Type 2 Diabetes Remission - UK Direct Trial update.

Diabetes UK have been publicising unpublished results from a 5 year follow-up of the DiRECT trial where a harsh calorie restriction diet ((825–853 kcal/day formula diet for 3–5 months)) was used to attempt remission of Type 2 diabetes in obese and overweight adults. 85 subjects from the initial intervention group of 149 were included in the follow-up.

After 5 years, 11 people were still in remission with a mean weight loss of 6.1 kg. This compares to an average 5-year weight loss of 4.6kg, with 3.4% in remission, for those in the control group.

At the 3 year point 48 of the 85 had been in remission, so only 23% had sustained remission from years 2-5. The percentage in remission in this group fell from 56.5% to 13%.

After the first year of DiRECT, remission was seen in 68 out of 149 subjects, or 46%. Follow up after the second year reported that 53 of the original 149 were still in remission, or 36%.

This suggests that the 85 people in the extension study had a higher success rate at the outset than the whole intervention group. Even if we scale up the 13% in remission at year 5 from 85 to the original 149 it would suggest 19 long term successes in total.

The other primary goal of DiRECT was to achieve a 15 kg weight loss, not least because remission is much higher if this level of loss is achieved. Despite the severity of the calorie restriction and the amount of support provided only 36 (24%) of original participants achieved this at one year, falling to 17 (11%) after 2 years. The Diabetes UK press release does not appear to clarify how many of the 85 had sustained a 15 kg weight loss at year 5, but reports a mean weight loss in the group of 6.1 kg at year 5 compared to 10 kg in the whole intervention group at the end of the first year.

Dr Nicola Guess has written an article suggesting that there is merit in looking at the macronutrient content of the diet beyond the energy balance, as studies show that liver and pancreas fat can be reduced by carbohydrate reduction without weight loss due to the change in fat use for energy and reducing denovo lipogenesis from high carbohydrate intake. This could improve the success rate and reduce the regression seen in DiRECT where weight loss proves hard to achieve and harder to sustain.

Chef succeeds on Atkins Diet

Another personal testimony from the Atkins UK forum :-

Hi Folks,

A have been following some of the threads on this forum for a couple of months now but have not posted until now, so this is my first post here. 

Atkins Diet success story

Shirley, age 63 and with hypothyroidism, reports a weight loss of 6 stone / 84 lbs / 38 kg in 17 months through following the Atkins diet without exercise and with support from the Atkins UK community forum. That's an average loss of over 1.2 lbs per week.

Here's her story in her own words......

We need to talk about Kevin (Hall)

A few months ago I chewed over a poster presentation by Kevin Hall and associates which presented the findings of a detailed metabolic comparison over six days of an 800 calorie intake reduction of either carbohydrate or fat alone in a crossover design. I was concerned about an apparent imbalance in calories / carbohydrate balance that suggested the reduced carbohydrate (RC) phase was depleting glycogen reserves and hence the study was not of a steady state condition.

I general I like the work done by Hall as I have a similar modelling background. There are however remaining concerns now that the full version of the paper has been published in Cell Metabolism.

Firstly I would like to address the "pictorial abstract" :

On the left we can presume that the ~800 kcal/day reduction in dietary fat intake was replaced by fat from body stores, as everything else is shown as the same. At 9.4 kcal/g that's a fat loss of 85 grams/day which is in line with the stated "89 ± 6 g/day of fat loss" for the RF diet (at 9 kcal/g it's a near exact match). So far so good.

On the right life gets complicated. The reduction in carbohydrates allows fat oxidation to flourish to the tune of +400 kcal/day - the reason people like me favour carbohydrate restriction. So the subjects are burning 400 more of fat but 500 less of carbs and hence energy consumption has dropped by about 100 kcal/day. Although burning 500 kcal less of carbs the intake of CHO has been reduced by 800 kcal - so 300 kcal  ( 81 grams/day) has appeared out of the woodwork, or more likely out of the body's glycogen stores.

With 300 kcal of bonus fuel entering the mix the fat loss of the restricted carb diet is impaired - with the same fat intake it relies on increased oxidation and this only rose by ~400 kcal/d which is indeed only half of the reduction of intake seen in the fat restricted phase.

The question remains as to how long this condition could be sustained before the additional carbohydrate reserve dried up and forced a further increase in oxidation of fat. A study for 6 days isn't even half of the Atkins induction phase and the carbohydrate intake here was ~140 g/day which is well north of any "Low carbohydrate" diet let alone anything ketogenic.

A secondary question arises from the fact that supplementary table S3 shows that there was no significant fat loss in the female subjects on either diet - in fact their % body fat went up (NS). I shall be returning to this study to focus on the men who did at least lose weight and reduce their fat mass significantly. I always prefer single gender studies as so much variability is added and significance lost by combining men and women.

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.

Date	28/08/2013	29/08/2013	31/08/2013	31/08/2013	31/08/2013	31/08/2013	31/08/2013	31/08/2013
Time	18:00	17:00	07:30	17:20	17:46	18:18	18:48	19:18
Glucose mmol/l	5.4	4.4	5.9	4.0	4.6	6.5	5.9	6.3
Ketones mmol/l	0.8	0.3	0.8	0.4
Ratio G/K	6.8	14.7	7.4	10.0
Notes	UK	UK	Turkey	End of day	Juice time	------ post juice drink testing ------
UK time off meter
Date	01/09/2013	01/09/2013	02/09/2013	03/09/2013	04/09/2013	05/09/2013	05/09/2013	06/09/2013
Time	04:47	11:02	05:15	05:31	04:09	05:00	06:40	04:15
Glucose mmol/l	6.3		5.8		5.3	5.8		4.9
Ketones mmol/l	1.6	2.3	2.8	2.4	2.9	1.4	0.6	3.4
Ratio G/K	3.9		2.1		1.8	4.1		1.4
Notes					Boat trip		after 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.

Better results from low carb than lower fat.

 There's a lot of chatter over the pond and on t'internet about a recent study comparing low carbohydrate diet advice with reduced fat.

The work was led by Drs Bazanno and Hu of Tulane University, New Orleans and funded by the US National Institutes of Health. Its stated objective was

to examine the long-term effects of a diet low in carbohydrates, as compared to one low in fat, on cardiovascular disease risk factors, including blood pressure (BP), body weight and composition, serum lipids, plasma glucose, insulin, adipocytokines (adiponectin, leptin, resistin), and C-reactive protein (CRP) among obese adults.

Facts about Carbs

Last week the NHS published an opinion piece opposed to low carbohydrate diets. They didn't even get past the first paragraph before naming and attacking well known diet plans that have helped many lose weight. This is a shame, as we need to use any approach that works if we are to address the obesity issue, and carbohydrate restriction has been demonstrated to work in many studies :-

The above are all Randomised Control Trials, analysed with references at authoritynutrition.com and a similar list is at dietdoctor.com showing a large majority of studies finding higher fat / weight loss in the low carbohydrate group of the trial to be better than in the low fat group.

In the NHS article a single study of the Atkins diet is referenced and it is said that

 "A 2003 study found that a low-carb diet can produce quick results, but over the long term it does no better than a balanced diet featuring carbs."

The full story is a little more complex...

 "Subjects on the low-carbohydrate diet lost significantly more weight than the subjects on the conventional diet at 3 months (P=0.002) and 6 months (P=0.03)"

The weight loss at 12 months was still better in the low carb group, but high attrition rates and some issues with the trial design like mixing men and women reduced them below statistical significance (P=0.26). A picture is worth a thousand statistics :-

The attrition rate itself is also of interest -

"The percentage of subjects who had dropped out of the study at 3, 6, and 12 months was higher in the group following the conventional diet (30, 40, and 43 percent, respectively) than in the group following the low-carbohydrate diet (15, 27, and 39 percent, respectively)"

 so it appeared that the low carbohydrate diet did at least work better for more of its participants in that they were more likely to stick with it. carrying forward baseline data means putting the weight of dropouts at their entry value, which makes both groups look worse than the reality of those who completed the programme.

As we would expect there were improvements to blood lipid composition in the low carb diet of this study, but the NHS omit to mention this. Similar results appear across the studies linked to in the above reviews, and recent systematic reviews confirm the benefit of low carbohydrate eating in terms of reduced cardiovascular risk.

So, a shameful piece of conventional wisdom and anti-low carb thinking is published in a context that requires balance, integrity and accuracy. Those of us hoping for a Damascene conversion on the way to Stockholm are disappointed, and the Swedish review that concluded "too much carbohydrate, not fat, leads to obesity" was clearly a better piece of work than asking "Dietitian Sian" for her opinion.

Here are three facts omitted by the NHS :-

1. There are no essential carbohydrates that we have to eat in order to live. This is not the case for fats and proteins where we do need to take in some of each of them in food as our bodies can't make them.

2. There is no diagnosable disease of carbohydrate intake deficiency. Diabetes on the other hand is a difficulty in processing or controlling carbohydrates which leads to high blood sugar levels with clinical symptoms that can be serious. Excess carbs are stored as body fat once glycogen stores are full.

3. The human body at rest uses fats to provide about 2/3 of its energy requirements, with 1/3 from carbohydrates. At high / strenuous exercise rates the proportion of energy from carbs approaches 100%.

Carbs for energy are taken from food and from glycogen reserves which are limited to a maximum of about 2000 calories (kcal). There is only 5 grams of glucose in your bloodstream (20 calories, about 15 minutes worth at rest). A lean athletic man of 75 kg / 165 lbs / 11 st 11 lbs with 12% body fat has about 70000 calories of fat reserves, ideal for endurance activity or periods of famine.

In the absence of dietary carbohydrates the brain switches to ketones as a fuel and glucose is made by the liver - we are dual fuelled / hybrid powered beings where carbs provide short term power / acceleration and fats provide long term endurance and survival. The NHS articles assertion that we are 100% fuelled by glucose is incorrect. Carbohydrates are a low density fuel - would you rather haul fat at 9 calories per gram or carbs at 4 cal/g over the Antarctic ice sheet or up Everest ?


Have a Happy Christmas !

Fat Fast / Cream Day

Well here I am 3 years down the line, and still eating low carb. My current weight is 11 stone 10 lbs ( 164 lbs or 74.5 kg if you prefer other units ) which is as low as I've ever measured. I must have weighed this as a boy, but boys don't weigh themselves. My BMI is 23 !! Low carb delivers, and I haven't "put it all back on again" as various cynics, refuseniks, dietitians and general tossers on the internet would have you believe.

I dropped 8 lbs recently on a rather good and special holiday, more of which later.

About a month ago I did a sort of "fat fast" to try to boost my weight loss a bit and see if I could increase the ketone levels in my blood - aiming for the "nutritional ketosis" nirvana that people enthuse about on the web. I wrote it up as a document that you can read or download from Google Drive

Dr Atkins described a fat fast in his original book in 1972, used to kick start his diet in some resistant individuals who needed to have very low levels of carbohydrate and protein to cut down their blood sugar levels and get the brain switching over to use ketones from fat as its primary fuel. From memory he aimed at 1000 calories with basically all of them (90%) from fat - macadamia nuts and some cream cheese for example. A fat fast cookbook has been published recently, for those looking for detailed guidance, but I haven't read it yet.

My fat fast delivered a 3 pound weight loss in one day, and ketone levels increased progressively with the overnight fasted result up in the magic "nutritional ketosis" range :-

I think a fair chunk of the weight loss was water associated with glycogen, as the lack of carb intake and the day's activities would have depleted my liver's glycogen reserves and forced the use of glucose and ketones produced by the liver to provide the body's energy requirements (along with fatty acids from my fat stores, of course).

My total food intake for the day was 1480 calories, with 78% from fat and 71 grams of protein, so this was not a real "hard core" fat fast to the letter, but a decent amount of food with controlled protein, low carbohydrate and lots of lovely nutritious fats to scare the cardiologists away.

It's interesting that 40+ years after Atkins wrote his book "Dr. Atkins' Diet Revolution" , and 10 years after his death, people like me can re-discover his ideas and find they are still relevant. They may in fact still be "best practice"  despite all the low fat calorie restriction dogma we have been subjected to since.