What laboratory testing is necessary when you start your weight loss journey on a Ketogenic, Low-Carbohydrate, Paleolithic or any other dietary changes? Why do you need them and what are you looking for? We discuss these questions and others on today’s PeriScope. Lots of questions from around the world to day . . . this one lasted a bit longer than normal . . . 45 minutes to be specific. But it’s a good one because of all of your fantastic questions! You really don’t want to miss this one.
You can see the video below or watch the video combined with the rolling comments here on Katch.me/docmuscles.
A list of the labs that we discussed are listed below:
Fasting insulin with 100 gram 2 or 3 hour glucose tolerance test with insulin assay every hour
CMP
CBC
HbA1c
Leptin
Adiponectin
C-Peptid
NMR Liprofile or Cardio IQ test
Lipid Panel
Urinalysis
Microalbumin
Apo B
C-reactive protein
TSH
Thyroid panel
Thyroid antibodies
AM Cortisol
This list will at least get one started, provide the screening necessary to identify insulin resistance (Diabetes In-Situ), Impaired fasting glucose, diabetes and allow for screening for a number of the less common causes of obesity.
I would highly recommend that you get these through your physician’s office so that appropriate follow up can be completed. These labs will need to be interpreted by your physician, someone who understands and is familiar with various causes of obesity.
I just completed my reading of Dr. Joseph Kraft’s Diabetes Epidemic & You. This text originally printed in 2008 and was re-published in 2011. I am not really sure why I have never seen this book until now, but I could not put it down. I know, I am a real life medical geek. But seriously, you should only read this book if you are concerned about your health in the future. Otherwise, don’t read it.
For the first time in 15 years, someone has published and validated what I have been seeing clinically in my office throughout my career. Dr. Kraft is a pathologist that began measuring both glucose and insulin levels through a three hour glucose tolerance blood test at the University of Illinois, St. Joseph Hospital in Chicago. This test consists of checking blood sugar and insulin in a fasted state, and then drinking a 100 gram glucose load followed by checking blood sugar and insulin at the 30, 60, 120 and 180 minute marks (a total of three hours).
Dr. Kraft completed and recorded this test over a period of almost 30 years on 14,384 patients between 1972 and 1998. His findings are landmark and both confirm and clarify the results that I have seen and suspected for years.
I am convinced that our problem with treating obesity, diabetes and the diseases of civilization has been that we defined diabetes as a “disease” based on a lab value and a threshold instead of identifying the underlying disease process. We have been treating the symptoms of the late stage of a disease that started 15 to 20 years before it is ever actually diagnosed. Diabetes is defined as two fasting BS >126, any random blood sugar >200, or a HbA1c >6.5%. (Interestingly this “disease” has been a moving target. When I graduated from medical school it was two fasting blood sugars >140 and the test called hemoglobin A1c (HbA1c) that we use today for diagnosis didn’t even exist). The semantics associated with this problem is that many of us recognize that the disease is not actually diabetes. The disease is (as far as we understand it today) insulin resistance or hyperinsulinemia. This is where Dr. Kraft’s data is so useful. Diabetes, as it is defined above, is really the fourth stage of insulin resistance progression over a 15-20 year period and Dr. Kraft’s data presents enormous and very clear evidence to that effect.
When I first entered private practice 15 years ago, I noticed a correlation and a very scary trend that patients would present with symptoms including elevated triglycerides, elevated fasting blood sugar, neuropathy, microalbuminuria, gout, kidney stones, polycystic ovarian disease, coronary artery disease and hypertension that were frequently associated with diabetes 5-15 years before I ever made the diagnosis of diabetes mellitus. I began doing 2 hour glucose tolerance tests with insulin levels and was shocked to find that 80-85% of those people were actually diabetic or very near diabetic in their numbers. The problem with a 2 hour glucose tolerance test, is that if you are diabetic or pre-diabetic, you feel miserable due to the very profound insulin spike that occurs. A few patients actually got quite upset with me for ordering the test, both because of how they felt after the test, and the fact that I was the only physician in town ordering it. So, in an attempt to find an easier way, I found that the use of fasting insulin > 5 nU/dl, triglycerides > 100 mg/dl and small dense LDL particle number > 500 correlated quite closely clinically with those patients that had positive glucose tolerance tests in my office. There is absolutely no data in the literature about the use of this triangulation, but I found it to be consistent clinically.
I was ecstatic to see that Dr. Kraft plowed through 30 years and over 14,000 patients with an unpleasant glucose tolerance test and provided the data that many of us have had to clinically triangulate. (I’m a conservative straight white male, but if Dr. Kraft would have been sitting next to me when I finished the book this afternoon, I was so excited that I probably would have kissed him.)
Insulin resistance or hyperinsulinemia (the over production of insulin between 2-10 times the normal amount after eating carbohydrates) is defined as a “syndrome” not a disease. What Dr. Kraft points out so clearly is that huge spikes in insulin occur at 1-2 hours after ingestion of carbohydrates 15-20 years prior to blood sugar levels falling into the “diabetic range.” He also demonstrates, consistently, the pattern that occurs in the normal non-insulin resistant patient and in each stage of insulin resistance progression.
The information extrapolated from Dr. Kraft’s research give the following stages:
Stages of insulin resistance by 3 hr OGTT extrapolated from “Diabetes Epidemic & You”
From the table above, you can see that the current definition of diabetes is actually the fourth and most prolifically damaging stage of diabetes. From the data gathered in Dr. Kraft’s population, it is apparent that hyperinsulinemia (insulin resistance) is really the underlying disease and that diabetes mellitus type II should be based upon an insulin assay instead of an arbitrary blood sugar number. This would allow us to catch and treat diabetes 10-15 years prior to it’s becoming a problem. In looking at the percentages of these 14,384 patient, Dr. Kraft’s data also implies that 50-85% of people in the US are hyperinsuliemic, or have diabetes mellitus “in-situ” (1). This means that up to 85% of the population in the U.S. is in the early stages of diabetes and is the reason 2050 projections state that 1 in 3 Americans will be diabetic by 2050 (2).
Insulin resistance is a genetically inherited syndrome, and as demonstrated by the data above has a pattern to its progression. It is my professional opinion that this “syndrome” was, and actually is, the protective genetic mechanism that protected groups of people and kept them alive during famine or harsh winter when no other method of food preservation was available. It is most likely what kept the Pima Indians of Arizona, and other similar groups, alive while living for hundreds of years in the arid desert. This syndrome didn’t become an issue among these populations until we introduced them to Bisquick and Beer.
The very fascinating and notably exciting aspect of this whole issue is that insulin resistance is made worse by diet and it is completely treatable with diet. This is where the low carbohydrate diet, and even more effective ketogenic diet or lifestyle becomes the powerful tool available. Simple carbohydrate restriction reverses the insulin spiking and response. In fact, I witness clinical improvement in the insulin resistance in patients in my office over 18-24 months every day. You can get a copy of my Ketogenic Diet here in addition to video based low carbohydrate dietary instruction.
Until we are all on the same page and acknowledge that diabetes is really the fourth stage of progression on the insulin resistance slippery slope, confusion and arguments about treatment approaches will continue to be ineffective in reducing the diseases of civilization.
It is well know that one of the most profound complications of diabetes is damage to the kidney and the very small arteries within the kidney acting as your body’s filtration system. The kidney begins to lose the ability to adequately filter and retain microscopic protein progressively over time. As the blood sugar and insulin levels continually rise over time in the patient with diabetes or pre-diabetes, damage to the delicate filtering system of the kidneys occur. This very common and progressively damaging problem is called “nephropathy.”
Chronic elevated blood sugar and insulin cause the filtering system to become more and more “leaky” and ineffective.
We knew in 1972 that patients with diabetes had thickening of the basement membrane or endothelium of the small tubles within the kidneys. In fact, 98.6% of diabetics tested had thickening of this area of endothelium and tubules also called the renal glomeruli (1). This allows the glomerulus or filtration system of the kidney to become more “leaky” and microscopic protein loss begins to occur through the kidney. This loss of important proteins in the blood is called “albuminuria” or “micro-albuminuria.” It is a flag that further damage of the kidney can and will occur without making significant changes to lower the blood sugar and the insulin. As of today, it is not totally clear how the basement membrane is damaged at the microscopic level, however, there is some evidence that elevated insulin has both a physical and immune type effect that stimulates oxidative stress, atherogenesis, immunoglobulins, as well as the formation advanced glycation end products leading to endothelial wall damage (2).
Recent research reveals that a ketogenic diet effectively repairs and/or completely reverses the albuminuria (3).
Evidence in my office of the significant improvement in micro-albumin can be seen in the one of a number of case studies below:
72 year old male with history of diabetes, diabetic nephropathy already treated with full dose statins, ACE inhibtors, metformin, and Januvia. (Remember, microalbumin should be <30 mg/g)
Date Microalbumin HbA1c
8/12/2010 2264 mg/g 6.4% Started carb restriction <30 g per day.
10/01/2010 1274 mg/g 5.2%
1/08/2011 1198 5.8% Admits to cheating over holidays
12/26/2013 2434 mg/g 6.8% Returned from 2 yr travel-off diet
2/27/2014 399 mg/g 6.3% Restarted carb restriction <20g per day
6/20/2014 190 mg/g 7.0% Traveling – no carb restriction
The patient began following a ketogenic diet in 2010. After improvement he moved out of town for two years and “fell of the wagon.” Upon returning h restarted his carbohydrate diet and was only partially following it. As you can see, he also admitted to some cheating on the carbohydrate restriction over the holidays. In light of this, carbohydrate restriction decreased his albuminuria from 2400 to 97 mg/g within a period of 18 months.
References:
Siperstein MS, Unger RH, Madison LL. “Further Electron Microscopic Studies of Diabetic Microagniopathy.” Early Diabetes: Advances in Metabolic Disorders, sup 1. New York: Academic Press, 1972, p261-271.
Nasr SH, D’Agati VD. “Nodular glomerulosclerosis in the nondiabetic smoker.” J Am Soc Nephrol. 2007;18(7):2032.
Poplawski MM, Mastaitis JW, Isoda F, Grosjean F, Zheng F, Mobbs CV (2011) Reversal of Diabetic Nephropathy by a Ketogenic Diet. PLoS ONE 6(4): e18604. doi:10.1371/journal.pone.0018604
This evening on PeriScope, we talked about the 10 things you can do to stay motivated on your low-carb lifestyle. A number of great questions were asked including:
How much carbohydrate should be restricted?
What labs should you be monitoring regularly?
What’s a normal blood sugar?
Why is Dr. Nally freezing in Denver?
Is fermented food good for you?
Why should you eat pickles and kimchi even when you’re not pregnant?
And, much much more . . . It’s like a college ketogenic course on overdrive . . . for FREE!!!
You can see the PeriScope with the comments rolling in real-time here: katch.me/docmuscles
We had a phone server crash this morning (the wonders of an electronic world we live in!!). If you have been trying to get a hold of the office, we anticipate it to be back up around 11:30 am Arizona Time. I am sorry for any inconvenience this may have caused. Please call back around 11:30 am if you had trouble getting through the phone system.
To the many friends, family and patients who served, spilled their blood and lost their lives in defense of this great nation. In all humility, I thank you!
It is not foolish and wrong to mourn the men and women who have died, but it is so much more important that we thank God that such men and women have lived.
May your day be full of happiness and joy because of the great sacrifice that so many willingly offered.
I am frequently asked about the sweeteners that can be used with a low carbohydrate diet. There are a number of sweeteners available that are used in “LowCarb” pre-processed foods like shakes or bars, or in cooking as alternatives to sugar; however, many of them are not appropriate for use with a true low-carbohydrate/ketogenic diet. You can see and print an article I published about these sweeteners here:
This has to be one of the most amazing demonstrations of gravity on an object that I have ever seen. NASA & the BBC, thanks for sharing . . . impressive.
A number of my patients have asked what I use personally as a protein supplement and whether I use protein shakes. I’ve struggled to find a great tasting protein shake that does not contain any artificial sweeteners (see my article The Skinny On Sweeteners) that raise the insulin levels. Most of the pre-prepared shakes (including the Adkins, EAS, Muscle Milk, and many others) will significantly slow weight loss and knock you out of ketosis due to an insulin response stimulated by drinking them.
My sweet wife just perfected our family’s favorite high fat, low carbohydrate protein shake. Oh, it’s good and it’s filling. You’ll love it and you won’t be hungry for at least 3-4 hours after savoring this sweet taste-bud sensation.
This is a great shake for a mid-meal snack or a quick meal on the go.
Many patients come to my office desiring to loose weight, but complain of no self-control. They feel they cannot loose weight because they don’t have the willpower. Willpower, or self-control, is an elusive and mysterious thing. “If only I had more self-control,” I hear people say, “I could . . . ” exercise regularly, eat right, avoid drugs and alcohol, save for retirement, stop procrastinating, achieve a noble goal, or loose weight. A 2011 American Psychological Association study reveals that almost 30% of those interviewed felt that lack of willpower was the greatest barrier to making a change in any of these areas.
So what is “willpower” or “self-control?” It is the ability to resist short-term temptations in order to fulfill a long-term goal.
I meet and work with people every day who feel they have no willpower. In actuality, will power and self-control are learned behaviors that develop over time. Anyone can have willpower, you just have to understand how willpower in certain areas can be strengthened and what makes it weak. In fact, a 2005 study showed that self-discipline or willpower was more important than IQ in academic successes. This study also found that increased self-discipline lead to less binge eating, higher self-esteem, higher grade point averages, better relationship skills and less alcoholism. Fascinating isn’t it!?
The answer can be found in a quote from Henry P Liddon, “What we do upon some great occasion will probably depend on what we already are; and what we are will be the result of previous years of self-discipline.” This means that willpower or self-control can be learned or improved. How, you ask?
First, you must establish and write down a reason or motivation for change. In addition, that change must fulfill a clear goal. Just wanting to loose weight isn’t good enough. You have to be motivated because of a consequence that arises from the obesity or overweight. And, you “loosing weight” isn’t a clear goal. You must set a weight reduction goal. It has to be clearly written down with your motivational reason. Willpower or self-control cannot begin to form until these two steps occur.
Second, you must begin to monitor your behavior toward that goal. When it comes to weight loss, I ask every one of my patient’s to keep a diet journal. In this journal they are asked to write down every thing they eat and drink. The night before, they are to write down their plan for tomorrow’s meals, then the next evening, they account for their success or failure by journaling on that same page what they actually ate and drank, then after comparing what they did, they plan for tomorrow and journal why they were successful or why they weren’t. It’s the last part that is so powerful, a short 3-5 minutes of self-introspection. Self-introspection is the key to behavioral change. It is the key that allows a person to see their habits and then make very small changes that break bad habits, solidify good habits and strengthens willpower.
Third, willpower is developed over time. It is developed by being accountable to ones-self on very little things every single day. But it MUST be written down. If I planned to eat bacon and eggs for breakfast and I didn’t, why? When I look at my day, I may realize that I went to bed too late to get up early and cook bacon and eggs. So, instead, I ate a yogurt that was in the fridge. I am accountable to myself. If I plan to eat bacon and eggs tomorrow, I must either go to bed earlier, prepare them the night before, or throw out the yogurt . . . so not to be a temptation again. This is written down and I make a very small change tomorrow.
Over time, this self-introspection becomes easier and easier, to the point that you do it sub-consciously. It is this sub-conscious self-introspection and change will be seen by others as self-control or willpower. Just like a working or strengthening a muscle, recording short goals and and accounting for them makes your self-discipline stronger. The self-discipline muscle becomes more powerful. In time, a split second decision not to binge on that piece of cake will be seen as strong willpower by those around you. You’ll recognize that it’s just flexing your self-discipline muscle.
So, my next question to you is . . . where’s your diet journal?
While on the 2014 Low-Carb Cruise a few weeks ago, I had the wonderful pleasure of being interviewed by “N=1 Health‘s” Howard Harkness. We had very nice conversation and discussed a number of topics relating to obesity medicine, weight loss, carbohydrate restriction and some of the history of medicine. Take a look at the interview here on N=1 Health.
As a bariatrician, I think about fat all the time. I guess you could say I have a lot of “fat thoughts.”
I frequently hear patient’s tell me, “Dr. Nally, I’m eating RIGHT, but I’m just NOT losing weight!”
If you’re not losing weight, your not eating correctly. 99% of your weight loss success is related to your diet. We have been poorly misinformed over last 40 years as to what a “correct” diet contains. We’ve been told to follow a low fat diet for the last 40-50 years. However, it is very apparent as patient’s follow a low fat diet that only a small percentage of them have success in weight loss, and the majority actually gains more weight and remains significantly hungry. When you look at the body’s physiology, fat restriction only stimulates increased hunger. The intake of any form of carbohydrate, whether that be simple or complex, stimulates an insulin response. Based on our genetics, that insulin response can be variable. some of us respond normally and others respond with between 2-10 times the normal insulin surge. Insulin is actually the hormone that drives weight loss or weight gain.
You and I will not be able to effectively lose weight until we control the response of insulin, and this can only be done through carbohydrate restriction.
ulated by drinking them.
