7) THE MANY WEIGHT LOSS DIETS POSSIBLE
h) Diets We do not Recommend
Dr Ezrin's Diet Plan
Dr Ezrin's Diet plan ("The Type 2 Diabetes Diet Book", Calvin Ezrin MD and Robert E. Kowalski) is very similar to Dr. Bernstein's Diet but has a break in period where very limited amounts of calories are ingested. Doctor Ezrin also recommends going into a slight ketosis during this break in period. His diet is only recommended for the obese, not for people who are just overweight. Doctor Ezrin, as is Doctor Bernstein, is an undisputed expert in the field of type 2 diabetes. His bibliography of research articles is extensive and his reasoning appears to be very sound. But his maintenance diet includes 250 grams of carbohydrates per day, 50% of the typical caloric intake. We believe that such a course of action will just lead to a person with type 2 diabetes gaining back all the weight they have lost and doing a lot of protein poisoning in the process. So we can't recommend this diet.
ADA diets
Both the American Diabetes Association and the American Dietetic Association previously recommended a diet which has very high levels of all types of carbohydrates, including such refined carbohydrates as crackers. Quoting a guest editorial in the American Diabetes Association magazine "Diabetes Forecast" on July 2006, written by Janine Freeman RD (Registered Dietician), CDE (Certified Diabetes Educator) titled "Low Carb isn't the Answer":
"The amount of carbohydrate you need is based on a number of factors, but in general, adult women should eat 45 to 60 grams per meal and 15 grams per snack, and adult men, 60 to 75 grams per meal and 15 to 30 grams per snack".
This represents what I'll call the "traditionalist approach". Contrary to the adamant claims of all the "experts", for type 2 diabetes this diet is simply not supported by the research, it has way too much carbohydrate in it. I was unable to find one piece of decent research supporting this position, not one! There is a lot of research where "normal" patients were subjected to closely controlled calorie restricted high carbohydrate diets, lost significant weight and their cholesterol and triglyceride levels improved. As we have pointed out elsewhere, it's not how you lose the weight as much as how much weight you lose. But carbohydrates create hunger. So individuals on high carbohydrate calorie restricted diets end up cheating and gaining the weight back. In any case, those who are on high carbohydrate diets have higher blood glucose levels than those on low carbohydrate diets. Both the American Diabetes Association and the American Dietetic Association were hanging onto this high carbohydrate diet like bulldogs. But the position of the American Diabetes association changed in December 2007. Per the Washington Post:
"For the first time, the American Diabetes Association (ADA) has come out in support of low-carbohydrate diets for people with diabetes who want to manage their weight. The ADA voiced its support of low-calorie or low-carbohydrate diets in its newly published 2008 clinical practice recommendations. "
This is a little misleading in that the ADA just broadened it's list of acceptable diets to include both high carbohydrate and low carbohydrate diet plans. High Carbohydrate diets for those with diabetes just don't make common sense. Why do doctors prescribe drugs which interfer with the absorption of carbohydrates in the body? The ADA "experts" claimed that large amounts of carbohydrate were absolutely neccessary to provide all the nutrients needed for good health. Then why did the early Inuit indians and eskimos of the artic and the Masai of Africa survive just fine on diets with virtually no carbohydrates? And both groups had very low rates of both diabetes and heart disease. Both groups are now beginning to suffer high rates of modern diseases as their intake of carbohydrates increases. Most modern carbohydrates are based on grains and Paleolithic hunter gatherers did not eat significant amounts of grain. Several books and articles claim that societies with high carbohydrate consumption had better health than their neighbors with low carbohydrate consumption. But they never mentioned the societies they were referencing! And our research showed just the opposite in case after case, the Masai are healthier than their agricultural neighbors, the meat eating cattle graising Tutsi (formally Watusi) are healthier and five inches taller than their agricultural Hutu (bantu speaking farmers) neighbors, the agrarian meat eating society of Crete is much healthier than the city dwelling population of Crete who eat largely processed foods, the American Pima Indians are in much worse shape than their more meat eating, more exercising tribal members in Mexico. Meat eating societies in both India and China are healthier than their agricultural neighbors. It has to be noted that in all these cases the "meat" refered to is NOT genetically engineered "feedlot" meat high in both fats and saturated fats.
One of the problems with the term "carbohydrate" is that it fails to recognize the huge difference between a grain based carbohydrate and a vegetable based carbohydrate. The first is bad for you, the second is good for you. But to the traditionalist, a carbohydrate is a carbohydrate. No research the author was able to find identified even a single essential nutrient which grains provide and vegetables don't provide. yet the traditionalists continue to insist on eating large amounts of grain based carbohydrates. The basis of their pyramid remains breads, cereals and other grain based products.
Quoting Frank Q Nuttall, MD, PhD and Mary Gannon PhD in " Carbohydrates and Diabetes" from the book "American Diabetes Association Guide to Medical Nutrition Therapy for Diabetes", page 87
"Since the availability of insulin and oral agents for the treatment of diabetes, food energy restriction and limitation in carbohydrate content have not been considered necessary."
Physicians see their duty as providing medicines which cure diseases. So if you have medications which "cure" or "control" the disease, nothing else is necessary. Unfortunately medicines do a very poor job of controlling type 2 diabetes. Weight loss, exercise and carbohydrate restriction do a much better job of controlling the disease. But few people accept the prescription of exercise, weight loss and carbohydrate restriction. More people will take a pill or a shot. So doctors just prescribe a pill or a shot and don't even investigate carbohydrate restriction.
High carbohydrate diets ignore the basic reason that diabetes is so bad. Diabetes works by allowing excess carbohydrate to poison body proteins. Reduce the amount of carbohydrate and the amount of protein poisoning is reduced correspondingly. Both A1c and blood sugar levels are directly proportional to the amount of digestable carbohydrate eaten. So why wouldn't a person with type 2 diabetes want to minimize their intake of digestable carbohydrate? Protein is 50% carbohydrate. This 50% is made available very slowly, both reducing the amount of carbohydrate in the blood by 50% and evening out the amount of carbohydrates in the blood. These are both very desirable for a patient with type 2 diabetes. Eating proteins is much like eating carbohydrates with a 50% fiber content, 30% carbohydrate content and a 20% fat content.
Again, if someone undertakes a high carbohydrate diet like this and observes the "calorie in versus calorie out" rule, they will lose weight. And weight loss is the ultimate goal. The "traditionalists" recommendations appear to be designed to overcome the resistance of people to permanently making major changes in their diet. The feeling seems to be that if people are only required to make minor changes to their diet, to reduce only their serving sizes and thus to reduce the "calories in", then long term compliance will be better.
Quoting Marion J Franz MS, RD, LD, CDE "A Dietician's Perspective on Medical Nutrition Therapy for Diabetes" from the book "American Diabetes Association Guide to Medical Nutrition Therapy for Diabetes", page 3
"The dietician should determine the nutrition prescription based on the food/nutritiion assessment of what the person with diabetes is currently eating. Eating patterns are modified based on treatment goals and changes an individual with diabetes agrees to incorporate into his/her lifestyle"
If a patient is not willing to make significant diet changes and this high carbohydrate diet is the only way in which a patient is willing to lose weight and keep it off, then so be it. Go for it. But don't present it as the best alternative or deny the superiority of the low carb approach.
Atkins™ High Protein Ultra Low Carbohydrate Diets
We can't recommend Atkins™ diet for two reasons; first is the phenomenon of "muscle wasting" and second is the fact that cholesterol and triglycerides do not drop anywhere near as much as they can drop. This lack of significant drop in blood lipids is due to the large amount of "feedlot" red meat and saturated fat found in Atkins™ diet.
A person with type 2 diabetes does not want to simply lose weight. They want to increase their muscle mass and decrease the level of adipose or fat tissue in their body. This strategy reduces their insulin resistance. High protein ultra low carbohydrate diets typically will drop weight faster than any other diet and they will drop glucose levels and A1c levels. Unfortunately, if a person exercises on a regular basis, a good portion of this weight lose is not fat tissue, it is lean muscle. And this is not good for someone with diabetes. So this is one diet we definitely do not recommend for anyone with type 2 diabetes. And we recommend solidly against any diet which recommends that the individual with diabetes go into ketosis.
The Doctor Atkins™ diets (and the works of doctors Ezrin, Eades, Feinman and Fine and the works of Gary Taube) made "ketosis" a household word. "Ketosis" is where the body burns fats (at rest but not during exercise) but doesn't reduce the fats to water and carbon dioxide; instead chemicals called ketones are produced. Ketosis is an extreme condition. Extremes need to be avoided in all diets, especially by those with diabetes.
Doctor Atkins™ diets now recommend about 20 grams of carbohydrate per day. This low level will typically produce ketosis. The claim of the Atkins™ diet was that "In the absence of dietary blood sugars from carbohydrates the body is forced to burn fat". This is only partially correct, it should state "In the absence of dietary blood sugars from carbohydrates the body is forced to burn PROTEIN for exercise and to burn fats to a partially oxidized state called ketones during times of relative inactivity". During even moderate exercise muscles must use blood sugar, they cannot use fat. During exercise a person requires reasonable levels of blood sugars, and blood sugars cannot be generated from fat in the body. Blood sugars can be generated from protein within a muscle cell (about 50% of proteins are actually carbohydrate), so during exercise, a person in ketosis burns his muscle proteins, not his fat. Fat or carbohydrates cannot be turned into proteins. The body can slowly replace the muscle proteins from protein in the food but the body will fall behind if exercise is regular. Since we heartily recommend regular exercise as one of the major ways to control type 2 diabetes, we cannot recommend any of the "ketosis" diets.
The mechanism of protein burning or "muscle wasting" in ketosis is well researched and has been known for many years. Fats simply cannot be converted directly to carbohydrates (i.e. the blood sugar glucose) in the body. If at least some form of carbohydrates is not available, the fat is broken down only partially, giving "ketones" instead of carbon dioxide and water. Thus the term "ketosis". Ketones can be utilized as energy by some of the body cells but the process is slow and doesn't work well during exercise. Proteins can be broken down into stored carbohydrates (glycogen) by the liver, but again the process is slow and inefficient.
One claim of these diet doctors is that mankind is designed by nature to go through periods of starvation and ketosis where he has to live off only his fat stores. In actuality most anthropologists agree that for most of Paleolithic man's life on the savannas of Africa starvation was a rare occurrence. There were always roots and nuts available, just not in great enough abundance to prevent slow weight loss. So ketosis is not "natural".
"Glucogen" is a form of carbohydrate stored by the liver and muscles to provide blood sugar during periods of exercise. Ketosis will reduce or eliminate these stores. Because these stores are reduced and there are few carbohydrates being ingested in ketosis, an individual in ketosis who exercises stands a good chance of low blood sugar, the "shakes", unsteadiness and mental confusion, i.e. hypoglycemia. This is especially true if that individual has type 2 diabetes.
The ketosis doctors claim that the metabolism and body temperature of a person increase when they are in ketosis but there are no meaningful research studies we could find which back this up and several research studies which found no change. Ketosis diets work because they are so limiting in the foods that can be eaten and because the diet they are most often compared to includes large amounts of refined carbohydrates (refined carbohydrates increase appetite). Note that long term compliance on the ketosis diets is low because they are so limiting (and because one in four people experience nausea and vomiting in ketosis). It is far healthier and more easily done to cut back on the calorie intake, the saturated fat intake and the refined carbohydrate intake. Healthier still is to cut back on these three intakes while increasing the exercise routine.
The corporations and foundations founded by Dr. Atkins fund a great deal of apparently very well done research which has tended to support his ketosis diet. But none of this research that we found has included a high protein diet where ketosis is avoided. And we are always a little skeptical when the funding for research comes from an entity that will benefit from the research. Unintentional bias is difficult to avoid. All these ketosis based studies are also "free" studies rather than "ward" studies. In "free" studies the study subjects are free to go home and eat whatever they want. It is well known that protein provides better satiation than "carbohydrates" as a whole. "Free" individuals on "high carbohydrate" diets will invariably overeat on refined carbohydrates. Overeating of refined carbohydrates typically results in increased hunger which in turn results in more overeating. Ketosis also tends to produce nausea, which will reduce the appetite. So the amount of "cheating" is greater in "high carbohydrate" diets than high protein ketosis diets.
"Ward" studies, where people are confined and prevented from cheating, have consistently supported the concept that calories in versus calories out is the only determinant of weight loss during dieting. One valid exception to this rule is muscle wasting in ketosis. Muscle protein only has 4 calories per gram weight while fat has 9 calories per gram weight. So two pounds of muscle can be lost at the same calorie restriction as one pound of fat. But losing muscle and not fat is hardly desirable, especially for someone with type 2 diabetes.
Ketosis accompanied by weight loss will typically result in little or no change in cholesterol and triglyceride levels. But a low refined carbohydrate, low saturated fat diet accompanied by weight loss can result in a 60% reduction in cholesterol and triglycerides. That's a big difference. This is because the large reduction in cholesterol and triglycerides inherent in a large weight loss will be offset by large amounts of feedlot red meat and saturated fats in the Atkins™ diet.
True Fad Diets
There are mainly diets which rely on a single food (cabbage soup, grapefruit, bananas and skim milk, etc.) or which rely on herbal supplements (Hydroxycut, hodia, etc.). These diets are truly dangerous and don't provide the variety of foods needed for reasonable nutrition. Hydroxycut, which is 90% of the dietary supplement market, was recently recalled by the FDA as it caused liver damage and other health problems. There simply is no "magic food" or "magic pill" when it comes to weight loss.Fasting diets
There are diets which require that a person fasts (no food intake at all) for days or weeks at a time. These diets can kill or severely damage the health of a "normal" person, let alone a person with type 2 diabetes. Fasting causes rapid onset of ketosis. A person with type 2 diabetes should never fast more than 14 hours. Fasting can severely damage the liver and kidneys. Fasting and ketosis can also result in low potassium levels and result in nausea, dizziness and a pounding heart.Purging Diets
There are many holistic or naturopathic diets which involve "cleansing of the body" of "poisons" by use of natural laxatives and cathartics. Once again, diets such as this can severely damage the health of anyone and need to be avoided. The gastrointestinal tract is a biologically balanced system, the "toxins" that are gotten rid off in purging or cleansing are largely beneficial bacteria which provide the body with important nutrients, such as vitamin K. So it is not beneficial to remove them from the body. Indeed, one of the problems of long antibiotic therapy is that the beneficial bacteria in the gastrointestinal tract are suppressed and antibiotic resistant deadly bacteria such as Clostridium difficile can multiply.Detox Diets
Rapid weight loss "Detox" diets which involve such regimens as only drinking three liters a day of a concoction of freshly squeezed lemon juice, water, maple syrup and cayenne pepper are obviously bad for anyone with type two diabetes. The vast majority of the calories comes from the maple syrup, which is largely high fructose corn syrup in most commercial syrups and table sugar (sucrose) in pure "real" maple syrup. And the amount of calories is way too low. Rapid weight loss of any kind is not desirable. It is generally water weight loss and it is generally put right back on as soon as the diet ends. Any diet needs to be a reasonable diet that a person with type 2 diabetes can live with for the rest of their lives.
Current Chapter: 7) The Many Weight Loss Diets Possible
a) Diets: Which One is the Best?
b) The "Hunter Gatherer Diet"
c) Moderation Type 2 Diabetes Diet
d) Good Diets
e) Reasonable Diets
f) Helpful Diets
g) Radical Diets
h) Diets We do not Recommend
i) Fad Diets and Pills
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