The Science of Human Potential

Do diabetes specialists have learning resistance?

The healthy diabetes plate is a peer-reviewed “evidence based guidelines for healthy eating for Type 2 diabetics”.PCD41A12s01

Here’s my rant around what I consider to be a gaping hole in sensible logic.

Here’s the biological logic:

  1. You have become metabolically dysregulated. In mainstream medicine, your doctor will call you “insulin resistant”.
  2. That means your body is having difficulty getting glucose out of your blood stream into your cells.
  3. Your body still needs to get rid of this glucose, so your pancreas produces more insulin to get the glucose into the cells.
  4. Chronically high insulin makes you more insulin resistant, requiring you to produce more and more insulin. It gets worse and worse. Fat oxidation is turned off, and adipocyctes (fat cells) take up extra glucose and fat.
  5. No matter how much insulin you produce, you can’t move all the glucose into cells. Your blood glucose is high which damages the body irreparably.
  6. Sometimes, because of the stress of overproduction of insulin, the pancreas will have burnout in the beta cells which produce the insulin. Then you’ll need extra insulin, like a Type 1 diabetic.

Here’s your choice:

  1. Take mainstream diabetes treatment advice and follow their dietary guidelines (see above and below). That will be a low fat, moderate carb diet, where you should probably restrict calories. This will result in continued high blood glucose and insulin as you are eating quite a lot of carbs. Whole grains and beans are suggested as they are higher quality and absorbed more slowly. That just means high insulin the whole day for the insulin resistant person. I’ve written about the evidence for this previously.
  2. OR Here’s a novel idea…..or am I missing something here all you diabetes specialists and dieticians? RESTRICT YOUR DIETARY CARBS to very low amounts (<50g/day), eat more fat, and everything will improve. Here’s the outcomes when you do this.
    Just a thought. A glaringly obvious solution to the problem of being unable to tolerate carbs and move them into cells……don’t eat them!

    Take a look at the diabetes food pyramid below…..a low fat diet will be a high carb diet, even with high lean protein, because excess protein ends up being dealt with in exactly the same way as carbs. I contend the only way that a diet like this can work to help a diabetic is if somehow they have enough will power to semi-starve themselves into a very low calorie diet. That diet now works because it too is now a low carbohydrate diet. Why does mainstream medicine seem to be so resistant to even considering this possibility? Who’s right here? Do I have learning resistance, or do the current guidelines just make no sense in the light of the evidence? Insulin resistance or learning resistance?

    pyramid

How ketogenic (low carb high fat) diets work

A really nice paper was just published by Paoli, Rubini, Volek and Grimaldi in the European Journal of Clinical Nutrition titled “Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets”

You won’t see a better review paper for summarizing the latest in how we think carbohydrate restriction affects various aspects of metabolic health; from weight loss to neurological issues to acne (yes acne!).

A second excellent review article was also published in Nutrition Today by Volek (again!) and Phinney, the low carb gurus. This one is called “A New Look at Carbohydrate-Restricted Diets: Separating Fact From Fiction”. Again this is an excellent scientific review paper.

What I should be doing in this blog is simply drawing your attention to this good work and you can go and check it out for yourself.

Except I’m aware that unless you work at a university, that’s easier said than done. You’d have to buy the papers, which means that most of the people who stand to benefit from the knowledge won’t.

Actually, copyright publishing is a scam of the highest order. What happens is that guys like Volek and Phinney put in heaps of work, often that work is paid for by either public institutions, or by research grants gained through public funds. They then (usually) slave away in the degrading process of blinded peer review, often having to respond to inane comments and endless rebuttals. When they are done, they then sign all of their IP over to a journal, which keeps it all for no cost (and all profit) in perpetuity. Can you imagine anywhere else in the business world that would happen besides academia? It’s laughable, but it is actually what happens to us academics everyday and frankly, we no longer find it funny.

Anyway, I digress. What I really want to do here is summarize the two reviews.

Let’s start with the Nutrition Today paper by Volek and Phinney, which is a nice synthesis of the available evidence for the biology of human energy regulation and homeostasis, and how a carbohydrate restricted diet operates. The main points here are:

  1. Saturated fat levels in the blood are not associated with dietary saturated fat intake, but dietary carbohydrate intake. They show evidence from both randomized controlled trials and population data for this.
  2. They discuss in detail what the keto-adapted (fat adapted) state is; how this comes about, including increased beta oxidation of fat, decreased hyperinsulinemia, and a reorchestration of substrate utilization in the body, including the use of ketones to fuel brain function. It is interesting that the majority of practicing dietitians, endocrinologists, cardiologists, and public health physicians have never heard of any of this.
  3. They point out what is a very important and obvious set of outcomes, which are well documented in the scientific literature; that treating a patient with insulin resistance with a low fat/high carb diet is palliative and going to make the problem worse. If you are having trouble getting glucose into your cells, then reduce the glucose load stupid!
  4. They show a nice little diagram, which I have reinterpreted and redrawn below, to show the role of dietary carbohydrate in metabolic (dys)function. To quote the authors “The major point is that SFA (saturated fatty acids), and the response to eggs, has a totally different metabolic behavior when consumed in the context of a low carbohydrate diet.”Slide1
  5. They show a meal plan for a typical low carb daily meal. This is excellent as it shows what real and tasty foods we are talking about.

2500 kcal daily food intake restricting carbs

Breakfast (scrambled eggs with sides of spinach and sausage)

  • Scrambled eggs: 2 large + 1 tbsp palm oil
  • Mozzarella cheese: 1 oz
  • Pork sausage: 2 links (48 g)
  • Chopped frozen spinach, boiled: 3/4 cup (142.5 g) + 1.5 tbsp butter

Snack

  • 1/2 Avocado: 67 g
  • Swiss cheese: 2 oz (56 g)

Lunch (broiled salmon and a side salad)

  • Broiled Atlantic salmon: 4 oz + 1 tbsp butter
  • Mixed baby greens: 2.5 cups
  • Diced tomatoes: 1/4 cup
  • Chopped onion: 1/8 cup
  • Feta cheese: 1 oz
  • Black and green olives: 4 each
  • Blue cheese dressing: 1.5 tbsp

Snack

  • Peanuts, oil-roasted: 1 oz
  • Hood Calorie Countdown milk: 1/2 cup

Dinner (sirloin with sauteed mushrooms and cauliflower ‘‘mashed” potatoes)

  • Beef sirloin tips: 3 oz
  • Olive oil: 1.5 tbsp
  • Sauteed mushrooms: 1/4 cup
  • Olive oil cooking spray
  • Cauliflower ‘‘mashed potatoes’’: boiled cauliflower 1 cup + shredded cheddar cheese 1 oz + Butter 1 tbsp
  • Sugar-free jello: 1/2 cup (121 g)

Macronutrients:

  • Protein: 134 g
  • Carbohydrates: 42 g, Fiber 20 g
  • Fat: 204 g
  • Cholesterol: 853 mg
  • SFA: 81 g
  • MUFA: 78 g
  • PUFA: 28 g

Reproduced from Volek and Phinney (2013), Nutrition Today

Now on to the second paper in the European Journal of Clinical Nutrition titled “Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets”. This is a comprehensive scientific review of the evidence and emerging evidence for the treatment and prevention of a range of chronic diseases with carbohydrate restricted (ketogenic) diets. I have adapted one of their figures into two new ones, showing the state of scientific evidence (strong and emerging separately) for “therapeutic uses of the ketogenic diet”. Hopefully these figures are self-explanatory.

I draw your attention to the “suggested mechanisms” under each one. I’m not going to go into these in detail but it is worth looking at these two figures and noting a few things:

  1. Carbohydrate restricted diets are a legitimate and well documented approach to the treatment of a wide range of issues.
  2. There are common mechanisms, mostly about reducing the load of insulin the body has to deal with. This is because the body has to dispose of less dietary carbohydrate. This point is seemingly lost on most in the field of chronic disease prevention and treatment. Hyperinsulinemia is a problem in itself, reducing it helps.
  3. As well, there are associated mechanisms associated with high insulin. There are problems in the IGF pathway, mitochondrial function, and inflammation.

Slide1

Slide2

There is now strong evidence to show that low carbohydrate diets are safe and effective treatments for several conditions, and have some likely positive effects for other conditions.

So that’s it. Two great papers. Hopefully I have captured the essence of what they are saying and where the evidence is at. This is important to get out there into the public and health community. While it’s all behind the paywalls of journals it won’t. So hopefully this helps.

Twelve Habits of Happy, Healthy People Who Don’t Give a Shit About Your Inner Peace

Some great  truths in this! Twelve Habits of Happy, Healthy People Who Don’t Give a Shit About Your Inner Peace.

TEDMED Peter Attia

Is the “obesity crisis” just a disguise for a deeper problem?

Dr Peter Attia’s TEDMED talk is out. He articulates very nicely, in good conservative medical speak, just what the alternative insulin resistance hypothesis is, and why we get fat and sick. The more detailed hypothesis I have covered in “Why some people stay skinny and others get fat.”  Well done Peter, we need to get this video out there, so please like it, pass on my blog, whatever to help with this.

Peter writes the blog eatingacademy and is President and Co-founder with Gary Taubes of the Nutrition Science Initiative (NUSI), who we will see way more often in the future. The non-profit has raised many millions now to fund state of the art nutrition research.

Full version here http://www.tedmed.com/talks/show?id=18029

Why some people must restrict carbs

Spot the difference
OK, I will start this by saying that this is a more academic piece about metabolic control in type 2 diabetics, and the ethics of feeding them low fat diets. It is a bit technical in places and deals directly with original research. Read on if you are interested!
The key message is that in my opinion, when you are insulin resistant, really the first option you should consider is restricting carbs. I hear a lot about “it’s the processed carbs, not the starchy veges that are the problem”, that “vegetarian and vegan approaches are good at reversing type 2 diabetes”, that “fibre solves everything” and so on.
Look, I agree that healthy humans can eat a wide variety of macro-nutrients that may contain plenty of carbs and nothing adverse will happen, but it’s likely that processed carbs will help metabolically well regulated healthy people into insulin resistance and a downward cycle of getting fatter and sicker. The mechanisms by which fructose (sucrose – table sugar is half fructose) work are being understood more clearly by modern science. The way fructose stirs up inflammation, blood lipids, liver fat deposition, addictive pathways in the mesolimbic system in the brain, and causes leptin resistance (the off switch hormone) are all important factors.
Once, or if, you become insulin resistant, I believe that macro-nutrient profiles are very important. Mainly, I am talking about restricting dietary carbs. Remember, if you are insulin resistant then you will have a problem getting dietary carbohydrate into your cells. The pancreas needs to produce more insulin to help do this. In the early stages of insulin resistance, all this means is you end up being hyperinsuliemic – having constantly high insulin – if you eat even moderate amounts of any dietary carbohydrate.
Hyperinsulinemia is known to have multiple direct and indirect effects on the body, making things significantly worse. Insulin is directly inflammatory. Insulin turns off fat oxidation and promotes fat storage and conversion of carbs into fat (de novo lipogenesis). Insulin probably blocks the hormone leptin in the brain (off switch not working again!). High insulin is directly implicated in many cancers, especially breast and prostate cancers. The list is growing all the time as we understand more about this essential hormone, which causes havoc when out of whack.
Interestingly, the treatment approach of most endocrinologists, dieticians and diabetes specialists is to advise those with insulin resistance to have a low fat, moderate protein, high fruit and vegetable diet. Taken correctly, and iso-calorically for weight maintenance, for even consistent small weight loss, this wil be a moderate or high carbohydrate diet. True, the carbs have some fibre and you could avoid all processed carbs. Nonetheless, it is overall carb load that is important here for the insulin resistant person.
Here’s the kicker – some of the “best” carbs recommended for these people by health professionals, because they are low glycemic index, don’t help. This is because these carbohydrates are absorbed slowly into the system; but because the insulin resistant person is so easily overwhelmed by even moderate carb loads, the result is day-long hyperinsulinemia. There’s plenty of evidence for this too.
The evidence comes, in the main, from feeding studies comparing normal metabolically functioning people, with type 2 diabetics.
Here are a few examples:
1. First, I have written about this before in less detail, the study with beans and glucose. The main thing about this paper is that it compares diabetics with healthy non-diabetic controls. This is very important to see the differential insulin response provoked by the same carb load. This study shows how the insulin responses to several types of beans are high and prolonged for Type 2 diabetics compared with controls.
2, This study in Diabetic Medicine in 1989 shows how rolled oat meals in diabetics result in massive hyperinsulinemia and hyperglycemia compared to the healthy controls after 3 hours. It seems to me that any of these meals are the last thing you would want to feed to a Type 2 diabetic.
Rasmussen et al (1989). Postprandial glucose and insulin responses to rolled oats ingested raw, cooked or as a mixture with raisins in normal subjects and type 2 diabetic patients.
Cooking and processing of food may account for differences in blood glucose and insulin responses to food with similar contents of carbohydrate, fat, and protein. The present study was carried out to see if short-term cooking of rolled oats caused an increase in blood glucose. Furthermore, we wanted to see if dried fruit could substitute for some of the starch without deterioration of the postprandial blood glucose response. We therefore compared the blood glucose and insulin responses to three isocaloric, carbohydrate equivalent meals in 11 normal subjects and 9 Type 2 diabetic patients. Meals composed either of raw rolled oats, oatmeal porridge or a mixture of raw rolled oats with raisins were served. In normal subjects, the three meals produced similar glucose (75 +/- 22, 51 +/- 16 and 71 +/- 23 (+/- SE) mmol l-1 180 min, respectively) and insulin response curves (3160 +/- 507, 2985 +/- 632 and 2775 +/- 398 mU l-1 180 min, respectively). Type 2 diabetic patients also showed similar postprandial blood glucose (515 +/- 95, 531 +/- 83 and 409 +/- 46 mmol l-1 180 min, respectively) and insulin (5121 +/- 850, 6434 +/- 927 and 6021 +/- 974 mU l-1 180 min, respectively) responses to the three meals. Thus, short-term cooking of rolled oats has no deleterious effect on blood glucose and insulin responses, and substitution of 25% of the starch meal with simple sugars (raisins) did not affect the blood glucose or insulin responses.
3. Here’s another paper in Diabetes Care from 1987. In this study they fed diabetics 50g of starch contained in various foods. The foods were neither isocaloric, nor matched for other marco-nutrients (see table). The insulin response was greater for many of the foods than predicted by the glucose response. There were no comparison controls though.
fig 3
The glucose and insulin areas under the curve are shown below. A few comments – while the lentils and kidney beans provoked a lower peak glucose, the rise took longer and the response was still increasing at 2 hours. Second, the results show that all foods produced hyperinsulinemia for several hours afterwards.
Untitled
fig2.1
4. And then this paper in Diabetes Care from 1998. Look at the insulin curve responses to three different meals below – a standard American meal, a low starch/high fibre meal, and a high starch meal. You’ll notice a few things. First, the subjects are hyperinsulinemic after all meals. Second, the low starch meal appears to do much better than the higher starch meal. This research is flawed because the macronutrient compositions of the two meals are different – so it’s not the carbs that define the different insulin responses. There are no healthy controls either – so who knows what the difference is between meals and insulin resistant/insulin sensitive subjects.
The “high starch” diet is 55% carbs, 15% protein, and 30% fat. The “low starch” meal is 43% carbs, 22% protein, and 34% fat. So we see here that people have better insulin responses on lower carb, higher protein, higher fat diets! Just reduce the carbs a bit more and you might have something that resembles a healthy diet for a Type 2 diabetic. Another example of poorly conducted research reaching the wrong conclusions about dietary carbs.
5. Finally, heres a paper in the Archives of Internal Medicine from 2005. The figure shows the day long insulin response of the same subjects (they are their own control) on a low carb diet. The low carb diet is ketogenic. To be fair, the diets are not isocaloric because the subject spontaneously ate less food, as is usual for a low carb diet. They were not restricted and ate to fullness though.
Boden-Insulin51
Take home message:
If you are insulin resistant, you are by definition carbohydrate intolerant. Conventional treatment is to reduce fat, eat less processed carbohydrate, but still at least a moderate carb diet. That will result in chronic hyperinsulinemia and make things worse. The best and most sustainable approach is to restrict carbs and to eat moderate protein with fat as needed to fill you up. You can achieve the same result on a vegan diet or a vegetarian diet, it doesn’t matter, although more difficult. I would hypothesize that any diet in which the symptoms of diabetes are reversed is a carb restricted diet, whether it be through carb retsriction alone or an overall very low calorie diet.
Call to action? Understanding that dietary carbs affect some people very negatively is very important but not understood at all by mainstream medicine. Start telling your doctor about this! Pass on this blog, email people, get on Facebook or Twitter – do what you can. This will be a ground up movement in changing public health nutrition.

Is exercise damaging my heart?

the-heart-300x300

Recent high profile athlete cases of heart problems, especially arrhythmias, has had many of us asking several questions about the endurance exercise we do on a regular basis. These include:

  1. What’s the risk?
  2. Is it linked to the actual exercise or something else?
  3. What might you do to mitigate the risk, but still get the benefits of being fit?

It really seems that the evidence is starting to stack up from case studies, to epidemiology, to mechanisms. Let’s explore the issues.

1. What’s the risk?

A recent study published in the European Heart Journal shows several things. Actually, there is a really great comment in a blog by cardiac specialist Dr John Mandrola.

To sum up (that is, to skip the abstract and comments below and get straight to the next point), there is strong associational evidence that hard and prolonged endurance exercise may damage the heart, which results in sometimes serious heart problems. The overall risk is doubled compared to non-athletes, but the overall risk is still only around 2%.

Here’s the abstract of the study…

Aims We aimed to investigate the association of number of completed races and finishing time with risk of arrhythmias among participants of Vasaloppet, a 90 km cross-country skiing event.

Methods and results All the participants without cardiovascular disease who completed Vasaloppet during 1989–98 were followed through national registries until December 2005. Primary outcome was hospitalization for any arrhythmia and secondary outcomes were atrial fibrillation/flutter (AF), bradyarrhythmias, other supraventricular tachycardias (SVT), and ventricular tachycardia/ventricular fibrillation/cardiac arrest (VT/VF/CA). Among 52755 participants, 919 experienced arrhythmia during follow-up. Adjusting for age, education, and occupational status, those who completed the highest number of races during the period had higher risk of any arrhythmias [hazard ratio (HR)1.30; 95% CI 1.08–1.58; for ≥5 vs. 1 completed race], AF (HR 1.29; 95% CI 1.04–1.61), and bradyarrhythmias (HR 2.10; 95% CI 1.28–3.47). Those who had the fastest relative finishing time also had higher risk of any arrhythmias (HR 1.30; 95% CI 1.04–1.62; for 100–160% vs. >240% of winning time), AF (1.20; 95% CI 0.93–1.55), and bradyarrhythmias (HR 1.85; 95% CI 0.97–3.54). SVT or VT/VF/CA was not associated with finishing time or number of completed races.

Conclusions Among male participants of a 90 km cross-country skiing event, a faster finishing time and a high number of completed races were associated with higher risk of arrhythmias. This was mainly driven by a higher incidence of AF and bradyarrhythmias. No association with SVT or VT/VF/CA was found.

Dr Mandrola says the following:

It’s pretty simple: extreme endurance exercise, done over the long term and with great intensity, increases the risk of arrhythmia. There’s no refuting this strong association. These observations are both plausible and consistent with prior studies.

There should be no surprise when an endurance athlete shows up with atrial fibrillation or some other arrhythmia. We are not surprised when masters-aged athletes suffer from other inflammation-induced maladies, like overuse injuries, heart attacks, infections, and even divorce; why are we surprised they get AF?

But context is important. Previous studies have shown Vasaloppet finishers enjoy lower overall mortality. They smoke less, carry less body fat, and report better eating habits. This bolsters the idea that the lifestyle of endurance racing confers good overall health to most participants. Exercise is good. That observation remains unchanged and unchallenged. In the US, we would do better with an epidemic of over- rather than under-exercise.

It’s also important to emphasize that association is not causation. We don’t know whether excessive exercise alone caused the arrhythmia episodes. There are too many possible confounding variables to make a causation link.

[Grant – true, but see below, there is mounting evidence that it is exercise that causes this]

And . . . just because intense and long-term endurance exercise increases the risk of arrhythmia does not mean athletes should avoid a sport they love. These studies don’t tell us to recommend against endurance exercise. They simply inform both doctor and athlete of possible consequences. There are always trade-offs.

As physicians and teachers, knowledge of the association between chronic inflammation and disease might help us give better advice to our athletic patients. My guess, and it is just a guess, I am no coach, is that the same things that help an athlete avoid AF might also make them faster. Do you think getting adequate rest and recovery improves VO2max? Do you think being content with something less extreme than an Ironman or cross-country ski marathon might be antiarrhythmic? What’s wrong with a fast 10K?

[Grant – see below – I think its more about changing nutrition and training methods, but more work needs to be done]

2. Is it linked to the actual exercise or something else?

This is an important point because the study above is only correlational. However, there is enough mechanistic evidence developing to show that the actual exercise itself might be the cause. A study in forty endurance athletes showed significant signs of right ventricular damage following an endurance event lasting between 3 and 11 hours.

The authors conclude that “intense endurance exercise causes acute dysfunction of the RV, but not the LV. Although short-term recovery appears complete, chronic structural changes and reduced RV function are evident.”

3. What might you do to mitigate the risk, but still get the benefits of being fit?

Overall, I would say that these studies and the broader developing evidence shows that excessive and extreme endurance training increase your risk of heart problems. Like anything else, that’s a population measure. What it actually comes down to is whether it affects you or not. That’s binary, not probabilistic. You will either develop a heart problem or you will not.

So what do you do? If you, like me, like the exercise; you understand the benefits are many and done well outweigh the risk, I would say reconsider how you train. I wrote about this is in a previous blog on polarised training and fat adaptation. Both are likely to reduce the oxidative stress on the body and the time you spend in the prolonged hard cardio zone.

Remember, loads of oxidative stress, glycogen burning, and reactive oxygen species has numerous effects on the body; especially the immune system, tissue damage, and DNA damage. This results in a longer recovery time, more sickness, and higher risks of longer term problems.

Take home messages:

  • Exercise is still overwhelmingly good for you. We have a population epidemic of marathon sitting, not marathon running.
  • But…exercise taken to extreme might damage your heart, and you won’t know you have done damage until it’s too late.
  • New training and nutrition techniques may reduce the stress on the heart and body because you go slower more often, and only occasionally really fast (and probably get fitter), and you burn mostly fat (with your heart using ketones as a fuel which it prefers).
  • So, stop flogging yourself at training, eat less carbs – especially sugar, and eat more healthy fat. You might even be faster! You also certainly will be helathier.

My three boys

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OK got your attention. Look I’m really trying to upgrade this blog and send out relevant (and helpful) material, so please let me know what can be improved and what you’d like to see. I’m also really happy to answer any questions, take your success stories in getting fit and healthy and so forth.

Any success or otherwise in carbohydrate restriction is really likely to help others so don’t be shy,

Just drop me an email grant.schofield@aut.ac.nz and I will do my best.

Grant

From bottom to top that’s Jackson (10), Sam (12), and Dan (3) – all good examples of plenty of potential!

How do I get fat adapted and train for triathlons?

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Hi Grant,
I met you on the weekend at the New Zealand Society of Positive Psychology after the morning workshop when you showed a group of us around your building. I asked you, as a ‘fellow triathlete’, about your diet and exercise regime. You directed me to your blog which I read and found very interesting. I have started on the road to a LCHF diet 🙂 So far so good.
I would really appreciate your advice on an exercise programme. Your current exercise programme sounded really interesting – not as grinding or as long as the programme I use. I need a coach – yes I am a needy person! South Island, ideally Christchurch, would be great if the person follows your ideas! I follow my training programmes to the letter – just the way I am. I would be delighted to be part of a research programme if that would be helpful to anyone. I am 60 years old this year and enjoy competing in Age Group Triathlons.
Looking forward to hearing from you.
Cheers,
Jane
Hi Jane
Great to hear you have made a start on the LCHF diet. Just some extra (unsolicited?) advice for the adaptation period. If you are sufficiently restricting dietary carbs to around 50 g or less a day, a few things are worth noting:
  1. Your brain will no longer have enough glucose to run purely on glucose for fuel. This means that until your body can re-orchestrate how it can fuel the brain, you will feel crappy. Some people call this the “keto” flu (because you are adapting to a state of nutritional ketosis). The brain will need to use the by-products of fatty acid oxidation (specifically beta-hydroxy butyrate, or BHB) to make up for the lower amounts of dietary carbs coming in. So most people have a period of a couple of days of mental haze. In my experience, if you have a job where you have to actually think, then plan to try to do this phase at the weekend. Training volume will have to decrease too.
  2. It is possible to mitigate some of the symptoms of the adaptation (dizziness, tiredness, brain fog) by supplementing with good quality medium-chain triglycerides (MCTs). These automatically put fats into your body which mimic the ketones (BHB). MCTs can’t be easily stored as fat and are burned intra-muscularly AND in the brain. Coconut oil is very useful for this. Butter has a good deal of MCTs. Other coconut products do too.
  3. Salt supplementation can be important. In the adaptation period many people find themselves getting dizzy due to hypotension (low blood pressure). What is likely to be happening is that the kidneys are dumping sodium to keep the sodium-potassium balance intact. So, eat heaps of coloured veggies to get the potassium up. Salt gets salt up too. We could be talking up to 5 g/day in the adaptation period.
  4. Keeping an eye on dietary carbs is very important as if intake isn’t low enough, you can end up in the grey zone of just feeling crap and never fat-adapting. A few tricks here are to:
    1. Use a computer-based or smart phone diet diary. If you are in Australia or NZ, the best and free one for this is “easydietdiary”. It links to Aussie and Kiwi food databases. A great learning tool.
    2. Over-consuming protein can also trick you out of fat adaptation because once you reach your daily requirements, you turn extra protein into glucose through a process called gluconeogenesis. Depending on activity levels, daily requirement will likely be 1.2-1.5 gram of protein per kg body weight. Again, the easydietdiary, or other food counters, can assist in seeing how you compare to this. I’m not saying you need to count food all the time, just get an idea of exactly what has what. Some foods are surprising (e.g., BBQ sauce = 53% sugar!).
The idea is that once you are fat adapted, your body should prefer fat as its primary fuel source. This has numerous benefits including more stable mood, lack of hunger and cravings, a better night’s sleep, easy weight control, and an ability to easily miss meals and enjoy the benefits of intermittent fasting.
Now, onto training for endurance sports in the fat adapted state. I have moved into a space which we call “polarised” training. A couple of really neat studies (see below) have come out recently which support this type of training over conventional threshold type training. It is especially good for those on a fat adapted diet because with this diet, you simply won’t have enough glucose supply in the liver and muscles to train in the athlete grey zone, where most (triathletes especially) spend their time.
Here’s what we are talking about:
Polarized training = 80%+ time spent in low intensity work, at or below VT1 (very easy), and 20%, or even less, in very high intensity work (above VT2), which means very hard and hurting. The overall training load and duration will be less than the conventional model, mostly because full recovery is required for the high intensity side.
That’s not what most athletes in endurance sport do. What I regard as the conventional model of endurance training is quite a bit of longer endurance work, but also 30-40+, or even more, in the VT2 range or just below. That’s sort of what some people call threshold zone.
In my opinion, and the evidence both mechanistically and experimentally is mounting, the trouble with the conventional training approach is that much of the training is powered by exclusive carbohydrate oxidation. This creates reactive oxygen species (ROS), glycated-end products, and cellular damage. All of these compromise immune system function and create cell level damage. This rolls out as a tired athlete, who gets sick more often, and recovers more slowly. It also means you are predominantly burning carbs for fuel and therefore need to fuel on carbs constantly. That means none of the benefits of being fat adapted. It also means you have to rely on glucose exclusively for fuel in races. This is a very limited fuel supply in longer endurance races, and the supplementation of carbs through gels and so forth can cause serious gastric distress. It’s also just damn hard to keep your weight under control when training and eating like this, at least for some people (including myself), and especially older athletes.
On the polarised training and fat adapted side, you are burning fat for most of your training and not creating the cellular damage and immune system compromise. You are fat adapted and feel great. You stay in shape more easily and the hard sessions are short enough that extra glucose supplementation isn’t necessary.
Here are some links to two recent studies on polarized training v conventional training for endurance runners and cyclists. Great outcomes on less training.
So what does polarised training look like for me? I do mostly easy long runs and rides (read no rush of ego-driven frenzy). When I feel recovered enough to do so, I do a short and very intense session. That could be once, twice or three times a week. It all depends on my life stress and nutrition quality.
Here’s a few examples:
  • Running track: 10 min easy jog, 10 by 1 min hard on the track, walk 1 min recovery in between. This means I get about 325 m round the track and then walk around to the start of the 400 m again. Actual distances will vary depending on fitness and running ability. That’s the session! Total time: 30 min / Total hard work: 10 min
  • Running treadmill: 10 min warm up. Crank the treadmill up to 19.5 km/hr (or whatever speed is hard for you). I do 4 times through 40 sec run, 20 sec rest, 30 sec run, 15 sec rest, 20 sec run, 10 sec rest, 10 sec run, 5 sec rest. I rest for 4 min after 2 cycles through this. This is very hard, but over quickly. You leave the treadmill going at full speed and hop to the side to rest. Total time: 24 min / Total hard work: 10 min
  • Bike road: Ride for an hour on a hilly circuit. Go flat out on every hill, cruise down. Total time flat out: about 20 min
  • Bike trainer: 10 by 2 min, increasing power every interval by 10 watts from about 340 to 400 w. This really hurts. 2 min rest in between and slightly longer if really hurting.
Those are a few ideas of what I like. I would say that people should make their own ones up to suit time and fitness (and how much you like the pain game!). The other thing you do have to do occasionally is some racing and race simulation, which will be more in that threshold sub-VT2 zone. Fine, limit the damage and take some carbs on board for that part. You will need them. The Kreb’s (glucose metabolism) cycle is spinning fast and the dietary carbs won’t spike insulin and turn off fat burning in this zone, as long as you aren’t silly about it.
Enjoy, and happy fat adapting!

Curing Type 2 Diabetes

I’m writing this post and getting these videos out there after a conversation with a diabetes nurse who was very happy to go around telling her diabetic patients, and anyone else who would listen, that “you can’t cure type 2 diabetes”. Really? No chance of completely reversing all the symptoms?

First is an interview with Dr Jay Wortman by the Diet Doctor (one of my favorite bloggers in the LCHF field)

The second is Dr Wortman’s film about curing diabetes in Canadian first nations’ people. It’s called “My Big Fat Diet“. It comes in three parts.

Enjoy

Help! My husband is a high cholesterol triathlete

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Hey Grant
I’m a bit stuck what to do and would appreciate your opinion on something:
My husband Bob is 43, weighs 80kgs, is a builder, very active (does half ironman etc) with me at triathlon club, seems to deal with work/stresses etc very well and yet every year is told that he has high cholesterol. Traditionally this would mean really watching the fats, butter etc, which we have done, but the readings never change. Obviously we need to look at trying something else but I’m not sure about the LCHF way for him. I already follow a lot of the principles and he will try whatever I give him quite happily.
Your thoughts?
Grant: Yes very interesting.
A few things to consider:
1. How much of a risk factor is high total cholesterol anyway? TC is really meaningless; I would want to see the numbers, especially the triglycerides to HDL ratio. LDL is also pretty meaningless as it is really LDL particle size and number which provide the risk. So it may well be that high cholesterol is not something he actually needs to worry about.
2. Inflammation can be a problem. That’s CRP on the blood test, and that is often exacerbated by loads of triathlon training, a very active job, a high carb diet and consumption of polyunsaturated fat. That’s really the main risk factor for heart disease and all the other metabolic disorders, like diabetes, cancer etc.
3. LCHF is probably a good option, but with a strict fat adaptation phase with reduced training and heaps of coconut oil, just to prove his body can run on ketones and that you can defeat the need for loads of carbs. That is a great self experiment. Then my advice is to stay with that basic approach but supplement with carbs as he sees fit. That way
you get the best of both worlds. But it’s a self experiment every human should do in my opinion – get fat adapted and prove to themselves that they can have a stable mood and energy, with dietary fat as the major source of dietary calories.
4. The LCHF approach is anti-inflammatory, which is great for reducing chronic disease risk factors. A modified “paleo” like LCHF, where you supplement more carbs, is also anti-inflammatory, so long as the carbs are things like kumara (sweet potatoes and yams also). All the work so far shows that this is the best way of reducing health risk for chronic
disease.
5. Being a fat adapted highly active person, who also trains for triathlons may, at least in my opinion (more research needs to be done for sure), reduce the inflammation and oxidative stress and cellular damage done by loads of glycogen -burning chronic cardio exercise. This is that moderate intensity training that triathletes engage in for hours on end. I’m not convinced that this is risk free for health. The heart damage seen in several high profile endurance athletes is some evidence of what I’m talking about. It’s likely that relying more on fat in training reduces this stress. It also forces you to do some really short, high intensity work because you simpy don’t have the available glycogen for higher
intensity threshold intervals, which are the most stressful on the body (e.g. 8 by 1 km running at race pace is stressful, but how about 10 by 1 min sprints instead?) Again, more research needs to be done, but it’s my contention that triathletes could be healthier by eliminating that mid-range chronic cardio training. You might lose a little race pace
speed, but that will be offset by not getting sick as much and being fat adapted for racing, which has significant benefits.
So that was just a few, now longish, thoughts. Good luck and get back to me if you have any other questions…..
Thanks Grant. So if he were to basically follow your usual eating programme (first blog) , also with some kumara/yams, this would be a good place to start?
Yes. Diet Doctor.com also has some more lengthy resources which I aspire to get up myself in due course
To increase coconut oil usage, what would you do -besides using it to fry with?
Yes, extra virgin coconut oil to fry with is great. It goes well at high temperatures. Best of all it’s a medium chain triglyceride (MCT). MCTs can’t easily be stored as fat; they are burned intra-muscularly or in the brain too. They likely have anti-inflammatory effects, even if it’s just because they burn with less oxidative stress than carbs. You can use coconut cream and/or coconut milk to make “fat” smoothies. Berries, coconut cream, some ice – yum! Some people also add butter and/or coconut oil to their coffee in the morning. This is the so called “bullet proof” coffee. Not sure about the name but it’s a cool way to get extra fat.

You mention reducing poly unsaturated fats, is this not oily fish, nuts etc? I thought they were good to have…

I’d avoid trans fats and manufactured poly unsaturated oils, like canola, peanut oil and other “industrial seed oils”. I would (and do) use copious amounts of olive oil, avocado oil, macadamia nut oil, butter and coconut oil. Oily fish (Tuna, Salmon, Sardines, Mackerel) is awesome and eat plenty. Nuts are great too. Some researchers think that nuts are quite high in Omega 6 fats which are inflammatory and compete with Omega 3 fats (oily fish). I actually eat quite a lot of nuts, mainly almonds, and should probably eat slightly less of these. Cashews are one to watch as they are quite high in carbs. They can be good for long runs and bike rides though.

Quite a bit to get the head around with only a small amount of knowledge on my part! I’ll continue to follow your blog, I’m finding it interesting and I’m slowly getting there!

My view is that it is worth taking some time to get up to speed with some of this stuff. I’ve spent most of my personal life and professional career thinking exercise is the most important thing you can do for your health. I still think it is important, but the nutritional context is by far the most important part of human health. While some people seem to go alright on high carb diets, others just don’t. Many seem to have trouble controlling their weight on such diets even though they are doing all the “right” things according to the healthy eating guidelines (low fat, eat grains, etc). The reasons seem to be a combination of chronically high insulin (their biology is easily overwhelmed by carbs), and/or intolerances, to wheat in particular. It doesn’t mean full blown celiac disease, it just means their body works better when they eliminate wheat. Much more research needs to done in this field. That’s mainly why I’m immersing my self in it.