Wednesday, 29 July 2015

Type 2 Diabetes - dietary advice from Diabetes UK

A couple of weeks ago I received an e-newsletter "Type 2 Together" about peer support for Type 2 diabetics arranged by the charity Diabetes UK. It featured a recipe :

One slice of this contains at least 4 times the amount of glucose in my bloodstream, so I am somewhat confused as to why this would be a good recipe for Type 2 diabetics. Perhaps it's because it is low in fat. That's right, patients with an excess of carbohydrate in their bloodstream and a problem managing it are apparently supposed to be primarily concerned about fat, so at least there's only 1g per slice.

The ingredients aren't exactly inspiring - mixed fruit, wholemeal flour and fructose - or sugar, sugar and sugar for simplicity.

Around the same time Diabetes UK were running a PR campaign about the number of foot amputations occurring in the UK diabetic population. As I understand it the foot amputations result from diabetic neuropathy, which is caused by elevated blood glucose, which in turn is caused by digesting carbohydrates.

If we're worried about foot amputations, why not suggest eating less carbohydrate !

The hand wringing about fat arises from increased heart disease in diabetics. I would imagine this is entirely due to the effects of elevated blood sugar on the cardiovascular system, so once again carbohydrate restriction would appear to have some merit.

I used the UKPDS risk calculator to estimate the effect of HbA1c on my personal heart disease risk over 10 years. With all other variables constant the risk rises with HbA1c :-

HbA1c %        10 year risk %
4                              4.7
5                              5.5
6                              6.5
7                              7.6
8                              9.0

So reducing HbA1c from 8 to 4 brings a corresponding halving of the heart disease risk. Once again, does this not suggest less blood glucose is good for the heart ? Especially when low carb diets also improve the CVD risk profile by increasing HDL cholesterol and reducing triglycerides.

Whichever way I look at it the Diabetes UK cake recipe and their dietary advice in general is a recipe for heart disease and amputations.

Tuesday, 21 July 2015

Ironic Nutritional Ketosis

A couple of years ago I had an enjoyable 1 week holiday at Jason Vale's mountain retreat in Turkey aka "Juicy Mountain". Jason is a "juicing guru" who advocates freshly juiced fruits and vegetables for health and combines this with vigorous exercise programmes and yoga in a stunning setting to give a cleanse of mind, body and soul. To be honest I was somewhat skeptical as I am no spiritualist or gym bunny and after 3 years of low carb eating I thought I may need counselling to go on a diet that was substantially carbohydrate based.

I took along my blood glucose and ketone testing kit but left most everything else electronic behind, in order to de-stress and "be present" as Becky the retreat manager requested we should be. We ate practically no food during the week but started each day with yoga followed by a small juice shot and then a long walk or similar. On returning there may be a gym or rebounding (trampoline) session before the first real juice of the day at 10am. After that came more exercise in the gym with the brilliant Tim Britton as our trainer and other less formal exercise like volleyball, swimming or borrowing the mountain bikes. Another juice at about 1pm preceded the relaxing afternoon in the 30+ degree C heat (90 F) before we were back in the gym or on the trampolines followed by "tea" at around 5pm and a final juice watching a DVD or similar at about 8pm. Yoga was led by Ken Ryan, a brilliant Irishman with a level of quirky charisma that only the Irish can aspire to, as demonstrated by him living in an actual cave on the mountainside.

Looking back I can identify several elements that contributed to my 7 pound / 3.2 kg weight loss during the week. Firstly we had a sort of intermittent fasting regime where we had virtually no calorie intake between 8pm and 10am the following day. In the morning we had yoga and exercise in a fasted state, walking for an hour up and down hills or doing a 5km run down and back up the mountain. Overall the calorie expenditure was high with several hours of physical activity per day and there was presumably a fairly low calorie intake from drinking about 1.2 - 1.5 litres of juices and blended smoothies per day as our sole "food" intake.

I estimate I was taking in around 1,000 calories a day (+/- 20%) with probably 80% from carbohydrate and when I used my Polar heart rate monitor I estimate my daily exercise was at least 2000 calories, most of which was in temperatures above 30 degrees C.

So to the numbers, below. I took a couple of baseline readings at home, then after flying to Turkey and arriving late at night a couple of readings on our first day in the retreat. The second reading was just before the evening juice and I followed that up with 3 half hourly glucose tests to see the postprandial effect of the juice - which was less alarming than I expected.

Glucose mmol/l5.
Ketones mmol/l0.
Ratio G/K6.814.77.410.0
NotesUKUKTurkeyEnd of dayJuice time------ post juice drink testing ------
UK time off meter
Glucose mmol/l6.
Ketones mmol/l1.
Ratio G/K3.
NotesBoat tripafter run

The days in September I mainly took a fasted reading on waking at dawn - we were "sleeping" in a very warm tent so tended to be up very early. The ketone levels I recorded were typically over 2.0 which is quite unusual for me, hence the 11:00 check on the second day. Google sheets link to data.

On the Thursday we had a "day off" with an excursion down to Gocek -

and a boat trip where the enthusiastic captains of our boats provided us with quite a lot of fruit to eat and tomatoes with salt which proved very popular indeed - the group nicknamed themselves "Salty Tomatoes" after the primal behaviour displayed getting to the salt from the guests who were going through "keto flu" symptoms as they adapted (or failed to adapt) to the reduced carbohydrate and low calorie intake.

My ketone levels halved after the boat trip which I thought at the time was due to the high sugar intake from the fruits, although the reduced activity level may also have been a factor. Our juices at the retreat had a high vegetable content and blended avocado so I think the boat trip food was probably a bad idea in the middle of a week of otherwise controlled intake. I suspect the trip and fruit is a necessary part of the retreat programme in order to stop people fleeing to buy food or to escape from the isolated mountain location.

The day after the boat trip we started our morning with a 5km run down about 500' of fairly rough mountain tracks and back up again. This was a repeat of a run done at the beginning of the week to assess our progress. My ketone levels after the run were low, perhaps because I had been using them or perhaps a continuation of the alleged effect of the boat trip. Either way I was back up over 3 the next and final morning before departure.

So that's the long overdue story of how a low carb eater lived the juicy life for a week and saw improved levels of blood ketones despite a predominantly carbohydrate diet at restricted calorie intake. I lost 7 pounds and fell below 12 stone (168 lbs / 76.3 kg  - I am 5'-10" / 1.80m) for the first time I can recall as an adult, I did exercise beyond any previous experience and had a really good time thanks to the excellent team in place at the resort and my fellow travellers.

Thursday, 9 July 2015

BBC Inside Health - Gestational Diabetes, Low Carb Dieting.

A recent edition of BBC Radio 4's "Inside Health" programme covered gestational diabetes and (separately) the experiences of a listener who lost 4 stone (56 lbs, 25 kg) on a low carbohydrate diet.

The programme web site is here, and the mp3 audio file should be available to download via this link however BBC media can be time or location limited so I apologise if it isn't available to you. I do have a copy of the mp3 so get in touch if you need one.

The gestational diabetes (GDM) item was based on the Rosie Hospital in Cambridge where they have recently published work on the sensitivity of different diagnostic criteria for GDM. The article in Diabetologia identifies patients with GDM who fall between the UK's NICE guidance on diagnosis and other criteria and looks at the risks of complications in that group. Full paper here.

Of interest to low carbers was the clear description by a dietitian on air as to how all carbohydrates including starch end up as blood sugar. She went on to say that this meant the hospital encouraged mothers-to-be to change from white bread to wholemeal as the lower GI reduced the blood sugar impact, which was a bit of a let down after a good start. Dr Mark Porter, who presents the program, said on Twitter that the Rosie Hospital's GDM program used diet and carbohydrate restriction, along with exercise, as its primary treatment method. Unfortunately this didn't come over in the audio, perhaps due to editing, so the message was more about changing the colour of your bread rather than eating a lot less of it in the first place.

The second item of interest concerned a listener Mark Robbins who called in to enthusiastically report his weight loss on a low carb diet. Dr Mark discussed this with regular sidekick Dr Margaret McCartney (a GP from Glasgow) and the eminent Professor Susan Jebb OBE. There was a general consensus that low carb dieting does work and that Drs Mark and Margaret see this in their practice patients. It was also agreed that diet trials of up to a year - said to be "short term" - support low carb dieting. Unfortunately nobody much does long term studies, perhaps due to cost or the difficulty of keeping subjects motivated and under control for so long.

Dr Mark asked (at 20m48) if there was a scientific reason / rational explanation of why low carb diets might make weight loss easy and Prof Jebb replied to the effect that "it is just about calories". Perhaps she needs to sit in on Metabolism or Biochemistry 101 classes and remind herself how chronic carbohydrate consumption elevates insulin which impairs the release and oxidation of fat from storage. To lose 25kg of fat in a year requires a fat oxidation rate of 2,9 grams per hour average above the dietary intake (or bodily production) of fat - that's about 25 calories an hour or 600 calories a day and probably 25% of the calorie burn of the listener. Clearly anything that increases fat release and fat oxidation rates is a good thing when you want to achieve this - carbohydrate ingestion does the opposite.

Speaking of Dr Jebb, she appears on the author list of a recent study "Dietary patterns, cardiometabolic risk factors, and the incidence of cardiovascular disease in severe obesity" which looked at 2000 Swedish subjects over 10 years. After much complex maths they concluded "An energy-dense, high-saturated-fat, and low-fiber DP was longitudinally associated with increases in cardiometabolic risk factors in severe obesity but not with CVD incidence" (my emphasis) so once again the "saturated fat is bad" mantra did not stand up to analysis, neither did the "high fibre" approach that Prof Jebb is so keen on. She will never be in favour of low carb diets while she's locked into a high fibre from whole grains and low saturated fat dogma that is increasingly looking "so last century".

Who eats whole grains ? Only pigeons, as far as I can see. Sorry Susan.




If you’re a vegetarian or vegan, whole grains and starchy vegetables may have traditionally been important components of your meals. These are the foods that you’ll reintroduce in Phase 3, Pre-Maintenance. However, they’re also some of the very foods that may have gotten you in trouble in the past. You may find that over time you can tolerate larger portions as long as you steer clear of refined grains and most processed foods.

Advice for Vegetarians and Vegans

  • Follow the general guidelines for reintroducing foods at the top of the Carb Ladder.
  • Follow the basics for Pre-Maintenance and for doing Atkins as a vegetarian or avegan
  • Always eat carbohydrates with fat and/or protein.
  • Add back starchy vegetables followed by whole grains before higher-carb fruits (other than the berries and melon acceptable in OWL). 
  • Continue to focus on foundation vegetables.
  • Regard starchy vegetables and whole grains (and legumes) as side dishes, rather than the mainstays of a meal.
  • Avoid white rice, white flour and other refined grains.
  • Use Atkins Cuisine pasta, Shirataki pasta or whole-grain pasta instead of conventional pasta made from white flour.
  • Bake with Atkins Cuisine All Purpose Bake Mix or soy flour instead of white flour.
  • Continue to use low-carb productssuitable for Ongoing Weight Loss.

[ Reproduced without permission from now-defunct page on - links may not work ]

Atkins for Vegans

Atkins for Vegans

It’s challenging for vegans, who don’t eat eggs and dairy products, to do Atkins, but not impossible. The trick is to get sufficient protein from seeds, nuts, soy products, soy and rice cheeses, seitan, legumes and high-protein grains such as quinoa. Weight loss may proceed more slowly because of the higher carb intake than that of those following the standard Atkins program. Vegans should make the following modifications:
  1. Start in Ongoing Weight Loss at 50 grams of Net Carbs so that you can have nuts, seeds and their butters, plus legumes, from the start.
  2. If you don’t have much weight to lose, start in Pre-Maintenance at 60 grams of Net Carbs, in order to include small amounts of whole grains and starchy vegetables from the start.
  3. Make sure you’re getting sufficient protein in plant sources.
  4. In order not to interfere with fat metabolism, add extra flaxseed, olive, canola, walnut and other oils to salads and vegetables to make up for the smaller amount of fat in most of your protein sources.
  5. Shakes made with plain unsweetened soymilk (or almond milk), soy (or hemp) protein, berries, and a little sweetener can make a tasty breakfast. Add some coconut milk to up the fat content and make the shake creamer.
  6. You can also make shakes with silken tofu. Try it puréed with peanut or almond butter for added protein and fat.
  7. Sauté silken tofu with onions and other vegetables to stand in for scrambled eggs.
  8. Mayonnaise made with soy instead of eggs, mixed with crumbled tofu, chopped celery and onions, and a little curry powder makes a tasty eggless salad.
  9. Silken tofu and soy creamer can be used in desserts, as can agar-agar in jellied desserts.  

When you move to Pre-Maintenance, follow the general guidelines for reintroduction and think of these foods, as well as legumes, as side dishes, rather than the mainstays of a meal. You may find that over time you can tolerate larger portions as long as you steer clear of refined grains and most processed foods. Add back starchy vegetables followed by whole grains before higher-carb fruits (other than the berries and melon acceptable in OWL). Continue to stay away from conventional pasta and other products made with white flour and other refined grains.

[ Reproduced without permission from now defunct web page ]

Atkins for Vegetarians

This is a copy of the content of a now-defunct page from the web site, the links may not work but it is reproduced here for information.

The Program: Ways to Create a Custom Diet Plan, With Atkins

Atkins for Vegetarian

It’s perfectly possible to be a vegetarian—or simply minimize your intake of animal protein, add variety to your meals and trim your food budget—and still do Atkins. The typical American vegetarian often consumes far too many carbohydrates in the form of pasta and other refined grains. As long as you have at least two varieties of plant protein each day, you can get a balance of essential amino acids (the building blocks of protein). Which leads to the second challenge. Plant proteins are “packaged” with carbohydrate. Your objective is to consume enough protein without simultaneously getting so much carbohydrate that it interferes with weight loss or weight maintenance.

To adapt Atkins to your needs as a ovo-lacto vegetarian:

  1. Start in Phase 2, Ongoing Weight Loss (OWL), at 30 grams of Net Carbs and introduce nuts and seeds and all unsweetened dairy products except milk (whether whole, skim, low fat, or no fat) and buttermilk before berries.
  2. Or, if you have no more than 20 pounds to shed and are willing to swap slower weight loss for more food variety, you may start in Phase 3, Pre-Maintenance, at 50 grams of Net Carbs.
  3. Make sure to get sufficient protein in eggs, cheese and soy products. Aim for no more than 6 grams of Net Carbs per serving of protein foods in OWL.
  4. Meat substitutes may be made from textured vegetable protein (TVP), soy protein (tofu and tempeh), wheat gluten (seitan), and even fungi (Quorn) among other ingredients. See Acceptable Induction Foods: Soy and Vegetarian Products for a more comprehensive list. Some of these products contain added sugars and starches and some are breaded, so read the list of ingredients carefully.
  5. Get most of your carbs from foundation vegetables.
  6. Most nonanimal protein sources (except for tofu and nut butters) are low in fat. Continue to get enough healthy oils in other dishes by dressing vegetables and salads with olive oil, canola oil, high-oleic safflower, walnut, flaxseed and other oils so as not to interfere with fat metabolism Also enjoy high-fat snacks such as half a Haas avocado or some olives.
  7. Add back nuts and seeds before berries. Nuts and seeds contain fat and protein that will make Atkins easier to do and more effective.
  8. Or, if you choose, add back legumes before other OWL-acceptable foods. But do so in extreme moderation (2-tablespoon servings), using them as garnishes on soups or salads.
  9. Tempeh, made with fermented soybeans, is higher in protein than tofu and more flavorful. Sauté tempeh with veggies in a stir-fry, crumble it into chili, soup, or sauces or marinate and grill it. Avoid tempeh products that include rice or another grain until you’re in Pre-Maintenance.
  10. Shakes made with plain unsweetened soymilk (or almond milk), soy (or hemp) protein, berries and a little sweetener can make a tasty breakfast.
  11. Purée silken tofu with berries and other fruit in shakes, adding peanut or almond butter for added protein; or sauté firm tofu with vegetables for lunch or dinner.

If you eat no eggs and dairy:

  1. Substitute crumbled silken tofu for scrambled eggs—a pinch of turmeric provides an appealing yellow hue. For baking, use an egg substitute product.
  2. Even some vegetarian products, such as Quorn, as well as shakes, may contain eggs or whey. Read labels carefully.
  3. Mayonnaise made with soy instead of eggs, mixed with crumbled tofu, chopped celery and onions, and a little curry powder makes a tasty eggless salad.
  4. Silken tofu and soy creamer can be used in desserts, as can agar-agar in jellied desserts.
For more ideas, see Atkins for Vegans.

Pre-Maintenance and Beyond

Whole grains usually loom large for vegetarians, and starchy vegetables are often important components of meals. However, they’re among the very foods that may have gotten you in trouble in the past. Follow the general guidelines for reintroduction and think of these foods, as well as legumes, as side dishes, rather than the mainstays of a meal. You may find that over time you can tolerate larger portions as long as you steer clear of refined grains and most processed foods. Add back starchy vegetables, followed by whole grains, before higher-carb fruits (other than the berries and melon acceptable in OWL).