Thus obesity results largely from hormonal dysregulation and insulin resistance, through complex processes. It’s not a dysfunction of energy balance. It may be instructive that insulin resistance also “travels with” the hormonal shifts of pregnancy, menopause, and sleeplessness, in similar ways.
THE WORLD IS GROWING IN SIZE…
For most modern humans, as discussed prior, a portion of the sugars and fats we consume is turned into belly fat. Even if the rate of conversion is modest, the effects accumulate over time. The incidence of obesity in the United States has tripled since 1970, and our current generation is projected to be the first to live shorter functional lives than their parents did. And as developing countries around the world catch up economically and culturally with America, their rates of obesity are catching up, too. Fast-food restaurants are everywhere—Cinnabon, McDonald’s, KFC, Cheesecake Factory, and others—all with colorful advertising and modern, fast-food prices and appeal.
Ironically, we see this occurring even in the Middle East, for example, where traditional cuisine is among the healthiest in the world. For centuries, meals there have been prepared from simple and inexpensive ingredients, including marvelous mixes of legumes, spices, meat, and small amounts of whole grains. It’s being replaced by fast food. And as temperatures in the region trend toward the brutally hot, most people take refuge in the comfort of air-conditioning—increasing sedentary behavior and compounding the risk of obesity, diabetes, and heart disease. Similarly, the obesity and prediabetes epidemics are spreading to China, India, and other countries, where healthful traditional diets are being swapped out for junk food that comes at generally lower cost and offers lower nutritive value.
SALT’S NOT AT FAULT
Sugar presents an even greater risk than the other white crystal that we are routinely cautioned against consuming too much of—salt. Sodium is prevalent in our diets, thanks to industrially processed foods, yet these same food products frequently contain added sugars and processed oils as well, which studies have associated even more closely with hypertension and cardiometabolic risk. Salt has been exonerated of the peril once attributed to it, meaning that it’s time we shifted our attention to the real culprit—sugar, the white crystal now of greatest concern. In yet another medical research flip-flop, a diet too low in sodium is now associated with higher risk of cardiometabolic disease.
SIX YEARS A (CEREAL) FREE MAN
I haven’t had a bowl of cereal in six years. I now eat two or three meals daily, always including a good quantity of healthy fat and adequate protein. I am seldom hungry, and enjoy sustained energy throughout the day. My body weight is constant and my key lipid (cholesterol subtype) levels and inflammatory markers (such as hsCRP, an indicator of blood vessel damage) are optimal—far better than they were when I was on the high-carb diet. My HDL (good cholesterol) has doubled, and is now over 100 mg/dl. My coronary artery calcium score—arguably the best marker for any vascular disease—is zero. I even subjected myself to a test that measures telomere length. This novel marker of how our cells’ DNA ages pegs me as a thirty-five-year-old, though I’m fifty-one.
I don’t fear that I might bonk during marathons, and I feel healthier overall. That being said, my twenty years of eating a high-carb diet and the resulting high insulin production (and progressive insulin resistance) has left me now with little more than a trickle of pancreatic function. I have prediabetes and extremely low insulin levels. But by avoiding carbs and living healthfully, I’ve lowered my HGB A1c (a marker of average blood sugar) from 6.3 to 5.5. A small serving of simple carbs sends my sugar to near 200 mg/dl, so I need to restrict carbs for the rest of my life. I’m doing this now, and still running marathons with vigor.
As one individual, I’m a pretty small sample size. But I’ve assisted many runners and nonrunners who have insulin resistance in shifting their diets to low carb, and have seen their key risk markers and health indicators improve, along with their feeling of well-being.
I had a patient whose blood sugar was out of control—persistently over 500 mg/dl—and she had increased her insulin injections to more than 500 units a day. A healthy body requires about 20 to 25 units. But the added insulin was not driving her blood sugar level down. She felt horrible. Incredibly, she was trapped in the regimen of conventional medical treatment that persists today: give such patients even more insulin, to try to overcome the extreme resistance.
My patient hadn’t heard of the alternative: get rid of the sugar (the fire) in her diet, which was driving the elevated sugar in her blood (the smoke). She cut out sugar and began eating healthful and satiating meals, and within three days she had reduced her insulin injections to 40 units (long-acting), once daily. After a week, her sugar levels were near normal, and she is buoyed by the belief that she can be well again. A bit of discipline and hope can go a long way in the long term.
THE BIG FAT LIE
So, what about cholesterol? Books and conferences have been devoted to debating its value and its peril. The perception that high levels of total cholesterol were associated with cardiovascular disease originated in the 1950s, when a high-profile researcher named Ancel Keys drew a flawed correlation between dietary fat and the risk of heart disease, based on partial data from six selected countries. The resulting “diet-heart hypothesis” posited logically, but incorrectly, that dietary fat and cholesterol elevated the levels of blood fat and cholesterol, and therefore led directly to clogging of the arteries.
This hypothesis, in turn, informed the creation of the ill-conceived 1977 Dietary Goals for the United States, which birthed the first version of the Dietary Guidelines for Americans. These were illustrated by the ubiquitous “Food Pyramid,” which succeeded at convincing Americans to consume less fat and more carbohydrate. This was replaced in 2011 by “My Plate,” a simpler graphic that encouraged a similar mistaken balance of foods. (See more on this in the next chapter.)
Dietary and blood cholesterol, it turns out, are not the bad guys at the crime scene of inflamed arteries. They are merely suspicious-looking bystanders.
Saturated fats in the blood come from two sources: the saturated fat that you eat (odd-chain fats), and the saturated fat produced in the liver (even-chain fats). Metabolically, these two categories of fats behave quite differently. The liver-generated fats are the most dangerous, because they end up as belly fat (visceral fat, or white fat). What Ancel Keys and generations of health professionals were unaware of, or disregarded, was that this liver-generated fat doesn’t originate from fat that we ingest. It is produced by the liver when we take in carbohydrates, fructose, and alcohol. It is this fat—not the ingested, dietary kind—that increases risk for diabetes and heart attacks.
I believe that our adherence, whether inadvertent or intentional, to the government’s guidelines is to blame for the fact that we have an obese nation—one that has grown fatter and sicker with each generation since 1980.
RETHINKING THE OTHER “C” WORD
Cholesterol, a lipid molecule, is present in every cell membrane of the body, and is essential for almost every endocrine function we have. It is insoluble in water, so it must be transported in a lipoprotein. This is where the terms HDL (high-density lipoprotein) and LDL (low-density lipoprotein) come in.
In popular usage, HDL has been described as “good” cholesterol (because, theoretically, it scavenges up plaque) and LDL as “bad” cholesterol (because it’s thought to clog arteries). But this distinction is misleading. Indeed, many of those who have suffered a first heart attack have LDL levels in the “safe” range, and many of those with LDL levels in the “unsafe” range will never have a heart attack. When looked at in isolation (outside rare genetic predispositions), a high LDL cholesterol level alone carries little risk.
For a moment, set aside LDL. The dance between carbohydrates and the liver affects other elements of cholesterol levels, too. In a standard lipid panel there’s one blood test
ratio in particular that can reasonably tell if you are at risk for prediabetes, diabetes, or a heart attack. The triglyceride ratio (TG/HDL) is calculated by dividing your triglyceride level (TG) by your HDL level. This should be close to or less than 1. A ratio creeping toward 4 or 5 portends bad news. The total cholesterol to HDL ratio is also useful with a target of less than 3. I see far too many panels with ratios that are 4 and above.
What causes a poor TG/HDL ratio? When blood sugar (and corresponding triglyceride) levels rise, the body tries to “clean up” the abundance of triglycerides by using HDL cholesterol (the “good” kind) to carry the triglycerides back to the liver, where they came from. Thus a low HDL level combined with a high TG reading indicates liver overdrive, and is a clear early sign of carbohydrate intolerance and insulin resistance.
The LDL story is complex and not fully understood. The lipoprotein is the vehicle for the cholesterol (the passengers). It’s really this lipoprotein vehicle that we care about, as the passengers are merely along for the ride.
There are many varieties of lipoproteins, across a spectrum. The LDL-C that your doctor orders and interprets is a calculated number (thus “C”) from at least five unique LDLs; it provides an aggregated estimate of the LDL cholesterol, without regard to the number and size of particles.
The LDL particle size is what makes the difference: a small number of large particles is good. But an abundance of small-sized particles correlates with insulin resistance, low HDL, and high triglycerides. Small-sized LDL particles are prone to oxidation and can easily penetrate the endothelial lining of our blood vessels, amplifying inflammation. When it comes to LDL and risk, you want the big vehicles, or particles. (Two thousand passengers riding in twenty one-hundred-passenger buses is safer than two thousand passengers riding in a thousand sports cars.)
Therapy with statin drugs can lower the LDL-C to an industry-established target, yet this still may not reduce cardiovascular disease risk. A patient may have a high number of small-sized particles yet a low LDL-C reading. This “discordance,” as it is known, is remarkably common among diabetics and the insulin resistant.
Simply put, it’s better to take care of your health than to take drugs. Pay attention to the circumference of your waist, and your sugar tolerance. Your TG/HDL ratio is a strong indicator of where you are in terms of insulin resistance.
GOOD NEWS AWAITS
The good news is that prediabetes (and even type 2 diabetes) can often be reversed through changes in diet. Improvement will be further leveraged by increased physical activity. When a tasty toxin such as sugar becomes acceptable, accessible, and affordable, public health suffers.
It was thirty years after medical studies decisively illuminated the dangers of tobacco that action was taken. Now taxes, restrictions on public use, minimum age of purchase, public awareness, and illness and death have effectively reduced the number of smokers. We must treat our toxic food environment the same way. In the history of public health, no problem affecting more than half of the population has been successfully dealt with by “treatment.” The only solution is prevention. For this, your diet, which is discussed in the next chapter, matters most.
DRILLS
Carbohydrate intolerance test
My brilliant colleague Dr. Phil Maffetone has developed a simple and effective way to determine if you are carbohydrate intolerant—which many of us are. The “2 week test” is not a diet, really, nor is it onerously restrictive, but it can indicate if you are suffering what may be the most overlooked epidemic of our time. You can learn more about it at runforyourlifebook.com.
Baseline lab work—to place you ahead of the curve
I urge even those who consider themselves healthy to have basic lab tests done, in order to establish a baseline for future comparison. All of the tests below are common and affordable, and are generally covered by insurance under an annual physical checkup.
Basic Tests
Complete metabolic panel, which includes liver function and enzymes, kidney function, and sugar levels
Standard lipid panel, with attention to the TG/HDL ratio and TC/HDL ratio
Hemoglobin A1c
Vitamin D and B12
Thyroid panel
Blood count (CBC)
Ferritin (iron stores)
hsCRP
Uric acid
Second-Level Tests for Higher Risk Groups
Fasted glucose and insulin tests (before breakfast, for instance)
75–100 gram Glucose Tolerance Test (GTT): glucose and insulin tests one to two hours after glucose drink
Advanced lipid profile (available from LabCorps). This test provides the important LDL particle size and number. (You want large size and small number.)
Coronary artery calcium (CAC) score, to quantify your coronary artery disease (about $100 at imaging centers)
Securing the test results is one thing. Finding a knowledgeable health care provider is even more important—someone who can help you interpret the results, especially taking into account your unique circumstances.
Create a sugar-free home or workplace
Just this year at my hospital, Jefferson Medical Center, we became the first hospital in the state to eliminate sugar-sweetened beverages for patients, staff, and visitors. My children are teenagers and not on a low-carb diet, but we do not have sugar-sweetened beverages, including juice, in our home.
CHAPTER 10
What’s for Dinner:
Setting Your Meal Course
Status quo, you know, is Latin for “the mess we’re in.”
—RONALD REAGAN
Your health and likely your life span will be determined by the proportion of fat versus sugar you burn over a lifetime.
—DR. RON ROSEDALE
MYTH: There are healthy and unhealthy diets.
FACT: Diets are not healthy. People are either healthy or unhealthy.
MYTH: Medical experts and government officials, over time, have figured out what’s best for us in terms of our nutrition.
FACT: Disturbingly, the government’s dietary recommendations may be contributing to the growth of prediabetes, type 2 diabetes, obesity, and chronic diseases.
Ah yes…diets.
Don’t do it. Don’t diet. Nearly every “diet” with a name is little more than a fad, or it has debatable efficacy.
Why do people following Weight Watchers fail to lose weight for the long term? Look up their “Points” list. If overweight folks consistently eat bananas and mangos (which have been granted their desirable zero Points ranking), most will gain weight. I was surprised when Oprah, who admirably got many women out running, posted an “I Love Bread” video, sponsored by Weight Watchers (in which she is said to have an ownership stake). Noshing on bread is a sure prescription for gaining weight.
Hopefully, you can join me in the liberating knowledge that miracle diets, products, and weight loss formulas simply do not work. To some it may sound curious, to others self-apparent: if “diets” were successful at sustainably reducing weight, then people wouldn’t need to obsessively follow them, and there would be no multibillion-dollar diet industry. Indeed, in the United States alone, $30 billion a year is spent on weight loss and diet programs. A diet plan that reliably doesn’t succeed at helping people to maintain their weight loss presents the perfect business model: the customers are assured of returning for more treatment.
What are we to believe about all the nutrition and diet talk, anyway? As John P. A. Ioannidis, a professor of medicine and statistics at Stanford University, wrote, “Almost every single nutrient imaginable has peer reviewed publications associating it with almost any outcome. In this literature of epidemic proportions, associations, and flawed assumptions, with few high quality randomized trials, how many results are correct?”
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nbsp; What does work is far easier, healthier, and less expensive: eating healthfully and mindfully until you’re full. You’ll find that this “non-diet” is tastier, too—which is a clue to how it works. Over time, no nutritional regimen can rely upon willpower. Counting calories has one immediate problem: it causes you to think about, and sometimes obsess over, what you are eating throughout the day—which only draws attention to your hunger. (Try telling a smoker who is attempting to quit that he should spend the day thinking about cigarettes.) The glut of “diets” out there would enjoy a lot more success if, rather than prescribing austerity or enumerating calories and nutrients, they offered a delicious and filling meal.
Let’s start by taking a look at what America is eating.
PYRAMIDS, PLATES, AND PRESIDENTIAL HOPE
The new Dietary Guidelines for Americans (DGA), released in early 2016, are an amendment to the original guidelines, issued forty years ago. By finally exonerating dietary fat and cholesterol, they are a step in the right direction, but are still a poor recipe for improving America’s health. You might not have paid much attention to these guidelines, but millions of kids who eat school lunches are subject to them, military rations and SNAP (formerly known as food stamps) are tied to them, and their broad strokes trickle down into the public’s perception of what’s healthy.
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