by Westman, Dr. Eric C. ; Phinney, Dr. Stephen D. ; Volek, Dr. Jeff S.
• To avoid hypoglycemia, patients following a low-carb diet who are taking blood sugar-lowering medications need to have them monitored and adjusted, as needed.
PRACTICAL POINTERS
How can those of you who are diabetic translate all of this information into action to transform your health? Here are three practical considerations:
1. The focus of this chapter has been on type 2 diabetes because it’s usually associated with being overweight, and also because most type 2 diabetics probably won’t need insulin injections if they can find and comply with their threshold for carbohydrate tolerance (CLL or ACE). Type 1 diabetics will always need some insulin, making its management much more technical on a carb-restricted diet. Though some doctors are now using the Atkins Diet for selected type 1 diabetics, instructions on how to do this safely are beyond the scope of this book. If you’ve been diagnosed with type 1 diabetes, or if you’ve ever been diagnosed with diabetic ketoacidosis, you should not try the Atkins Diet on your own. And if you do try it under medical supervision, be sure that you’re being instructed and closely monitored by a doctor familiar with Atkins.
2. Second, if you’re taking medications to control blood sugar (diabetic drugs) or drugs for high blood pressure, be sure to work closely with your doctor, particularly in the first weeks and months of the diet. It’s during this time that diabetes and blood pressure improve rapidly, which usually requires reducing or stopping the medications used to treat these problems. This should always be done with your doctor’s knowledge and consent.
3. Be consistent about sticking with the program. While we advise this for everyone following a low-carb diet—whether your problem is weight, diabetes, high blood lipids, or high blood pressure—consistency is of the greatest importance if you start out with diabetes. This is because type 2 diabetes represents the highest level of insulin resistance, so if you break the diet, your body’s return to carbohydrate intolerance will be rapid and the swings in blood sugar wide. If you’ve gotten off of most of your diabetes or high-blood-pressure drugs in the first two weeks of the diet and celebrate this victory by three days of eating everything in Vegas, the metabolic bully will beat you up and you’ll return home with these problems once again out of control. (In this case, what happened in Vegas won’t stay in Vegas!) Yes, as you lose weight, your underlying tendency to be insulin-resistant often improves. But most diabetics still remain somewhat insulin-resistant even after substantial weight loss, so staying at or under your carbohydrate threshold has greater importance for you in order to avoid the long-term medical problems caused by poorly controlled diabetes.
A CHALLENGE THAT’S WORTH THE EFFORT
Using the Atkins Diet to manage type 2 diabetes is probably the most potent use of this powerful tool, but it’s also the most demanding. Make sure that you (and your doctor) are ready to apply the time and energy necessary to be successful—both in the near term and for years to come. To that end, we have provided a combination of scientific and practical information in this chapter so that both you and your physician can be assured that this use of the Atkins Diet can be safe and effective.
Acknowledgments
We are like dwarfs on the shoulders of giants, so that we can see more than they, and things at a greater distance, not by virtue of any sharpness of sight on our part, or any physical distinction, but because we are carried high and raised up by their giant size.
—Bernard of Chartres, 1159
For a quarter century, as an academic physician doing research on low-carbohydrate metabolism, my life ran parallel to that of Robert C. Atkins. Sadly, our paths never crossed. About a decade ago, however, two leaders of a new generation of medical scientists contacted me. Building a bridge between the heretofore separate realms of academic research and the clinical brilliance of Dr. Atkins, Dr. Eric Westman and Dr. Jeff Volek have forged the scientific foundation of the New Atkins. As a result of their efforts and the support of the Atkins Foundation, there has been a resurgence of scientific interest in the Atkins Diet. It has been my very great pleasure to collaborate with them, first on current research studies and now on the creation of this book.
I also wish to thank Drs. Ethan Sims, Edward Horton, Bruce Bistrian, and George Blackburn for teaching me to subject standard dietary practices to scientific scrutiny. Their guidance helped to shape my life and my career. I also owe a debt of gratitude to my many patients and research subjects for opening my eyes to unanticipated results. And, most important, thanks to my lovely family—Huong, Lauren, and Eric—for their unquestioning support and their tolerance of my cooking.
—Stephen D. Phinney
I must first thank those people who have shaped my scientific thinking and specifically contributed to a line of research on carbohydrate restriction. Dr. William J. Kraemer initially sparked my interest in science and has offered unwavering support for almost twenty years as we have continued to collaborate on research and become best friends. I’m not sure if he qualifies for MENSA, but my coauthor Dr. Stephen Phinney is a bona fide nutritional genius. In 1994, I first read his enlightening papers on experiments he conducted in the early 1980s on metabolic adaptations to very-low-carbohydrate diets. A decade later I’m fortunate to consider him a close friend and colleague. Several other colleagues have significantly influenced my views of nutrition and positively impacted my research. Drs. Maria Luz Fernandez, Richard Feinman, and Richard Bruno are all brilliant collaborators on past and current research projects whose relationships I treasure. I have also been privileged to work with several tireless and talented graduate students over the years, all of whom dedicated countless hours to conducting more than a dozen experiments aimed at better understanding how low-carbohydrate diets improve health.
It’s been a pleasure working with Eric Westman and Stephen Phinney. It is also necessary to acknowledge Dr. Robert C. Atkins, who had a remarkable and permanent impact on my life. His recognition of the importance of science to validate his dietary approach and his generous philanthropy has been a major reason I was able to conduct cutting-edge research on low-carbohydrate diets over the last decade.
I am forever grateful to my selfless mother, Nina, and my father, Jerry, for their unconditional love and support, and all the sacrifices they have made in order to make my life better. My two cherished boys, high-spirited Preston, who recently turned two, and Reese, who was born during the writing of this book, give me a deep sense of purpose and perspective. Coming home to them is the perfect antidote to a stressful day of work. Most important, thanks to my beloved wife, Ana, who keeps me balanced and makes life infinitely more fun.
—Jeff S. Volek
I acknowledge first the enthusiastic love and support of my wife, Gretchen, and our children, Laura, Megan, and Clay. I learned to tilt at windmills from my parents, Jack C. and Nancy K. Westman, and brothers, John C. Westman and D. Paul West-man. Innumerable friends, colleagues, and data-driven academic environments enabled this book—and the science behind it—to materialize.
Thanks to Dr. Robert C. Atkins and Jackie Eberstein for having the openness to invite me to visit their clinical practice. Thanks to Veronica Atkins and Dr. Abby Bloch of the Robert C. Atkins Foundation for continuing his legacy. Thanks also to the doctors and researchers who allowed me to visit their practices or collaborate on research studies with them: Mary C. Vernon, Richard K. Bernstein, Joseph T. Hickey, Ron Rosedale, members of the American Society of Bariatric Physicians, William S. Yancy, Jr., James A. Wortman, Jeff S. Volek, Richard D. Feinman, Donald Layman, Manny Noakes, and Stephen D. Phinney.
—Eric C. Westman
As a team, we wish to acknowledge the Herculean effort expended in bringing together all the components of this book by project editor Olivia Bell Buehl and Atkins nutritionist Colette Heimowitz. Dietician Brittanie Volk developed the meal plans. Thanks also to Monty Sharma and Chip Bellamy of Atkins Nutritionals, Inc., for their insight on the importance of publishing this book and their patience as it took on a life of its
own.
Glossary
ACE: See Atkins Carbohydrate Equilibrium.
Aerobic exercise: Sustained rhythmic exercise that increases your heart rate; also referred to as cardio.
Amino acids: The building blocks of protein.
Antioxidants: Substances that neutralize harmful free radicals in the body. Atherosclerosis: Clogging, narrowing, and hardening of blood vessels by plaque deposits.
Atkins Carbohydrate Equilibrium (ACE) : The number of grams of Net Carbs that a person can consume daily without gaining or losing weight.
Atkins Edge: A beneficial state of fat-burning metabolism, caused by carbohydrate restriction, that makes it possible to lose weight and maintain weight loss without extreme hunger or cravings; a metabolic edge.
Beta cells: Specialized cells in the pancreas that produce insulin.
Blood lipids: The factors of total cholesterol, triglycerides, and HDL and LDL cholesterol in your blood.
Blood pressure: The pressure your blood exerts against the walls of your arteries during a heartbeat.
Blood sugar: The amount of glucose in your bloodstream; also called blood glucose.
BMI: See Body mass index.
Body mass index (BMI): An estimate of body fatness that takes into account body weight and height.
Carbohydrate: A macronutrient from plants and some other foods broken down by digestion into simple sugars such as glucose to provide a source of energy.
Cholesterol: A lipid; a waxy substance essential for many of the body’s functions, including manufacturing hormones and making cell membranes.
C-reactive protein (CRP): A chemical in blood that serves as a marker for inflammation.
Diabetes: See Type 1 diabetes and Type 2 diabetes.
Diuretic: Anything that removes fluid from the body by increasing urination. Essential fatty acids (EFAs): Two classes of essential dietary fats that your body cannot make on its own and that must be obtained from food or supplements. Fat: One of the three macronutrients; an organic compound that dissolves in other oils but not in water. A source of energy and building blocks of cells.
Fatty acids: The scientific term for fats, which are part of a group of substances called lipids.
Fiber: Parts of plant foods that are indigestible or very slowly digested, with little effect on blood glucose and insulin levels; sometimes called roughage.
Foundation vegetables: Leafy greens and other low-carbohydrate, nonstarchy vegetables suitable for Phase 1, Induction, and the basis upon which later carb intake builds.
Free radicals: Harmful molecules in the environment and naturally produced by our bodies. Excess free radicals can damage cells and cause oxidation.
Glucose: A simple sugar. Also see Blood sugar.
Glycogen: The storage form of carbohydrate in the body.
HDL cholesterol: High-density lipoprotein; the “good” type of cholesterol.
Hydrogenated oils: Vegetable oils processed to make them solid and improve their shelf life. See Trans fats.
Hypertension: High blood pressure.
Inflammation: Part of the body’s delicately balanced natural defense system against potentially damaging substances. Excessive inflammation is associated with increased risk of heart attack, stroke, diabetes, and some forms of cancer.
Insulin: A hormone produced by the pancreas that signals cells to remove glucose and amino acids from the bloodstream and stop the release of fat from fat cells.
Ketoacidosis: The uncontrolled overproduction of ketones characteristic of untreated type 1 diabetes, typically five to ten times higher than nutritional ketosis.
Ketones: Substances produced by the liver from fat during accelerated fat breakdown that serve as a valuable energy source for cells throughout the body.
Ketosis: A moderate and controlled level of ketones in the bloodstream that allows the body to function well with little dietary carbohydrate; also called nutritional ketosis.
LDL cholesterol: Low-density lipoprotein. Commonly referred to as the “bad” type of cholesterol, but not all LDL cholesterol is “bad.”
Lean body mass: Body mass minus fat tissue; includes muscle, bone, organs, and connective tissue.
Legumes: Most members of the bean and pea families, including lentils, chickpeas, soybeans, peas, and numerous others.
Lipids: Fats, including triglycerides, and cholesterol in the body.
Macronutrients: Fat, protein, and carbohydrate, the dietary sources of calories and nutrients.
Metabolic syndrome: A group of conditions, including hypertension, high triglycerides, low HDL cholesterol, higher-than-normal blood sugar and insulin levels, and weight carried in the middle of the body. Also known as syndrome X or insulin resistance syndrome, it predisposes you to heart disease and type 2 diabetes.
Metabolism: The complex chemical processes that convert food into energy or the body’s building blocks, which in turn become part of organs, tissues, and cells.
Monounsaturated fat: Dietary fat typically found in foods such as olive oil, canola oil, nuts, and avocados.
Net Carbs: The carbohydrates in a food that impact your blood sugar, calculated by subtracting fiber grams in the food from total grams. In a low-carb product, sugar alcohols, including glycerin, are also subtracted.
Omega-3 fatty acids: A group of essential polyunsaturated fats found in green algae, cold-water fish, fish oil, flaxseed oil, and some other nut and vegetable oils.
Omega-6 fatty acids: A group of essential polyunsaturated fats found in many vegetable oils and also in meats from animals fed corn, soybeans, and certain other vegetable products.
Partially hydrogenated oils: See Trans fats.
Plaque: A buildup in the arteries of cholesterol, fat, calcium, and other substances that can block blood flow and result in a heart attack or stroke.
Polyunsaturated fats: Fats with a chemical structure that keeps them liquid in the cold; oils from corn, soybean, sunflower, safflower, cottonseed, grape seed, flaxseed, sesame seed, some nuts, and fatty fish are typically high in polyunsatu-rated fat.
Prediabetes: Blood sugar levels that are higher than normal but fall short of fullblown diabetes.
Protein: One of the three macronutrients found in food, used for energy and building blocks of cells; chains of amino acids.
Resistance exercise: Any exercise that builds muscle strength; also called weight-bearing or anaerobic exercise.
Satiety: A pleasurable sense of fullness.
Saturated fats: Fats that are solid at room temperature; the majority of fat in butter, lard, suet, palm and coconut oil.
Statin drugs: Pharmaceuticals used to lower total and LDL cholesterol.
Sucrose: Table sugar, composed of glucose and fructose.
Sugar alcohols: Sweeteners such as glycerin, mannitol, erythritol, sorbitol, and xylitol that have little or no impact on most people’s blood sugar and are therefore used in some low-carb products.
Trans fats: Fats found in partially hydrogenated or hydrogenated vegetable oil; typically used in fried foods, baked goods, and other products. A high intake of trans fats is associated with increased heart attack risk.
Triglycerides: The major form of fat that circulates in the bloodstream and is stored as body fat.
Type 1 diabetes: A condition in which the pancreas makes so little insulin that the body can’t use blood glucose as energy, producing chronically high blood sugar levels and overproduction of ketones.
Type 2 diabetes: The more common form of diabetes; high blood sugar levels caused by insulin resistance, an inability to use insulin properly.
Unsaturated fat: Monounsaturated and polyunsaturated fats.
Notes
Chapter 1: Know Thyself
1. C. D. Gardner, A. Kiazand, S. Alhassan, S. Kim, R. S. Stafford, R. R. Balise, et al., “Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors among Overweight Premenopausal Women: The A TO Z Weight Loss Study: A Randomized Trial,” The
Journal of the American Medical Association 297 (2007), 969–977; I. Shai, D. Schwarzfuchs, Y. Henkin, D. R. Shahar, S. Witkow, I. Greenberg, et al., “Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet,” The New England Journal of Medicine 359 (2008), 229–241; J. S. Volek, M. L. Fernandez, R. D. Feinman, and S. D. Phinney, “Dietary Carbohydrate Restriction Induces a Unique Metabolic State Positively Affecting Atherogenic Dyslipidemia, Fatty Acid Partitioning, and Metabolic Syndrome,” Progress in Lipid Research 47 (2008), 307–318.
2. Shai et al., “Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet”; A. J. Nordmann, A. Nordmann, M. Briel, U. Keller, W. S. Yancy, Jr., B. J. Brehm, et al., “Effects of Low-Carbohydrate vs Low-Fat Diets on Weight Loss and Cardiovascular Risk Factors: A Meta-analysis of Randomized Controlled Trials,” Archives of Internal Medicine 166 (2006), 285–293.
3. C. D. Gardner et al., “Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors among Overweight Premenopausal Women.”
4. G. Boden, K. Sargrad, C. Homko, M. Mozzoli, and T. P. Stein, “Effect of a Low-Carbohydrate Diet on Appetite, Blood Glucose Levels, and Insulin Resistance in Obese Patients with type 2 Diabetes,” Annals of Internal Medicine 142 (2005), 403–411; E. C. Westman, W. S. Yancy, Jr., J. C. Mavropoulos, M. Marquart, and J. R. McDuffie, “The Effect of a Low-Carbohydrate, Ketogenic Diet Versus a Low-Glycemic Index Diet on Glycemic Control in type 2 Diabetes Mellitus,” Nutrition & Metabolism (London) 5 (2008), 36.
5. E. H. Kossoff, and J. M. Rho, “Ketogenic Diets: Evidence for Short- and Long-Term Efficacy,” Neurotherapeutics 6 (2009), 406–414; J. M. Freeman, J. B. Freeman, and M. T. Kelly, The Ketogenic Diet: A Treatment for Epilepsy, 3rd ed. (New York: Demos Health, 2000).
6. T. A. Wadden, J. A. Sternberg, K. A. Letizia, A. J. Stunkard, and G. D. Foster, “Treatment of Obesity by Very Low Calorie Diet, Behavior Therapy, and Their Combination: A Five-Year Perspective,” International Journal of Obesity 13 suppl. 2 (1989), 39–46.