Carbohydrate Intolerance, Institutional Intransigence

It is time for me to share with you the story of Jimmy. He is a respected leader among the Kwakiutl people of Vancouver Island. He is educated and cosmopolitan while also remaining down-to-earth and connected to his home community. He is a bright, intelligent and good-hearted man. I am honoured to count him amongst my friends.

Not that long ago he was also a classic example of the devastation that metabolic syndrome and type 2 diabetes are wreaking in the Canadian Indigenous population. At 48 years of age he had been taking insulin for 17 years. Even with four shots a day of two types of insulin he was not able to get his soaring blood sugars under control. He was medicated for high blood pressure, which also remained stubbornly high. His lipids were bad and his doctor wanted him to start taking a statin. He was significantly overweight and had already suffered from a stroke. He was definitely on track for a bad outcome and likely sooner rather than later.

At that time, I was speaking out about my own diabetic experience where I had corrected everything in very short order by simply removing carbohydrates from my diet. When addressing a First Nations audience, I would draw parallels between my modern low-carb diet and their ancestral diet which was very low in carbs in this part of the world. Jimmy heard me give this talk a couple of times and then the penny dropped. He decided to try eliminating carbs from his diet.

He went to his health centre and got weighed and measured and then he started sending me email updates. I got the first note after two weeks and he reported that he had lost 17 lbs and was now getting normal fasting blood sugars and had stopped taking insulin. Completely. Consider that for a moment. Years of struggling to control blood sugar with heaps of insulin, injecting four times a day, and failing. And now, after one simple dietary intervention, he is completely free of the needle and running normal values.

A couple of weeks later, he reported a total weight loss of 31 lbs and was now normotensive and free of his antihypertensive drug. At nine weeks, he had lost 37 lbs and was continuing to record normal blood pressure and blood sugar readings. At 18 weeks, his total weight loss was 46 lbs and all his markers were normal on no medications. He had his lipids done and those were also within normal range, now, as well.

I asked him if he had exercised as part of this intervention and he said “no”. All he did was take starch and sugar off his plate. And he did this without any books, videos or coaching. At this point, he was still very overweight, yet he was metabolically normal.

That was seven years ago. In the ensuing interval, he has been able to maintain normal cardiometabolic markers as long as he complies with his carb-restricted diet. Apparently there have been a couple of instances of relapsing to a carb-rich diet with predictable results. He reports that the first thing he notices when he eats carbs is that he is suddenly hungry all the time. Then everything goes sideways. His BP goes up along with his blood sugar and his weight. Then, once he gets back on the diet, everything normalizes again.

What I find really remarkable about his story is how clearly it defines the fact that type 2 diabetes is a food intolerance. He has an intolerance to carbohydrates. When he eats them he gets into all kinds of metabolic trouble. When he avoids them, he is fine. When I trained to be a doctor we had a lecture on how you diagnose a food intolerance. That is how it is done. Jimmy is intolerant of carbohydrates and so is everyone else who has diabetes and, I would argue, metabolic syndrome or any other manifestation of insulin resistance.

The excellent series of studies done by Jeff Volek at the University of Connecticut have demonstrated quite clearly that all the features of metabolic syndrome get better on a low-carb diet. Eric Westman at Duke has published evidence that type 2 diabetics do very well on a low-carb diet, much better than on a low-glycemic index diet or a conventional diet. Others have published similar findings in the past, Frank Nuttal and Mary Gannon at the University of Minnesota, for example, who showed that type 2 diabetics can achieve normal blood sugar control by simply restricting carbs and that this can be done in the absence of weight loss.

So the evidence is out there and has been for awhile. Yet, we have a medical establishment that insists that people with profound manifestations of this food intolerance should eat more than half their calories from the very foods they cannot tolerate. And to accomplish this, that they should take a plethora of medications and eventually start injecting insulin, as well.

What’s wrong with this picture?

I was in Denver last week at the annual conference of the Nutrition and Metabolism Society. One of the speakers was a professor of nutrition and medicine, a high ranking functionary in the American Diabetes Association and somebody who is directly involved in producing the guidelines that I find so perverse. I was the moderator of the session in which she spoke and was invited to join her, along with Richard Feinman and Eric Westman, for lunch. I think it was perhaps a little bit inhospitable and maybe even unfair to expect her to defend the whole corrupt edifice of conventional diabetes management but that is essentially what happened as we ate our various salads in the hotel dining room.

Her position was that the ADA relied on the available evidence to make care recommendations and that there wasn’t sufficient evidence to support a low-carb recommendation at this point in time. Okay, fair enough, I guess. They shouldn’t run off half-cocked and should do their due diligence to make sure the recommendations are soundly based in good science. The problem, however, is more nuanced than that. The problem is that the system is exquisitely designed to protect the status quo and it does this in many ingenious ways. The typical review process will set boundaries in terms of which studies can be considered as valid evidence. A typical requirement would be a minimum size for the cohort studied. Obviously, larger numbers give you more accurate information on whether something works, is safe, etc. so this is done for valid reasons. To a point. This is a big problem for the low-carb studies because the researchers who know how to do a proper low-carb trial, who get good compliance and whose results show the true benefits of the diet have real difficulty getting funded from conventional sources. There is a strong bias against this kind of diet, it is viewed with a lot of disdain among conventional nutritionists and some people think it is downright harmful.

Richard Feinman argued that the cut-offs are arbitrary, that there is no evidence that data from a cohort of 10 is any less valid than a cohort of 100. While there is an argument for larger numbers in order to generate sufficient statistical power, he is right in the sense that when the effect size is great (as it is with a low-carb diets) the results from a small number of subjects can be statistically significant and should not be ignored. I would argue that even case studies, like Jimmy’s story, are valid evidence, surely valid enough to justify further research, if not a policy change. Consider Banting and Best. How many subjects did they try their newly discovered insulin on before it became the default treatment for diabetes? How many randomized clinical trials did they run? How many review committees sorted through the studies and generated recommendations?

In any branch of science it is always hard to advance research that supports an idea that is orthogonal to the currently accepted paradigm. To get funded from conventional sources, your research proposal is reviewed by a committee of “experts” who come by their status having advanced through the ranks of believers in the current dogma. They are not going to look favourably on a research proposal that challenges the fundamental basis of their belief system. In this respect, the business of science looks more like a faith-based endeavour than a rigorous attempt to find the truth. At any rate, the upshot is that good research in support of low-carb diets will be under-funded and, thusly, will have smaller numbers. And when the research reviews are conducted, they often fall below the cut-off and their findings are therefore ignored in the setting of policy. (By the way, I have intimate knowledge of how this works as I have sat on research review committees and have watched the defenders of conventional dogma in action.)

So, my ADA colleague’s response to our pleas for the inclusion of a low-carb diet in the guidelines was easily brushed aside for lack of evidence. The system preserves itself at the cost of how much human suffering?

Richard was practically choking on his bunless burger in a fit of apoplexy during this part of the discussion so I whipped out my laptop and pulled up my PowerPoint slides which detail Jimmy’s story. I told her that there was an inexplicable disconnect between the clinical “coal face” and the echelons where research agendas are set and where evidence gets translated into policy. I talked about how his story was not unique, that there are plenty of others like him. Eric confirmed that, in his clinic, he sees these kinds of results all the time. And yet, there is an apparent total lack of curiosity in the research establishment to explore the potential of this powerfully therapeutic intervention. I said that if I had administered a drug to Jimmy to get those results, the research establishment and drug industry would have been all over this in a heartbeat. Richard added that we would all be wealthy from buying stock in the company that brought such a drug to market.

She was unmoved. Her immediate response on hearing Jimmy’s story was that “everyone is different”. Her more extended response was that low-carb researchers should continue to submit proposals to the hostile (my word, not hers) review committees and hope to eventually get funded and then included in the evidence that is deemed substantial enough to influence the guidelines.

Lunch ended shortly after that and she left as expeditiously as she could without actually breaking into a trot. I felt a little badly that we had thrust the whole burden of defending the indefensible onto her shoulders. On the other hand, I don’t know what else we can do at this point but to shout from the roof-tops that an inherently corrupted establishment is ignoring a simple, safe and effective intervention that has the potential to relieve an enormous amount of human suffering while saving the health care system from bankruptcy, even when the evidence is in their face. At some point there has to be some kind of reckoning, some form of accountability for this enormous malfeasance. I hope I see it in my lifetime.

And so, back to my friend, Jimmy. A lot of people will concede that amazing results can be achieved by a low-carb diet in the short term but will argue that nobody can sustain such a “restrictive” diet over the long haul. A few months back, Jimmy sent me this photo along with a report that, after seven years, he has lost another 50 lbs and is consistently maintaining normal cardiometabolic markers on no meds.

Have a look and decide for yourself whether this is evidence that a low-carb diet should be considered a valid therapy for metabolic syndrome and type 2 diabetes.


(Jimmy has given me permission to share his story and show his photo)


25 thoughts on “Carbohydrate Intolerance, Institutional Intransigence

  1. Excellent post, Dr. Wortman. Thank you for sharing Jimmy’s story. I wish him all the best and I hope that he will stay on his ketogenic diet for life.

    (BTW, I also find your own story very inspiring. I recently finished reading “The Art and Science of Low Carbohydrate Performance” by Drs. Volek and Phinney and the section about your life (pages 131-137) reads as a Hollywood movie.)

    I am not and have never been a diabetic but I use a ketogenic diet to manage my weight and to preserve my health. I think that everyone has to take responsibility for their own health. The Internet technology has changed everything and has provided all of us with much easier access to information and knowledge sharing. In today’s world, we cannot expect (or afford) to be a passive “receiver” of health services and health advice. We must take a much more active role in the process of managing our own health and our country’s shrinking healthcare resources. We cannot delegate or outsource that to either politicians or health care professionals.

    Older doctors may not have skills to engage in what Ben Goldacre calls “working collaboratively with the patients towards an optimum health outcome”. However, younger doctors (i.e. Gen- Y), who grew up collaborating on the Internet and challenging authority, do have those skills and I am confident that things will be moving in the right direction sooner rather than later. These Gen-Y doctors will soon be professors at medical schools, will have much more control over the curriculums, and will not be afraid of considering non-conventional approaches while “working collaboratively with the patients towards an optimum health outcome”.

    In the meantime, we must all do as much as we can to contribute to knowledge sharing and the promotion of a collaborative approach to health management. We must all strive to become informed consumers of health care services.

    Dr Jay’s Reply:

    Thank you for your comments. I do think that educating the med students is important. I give an annual lecture to the medical class and it seems to have become quite popular. This gives me hope.

  2. An exceptional post. I often despair/marvel at how well-meaning people can be so adept at blocking forward movement without ever suspecting they might be doing a disservice to others. This post helps illuminate that. I think there is also a widespread, terrible education in science, such that people with graduate degrees are no longer able to understand that a single instance is sometimes enough to refute a theory.
    Perhaps while I’m writing I can ask you a question: do you know of any harm from being in ketosis for a long period of time? (ie. weeks or months or more)

    Dr Jay’s Reply:

    I agree. Even a PhD is not necessarily a sign of a discerning, analytical mind, as it should be, unfortunately.

    As far as I know, there is no harm in long term ketosis at the physiological levels that result from carbohydrate restriction. I am counting on this to be true as I am approaching the 10 year mark myself!

  3. Thanks Dr. Wortman for sharing another inspring story.

    I’d like to share my story as well. I’m a resident of Ontario and have been told by my doctor that I have Impaired Glucose Tolerance for the past 5 years. Unfortunately my recent blood work showed quite bad numbers and I was told that I had slipped to the “dark side”. I started immediate research and found your story – from the Youtube video of your interview to this blog. I started practicing the low-carb diet right away and I think I have experienced similar situation as when you were first diagnosed – all my numbers (FBG and before and after meal numbers) dropped back to normal range within a matter of a days.This is truly amazing!!!

    I had also researched other diet including the vegan diet, I think it would probably work as well however your diet is way practical and could really be a potential life-saver for a lot of people.

    As a newbie, one question I’ve been thinking is that what is the difference between “control” vs. “reversing”? My take-on is that I know my pancreas is probably a bit damaged compared to a normal person in a way that they can eat carbs – their BG will rise but the pancreas can still regulate that, i.e. bring the BG back to normal within a few hours. We diabetics probably can’t – however, by “reversing” does it mean that not only we can control the diabetes, but our metabolic system can go back to normal or near normal status after a period of time? I know that diabetes is an incurrable disease “officially” – however in your practice, are there any patients “reversed” their diabetes if they were in a very early stage of diabetes?

    Much appreciated!

    Dr Jay’s Reply:

    I am sometimes asked whether my LCHF diet has cured my diabetes. I don’t think it has for this simple reason, if I start eating a high carb diet I will reliably get into metabolic trouble again. Whatever it is that has been damaged in my metabolism, it is still damaged. The way I look at it now is as I have discussed in the post; it is a food intolerance. When treated as such, everything is fine. Would I like to go back to eating carbs? Perhaps when I see a nice Key Lime pie or something like that I have a little twinge of temptation but the fact is that I am quite happy with my LCHF diet and am never far off my 20-30 gm/day carb intake. The temptation to eat sugary and starchy things has pretty much gone away. So it becomes somewhat moot whether I have been cured or not. I do watch the science in this area and will be interested to see if others demonstrate a “cure”, especially the research that is looking at bariatric surgery patients.

  4. “Taking candy from a baby” , will always elicit a very “screeching” and very definite and defining moment.

    Then we whimper.

    — Psychological and physical pain we have inflicted.


    Like a needle.

    Albeit, big babies that we all are.

    Every single one of us.

    We don’t know that it’s for our own good, — nor that we are addicted and drug addicts onto ourselves.

    We simply want our candy back.

    We only know that we suffer and want our sugars and starches back into our lives.

    We don’t know that we are “high”, and it’s our “high”, we want back.

    We want to be high.

    We have never known “not being high”.

    We think it’s plain and dull, when in fact it’s robust and energetic and tastes great.

    Once you get their.

    But we don’t know that and we also easily forget.

    Our addictions draw us back.

    Like heroin addiction

    But we don’t know that either.

    Great work Dr. Jay! — Keep it up!

    Dr Jay’s Reply:

    There is definitely a link to addictions in all of this.

  5. Jimmy really was a poignant story but it was a tough lunch. I do not think, however, that “she was unmoved.” She was defensive and, as you say, none of us had really prepared for a debate at lunch but she was genuinely surprised that we did not recognize that the ADA was the great scientific judge and that we dared to think that we were not all amateurs following Dr. Atkins. I think she genuinely did not know how arrogant and hostile her attitude is living in the environment that she does. It is not just that the cut-off for the number of subjects is arbitrary. Your example, incidentally, is perfect: Banting only needed one experiment but it took many to convince McCloud who was the director of the lab. When he finally got it, he jumped in and the Nobel Prize was given to Banting and McCloud. Banting shared the money with Best who had done most of the laboratory work and Banting spent the rest of his life hating McCloud. It is not just that the number of subjects must fit the question that you ask. It is the arrogance which, again, I think she was not aware of, in dismissing Nuttal & Gannon’s work. The assumption is that they are somehow incapable of doing the right experiment, that they chose 8 subjects because they don’t understand science or don’t have the high standards of the ADA. Why did they choose to do eight subjects? They are very careful scientists and must have thought that that would bring out the relevant points. If the ADA committee did not think the design was inappropriate, they should cite it and and explain why. To assume that they know better and just ignore their work is hostile and inappropriate. In their most recent work (available without subscription at they show individual data for eight subjects. All but one had dramatic improvement on the low carb diet. What would be gained by adding two more subjects? The final irony is that the earlier work that I showed in my talk and that they ignored was, in fact, funded by the ADA. It was a tough lunch. And my hamburger was over-cooked.

    Dr Jay’s Reply:

    Thanks for adding to the Banting and Best story. I have always thought that when we do hit the tipping point, it will be the ones who were the biggest impediments who will step up to take all the credit for this great discovery. Sorry about your burger; my Cobb salad was kind of marginal, too. On the other hand, the Brazilian steak house dinner was terrific.

  6. Thank you very much Doctor for your response.

    Another question I have is that besides the ketosis topic you discussed, we know that in a traditional/ main stream view, the pancreas and over all metabolism functions of T2D patients will “inevitably” deteriorate over time – is this true in your view for someone on a LCHF diet? Based on what you have experienced in the past ten years – can we assume that as long as we don’t irritate the system with high carb diet, it will stay stable if not improved over long period of time or even life time? e.g. 10 years so far in your case and 7 years in Jimmy’s case.

    Thanks again in advance.

    Dr Jay’s Reply:

    It has been shown that beta-cell capacity drops once insulin resistance is established. This decline continues even after medications and insulin are started. I suspect that a low-carb diet can arrest that decline but I don’t have evidence to support that. It would be something to test in a long-term trial but that is an expensive proposition and I don’t think the funding agencies are predisposed to support that kind of trial at the moment, unfortunately.

  7. It’s also interesting that you mentioned the Bariatric surgery. Another report I read was a research team led by Prof. Roy Taylor at UK’s New Castle University completed a project to mimic the acute effect of this surgery by limiting newly diagnosed (<4 years) T2D patients' energy intake to a miminum 600 Cal a day for 8 weeks. They proved that T2D could be reversed and after 8 weeks most of the patients' pancreas functions improved to near normal status.

    Dr Jay’s Reply:

    I am aware of that study. I pretty much proves that it is not the surgery that delivers the post-op improvement but rather it is the diet. It will be interesting to see if the “cure” they report is sustainable. I think it would be hard to adhere to that kind of diet for long and impossible once weight loss stops. If they return to a high carb diet at that point, I think they will run the risk of a relapse of their diabetes. I think the long term sustainability would hinge on eating basically a LCHF diet from that point onward. I suspect that won’t be their choice, however.

  8. This story should be putting some of the drug companies out of business but sadly change seems very slow.

    Firstly I must comment that this website is a very valuable resource, I have sensed that carbs do not work for me for about 20 years and have slowly moved away from eating them with positive health benefits.

    When my first child was born 9 years ago we decided no sugar and wheat/gluten.
    This has worked well for both our children.
    Since reading the information on this site 9 months ago we have made more changes and had more benefits.

    One of the most useful insights was that high blood sugar causes the immune system to not work so well, since we have been more firm in adhering to this way of eating, illness has been absent from our family, no sore throats or other illness coming home from school with the kids, remarkable!

    My wife has lost 10kg with no extra exercise (but still plenty of occasional treats, she can resist anything but temptation) even more remarkable!

    Our children and myself all had trouble sleeping after a high carb meal, now we all sleep well, and the children are calmer.

    And most surprising, everyone’s bowel movements have normalised.

    thank you, this has made a huge difference to our quality of life.

    Dr Jay’s Reply:

    I am so glad to hear you and your family are all benefitting from this way of eating. I have travelled in your part of the world and actually wrote an article that was published in the health promotion journal there a few years back. I never got the feeling, however, that there was much uptake on LCHF at the time. I hope that is changing now.

  9. Forgot to mention, as you would expect our children have nil tooth decay.

    Dr Jay’s Reply:

    While it makes intuitive sense that eliminating sugar and starches would reduce the likelihood of dental caries since the bacteria in the mouth that cause the decay would have nothing to feed on, it turns out that there is a systemic component to dental health that may be even more important. Here is an article that explains how that works. I think you will find it very interesting:

  10. Gary Taubes, Peter Attia, and others are creating “NuSi” to raise private money for low carb research. I think this is the only way to bring well-done studies into the system.

    Unfortunately, I can see such studies being rejected by the ADA because of claims that the funding source is biased. Meanwhile studies funded by drug companies, big agriculture interests, and soft drink companies will contiue to be used.

    What you’re doing–that grass roots, one patient at a time approach may seem like drops of water in the ocean, but the momentum is gaining. Sooner or later patients are going to walk into their conventional medical doctor’s offices and demand the approach that their friends and neighbors are doing so well on.

    Don’t give up hope–keep on!

    Dr Jay’s Reply:

    I am looking forward to the launch of NuSi which I think will happen sometime this summer. I hope they can get some of the needed studies underway. The problem will still remain, though, that the reviewers can easily ignore compelling evidence by making arbitrary decisions in terms of which studies to review. And, as you point out, they can also infer bias because of the funding sources. I do think it will take a groundswell from the grassroots to push this over the top. It’s not going to happen because the current establishment has a sudden epiphany. That’s why I continue to try to change the world, one airline passenger at a time (I travel a lot and whoever has the misfortune of sitting next to me usually gets the full indoctrination between wheels-up and down).

  11. Thank you so much for this blog. I appreciate the work you are doing to try and move the science forward. I’ve been mystified why the low-carb approach is considered so controversial, when it is absolutely clear that it is a REQUIRED and necessary dietary approach for me personally.

    I was lucky that I was first introduced to low-carb by a family physician in the early 1970’s when it was briefly popular… at the age of 12, I dropped 20 extra pounds on it. Then I went off it. Since then, every time in my life I have gone off it, I had health problems. When I have started again, I’ve improved tremendously. Yet, no physician since then has ever recommended low-carb as the answer– it was just a trial and error process of me deciding to go back on it, because I know it works.

    Some of the health issues have been two pregnancies with gestational diabetes. I also have a completely fatty-replaced pancreas (noticed on a scan for something else). No doctor has ever been able to explain the pancreas… but recently I read a new study about a link between fatty pancreas and metabolic syndrome. To which I say…. duh!

    After going through menopause off the diet I gained 35 lbs, had high blood pressure for the first time ever, and was diagnosed “pre-diabetic”. I have been back on low-carb since then.. the entire 35 lbs are gone, and blood pressure and sugar back to normal.

    In truth it is not at all hard, instrinsically, to stay on low-carb because you just stop caring about carbs whatsoever. The only difficulty is social, because sugar is in everything.

    Dr Jay’s Reply:

    It is unfortunate that you had to figure this out for yourself with so many set-backs along the way and with no support from the medical profession most of the time. Hopefully that will be changing soon as physicians are getting more exposure to the LCHF literature.

  12. There is certainly no current “mainstream” acceptance or even awareness of LCHF here, however it is happening slowly, I believe it is inevitable.

    My Family has spent time living and working in remote locations amongst our indigenous population, we have seen first hand how they suffer serious problems with high carb diets, their traditional diet of course is LCHF, early drawings by European settlers show a healthy and athletic population, its very sad since the solution is not a complex one.

    I have read that in the case of some over weight diabetics the condition could be reversed by an extreme diet for a few weeks, the suggestion being that it was caused by fat deposits in the pancreas? I find this a little doubtful, certainly in my own case I have had problems with carbs for as long as I can remember and it hasn’t really changed, I still find I can tolerate a small amount with no problems. (I have never been overweight)

    I really like that you call it carbohydrate intolerance and that the solution is simple and very effective, its a very positive approach.

    Labelling it diabetes and then being faced with living with the condition and managing it using conventional medicine is fairly daunting and pretty depressing.

    You have given a lot of people hope and direction, and I guess a second chance.

    Very interested in the information on diet / dental caries oxidation, I worked in engineering so no medical training however I have studied my own condition for 30 plus years…..I noticed before I became as focussed on LCHF I would get very frequent sore throats/swollen glands that just wouldn’t go away and they were always initiated by events such as birthday parties or celebrations with the consumption of some alcohol and sugary food, over a period of many years I saw a clear pattern, I had assumed that it was caused simply by getting over tired since I don’t sleep at all well after carbs but thinking in terms of oxidation maybe there was more to it. I have had no illness since being strict with my diet despite being forced to work through the night on a couple of occasions, previously this would have guaranteed me “illness”.

    The older I get, the more i question accepted wisdom.

    This article also made me think, could a mothers diet have an effect on the developement of their childrens teeth, (I have 2 sets of friends whose childrens teeth have not developed properly) I had not even heard of this condition previously and suddenly I know of 2 cases personally?

    What other problems could a mother unwittingly cause her unborn child because of diet problems if she was intolerant of carbs?

    Dr Jay’s Reply:

    I have Aborigine friends and have visited some of the remote regions where they live. They tell me stories of their traditional diet which suggests to me that they valued fats and ate a diet that was fairly low in starch, devoid of sugar, moderate in protein and high in fat. When you look at what they eat now it is no wonder they are experiencing terrible epidemics of chronic disease. Ironically, Dr Kerin O’Dea, one of the famous Australian researchers who demonstrated that diabetes among Aborigines could be virtually cured by a return to a traditional way of life, believes passionately that they ate a low-fat traditional diet. I got into a rather heated argument with her on this issue at a diabetes conference where she wanted to enshrine this idea into a policy document for indigenous people everywhere. She was quite annoyed with me for pointing out that where I work, the indigenous people ate a very high fat traditional diet.

    On the dental issue, yes, I think there are possible effects of high carbs during gestation that can have an impact on the infant. The whole area of epigenetics is fascinating in this respect. In the 1930’s, Pottenger showed that the effects of a poor diet fed to cats could still be found three generations later. We now understand that epigenetic effects are important in human health, too, and can be transmitted across generations. Weston Price, also working in the 1930’s, elucidated the effects of a diet high in refined carbs and sugar on the development of the jaw and teeth. This explains why so many people in modern times have crowded teeth and need orthodontic work. So, although I don’t have all the details about those dental cases you mention, I would not be surprised to find that there was a direct link to maternal nutrition. And, now there is evidence that obesity and type 2 diabetes are also influenced by epigenetics.

    The effects of sugar on immune system function is another important issue. In an earlier post on this topic, I have included links to a couple of studies done over forty years ago that demonstrate how, even a small dose of sugar, can impair the response of your leukocytes to invading pathogens. I, too, have observed that I rarely succumb to any kind of virus or bacteria since cutting the carbs from my diet.

  13. Dr. Jay:
    Just wanted to let you know that we got the new Phinney/Volek book. My partner Ken (retired physician and avid cyclist with no family history of insulin-resistance) devoured it and I am reading it slowly. Since finishing the book, Ken became re-determined to follow a ketogenic diet (he had great success last summer – biking season – but fell off the wagon over the winter, although he didn’t eat nearly the SAD level of carbs, but beer is his nemesis). We have been able to start our serious training for two multi-day road trips coming up in June. Three days in a row, we skipped breakfast, then hit the bike trails and did rides of 36, 54, and 17 (with major hills) miles. Following our rides, we drank mugs of homemade beef broth with a tablespoon each of coconut oil and Kerrygold butter. Absolutely delicious, and neither of us felt like eating a full meal. Later in the day, we had a normal meal of a small rib-eye steak, Caesar salad with my homemade dressing, and cooked vegetable such as brussels sprouts. We were not fatigued and had no muscle soreness and were ready to get up each morning and hop on the bike again. I am absolutely amazed that we can do this; it seems almost superhuman. You may remember that I am a 59-year old music professor with little athletic inclination (and a significant family history of metabolic syndrome including three generations of “type II diabetes)who only took up cycling 5 years ago. Ken is the animal – at age 70 he can ride like the wind and pass all the young guys on the trail. I do not believe that my fitness level comes from the biking – the ability to bike is the result of my diet.
    We bought some ketostix today (I used to test, but quit years ago) and both of us measured at a moderate level of ketones.
    Although I’ve followed your blog and other postings :), I enjoyed reading your “testimonial” in “The Art and Science of Low-Carb Performance, ” which I am recommending to everyone I know.
    Finally, my former student, who just had preemie triplets, posted on Facebook that she motivated herself to get up at 4:00 am with a pop-tart. I could not hold back, and wrote a lengthy reply suggesting she really did not want to feed herself or her precious babies that garbage and recommended that she read about you and Issy and directed her to this blog.

    Dr Jay’s Reply:

    Great story! It sounds like your husband likes to bike the way I like to ski. Good for him!

    The story of the young mom is sad. I admire you for jumping in with advice although it is a very tricky situation. The last thing people want to hear is that they might not be good parents. I hope for the sake of those kids that your input was well received.

  14. Dear Jay,

    I am a clinical pharmacologist in London, Ontario. I have been discussing diet with Gary Taubes, Peter Attia and others. Here is my issue. I’ve been on low carb since Nov 2011 and made remarkable progress – reduced weight to 133 lbs. (37 lbs of weight loss), reduced my hsCRP by 70%, increased my HDL by 50%, reduced my triglycerides by 80%, etc. I was not substantially overweight but I was on the road towards metabolic syndrome (borderline BP, low HDL, high trigs, increased waist circumference). It all sounds great and typical so far, but here is the problem – my LDL-C went up to 6.56, my total cholesterol went up to 8.4, and my colleagues all thought I had suddenly developed familial hypercholesterolemia!

    I wonder, and some seem to agree, that certain individuals may be innately predisposed to hyperabsorb dietary cholesterol from eggs, red meat, high fat dairy and so forth. Have you experienced this in any of your patients? I don’t yet have the “after” results of the following changes that I made – start crestor (rosuvastatin) at 10 mg/d and replace alot of dietary cholesterol and saturated fat with leaner protein sources (fish, nuts, egg whites, tofu, chicken). I have not eased up on the carb restriction but I am restricting my fat intake. It hasn’t been easy as I really enjoyed the steak, cheese, whipping cream, cream cheese, lamb and other red meat sources.

    Incidentally, my homocysteine more than doubled on LCHF (low carb high fat) – from 7 to 17, despite having a B12 level over 600. I don’t know why this is – perhaps an issue with renal filtration or methionine loading from all that meat (though the literature does not seem to support this). Epidemiologically, homocysteine is an important risk factor, although it does not seem to be treatable in randomized trials.

    I would very much like to hear your input on dietary-induced hypercholesterolemia in people who go on LCHF. What proportion does this occur in? I looked up evidence from a large meta-analysis of nearly 1,000,000 people, which suggested that with my total cholesterol, I had about a 12-fold increased risk of dying from ischemic heart disease than I was at baseline. This prompted me to make the changes I wrote about above. Looking forward to your comments – and great blog, by the way!

    Dr Jay’s Reply:

    One of the constraints of doing this type of blog is that I cannot practice medicine using this venue. This is true for a number of reasons which include liability issues and the fact that I am not your doctor and don’t have access to the full range of information that a doctor needs to provide medical advice. Having said that, I can make some general observations. I have not actually seen this kind of reaction in my own personal experience although I have heard this can happen. Generally, what I have seen is a more modest rise in total cholesterol and LDL-C. One thing to remember when looking at LDL-C is that a very low or very high triglyceride reading can confound the LDL number by as much as 20%. In terms of mortality risk, total cholesterol is actually a poor indicator. In Framingham, for instance, mortality rates went up as total cholesterol went down. LDL-C on its own is also not a terribly good indicator of CVD risk and this is especially true when you are eating a LCHF diet (for reasons expounded by Braithwaite, below). Recognition of the deficiencies of using a single marker like LDL-C is evidenced by the fact that we also look at the ratio of total cholesterol to HDL. It turns out that an even more important ratio is that of triglycerides to HDL. The significant drop in triglycerides and rise in HDL that a LCHF diet delivers will shift the TAG/HDL ratio in a healthy direction. A ratio of less that 2.0 is considered good and lower is better (I take comfort in the fact that my own ratio is usually around 0.3). As far as statins go, I am not a big fan. I think their benefit is not that great and appears to be demonstrable in a fairly defined subset of patients, ie older men with demonstrated CVD and, even there, it appears that their benefit may derive from their anti-inflammatory properties rather than their ability to lower cholesterol. Not everyone agrees with that opinion, however, as I am sure you know.

    A final general observation: a LCHF diet is such an enormous metabolic game-changer that much of what we know from existing research may need to be re-examined in a LCHF setting to be relevant in that setting.

    I am sorry I cannot offer more direct insight into your personal situation.

  15. Dan, of the 1,000,000, how many were on a low-carb diet? High LDL-C on a high carbohydrate diet is different than on a low-carbohydrate diet. The LDL on high-carb are likely transporting lots of triglycerides and the high LDL-C indicates a proliferation of LDL particles (high LDL-P), especially small dense LDL. If on a low-carb diet triglycerides are low and HDL is high, the LDL-P may be fine and the high LDL-C merely indicates a preponderance of large and bouyant LDL particles resistant to oxidative damage. The same number of LDL-P can have high LDL or low LDL, depending on how much cholesterol is in the average LDL particle. For the same number of LDL-P, higher LDL-C is a good thing, in terms of CVD risk.

    I too have found my LDL-C went up a lot, but every other CVD risk factor indicates significant improvement. My TRG:HDL ratio, for example, is 0.23 (using mmol), well into the ideal range with the lowest CVD risk. My blood pressure has decreased from 120/90 to 95/65. Along with the low-carb and increase in LDL has come reversal of greying (grey hair disappeared), much improved skin health (softening of skin my wife envies), loss of wrinkles, reversal of tooth decay. My skin seems to respond very positively to dietary coconut oil, which seems to raise my cholesterol (removing coconut oil lowered my LDL but negatively affected my skin suppleness).

    The nutritionist Barry Groves argues healthy total-C should be 7 or 8 (for the reduced-carb diet he advocates) to minimize all-cause mortality.

    I am curious as to why LDL would increase, of course, and especially whether it is an adaptive, beneficial response, but I remain unconvinced it is a CVD risk on a reduced-carb diet, especially where LDL-P is in normal range.

  16. First and foremost, I would like to thank both Jay and Murray for responding to my post. This issue has been bothering me for a long time. I am not really looking for direct medical advice, but rather, since I counsel many patients, it is important I get the science right so that I don’t hurt others (primum non nocere – “first, do no harm”). Because of the really dramatic rise in my LDL and total cholesterol on a low carb liberal fat diet, I started a statin and swapped out much of the dietary cholesterol and saturated fat within my diet.

    My LDL has always been in the 4 to 4.5 range, and on crestor 5 mg every other day (a regimen I took a couple years ago), the LDL was actually a pretty decent 3.0. After 4 months of LCHF, the LDL jumped up to 6.56 and total cholesterol into the mid 8’s. These values are fairly typical of what one would see in a condition called heterozygous familial hypercholesterolemia, which produces symptomatic atherosclerosis (heart attacks and ischemic strokes) in one’s 30’s, 40’s, and 50’s (i.e. premature atherosclerosis). Analysis of apoB confirmed the LDL finding was not false or due to a triglyercide issue (admittedly my trigs are now quite low, at about 1.00).

    The other interesting thing – and I found out about this just the other day – is that my homocysteine level jumped – from 7 to 17. Now admittedly multiple randomized trials do not demonstrate any benefit for lowering homocysteine, but epidemiologically it remains a very important risk factor (e.g. recent paper in J. Am. Coll. Cardiol. showing that homocysteine possesses a very good ‘net reclassification index’). My serum B12 was fabulous, at greater than 600, so I do wonder if the increase is either 1) artifactual; or 2) due to methionine loading in meat (although the literature I have found suggests that vegans have much higher homocysteines than meat-eaters – makes sense, as they are B12-deprived).

    In summary, my LDLc and apoB jumped to tremendous levels on a low carb high fat diet, putting me at or above the 95% percentile for risk. From what I have figured out and read on my own, a small proportion of the general population (5-10%?) likely possesses genetic mutations in cholesterol transporters in the small intestine which makes them ‘hyper-absorbers’ (I can only assume I am one of them, since there were no other changes over the past 4 months, ie in exercise or medication – I was on nothing over this time). Would such people be harmed by cholesterol hyper-absorption? Would any such harms be more than counterbalanced by the reductions in inflammatory markers, interleukins, fasting insulin, glucose load, postprandial lipemia, HDL:TAG ratio and so forth? I don’t know that there is any way to tell, unless you were to non-invasively image my arteries over a long time and measure plaque growth. Would make for a neat n=1 crossover study!

    In the meantime, I will continue to substitute out saturated fat and dietary cholesterol, while keeping my carb intake as low as possible. This way, I get the best of both worlds, but I realize it’s not as easy to sustain, or even to counsel, to my patients. Certainly unrestricted fat and dietary cholesterol would be easier and yummier. I have also seen big jumps in total and LDL in some of my patients, with some worsening of the total:HDL ratio (usually attenuated by the jump in the denominator – ie the HDL).

  17. Dan, if both carbs and saturated fats are restricted and protein is not excessive, then calories are needed from some other source. I presume you consume lots of olive oil or something similar, to have monounsaturated fat as a principal source of calories. Too much polyunsaturated fat (especially omega-6) is undesirable. As Phinney and Volek remark (The Art and Science of Low-Carbohydrate Living), polyunsaturated fats are like vitamins. The body needs a baseline amount of essential fatty acids, but not a lot, and even less on a low-carbohydrate diet.

  18. My two cents worth for Dan, is that I think that it’s all of that dairy he’s eating that is messing him up and causing his problems. Gobs of fat with your meat is both satiating, great tasting and good for you. — Dairy, even though it is thought of as simply animal fat if you remove the lactose, is not that.

    The molecules are different.

    It’s unnatural.

    Fatty meat and fish and poultry cooked in their own fat, on the other hand, and then your low low carb vegetables is where it’s at.

    Nothing else but water and maybe a few seasonings.


    Your numbers and your health will become perfect.

    You will rejuvenate and become like your ancestors, living to over a hundred years old and in perfect mental/physical health and with zero child and birth mortality.

  19. Actually I eat very little dairy and scant omega-3 or omega-6. I get my protein from lean protein sources such as nuts (not roasted, salted or oxidized), goat yogourt (which I do not consider dairy – as it comes from a goat, not a cow; it also has a very low carbohydrate content, has live cultures, and net about 5 g of carbohydrates per 3/4 cup serving), fish (mostly lean fish like red snapper but occasional salmon and tuna), chicken (occasional), egg whites and organically-prepared tofu (low carb). I’ve cut down on most sources of dietary cholesterol including red meat, egg yolks, the skin and subcutaneous tissue of fowl, whipping cream, hard cheese, cream cheese, sour cream, milk (latter also high in carbs, of course). I’ve never eaten pork (for religious reasons rather than dietary or nutritional ones). I try to stay away from carbs. There are some good substitutions and recipes I can recommend, direct from Atkins, which allows both low dietary cholesterol (should you feel it important – e.g. for a hyperabsorber like me) and low dietary carbohydrate (for those with metabolic syndrome, hypertension, obesity, diabetes, vascular disease or the atherogenic dyslipidemia of “syndrome X” – high trigs/low HDL/sdLDL).

    Slavish adherence to the LCHF regimen more than doubled my serum and LDL cholesterol; also caused some worsening of my total:HDL cholesterol ratio (despite HDL improvement).

    I guess I am walking two tightropes here – dietary cholesterol and dietary carbohydrate. It can be very difficult to find a middle road – via the uptake of lean protein sources, MUFAs and PUFAs. I still haven’t figured out the role of SFA in all this, although all sources I have read suggest it also boosts serum cholesterol levels, at least in some people. Thus I stopped eating coconut oil and butter (the latter another source of dietary cholesterol of course). I avoid partially hydrogenated vegetable oils, trans fats, fast food, junk food and processed foods. I make and prepare all my own foodstuffs with the exception of sashimi (and I avoid the soy sauce there – perhaps I should bring my own low carb tamari to the restaurant).

    I have never heard that an excess of PUFA can be harmful – it would be interesting to see what a (non-Danish) Greenlander thinks of that! Their PUFA intake is very high, as is many maritime cultures (e.g. Japanese, at least prior to Westernization), with OM3:OM6 ratios of 1.0. Am I wrong in this? Their rates of ischemic stroke, coronary disease, diabetes, and cancer are so low as to be reportable conditions (same as Labrador Inuit, prior to the 1950’s-1960’s). Perhaps it has changed with the advent of modern civilization. I am guessing Dr Wortman knows the answer to this, as he is directly involved.

    Thanks for an enjoyable discussion.

  20. Dan, I find nuts are problematic. I love nuts but they have phytic acid which apparently impedes absorption of minerals. Many cultures soaked and roasted nuts before eating them, which apparently significantly reduces the phytic acid. I was eating nuts every breakfast (soaked and lightly roasted under 300F coated in oil and rosemary to reduce oxidation). But then my oven died. Pending its replacement for several weeks (don’t ask), I ate nuts just soaked but then noticed some tooth demineralization developing. I quit the nuts, added some raw sheep’s milk cheese and some cow milk butter from sheep/cows grazing on rapidly growing grass, cod liver oil, organ meat daily and seaweed, as per the Weston Price dental approach, which has good clinical success. This remineralized my teeth quite rapidly. Price’s survey in the 1930s found that two of the healthiest peoples he found were in high valleys in Switzerland and the Massai tribe of Africa, both of which relied heavily on fermented, raw cow’s milk products. They had well-formed arches and occlusion and hardly any dental caries, despite not having toothbrushes and great overall health. On the other hand, there is lots reported on difficulty with dairy, so I have difficulty settling on a view concerning dairy. Those in the Price Foundation argue both pasteurization and homogenization should be avoided, based on their experience and supposed destruction of enzymes. One of the cheesemakers I know says she finds lambs do not thrive on pasteurized milk, as compared to raw milk. The Price Foundation group have found, though, that the “Activator X” that cultures prized in dairy and organ meant from animals grazing on fast-growing grass does seem to remain active despite pasteurization. Also, fermentation would denature the proteins somewhat. Casein proteins are way too large to be absorbed through the gut lining, but people who eat gluten-grains likely have some leaky gut, allowing undigested protein in and perhaps opening the way for dairy reactions. One has to look at the Swiss and Massai diets carefully before inferring that dairy is okay.

    Also, many nuts are also high in omega-6: almonds, pecans, walnuts, for example. I limit these and have more hazelnuts and macademia nuts instead.

    Again, one has to be careful drawing inferences from other cultures. Ooilichan butter, for example, is made from smelt, but it is rendered in a way that mostly eliminates the PUFA content. So although coastal Aboriginals in Canada ate lots of fish, their PUFA consumption would have been much less than one would otherwise infer from a high marine diet.

  21. Murray, I remember a small study by David Jenkins suggested improvements in glycoslyated hemoglobin with the use of nuts – hemoglobin A1c being a marker of diabetes. I boil things down to a few basic principles, because I am now aware of my own metabolism, which seems to be sensitive to both carbohydrates, saturated fat and cholesterol. The questions I ask are:

    1) Is this product high in refined carbohydrates, and if high in not-refined carbohydrates, would it likely lead to large surges of glucose and insulin in the body? To me, this eliminates alot of grains and all sugar.

    2) Is this product high in saturated fat or dietary cholesterol? This has taken away organ meats, red meat, cheese, cream, butter, coconut oil, ghee — all of which are hypercholesterolemia to a hyper-absorber of cholesterol (like me).

    3) Is this a highly industrially processed food? If so, I start to get suspicious. Here I think of chemical additives, non-sugar sweeteners, trans fats, partially hydrogenated vegetable oils and virtually all fast food and junk food.

    These are my higher-order considerations. I have some lower-order ones that I find helpful (what type of oils to buy, which type of yogurt might be best, whether I should be soaking or roasting nuts or not), but I think the science here is much more controversial. I suppose I am doing all sorts of things wrong – consuming unsoaked/unroasted nuts, eating pan-fried tofu, consuming organic goat milk yogurt – one could probably find a potential fault-line in virtually anything I consume, but on the whole, I think I am better off than 95% of my peers (who still consume from the inner aisles of the grocery store and any aisle of the fast food restaurant).

    Things that do not worry me too much – phytic acid, OM6:OM3 ratio (although some days this does concern me), casein (though I consume little dairy except the goat’s milk yogurt), phytoestrogen content of soy (which theoretically could stimulate male breast cancer – an extremely rare disease I hope you and I never get), salt (though obviously this is linked to hypertension and heart failure). I do worry people are eating far too much junk food, refined and unrefined carbs, and industrial additives. Having said that, I did pan-fry my tofu in high heat canola oil this morning – I read seven papers last night citing hypercholesterolemic effects of coconut oil (which I once consumed, prior to my own severe hypercholesterolemia).

    The other thing I try to stay away from are supplements, which I see as an unnatural way to try to attain a fountain of youth. I am not against medications – in fact they are far better tested than most supplements. Oral vitamins are essentially pharmacological doses of nutraceuticals, most of which have either shown neutral effects or harms in large randomized trials. The public tends to view them as “healthy”, when they are nothing of the sort. I can cite dozens of large clinical trials with hard endpoints to back this up. Exceptions may be (or may not be – depending on the study) vitamin D and omega-3 fatty acids — but again it depends on the person, the genotype and the dose (and what is the intended indication for therapy). By contrast I can tell you that aspirin reduces most forms of cancer and is often overlooked; statins reduce most forms of cardiovascular disease and are often maligned.

    Thanks for listening to me rant on; I’ve enjoyed this discussion.

  22. Re: Dan’s LDL worry. Dr. Natasha Campbell-McBride (Russian trained) creator of the GAPS diet (Gut and Psychology/Physiology Syndrome) made a an interesting analogy about cholesterol. She said: blaming LDL cholesterol is like blaming the ambulance for the car accident. LDL is like the ambulance going to the accident and HDL is the ambulance going back to the hospital with the patient. If LDL is elevated that may just mean there is some wound repair happening and this is good. So, Dan may have some sub-clinical atherosclerosis inflammation somewhere be it in the gut, heart, or anywhere and he’s not aware of it. If so, the LDL is up probably because it is a key component of tissue repair and it’s busy healing Dan.

  23. For Dan,
    I am not on Gaps diet, but somewhat familiar with it. My diet is low carb veggies and spices, meat, and meat fat, butter, especially grass fed butter, and coconut oil. A few almonds on occasion. All those fats are a mixture of saturated, monounsaturated, and polyunsaturated. My diet is high in coconut oil. I do not fear it at all. I saw so much healing going on after using so much of it. I read so many studies, and comments. One was on Alzheimer, and said some with that gene associated with it, have problems getting cholesterol into the brain(that it can pass the brain barrier). For those people, their bodies will produce more cholesterol to make up for this. Your body very much needs that cholesterol, and will continue to make more of it, even though you do not eat it. Red meat, egg yolks, and all those foods are especially good for the body, containing D, A, E and all the fat soluble nutrients. Taurine and cysteine, are very much needed for the heart and brain.

    You can read some of the numerous studies shown in this site on saturated fat, and what happens when you don’t get it in your diet, or try to lower it. There are studies there on side effects of statin drugs.. I noticed a yahoo group of those that “quit their statins”. There are studies on soy in that site also.

    Hope this helps.

  24. re: Dan’s LDL worry. Many people have a significant elevation in LDL and LDL particles after switching to HFLC. I’m one of those people. And like Dan, I have great health markers other than the high LDL. Scientifically, I’d really like to understand why this happens and whether it matters. Maybe having high LDL-C and LDL-P really doesn’t matter when people eat this way–but maybe it matters and we need to make adjustments. Like Dan, I’m cutting back on the saturated fat but maintaining low carb for all the health benefits. I’m a little curious why Dan decided to start meds instead of just changing his diet. And, I think hearing Dr. Jay’s scientific or medical opinion on why this happens isn’t the same as practicing medicine on the net–we’re justing looking for explanations on why some people have perfectly normal lipids before HFLC but don’t after switching. I think some people like me and Dan are hyper-absorbers and can’t implement this diet the same way as others. Sadly!!! I miss cream in my coffee!

  25. Thank you so much for researching this, writing this piece, and most importantly, continuing to be a proponent of the paleo/low carb lifestyle in the face of so much opposition. I lost 50 lbs on the low-carb diet years ago, but I was young, active, so when I reached a happy weight, I left the lifestyle, and of course, put it all on again. Recently, a host of health problems led me to do some research of my own, which led me back to low-carb. I am not exaggerating when I say that, within two weeks, ALL of my health problems disappeared. I was having swollen legs at night, (and sometimes, starting in the early evenings), leg pain, abdominal bloating, high heart rate, out of breath just climbing a short flight of stairs, no stamina, lethargy…etc. All gone. Not just gone either – I feel 15 years younger. I ran up the stairs at my boyfriend’s house the other day and wasn’t even slightly winded.

    Which is why I am completely flummoxed about the opposition to this eating plan, including from my boyfriend. People HATE the low carb diet. I had to look him in the eyes and say, “Baby, I feel like I’m alive again. I don’t have edema. My resting heart rate is 65! It hasn’t been there in years! I’m AWAKE during the day now, and don’t want to nap after meals. WHY would you be opposed to something that makes me feel so good?” He finally admitted that he was happy I was feeling better, but GOD, it took a while.

    I have started losing the weight again (it just falls off when you eat low carb – and I haven’t had time to get to the gym!), but the thing is, I don’t even care so much about that. I mean, yeah, it’ll be great if I can get my girlish figure back, but really, I’m doing cartwheels over the fact that I can hike in the woods again and really enjoy it!

    Please, keep fighting the fight. I can’t do it – I’m a film and video editor…no one will listen to me on matters of biology or physiology. But we need people like you to keep at it, because it really *is* the answer to diabetes, pre-diabetes (which I suspect I may have been), obesity, high blood pressure, and numerous other ailments that plague many Americans.

    I want you to know that you are appreciated. Thank-you.

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