I have to confess that I don’t get my bloodwork done as often as I should. For type 2 diabetics, HbA1c is supposed to be done every three months and annual testing is recommended for lipids and kidney function as is an annual eye exam for signs of diabetic retinopathy. In my case, nine years post-diagnosis, I get my A1c done along with lipids and kidney function every 18 – 24 months, at best. My last eye exam was three or four years ago and I don’t test my fasting sugars at all. Is this irresponsible? Am I setting a poor example? Perhaps. But, before you judge, have a look at my most recent results:

Fasting glucose 5.7 (3.3-5.5) mmol/L

HbA1c 5.7 (4.5-6.0) %

Sodium 141 (134-145) mmol/L

Potassium 4.5 (3.5-5.0) mmol/L

Urea 6.5 (2.5-9.0)

Creatinine 73 (70-120) umol/L

Estimated GFR 97 (>60) mL/min

ALT 21 (<60) U/L

AST 23 (<35)U/L

CK 102 (<300) U/L

Total Cholesterol 5.82 (2.00-5.19) mmol/L

LDL Cholesterol 3.49 (1.50-3.39) mmol/L

HDL Cholesterol 2.05 (>0.90) mmol/L

Chol/HDL ratio 2.84 (<4.9)

Triglycerides 0.62 (0.45-2.29) mmol/L

Apolipoprotein B-100 0.95 g/L

TSH 2.4 (0.38-5.5) mU/L

C Reactive Protein 0.5 (<5.0) mg/L

What does it all mean? Well, according to the guidelines, my fasting glucose being slightly elevated means I am at risk for type 2 diabetes. This, coupled with the fact that my HbA1c is also on the high side of norma, if I were a non-diabetic, would indicate risk of diabetes and mandate further testing like an oral glucose tolerance test. In my case, however, since I am already diagnosed with type 2, those results are actually pretty good. The target for HbA1c in diabetes management is <7%, far higher than what is considered normal. Why is this? My opinion is that this reflects a tendency to move the goal posts when we can’t get better values with the conventional therapies. For people who use drugs and/or insulin, to get better values than that is difficult and possibly dangerous. In the ACCORD trial, where they threw the pharmaceutical kitchen sink at people to try to get better values, they actually ended up killing more people than with the conventional more relaxed approach. So, there is a tacit admission of defeat in this target in my opinion with physicians now believing that it is perhaps even dangerous to try to get down to normal HbA1c values in their patients. For those who understand that diabetes can be managed quite well by carbohydrate restriction, the achievement of normal HbA1c values is not surprising at all and certainly not dangerous.

My elevated fasting glucose suggests that I still have hepatic insulin resistance but not too severely.  It certainly isn’t leading to an elevated HbA1c and I don’t think I am experiencing hypoglycemia, at least that I can detect subjectively, so I am not too concerned with that one abnormal value.

As you can see, my kidney function is fine. My creatinine, which tends to rise if kidneys are diseased, is actually at the low end of the range, which is good. My glomerular filtration rate is also well into the normal range. That is good to know as kidney failure is a common complication of type 2 diabetes. Mine appear to be perfectly fine.

Ditto my liver. Based on these liver function test results, my liver does not appear to be under any kind of stress. So far, so good.

Now the interesting part, the lipid profile. Here is where I deviate a bit from the norm. My total cholesterol, LDL (so-called bad cholesterol) and HDL (good cholesterol) are all elevated. The numbers for cholesterol and LDL are not terribly high but if I were being managed according to the book, I would be a candidate for statins based on these results alone. In case you didn’t already know, I am not a big fan of statins, for myself or anyone else. I find the science is full of contradiction and I suspect that the evidence that statins are beneficial may be due to their anti-inflammatory effect rather than their effect on LDL.

Let’s look a little closer at my lipid results. My HDL is way up there, which is good because it turns out that the best predictor of cardiovascular risk is actually the Cholesteral/HDL ratio. In my case, I am well down into normal territory with that value. And my triglycerides are in the basement. This is good and is a common result of carbohydrate restricted dieting. Some argue that the ratio of HDL to triglycerides is a better predictor of CVD risk than the cholesterol ratio. If that is the case, I am in excellent shape here.

I also got an ApoB done for the first time. On it’s own, ApoB is supposed to be a marker of CVD risk. The ratio of ApoA to ApoB is supposed to be as good or better than the cholesterol/HDL ratio as a predictor. I didn’t get that done. Perhaps next time. ApoB also tells you something about the particle size of your LDL. Smaller particles are thought to be more dangerous. The lab didn’t report a normal range for ApoB but, digging around in the research literature, it is apparent that for men ApoB should be somewhere between 0.55-1.25 g/L. In a Framingham Offspring study, it was found that 1.00 g/L was at the 50th percentile and that men whose ApoB was greater than 1.20 had elevated CVD risk. With these data in mind, I am happy with my ApoB of 0.95 g/L.

As you can see, my thyroid appears to be functioning normally.

And, last but certainly not least, my CRP is very low. This may, arguably, be the most important test of the whole lot. We know that this whole range of chronic diseases, from obesity to metabolic syndrome to type 2 diabetes and cardiovascular disease, is underpinned by inflammatory processes. Jeff Volek et al, has been showing that if you follow a range of inflammatory markers, a low-carb diet delivers a powerful anti-inflammatory effect. We also know that these chronic conditions belie a state of high oxidative stress, as well. Oxidative stress and inflammation go hand in hand. We know that it is in that high inflammatory/high oxidative stress milieu that oxidization of cholesterol, damage to cell membranes, injury to blood vessels and interference with metabolic functions occur and that these drive chronic disease. If oxidative stress and inflammatory levels are low, the potential damage of higher LDL or elevated glucose is much less an issue. As I said earlier, it is perhaps the inflammation reducing effect of statins that delivers a benefit. Evidence in support of this idea can be found in the JUPITER study where a cohort of men with normal LDL but elevated CRP clearly benefitted from statin therapy.

I am not advocating statins, however, I am advocating carb-restriction. No drug, or combination of drugs, can deliver the range of therapeutic benefits that these blood tests demonstrate. I have a slide I use in my lectures which lists the 20 classes of drugs used to treat metabolic syndrome and type 2 diabetes. Meanwhile, one simple dietary change delivers a better result. If you subscribe at all to Occam’s Razor, you will know which is the right therapy.

These test results are consistent with my previous tests since I have been following a very low carb diet. Now, can you see why it is perhaps not irresponsible for me to test infrequently? Can you also see that, if more type 2 diabetics were to follow a low-carb diet as I do, there would be tremendous savings to the health care system, not just in testing but in reductions in complications as a result of improved management? At some point, the evidence will become so overwhelming that this will have to become the first line treatment. Or, the cost of the failure of the conventional approach will grow to the point that the current system of care will collapse under its weight.

I’ll report back again in a year or two … or three.

And a big thank you to everyone who offered to help with WordPress.

BTW – the fish was released.

Well, my beautiful little low-carb n=1 has had her first fever. Just a few days shy of her 2nd birthday she started running axillary temperatures between 39 and 40. No other symptoms, just a fever and lethargy. She was the perfect little patient, she stayed in our big bed all day sleeping and watching Max and Ruby on the tv. Not a peep of complaint. By the following morning, she was back to her normal active, chatty self, running around the house, dancing, chasing the cat, playing with balls in the yard – it’s hard to keep up. I think these mild childhood illnesses exist partly to strengthen the bond between parent and child. You feel so protective and close to them when they are sick at that age. Anyway, I can no longer boast that she has been completely free of fever although she is still yet to have a rash.

She is talking in complete sentences, now, too and she definitely has a lot to say. This morning, after sharing my breakfast of frittata, tomato and mayo, she said, “Thanks for the nice breakfast, Dad”. And she has discovered that it pleases me when she says, “Daddy’s car is good”. We are still on track with her low-carb high fat diet. It’s not so much that we don’t allow any carbs but that she isn’t attracted to them. My 11 year old son, for instance, sometimes eats brown toast with almond butter for breakfast and will offer some to his sister. She will sample the almond butter and leave the toast untouched. He has actually switched to scrambled eggs now with a little sausage or bacon which makes me happier. He is currently taking a sailing course where he spends all day on the water, solo in a small dinghy, so he needs a good breakfast. Both of them are thriving on diets virtually devoid of sugar and very low in starch. I really can’t see any justification for adding those types of foods into their diet.

Even though we are approaching the end of summer, the traditional time for reading a book or two, I want to talk about books because there have been a number of new ones published in the last year or so that I am recommending.

The first of the new batch, of course, is the latest in the Atkins diet series, “The New Atkins for a New You”. The Atkins Nutritional corporation, which owns the publishing rights, contracted with three researchers I know well to write the definitive update of this popular low-carb diet. Drs Steve Phinney, Eric Westman and Jeff Volek have all done excellent research on low-carb diets. Steve did his PhD work at MIT on high-fat low-carb diets in the late 1970s. He showed that exercise tolerance, which drops when you cut carbs, actually will return to baseline or better if you stick with the diet. This was lost on earlier researchers who stopped their studies before their subjects had sufficient time to adapt. Steve figured this out by reading the diaries of European explorers who lived among the Inuit and who ate the Inuit diet of 80% fat and 20% protein. He has continued to contribute to our understanding of diet and metabolism over the years both in academia and in the corporate world. His focus has been on the use of nutrients for therapeutic purposes and he holds several patents in this area. Eric Westman runs a clinic at Duke University where he treats diabetics with a low-carb diet and gets excellent results. He started researching low-carb diets about 12 years ago when he observed some of his patients using this method to shed weight and get off meds. He actually went up to Manhattan and met with Dr. Atkins to learn firsthand how the diet worked and what kinds of results one could expect. He then did one of the first modern trials of a low-carb diet which was published in 2002 and has continued to do research and publish in this area since that time. Dr Jeff Volek is a kinesiologist and registered dietitian at the University of Connecticut where he has a large lab and, at any given time, about 20 grad students. He has been publishing very well executed studies which show the benefits of low-carb dieting on a range of conditions associated with insulin resistance. I use his material in my lectures because they are the best resources we currently have to demonstrate the “efficacy” of low-carb diets vs the usual studies which demonstrate “effectiveness”. This is an important distinction since efficacy is what we want while effectiveness can be influenced by any number of factors that reduce compliance. When you look carefully at most of the low-carb studies, especially the ones that get published in high impact journals, they make a mess of the low-carb arm and therefore get poor compliance. Then an “intention-to-treat” analysis is used on the data which waters down the reported benefits of low-carb. Jeff’s studies are done properly, with high compliance, so that the benefits of low-carb are more clearly represented in the results. All that to say that this team of authors has the scientific and clinical chops to deliver when it comes to writing a guide on how to effectively do a low-carb diet. They have done a good job with this book and I have been recommending it to all and sundry. One of the things I especially like is that you don’t even need to read the book to get started, you can just go to page 246 where there are extensive meal plans, and start eating according to the diet. You can then read the book at your leisure as the pounds fall away.

The second recent book is the latest from my friend Gary Taubes, “Why We Get Fat and What To Do About It”.  After his 2002 New York Times article, “What if it’s all a Big Fat Lie”, and his subsequent opus, “Good Calories, Bad Calories”, established him as arguably the most knowledgeable and prodigious critic of the foibles of nutritional science in the western world, Gary has become an icon in the low-carb universe. I recommend GCBC but I know that many people find it too densely scientific to get through. To me it reads like a whodunnit and I couldn’t put it down but I had already been immersed in the science of nutrition for awhile. I think Gary’s publisher noticed that this was an issue, as well, and pressured Gary to write a lighter version that would be more accessible to the general reading public.  He has done a good job of that with WWGF. My wife couldn’t put it down and her science background is in math and computers. For anyone who wants to understand the history of nutritional science and that there are actually competing ideas as to what might be a healthy diet, I highly recommend this book. If you are new to this area, you will find things you assumed were bedrock in terms of nutritional advice are, in fact, highly debatable and, in some cases, outright wrong. One of the things my wife tells her friends when recommending the book is that it is not just about weight, it is about all aspects of health.

If those two books weren’t enough to completely fill a beach vacation reading list, my friends Phinney and Volek recently came out with, “The Art and Science of Low Carbohydrate Living”. After they wrote the new Atkins book, they wanted to develop a manual that could be used by physicians to manage their patients on a low-carb diet. I gather that the Atkins people weren’t interested so Steve and Jeff decided to go ahead on their own. I had met with an Atkins VP last summer at a conference in Switzerland where we had several conversations about where they could go with the brand. I felt strongly that there was enough evidence now to advocate this type of diet for the treatment of metabolic syndrome and type 2 diabetes and that the corporation should start targeting physicians. It seemed to me that to go in this direction would enhance their brand by getting more widespread buy-in from physicians and anything that promotes the diet would, I believe, increase sales of their products. The books, for example, could be recommended by physicians to their patients to guide them on the diet. At any rate, I gather that this was a no go, in fairness, possibly because the corporation was in the throes of another take-over at the time so Steve and Jeff set out to write the definitive physician’s guide on their own. The result is a book that, while it targets physicians, is accessible to the general reading public. It is written in a casual and, at times, witty style while providing lots of good information on the why’s and how’s of low-carbohydrate dieting. Some people who have read it have told me it is the most convincing of the low-carb books so far. The authors certainly have the scientific background to deliver what you need to know about the metabolic consequences of high-fat low-carb vs the alternatives and they do so in a way that is readily understandable and backed up with the appropriate citations. Another good book for anyone who is starting to question the current dietary recommendations for healthy living.

Okay, one more to go. Jeff O’Connell was a writer for Men’s Health when I first heard from his a few years back. He was interested in the study at Alert Bay and wanted to do a story on it for the magazine. He had developed an interest in diabetes and had begun to write about it. As it turned out, he was not able to get up here to visit the study but in the meantime did arrange for me to be featured as one of the 20 “Health Heros” in their 20th anniversary commemorative edition. A couple of years went by and then, out of the blue, I heard again from Jeff asking if he could visit. By this time the study had wound down so I suggested he follow me as I visited a string of First Nations communities in the north and spoke at a local diabetes conference in a small northern town. During those few days I learned that Jeff had developed pre-diabetes, that his father was severely affected by advanced type 2 diabetes and that he had a book advance to write about this epidemic that is now gripping the world. The result is his just published book, “Sugar Nation”. Now I am perhaps a little biased, and you may see why when you read his flattering portrayal of me in the book, but I am again highly recommending this book to anyone interested in learning about the diabetes epidemic and how we got into such a fix. His personal quest to understand his condition and his travails in obtaining helpful advice from the medical profession and the other authorities who are supposed to be leading us out of this morass becomes a damning expose of the madness of the current approach. His down-to-earth writing style and his ability to discuss the science in easy to understand terms make this book very accessible. He concludes that a combination of carbohydrate restriction and exercise is the solution to both the prevention and the treatment of diabetes and insulin resistance. I agree with him, although my focus has been more on the carbohydrate restriction side of things. I have to confess that after reading his book, however, I did shift my morning exercise routine from cardio to high intensity interval training. So far, so good. I’ll let you know how that has worked out once ski season starts.

I hope you find these mini-reviews helpful and I certainly encourage you to read any or all of these books to better understand how a seemingly simple shift in your diet can have huge beneficial consequences in your life.

If you are reading the low-carb, and some of the anti-low carb, blogs these days, you will find them buzzing with discussions about the recent Ancestral Health Symposium held in Los Angeles last week. The famous Loren Cordain described it as: “The Woodstock of Evolutionary Medicine”. It gathered together a bunch of the prominent researchers, clinicians and bloggers who are pursuing paleo/low-carb/ancestral diets of one sort or another. By all accounts it was a huge success. I have to admit that I wish I had attended. I was invited to speak but decided, for a number of reasons, not to go. Now I am regretting that decision.

At some point the lectures will be available for viewing on the web. I look forward to seeing them, but, as with all events of this type, it is the rubbing of shoulders, the hallway chats and the peripheral breakfasts and dinners with colleagues where one gets the most benefit. It would have been a chance to catch up with old friends like Richard Feinman, Gary Taubes, Mike and Mary Dan Eades, Jimmy Moore and others and to finally meet some of the nutritional iconoclasts whom I have been admiring from a distance; people like Tom Naughton, Loren Cordain, Robert Lustig, Denise Minger, Chris Masterjohn, and many more.

There are a number of reports and discussions I have been reading this past week. Perhaps one of the most interesting is a debate on the validity of Gary Taubes’ ideas on the aetiology of obesity which can be found at the blog of Stephan Guyenet who spoke at the symposium and was challenged by Gary in the Q&A. There is video of this exchange on the web and some buzz because people thought Gary was rude. This is interesting because I have heard that from other people, too, and it is sometimes used as a justification for rejecting his ideas. For the record, I have never found Gary to be rude to the point of objection. I would say he does not always suffer fools gladly and is averse to sugar-coating a blunt message. Perhaps it is because I survived a medical education where those were the orders of the day, or maybe it’s because I pretty much agree with everything he says (and remember, I come from Canada where it is more important to be nice than it is to be right), or maybe I am tone deaf to rudeness, but any way you slice it I think Gary has a lot of very important things to say and we should listen. So, I don’t find Gary’s challenge to Stephan to be objectionable. Beyond that, however, it seems to have become a point of departure for a debate on the merits of the carbohydrate hypothesis. I would encourage you to have a look at Stephan’s blog (www.wholehealthsource.blogspot.com) if you are interested in some thoughtful discussion on this topic. For the record, none of the counterarguments so far have swayed my conviction that carbohydrate-restriction is the preferred therapy for the range of conditions associated with insulin resistance.

There’s nothing like a good debate, however, to sharpen your focus and make you re-evaluate your evidence. No harm in that.

Now, I am trying to insert a photo here to show what I would have missed had I gone to the symposium but I can’t get the photo uploaded. If anyone with WordPress expertise can help me troubleshoot this, I would appreciate some advice.