian’s organisations frequently criticise low carbohydrate diets for not being proven safe in the long term. Poorly controlled diabetes (where blood glucose is higher than for people without diabetes) on the other hand, has been proven extremely unsafe in the medium to long-term. For people with diabetes, a restricted-carbohydrate diet is almost certain to lower blood glucose and remove or eliminate medications. This one ‘radical’ diet change can hardly fail to alleviate most of the ill effects of diabetes, medicinal side effects and both of their risks. Clearly, the ‘unknown risk’ of the low carbohydrate diet in the long term can be weighed against the near certain risks of diabetes. Otherwise, blindness, amputation, cardiovascular disease, dialysis from kidney failure and a shortened lifespan will nearly always be the end result.

I have now passed eighteen months on a low carbohydrate diet. That means I have exceeded the 74 weeks of the ‘best’ vegan diet study by Barnard. I thought it was time to wrap up the comparison and reflect on my health progress to see where my health journey could now go. That is the focus of this post.

HbA1c Chart

Let’s get straight into that with an update to my HbA1c chart.

My results plotted against Barnard’s Vegan Diabetes Trial Results

At the end of August, I was a little disappointed. The downward trend ceased and my result was actually 0.1% higher than in May. This was mitigated by the fact that the result is only accurate to one decimal place anyway and the later result in December came in again at 5.6%. All these results are still in the non-diabetic range. I still take 500mg of metformin as this remains beneficial to further recovery despite having non-diabetic blood glucose. That can be compared with 2000mg of metformin, Januvia and Diamicron before low carb.

Unlike the conventional and vegan diets in the trial, my blood glucose has stabilised and not led to an increasing HbA1c after three to six months that sustains and increases medications. Compared to HbA1c population statistics, it is about four standard deviations lower than the vegan diet and that is maintained on a minimum amount of metformin- unlike the more heavily medicated study participants.

Finally, my ending HbA1C is about ten standard deviations less than the vegan study statistics. Statistically, it is practically impossible for any of the 49 vegan (or 50 conventional diabetes diet) participants to have achieved a similar result.

Long-Term HbA1c & Glucose Control

In the context of my long-term results, the last eighteen months of a low carbohydrate diet since month 31 on this chart, have been an unqualified success. I have had non-diabetic blood glucose for fifteen months, and even non-pre-diabetic blood glucose for at least 6 months.

It is important to realise that HbA1c is really only an average. Large fluctuations up and down can still give a good average but have the considerable risk of complications due to glycaemic variability. My blood glucose measurements have a standard deviation of an excellent 0.8 mmol/l and the tight glucose control that a low carbohydrate diet gives can be seen below. I have a normal non-diabetic HbA1c with low glycaemic variability. My blood glucose measurements were 98% within target showing tightly controlled blood glucose. Such is the efficacy of carbohydrate restriction for diabetes.

You can also see the effect of one inadvertent meal which included carbohydrates at my daughter’s graduation function. Refined carbohydrates are insidiously a part of our food supply and no one is perfect!

My Overall Health

Unfortunately, with very high blood glucose, I had just about every bad effect from diabetes that researchers have shown. So how is my health after eighteen months on a ‘fad’ diet of unprocessed foods low in refined carbohydrates and no ‘healthy’ whole grains?

My total and LDL (‘bad’) cholesterol is about the same despite having increased my saturated fat intake greatly
My HDL (good) cholesterol is up by about 40% and triglycerides are down by about 33% meaning that my ratio of triglycerides to HDL more than halved! The ratio of triglycerides to HDL is an important predictor of coronary disease.
My liver function tests have normalised. This indicates remission of a fatty liver which is common in people with type 2 diabetes.
My fasting insulin has had its lowest reading ever of 12 mIU/L (compared to 26 previously) and is in the normal range for the population and it coincided with a fasting glucose of 5.3 mmol/l. This is an indication of improved insulin resistance.
I have control of my appetite and eating and can easily fast 16:8 or 23:1.
My neuropathy (tingling and coldness in my toes) has reversed.
My long-distance vision deterioration has reversed with lower blood glucose.
My balance, memory & cognition have returned to what they were.
I no longer have chronic bacterial and fungal infections. Only one cold in the past 18 months compared to constant illness in the times preceding.
Retinal scans and analysis by specialists confirm no further deterioration in my vision from retinopathy.
My kidney function is no longer abnormal.
Episodes of gout are less frequent and less severe.
My blood pressure is an excellent 117/74 despite adding ample salt to my food.
I don’t have irritable bowel symptoms anymore. Among other discomforts, I was prone to unexplained and fairly frequent bouts of diarrhoea. My energy levels are good and I rarely feel bloated and my ‘gas’ production is negligible.
My weight loss is 16 Kg and importantly my neckline and waist have shrunk. I have moved from obese to just overweight.
I no longer have depression from having diabetes.

But not everything is the same. I do have one negative. I am more prone to constipation which I almost never suffered from before. This is almost always a problem if I do not hydrate properly. Looking at the list above, I sure can live with that!

It is undeniable that my health is vastly improved. My doctor is extremely pleased, I am extremely pleased and my family is extremely pleased.

Social Effects & Adherence

Quite bizarrely, the Dietitian’s Association of Australia cited (without evidence) that the low carb diet should not be used for diabetes because the health of other family members could be impacted. Would they make that comment for a coeliac? Nonetheless, I can report that when we have meals, the family generally eats the potatoes or carbohydrates and I have a different vegetable. If only I could get my children to avoid processed foods, skip the fries and stop asking for sugary drinks completely like I do! It seems that is even beyond my powers as a role model. However, because of my eating requirements and awareness, we have less refined carbohydrates and processed foods and my children have reduced their sugar intake. Maybe they meant that they didn’t want anyone’s health to improve?

When I go out to eat, I rarely have a problem finding something. If there are carbohydrates, I usually can get another vegetable substituted.

This is otherwise an unremarkable non-issue.

Measuring My Metabolism

In late September, I had my metabolism measured by Metabolic Health Solutions (MHS). In full disclosure, this was done for me at no cost. I had not understood before how metabolism, weight loss and diabetes tied together. Now I think I do!

My testing showed that my Resting Metabolic Rate (RMR) was 2145 kcal which is towards the top end for my age and body. That is good. It explains that I have the metabolism to potentially lose weight without vigorous exercise. My efficiency (FEO2) was 17.3% confirming that I am no athlete as it would be optimal if less than 15!

Very surprisingly, the test showed that my fuel mix was 24.7% from fat and 75.3% from carbohydrate. This surprised me as I thought that, being on a low carb diet, I would automatically be a good fat burner! Ideally, this should be almost opposite with 80% fat burning and 20% carb burning.

It seems my metabolism is more than happy burning carbohydrates from protein. It does explain why I generally have had trouble losing weight and still have trouble. Clearly, if one is a good fat burner and does not eat a lot of fat then one will burn body fat. Being a carb burner fully explains why, when I went on a slightly higher fat moderate protein diet, I stalled. Even though it was low carb, my body was still getting most of its energy by making glucose from protein.

Solutions for me include some longer fasts, a more ketogenic diet to encourage fat metabolism, and exercise.

Since that testing (and to be transparent as my blog is non-commercial) I have begun working with MHS because I am impressed with how this information can inform your weight loss and metabolic health strategy. The world has a lot of metabolically sick people.

Where to From Here?

It is still my aim to achieve an HbA1c of 5.1% or below. As I indicated in my last post, control theory would indicate that I am unlikely to achieve that on the current trajectory. The steady progression downwards has arrested and I am about one standard deviation from the target. I do want to lose further (fat) weight. I must change my approach or it seems I will always be above the setpoint or take a very long time to reach it. My sleep patterns are pretty good and my diet is working well. I am still doing only a little exercise. Here are some options.

A Ketogenic Diet

Presently my diet has quite a bit of protein in it. This does not raise my blood glucose as carbohydrates do but it keeps me out of ketosis a lot of the time. By operating more deeply in ketosis, my blood glucose would fall markedly more and I would likely achieve my 5.1% HbA1c. That means a higher fat diet. If I limit my protein I will also have reduced capacity to burn carbs (presuming I can spare muscle) and this may help me become a better fat burner.

I enjoy the higher protein low carbohydrate diet. I do not see a ketogenic diet as a long-term option for me since it more difficult to get sufficient nutrient density on a high-fat diet- but this might be something I do for a while if it helps me to become a better fat burner.

Some Longer Fasting

Most days I fast 16:8 by skipping breakfast. By extending this I can cause my metabolism to use my own body fat since while fasting it will not have carbohydrates, fat or protein from diet and should prefer to use my own body fat. As a 75% glucose burner, I need to be careful that my body does not decide to obtain glucose by catabolising muscle until I can change that.

High-Intensity Exercise

I do not exercise much and have exercised little over the 18 months. Among other things, I wanted to see how far I could go with diet and did not want to confound diet and exercise. By building more muscle and doing high-intensity exercise I should be able to deplete my glycogen more easily and frequently, leading to a reduction in average blood glucose, as well as increasing my insulin sensitivity. High-intensity exercise will also be helpful, combined with fasting or a keto diet to reduce muscle loss, and help me to become a better fat burner.

To be honest, I have never been a marathon runner and likely never will be, so part of my challenge is to find the exercise that I will enjoy.

Metabolic Health

Having some real numbers from metabolic health testing has allowed me to focus on what I can do to improve my metabolic health. I am now more motivated to exercise and then be re-tested to see how I have improved.

A Note for Vegans

Sorry, but in my case, it was no contest. A vegan diet can (without question) improve your health if you are obese and have diabetes mainly by its calorie restriction, but Barnard’s study compared with my journey shows that it is neither as sustainable nor as optimal for me as carbohydrate restriction when compared against the study people. I went the distance of 78 weeks versus the study’s 74 weeks and it is “Game Over”.

Final Word to Dietetic Associations

Shouldn’t I be dead by now from the ‘fad’ diet? In fact, if I had listened to you I might have been well on my way to dialysis or amputation. I think you need to get over your prejudice against low carbohydrate and higher fat diets. After all, despite some health-washing to make the much-lauded Mediterranean Diet appear as a low-fat diet- it is actually also a high-fat diet.

It is without question for me or my doctor that a low carbohydrate approach has led me to vastly improved health and a reversal of diabetes. If you have any real semblance of taking an evidence-based approach, that should also be obvious to you. You say that your members deliver services that are not ‘one size fits all’ but in practice if you have dietary guidelines uniformly applied to everyone (sick and healthy) it really is lip service!

More importantly, when you get medically and metabolically tested, it is well apparent that your dietary, exercise and eating must be individualised to optimise your metabolic health and that it is likely to change over time. It is reprehensible that dietitians are not systematically identifying the people for whom a low carbohydrate diet is beneficial and helping them with an individualised journey.

It is a shame that you (dietetic associations) keep your members in the Dark Ages of dietetic practice. I suggest that if you don’t change then consumers should figure it out for themselves and vote with their feet.

Oh, that’s right. We are!

🙂

Engineering a Cure for Type 2 Diabetes

Engineering Nutrition?

With the failure of forty years of dietary guidelines to arrest or improve the incidence of diabetes and obesity, new thinking and approaches are needed. Applying an engineering mindset to nutrition has attracted attention as some of the new thinking has emerged using root cause analysis and other engineering tools. This has resulted in new insights for the medical and nutrition communities.

This is not really new, I pay homage to doctors like Dr Bernstein who trained as an engineer first, then as a trained doctor realised how controlling diabetes was like an engineering control problem.

Recently, however, as a recovering type 2 diabetic, I plotted my HbA1c against the results of a long-term vegan ‘cure’ for diabetes study to see how it compared. I was astounded by the superior result and tweeted that it was a fifteen sigma improvement. While not really correct, it got me thinking of my recovery in terms of engineering control theory and quality management.

Putting aside whether a cure is possible (for type 2 diabetes) and considering treatment, what if we view diabetes as an engineering control problem and applied control charting to understand the quality of different management options? Note that while I have type 2 diabetes, the glycaemic control problem is common to type 1 and so much of this analysis also is relevant to them too.

Broken Control System

Glucose comes from sugar and other carbohydrates (carbs) like starch from bread, rice and pasta. Your body uses about 130g of glucose a day (about 33 teaspoons). Normally, there is no more than about one teaspoon of glucose in your blood at any one time. Simply, if there is not enough glucose in your blood, you can black out or die as your vital organs cannot function. As your muscles, brain and other organs consume glucose as fuel, your liver, pancreas and digestive system release hormones including insulin to regulate glucose to a tightly controlled level. That magic number is normally about 5.6 mmol/L (or 100mg/dL depending upon the units you use).

You might wonder, what will happen if you don’t eat any carbohydrate? Fortunately, probably as a result of adaptation, the body is fine as it can make what you need from other sources. This happens mostly in your liver. It is called gluconeogenesis or GNG for short.

Essentially with diabetes, the control system that reduces blood glucose (BG) is broken. The homeostasis (self-regulation) of your BG is ineffective because your body’s response to insulin (which lowers BG) is diminished (called insulin resistance) and/ or your ability to produce insulin in response to carbs is insufficient to lower BG quickly enough. For type one diabetes, insulin production is at or near zero.

Consequently, glucose that your body gets from carbs (or makes in the liver through GNG) will raise your BG and it will only fall slowly because your body is unable to produce or respond to insulin properly. So BG is easily raised but slowly and poorly lowered.

Conventional Diabetes Management

Let’s leave the medical theories about why the system is broken alone for the moment and assume we have to do the best with what we have got.

Conventional diabetes management seeks to lower your BG towards normal but not so that it drops too low. This is done by exercise (to consume glucose), diet and medications that replace insulin, reduce glucose production or eliminate glucose from the body.

In conventional diabetes management, juggling these factors on a daily basis is hard and is the focus for someone with diabetes. Every three months you go to see your doctor to see how you are doing overall and to see if your medication should be adjusted.

Unfortunately, it is hard to achieve and maintain this great juggling job. It is hard to replace a well working system in the body once broken. The typical person with diabetes has BG that, on average, is too high. It may also drop too low with too much medication leading to coma or death. High BG is associated with all of the ill effects that people with diabetes suffer including blindness, kidney disease and amputation. For most, eventually, doctor’s visits mean an inevitable adjustment upwards in medication and higher BG. High BG results in deterioration for a person with diabetes over time, more medication, more complications. Diabetes is therefore regarded as a chronic disease with an inevitable worsening progression.

With that prognosis, it makes little sense discussing getting back to normal BG. It makes little sense to see this as a control process that can be brought under near normal control.

THAT IS (FORTUNATELY) COMPLETELY WRONG!

HbA1c Measurement

I mentioned a three monthly visit to your doctor. Your BG changes throughout the day. In order to assess your overall BG control, a test measuring ‘haemoglobin A1c’ (HbA1c or just A1c for short) measures how ‘sticky and sugary’ (glycated) your blood is. As blood cells turn over every three months, A1c gives you about a three month average of your BG control.

I mentioned that if your systems were working properly, your BG would average about 5.6 mmol/L (or 100mg/dL). It turns out that this corresponds to an A1c of 5.1% (or 33 mmol/mol). This is an average for the healthy population or ‘population mean’. Statistically, the standard deviation from the mean is about 0.5% and it is deemed that you have prediabetes if you exceed the mean by one standard deviation or >5.6%. Similarly above about two standard deviations (>6.1%) you are diagnosed as having diabetes. The higher above one standard deviation you go, the worse becomes the health risks of diabetes.

Control Charts

Control charts are a tool used in engineering and management science to help us understand what is happening with a process. Essentially a control chart gives you a measure of how close a controlled system is performing to expected behaviour (the mean or average target for a parameter) when considering its deviation from the desired behaviour. Control charts give you a measure as to the quality of the outcome of a process and should help decide what you may need to do to bring a process back into control.

You can read about using control charts here.

If the aim is for a person with diabetes to approach the health of a ‘normal’ person, then we must restore the control as near as possible to the BG of a healthy person. A control chart type of methodology is used in some glucose monitoring programs to measure the quality of control of daily BG.

So when looking for long term control/ improvement, why not plot the mean of HbA1c and its standard deviations for healthy people? We can then use the control chart methodology as a yardstick to see how various treatments compare and to hopefully gain better BG control towards a cure.

Diabetes Control Chart using HbA1c

I have reproduced the results of a study on diabetes as a control chart. That study looked at about 49 vegans and another 50 people on a conventional diabetes diet. You can read this study here. I have added to that a plot of my history on a low carbohydrate diet. I have added in the bands of standard deviations (s, 2s, 3s, etc) in bands of colour from green to red.

Some points about this control chart in general:

Excellent control would see points close to 5.1% and ideally in the light green zone within one standard deviation (±s).
In control chart theory, any data point more than three standard deviations (±3s) is deemed ‘out of control’. Something is really wrong with the system and control process itself for this to occur.
Not one of the measurements is below the population mean of 5.1%

Conventional Diabetes Diet

This diet was a low fat, calorie deficit diet designed for weight loss. This gave the worst outcome. At the end of the 74 week period, the average A1c results were nearly above where they started. No average A1c was better than 5s. By the end of the trial, only about half of the participants were adhering to the diet. This was despite cooking lessons, weekly meetings with a dietitian and other intensive assistance. This diet was high in carbs as they are 60-70% of total energy.

Vegan Diet

The vegan diet lacked meat, eggs and dairy but was not calorie restricted. This gave a slightly better outcome. No average A1c reading was better than 4s. By the end of the trial, only 44% were still adherent and the outcome was beyond 5s. This was despite similar intensive assistance to that given on the conventional diet. Probably, as a result, some of the gains in A1c made earlier in the trial were lost and the vegans also deteriorated again. Had the trial and the upward A1c trend continued, it appears that the vegans might also have ended up worse than they started. This diet was very high in carbs being 75% of total energy.

LCHF/Keto Diet

My diet lacked carbs. No sugar, rice, pasta, bread, sugary fruit and starchy vegetables. I also drank alcohol sparingly. Most people with diabetes are advised to eat between 200g and 300g of carbs per day spread out over the day. I aimed at first for less than 50g per day (<10% carbohydrate) and after about three months I was reliably lower than 25g (<5% carbohydrate) per day. This normally would be a ‘keto diet’ however it is hard for people with diabetes to stay in significant ketosis without extended fasting so I prefer to call it LCHF. I also did practise intermittent fasting simply because I was not as hungry as I was with a higher carbohydrate diet. Many people report this. Typically this involved not eating breakfast so that it was 16 hours after the previous night’s dinner before I ate the next meal.

There was no assistance from a dietitian or cooking lessons for me. I did read the free information on the dietdoctor.com website to get the bulk of my nutrition from real food sources (meat, eggs, fish, fruit, vegetables, nuts & dairy) that were low carb. Unlike the diets in the trial, adherence was easy for me, although I had to unlearn a lot of ‘advice’ that dietitians had previously told me on my way to developing diabetes. Unlike the study diets, I ceased three diabetes medications after three months but then began taking one-quarter of the dose of metformin again at that time.

I did no appreciable exercise like running, swimming, cycling but took an occasional walk. In the first six months I easily lost about 12KG of weight, moving from obese to overweight. My weight has been quite stable since then.

Unlike the other diets of the study and my previous diabetes history, all my readings (except baseline) were within 2s and went below s before the year on LCHF was finished. Clinically, below 2s is pre-diabetes and below s is non-diabetic so I have been very happy with that result. The downward trend was recently confirmed as still occurring with a recent estimate of A1c from my glucose meter readings.

Engineering Analysis

Straight away we can say that the study diets are ‘out of control’. With no points less than 3s there is little prospect of either ‘process’ (diet) bringing control to equal the population mean. Further with all points 4s or higher, the mean (goal A1c of 5.1%) will never be reached. Quite simply, something is causing the A1c to be unacceptably high that the process being used cannot overcome. From an engineering standpoint, these are defective processes that cannot achieve the target. The trends were initially towards but end up moving away from the target long term. Management theory would tell you that the individual in the process (person with diabetes) will be powerless to achieve control. It is ridiculous to blame the person with diabetes for this result yet many of us blame ourselves. The theory says that to continue to expect reasonable control to the target wanted is foolish. You must use a different process or make some other significant change to the system.

That is not the case with the LCHF diet. All points are within 2s, some s, and we have a trend that may eventually result in the target being achieved although none of the measurements so far have been below the target.

Engineering Solution

If I were presented this as a control system problem I would immediately conclude that there was an unaddressed control offset, especially in the study diets. The engineering solution would be to apply ‘Integral Control‘ to attack that offset so that the control range is eventually brought closer to the target. This means relatively slowly increasing or reducing the level of the controlling factor until control can be achieved.

Further, both diets represent a perturbation in the system that slowly corrects back to its original level. Like throwing a stone in a pond. The ripples eventually subside and things head back to what they were- in this case, a level that is too high.

We know that carbs, be they from the liver (GNG) or diet, raise BG and A1c in people with diabetes who do not have enough (or do not respond properly to) insulin. The amount of carbohydrate is the controlling parameter for BG and A1c. It is straightforward that a solution is to reduce carbs permanently- but by how much? For me, the LCHF result shows that even if we drop dietary intake to a minimum, the target would still not be reached quickly due to their production by the liver (from GNG).

So a very apt control analogy is a sink with a small inflow of water from the bottom (GNG), a drain draining away by a controllable flow (insulin action and exercise), and a tap with the ability to put in a variable inflow which by eating carbs could be continuous if spread into small meals, large and rapid if a lot of carbs (say sugar) is consumed or minimised if restricted.

Now if we want to keep the sink at a certain level (say half way) we can exercise to drop BG and eat fewer carbs to lower the level. If we leave the tap running at a rate that exceeds the draining rate or suddenly empty a large bucket of water into it, the sink fills and we will now be permanently above the level we want. This is what we see with conventional and vegan diabetes management in the study. In this situation, it is common sense to turn off the tap- carbohydrate restriction. 200 to 300g of carbohydrates per day is the problem in this control system.

Exercise Helps but Diet Rules

Exercise is a help but consider that the average person must run about 7 km to ‘burn the carbs off’ from a 500ml serve of coca cola. Even if you do run the 7km, in the time between drinking the drink and completing your run, those carbs are giving you high unhealthy BG. Better just not to eat or drink the carbs in the first place. You cannot outrun a bad diet.

All of the diets have too many carbs for the available and effective insulin to bring down BG to normal metabolic levels and that explains why the target was never reached by any of them.

Reaching the Target

Unlike the study diet, we should expect the LCHF diet might reach the target in the next nine months or so if the present trend continues. The simplest course of action for the LCHF diet would be to keep going and see if the system settles to the desired target. If it does not or if a quicker result is wanted, other interventions could be tried to reduce carbohydrate including longer fasting, increasing exercise, upping metformin dosage or looking for another metabolic option. So now, as a vegan doctor (Dr Joel Kahn) commented to me upon looking at my results on Twitter, maybe slow and steady wins the race? That might well be the first of his advice I have ever taken.

Am I a Special Case?

At this point, you may be wondering if carbohydrate restriction might help your diabetes or am I a one off? Let us explore that. My results prior to carbohydrate restriction were consistent with the conventional diet people from the study. The best HbA1c I saw was 7.3% and as you can see below, carbohydrate restriction was the difference beginning around month 31.

HbA1c graph — My results prior to low carb (month 31) were consistent with the study

The value of a case study is that it shows what CAN happen. There are no guarantees, but given similar circumstances to me, yes this can happen for you. Many other people report that it happens for them. In fact, we would expect it to happen from the biochemistry and control theory I have explained. This is even though everyone with diabetes is a little different. It means your mileage may vary.

Biochem is complex. Perhaps the major appeal of LCHF to an engineering mind is that, based upon engineering theory, it makes perfect sense. Dietitians are constrained by a myriad of epidemiological studies which show increased risk of this or that from doing that or the other thing. If you accept that A1c is a measurable proxy for the underlying health issues of diabetes, clarity to focus on the job of controlling A1c occurs and carbohydrate restriction is obvious. Once that is done, focussing on optimising diet within that constraint is the task. This fits nicely with the theory of constraints as a way to tackle complex systems.

LCHF, Vegan or Conventional Diets?

The vegan diet did perform better than the conventional diet in the study but both were a control chart fail. It is however theoretically possible that one of the 49 vegans achieved similar results to me. My result towards the end shows that my A1c was about fifteen standard deviations below the vegan mean. In other words if we assume a normal distribution and there were 100,000,000,000,000,000,000,000,000,000,000,000,000,000 vegans in the study, we could expect about one to have results as good as mine. Unfortunately, there were only 49 vegans in this study. This is a time when an n=1 (me) is statistically significant.

To be clear I am not saying that a vegan diet could not achieve the same result, but it would have to be low in carbohydrate and total energy so a vegan (or any) starvation or fasting diet would probably also work.

If common sense, the engineering theory, my simple Biochem explanation or my results do not explain why a carbohydrate restricted approach is best then read this paper. An excellent (and more complicated) comparison between the Keto (LCHF) and vegan approaches to managing diabetes is available from Marty Kendall’s website. You will also find a lot of other excellent information on nutrition there should you be concerned that restricting carbs may put you at risk of nutritional deficiency.

The Vegan propaganda machine is fond of saying that restricting carbs (the keto diet) masks the problem by addressing the symptoms whereas only the vegan diet ‘cures the disease’. Based upon the study we looked at, it appears to be an untrue claim. I don’t care whether you eat live chickens or just grass to avoid animal harm, the first thing that someone with diabetes should do is minimise their carbohydrate intake. If you must eat some, then not too many and make sure they are ‘complex’ and unrefined.

Dietitian Says ‘No’

So what if you see a dietitian and they try and dissuade you from a carbohydrate restricted approach. They may have the following objections to which I give you some answers:

You need carbs and your diet will lack fibre and vital nutrients from foods you will exclude like whole grains.
Answer: Some fats and proteins are essential but carbs are not. Even if you could have zero carbs in your diet, your body makes them (via GNG). If fibre is of concern then eat more low carb vegetables. Vital nutrients? See Marty Kendall’s website. If a dietitian can’t give you a healthy carb restricted eating plan, time to walk!
It helps some people but people can’t stick to it in the long-term. We also don’t know how safe it is in the long term.
Answer: Well what if a person it can help is me? Shouldn’t I try it? Looking at the conventional and vegan diets in the study, adherence was also less than 50%. Adherence is a matter for any way of eating and it is up to you. You don’t have to be a statistic. Finally, what does the long-term look like if your A1c stays at ~6, 7 or 8% and above? The risks of a high A1c are very well known. If LCHF is a devil, it is the devil you want to know.
Keto? Low Carb? Control charts? [Insert other doubt raised here]? Do they have any evidence of success from a study in a peer reviewed journal? My clients have excellent success on [insert a diet/ program here] instead.
Answer: Please give me evidence of a study showing [insert their diet/ program] can achieve an A1c approaching 5.1%. Please give me evidence of the success rate of your clients achieving a sub 5.6% A1c.
On LCHF/ keto you are limited. Studies show that eating [insert food of concern] or not eating [insert dietitian ‘superfood’] will make you die sooner.
Answer: Have you ever seen someone on dialysis or with a diabetic foot? It is your job to give me a diet for normal blood glucose, then we can optimise it for other concerns. Do your friggin’ job and shelve your dogma.

The system is failing all of us. More of us are getting obese and diabetic following the standard way of doing things. I developed diabetes on a near exemplary low-fat diet. I can only encourage you to be a robust health consumer. You should not assume that in the face of the diabetes epidemic that has grown under national eating guidelines and dietetic advice, that the experts have it right. Diabetes takes no prisoners and you shouldn’t compromise your outcome just to be nice to a health professional.

Time for Dr Google?

Dietitian’s organisations lampoon ‘Dr Google’ just like clothing retailers said people would never buy clothing online. Honestly though, if you are seeing a dietitian who is not on board with carb restriction for diabetes, you are wasting your precious time and health.

If you can’t get proper help from a local professional then there are sites like dietdoctor.com, forums like the ketogenic forums and facebook groups like type 2 diabetes straight talk or type one grit. If you are in the US, Virta’s service could be a good choice. Any of these would be preferable to a low carb inexperienced dietitian!

If you DIY then be conscious that some medications that you may be on (notably sulphonylureas and insulin) can be very dangerous to take if you suddenly reduce your dietary carbohydrate. If trying this, you should consult your doctor to clear or adjust your medications appropriately.

Diabetes: A Tale to my Daughter of Lions and Sheep

My Daughter’s Angst

I want to tell you a true story about my diabetes and it is also about lions and sheep.

Recently I rolled my ankle while exercising and as a result, I had a sore foot. I was hobbling around at home and my daughter noticed. She didn’t say anything but a few days later my wife relayed a conversation that she had with another mother from my daughter’s school about my diabetes. That mother was a nurse.

You see my daughter had been picked up from school by the nurse with her daughter. During the car ride, my daughter had said that I had diabetes. My daughter was really worried that my foot was going to be amputated because that is what happens to people with diabetes. The mother, very concerned, proceeded to tell my wife about possible treatments for diabetic feet.

What Would you Say About Diabetes Complications?

Do you have diabetes? What would you say to your daughter or loved one? I’ll tell you what I told her. I hope it is useful for you if you are in a similar situation.

“Firstly,”, as I explained to my daughter. “you need to be aware that retinopathy is diabetic blindness, neuropathy is diabetic nerve disease (a precursor to diabetic amputation) and nephropathy is diabetic kidney disease that usually leads to dialysis.”

“Now a measure of your diabetes severity is called HbA1c or A1c for short. Your A1c is a measure of the sugar in your blood cells. This is useful because your blood cells are renewed every three months so you kind of get an average of the sugar level in your blood over that time.”

A Dirty Little Secret

“Below 5.8% you are normal, and above that, you have pre-diabetes until 6.5% when you have full diabetes. Diabetes organisations tell us to aim for an A1c of between 6.5% to 7.0% but darling there is a dirty little secret there. You see eating carbohydrates (as they recommend) it is hard to get that low. If fact many people do not get below 7.0%!”

“Sweetie, have a look at this graph that maps those complications against HbA1c in people with diabetes.”

complications risk diabetes — Patients with type 1 diabetes (n=1,441) Adapted from DCCT. Diabetes 1995;44:968-43.

“You can see that someone with an A1c of 7.0% has almost double the risk of all those complications as someone at 6.0%. Someone wth an A1c of 9.0% has about five times the risk of going blind!”

My Diabetes Results

“But you said that most people struggle to hit 7.0% where they double their risk” she said: “Daddy, what is your A1c?”

I showed her my test results. “Well, when I was taking 3 different diabetes medications my A1c was 9.0%, but when I restricted carbohydrates (LCHF diet), my A1c dropped to 6.0% while taking no medications. That took three months. Now my A1c is 5.8% and my risk is essentially the same as someone without diabetes.”

The nice ending to this story is that now my daughter’s mind is at ease AND she thinks her daddy is a ‘lion’ for beating diabetes complications.

But I am not an animal superhero. This kind of result has been repeated by many people. It is a result based on science and results like mine must, therefore, be repeated by others.

So if you have had this awkward conversation with your son, your daughter, your wife, husband, lover or another dear relative or friend, consider backing up your assurances that you will be all right by taking control of your health. Restrict your dietary carbohydrates.

Maybe you have denial and uncontrolled diabetes and haven’t told anyone close to you. If you have not had this conversation, then still take control of your diabetes and nix your chances of complications so you can have a positive experience like I did. Better than having instead to try and explain your complications to close ones in the hospital.

Be a Lion, not a Sheep

Dietetic and diabetes associations do not want you to know this information. They have tried to silence the people that are telling you and expect you to use their services like helpless sheep. Thank God they cannot stop me telling my daughter the truth nor telling you this true story.

Consider that:

The Association of Dietitians from South Africa (ADSA) complained against Prof. Tim Noakes and continue to ignore the evidence that he presented in pursuing his comprehensive acquittal. It showed that the LCHF diet was beneficial to health.
Dietitians complained against Orthopaedic Surgeon Dr Gary Fettke to silence him against giving this advice to patients. How despicable to ask him to keep quiet when he can prevent amputation by diet.
The Dietitians Association of Australia (DAA) deregistered dietitian Jennifer Elliott after another dietitian complained a patient was confused by her low carb advice and they reinforced their advice that results in higher risk of diabetic complications.
The DAA complained against Carynn Zinn, another low carb dietitian in New Zealand where they had no authority nor any reasonable business to do so.

Why is this being Suppressed?

Low carb is actually quite simple and its safe. On one level its just “give me a plate of healthy meat and vegetables for dinner (and hold the potatoes)” but the organisations act like you will eat rat poison.

I do not believe in conspiracy theories- but business is business. Businesses love sheep that just keep paying money for their products. As they are profitable, they have money for marketing to keep everyone buying. Marketing can pay for favourable research studies and it can sponsor dietitian’s conferences. It is worth spending marketing money to keep revenue streams going and growing. That is completely normal.

LCHF means you eat a lot less processed food (like breakfast cereals) from the food industries that sponsors dietetic associations. It appears dietetics associations are happy to ignore science and promote bad and unscientific advice from their members because it keeps you going back with a chronic condition or when their advice fails and you regain weight or worsen.

Consider too that the amount of diabetes medicine you need is almost proportional to the carbohydrates you eat. I ate next to no carbohydrates and went to no medications. You will need less medication if you restrict your carbs- naturally if you do plan to reduce medications then talk to your doctor first. Any reduction benefits your health and wallet but is not good for pharmaceutical companies.

Be a lion, not a sheep, and if you are still not sure I leave you with part of the testimony by Tim Noakes that these organisations do not want you to see. If this does not convince you there are 80 more short videos that the dietitians pretend to ignore that you can watch.

Whether you have type one diabetes and follow Dr Bernstein’s low carb diet or type two diabetes, if you do take this journey I know you will almost certainly have similar results. Do tell me and pay it forward by telling others, but do me a favour and don’t tell my daughter.

You see it’s nice for a daddy to be a lion to his little girl for more than just one day.

Joseph Finau: A Kiwi Tongan Being Like Daphnis

Australia’s Indigenous Health Woes

The official statistics I have quoted on indigenous health related to diabesity are appalling. Anecdotally too, there are horrific case examples.

We looked at the nonsensical state of innovation in diabetes and diet. In a situation analogous to the slowness to accept the cure for scurvy, we have seen forces that appear to be holding back effective dietary solutions for indigenous health. Those solutions, based on a traditional diet, were demonstrated back in the 1980s.

The situation looks bleak, but the low-carbohydrate movement has always focussed on grassroots solutions. That is a good strategy. You see the stakeholders who have the most to gain are people whose health is improved. The problem with low carb is that almost everyone else has something to lose. That is particularly the case for the food and pharmaceutical industries who benefit from the status quo. If you are in government and reading this, I have a message. It is incredibly short-sighted not to openly understand whether there are the disempowered stakeholders you should put first. This is an ancient problem for bureaucracy. You need to be counter-intuitive and anthropological. But we are getting deep. The efficient management of innovation by the government is a topic for another post.

Be Like Daphnis

The good news is that change is happening at the grassroots. I came across this Internet meme about Daphnis. It is one of the smaller moons of Saturn and the small ripples it makes in the rings of its much larger neighbour, and it seems appropriate to represent the change we can individually make. I think it is also very apt for this post.

We examined the success of Joy Aghogho in Nigeria. Dr Jay Wortman has done fantastic work with the First Nations peoples of Canada (see his comment in a previous post). Island nations like Vanuatu are going back to traditional foods although one wonders if they have the science completely right.

Joseph Finau: A Kiwi Tongan

I want to focus on the efforts of one individual in New Zealand who is making a difference. Joseph Finau commented on one of my posts, and I think it is worth considering his recent journey.

Joseph is a single dad from Auckland, New Zealand who has a remarkable story of battling diabesity and weathering personal tragedy. Losing 100KG (220 lb) is something entirely amazing but moving beyond that I want to celebrate his success in innovating within his community.

According to the 2013 NZ census, about 60,000 people of Tongan descent live in New Zealand. Most live in the North Island in and around Auckland. Like many Pacific peoples, and in common with the Aboriginal and Torres Strait Islanders, Tongans have suffered from diabesity in the transition from a hunter-gatherer diet and lifestyle to a Western diet and lifestyle. For their diet, diabesity is commonly blamed on the eating of turkey tails, lamb flaps and corned beef. Joseph has a different point of view- one born from the perspective of his success.

I believe that going back to the way our ancestors ate is the only way to cure ourselves from this western disease (Diabetes). for the last 3 years I’ve been eating Island foods mixed in with Western foods. example: Taro leaves & coconut cream & corned beef. Tongans loves corned beef but told it’s no good. the thing is? CORNBEEF has NO CARBOHYDRATES or SUGAR which means it’s low carb.

Joseph has adapted the Western foods Tongan’s love with some traditional food (less the starchy staples) to make Tongan and Pacific island dishes the low-carb way. That is also what the Nigerians have done and it is also what Western low-carbers have done. Corned beef cooked with cabbage in coconut cream and raw fish (AKA ceviche or kokoda) are but two dishes. Joseph has addressed one of the complaints, that low carb is too expensive, by also thinking about the economics for large families who need to be fed on a budget.

Is Low Carb Too Expensive?

The economics of low carb are an interesting topic perhaps for a future post. Let us just say here that the current criticism that low carb is expensive has some validity. It is also true that economies of scale have not yet kicked into the food supply. For sure there will be winners and losers. We only need to look at what has happened to the cost of solar power as economies of scale kicked in. A technology that was always a great idea but was uneconomic is now economic.

Data from the Solar Energy Industries Association and GTM Research show the inverse relationship between scale and cost. CREDIT: SEIA.org

However, for the moment Joseph does have solutions that work for him and his community on a budget. As he shows, it doesn’t have to be about grass fed steak, tinned corned beef (which Tongans already eat) is fine.

LOW CARBZ 4 STARTERS & BIG FAMILIES. (Food is medicine)

Joseph has a Facebook group to reach out to people in his community and around the world. He runs cooking workshops, and his group has a procession of recipes from the one thousand or so members.

Kiwi Tongan Cooking — Joseph Finau shows how to cook LCHF Tongan style

Now one thousand members may be small compared to the 340,000 now in the Ketogenic Lifestyle (Nigerian) group, but with 190,000,000 Nigerians and only 170,000 Tongans and Kiwi Tongans, it is actually quite significant.

What are the lessons for Australia?

Many people have long regarded Tongan diabesity as an intractable problem. Joseph is proving them wrong.

It seems that low-carb can be adapted to almost any cuisine and budget. By analysis of the Nyungar diet and by looking at the work of Prof. O’Dea and (most importantly) consulting with the communities, we should be able to adapt Western food to be closer to the macronutrients that Aboriginal and Torres Strait Islanders became metabolically used to for 30,000 to 50,000 years. It should be possible to make it affordable, available, and it should be more culturally appropriate than the food choices available today.

I am not saying it would be easy. I hesitate to suggest solutions for a people who have had plenty of ‘advice’ from my kind in the past. Social issues are always complex. Any solution must come from their grassroots. We need some champions like Joseph to lead the way to say eating needs to be different. Staple ‘modern’ bush tucker needs to be redefined and delineated from a preference for McDonalds or KFC. Awareness needs to be built about traditional diet and the reasons that fats and sugars are sought after, but need not be consumed in excess. That needs to be internalised. If it is hard for urban dwellers to avoid fast food, then the other side of the coin is poor access to healthy food in remote communities.

In the end, it will be a personal choice. However, if people and communities don’t have knowledge of this option, how can they choose a traditionally oriented diet for optimum health?

‘Blind Freddy’ can see that the existing approach is not working. It doesn’t work for the indigenous people of the world, and it isn’t working for us. We need different thinking.

Is a ‘Sugar Tax’ a Solution?

A sugar tax might provide revenue for some change while food supply economics normalise. If we are to have a sugar tax, why not apply it to tax the majority of unhealthy eating Australians to subsidise the food supply of those who may struggle to afford healthy food because of their socioeconomic or geographic disadvantage? Focus the funds on innovation to change ingrained food habits. This would be likely to normalise when the economics of the food supply and demand and supply settle down anyway.

No-one is arguing any more against sugar being unhealthy (apart from the food lobby). Before taxing other ‘unhealthy’ foods, the science needs to be settled.

It is in the nature of researchers to always call for more research funding. Frankly, when you see misguided research that appears to be being undertaken into diabesity, there are much better uses for the money. I am neither anti-research nor anti-academic, but funding should be judicious and focussed on settling the science for starters.

What are the lessons for NZ?

My Anzac cousins, you chose not to federate with us, and I get that. The last thing you need is some Aussie blogger telling you what to do! Joseph is doing fine, and you have other fantastic people in the low-carb community, but I have to question:

Why on Earth do your bureaucrats and food policy people follow Australia when we think that our dietary guidelines and institutions are dumb and broken?

It perhaps says a lot about the power of trans-Tasman economics over trans-Tasman rivalry, and there is probably a PhD thesis somewhere in that.

I think it is time to assert some of that famous independent Kiwi thinking. Otherwise, pretty soon the change will be over in Australia, and we will claim that Prof. Grant (Schofield) was really an Aussie researcher- just like Split Enz was an Aussie rock band.

Keep Going Joseph

My message to Joseph is simple. You may not have 340,000 group members on facebook but you are like Daphnis, and you are making waves at the grass-roots and leading by example.

You are not half the man you used to be, but twice the man most of us will ever be.

“Kai mate”, my Kiwi Tongan friend, and may that eating be low carb for a long and healthy life.

Prof. Andrikopoulos: The Sir John Pringle of Australian Diabetes?

A Paleo Solution?

In our last post, we saw that Paleo dietary solutions were researched and shown useful for diabetes in Aboriginals in the 1980s. Diabetes and other chronic disease were obviously caused by a western diet and lifestyle, and yet the recommendation to Aboriginal and Torres Strait Islanders was to eat the very same Western diet that was making those chronic diseases prevalent in Western people like me.

Here are the healthy eating charts for Aboriginal and Torres Strait Islanders and the one for all Australians.

Indigenous Healthy Eating Chart not Paleo — Healthy Eating for Indigenous Australians

Australians Healthy Eating not Paleo — Healthy Eating for Australians

Prof. O’Dea’s work showed some forty years ago that we are metabolically different yet these nutrition charts treat us as metabolically equivalent. Prof. O’Dea also revealed that the traditional diet reversed chronic diseases for the First Australians however but for token changes, neither chart reflects a traditional diet. A traditional diet would be around two-thirds meat with few carbohydrates and seasonal fats. It would not have taken too much effort to look at the macro-nutrients of the Nyungar diet or Prof O’Dea’s data and devise a better-suited eating chart. Instead, I am sorry to say; this is like someone drew in a token lizard and kangaroo and substituted and moved some other pictures around. The emergency of diabetes and chronic disease among Aboriginal and Torres Strait Islanders deserves better than this. In fact, as Prof. O’Dea alluded to, we all might be better eating from the same chart reflecting an Australian ‘Paleo’ diet.

A Deeper Mess

When we examine what people diagnosed with diabetes should eat, the recommendation is that they still eat the same as in these charts. All Australians with diabetes should ask themselves something at this point.

If we have used those dietary guidelines as a nation and we have ended up getting fatter and sicker, why will continuing with that advice solve the situation?

The question is profound, but the answer is obvious. Of course, it won’t. Like this country’s obesity and diabetes statistics, your personal statistics will continue to get worse trying to follow that advice. Australia is chronically sick as a nation trying to eat that way, and you are also chronically sick trying to eat that way. Aboriginal and Torres Strait Islanders are even more unwell, and they point the way for all of us.

I must emphasize the word “trying”. You see some people try to explain away the problem by saying that people do not follow the guidelines. They imply that their technical perfection is the only effort needed as if their job was done. Population health demands actual outcomes not theoretically perfect guidelines that people cannot or will not follow.

Where is Innovation?

What has held Prof. O’Dea’s revelations of forty years from a possible practical application? It would be scandalous if this was deliberate as it really would by tantamount to a systematised dietary genocide of the First Australians. We can probably rule that conspiracy theory out though as it is killing us all. How could we arrive at this point where we are all getting sicker trying to follow this advice? This is not a problem of nutrition, and it is not an issue of the science. It is a problem of innovation.

We have already seen in past posts that dietetic organisations like the DAA appear preoccupied with things other than our health (including whole-grain breakfast cereals) and what seems to be dietary dogma. This contributes to the innovation problem.

What about the diabetes research community? While the problems are systemic, innovation can sometimes be held back by an individual at the top who holds views of the status quo. Usually, it is that the existing paradigm and way of thinking is a source of their power. Sometimes there are other reasons. It is instructive to look at the views of those who rule the roost on diabetes advice.

The Australian Diabetes Society

Prof. Sofianos Andrikopoulos is arguably the foremost Australian diabetes researcher being the current CEO and past president of the Australian Diabetes Society (ADS). The ADS vision is: “To be the leading society for research, medical practice and education in diabetes”. They work with Diabetes Australia and the Australian Diabetes Educators Association (among others) who are on the front line to deliver diabetes management in practice. The ADS lists ‘innovation’ as a value.

Organisational Innovation

It takes a certain mindset for organisations and individuals to embrace innovation. In my analysis of companies, the innovative ones have CEO’s that can think differently and embrace with an open mind and build that capability in their organisation. Those organisations have the capability to think of the things that delight the ‘end user’ including things that even the end user never even thought of. They also have the understanding to look for user trends. Users often ‘hack’ a product to make it work better. When they see that ‘hack’ they pick up on that and research it thoroughly to find out why their product or service is being hacked for insight. They don’t discount anecdote or exclaim “N=1!” because that is frequently how invention starts.

Innovation is often mistaken for invention. These are different words with different meanings. Invention is discovery, while the act of innovation is the process of introducing something new. One need not invent to innovate and ego, expertise and the need to be seen as infallible are often the enemies of innovation.

Innovating to Solve Scurvy

I am reminded of the health innovation to use citrus in the British Navy to cure scurvy. There is ample literature on this subject and I don’t propose to redo that work. Here is one reasonable account. My summary:

In the 1700s, the British Navy was facing a battle with a chronic disease called scurvy. In some ‘battles’ it lost most sailors to scurvy than to the troublesome French with whom they were fighting. No matter what they seemed to try, the health of sailors degenerated until they died.
Scurvy is of course due to vitamin C deficiency but this was unknown at the time. Scurvy was seen as a complex problem that was multifactorial and even James Lind (who eventually solved it) “saw scurvy as having many causes, including poor hygiene and discipline“. Most believed that diet was a factor.
Lind undertook ‘medical trials’ to determine the root cause and pioneered the use of citrus juice to prevent scurvy as early as 1753, however authorities did not endorse it.
In the meantime, while citrus juice was still not official policy, “some naval surgeons, however, looked on it as a medicament that they might occasionally provide from their own purse“. No doubt their lack of scurvy was just an anecdote.
Historians attribute a big part of the delay to accept Lind’s work to the personal beliefs of the very eminent Sir John Pringle, who held a differing theory on the cure for scurvy.
It took Pringle’s retirement and death (in 1782) and the appointment of Gilbert Blane as the commissioner of the Sick and Hurt Board, for this simple treatment protocol to be agreed by the Admiralty. That was not until 1795.

The Analogy

What does this have to do with diet and diabetes?

We are facing an epic battle with diabetes as a chronic disease- just like scurvy.
Diabetes is seen to be a complex and multifactorial problem with diet being a major factor- just like scurvy.
O’Dea’s work in the 1980s showed that a Paleo diet, high protein but lower in carbohydrate and fat was a solution for the most sensitive people to this problem (Australian Aboriginals)- just like Lind.
Many of us who have effectively cured our diabetes with that kind of diet are like those lemon juice drinking ship’s surgeons. Some of us are indeed doctors.
So what are the ‘beliefs’ of Prof. Andrikopoulos about the paleo (low carbohydrate) diets and are they holding up acceptance? We can point to two major pieces of work.

The Paleo Mouse Study

In early 2016, Prof. Andrikopoulos published a study of the effect of a paleo diet on mice. His own university wrote a summary of it here. A perusal of his publications shows an extensive list of endocrine-related papers but, unless I am mistaken, no more mainstream diet and nutrition studies until this one.

This study really hit the headlines and caused a media frenzy. I lost count of the news and blog articles that it caused and I spied articles in China, India, Canada and the United Kingdom.

I am not going to analyse this paper in any detail however, many others have found issues with it.

Primarily those issues are:

Mice are not representative of people for dietary research (although they may make good models for endocrine research).
There are plenty of RCTs in humans that show the opposite effect to this study.
This was not a human Paleo diet anyway. Neither by type of food nor by macro composition.
It was not the ancestral (Paleo) diet for a mouse so no wonder it caused health issues.

Mouse Study Fallout

Many critics in the paleo and low-carb high fat (LCHF) community were annoyed by what they saw as a biased attempt to discredit their way of eating and some disparagingly tagged the professor with the nickname “Dr Mouse”.

It certainly left other academics scratching their heads. Prof. Aaron Blaisdell wrote:

Why would the lead author, a scientist of reputable standing in the Australian academe, have been so misled?

Cambridge scholar, Nathan Cofnas, wrote back to the journal the paper was published in to say (among other things):

Mice in the experimental condition were fed something loosely based on a version of the human Paleo diet, which for mice is not Paleo.

An academic peer from New Zealand, Prof. Grant Schofield, seemed annoyed when he wrote:

We think that the way Prof Andrikopoulos presented his results in the media was disgraceful. He can’t be unaware of the human research into LCHF for diabetes and the problems with mouse models. He could easily learn, if he wanted to, about relevant research into the Paleo diet too. Absolutely none of this research supports the claims that he’s making on the basis of his 9 mice.

His claims, despite being based on minimal evidence having very limited relevance. seem designed to disrupt the efforts of those of his colleagues who are using LCHF diets to benefit people suffering from obesity or diabetes.

He and three peers G Henderson, C Crofts, and S Thornley also wrote in their letter to the Journal of Nutrition and Diabetes:

The unfounded conclusions of Lamont et al., and the widespread publicity given to their criticisms of LCHF diets, amount to ‘an unjustifiable interference with a method that is working well’.

It is unclear how this research fits into a systematic endocrinal research program as may be seen in Prof. Andrikopoluos’ other work. Instead, this sudden foray into dietetic research appears to support assertions of interference and a disruptive agenda. I note that at the time that this research was being contemplated and undertaken, Chef Pete Evans and the Paleo diet was very topical. It is possible that Pete Evan’s popular message had somehow upset the Prof. Andrikopoulos and motivated this study to be undertaken. While I applaud academics who involve themselves in topics of controversy (we need more of it), I question the use of these research resources when diabetes is in crisis if that was the motivation. That is, unless the NHMRC is counting media articles instead of citations these days as a KPI.

The MJA Paleo Article

Prof. Andrikopoulos doubled down with a second foray into nutrition when he wrote a journal article for the Medical Journal of Australia that was also not supportive of Paleo diets (low carb) for diabetes in August 2016.

It was also reported widely in the medical media and it was also criticised again– although not as resoundingly as the mouse study. I think it should have been due more criticism.

In the Shadow of CSIRO

It is surprising to realise that when the journal article was written, the CSIRO had already done considerable work on its low carb diet with 93 participants for 24 weeks for diabetes and published in mid-2014 yet that is mentioned nowhere. With his profile in the ADS, that work must have been known to him. About six months after that ‘warning’ that went to doctors through the journal, the CSIRO has published a popular book on the subject on sale to the public. Imagine when patients begin talking about the CSIRO diet and their doctors lack information.

It is all the more surprising when you realise that the mouse study itself was undertaken in the shadow of the CSIRO work. While the diet composition was different (58% vs 80% fat for example) they are similar enough to question why the mouse trial was done at all.

Diabetes Research Leadership?

Prof. Andrikopoulos concluded in his mouse study:

The potential effect of popular weight loss diets needs to be carefully considered with the help of sound evidence before they are recommended for type 2 diabetes.

… and his journal letter:

…. clearly more randomised controlled studies with more patients and for a longer period of time are required to determine whether it has any beneficial effect over other dietary advice.

Prof. Andrikopoulos, as a diabetes research leader through the ADS should be and should have been the driving force to solve these questions. Leadership is not owned, it is given. Unless he has been very busy in the last months solving these important questions of potential dietary diabetes therapies, his leadership position looks diminished.

If indeed, it is as it seems (that these research questions have already been answered) then it would instead appear that his beliefs have been killing the innovation efforts of others.

Back to Our Historical Analogy

What I curiously discovered in writing this blog is that Prof. Andrikopoulos refers to one of Prof. O’Dea’s papers from the 1980s when writing his journal article. Was that reference by Prof. Andrikopoulos to Prof. O’Dea similar to how Pringle may have referred to Lind’s work?

History is indeed repeated by those who do not heed its lessons. If O’Dea is Lind, and Andrikopoulos is Pringle. One speculates who will be the Gilbert Blane who now shows the leadership to bring change and when?

Whether a low-carb paleo diet is 80% fat as in the mouse study or low-fat high protein as in O’Dea’s work, the ADS cannot ignore the low-carb issue any longer. People are getting sicker and dying waiting for innovation. Chronic disease in Aboriginal health is a national shame. It is time for change.

In my next post, I will examine how other indigenous people and groups are tackling their diabesity challenge at the grass roots.

Nyungar Diabetes: Australian Dietary Genocide?

NOTICE

Aboriginal and Torres Strait Islanders to should use caution viewing this post, as it contains images of dead persons. Nothing in this post should be taken as criticising or diminishing the efforts of the Nyungar or Aboriginal and Torres Strait Islander communities in pursuing their health or be construed as criticism of them for an unfortunate situation. The Nyungar have a deep and rich oral culture of which I am not a part. Therefore, I hope to be excused for any error due to the interpretation of things via the written words of mainly white historians. It is worth the risk to be wrong because this issue deserves highlighting and, as always, my comments are open to people to improve the information on this blog.

Nigerian Musings

In my last post, I talked about the phenomenal success of the ketogenic diet in Nigeria where hundreds of thousands of Nigerians were using a Facebook group to solve their obesity, diabetes and PCOS health problems with a ketogenic diet. Then I saw an article on Siberian health problems from carbohydrate consumption and other lifestyle change in Russia. It got me to thinking, how are Aboriginal and Torres Strait Island Australians faring?

A Diabetes Emergency in Aboriginal Australia

It is, unfortunately, no secret that diabetes is out of control for them and this crisis was seen as that many years ago. Even when compared to lower socio-economic Australians the statistics are horrifying. Whereas among other Australians, type 2 diabetes is virtually unknown in people under 25, the rate for Aboriginal Australians is 1.5% for people aged 15 to 24, and 0.5% for children aged 2 to 14! After that, the rates are about four to five times other Australians until age 55+ where 40% have diabetes. In general, Australian Aborigines develop diabetes twenty years earlier than other Australians and are about twice more likely to be hospitalised.

Why is it so bad?

Indigenous peoples in other places like the Arctic and the Pacific Islands experience similar problems with obesity and diabetes. This was blamed on ‘thrifty genetics’ that predisposes them to weight gain.

While the existence of a thrifty gene is now disputed, the common thread is that their hunter-gatherer lifestyle has changed to a Western diet. As concluded from this study, that change results in health problems linked to insulin resistance. The fat deposition is very noticeable in aboriginal people. They tend to put on weight around the middle yet can remain quite lean elsewhere, and this is backed up by the cited study.

There is a predominantly central pattern of fat deposition in both men and women, which is associated with greater insulin resistance and cardiovascular risk than is peripheral fat deposition.

Past Research into Diet

Prof. Kerin O’Dea undertook pioneering work into traditional aboriginal diets, obesity, diabetes and heart disease. In her study from 1988, it was noted that even in underweight subjects still adhering to a more traditional way of life; there was higher fasting insulin and elevated triglycerides (signs of insulin resistance) even though their diet was low fat and comprised of lean meat.

In a book chapter from 1988 “The hunter-gatherer lifestyle of Australian Aborigines: implications for health.” Prof. O’Dea looked precisely at what we could learn from a ‘Paleo’ type diet of aborigines. In summary:

Aboriginals become obese and develop diabetes (along with high blood pressure and heart disease) when they stop eating traditional food.
Before European contact, they were lean and physically fit, and there was no evidence of chronic disease. They were ‘underweight’ with low BMI (13.4 to 19.8 kg/m²) without having signs of malnutrition.
There was a lack of literature and nutritional data on an entirely traditional diet, and so she studied people living mostly traditionally.
One group she studied had “a traditionally oriented diet” with a BMI of ~17kg/m² and exhibited low fasting glucose (3.8±0.4 mmol/L) but still showed other diagnostic signs of insulin resistance.
Referred to her previous seven-week study of a traditionally oriented diet (about 1200 calories). It had two-thirds of calories from meat, 13% from fat, 54% from protein and 33% from carbohydrates when the group were inland where tubers and honey were more plentiful. The carbohydrate quantity dropped to a level estimated at less than 5% when on the coast with protein at about 80% and fat at about 20%. The trial showed a normalisation or improvement of the metabolic factors associated with diabetes.
She concluded that a traditional aboriginal (Paleo) diet could reduce primary diabetes and cardiovascular risk factors in the general population but noted it was unlikely to be popular with nutritionists.

This type of diet is also unusually rich in animal protein and high in cholesterol- characteristics not generally favoured by nutritionists in making recommendations for better health.

Other Research

Prof. O’Dea performed other ground-breaking research regarding diet, diabetes and Australian aboriginals. These included:

A 1980 three-month cross-over study that compared an aboriginal urban diet and traditionally oriented diet (50% protein, <20% carbohydrates, >30% fat) with a Caucasian control group that showed aboriginal people exhibit a stronger insulin response to glucose than Caucasians which was less pronounced after a traditional diet. This was likely to be a major factor in their predisposition to diabetes.
A study in 1982 on the effect of a high protein, seafood based, very low carbohydrate ketogenic diet for two week period. This showed a significant but small improvement. Most other trials of ketogenic diets have proceeded for longer periods as two weeks is about the time required for initial ‘fat adaptation’. It can be wondered what might have been the result had this trial been longer.

The Nyungar

My armchair research is not as ground-breaking, but I do want to add. I decided that I would like to focus this blog on one particular group. The Nyungar (or Noongar) whose lands I dwell upon in South Western Australia. Why? The Nyungar were lean and healthy eating a traditional diet until relatively recently, and much of that diet is well recorded.

It is unknown exactly when the Nyungar came to these lands, but there is evidence dating to at least 30,000 years- or greater than 1,500 generations ago. History records that Europeans did not first settle here until 1826. Along with European settlement came new foodstuffs, disease and farming practices previously unknown to the Nyungar. Flour became especially attractive to them as they had nothing as starchy in their traditional diet. Some of the trouble with settlers was for stealing flour however despite new found foods, the traditional way of eating is said to have existed until the 1960s. Allowing some leeway, it was only three to five generations ago that the Nyungar changed their diet.

Many things changed with the coming of settlers, but I will focus on their food. It is common sense to do so as obesity is roughly 80% metabolism and diet and only 20% exercise and other lifestyle factors. The Nyungar did not run marathons for fun. Like other hunter-gatherers, their activity was low level for long periods and aimed at surviving. If you doubt that common sense, remember that it takes a 6.8km run to burn off a serve of coca cola and takes little effort to drink a few serves. I do not know why people confound themselves with other factors and think that we are obese because people just aren’t moving as they used to. It is a factor, but you cannot outrun a bad diet- contrary to the favoured myth of the fitness industry.

Nyungar Diet Today

So what was their diet like then and what is it like now? Some of the information I am about to present comes from this paper from 2010. It suggests that the current diet is high in fat, sugar, fast food and carbohydrates and that it is given to infants at an early age.

The majority of infants had received ‘fast foods’ by 12 months of age with 56.2% had been given coca cola, 68% lemonade and 78% fried chips.

Unsurprisingly, many are on the same poor Western diet that causes diabesity all around the world. The same one that results from giving advice to the populous to minimise salt, fat, sugar, avoid saturated fat and to eat 45 to 65% of dietary intake from carbs (Australian Dietary Guidelines) and the food industry adjusts its products to match. The diet exacerbated by the fast food industry with its fattening mix of carbohydrates and polyunsaturated seed oils.

Traditional Diet

What was their diet? Well, the account of foods is quite detailed in this paper too. It was a meat based diet rich in meat, offal, but low in green vegetables with some tubers with limited grains, fruit and sugars. The effect of that diet is apparent below.

Traditional aboriginals — Obesity and diabetes were unheard of on a traditional diet. Courtesy Wikimedia Commons

Respectfully, I have not put any pictures here of today’s Aboriginals and Torres Strait Islanders following (as best as they can) the Australian Dietary Guidelines but you can do your own google search. You are likely to find that, along with all Australians, people are not as lean. It is important to remember however that research showed that even lean Aboriginal and Torres Strait Islanders were predisposed to diabetes.

I think it is important that a reader gets some context of the ‘bush tucker’ food available here- especially the carbohydrates. The exceptional skill that the Nyungar had to live on this land is hard to appreciate unless you have spent time here. We do not have natural forests of edible nut trees with an undergrowth of berries. There was no farming, and everything was taken in season leaving enough to replenish naturally. Surviving on meat and fish here is one thing, determining the edible plants among the majority that are toxic belongs to Nyungar knowledge won over millennia that is foreign to me. Let us look more closely at the carbohydrates in their diet. These were said to be from the zamia palm, seeds and nuts (primarily wattle seed), fruits, nectar, honey and tubers.

Sugars: Nectar, Honey and Fruits

Banksia Nyungar Food — Banksia nectar was a Nyungar treat

Nectar from plants like the Banksia was seasonal at the flowering time. The nectar would obviously form a seasonal treat or snack in their diet- much like when Europeans suck on a honeysuckle.

There was no organised cultivation or production of snack products. As you might imagine too, just like these available for all Australians at my local supermarket, such snack treats would not form the mainstay of their diet.

Honey

Honey is a product of the concentration of nectar by bees. Unlike the European bees that arrived with settlers, most Southwest Australian bees are solitary and small. You just don’t get the same prodigious quantities of honey from them. Australia’s honey producing stingless native ‘sugarbag’ bees are not native to South Western Australia.

Fruit

The fruit the Nyungar ate is typified by the native peach or ‘Quandong’. It is the size of an oversized grape and has limited meat. In fact, the ones in this picture are quite luscious compared to ones I have found in the wild. The ones I have seen have very thin flesh and a large nut with an oily kernel eaten roasted. It is a bit like a macadamia with a root beer flavour.

The Quandong has a short season of about a month over Summer in each locale ripening progressively from North to South in range over four months. It is also a small parasitic tree depending on specific compatible host trees, so both the fruit and the tree are not plentiful. The quandong is high in vitamin C but not overly sweet. If you can gather a sufficient quantity (an undertaking of some effort) and then combine with sugar, it makes a pleasant jam. Eaten fresh, the Nyungar would have had a tart treat.

While sugars were undoubtedly sought after, you would defy credibility if you were to maintain that the traditional Nyungar diet had any substantial sugar. It is recorded that the Nyungar collected nectar mixed with water for a sweet drink and also fermented it into an alcoholic drink (called Gep). Without bees to do the work, you can be assured that even when such seasonal pursuits were possible, they were well below the WHO stretch target of 5% of calories from sugar. You can be fairly sure that due to local availability and seasonality, most days would have no sugar intake at all.

Starches: Wattle, Tubers and Zamia

Wattle seed was probably the dominant seed that was eaten. In season it was ground and made into cakes cooked on an open fire and qualifies as the primary Nyungar grain. It would have been typical of the seeds that the Nyungar ate. Nutritionally, it was very high fibre (54%), and with a net carbohydrate content of 10.5%, 20% protein and about 6% fat, it is a very low carbohydrate grain compared to wheat (~70% carbohydrate).

Tubers were the last and probably most significant of the starches, and the Nyungar diet had a varied number. While I can find no nutritional analysis for these plants, it is important to remember that they were opportunistically collected, seasonal and never farmed or selected to improve the size and nutritional content. It is also a factor that tuberous plants tend to be found inland in the forests, and not on the coast.

Zamia: Carbohydrates or Fat?

Unlike other groups in Australia, the zamia palm is said not to have been eaten by the Nyungar for its more starchy seed, but instead for the poisonous oily macrocarpa which was specially treated to make it safe to eat. Contrary to what may have been assumed, to the Nyungar this was valued as a fat and not a carbohydrate source- much like the oil palms of the tropics.

Nyungars were not Vegans

The major part of the Nyungar diet, as written in many sources, was animals, eggs, birds, fish and grubs. As previously linked:

Traditional foods from this region varied but included emu, kangaroo, possum, goanna, fresh water crustaceans (maron and gilgies), bardi grubs from under the bark of eucalyptus trees or in the roots of mallee trees, wild duck, mallee hen eggs taken from the mound where multiple eggs were found and fish for people who lived on the coast permanently or in different seasons. Everything edible on an animal carcass was consumed, including organs such as the liver, kidney, brain and intestines.

It is evident through their preference for eating the oily zamia palm and other accounts of meat eating that they did seek fat although it was also not a high-fat diet. Fat would have been mostly from animal sources, and most wild sources from meat are not as high in fat as the domesticated ones that we now eat.

A Paleo Diet?

Putting this diet into modern terms, it would be pretty close to what people call a ‘Paleo Diet’. No dairy, but with eggs, meat and fish as available with limited vegetable content as could be foraged. Looking at the descriptions of Prof. O’Dea’s work and the descriptions above, most Nyungar would probably be on a high protein (say 40%) medium fat (say 40%) and low carbohydrate (say 20%) diet with inland Nyungar probably eating more tubers for some more carbohydrates than others.

The actual composition would be subject to the seasonal and local availability of the carbohydrate sources like tubers; it would have been at times, a ketogenic diet- particularly if the hunt and forage were insufficient.

With so few carbohydrate and fat rich foods, there is no doubt that the Nyungar would have prized fat and carbohydrate foods as high energy sources. This is likely to be why they took the time and trouble to detoxify oily zamia palm fruits.

The Cause is Apparent

We have looked at some of the past research and taken a look at the likely composition of the Nyungar diet. It should be fairly obvious why the Nyungar would suffer from insulin resistance, obesity and diabetes when fed a Western diet. Even if you disregard the similar opportunistic diet that they ate while migrating to Southwest Australia they have had more than 1,500 generations to adapt to the low carbohydrate, low-fat food in their country. We have given them three to five generations to adjust to a high carbohydrate, high-fat Western diet. The effect of our dietary advice has tripled obesity since the 1970s for all Australia. It even gives us the diabetes epidemic that Australia now faces. No wonder the Nyungar have been so severely affected by it.

I am of Northern European descent. My ancestors have had over one hundred generations to adapt to a higher carbohydrate diet made possible through agriculture, but even that is not long enough. No wonder I developed diabetes in my forties while some Nyungar get it in their twenties. Doesn’t that make perfect sense?

The Australian Dietary Guidelines

Even if the diet that Australians ate was exactly to the Australian Dietary Guidelines (essentially low-fat with 45 to 65% of energy from carbohydrates with multiple meals spread throughout the day), it still is far from their traditional diet of one main meal, low in carbohydrates, after the hunting and foraging were completed.

Now we hit the great conceit. You see with all of our science and technology we have worked out that the ‘perfect’ diet for Australian humanity is expressed in the Australian Dietary Guidelines. The Nyungar and other groups should eat our perfect diet born of science because to do otherwise would be to deny them health. It would be discriminatory to have them follow a different diet.

If I were to espouse their original low-carb, low-fat, high protein diet, people would say: “Yes but in their primitive way of life they died young”. To that, I would say: “That is why we have modern medicine including antibiotics, sterile surgery, vaccinations, pre and ante-natal care, effective drug therapies and more”. Further, as obesity and diabetes were completely unheard of on their traditional diet, no-one would likely die of diabetic complications, suffer diabetic induced cardiovascular disease, diabetic blindness, kidney failure and amputation. Isn’t that what we are seeking to fix?

No one is suggesting that the Nyungar must go back exactly to their traditional diet and lifestyle. There is no reason though why healthy eating of similar composition to their traditional diet cannot be recommended. It is not, though. In fact, the diet that I am on is denied as an option for the Nyungar by Diabetes Australia and Diabetes WA. My diabetes effective low carb healthy fat diet would be pretty close to their traditional diet. It is safe, maintainable and gives me normal blood glucose that means I will avoid diabetic complications.

Most importantly, it has reversed my diabetes.

Calling it Out

No Facebook groups are helping the Nyungar, or other groups achieve low carb weight loss and curing their diabetes as the Nigerian ladies have achieved through self-organisation. Our First Australians are depending on not-for-profits who are failing them.

Advice from Diabetes Australia for Aboriginal and Torres Strait Islander’s with diabetes may include the call to eat more bush tucker, but it is otherwise much the same as for all Australians. In particular, it does not suggest limiting, total carbohydrate. The CSIRO has recently proven this to be effective, and actually, Prof. O’Dea’s studies also showed its efficacy some forty years ago. It seems unfortunate that it was not a favoured message of the nutritionists either now or then.

This issue has to be called out, and so I am doing so. To continue pushing the Australian Dietary Guidelines for people with diabetes, and in particular for the First Australians like the Nyungar, is tantamount to Australian Dietary Genocide. It is making us all, white fella and black fella, very very sick.

My next post will examine this issue further.

Nigeria: Sisters are Doin’ it for Themselves

Our Shame

In Australia, our fat-cat bureaucrats, egghead scientists, over-lobbied politicians, salivating not-for-profit CEOs, conflicted dietitians organisations, greedy pharmaceutical companies and over sweetened food industry CEOs are debating obesity strategy and sugar or health taxes. The government has already dispensed a National Diabetes Strategy that this motley crew put together that wouldn’t even make it onto the fiction best seller’s list, let alone solve the problem, as it fails to contemplate changing dietary recommendations as solutions. Taxing us to tackle obesity? Unfortunately, they take themselves too seriously.

As a health consumer, what do you think? Before you answer, I’ll tell you that you should simply not give a damn (or insert your favourite four letter word here). Sorry for the language but when you realise that other than your statistic, it is not about you. Not one of these is truly advocating for you with your chronic obesity or diabetes. It is all to do with their interests like funding for their members and organisations, research buckets of money or profits. They have forgotten you and the experts are dead. After all, if they actually fix your chronic diabetes or obesity, what would they do with themselves?

Meanwhile, In Nigeria…

A quiet revolution is underway. Let us look at something that really should matter to you much more than the business plans and career advancement of all those types above.

Nigeria’s population is pushing 190 million. The traditional diet is quite high in carbohydrates with palm oil and other fats, and it used to be a sign of affluence to be chubby- but not anymore. It has upwards of five percent of those people with diabetes, many more pre-diabetic and far too many are obese. The obesity rate climbed eight times from 1.3% in 1974 to 10.3% in 2014. Fertility is impacted by PCOS. Yessiree, Nigeria has an insulin resistance problem.

Is Nigeria Lacking Dietetic Advice?

How can this be? Surely most people are not so affluent as to be obese? Nigerians probably have a good deal of plant-based diet as meat is more expensive. They have national dietary guidelines that are just as good as ours. Those guidelines recommend that Nigerians have a rich carbohydrate diet, limit fat and avoid saturated fat. Those guidelines say they should have lots of fruits and vegetables and not eat too much red meat. They have a dietitians association that gives them the same advice as everyone else in the world gets. Perhaps Nigerian Dietitians have the same problem as the DAA in that they have the same fantastic dietary guidelines, but no one follows them. Strangely this is an epic fail in every country, but we keep on doing the same thing and hearing the same excuses.

Perhaps it is all the new sedentary jobs in Nigeria that have caused these health problems? The Internet penetration is at about 52%- approximately 97 million people and about 16 million of those are on Facebook. Of course, to think of Nigeria as a poor, backwards country is not only insulting, it is untrue. There is one key technology statistic they lead in. I noticed that they even beat the United States.

Google Trend

If you search for the term ‘ketogenic’ on Google Trends, you see that Nigeria beats all other places in the world. “It must be some mistake,” you say? It is not. While our societies are nauseatingly debating sugar taxes, how to prevent obesity, coming up with ineffective national diabetes strategies and suppressing low carb for greed under a thin veneer of philanthropy, the ladies of Nigeria are transforming their health and the health of their country.

Now the low-carb deniers are probably going to suggest some tin-foil hat conspiracy. Maybe Prof. Tim Noakes has been commuting North every week spreading his vile message? No. It is a grassroots revolution.

In Nigeria, the low-carb diet is best known under the term ‘ketogenic’ diet, and so it has slipped under the radar compared to terms like Paleo, LCHF and Banting.

Nigeria Ketogenic search trend — Nigeria Ketogenic Diet Rapid Growth

The Google trend search also shows that adoption has been extremely rapid. From a near standing start, it accelerated in about August of last year. It had the usual January bump that we see in diet trends. What is driving this? No surprises folks. It is because it works and the ladies know it.

Ketogenic Lifestyle

One of the largest groups on Facebook is called “Ketogenic Lifestyle”. It started posting its ketogenic information in August of last year when the surge happened. It has about 316,000 members and has grown very fast. What may surprise you is that this group caters to provide support for Nigerian low-carbers. Almost all of the members are Nigerian, and the majority are women. How the three admins manage a Facebook group with over 300,000 people is probably worthy of a separate post (and a gold medal)!

This group was started by Joy Aghogho whom some of the members refer to as “Aunty Joy”. Joy is exactly what they feel every time a sister, infertile in the past from PCOS, announces their pregnancy. The posts are a procession of advice and information and then beautiful ladies. Beautiful and large before, beautiful and healthier after keto. They know the keto diet is a therapeutic diet that can counter the health scourges of their country (diabesity) as well as PCOS and epilepsy. There is not a dietitian in sight. These are ketogenically educated ladies, and they seem to know it better than most Australian APDs!

The Numbers

Let us just run some numbers for the bureaucrats and CEOs who may happen to come across this health consumer’s blog. 316,000 Nigerian Facebook users can actually be doubled when you consider that their partners are probably eating keto too. That is four percent of the Facebook user population. Given that societies like Nigeria have very dynamic and active personal networks radiating from each user, that figure may well be a good proxy for the penetration of the ketogenic diet into Nigeria itself. This figure is significant as the official rate of diabetes in Nigeria is 5%, and the ketogenic diet normalises and reverses type 2 diabetes and offers type 1s normal blood glucose. There is likely to be a great crossover between the obese and diabetic population (10.3% and 5%) and the ketogenic diet population.

The Implications

So here are some questions and implications for various people from the ketogenic health explosion in Nigeria.

For Government Health Ministers and Health Bureaucrats:

Will Nigeria beat diabesity before your country even considers the right move? It looks like you need to get away from the noisy lobbyists and interest groups and investigate what is happening for health in our own Facebook communities.

For Pharma CEOs:

Nigeria is probably not even a blip on your sales figures, but you now have a duty to your shareholders to inform them of the risk from other country populations adopting low carb- particularly at the rate of growth seen in Nigeria.

For Pharma Shareholders:

Along with the Credit Suisse report, time to reassess your long-term investment unless your CEO has communicated a clear strategy to manage dietary change to low carb.

For Diabetes Not-for-profits:

Are you really committed to innovation to improve the lives of people with diabetes? If not then find another job.

For Food and Drink Industry CEOs:

Time to stop resisting with marketing that will damage your future brand. Consider what your products will be in a low carb future and like pharma executives- consider your projections carefully.

For Food and Drink Company Shareholders:

Along with the Credit Suisse report, time to reassess your long-term investment unless your CEO has communicated a clear strategy.

For Dietitians and their Not-for-profits:

Even if you STILL think this is a diet fad, shame on you to force health consumers to fix themselves via Facebook. Ignoring this health revolution is making you irrelevant.

For the higher carb chronic disease sufferer:

Time to try what these smart Nigerian ladies know.

For the researcher:

Plenty of epidemiological data here about the mass-effect of ketogenic diets on weight loss, POCS, Diabetes and health. Time to pull out your head and head to Abuja or talk nicely to Joy.

For the existing low-carber:

See what the low carb community can do.
Keep calm and keto on with our Nigerian sisters!

Health Networking for Chronic Disease

The Usual Channels

We have accepted that your regular networking channels for health may offer some relief, but they won’t offer you anything approaching a cure. For example, If you are looking to reduce your dependency on medications? Avoid any ‘lifestyle information’ that has the seal of approval from pharmaceutical companies.

If you have diabetes and might try to reduce your carbohydrate, Diabetes Australia tells you to eat to the Australian Dietary Guidelines like the rest of the population (45 to 65% of calories from carbohydrates) when it is common sense that pharmaceutical use rises the more carbohydrates you eat. Eli Lilley supports the awards for diabetes educators in Australia and so is it a curious coincidence that their educator gave advice to me to eat more carbs?

We saw that Sanofi has a website to send you to chemists that they have educated to use their product. Dietitians Associations have breakfast manufacturers as partners. They continually tell you not to skip breakfast and to eat whole grains like it is a religion. Despite this, in Australia, your doctor will refer you to dietitians, and the government pays your fee to see them!

Unchain Yourself

You don’t need to chain yourself completely to this mess. Just accept that it is full of possible conflicts and corporate marketing and interests. You would go crazy trying to get to the truth while understanding this is just the chronic health industry that you want to leave behind.

Our quest to get some low carbohydrate dietetic advice looks bleak. Can it really be hard and dangerous to do it yourself? Worse than any danger from a short-term dietary change would be to do it incorrectly, not see any benefit and miss out on future good health.

Health Networking

So the big hint that came out of our PCOS analysis was that we saw in the Facebook comments on the DAA press release that there were Facebook comments from people who were doing low carb and who did not agree with the press release.

However, before we go there it is critical to understand the Macrofour principle:

The experts are dead!

If you don’t get that, then go back and re-read my blog from the beginning. Without that understanding, you may be seduced by all of the rhetoric of the people who have not walked a mile in your shoes. When they say ‘build your health team’ it really means ‘learn how to depend on us’. When they say ‘learn how to manage your disease’, it means ‘learn how to get comfortable with our products and services for life’. There is no conspiracy here. It is all just good business. After all:

There is not profit in healthy people and there is no profit in dead people. The chronically sick are the most profitable.

So as I said before, take the best that system can offer to buy you time, but do not accept that it is your best solution.

Finding the Right Experts

When I say the experts are dead, it doesn’t mean that all experts are useless and all expert knowledge is useless. Quite the contrary. The solution to your problem is likely to be underpinned by science and experts. They are just not the experts that would have you manage your chronic condition until you die. Equally, you need to avoid the snake oil salesmen who dishonestly offer you a product or cure. It seems a difficult road to navigate but there is a solution.

The Internet and Facebook are part of your ‘Health Team’

Social media is social networking. Social media health groups are health networking. If a better solution is being practised somewhere in the world, then somewhere on the internet is a forum or group that is exercising it and sharing the knowledge. You just need to find it.

Start by talking to people. Were they like you? What have they done? What worked and what didn’t work. Remember, your N=1 is not their N=1; but it might be N=2!

Dietitians Examples

Back to getting dietetics advice. A recent change in Australia is the formation of a group of independent dietitians. They were set up to form a register of consultant dietitians who had no other conflicting commercial interests. There are similar organisations of dietitians through Facebook groups. In the very next days, dietitian Matthew O’Neill is running an online seminar on low carb aimed at reconciling mainstream dietetics advice. They may still not be the experts you are looking for, but the reason that I know of these options is through social networking on Facebook, Twitter and the Internet.

In a similar fashion, we saw that Dietitian Franziska Spritzler favours a low-carb approach for PCOS and other ailments. Feng-Yuan Liu had an article written about her on Foodmed.net and Metro Dietetics where she works, understands the therapeutic low carb approach and has better information (based on my analysis) than the DAA for PCOS.

If you have diabetes and need intensive help, then Jennifer Elliott has a program that can be undertaken with doctor support. While being deregistered from the DAA might seem a bad thing, in the opinion of the low carb community on Facebook, she is very competent and knows her stuff. Especially when we have examined the DAA’s poor PCOS press release, it may be that being deregistered from the DAA is actually a badge of competence and innovation.

Of course, if you are in Tasmania, you could probably not go past the Nutrition for Life Team. Started by ‘silenced’ orthopaedic surgeon, Gary Fettke and run by his wife, Belinda. It seems that being deregistered, banned or silenced is almost a pre-requisite for credibility. We may look at that more closely in the future.

The point is that I know about these dietetic resources from networking in the low-carb community.

Where Else?

This is not exhaustive. There are these and many other resources. You can discern the worth of these by using your extended health team and the wisdom of crowds. You need to learn from people who have walked a mile in your shoes and hopefully have achieved a better outcome.

In a coming post, I will collate a list of Facebook groups and other resources for people to examine. These may have dated by the time you read this blog, but others will have taken their place. You will need to find them.

If you have low carb services or run a facebook group or other forum and may not be represented in the channels I may use or want to check that you are included, then please contact me. To be perfectly clear I do not accept payment for mention in my posts and any inclusion is at my complete discretion after having regard for your standing in the low carb community.

Finding Advice for a Very Low Carb Ketogenic Diet

Where Can we Get Advice?

If you have read my previous posts, you may have decided to trial a Very Low Carb Ketogenic Diet. In my last post, I thought I would start to give you some practical advice to achieve that.

Before we start looking at that, I would like to state the Macro Four principles of chronic disease management.

The Experts are Dead!

The experts do not care about N=1 but you do!

And now I introduce the third and probably the most important one.

Find people who have walked a mile in your shoes.

Why do I say this? Well, suppose that there is a cure out there and that people have discovered it. Let us say that cure is effective and people have been quietly taking benefit from it for a while. Let us say that cure has not been given the official anointment in your country or local area but has been widely practised in another- officially or unofficially.

The official channels of your health system may not offer you that cure for decades. However, there would exist a pocket of people quietly benefitting from that cure but because they are probably ‘unofficial’ you may not hear of it. You could perhaps find a group of fellow sufferers and talk to them. Alternatively, lets say you have decided to try a ketogenic diet, find a large group and ask- Has anyone found this has helped condition X? You have little to lose from this approach. It is just talking to people.

Health Networking

Health networking is your surest way to find that is to find a group of fellow sufferers and talk to them.

Seeking advice. Hope or Despair — How will you find advice?

Before we talk about where you may find those people to get some advice, let us talk about the common places that you won’t find those people. After all, your time without relief is time suffering. You want to spot the time wasters.

Not-For-Profit Advice?

You are unlikely to find someone with a advice for a better solution at a self-help group educated by your local, not for profit organisation for your chronic condition. That is because those ‘experts are dead’ and they will offer you conventional therapies that mean that you will remain chronically sick. Their advice may be complementary to a path you choose to take, or they may even discourage you from an alternate solution.

Why would they do that? The reasons are many and varied.

They follow the standard treatment.
You probably won’t find ‘cured’ people there.
Their mission statement probably perpetuates the ‘learned helplessness‘ that you want to leave behind.
That standard treatment might be as preferred by outside interests like the pharmaceutical or food industries.

If that seems strange to you it isn’t. Let me state that I do not believe in ‘conspiracy theories’. On the other hand, there is almost always an explanation for human behaviour however, nonsensical or odd. Most of the time it can be understood by looking at the flow of money.

Earlier, I focussed on PCOS because I expect that by the time many of you read this blog, the example of type 2 diabetes will seem so obvious in retrospect. Then again, maybe not!

Following the Standard Treatment

Nonetheless, here is my experience as someone with type 2 diabetes. I was diagnosed with type 2 diabetes about five years ago. I duly followed what Diabetes Australia recommended. Without repeating some of my earlier blogs, it was a disaster. My health deteriorated.

After some three months on a VLCKD and with greatly normalised blood glucose, I rang up their help line to see what advice they would give. Sure enough, the CREDENTIALED DIABETES EDUCATOR told me to eat more carbohydrates. That would have been a disaster.

You Won’t Find ‘Cured’ People

Me ringing up was an oddity. I am just the kind of contrarian individual who would do that. I have toyed with the idea of going to one of the self-help groups to spread the word but who wants an ugly scene with the group expert? So once someone has found a solution, they won’t frequent those social circles. You need to find the people who have the ‘cure’ and talk with them!

They Mean Well but Teach Learned Helplessness

Chronic disease charities do say they want to end their illness. In the end, they accept donations for a mission and are a corporation in their own right. They probably honestly want to give you help and advice. Take it. Check it. Then discard any notion that is the end of it. Avoid any learned helplessness that may come from depending upon them and seek to do better.

The Influence of Industry

Now we get onto the thorny question of the influence of industry on not-for-profit entities. There are no conspiracy theories on this blog. It is normal corporate behaviour to protect and maximise a revenue stream for shareholders by spending budget to create profits. That is just business. When was the last time you heard a CEO say: “We think there is a better solution than our product. Please use that solution.”? Primarily for the health and pharmaceutical industries, the expenditure to protect a revenue stream comes under the ‘marketing budget’ and the ‘Research and Development’ budget.

Not-for-profit’s too are still corporations. They do not have to look after your health although they may state that they do. It would be rare for a government to legislate that. If a not-for-profit says that they are there to look after your health, it is (in most countries I know of) pure self-regulation. They are more likely to take care of their member’s interests, but they are not even obliged to do that!

Will Your Local Pharmacy (Chemist/ Drug Store) Provide Advice?

You might bump into someone at your local chemist who has a solution but will they talk to you to tell you? So here is a story. I had just gone to the chemist to buy some glucose testing strips after I had ceased my diabetes medication due to going low carb. There was a lady about 70 years old. She was filling her prescription for the diabetes drugs that I had just ceased. I almost spoke to her to tell her that there was another way but then realised that she would probably think I was crazy. I was not her doctor or dietitian. Now I am no shrinking violet, so your chances are not good for that to happen. On the other hand, if you are that person who is told this by some ‘crazy’, maybe you should give it some consideration?

Pharmaceutical Marketing

But there is another reason your chemist may not provide advice. I give you a ‘wonderful’ website to manage your diabetes if you are Australian. Now you have to look hard to the copyright message at the bottom to see that this site is owned by Sanofi- a pharmaceutical company. It is a standard commercial behaviour to protect revenue streams so, while their advice is probably valid to help you manage your diabetes through their medicines, don’t expect to find any therapies to get you off them on this website. Want proof? Have a look for any mention that, with diabetes, you should avoid sugar or reduce carbohydrates.

Also, do not expect to get such advice at the chemists that they point you to. They tell you that they have educated these pharmacists. Education is usually part the marketing budget. So if you want advice on how to manage a lifetime of medications, then those chemists and their pharmaceutical company education will suit you well. Alternatively, if your desire is to eliminate or reduce your dependency on medicines, I would now be asking my pharmacist if they have any pharmaceutical company training in my medication and be aware that may cause bias. I do not know what else the pharmacist receives in this arrangement (if anything), but maybe one of them or Sanofi could tell us in the comments below. Still, that website could be useful to tell you which chemists to avoid.

Does this shock you? Maybe mildly? Well, get used to it health consumers with some dollars to spend. This is normal commercial behaviour. In this blog, we will examine many other examples as we find out how we might find that elusive cure for our chronic disease.

Next, we will consider whether you may get a solution from Dietitians.