Avoid Eating Fat. Advice From Siri

TheFatNurse saw this ad over the weekend. Apparently the key to a successful life is to avoid eating fat…according to Apple. Le sigh.

Malkovich: Life.

Siri: Try and be nice to people. Avoid eating fat. Read a good book every now and then. Get some walking in. And try to live together in peace and harmony with people of all creeds and nations.

Malkovich: That’s pretty spectacular advice, actually. Thank you. I enjoyed this chat immensely. You are very eloquent.

Siri: That’s nice of you to say.

What if TheFatNurse Was Secretly a Double Agent?

Sometimes the news of saturated fats not being so unhealthy can come as a shock and met with huge denial. Every now and then TheFatNurse is met with these critiques…the response? Well actually TheFatNurse didn’t do everything in this comic but definitely thought through the events!

 

1 in 4 Teens Pre-diabetic or Diabetic. What Can They Expect?

One in four US teens are pre-diabetic or diabetic according to the CDC. To keep things in perspective, the rate was 9% in 1999 so things are increasing at a fast pace. So what kind of diabetic advice can some of these kids expect? Well here’s a little snippet from a review book TheFatNurse used for the RN license exam on lifestyle recommendation for diabetics:

Pretty much stuff you hear all the time right? Saturated fat is bad and make sure you eat complex carbs like whole grains not the white stuff. TheFatNurse also noticed that up to 70% of calories should be composed of carbs and monounsaturated fats. However, you may be surprised to know that such high carbohydrates weren’t always used to treat diabetics. From an ADA associated site article 5 years ago:

“Early on, it was recognized that carbohydrate had the largest impact on blood glucose levels. Between 1921 and 1950, diabetic diets generally limited carbohydrate to about 20 percent of calories (fat was about 60 percent). For a 1,500-calorie diet this would provide about 75 grams of carbohydrate and 100 grams of fat.”

TheFatNurse remembers going over diabetic recommendations back in Nursing school and thinking…if carbohydrate consumption can spike BG levels…why not just reduce the amount of carbohydrates in the diet? Apparently they thought this way too in the 1920s. This was partly due to insulin not being as widespread since it was still in its infancy:

“In the 1950s, experts recommended that the amount of carbohydrate be increased to about 40 percent.”

“In the 1980s the glycemic index was developed to compare how quickly carbohydrates in food are broken down in the body, converted to glucose, and released in the bloodstream. Surprisingly, it was found that sugar had less glycemic effect than white bread. The advice to avoid sugar was rethought, and the concept of counting carbohydrates became popular. Because experts were beginning to understand that fat may be linked to cardiovascular disease, the new recommendation for carbohydrate became about 50 to 60 percent of one’s diet, which in turn decreased the recommended percentage of fat to about 30 percent.”

So these developments lead to 60% of a person’s diet being composed of carbohydrates in which it should be mainly whole grains. Interestingly enough they mention white bread being worse than table sugar on the GI scale (70 vs 64)…but they didn’t mention whole grain wheat bread. Well, for those interested, Wheat bread is also worse than table sugar via the GI index (64 vs 68). This is primarily due to sucrose (table sugar) being composed of half glucose and half fructose. Therefore, the advice from TheFatNurse’s Textbook on promotiong fiber intake through whole grain consumption…if we are basing it on GI index…might need some reevaluation mayhaps?

Additionally, what about the fear of saturated fats on diabetics? It’s true that Diabetics are at high risk for heart disease, but if you’ve been following this blog or any of the dispatch authors then you will know the connection between saturated fat and heart disease can be murky. Of course, whenever reviewing articles, it’s important to make sure the study population reflects the population one is targeting. Therefore, research on saturated fat and heart disease in non-diabetic patient samples would be interesting but not always applicable to the diabetic population. So what are some recent research studies using diabetic samples?

Whoa hot off the presses! A two week old study involving 61 Type 2 diabetics randomized into a low carb or low fat diet:

“In the low-carbohydrate diet, 50% of the energy came from fat, 20% from carbohydrates, and 30% from protein. For the low-fat group the distribution was 30% from fat, 55-60% from carbohydrates, and 10-15% from protein, which corresponds to the diet recommended by the Swedish National Food Agency.”

From the study:

“The patients were randomised to either an LCD or a traditional LFD, both with an energy content of 6,694 kJ/day (1,600 kcal/day) for women or 7,531 kJ/day (1,800 kcal/day) for men.  “

Limiting carbs to just 20% of diet? Hey that’s the 1921 diabetic diet in the US! However, TheFatNurse wishes they would have kept protein consistent between both groups to isolate the effect of carbs better.

“Despite the increased fat intake with a larger portion of saturated fatty acids, their lipoproteins did not get worse. Quite the contrary – the HDL, or ‘good’ cholesterol, content increased on the high fat diet.”

As covered before, how well HDL-C as a gauge for risk is controversial and many now feel looking at LDP particles as a much better indicator of risk. However, based on traditional measurements, this would be good.

“In both groups, the participants lost approximately 4 kg on average. In addition, a clear improvement in the glycaemic control was seen in the low-carbohydrate group after six months. Their average blood sugar level dropped from 58.5 to 53.7 mmol/mol (the unit for average blood glucose). This means that the intensity of the treatment for diabetes could also be reduced, and the amounts of insulin were lowered by 30%.”

“No statistically certain improvements, either of the glycaemic controls or the lipoproteins, were seen in the low-fat group, despite the weight loss.”

Link to actual study

The studies ‘conclusion:

“…aiming for 20% of energy intake from carbohydrates is safe with respect to cardiovascular risk compared with the traditional LFD and this approach could constitute a treatment alternative. “

Interestingly enough, there are actually quite a bit of studies that have shown support for lower carb diets for diabetes. Here is another recent one using a low carb mediterrean style diet:

“compared the 2003 ADA diet (50 – 55% carbohydrates, 30% fats and 20% proteins) with a traditional Mediterranean (TM) diet (50 – 55% LGI carbohydrates, 30% fats – high in monounsaturated fat content, 15 – 20% proteins) and a low carbohydrate Mediterranean (LCM) diet (35% LGI carbohydrates, 45% fats – high in monounsaturated fat content, 15 – 20% proteins). “

While the higher fat content in mediterranean diets are normally composed of monounsaturated fats, it’s total fat content is still higher and carbohydrate content lower than ADA recommendations. Let’s compare the baseline results with the 12 month intervention respectively. As mentioned, the traditional markers may not actually mean as much but we can use the “poor man’s” insulin resistance of triglyerides/HDL instead. As Dr. Dayspring informs us, a ratio of 3 or above indicates likely insulin resistance.

ADA: 2.99 -> 2.26
TM: 2.79 -> 1.45
LCMD:  2.94 -> 1.36

“A low carbohydrate Mediterranean diet also increased HDL-C levels and was superior in reducing LDL, TG and HbA1c levels compared to ADA and standard Mediterranean diets. It would appear that the low carbohydrate Mediterranean diet should be recommended for overweight diabetic patients.”

So most patients were close to the 3 ratio cutoff and made vast improvements on all three diets. What’s a little disturbing is the ADA diet performing the worse out of the three. In contrast, the lower carb med diet won out. Even the regular med diet won out over the ADA diet. Of note, a 35% of total calories from carbs in the lower carb med diet wouldn’t be consider low enough in carbohydrates in some low carb communities. Would a 1920’s style med diet with 20% carbohydrates have performed even better? Regardless, the results from both studies definitely give pause to the ADA recommendations on carbohydrate consumption.

“In recent years, low carbohydrate diets have been shown to be effective in improving glycaemic control and body weight in type 2 diabetes [21 – 24] as well as weight loss in obese patients [25–27]. Based on this increasing evidence, in 2008 the ADA included a low carbohydrate diet as a possible intervention.”

What!? The ADA actually encourages some people to adopt a low carb diet!? Hard to tell from browsing their site which seems to be focused on fat reduction (particularly saturated fat) and eating whole grains. More importantly, TheFatNurse would have liked to have learned about low carb and diabetics back in nursing school. TheFatNurse wanted to find a current breakdown of nutrients like the 2003 ADA diet breakdown mentioned in the previous study but alas could not on their site. TheFatNurse did find this tho:

Is this suppose to be a “my plate” for diabetics?

Looks kinda like this don’t it? If it works like my plate…then 75% of a diabetics diet is suppose to be carbohydrate(pasta, cereal, fruit in the picture)?

The Bottom Line: TheFatNurse was taught to memorize and recommend a specific low fat whole grain diet for diabetics. However, looking into the literature reveals there could be better options for some people. Shouldn’t these other options be taught in school or at least mentioned on the licensing exam? Of course It’s up to all healthcare practitioners to keep up to date with the literature but that may be difficult and worth a whole new future discussion.

***Please remember the information in this post is purely for academic thought and not clinical. Any interest in diet change should be consulted with your primary care provider first.

Selling Soda = $15,000 Fine but Snickers and Milkyway Bars are Nutritious

The news article is here. The confusion comes from a bureaucratic mess where they try to regulate when sodas can be sold in an effort to try and promote healthy habits. Sodas are banned during lunch but can be bought before or after to be consumed at any time. Some interesting quotes:

“While sodas are out, Gatorade is allowed.”

Whoa…the last time TheFatNurse drank gatorade it only came in red, yellow, and orange. While looking for specific grams of sugar for gatorade TheFatNurse did not even recognize any of the gatorade products out there! Suffice to say, the sugar in most gatorades is pretty horrendous.

“You can sell Snickers and Milkyway bars because they have nuts and they’re nutritious. You can’t sell licorice, but you can sell ice-cream,” Burton said”

Representation of TheFatNurse’s reaction to that statement

Now, TheFatNurse believes regulation of what people consume isn’t vey effective and it’s much better to educate and encourage people to choose for themselves a healthy life. So TheFatNurse’s WTF reaction isn’t to the bureaucratic mess they’ve created. Instead, how can one classify a Snickers or Milkyway bar nutritious!? Although, if TheFatNurse had to choose between a gatorade, milky way, or a snickers, the snickers wins out all the time. Not because of it’s counter intuitive GI index of 40 (its still sugar loaded candy!), but because its so damn tasty.

 

Update: Oh look Snickers really is a “healthy” snack (Thanks Kevin!): 

The World’s Most Powerful Doctor

TheFatNurse loves looking through the literature when exploring dietary issues to build a case for fats. However, even when providing numerous studies and quoting important researchers like Dr. Dayspring or popular healthcare bloggers like Dr. Eenfeldt…there are some doctors who are just too powerful to beat…how does one get through!?

The quote on cutting out fat to save lives from Dr. Oz @5:03 from:

LDL Cholesterol = Bad? Not Quite That Simple

Continuing with this week’s HDL mainstream news, TheFatNurse thought you should be aware of a man named Dr. Ronald Krauss and his work on LDL cholesterol (you know, the “bad” one). In the 1980’s, Dr. Krauss was one of the prominent researchers to point out that many studies showed those with heart disease and those without had almost the same LDL levels.

“If you look in the literature and just look at the average coronary patients…their LDL-cholesterol levels are often barely discernibly elevated compared to patients who do not have coronary disease.” (1)

So how prominent a figure was he? He was once the chairman for the nutritional committee for the American Heart Association (AHA) – The same AHA that was recommending low fat intake resulting in more carbohydrate intake as a consequence in order to decrease heart disease. This is ironic, as mention by Gary Taubes in Good Calories Bad Calories, since Krauss had found associations between carbohydrate increase and the risk of Heart Disease.

Did Krauss’ research make him a socially awkward penguin in the AHA?

Additionally, Krauss also found substituting fat with carbohydrates increased small dense LDL particles which are associated with increased heart disease compared with the not as dense LDL particles from saturated fat which is not as bad. (2) In a NPR interview (2007):

“…recommendations are now pushing hard for lowering LDL cholesterol by reducing fat and saturated fat…based on the assumption that it would improve LDL related heart disease risk. Our evidence is it doesn’t effect the dense LDL at all. Substituting carbohydrate for fat, a natural consequence of those recommendations will actually increase levels of the small LDL”

“…processed and refined starches and sugars that are the most deleterious metabolically…food that contain a lot of fiber…have a lot of bulk but not as much carbohydrates…this recommendation [eating more carbs rich in fiber] is very difficult in practice…[agree with Taubes in] considering all carbohydrates as  potentially adverse.”

Dissecting Heart Disease Like a Boss

Much of Krauss’ work points to how much of the advice that is considered fact may instead be harmful to us. In an interview just last month (3):

“…we fed these low fat diets and reduced the fats by substituting carbohydrates, which was at that time and still remains the current paradigm, we really didn’t achieve what we had wanted to achieve…some improvement in the overall amount of cholesterol in the very small percentage of individuals who had very high amounts of small LDL particles in their blood already… the majority of people we studied, the high percentage of people who had the normal metabolic profile, with more of the safer, Pattern A, larger particle LDL, shifted into the riskier, pattern B mode when we reduced their saturated fat intake.”

Because of his work, Krauss is well known in the low carb community when they need supporting claims from a well established nationally recognized physician and researcher:

“…we were certainly concerned about increasing heart disease risk, so we turned our attention ultimately away from feeding higher carbohydrate, lower fat diets, to doing the reverse, to lowering carbohydrate and raising fats, and that’s where we intersected with the world of people very interested in very low carbohydrate diets.”

“[Interviewer] You’re saying that in people who ate more fat and less carbohydrate, and in fact, who ate more saturated fat, they had a little more total cholesterol fat in their blood, but it was mainly being transported in big, fluffy LDL particles, which are the kind that scientists who study heart disease consider pretty safe.

[Krauss] Yes. When people ate more fat and less carbohydrate, the number of small particle LDLs remained low, and switching from monounsaturated to saturated fat didn’t increase their number at all.  In fact, when people switched from mono- to saturated fat in this study, the large particle LDLs might have gone up a little bit…the small particles went down.  So by anybody’s current criteria about whats’s important for heart disease risk, saturated fat caused no increase in risk.”

What is interesting about the LDL particle theory is the debate on whether or not the size and density of the particles matter. Krauss seems to believe the smaller denser particles are more of a concern, whereas others believe it doesn’t matter such as Dr. Dayspring from last week’s post. As Krauss states:

“I and many of my colleagues would argue that the biggest concern is warranted when the number of smaller particles is high, not the larger ones.”

However, both viewpoints can be compatible based on numbers and the ability of the larger LDLs to carry more cholesterol:

“It’s definitely associated with lower heart disease risk if the cholesterol is carried in larger particles, and that’s because there are fewer of them”

Confused? Here’s a lecture from Dr. Tara Dall that might clarify things better:

So does Krauss’ work offers more support that you can eat all the saturated fat you want? After all in the same interview last month:

“…in our 2006 study, the blood work was better when feeding people higher fat diets, than…feeding them lower fat and more carbohydrates…keep in mind, this was in the setting of lower carb and a mixed protein diet, proteins from various sources from white meat and dark meat and chicken and fish and beef.”

However, you may recall TheFatNurse posting last month about another Krauss study that showed saturated fat could be associated with increased CHD risk if it came from high amount of red meat (all beef in that study). Krauss touches upon that study in this interview:

“…keep in mind, this was a very high beef diet.  People were eating beef breakfast lunch and dinner.  So this is really way outside of what we would ever consider to be a usual health practice.  Maybe some people do it.  But not many.”

Cause you’re in the low beef study group dude

Currently, Krauss is using these latest results to try and isolate the reason for excessive red meat being associated with heart disease. Whereas before someone might easily blame it on the saturated fat, Krauss believes it could be other dietary consumptions with the saturated fat in red meat. Is it the iron? That’s one idea from Krauss and TheFatNurse looks forward to seeing more from Dr. Krauss in the future.

Bottom Line: Dr. Ronald Krauss has been a pioneer in the field of dietary consumption and heart disease. His work throughout the years shows how science and nutrition are constantly evolving and we must never accept anything as fact until it’s been fully tested. When long held facts such as “HDL = good LDL = bad” or “saturated fats can cause heart disease” are no longer that clear cut, we as a society need to be open to reexamining these long held beliefs and begin research on new ones.

1) Taubes, Good Calories Bad Calories, page 170

2) http://www.npr.org/templates/story/story.php?storyId=15886898

3) http://www.meandmydiabetes.com/2012/04/17/ron-krauss-saturated-fat-red-meat-it-depends/

“Do I Look Fat?” How Low Carb Can Answer This Impossible Question

“Do I look fat?” A question that can drive many men to be former friends and ex-lovers if not answered with the exact precision of a scalpel. Googling this question reveals a correct answer has yet to be found in all of human history…but TheFatNurse discovered how easily this question can be dodged by simply living a low carb lifestyle…unless low carb becomes too well known!