Part 24 (2/2)

The underlying cause of type 2 diabetes is a controversial topic. In general, diabetes is a disorder of carbohydrate metabolism caused by a combination of hereditary and environmental factors. The latter includes the composition of the diet, obesity, and inactivity. However, many people eat a poor diet and are sedentary but never develop obesity or diabetes. Similarly, some obese, sedentary people have normal blood sugar levels. Nonetheless, overall, obesity and inactivity increase an individual's risk of developing diabetes, but some individuals seem more protected than others. This indicates that genetics play an important role in the development of the disorder. Another important factor is age: your body may tolerate bad behavior at age 30 but not necessarily at 60.

Your body uses the hormone insulin to trigger the movement of blood sugar into the cells, but, as you learned in the previous chapter, at high levels insulin also promotes metabolic syndrome, including excess fat storage, inflammation, and the formation of plaque in your arteries. Inflammation has increasingly become a topic of interest because people with type 2 diabetes typically have increased blood levels of inflammation biomarkers such as C-reactive protein (CRP), and this biomarker in turn accurately predicts who will later develop such complications of type 2 diabetes as heart disease, stroke, and kidney failure.1 More important, however, when large populations of adults without diabetes are screened for CRP levels and then followed for five to ten years, the quarter of the population with the highest levels has two to four times the likelihood of subsequently developing diabetes.2 What this means is that inflammation comes before the overt signs of diabetes develop. In other words, inflammation looks less like an effect of diabetes and more like an (if not the) underlying cause. Coming back to our a.n.a.logy of carbohydrate as a bully, it's simple but appealing to think that dietary carbohydrates repeatedly ”bruise” the body. Further, it would seem that some people respond to this bruising by becoming inflamed, and this inflammation eventually results in damage that causes cells to become insulin-resistant and organs to eventually fail. What this means is that inflammation comes before the overt signs of diabetes develop. In other words, inflammation looks less like an effect of diabetes and more like an (if not the) underlying cause. Coming back to our a.n.a.logy of carbohydrate as a bully, it's simple but appealing to think that dietary carbohydrates repeatedly ”bruise” the body. Further, it would seem that some people respond to this bruising by becoming inflamed, and this inflammation eventually results in damage that causes cells to become insulin-resistant and organs to eventually fail.

So how does this simple a.n.a.logy help us understand something as complex as the underlying cause of type 2 diabetes? Well, take away the bully, and the bruising stops. Right? In the previous chapter we gave you strong evidence that carbohydrate restriction in people with metabolic syndrome (aka prediabetes) results in a sharp reduction in the biomarkers of inflammation. Now we'll show you that type 2 diabetics consuming a low-carb diet experience improvements in blood sugar, blood lipids, and body weight-sometimes dramatically so.

A LOOK AT THE RESEARCH.

There are several different types of studies used to understand the effect of eating different foods on human health. In previous decades, scientists tended to rely on observational studies of what people ate and how that affected their long-term health (nutritional epidemiology), but prospective clinical trials are considered more accurate. Studies on individuals in an ”inpatient” clinical research ward provide tight control over what people eat, but they tend to be limited to a week or two, during which research subjects remain hospitalized, with a few notable exceptions.

In other studies, researchers give subjects food to take home to eat. However, there's no a.s.surance that people won't eat other food in addition to the supplied meals. Finally, another type of research involves instructing people to buy and eat certain foods and return for instruction and support-often over a period of several years. These ”outpatient” or ”free-living” studies tell us a lot about whether a certain diet is sustainable in the ”real-world” setting. But the interpretation of such studies is limited because people don't necessarily follow the dietary instructions. Here are some examples of studies that have shown that the Atkins Diet is a safe and effective treatment for type 2 diabetes.

INPATIENT STUDIES.

In a pioneering study done thirty years ago, seven obese type 2 diabetics were placed on a very-low-calorie ketogenic diet, first as inpatients and later as outpatients.3 Initially, these subjects had fair-to-poor blood glucose control despite the fact that they were already taking 30 to 100 units of insulin per day. Within twenty days of starting the low-carbohydrate diet, all the subjects were able to discontinue their insulin injections. Nonetheless, their blood glucose control improved, as did their blood lipid profiles. The authors noted that blood glucose control improved much more rapidly than did the rate at which they lost weight, indicating that carbohydrate intake was the primary determinant of glucose control and insulin requirement rather than obesity itself. Initially, these subjects had fair-to-poor blood glucose control despite the fact that they were already taking 30 to 100 units of insulin per day. Within twenty days of starting the low-carbohydrate diet, all the subjects were able to discontinue their insulin injections. Nonetheless, their blood glucose control improved, as did their blood lipid profiles. The authors noted that blood glucose control improved much more rapidly than did the rate at which they lost weight, indicating that carbohydrate intake was the primary determinant of glucose control and insulin requirement rather than obesity itself.

In a 2005 inpatient study ten obese people with type 2 diabetes were fed their usual diet for seven days, followed by a low-carbohydrate diet (the Induction phase of Atkins) of 20 grams of carbs a day for fourteen days.4In both cases, subjects were allowed to choose how much they ate, so the only change after the first week was eliminating most carbohydrate foods. Because this study took place in a research ward, the researchers were able to doc.u.ment the subjects' total food intake. They found that when subjects followed the low-carb diet, they continued to eat about the same amount of protein and fat as before, even after two weeks of carb restriction and although they could have eaten more protein and/or fat to make up for the missing carbohydrate calories if they desired. This means that they naturally ate fewer calories when carbs were restricted. In addition to losing weight, the subjects also showed improvements in their blood glucose and insulin levels. Many were able to eliminate their medications, and their insulin sensitivity improved by 75 percent on average, similar to the observations of the 1976 study cited above. More important, this recent study showed that instructing people to limit their grams of carbohydrate (without restricting calories or portion size) resulted in their eating less food and rapidly improving their insulin sensitivity.

OUTPATIENT STUDIES.

A recent outpatient study compared a low-carbohydrate diet to a portion-controlled, low-fat diet in seventy-nine patients over a three-month period.5 After three months, subjects in the low-carb group were reportedly consuming 110 grams of carbohydrate per day (the upper range of the Atkins Lifetime Maintenance phase). Compared to the low-fat group, the low-carb group had improvements in glucose control, weight, cholesterol, triglycerides and blood pressure. In addition, more people in the low-carb group were able to reduce medications than those in the low-fat group. After three months, subjects in the low-carb group were reportedly consuming 110 grams of carbohydrate per day (the upper range of the Atkins Lifetime Maintenance phase). Compared to the low-fat group, the low-carb group had improvements in glucose control, weight, cholesterol, triglycerides and blood pressure. In addition, more people in the low-carb group were able to reduce medications than those in the low-fat group.

Another, very recent outpatient study compared the Induction phase of Atkins (20 grams of carbohydrate daily) to a reduced-calorie diet (500 calories a day below their previous intake level, low in fat and sugar but high in complex carbs) over a six-month period.6 They found greater improvements in blood sugar levels and greater weight loss in the Atkins Induction group. What was especially exciting, however, was that individuals who were taking insulin often found the beneficial effects of the low-carb diet quite powerful. Subjects taking from 40 to 90 units of insulin before partic.i.p.ating in the study were able to eliminate insulin altogether, while also improving glycemic control. These results were similar to the inpatient studies described above. They found greater improvements in blood sugar levels and greater weight loss in the Atkins Induction group. What was especially exciting, however, was that individuals who were taking insulin often found the beneficial effects of the low-carb diet quite powerful. Subjects taking from 40 to 90 units of insulin before partic.i.p.ating in the study were able to eliminate insulin altogether, while also improving glycemic control. These results were similar to the inpatient studies described above.

And finally, the Kuwaiti low-carb study cited in chapter 1 chapter 1 included thirty-five subjects whose blood glucose was elevated at the start of the study. The average value for this group returned into the normal range within eight weeks of following the low-carb diet, and at fifty-six weeks, this group's average fasting blood glucose had been reduced by 44 percent. included thirty-five subjects whose blood glucose was elevated at the start of the study. The average value for this group returned into the normal range within eight weeks of following the low-carb diet, and at fifty-six weeks, this group's average fasting blood glucose had been reduced by 44 percent.

In summary, these five studies, in a variety of settings, all showed dramatic improvements in blood glucose control and blood lipids in type 2 diabetics consuming a low-carb diet. When these studies included a low-fat, high-carb comparison group, the low-carb diet consistently showed superior effects on blood glucose control, medication reduction, blood lipids, and weight loss. Weight loss is particularly important because treatment goals for patients with type 2 diabetes always emphasize weight loss if the individual is overweight, yet the drugs used to treat diabetics almost all cause weight gain. So let's look at this briefly, as the ability to deliver improved blood sugar control and and weight loss distinguishes a low-carb approach from all other nonsurgical treatments for type 2 diabetes. weight loss distinguishes a low-carb approach from all other nonsurgical treatments for type 2 diabetes.

WEIGHING THE OPTIONS: COMMON SIDE EFFECTS OF MEDICATION.

On its surface, the management of type 2 diabetes seems pretty easy: just get your blood glucose back down into the normal range. But insulin resistance characterizes this form of diabetes; put simply, the glucose level ”doesn't want to go down.” This means that the body is less responsive to the most powerful drug used to treat it: insulin. So the dose of insulin that most type 2 diabetics are prescribed is very high. Moreover, because insulin not only drives glucose into muscle cells but also accelerates fat synthesis and storage, weight gain is usually one side effect of aggressive insulin therapy.7 Other pills and injected medications have been developed to reduce this effect, but on average, the harder one tries to control blood glucose, the greater the tendency to gain weight. Other pills and injected medications have been developed to reduce this effect, but on average, the harder one tries to control blood glucose, the greater the tendency to gain weight.8 The other major side effect of attempting to gain tight control of blood sugar is driving it too low, causing hypoglycemia, which causes weakness, shakiness, confusion, and even coma. If these symptoms appear, the advice is to immediately eat a lot of sugar to stop the symptoms, which jump-starts the blood sugar roller coaster all over again. Interestingly, once type 2 diabetics complete the first few weeks of the Atkins program, they rarely experience hypoglycemia. That's because of the body's adaptation to burning fat for most of its fuel during carb restriction, in concert with the ability to reduce or stop most diabetic medications (including insulin) within a few days or weeks of starting the Atkins Diet. The other major side effect of attempting to gain tight control of blood sugar is driving it too low, causing hypoglycemia, which causes weakness, shakiness, confusion, and even coma. If these symptoms appear, the advice is to immediately eat a lot of sugar to stop the symptoms, which jump-starts the blood sugar roller coaster all over again. Interestingly, once type 2 diabetics complete the first few weeks of the Atkins program, they rarely experience hypoglycemia. That's because of the body's adaptation to burning fat for most of its fuel during carb restriction, in concert with the ability to reduce or stop most diabetic medications (including insulin) within a few days or weeks of starting the Atkins Diet.

So why isn't it good enough just to cut back on one's calories without cutting back on carbs? It's true that going on a diet and losing weight typically improve diabetes control. Well, first of all, dieting won't necessarily result in weight loss, and any weight loss may not be sustained. Second, even weight loss is usually not enough to significantly reduce medication dosage. Finally, since diabetic drugs still produce side effects and appet.i.te stimulation, losing weight on a standard diet is a difficult tightrope for a diabetic to walk.

Once you understand this tightrope of weight loss during drug treatment-some would call it a Catch-22-it's easier to appreciate the advantage of using the Atkins Diet to manage type 2 diabetes. When you remove added sugar, significantly reduce carb intake overall, and confine your consumption primarily to the foundation vegetables allowed in Induction, your insulin resistance rapidly improves, and blood glucose control improves-usually dramatically. Additionally, most people find that they can stop or substantially reduce their diabetes medications. As a result, the path to meaningful weight loss changes from a tightrope to a wide road. As long as you stay within your carb tolerance range, you should be able to navigate your way to health.

IF AND WHEN TO EXERCISE.

You might be familiar with many of the potential health benefits of exercise, but you probably don't know that exercise has insulinlike effects. This is relevant for type 2 diabetics with insulin resistance, because performing just a single bout of exercise improves insulin resistance for several hours. A number of studies have shown that regular exercise improves blood sugar control, even if it doesn't significantly improve weight loss.9 Because weight loss is so difficult for people with type 2 diabetes and because doctors have little else to offer (other than drugs) in the way of effective remedies, exercise is always near the top of the list of official guidelines. Because weight loss is so difficult for people with type 2 diabetes and because doctors have little else to offer (other than drugs) in the way of effective remedies, exercise is always near the top of the list of official guidelines.

Given this information, simple logic dictates that we should tell everyone with diabetes to get out and exercise. But not so fast. First, exercise holds an exalted position in diabetic treatment because the usual diets almost always fail. We need to consider what role exercise should play if the tables are turned and you have access to a diet like Atkins that almost always ”works” and that simultaneously causes insulin resistance and blood sugar control to improve significantly. Unfortunately, we don't yet have the perfect answer. Yes, we've proved that once people adapt to the Atkins Diet, they're capable of lots of exercise. But no one has done a study of diabetics on Atkins in which some of them exercise and some of them don't, to prove that adding exercise to an already successful diet improves blood sugar control or increases weight loss enough to justify the added effort.

Second, if you're diabetic, you're at increased risk for heart attack, and most people with type 2 diabetes are overweight (at least, before they start Atkins). So if you were offered the choice of either starting the program and exercising at the same time, or alternatively starting Atkins first, getting your blood sugar under control, reducing or stopping medications you might be taking for diabetes, and getting some weight off your ankles, knees, hips, and lower back, which would you choose?

Clearly, the key question is not really if if but but when. when. The Atkins Diet opens the door for you to exercise, and exercise has a lot of benefits other than weight loss (and may even improve your blood sugar control). As we've said previously, if you're already physically active, keep it up, being careful not to overdo it while you're adapting to fat burning in the first few weeks. But if it's been a while since you did much of anything vigorous, consider giving yourself a few weeks or months to unburden your heart and joints before taking on a 10K run or trying to burn out the treadmill or pump iron at the gym. The Atkins Diet opens the door for you to exercise, and exercise has a lot of benefits other than weight loss (and may even improve your blood sugar control). As we've said previously, if you're already physically active, keep it up, being careful not to overdo it while you're adapting to fat burning in the first few weeks. But if it's been a while since you did much of anything vigorous, consider giving yourself a few weeks or months to unburden your heart and joints before taking on a 10K run or trying to burn out the treadmill or pump iron at the gym.

THE CURRENT OFFICIAL GUIDELINES.

Okay, we've explained how Atkins offers unique benefits to someone with type 2 diabetes. So why isn't everyone with the disorder doing it? The answer is that the low-fat-diet fad of the last forty years, backed by the food industry and government-sanctioned committees, has taken a long time to run its course. Only with the recent research we've cited in the last few chapters has the mainstream medical community begun to be receptive to the value of low-carbohydrate diets. Standard treatment guidelines are beginning to reflect this change. This is where we stand today.

The goal of medical nutrition therapy for type 2 diabetes is to attain and maintain optimal metabolic outcomes, including: - Blood glucose levels in the normal range or as close to normal as is safely possible to prevent or reduce the risk for complications of diabetes- Lipid and lipoprotein profiles that reduce the risk for blood vessel disease (i.e., blockage of blood flow to your heart, brain, kidneys, and legs)- Blood pressure levels that reduce the risk of developing vascular disease The American Diabetes a.s.sociation (ADA) has acknowledged the use of a low-carbohydrate diet in achieving these goals in its 2008 guidelines, which include:10 - Modest weight loss has been shown to improve insulin resistance in overweight and obese insulin-resistant individuals.- Weight loss is recommended for all overweight individuals who have or are at risk for the disease.- Either low-carbohydrate or low-fat calorie-restricted diets may be effective for weight loss in the short term (up to one year).- Patients on low-carbohydrate diets should have their lipid profiles, kidney function, and protein intake (for those with kidney damage) monitored regularly.- 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 a.s.sociated 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 a.s.sured 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 grat.i.tude to my many patients and research subjects for opening my eyes to unantic.i.p.ated 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 relations.h.i.+ps 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 publis.h.i.+ng this book and their patience as it took on a life of its own.

Glossary ACE: See See Atkins Carbohydrate Equilibrium. Atkins Carbohydrate Equilibrium.

Aerobic exercise: Sustained rhythmic exercise that increases your heart rate; also referred to as cardio. Sustained rhythmic exercise that increases your heart rate; also referred to as cardio.

Amino acids: The building blocks of protein. The building blocks of protein.

Antioxidants: Substances that neutralize harmful free radicals in the body. Substances that neutralize harmful free radicals in the body. Atherosclerosis: Atherosclerosis: Clogging, narrowing, and hardening of blood vessels by plaque deposits. 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. 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. 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.

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