Sunday, May 11, 2014

We Hate the ADA; Why does the Perfect Health Diet Get a Pass?

Some people keep touting the Perfect Health Diet as low-carb, but carb levels that are mostly in the triple digits aren't generally regarded as low-carb; in fact, one of the authors says low-carb diets are unhealthy.

A lot of us hate the American Diabetes Association's advice for diabetics: start with 45g to 60g of carbohydrate per meal and go higher or lower from there. That's 135g to 180g of carb.

Perfect Health Diet advice for diabetics: eat 20% to 30% of your diet as carbohydrate. On 2,000 calories, that's 100g to 150g of carb. On 1,700 calories, that's 85 to 128g; on 2,200 calories, that's 112 to 168g. Depending on your carb and calorie intake, carbs would be 85g to 168g per day. That's not a mile off from the ADA's recommendations.

Paul Jaminet, one of the authors of the Perfect Health Diet, says, "the basic biology here is that the body's physiology is optimized for a carbohydrate intake of about 30%." He warns against a diet of 10% carbohydrate:

Among these are hormonal changes including low T3 thyroid hormone and high cortisol. This condition makes fasting problematic and diabetics tend to develop high blood glucose levels in the morning after the overnight fast. Due to high fasting glucose and severe insulin resistance, HbA1c may be elevated by this strategy compared to a 20% or 30% carb diet. Various pathologies, including hypoglycemic episodes, dysregulation of serum fatty acid levels, ketoacidosis, and adrenal dysfunction become more likely.

Ten percent sounds low, but it's a pretty average low-carb diet. On 2,000 calories a day, 10% carbohydrate would be 50g of carb; on 1700 calories, it's 43g; on 2200 calories, it's 55g. These numbers are around what some low-carb doctors recommend for their patients. Fifty grams isn't even a VLC diet, generally considered around 20g or less per day. Dr. Richard Bernstein, one of the foremost experts on diabetes, clinician, and a type 1 diabetic himself, recommends the 6-12-12 rule: six grams of carb at breakfast, 12 at lunch, and 12 at dinner (30g total) and a target blood sugar of 83. Dr. William Davis, another clinician, recommends keeping carbohydrate to 40-50 grams per day (30 for more carb-sensitive patients) to keep post-meal blood sugars below 100.

Jaminet's claims about the dangers of low-carb diets seem questionable. I admit I'm not up on all of the endocrinology Jaminet refers to, but according to what I've read, ketoacidosis, for the most part, occurs only in type 1 diabetics who are severely ill, and it's post-meal blood glucose spikes, not A1c, that are more important. HbA1c is an average blood glucose. Jenny Ruhl at the Diabetes Update Blog has a page devoted to debunking low-carb scare studies in general. (There's even more on the blog.) She addresses kidney disease and cholesterol; elsewhere, hypoglycemiaDr. Bernstein's Diabetes Solution mentions many common causes of hypoglycemia; simply following a low-carb diet isn't among them. Most of the causes he mentions involve improperly taking insulin. As for thyroid, several clinicians have remarked that they don't see problems like hair loss and cold hands or unhealthy changes in thyroid levels in their patients; researchers and others have stated they hadn't seen studies showing low-carb diets harming thyroid function.

There have been intervention studies on low carb diets and diabetes showing improvements with those diets. One study by Eric Westman et al put type 2 diabetic volunteers on either a ketogenic (less than 20g carb per day) or a low GI, restricted calorie diet. The keto group ate, on average, 13% of calories from carb and saw more improvement in HDL, weight loss, fasting glucose, fasting insulin, and medication reduction than the other group. There was no indication of any of the problems Jaminet warns against in the adverse effects section. Jenny Ruhl has summarized several similar studies, and gives a warning about high carb, high fat diets (the Perfect Health Diet among them):

Low carb diets are very healthy as long as they are really low carb. But the bad news is that if your carbohydrate intake starts to rise over 120 grams per day, your diets will become very unhealthy unless you cut back on fat. A high fat intake is only healthy with a truly low carb diet. The studies that convinced doctors in the 1970s that low carb diets were dangerous were all studies of people eating "low carb" diets of 150 grams of carbohydrate a day or more. And more recent research suggests that those diets are just as unhealthy now as they were then. If you can control your blood sugar with a diet that cuts carbs to a level nearer 150 grams a day, as opposed to 100 grams a day, keep your fats to 30% of all calories and you'll be fine....
In quite a few high profile studies published recently the "low carb" diet turns out to be one containing anywhere from 120 to 180 grams of carbohydrate a day. For most of us, this is far too much carbohydrate. It will raise our blood sugar dramatically and when that happens, we lose all the benefits of carb restriction.

In the comments of a blog post, Ruhl says,

Several of the research studies I reviewed when writing my new book found that as carbs rose over 110 g a day and certainly by the time they approached 150 g a day if people did not cut their fat down to no more than 30% of calories their cholesterol profile switched to the kind that suggests small atherogenic, rather than large, healthy LDL particles, which is not a healthy profile. Many people eating high fat intakes at that carb intake level ended up regaining lost weight at a swift rate.
The Perfect Health Diet recommends getting most of your calories from fat; however, this is bad idea in the context of a diet that can easily rise above 110g of carbohydrate a day.

Before Tom Naughton went off the rails with safe starches, his two adorable daughters made a video explaining why the combination of fat and sugar (or easily digested starch like potatoes) is bad for you: When your blood has too much glucose, it burns the glucose and stores the fat. Later, if the insulin makes your blood sugar go to low, you cannot, of course, burn any more sugar, but in the presence of insulin, your cells won't release fat. In other words, you're hungry again. Or as their father once put it, you're not getting fat because you're eating more, you're eating more because you're getting fat. Eat some more starch, with or without fat, and you might become fat and diabetic.

But I think Dr. Bernstein sums up the Perfect Health Diet best: "This sounds like BS to me!"

14 comments:

Almond said...

I read the book. I think woo did a good job of covering functional hypothyroidism on a LC diet on her blog. Not impressed by the new carb recommendation of upping it to 100g a day....

Lori Miller said...

Woo also left some comments at the Diabetes Update Blog on her thoughts that what seemed like low thyroid might have been low leptin.

Lowcarb team member said...

Dr Bernstein talks sense .....

All the best Jan

tess said...

Wooo understands leptin MUCH better than she does thyroid. she has personal experience of leptin, but only knows thyroid in literature. she totally IGNORES other people's experiences when it disagrees with her textbooks. -- hilarious, since she gets very upset when others ignore HER personal experiences which don't agree with CW!

Galina L. said...

In order to eat starches again in a PHD range a person will have to start measuring and fretting again, and asking herself/himself a question - am I eating too much fat, did I put more than 1 Tbs of cream in my coffee, how about a butter in my broccoli? All that instead of relying on the sense of a satiety. I would rather avoid such hassle when I have a choice. Besides, ketosis has a lot of benefits for mental health state, and much more people than epileptics may find it useful.
I din't have to increase my thyroid meds on a LC diet, and my hair are better than before.

Lori Miller said...

I only know what I read about thyroid. I never had a problem with mine.

Lori Miller said...

The PHD trades benefits that are definite (controlled blood sugar, limiting insulin, making ketones, not having to eat often) for avoiding harm that's speculative (thyroid problems, "glucose deficiency," burning out your liver, etc.).

Lori Miller said...

True. Eat small amounts of carbohydrate, take small amounts of insulin, and you avoid big mistakes in controlling your blood sugar.

Galina L. said...

Jan, you are a good example of a healthy individual eating LC without any issues.

Galina L. said...

I don't consider PHD passable for a LCarber - just another Paleo blog which I hardly ever read, unless they discuss fermented veggies.

Lori Miller said...

The thing is, it's neither low-carb nor paleo since it includes a bargeload of rice and potatoes (both neolithic, high carb, high GI foods). IRL, who's going to eat a bunch of sweet potatoes or taro root or plantains all the time?

Galina L. said...

I care more about the macronutrient composition of a diet than about it being paleo or not. I would choose Atkins with his mayo over any totally paleo regiment if it includes liberal amount of sweet potatoes.

Rick Gladney said...

I didn't have long term success with Adkins. I eventually backslid because I felt bad and didn't have enough energy. With Paleo, it's the exact opposite. I have four times the energy and vitality. Even though on Adkins you reduce your gluten intake, there's something that didn't work well for me.

Lori Miller said...

This reminds me of a point made in the book It Starts with Food. Let's say you're allergic to cats, but you live with 20 of them. Even if you get rid of 19 of the cats, you're still going to be miserable.