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.

control chart
Three diabetes diet options plotted on an engineering control chart

Some points about this control chart in general:

  1. Excellent control would see points close to 5.1% and ideally in the light green zone within one standard deviation (±s).
  2. 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.
  3. 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:

  1. 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!
  2. 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.
  3. 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.
  4. 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.

Yoghurt: Saving Money and Carbs

Low Carb Yoghurt: Tips & Tricks

For a change of pace after a lot of heavy posts,  I thought I would share some money saving tips about yoghurt- inspired by Joseph Finau who is helping people do low carb on a budget.

Some people don’t eat dairy at all on a low carb diet, and many following a paleo lifestyle also do not regard it as paleo. Coconut yoghurt may be an option, but that is a different beast to the milk based yoghurts that I will discuss and it often has gelatine or other thickeners. Unlike dairy milk, coconut milk is also already low carb and sugar is sometimes added to ferment it.

Low carb yoghurt
Yoghurt can be much lower carb than you think

This post is about getting the sugar (lactose) and cost out of dairy yoghurt. Some people are lactose intolerant but can tolerate yoghurt which has reduced lactose. Many others have a high regard for fermented foods like yoghurt in their diet. Yoghurt (and especially Greek yoghurt) can be very expensive. If you do eat dairy, but are put off by its carbs or price, then this post is for you.

Carbs and Cost of Bought Yoghurt

Many commercial yoghurts are high in added sugar and carbs. They may have additives like gelatine or other thickeners. Most of all they are expensive. A one-kilo tub of premium yoghurt can cost $7 to $8. Making your own can make it more carb friendly, even lower in lactose and a lot cheaper.  Would you believe $1 a litre or maybe less? It is pretty easy once you get the hang of it. We never buy made yoghurt, and you will probably not do that either once you learn some tricks. So how do we do it?

Do You Need Yoghurt Maker?

You can make yoghurt in a warm place in a bowl, but a yoghurt maker takes the guesswork out of it. A 1-litre electric yoghurt maker can be picked up on eBay for around $12. I recommend getting a bigger one (1.5 to 2 litre in capacity) if possible.

If you don’t use a yoghurt maker, then an insulating the container like a wide mouthed vacuum flask or wrapping the bowl in a tea towel might be useful. Having somewhere warm to keep it while it ferments (like a warmed oven) is useful. Using a light bulb for heating (as it a chicken incubator) may also be an option. Whatever you do, it is important to keep it below 45C or 113F or the culture may be killed.  If the temperature is lower than 40C or 103F then it may take much longer to ferment.

Do You Need a Starter Culture?

You need milk and some starter, and that is all.  You can use some store bought yoghurt (if it has live cultures) as a starter or you can purchase the culture from a cheese supply store some of these stores sell online and ship the live culture in a cool pack. Here is a google search that you can add your country’s name onto to find a possible online source.  Although more expensive (about $13), once you are a committed yoghurt maker I recommend purchasing the starter because:

  • It gives consistent results. Most cultures are a mix of two or more bacteria. Re-using yoghurt batch after batch may deteriorate the ratio.
  • It is small and stores in the freezer
  • Commercial strains may be chosen for sweetness. You want a high acid/ low lactose variety
  • I only use a tiny amount (about 1/8 teaspoon)
  • You can search for a more acid tolerant starter culture which should give you lower carbs.
  • My last small jar of culture went for more about eight years of yoghurt making! So divide the cost by 300 to 400!

Which starter? There is some technical info here. You can always email the vendor and ask for their most acid tolerant starter or ask for one leaving the lowest lactose.

Instructions

  1. Heat the milk until it is nearly boiling.
  2. While hot, pour into the container you will make the yoghurt.
  3. Allow it to cool to be lukewarm. Use about 1/8 a teaspoon of yoghurt culture or a tablespoon of yoghurt from a commercial yoghurt. If the milk is too hot (>45C / 113F), you will kill the culture and the milk will not ferment.
  4. Allow the milk to ferment for 12 hours (or longer) in a warm place (40 to 45C/ 103 to 113F ).  That is what your yoghurt maker does.
  5. If there is a clear liquid on top, don’t worry, that is normal.  It is whey.
  6. For Greek yoghurt, allow it to strain through a sieve until it is the right consistency.
  7. Store in a container in the fridge adding in low carb sweetener when you use it.

Making Lower Carb Yoghurt

As the lactose is fermented by the bacteria in the culture, it is converted to lactic acid which makes it sour. Commercial yoghurts may shorten the fermentation time to save money or to make a sweeter product. Only 20 to 25% of the sugars are converted. Once they are chilled, further fermentation is very slow. By making your own and fermenting it for longer, you can make sure it is much a lower carb yoghurt. It is suggested to ferment it until the whey (clear liquid) separates which can be as long as 20 hours. The fermentation slows as the acidity rises stopping at about 4 to 5 grams of carbs. This is where a high acid culture can help to reduce carbs further.

Now you have basic yoghurt. If you paid $1 a litre for your milk, you now have a litre of low carb yoghurt for $1. The next trick to go even lower carb is straining.

Straining

Greek yoghurt is yoghurt with some of the whey strained out usually for about 4 to 8 hours.  Labneh is a yoghurt cheese that has substantially all of the whey removed, often using a weight or pressure.  It may have salt, sweetener or herbs and spices added.  By straining yoghurt for longer (1 to 2 days), you get labneh.

You can buy a commercial greek yoghurt strainer, but a colander with filter paper or muslin cloth over a bowl or the sink does an excellent job. If you use a bowl, you can use the whey in other cooking. It is possible to just use a very fine sieve (metal or plastic) if you very carefully spoon the set yoghurt into it using a large spoon and taking care not to disturb the ‘curd’. I prefer this as I don’t like buying filter paper to throw away or washing muslin cloth. If your yoghurt runs through your sieve then your sieve is too big, you didn’t ladle it carefully, or it wasn’t fermented for long enough.

Advantages and Disadvantages of Straining

The benefits of straining are:

  • You lose more of the lactose and other sugars that were not digested by the bacteria as they are soluble and in the whey, so it becomes lower carb even still.
  • You lose the whey which is a protein that some people with diabetes regard as being insulinogenic (stimulates insulin to rise).
  • The yoghurt becomes thicker naturally without adding anything, and this makes it more versatile for use as a dip or cream cheese.
  • The acids are also soluble and disappear with the whey so the yoghurt can be less tart.

The disadvantages of straining are:

  • You lose about a third of the volume of the yoghurt (hence why I recommend a large yoghurt maker).
  • The lower acid may mean it will keep for less time.

On the shorter shelf life, it usually isn’t a problem as you are making it at home you don’t need to factor in time for it to sit in the supermarket waiting to be purchased. Salt is often added to labneh, and this probably extends its shelf life a little. You and your family may find it so yummy that it may also be irrelevant.

What is the Carb Count?

Here are a few commercial yoghurt carb facts.  Standard unsweetened commercial yoghurt may have 8g of carbs however this can halve to about 4g when more fully fermented which is where commercial greek yoghurts and labneh also sit. You should do even better than that. I expect that my home-made Greek yoghurt and labneh approaches 2g. This article has a good overview.

Squeezing Out the Cents

Having squeezed out the carbs, let’s squeeze out the cents. I often make yoghurt with the milk that the supermarket is selling cheap because it is close to the ‘use by’ date. It is fine for that because you pasteurise it and the yoghurt bacteria do an excellent job of acidifying and creating other antibacterial agents that stop other mould and fungi anyway. Making yoghurt is a biological ‘reboot’.

If you don’t want to invest approximately $40 capital in your yoghurt factory, by now you can see that you could get your yoghurt factory to pay for itself.  Make your first few batches without a yoghurt maker and using some leftover yoghurt.  Make it with reduced price milk from the supermarket to save even more. By putting your savings into a piggy bank, a few batches of that pays for your yoghurt maker.  The next few batches pay for some starter which you can even share with a friend if you wish to get going sooner.

After that, you are miles ahead.  It isn’t difficult or time-consuming to make, but you do need to plan ahead.  I often make it overnight, and it is nice to think of billions of bacteria working for you for free while you sleep. It is kind of therapeutic like counting sheep.

Time to Rethink Yoghurt?

If you are like me, you may have dropped yoghurt when you stopped eating horse food (aka cereal). It could be a chance to rethink this naturally fermented food. Make your own to keep it low carb and real. As for uses, there are plenty of yoghurt recipes that you might have been avoiding due to the carbs. How about for dressings, sauces or as a (frozen) dessert? How about a refreshing lassi made with your own low carb yoghurt- great on a hot day. It sure beats coca cola or franken-soft drinks full of chemicals.

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 grass roots 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 your 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!

Can We Get Low Carb Help From Dietitians?

Can We Trust Dietitians?

Not to re-invent the wheel as Foodmed.net did an in-depth series of articles on the Dietitians Association of Australia (DAA). These reports questioned in particular whether food industry sponsorship skewed their advice, whether their spokespeople were in touch and not influenced by industry, how there was likely to be dubious media information from such involvement and how there was apparent suppression of opposing views. The author, Marika Sboros, was not the first investigative journalist to report on the issue of possible industry influence in the DAA. She did not pull punches in suggesting that they engaged in fake news and disclosed that significant amounts of their revenue came from industry sponsorship. The DAA’s only response (that I am aware of) was this statement on their website.

What is the reality?  Can we trust the DAA and its dietitians in general for their advice? It is an important question for health consumers and not just Australian ones.  DAA is part of an international organisation, and they all appear to sing from the same dietary hymn sheet (standards).

In our analysis of the paper behind the DAA press release we discovered that the women with PCOS were part of a self-help charity and were probably following a lower carb approach out of the ‘wisdom of the crowds’. That said it did not appear to be a very low carbohydrate diet being on average 42% carbs by energy. The DAA seemed to recommend increased carbohydrate consumption when we found that there was no evidence for that from the cited study.

In fact, from reviewing the literature and interpreting the evidence, the advice should be that PCOS sufferers would benefit by reducing carbohydrates starting with sugar.

Press Release Review

Now considering the press release analysis, I note that among other things the DAA:

  • Did not make it clear to a largely uninformed public that this was not an intervention study. In other words, there was no experiment to put equally sick subjects a low carbohydrate diet and evaluate their health improvement.  At best it is a small epidemiological study.
  • Did not clearly disclose that the reason for the reduced carbohydrates was likely to be due to self-help information. This made it appear to the health consumer that the lower carbohydrate intake could be causing their problems.  This type of study cannot be used that way, but this would not be known to a health consumer.
  • Recommended the consumption of whole grains which was an untested outcome. Again, for the health consumer who did not read and interpret the full paper, this would be misleading. The study made no reference to whole grains whatsoever.
  • Did not disclose that the reduction in carbohydrates was significantly from a reduction in sugar. Sugar reduction is in line with WHO and Australian Dietary Guidelines, and the PCOS cohort was statistically closer to the WHO target.
  • Did not disclose that neither the PCOS nor healthy women were complying with dietary guidelines or physical exercise recommendations.
  • Made no comment on the relative good health of the PCOS women.

Now the DAA might say that some of this were the author’s responsibility. However, I also note that they managed the peer review and accepted the quality of this paper for publication in their journal, so they also bear that responsibility.

I cannot find a sound evidence-based reason why the DAA would produce such a press release from that paper.

Industry Influence?

In the DAA example, I cannot say that this paper was influenced by the desire to ‘market’ whole grains for the food industry as Marika Sboros’ articles might suggest, but that is one possible reason. Many dietitians work in food manufacturing, and the commercial pressure to maximise profits for shareholders look to be at odds with the consultant dietitian’s advice that consumers need. How does one organisation properly reconcile these very different aims?

Dietitians Association of Australia Spokesperson Margaret Hays
Margaret Hays looking through a collection of cereals after suggesting not to skip breakfast (C) Copyright 9 News

I note that one of the corporate partners of the DAA is the Australian Breakfast Cereal Manufacturer’s Forum. They would have something to gain if more women eat wholegrain cereal for breakfast because they are fearful for their fertility.  It would be scandalous if that were the aim of the DAA in producing this press release.

Other Explanations?

Another possible explanation is that they are incompetent to interpret research and apply an evidence-based approach. If that is the case, it makes it hard to recommend seeing their members (APD dietitians) carte blanche as the DAA is responsible for monitoring their ongoing training and providing information.

Another possible explanation is that they have dogma and dietary beliefs rather than science and have simply used this research to push pre-conceived dietary information on the public. That would also be quite scandalous if it were true.

It could just be an advertisement to drive concerned women, trying to conceive, to see their APD members. The need to see their members indeed featured as a media message.

It could be just due to very poor management of this organisation or even just one dumb mistake.

The circumstances around this paper and press release, coupled with questions that Marika Sboros has raised about the DAA, also call into question the very peer review process of this paper and subsequent use of it as a consumer health message. I am not a nutrition scientist, but to me, it raises questions about the integrity of the DAA’s journal to be free of industry influence. It is one thing for the authors to declare conflicts of interest (and I do not suggest that the authors of this study have any undeclared conflicts); but what about the journal owner (the DAA) itself?

It is speculation because we do not have all the facts, and I don’t think there is much point in speculating further. My comment section is, of course, open to the DAA, its staff, its dietitians or the public to comment. If you are a whistleblower or do not want your comment published, I will also respect that. If we can definitively answer this, I would be happy to update in this or a future post for the many health consumers out there that would be bewildered, like me, about this issue.

Ripple Effects

Whatever the reasons and motivation, unfortunately, among the media to pick this up were the Huffington Post and News. You can see that if you read those articles, you would not find an alternate view. You might take the advice as those news outlets appear to have done no critical analysis of the DAA press release.  Their many female readers may have taken this message to heart.

Dietitians Association Facebook Post
Facebook Post of PCOS Press Release

It also appeared to generate social media activity and some women ‘tagged’ their friends to read this article. Did those friends have extra grainy bread or cereal after reading it?

As a health consumer, I find this unsatisfactory. It does demonstrate how the media ends up reporting health advice that misleads the public. We can partially blame the media for this.  They should have sought alternate views rather than taking a press release and just reporting it and only speaking to the DAA.  However, the journalists apparently relied on the science in a press release from the DAA to be fair, evidence-based and accurate.

The Outcome for PCOS Women

The net effect of the press release is to give the exact opposite advice that they should have. If anything, the message should have been to reduce carbohydrates starting with sugar. The effect could be child-denying for a woman with PCOS trying to conceive and potentially life-threatening. It is horrific to me, and I am appalled that the DAA has not yet corrected this of their own volition. 

I call for this press release to be retracted and for better advice to be given. The DAA should also make efforts to contact every woman who may have read this press release. In fact, in my opinion, it is appropriate for any woman with PCOS who read this to be offered free dietetic sessions with the corrected advice lest it spawns a future class action.

I note though that they tried to diminish Marika Sboros’ work by calling them blog posts and calling her a blogger when she has had a distinguished journalistic career spanning decades.  They also make the point that she is not Australian based with the implication that it diminishes her journalism.  That approach indicates both arrogance and a tendency to run on spin rather than facts. That behaviour is akin to the arrogance of Donald Trump’s handling of Whitehouse reporters. DAA, health consumers, deserve answers, not dietetic spin; but why would you listen to an Australian consumer health blogger like me?

DAA management, if you feel you don’t owe health consumers a public explanation, how about coming clean to your dietitian members? After all, they pay most of your salary. Your training, advice and alleged intimidation of those with new ideas may be exposing them to lawsuits and liability. We can vote by not engaging your members’ services, and they can vote to sack you if your answer to them is unsatisfactory.

Media Manipulation or Setting Journalism Standards?

I note that the DAA gives out a cash and in-kind award for what it regards as good nutrition journalism. The award can be majority decided by the CEO, who presumably approved that PCOS press release, and their media manager who wrote it. Should the award be meaningful when its own press release standards appear to be so poor or if it has an agenda to push particular nutrition dogma rather than evidence-based science? If the journalists who won the award, wrote favourably of nutrition advice that marries with DAA sponsors or favours the DAA’s views, it could be seen as a cash incentive for having promoted its sponsors interests or dietary dogma. While it has sponsors of any kind, it seems a very ethically-sensitive undertaking for the DAA to be doing this.

Lessons from this Case Study

I think you need to make up your own mind about all of this. The bottom line is that, as health consumers, we need to be mindful that organisations can be influenced by many factors. Those factors can be other than for our health. My suggestion is that as health consumers we should boycott not-for-profit organisations that have industry sponsorship or donations. Otherwise, at least have very low regard for their advice.

While the DAA looks to be quite poor about communicating evidence-based nutrition science, it would be unfair to say that all their members or dietitians are useless to give low-carb dietary advice. These are highly trained nutrition specialists. They know more about metabolism than we are likely to. If well trained and of an open mind, they should also be able to learn and grasp new concepts. They should interpret them rather than being mired in their organisation’s dogma or other interests.

There is something we can learn from this if we are looking for help. There was some public outrage at the press release. Some people posted negative Facebook comments. Many of these people appeared to share an alternative view towards low carb. As an idea, perhaps you could try communicating with them to ‘health network’ for a solution.

In my next post, we will look further at how we could perhaps find helpful dietitians and other advice.

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.

  1. They follow the standard treatment.
  2. You probably won’t find ‘cured’ people there.
  3.  Their mission statement probably perpetuates the ‘learned helplessness‘ that you want to leave behind.
  4. 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.

Is a Very Low Carb Ketogenic Diet (VLCKD) Safe?

Reconciling Strange Advice from Dietitians

If you are reading these posts, you will remember that we started this journey because we saw a media release that seemed odd. The Dietitian’s Association of Australia (DAA) recommended that ladies with Poly Cystic Ovarian Syndrome should eat more ‘grainy bread’. We found that advice not to be supported by the evidence and discovered that a Very Low Carbohydrate Ketogenic Diet (VLCKD) might be a solution. If you have come straight to this post, I recommend you read the previous three posts first.

So if the weight of evidence supports lowering our carbohydrate intake, is this going to harm our health and particularly, will it be harmful to undertake a VLCKD?

Revisiting the Evidence from the Studies

Our starting point is the very study that the DAA cited to suggest that ladies with PCOS (who reduced their carbohydrates) were harming their health and chances of fertility.

We note that these ladies only cut their carbohydrates by 5% and this appears to be cut by reducing sugar mostly.  Did that harm their health?

Well, we need to remember that PCOS is a serious disease that can often progress to diabetes.  Sufferers may have worse cardiovascular health.  The case-control study cited by the DAA shows us something kind of interesting.

Despite the PCOS ladies all being sick, there was no significant difference in their health markers except for some of those indicating PCOS!

All of the following were not significantly different from the healthy ladies: Fasting glucose, Fasting insulin, HOMA2-β, HOMA2-IS, HOMA2-IR, All Cardiovascular risk factors, SHBG, DHEA-S and FSH.

By that information, dropping carbohydrates by 5% and increasing saturated fat appears to have done these ladies little harm when compared to the control group.  That is especially the case for cardiovascular risk. We need to be mindful however that a VLCKD cuts carbohydrates much more aggressively.

We have the other studies cited by us that showed insulin resistance markers improved, cardiovascular markers remained insignificantly different or improved, and the ladies lost weight. It does not appear that any of these studies support that lowering carbohydrates has worsened the health of study participants. This was so even when they were following a VLCKD.

Evidence of Danger of a VLCKD

If you google “dangers of a ketogenic diet” you may see some issues raised.

  1. You may have low blood sugars
  2. You may have flu-like symptoms for a few days
  3. Concern over a life-threatening condition called “Diabetic Ketoacidosis” or DKA
  4. Acidosis (a more acidic body chemistry)
  5. Kidney Stones
  6. Thyroid problems
  7. Nutrient Deficiency
  8. Constipation

Should you consider these? Yes, of course, you should. Will all of these apply to you? Almost certainly not. For example, DKA is almost exclusively a concern for type 1 diabetics.  Even then, you are reducing your blood sugar, and this is a condition of high blood sugar.

Should you be concerned that you may have low blood sugar for example? Of course you are as one of the effects you are seeking is precisely this. The health effects of too high blood sugar are well documented.   However, if you are on blood glucose-lowering medicine this may be of concern as some types of medicine (although not metformin which you are likely to be on for PCOS) could cause hypoglycemia (dangerously low blood sugar).

If you are on any medications, obviously you need to discuss this with your doctor and be mindful that this is a therapeutic diet and your medication may need adjustment. For example, if you were on a diet to reduce your blood pressure and it was effective, you would need to adjust medication you were using to lower blood pressure.

Other Information on Risks and Safety

The Diet Doctor website has an extensive array of information about low carb and keto diets and particularly some of the concerns that there may be. I won’t cover those here on my blog because I don’t want to reinvent the wheel.

VLCKD and cycling
Is a VLCKD safer than cycling?

Now if I were to recommend to you to start cycling for your health and give you public advice to do so, I would need to run through all the things that you should consider.  You should respect other traffic, wear a helmet, pump up your tyres to the right pressure, ring your bell to warn pedestrians, wear bright clothing, eye protection from dust and glare, adequate footwear, etc.  Does that mean you should not try cycling for your health? I think you probably get the idea.

Long Term Considerations

I have seen “authorities” (including the DAA) warn that a VLCKD is dangerous because it has not been tested in the long-term. The implication is that you should not try it in the short term for this reason. I find that logic a little strange. It is important to realise that we are not committing to this diet long-term.  A VLCKD is something that we are potentially going to to try for three to six months- about the length of those studies. We could expect that our results may not be too different from the study participants; but if they are, then like all trials we can re-assess from what we have learned.

So to be clear the approach is to do the N=1 trial on ourselves.  If a medical professional monitors us, we will have N=1 results from relevant tests. Assuming that our health improves, we can continue. If there are adverse changes, then we can reassess and look for other reasons why our outcome differed from that expected.

Your N=1 Trial

Now if someone wishes to make headlines of the fact that I am advocating “self-experimentation” they obviously haven’t walked a mile in the shoes of someone with a chronic condition. The alternative is the following process.  We could wait to have:

  1. Experts do all the experiments on hundreds or thousands of people.
  2. The experts write it up.
  3. It accepted by a reputable journal.
  4. That study peer reviewed.
  5. The paper accepted by peers and published.
  6. It further accepted by the research community.  Acceptance may take a very long time- particularly if it is against orthodoxy.
  7. The study converted into treatment protocols.
  8. Bureaucrats anoint the treatment protocol as effective and safe.
  9. Clinicians accept the treatment protocol as effective and safe.
  10. Your doctor now advise you to make the change to stop eating some foods.

You are looking at a process that takes multiple years or decades.  We will probably come back to this in a later post. Now if that is a new drug with potentially toxic side effects I would, in almost all circumstances, want that process to be robust.

Wait or try now?

Standing in your shoes, however:

  1. If you are trying to conceive, your biological clock is running down.
  2. You are probably suffering from side effects and symptoms that are unpleasant.
  3. An unresolved condition like PCOS is likely to progress to more serious health concerns.
  4. We are talking about reducing, avoiding or eliminating certain foods from our diet.  We aren’t looking to take an experimental cancer drug!

What is a significant and risky change for the ‘system’ to recommend to the general population for N=millions is a different decision for N=1.  Is it safe to for millions of people to try a VLCKD? If it were cycling and I recommended it, some people would die as a result of that recommendation. Is it safe for you and is the risk worth the potential benefit?  I think we can both agree that you are capable of making that decision.

It is your decision. Do you take it?

Assuming that you do, then next we will look at some of the practicalities of doing your trial.

The Case for a Low Carbohydrate Diet for PCOS

We are moving through some questions to determine if we should try a Very Low Carbohydrate Ketogenic Diet (VLCKD) to help with PCOS.  If you have not read them, then you should read the previous posts before this one.

In previous posts, we examined the Dietitian’s Association of Australia’s (DAA) press release recommending that ladies with PCOS increase their carbohydrate intake with ‘grainy bread’.  We concluded that the evidence cited by the DAA did not support that recommendation.

The next question we will look at is:

Is there Other Evidence that Supports Lowering Carbohydrate Intake?

Here, with appropriate cautions, we can leverage the work of an expert.  I point you to this post by Franziska Spritzler a dietitian who favours a low-carb approach for PCOS.

To be clear, we should be as sceptical of Franziska as we are of the DAA and need to be of all experts when ‘the experts are dead’.

In summary, she says:

  1. Her opinion is that standard carbohydrate amount, and timing advice for people with diabetes and PCOS is unhelpful.
  2. Women with PCOS are likely to have metabolic problems, type 2 diabetes and cardiovascular disease.
  3. She mentions the VLCKD pilot study that interested us.
  4. She focuses on hyperinsulinemia and insulin resistance (IR) as core problems for PCOS. The previous study and DAA the press release that we examined also noted that.
  5. She puts forward that the usually recommended carbohydrate diets are not helpful for those conditions whereas a low carbohydrate approach is.
  6. A study looking at the best dietary approach (examining six) was inconclusive; however, none of those was a VLCKD.
  7. She is in favour of a very low carb diet to address PCOS.

I don’t feel that it’s enough to simply encourage weight loss without providing guidance on how to do so in a sustainable way that  has been shown to improve IR and insulinemia — i.e., limiting carbs to 50 net grams per day or less.

What is the Common Ground?

But now I recall that the DAA referred paper put forward that saturated fat caused insulin resistance.

So it seems that most dietitians would agree that a diet that addresses hyperinsulinemia and insulin resistance is best for PCOS; however, they differ over whether those conditions cause (or remediate by the removal of) saturated fat or carbohydrates. Also diets for weight loss are recommended.  Now we are getting somewhere! 

The DAA referred paper cites this study to support that saturated fat (expressed here as fat quality) is the villain.  That study concludes:

Most studies (twelve of fifteen) found no effect relating to fat quality on insulin sensitivity. However, multiple study design flaws limit the validity of this conclusion. In contrast, one of the better designed studies found that consumption of a high-saturated-fat diet decreased insulin sensitivity in comparison to a high-monounsaturated-fat diet. We conclude that the role of dietary fat quality on insulin sensitivity in human subjects should be further studied …

It is inconclusive to me from this study that saturated fat causes insulin resistance.  Further, we find this study which found that in laboratory testing, saturated fat did not cause insulin resistance.  It said about that conclusion:

We acknowledge that this does not agree many epidemiological reports supporting the notion that diets high in saturated fats are associated with insulin resistance and an increased prevalence of type 2 diabetes [1].

It appears that saturated fat causing insulin resistance is far from proven.

More Evidence to Lower Carbohydrates for PCOS?

So back to carbohydrate restriction for PCOS and there is this study.

An 8-week low-starch/low-dairy diet resulted in weight loss, improved insulin sensitivity and reduced testosterone in women with PCOS.

I note that this was a low carb diet, but not necessarily low enough to be ketogenic.  It was also not a randomised control trial as there was no control group. Most participants would have been on less than 130 grams of carbohydrates per day. At 79g of fat (19.5g saturated), this is a high fat, high saturated fat diet.

Nonetheless, the results showed improvements in weight, testosterone and insulin sensitivity (insulin resistance) and an improvement in vitamin D levels, blood lipids (triglycerides, VLDL) with no adverse effects to ‘cholesterol’ overall.

Finally, a third study is this study, which might be missed by many because the 15 PCOS participants were in the cohort of sixty people.

Patients with polycystic ovary syndrome lost 14.3%+/-20.3% of TBW (P=.008) … at 24 and 52 weeks, respectively, without adverse effects on serum lipids.

The diet in this study was a ketogenic diet. The results were similar to the last study. They lost weight, reduced fasting insulin and had no adverse effects on their ‘cholesterol’.

I think it is significant enough to comment that anecdotally, women have a hard time losing weight with PCOS yet the experts are unanimous that overweight women with PCOS should lose weight.  These studies all demonstrated weight loss by carbohydrate reduction for women with PCOS was significant and effective.

Decision Time

But at about this time I come back to the point.  Do I cut my carbs or not or do I I wait for the boffins to settle their argument?

Well this is where I invoke another macrofour principle: 

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

In case you are not familiar “N=1” is the retort from an expert to refute an anecdote that someone was cured by doing something. You see they need a lot more evidence than one person before they will agree with or recommend it.  You don’t because you care about your N=1. So at this point, it is simple. You are not getting advice because scientists haven’t solved their arguments in time to advise you now.  You can make this decision for yourself- or it may be years for them to settle their argument. 

corn flake box carbohydrate
Cure please, not cereal

Personally, I am uninterested in scientist’s careers, egos and the various other distractions that could come into it like pharmaceutical profits or that someone wants to sell me a box of cereal.  I just want to get well.

If you have followed a low-fat (and particularly a low saturated fat diet) and your PCOS has not improved enough, then you have already tried the low saturated fat advice.  Did it work for you? If not then your N=1 says to favour the low-carb diet.  Alternatively, if you have been on a low-carb diet for a while and have PCOS, then try cutting saturated fat. 

Finally, if you have followed a high carbohydrate and high saturated fat diet you are either going to have to choose or cut both.  Before we move on to the safety of carb reduction, let us see whether we should lean one way or the other.

Low Carb or Cut Saturated Fat?

I think that the reader can conclude that the weight of evidence presented leans towards reducing carbohydrates, not saturated fat as having a positive effect on PCOS. We couldn’t find anything to suggest that increasing carbohydrates would help.

So despite dietitians being discordant, the weight of evidence leans towards carbohydrate restriction for PCOS.

Further, by looking behind the press release, we found that in particular, some women were reducing sugar.  So, to finish off, here is a recent post from Dr Jason Fung about sugar and insulin resistance.  Dr Fung is a Canadian kidney disease specialist. He advocates low-carb and fasting to help fix insulin resistance and to stop you losing your kidneys to diabetes.

While you read, please consider whether the wisdom of the crowds was present when the PCOS ladies in the DAA referred study chose to cut their sugar. I will prime you with the fact that sugar is the same as sucrose and each sucrose molecule breaks down into a molecule each of glucose and fructose.

Next, we will look at the safety of a VLCKD.

DAA Says Increase Carbohydrates

A Cure for PCOS?

In our previous post, it seemed there might be a dietary treatment for ‘our’ chronic condition of PCOS. The treatment was a Very Low Carbohydrate Ketogenic Diet (VLCKD). That advice lowers carbohydrate intake against the opinion of the ‘expert’ dietitians (DAA). Before we do that, it is prudent to ask a few questions to see if we could use that to aid our condition,  These are:

  1. What is the evidence for raising carbohydrate intake?
  2. Is there other evidence that supports lowering carbohydrate intake?
  3. Is a VLCKD going to be safe?
  4. On balance, is this worth trying (or should I eat more wholegrain bread)?

Let’s tackle these questions over this and the next few posts.

What is the evidence for raising carbohydrate intake?

The Dietitian’s Association of Australia (DAA) cites one study to justify that women should increase (wholegrain) carbohydrate intake.  We can read an abstract of that study at the link below. This DAA published the study in it’s journal ‘Nutrition & Dietetics’ which the DAA says is: “Australia’s leading peer-reviewed journal in its field …”.

Suboptimal dietary intake is associated with cardiometabolic risk factors in women with polycystic ovary syndrome

Let’s take a closer look, but before we start, I will uncouple comments about saturated fat. The focus here is on carbohydrate recommendations.  The reason for that is not to avoid the issue.  Saturated fat is a topic on its own, and you can have a VLCKD that is high in protein or fat. Also, any fat in a VLCKD need not be mostly saturated.

The paper concludes that:

The present study has identified suboptimal dietary patterns in women with PCOS, and highlighted dietary factors associated with cardiometabolic risk factors that warrant monitoring in both lean and obese women with PCOS.

In plain English, the authors found: Ladies with PCOS are not eating to the dietary guidelines. Dietitians should look closely at the diets of women with PCOS regardless of their weight.

How was the Study Conducted?

The study came to that conclusion by comparing the diets of 38 women who had PCOS to 30 women who did not have PCOS (control).  This type of study is a matched case-control study.  The women were matched to be roughly similar in body mass index (how overweight or obese they were). The participants recorded what they ate in a seven-day food diary, and then that was analysed and compared between the two groups.

This is not a randomised control trial (RCT) nor is it a crossover study. It is not designed to test a hypothesis about a low carb diet. It does look at the different diet and health of an average ‘healthy’ group with a sick group.

The DAA appears to have taken this study and indicated an association between the level of carbohydrate in the sick group compared to the control group. The reader might conclude that the healthy group is more healthy because they eat more carbohydrates. The reader might also conclude that the sick group became sick because they eat fewer carbohydrates.  Those would both be wrong conclusions. A problem with using this study in that way is that while there may be an association, the reason for that connection may not be apparent or even investigated. In fact, there may be no reason for the connection at all.

Food diaries are regarded as being better than food questionnaires, but still may not be accurate- especially if the seven day period does not reflect long-term eating patterns.  Some of the problems with associational studies and food diaries are discussed in more detail here.

Key Results

However imperfect food diaries and associational studies may be, though, the paper (not the abstract) is detailed about what the researchers did and what the outcomes were.  The PCOS group had 42% of calories from carbohydrates vs. 47% for the ‘healthy’ subjects. The PCOS women ate significantly less sugar (88 grams per day) than the ‘healthy’ women (114 grams per day). That is about six teaspoons per day. As sugar is a carbohydrate, that difference accounts for almost all (about 95%) of the reduction in carbohydrates!

Analysis of Sugar is Omitted

We can conclude from the study that the PCOS women were eating fewer carbs (according to their diaries), and it appeared that the reduction was mostly by reducing sugar.  Anything outside the seven days of a diary is extrapolation.  It tells us nothing about whether, if the two groups and control increased or decreased carbohydrates (sugar consumption), they got better or worse. It says nothing about the diet that women were on when they developed the condition.

DAA forgets Sugar is not a healthy food
PCOS ladies reduced sugar

The World Health Organisation recommends that a maximum of 10% of daily energy come from free sugars with a target of 5% being desirable. I note that the ‘healthy’ group were getting about 23% of their energy from total sugars compared with about 18% for the PCOS group. The study did not break down the free sugars. However free sugars are a significant proportion of most people’s total sugars. For some reason, the study made no comment whatsoever about the lower total sugar and neither did the DAA.

In the Paper, not in the DAA Press Release

There are some other things that we cannot learn from the DAA press release or abstract that are significant.  We need to read the paper to find out that:

  1. Neither of the two groups was compliant with dietary and physical activity recommendations for health!
  2. Two-thirds of the PCOS sufferers were of healthy weight.
  3. When we compare the ‘sick’ (PCOS) group with the ‘healthy’ group, the PCOS group do exhibit health markers indicating PCOS (as expected). In other health markers (such as cholesterol) they are not significantly different to the ‘healthy’ group. Given the sad progression of PCOS to affect cardiovascular risk, this is an interesting finding.
  4. The PCOS participants came from a PCOS self-help charity, and it was possible that many had lowered their carb (sugar) intake after diagnosis (joining). While the charity does not advocate a low carbohydrate diet, there were articles on their website that discussed low carb diets. This provides the most likely reason for the lower sugar intake in the diet of the PCOS sufferers.

This last point may also actually indicate that some patients have discovered that a low carbohydrate approach works. However, if more moderate carb approach after diagnosis had effectively improved or worsened their condition, then this study was simply not set up to evaluate that.

In the DAA Press Release, not in the Paper

Finally, I note that the DAA mentions the following foods that are suggested as good to eat:  (whole)grain, apples, (grainy) bread, legumes and oats and tells you to avoid: butter, coconut (oil), (fatty) meat, biscuits, cakes and pastries.  None of these was specifically mentioned in the paper, and as far as can be told from reading the paper, it is just as likely that both groups ate or avoided them all.

I think the researchers did perhaps owe us a mention of the sugar differences in their results. However, the extraordinary thing is that the DAA seems to have taken this research and used it to suggest women with PCOS should be eating more carbohydrate by promoting the eating of grains, legumes and bread in particular.

It is my understanding that there is no specific diet guideline for PCOS although dietary plans for weight loss are recommended. I would have thought that the DAA would have highlighted the reduction of sugar that the women practised before advocating people eat more carbohydrate. If the aim was weight loss, then a message about sugar reduction should also help. The WHO targets are probably being exceeded, and dietary guidelines are to limit free sugar. At best, sugar is empty calories.

No Evidence to Increase Carbohydrates

There is no clear evidence that I can find from this study that women with PCOS should be increasing their carbs. There is nothing in this study that showed increasing carbohydrates would improve PCOS symptoms.

Alternatively, this study does indicates there is likely to be a trend or practice for some women with PCOS to lower their carbs.  That seems mostly due to them lowering their sugar intake.

Although it was a little frustrating to have to go beyond the press release, I am glad that we looked into the detail and did not discount lowering our carbohydrate just yet. If anything, it is of curious interest that some women with PCOS are reducing their carbs and sugar intake while the DAA does not appear to think this is a good strategy.  Is this the wisdom of crowds?

In my next blog, we will examine the next question on our list.

Is there other evidence that supports lowering carbohydrate intake for PCOS?

Discordant Dietitians

Horrible Histories

So, if you have read the previous posts in order, you may be ready to take control of your health. Maybe not. You may not be convinced that the experts are dead or you may still be sceptical of me and my posts.  In any case, you are probably wondering what the best course of action is?  How do you decide what to do to take action for your problem? Let’s look at an example so we can understand it in more detail.

My children are fans of the TV show ‘Horrible Histories‘. If you know it you will appreciate that they are fond of their alliterative titles like ‘Terrible Tudors’ or ‘Rotten Royals’.  I think that when we look back on the period from 1970 until 2020, they would say: ‘Discordant Dietitians’. Why do I say that?  Let us take a deep dive into one example where dietitians appear to be not preaching best practice.

Polycystic Ovarian Syndrome (PCOS)

PCOS is a chronic disease.  You can read a few articles about it here.  For a woman it is heartbreaking.  Excessive weight gain, hormonal problems, difficulty conceiving and increased risk of diabetes.   I am male and therefore not a sufferer, but I note that it is related to type 2 diabetes.  You see, like type 2 diabetes, PCOS shares an underlying ‘symptom’ of Insulin Resistance which I believe is likely to be their common heritage.  I have effectively cured my type 2 diabetes by using a low carbohydrate diet.  That is why I was surprised to come across the following press release which appeared to advocate eating more carbohydrates and to avoid the low carbohydrate approach for PCOS that had worked so well for me with type 2 diabetes.

NOTE: Macrofour is in no way affiliated with the Dietitians Association of Australia (DAA)

Taking on PCOS!

Now you may or may not have PCOS.  I suggest that you pretend you do so we can use this as a beginning tutorial on why and how you might take control of your health.

I also recommend that you suspend any belief that this wouldn’t apply in your country.  There are international linkages between most of the dietetics associations, and I think it would be a mistake to assume that this is a purely Australian example.

Let us say you have PCOS and take the advice of the DAA.  You go and see an APD (Registered Dietitian) and, as the press release indicates they put you on a diet inclusive of wholegrains- under the Australian Dietary Guidelines, it would be between 45% and 65% of your recommended daily energy from (wholegrain) complex carbohydrates.

I cannot preclude that it would not make you better. I note that, as a consumer, you could always ask for a money-back guarantee if you adhere to their recommended diet and your PCOS does not resolve. Good luck!

Noting that PCOS is a ‘chronic condition’ we take the ‘Macrofour approach’.  The experts are dead, and all they promise you is a future of chronic disease. So if you have faith in an APD, still see one and do what they say. Equally, if your doctor has put you on medication you would be wise to get the benefit of that and not to vary it without discussion.

Become a PCOS Expert

But the Macrofour way is to become your own expert and do your own independent research. Maybe you ‘google’ and find this academic paper:

Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets

Finally, although we only have preliminary evidence of the positive effects of VLCKD in PCOS,77 there are clear mechanisms that are consistent with the physiological plausibility of such dietary therapy.

Let’s unpack that statement. VLCKD is a Very Low Carbohydrate, Ketogenic Diet.  Fancy talk for a diet that restricts carbohydrates to something less than 20 grams per day.  That compares with the approx. 300 grams per day that the DAA would have you on if you followed the US or Australian Dietary Guidelines.  From the press release, the DAA advises:

Ms Hays also advised women to ignore current health trends, such as shunning carbohydrate-rich grains …

A quick calculation shows that if the VLKCD was the solution, and you were very strict on your other carbs, that would be only one slice of bread for the day (allowing for some sundry other carbohydrates in your diet).  Enough for half a sandwich! I would suggest that you would indeed need to shun grains to try this therapeutic diet. Again I quote from the press release.

Margaret Hays said in food terms, this means women with PCOS are … missing out on a thick slice of grainy bread …

So the DAA says that with PCOS we should eat an extra slice of bread every day because a study showed that women who suffer PCOS weren’t eating enough carbohydrates.  That would not allow me to have a VLCKD.

Is a VLCKD a Solution?

Would this VLCKD work? Maybe we should look for more evidence? We notice that the paper linked to a reference number 77.  Two clicks away we can read that in that (small) study:

There were non-significant decreases in insulin, glucose, testosterone, HgbA1c (sic), triglyceride, and perceived body hair. Two women became pregnant despite previous infertility problems.

Wow!  On the surface, it appears to sound promising. There were only five women at the end of the trial, but two of those became pregnant!  That alone would make me start to wonder. You may not know the significance of the other reductions mentioned, but I think you can appreciate that a reduction in body hair is desirable for any woman- let alone one with PCOS.  Testosterone, glucose, insulin, HbA1c and triglycerides reductions- trust me- that is all good too- especially if you have PCOS! A VLCKD sounds like a ‘cure’, but it is a very small study.

Too Soon to Rejoice

So do we run off and change our diet against all the recommendations of the DAA?  Well, it looks promising, but I would suggest that there are some other things that we should check first.  Foremost among them is whether this VLCKD might be dangerous. Maybe there are some other things we could do to check before we change our whole diet and lifestyle?  After all, the DAA is a not for profit body that says it is interested in the health of Australians at least.  They should have something useful to say for your health.  Shouldn’t we be wary of going against their very clear public advice?

If the ‘experts are dead’ for PCOS can you guess what our next move might be?