tarnowerhermanThe only person definitely known to have died as a consequence of an association with a low-carbohydrate diet is Dr. Herman Tarnower, author of the Scarsdale diet, although, as they used to say on the old TV detective shows, the immediate cause of death was lead poisoning. His girlfriend shot him. Not that folks haven’t been looking for other victims. The Atkins diet is still the bête noire of physicians, at least those who aren’t on it — a study published a few years ago said that physicians were more likely to follow a low carbohydrate diet when trying to lose weight themselves, while recommending a low fat diets for their patients.

But doctors, after all, have first to avoid harm, so when I gave a talk at at the European Society for the Study of diabetes (EASD) held in Vienna in 2008 on treating diabetes with carbohydrate restriction, someone in the audience was concerned about constipation. Constipation. This, in a disease that is the major cause of acquired blindness and second only to accidents as a cause of amputations. Is that what all the “concerns” are about? Is that really risk?  Isn’t constipation just one of those minor intermittent annoyances that flesh is heir to? I don’t know whether low carb people have more constipation than anybody else but even if they do, let me try to explain what I think constitutes real risk. I’m going to ask: What would it be like if there were real risk in a low-carbohydrate diet?

Moderation in All Things.  Except Drugs.

You always think of the best answer a few hours later. (I am grateful to Paula Nedved for the information that the French call it l’esprit d’escalier (literally, staircase wit). Another audience question that I got at the EASD conference was whether a more moderate version of the diet that I was talking about wouldn’t be better.  My answer: “No. If you use a moderate diet.  You get moderate results.”  Not that bad, but, of course, it was on the way back to the hotel that I realized what I should have said:

“A low carbohydrate diet is moderate.  If you want know what is extreme, it is putting into your body, a thiazoladinedione (TZD), a chemical unknown on the face of the earth until twenty-five years ago. A TZD is extreme. But TZD’s work. They lower HbA1c and increase insulin sensitivity and there is reduced risk of hypoglycemia. In other words, extreme is good if you are trying to deal with an extreme situation. Moderation gives you moderate results.”

That’s what I should have said.

But what if somebody had pointed out, as in the Perspective in the Permanente Journal: “However, the TZDs — specifically, rosiglitazone — have faced a great deal of criticism because of the discovery of worrisome adverse affects…. The most debated side effect is whether rosiglitazone causes heart attacks.”

Risk? Oui, d’ACCORD

To get a sense of what it might be like if low carbohydrate diets actually caused risk, we should look at therapeutic interventions that have produced demonstrable problems. I was surprised to see the headline in one of the media outlets that I subscribe to.

Accord_Halted_Endocrinetoday

The story is that the National Institutes of Health stopped the “intensive blood glucose-lowering arm” of the ACCORD trial. The name stands for Action to Control Cardiovascular Risk in Diabetes and, the cause for stopping that part of the trial was unexpected deaths, about half of which, according to the NIH, “were from cardiovascular diseases, such as heart attack, sudden cardiac death, stroke, heart failure, or another cardiovascular disease condition.”  The intensive glucose-lowering, however, meant intensive drug treatment.  For a branch of medicine built on pharmacology, such a failure must surely be a problem. Imagine if that were found in the (imaginary) low-carb arm of the trial. The NIH would be on the phone saying that Low-Carb kills. Low-carbohydrate groups, however, are never included in large trials. If you ask, they will say it is too risky but, really, one suspects it is because the low-carbohydrate diet might do as well in long-term trials as they do in short-term trials and ‘twould have anger’d any heart alive to hear the men deny’t.

In the current case, this would be very likely because what was targeted was control of blood glucose in people with diabetes which even the American Diabetes Association admits is best done by lowering carbohydrate intake. What to do with the ACCORD study? Simple, if you can’t hit the target, change the target. If intensive drug treatment to lower blood glucose has bad side effects, it must have failed because we shouldn’t have been targeting glucose. The announcement from ACCORD was received with amazement as if this were a great new scientific discovery. Elizabeth Nabel, then head of the National Heart Lung and Blood Institute issued a telephone report:

“… ACCORD is the first major clinical trial to study whether lowering a raised blood sugar level, to a level similar to that seen in people without diabetes, reduces the risk of cardiovascular disease. We now have one part of the answer to this question. The study will continue to examine other ways to lower the risk of cardiovascular disease, in high-risk adults, with Type 2 diabetes using blood pressure and lipid lowering approaches.”

And, as described by Gina Kolata in the Times:

“Dr. John Buse, the vice-chairman of the study’s steering committee and the president of medicine and science at the American Diabetes Association, described what was required to get blood sugar levels low:…’Many were taking four or five shots of insulin a day,” he said. “Some were using insulin pumps. Some were monitoring their blood sugar seven or eight times a day.’ They also took pills to lower their blood sugar, in addition to the pills they took for other medical conditions and to lower their blood pressure and cholesterol.”

Paraphrasing all the people to whom the original has been attributed: “If you can’t drive it in with your hammer, maybe it’s not a nail.”  You can probably see where this post is going: the major health risk associated with a low-carbohydrate is that you might be talked out of it and get into a program where you will do something else.

The movable target.

In any melt-down there’s always somebody who saw it coming. Stephen Havas’s comment in Archives of Internal Medicine described how

“led to numerous stories in the mass media noting how experts in the field were stunned by the findings. Yet the results of this trial were predictable. For almost 40 years, there has been evidence that intensive lowering of glucose levels in patients with type 2 diabetes mellitus (DM) can lead to significant harm and has limited benefits.”

 This would certainly be news to people who have consistently lowered their blood glucose by restricting dietary carbohydrate and found great benefit and no harm.

“Unlike blood glucose level, there is strong evidence that controlling high BP and high blood cholesterol levels significantly reduces both macrovascular and microvascular complications in persons with type 2 DM. Clinicians should therefore focus more on controlling these other risk factors than on glucose levels.” [my italics]

 I don’t know whether there are physicians who think that it is either/or, but how should we target cholesterol? You’re kidding. Right?

Good news – bad news.

The headline in Medpage Today tells us that “Large Study Affirms Safety of Statins” which should be good news since everybody has somebody close to them who is on statins. The story is about a meta-analysis — that is where you have a bunch of weak studies, most of which have shown nothing or very little and you average them on the assumption that many wrongs make a valid scientific conclusion.

HealthRisks_Interlocking_Sept3The study “confirmed that statins as a class are well tolerated, although safety profiles vary from agent to agent, researchers found.” Although? It turns out “Statin therapy was associated with increased odds of diabetes and elevations of liver enzymes compared with placebo” but, the good news: “there were no differences in development of myalgia or cancer, elevations in creatine kinase, or” — and here, I am not sure whether this is good news or bad news — “there were no … discontinuations because of adverse events.” The problem in statins revolves around the concept of “gain outweighs risk,” so maybe there should have been a few discontinuations rather than suffering adverse events on the chance that it was worth it. And there are more disclaimers: “There is this risk of some diabetes and you have to check some liver function tests, which we’ve known about, but …” The figure shows what I call the interlocking pharmacologic risk paradigm.

 Cover-up – the triumph of acronyms.

“I’m not making this up.”

— Anna Russell, Wagner’s Ring Cycle.

 What the Permanente Journal, cited above, was referring to was Avandia® (Rosiglitazone). I don’t know what researchers in carbohydrate restriction would do if the “concerns” of the nay-sayers had actually panned out — if there had actually been risk of the magnitude of the side-effects of drugs. I doubt that we would have convened a committee of experts to tell us that it was really ok. The FDA, on the other hand, has an Endocrinologic and Metabolic Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee.  The committee has at its disposal one of the most remarkable programs called Risk Evaluation and Mitigation Strategy, or REMS. Part of this is the Elements to Assure Safe Use (ETASU) program which, according to one of the health bulletins that I subscribe to “was initiated in 2010 because of concerns about cardiovascular (CV) safety.”  Armed with what is now the REMS/ETASU, most of the panel was for keeping Avandia® out there, to be freely prescribed again.  Five of the members voted to continue the current REMS/ETASU guidelines which restrict Avandia®  use but only 1 member (the consumer representative), voted to remove rosiglitazone  altogether.

REMScover

“Mitigation Strategy” is the scary part. (The strategy is in the spin from the committee report, not in the treatment). I don’t know if it is pronounced as words, as in the strict definition of an acronym, but REMS/ETASU is some kind of record.  In a previous post on the language of food, I pointed out how French-derived or Latinate words are widely used to give an aura of seriousness that might not be deserved.  Risk-Evaluation-and-Mitigation-Strategy-Elements-to-Assure-Safety, translated into Anglo-Saxon-derived words might be We Make You Think it’s Good (WMY-TIG ).

Headlines

So, in the end, if there really were risk, my mail-box would have constant headlines, about  low-carb diets, of the following type:

Research ties metformin to cognitive impairment in diabetes DiabetesPro SmartBrief Sep 10, 2013
HPS2-THRIVE: High myopathy risk with niacin/laropiprant theheart.org/Lipid/metabolic Feb 26, 2013
Niacin/laropiprant products to be suspended worldwide theheart.org/Lipid/metabolic Jan 11, 2013
Statins linked to fatigue in randomized study theheart.org/Lipid/metabolic Jun 11, 2012
Statins Linked to Cataracts in Large, Retrospective Study theheart.org/Cardiology Sep 20, 2013

But there would be good news too, along these lines:

Most patients with statin intolerance can eventually tolerate therapy Healio/Endocrine Today Sep 10, 2013
STOMP: Atorvastatin doesn’t reduce muscle strength heheart.org Dec 4, 2012

The Risk

If there really were risk of low carb diets, it is not known how we might implement REMS/ETASU to determine if the normalization of blood glucose, weight loss and improvement in atherogenic dyslipidemia as well as removal from drugs that are seen in low carbohydrate diets are really balanced by the threat of constipation.  Nonetheless, it seems clear that the  real risk of low-carb diets is that you will tell your doctor that you are on such a diet and they will come up with their recommendations based on the FDA-REMS/ETASU.

Comments
  1. Good one doc. But there is a little problem here I wish you’d have addressed. You said:

    “This would certainly be news to people who have consistently lowered their blood glucose by restricting dietary carbohydrate and found great benefit and no harm.”

    Unfortunaley, legions of people claim that their LCD caused them harm – great harm – and these are not just FaceBook knuckleheads whose LCD consisted of 9 pounds of ground beef and nothing else. Smart people who are considered experts like yourself – Dr. Paul Jaminet as an example, claimed that his VLCD screwed him up but good. Many claim is completey screwed their BG levels and made them insulin resistant.

    If you could comment on this I’d appreciate it.

    • rdfeinman says:

      Worth getting the details on and worth studying but as anecdotal reports seems like rare. How big is a legion?

    • rdfeinman says:

      Generally, if 100 people do well in a formal, registered clinical trial, people would say you need 200 but if some guy — who, for all we know, may think that a potato is low-carb — has a bad reaction, a guy who doesn’t think to ask a doctor or even look at an on-line forum, then suddenly there’s big risk. Again, how many platoons in a legion?

    • Marilyn says:

      Fredrick, if I remember correctly from Peter’s “Hyperlipid” blog, any insulin resistance brought on by a VLCD is quickly and simply resolved when one eats more carbohydrate.

      • rdfeinman says:

        Also, you have to be careful about how insulin resistance is measured. In particular, you have to distinguish between down-regulation of the machinery for metabolizing glucose due to low levels as found in many hormonal systems, as compared to a pathological change.

    • Trina says:

      Fred, to be clear, Paul was following what he considers a zero carb diet (he explains why he feels above ground veggies don’t count). His experience was with very low or zero carb. He continues to promote what he feels is a lower carb diet but cautions against zero carb.

      In one post he refers to this study, “Similar patterns of reduced T3 and elevated cortisol excretion were recently seen in a clinical trial of a 10% carb weight maintainance diet. [4] This trial shows that even in the absence of calorie restriction, carb restriction is sufficient to reproduce much of the “athlete triad”/starvation hormonal pattern.” http://www.ncbi.nlm.nih.gov/pubmed/22735432?dopt=AbstractPlus

    • Frederick, Jaminet didn’t have diabetes, obesity, epilepsy, or any of the conditions that VLC is usually prescribed for. He did get health benefits from VLC – he is almost certainly better now for having tried it. His Perfect Health Diet is still lower in carb than the diet he ate before. And his Q&A thread consistently features questions from readers who cannot eat the higher amounts of carbs he recommends and stay healthy (and he’s not dogmatically insisting that they should).

      The insulin resistance of VLC is a non-issue. So what if you fail a GTT? Who says you needed a bolus of glucose anyway? As long as you follow the diet your insulin will be appropriate to your glucose intake – and if you’re diabetic, this won’t be happening on a normal diet.

      • Trina says:

        I think the greater debate is whether we need them or not. Many insist we don’t need them at all but Paul’s platform is that we do need some (even diabetics).

        From Paul:

        I believe that:

        -Optimal blood glucose levels are in the 90 to 100 mg/dl range. High-carb diets cause below-optimal levels of blood glucose, especially during fasts. (Indeed, high-carb dieters routinely experience hunger and irritability during long fasts.) Very low-carb diets cause elevated blood glucose due to the body’s efforts to conserve glucose by suppressing utilization. Excessive suppression of glucose utilization is unhealthy.

        -A 20% carb diet, while not optimal for every single person, is healthy for nearly everyone. Twenty percent may be the best single prediction of the optimal carb intake for the population as a whole. Even diabetics can do well eating 20% carbs.

        I know a T2D who is currently experiencing the same mucus deficiency that Paul described having been through. She has been following a vlc woe for years and is having several health issues.

      • rdfeinman says:

        Still doesn’t sound like Avandia.

  2. Alexandra M says:

    Excellent piece! The only thing I didn’t get was this:

    “So, in the end, if there really were risk in low-carb diets, my mail-box would have constant headlines of the following type…”

    Maybe my irony meter is broken? Or did you mean “would not have constant headlines?”

  3. Marilyn says:

    “But low-carb diets cause constipation. . .”

    Not everyone who eats a low-carb diet is constipated, and not everyone who’s constipated is on a low-carb diet.

    Next dangerous side effect of a low-carb diet, please?

    • rdfeinman says:

      As in the post, biggest risk is telling your doctor that you are following the diet.

    • Dana says:

      I suspect those who are constipated on a low-carb diet are the ones who are trying to go low-carb and low-fat at the same time. Does. Not. Work. If all you eat is protein you are going to be bound up; it’s inevitable. You need more water to handle the processing of protein in your body, and most people don’t think to drink more.

      I found that fatty meat was more than enough to get me going and that I had to actually eat high-soluble-fiber veggies (think “pumpkin”) to slow me down some. I seem to recall reading something about the gallbladder stimulating bowel activity, but now I can’t find it. :(

      But, you know, we’ve been telling ‘em to eat high-fat if you’re going to eat low-carb, and that it’s perfectly safe. Not our fault they won’t listen.

      • rdfeinman says:

        Even so, not up there with dying of heart disease.

      • trekkiemaiden says:

        Ha, I’ve been constipated all my life. The difference being on HCLF it is accompanied by wind and bloating, on a LCHF it’s just constipation. Having said that, have discovered psyllium husks and I add a dsp to anything I’m eating in the day (cook with it) and that side of things has all but disappeared. Would say it’s a miracle. Constipation – so what LOL

      • rdfeinman says:

        Many of the papers advocating HCLF also present with wind and bloating.

  4. Kris Johnson says:

    The Perfect Health Diet gets into some details of the carb restriction that are quite enlightening. They have put a lot of research into their book, introducing the concept of ‘safe starches’. Well worth reading

    http://perfecthealthdiet.com/the-diet/

    • rdfeinman says:

      I don’t doubt that they or somebody else might have the perfect diet but the blogpost is only about what it would take for me to see risk in a low-carbohydrate diet (or anything else).

    • Dana says:

      My experience with “safe starches” is weight stall or weight gain and bowel discomfort. They might be “safe” in that they are not as devastating as glutenous-grain starches, but that’s like saying an aspirin overdose is safer than cyanide.

      (I also get swollen fingers but I am not sure whether to blame that on the starches or on the dairy that I’m usually also consuming when I get stupid and start eating rice again. I think casein and I have kind of a love-hate relationship going on, to tell you the truth.)

      I don’t think enough research has been done on fat-burning versus starch-burning and exercise, either. The athletes I’ve seen in the Paleo community complaining that they “need” carbs to be able to perform tend to be the CrossFit types who consistently overdo it. If on the other hand you exercise the way Mark Sisson and Dr. Al Sears say is healthier, you can do just fine as a fat-burner and don’t need the extra glucose and glycogen. And you shouldn’t wind up with a rip-roaring case of inflammation or put yourself at risk for muscle breakdown either. (That’s a big long word, starts with Rh, I can’t remember how to spell it. I bet Dr. Feinman knows though.)

      • rdfeinman says:

        Rhabdomyolysis and Rhinoceros are the two that come to mind. The point of the blog post is that both are serious but have not actually been seen with low-carb diets.

  5. Kris Johnson says:

    There is a review of Perfect Health Diet here, though I can’t bring it up now
    http://www.westonaprice.org/thumbs-up-reviews/the-perfect-health-diet-by-paul-and-shou-ching-jaminet
    WAPF has been under frequent attack by moles that don’t like their attacks on the establishment!

    • rdfeinman says:

      I can’t get that link to respond either but reply, duplicated in next comments: I don’t doubt that they or somebody else might have the perfect diet but the blogpost is only about what it would take for me to see risk in a low-carbohydrate diet (or anything else).

  6. Galina L. says:

    I have being asked about constipation on a LC diet all the time, somehow many people think that only whole grains contain necessary fiber which is required for a normal regularity. What about fiber in vegetables? Actually, according my observations, eating mostly meat doesn’t stop peristalsis in a digestive tract, especially if cheese is consumed in small amounts.

    • rdfeinman says:

      The point of that story was that this was an audience of mostly physicians and other health professionals who would have seen the seriousness of diabetes and would not think to ask about constipation from a drug. In this context, the metaphor of half full vs. half empty is probably not too good but there was a clear lack of perspective and a clear distrust of something that they should have embraced.

      • Galina L. says:

        I actually understood the point of the story, but decided to comment of that funny association between LC and a constipation.
        The question also demonstrated than people in the attendance didn’t know much about eating a LC diet and definitely didn’t read any discussions on the internet about LCarbing. It is out of their attention zone, or they would bring up something about physiological IR, like Fredrick Hahn did.
        @Frederic,
        I am one off the people who got elevated but not pathological fasting BS numbers
        . I got it not from my adaptation to LC, but later from getting used to exercising in a fasted state and prolong fasting. It allows me to have absolutely amazing endurance and prevents “hungry migraines” or any sub-optional sensations if I don’t eat longer than usual. From my perspective such adaptation doesn’t look harmful.

      • rdfeinman says:

        That was one problem with the audience. The other was how the extensive experience most of them must have had with real risk was not really considered. So, the post was only indicating what risk looks like but, in fact, not doing low-carb my require the drugs that were cited.

  7. Marilyn says:

    Another “danger” I’ve heard about is “too high in protein.” Since diets are often expressed in % of calories, maintaining a constant amount of protein, but dropping carbs from 300 to 30 grams, is going to make protein a much higher % of calories. So all of a sudden, we have a “high protein” diet.

    • rdfeinman says:

      And sometimes, protein is good because of the danger of high fat, or “ultra-high-fat” but if they couldn’t find a problem in forty years of trying, it isn’t there. But then again there’s little rational about this.

  8. LeonRover says:

    Don’cha just love American-style hyperbolic Marketing; it contaminates all Food Discourse, to wit:

    Jaminet’s “theperfectdiet” is 35% starch.

    Kwasniewski’s “jan-kwasniewski-optimal-diet” is an 80% animal fat diet.

    And commenters castigate Coca, McDonalds,Kellogs etc.

    “There’s nowt as queer as folk” – as the Actress said to the Bishop.

    Sláinte

  9. Joanne Hurley says:

    Nice post. We just started a 16 week class using the low carb eating plan with forty senior adults. Low carb meaning following Bernsteins 6-12-12 plan.

    _____

  10. Paleo Fatman says:

    I started out with a diet as close to carb-free as I could manage. I had read, anecdotally of course, such a diet would result eventually in an increasing fasted blood glucose. After two weeks of being “zero-carb,” my fasted BG did indeed start rising. After five days of the rising FBG, according to my diary, I started a very low-carb menu, keeping total carbs less than about 40gm per day. I’ve been on this particular diet for almost six months and my BG is rarely above 90 mg/dL, usually staying in the 68 to 85 mg/dL range. So far there has been no problems. I sleep VERY well, I have lost about 30 pounds of fat, my blood pressure is way down, etc. For me, this very low-carb menu is ideal.

    • Margie says:

      I eat a VLC diet (30 grams per day) and my fasting blood glucose is usually 80. I’m over 60 and have been eating this way for several years.

  11. steve says:

    First, I would ask what is the definition of moderation? Can you point me to studies that show 50G or less of carbs is better for metabolic markers that say 100-150G? Of course less is better when it comes to carbs, but there is such a thing as the law of diminishing returns.

  12. I like Paul Jaminet, and most of what he writes is sensible. However, speaking as a Very Low Carbing T2D, the choice is easy: I choose a low-carb lifestyle because the known risk of diabetic complications seems much more significant to me than the speculative risk of “thyroid problems etc” . By eating <25g of carbohydrates a day, I've managed to keep my HbA1c below 5% for the past 2 and half years (down from 10.9% at diagnosis). Maybe my thyroid might pack up eventually, but I'm fairly sure that I won't be experiencing diabetic complications like amputated toes, or bleeding eyeballs.

    • FrankG says:

      Exactly the point I was about to make Stephen, regarding the perspective of these physicians and also as a Type 2: there are indeed recognised, well documented and uncontroversial long-term complications of raised BGs — all nasty, painful ways to die early — weigh these against some questionable concerns about LCHF such as the weaselly “well we don’t really know the long-term safety of such a diet”, plus the fact that all my health markers have improved (subjectively and as measured by my Doctors) then my choice is clear.

      As for constipation… not a problem. Sure there was period of adjustment to an LCHF way of eating but isn’t that the way with any significant change in diet? Why does it seem as if LCHF is judged by a different standard? Same as the folks who cry “but surely it can’t be healthy to exclude an whole food group?”, where were they during all the recent decades while we have all been admonished not eat fat?!?

      • rdfeinman says:

        I thought that constipation was something that most consider a sometime part of life. Not a health risk.

      • Raphi789 says:

        I would agree. Would you wish to speculate as to how right/wrong this might be? If not, why?

      • FrankG says:

        I really don’t see infrequent constipation as a serious issue… especially when ranged against dental caries, peripheral neuropathy, blindness, renal failure, CVD, below knee amputation followed by an early death.

        The only reason I mentioned it at all is because, so far as I am concerned, it is NOT a problem with an LCHF way of eating. The need for “plenty of fibre” is think, another one of these universal “truths” that does not stand up to scrutiny.

        I think the only people so obsessed with their bowels were the Victorians… and they fixated on several other bodily functions as well :-P

        Incidentally Dr Feinman I also agree with your sentiments regarding the term “moderation” — I am sick of it! When people say “oh just eat a well balance diet.. everything in moderation” …it is a completely meaningless platitude. My LCHF diet is perfectly balanced for ME!

      • rdfeinman says:

        Actually, moderation is okay if you don’t overdo it.

      • FrankG says:

        I think what really galls me though is that LCHF was not even discussed as an option when I was first diagnosed with Type 2 Diabetes. I had to find out about it myself and even then acted against my Doctor’s and Dietitian’s advice.. were I not so stubborn and opinionated I would probably have been dissuaded from even trying such a dangerous course of action!

        Then to find out that the reasons it is not offered are speculative at best, political and profit-driven at worst, is a crime.

        I wonder how many lives have been negatively affected by this approach?

        How does it go..? “First do no harm.”

        I do note that the American Diabetes Association is only recently and grudgingly offering low carb as an option for BG management and weight loss but still couched in cautionary terms such as only to be used short-term and unknown long term safety. Baaa!

      • rdfeinman says:

        And the ADA has continued to refuse to cite the appropriate work of Nuttall and Gannon who showed clearly the benefit of low carb for diabetes even under conditions where no weight is lost. I would file your story with the AMA and the NIH. Send us a copy (and their answer) if you do.

  13. marie says:

    Oui, d’ACCORD, les conclusions sont criminels!
    Really, what is it about the medical ‘sciences’ that so many of their professionals spur the scientific method and actually get away with it?
    There’s nowt as queer as this, or as blatantly so, at APS or at ACS or MRS.
    (l’actrice)

  14. Raphi789 says:

    Jaminet argues that adequate levels of gastrointestinal mucus are harder to maintain when on a very LC diet / 0-carb diet. Hence, increased risk for gastrointestinal cancers AND constipation… Is there any suggestion:
    1) that the rate of gluconeogenic synthesis cannot keep up (long-term) with the glucose demands relating to mucin production?
    2) that the body will preferentially divert glucose requirements to the brain, to the the extent that it will leave our mucin-glucose related needs significantly wanting? (like when exercising momentarily slows down our digestion and other non-immediate priorities)

    Jaminet’s arguments are plausible but seem a bit thin when it comes down to actually demonstrating that our natural gluconeogenic output capabilities are mismatched to natural glucose requirements…Any comments on the matter would be appreciated.

    • rdfeinman says:

      Like most risks of low-carb diets, this is all conjectural.

      • Raphi789 says:

        I would generally agree. But in this example, would you wish to speculate as to how the glucose-mucin relationship as described by Jaminet could right or wrong?

      • rdfeinman says:

        I’m afraid I don’t know about this. What are the data?

      • Raphi789 says:

        There don’t seem to be many studies directly addressing mucus deficiencies in the context of low-carb/ketogenic diets. I think preemptively increasing starch and sugar intake on a whilst low-carb diet for fear of future GI related issues certainly requires assuming the heavy burden of proof…

        However, here are Jaminet’s 2 short articles on the possible link between dietary carbohydrate intake levels and mucus deficiency

        http://perfecthealthdiet.com/2010/11/dangers-of-zero-carb-diets-i-can-there-be-a-carbohydrate-deficiency/ – Can there be a carbohydrate Deficiency?

        http://perfecthealthdiet.com/2010/11/dangers-of-zero-carb-diets-ii-mucus-deficiency-and-gastrointestinal-cancers/ – Mucus Deficiency & gastrointestinal Cancers

        I included this interesting study discussing where the authors present the methods they use to characterize bacteria-mucus interactions in the GI tract, using carbs and lectins as probes.

        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659345/ – Mining the “glycocode”- exploring the spatial distribution of glycans in gastrointestinal mucin using force spectroscopy
        —From their Conclusion: “We have demonstrated that force spectroscopy can be used to characterize the distribution of specific carbohydrate species and reveal differences in the highly complex structures of different mucins. Comparison of the spatial information derived from mucin probed with different lectins provided additional information about the composition of the side chains. This new approach is relevant to biological interactions, which mediate host-bacterial interactions and disease pathology in the GI tract. In addition, this method provides the ability to quantify the binding affinity between carbohydrate moieties and lectins and so provides a blueprint to measure the molecular recognition pattern of bacterial adhesins (from commensals and pathogens) to mucins. Taken together, these approaches will help in deciphering the molecular mechanisms underlying bacteria-mucus interactions in the GI tract.”

      • rdfeinman says:

        This may all be important but going back to the theme in the post, we don’t see stories about low carb diets along the lines that “the National Institutes of Health stopped the ‘intensive blood glucose-lowering arm’ of the ACCORD trial….and, the cause for stopping that part of the trial was unexpected deaths, about half of which, according to the NIH, ‘were from cardiovascular diseases, such as heart attack, sudden cardiac death, stroke, heart failure, or another cardiovascular disease condition.’” Nam sane?

    • Trina says:

      “Decreased production of molecules like hyaluronan and mucin and reduced levels of T3 thyroid hormone, then, are outcome of dietary glucose deficiency. Pathologies this may produce include dry eyes, dry mouth, constipation or hard stools, and slow healing of scratch wounds.” http://perfecthealthdiet.com/2011/10/jimmy-moore%E2%80%99s-seminar-on-%E2%80%9Csafe-starches%E2%80%9D-my-reply/

      “Dr. Jaminet, on the other hand, believes that once you get below a certain threshold of glucose in your diet, you can start experiencing certain health challenges.

      His perspective has slowly won me over, simply because I have personally experienced some of the health challenges he brings up as being linked to glucose deficiency. I noticed that when I restricted my carbs to vegetables only (cutting out all grains and non-fiber starches), it paradoxically raised my triglycerides. I would also get extremely fatigued when working out, and it worsened my kidney function, too. So, I believe I’ve proved to myself you can go too low on glucose.” Dr Mercola

      There is plenty of empirical evidence around. Many people turn to Paul when they develop the exact issues he describes. One need only read a few well known paleo blogs to see even more evidence of people suffering hormonal dysregulation.

      • rdfeinman says:

        Again, is doesn’t seem like it is up there with ACCORD.

      • Galina L. says:

        Do people who have to live on meat(like Inuits) developed complications mentioned above?

      • rdfeinman says:

        I don’t understand. What complications? The idea is that we don’t see complications.

      • Galina L. says:

        The potential problems which could be resulted from a low mucus production mentioned by Jaminet. I never saw any data that Inuits suffered from a mucus deficiency.

      • Margie says:

        This seems unusual to me. As a longtime VLC diet follower, my triglycerides are very low, typically in the 50s. But then Dr. Mercola was an opponent of high doses of Vitamin C, making lots of claims, until Dr. Ron Hunninghake of the Riorden Center, that has done long-term work with Vitamin C and cancer, showed him the error of his ways.

  15. Martin Levac says:

    The main risk of low-carb is still very much present in everyone’s mind. Fat is bad, low-carb contains lots of fat, low-carb is bad. I believe this is the biggest obstacle for low-carb in every pertinent aspect. For the consumer, the fear of fat leads him to abandon low-carb and return to his previous diet. For medical professionals, it prevents them from genuinely prescribing low-carb to patients. For the medical establishment, it prevents the existence of low-carb itself, as the dominating paradigm of the medical establishment is that low-fat is king, and low-carb directly opposes low-fat’s kingdom. For the official nutritional guidelines, it’s the same thing. For the food industry, same thing too. For sports, carbs are it. For biochemistry, glucose-preferred-fuel paradigm. All of it derived one way or another from the fear of fat.

    • rdfeinman says:

      The blogpost is intended to put all this in some perspective. Feel free to send it to your favorite consumer, medical professional, food industrialist sports figure and biochemist.

  16. Anon says:

    @ Dana

    +1 regards low carb/low fat. Exactly my experience

    Add the fat back in, no problem. Although things did improve in the previous case over time (I guess the body can adapt to almost anything)

  17. Becky says:

    Jaminet’s claim about bowel mucosa was arrived at by his own research, added to the fact of his own experience with acquiring diverticulosis on VLC. It’s not mentioned in his book, but he has mentioned the VLC/diverticulosis issue in podcasts and interviews.

    Diverticulosis (outpouchings in the bowel) has as its one sole cause … constipation. Pressure in the backed-up bowel causes weak spots to balloon out. These pouches can become filled with fecal matter that can harden, puncture the bowel wall and, if opportunistic bacteria become involved, become infected, leading to very serious consequences such as peritonitis or sepsis. Infection of the pouches is called diverticulitis. It can be a horribly life-changing condition, sometimes leading, as a last resort, to removal of problematic sections of bowel. Best case scenario is a six-day course of Cipro and Flagyl, antibiotics that really screw up your digestive flora while at the same time saving your life.

    I had been merrily rolling along on my VLC diet, enjoying all of the benefits of good mood, good sleep, weight loss, and even the disappearance of my Hashimoto’s thyroiditis antibodies. They just disappeared. Amazing stuff.

    I was rarely ever constipated and never seriously so. Things were going quite smoothly. But it only takes ONE episode of straining to create pouches. As years go by, more can be created, even with mild straining.

    Suddenly, after two and a half happy VLC years, I found myself in the hospital with diverticulitis, being treated by IV with aforementioned antibiotics, an oral course of both of them after my release, and 42 days later ANOTHER attack of diverticulitis, with said antibiotics being prescribed AGAIN.

    The colonoscopy I had before starting VLC showed no pouches. The post-diverticulitis colonoscopy (it is routine if you have a first attack) showed pouches scattered throughout the colon.

    The idea that the bowels can be weakened by something (VLC? Age? Other or both?) and become prone to diverticulosis-style pouching when straining even a little bit, doesn’t sound farfetched to me.

    My life has dramatically changed. The anti-supplemental-fiber gurus no longer have me defending them. Psyllium seed fiber, acacia fiber, less red meat, more rice, potatoes and sweet potatoes (bulk), and yet MORE vegetables and fruit, and a lot of probiotics (to defend against bad bacteria with good), are keeping me going as I try to eat and live without fear of more attacks.

    The gastroenterologist told me that fat slows digestion and bowel transit time. I no longer blithely snack on half an avocado or spoonfuls of coconut butter.

    My takeaway from all this is that getting behind ONE template for ALL people, even in a general way, could be very, very wrong. We are all, I think, FAR more biologically unique from one another than we can possibly realize. People can live long, healthy lives and eat grains. People can live long, healthy lives without eating much meat. We must beware bringing all decisions about major changes in diet back to the “findings” of one or two “respected” or even “revered” people. It stands to reason that if a person goes on a diet to correct blood sugar imbalances, for example, other changes in the body will occur as a result. And not always positive ones. It seems that is how life is set up.

    • rdfeinman says:

      Sorry to hear these problems. I think most of us agree that “ONE template for ALL people, even in a general way, could be very, very wrong.” And I did not mean to imply that we do not want to know about risks from low-carbohydrate disease if there are any, even if it is for isolated individuals. These will never be investigated as long as we have a medical system that can attribute risk without substantiation and, simultaneously, dismiss as collateral damage, risk from recommended therapies. I listed the drugs as an example of what risk would look like if there were any for low-carbohydate diets but, in fact, drugs are frequently the alternative to the diet whose risks are not identified.

    • Gretchen says:

      @Becky: I find that eating almonds and lots of greens prevents constipation *for me.* Of course there are carbs in almonds (and a few in greens), but not a lot.

    • Mary Lewis says:

      What causes diverticulosis and diverticular disease?
      Scientists are not certain what causes diverticulosis and diverticular disease. For more than 50 years, the most widely accepted theory was that a low-fiber diet led to diverticulosis and diverticular disease. Diverticulosis and diverticular disease were first noticed in the United States in the early 1900s, around the time processed foods were introduced into the American diet. Consumption of processed foods greatly reduced Americans’ fiber intake. Diverticulosis and diverticular disease are common in Western and industrialized countries—particularly the United States, England, and Australia—where low-fiber diets are common. The condition is rare in Asia and Africa, where most people eat high-fiber diets.1

      Two large studies also indicate that a low-fiber diet may increase the chance of developing diverticular disease.2

      However, a recent study found that a low-fiber diet was not associated with diverticulosis and that a high-fiber diet and more frequent bowel movements may be linked to an increased rather than decreased chance of diverticula.3

      Other studies have focused on the role of decreased levels of the neurotransmitter serotonin in causing decreased relaxation and increased spasms of the colon muscle. A neurotransmitter is a chemical that helps brain cells communicate with nerve cells. However, more studies are needed in this area.

      Studies have also found links between diverticular disease and obesity, lack of exercise, smoking, and certain medications including nonsteroidal anti-inflammatory drugs, such as aspirin, and steroids.3

      Scientists agree that with diverticulitis, inflammation may begin when bacteria or stool get caught in a diverticulum. In the colon, inflammation also may be caused by a decrease in healthy bacteria and an increase in disease-causing bacteria. This change in the bacteria may permit chronic inflammation to develop in the colon.
      [Top]

      http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/#cause

  18. Marilyn says:

    Frank G – “First do no harm.” Fat has been the villain in so many peoples’ minds for so long, I’m sure a low-carb diet with its higher fat would be considered “doing harm.” Somewhere, I read of another of these twisted “do no harm” applications: There will never be another big statin trial because it would be unethical — it would do harm — to deprive a control group of the benefits of statins.

    • rdfeinman says:

      You mean there will never be another placebo-controlled study. Huge studies will continue to be funded to compare different statins or statins to the next drug. There’s the classic comparison (JAMA 2004;291:1071-80.) of moderate (40 mg) vs. intensive (80 mg) statins. In diet, if something works, we should try a moderate version but, in drugs, if 40 mg works, we should try 80 mg. which actually makes sense. Of course they used 40 mg of pravastatin and 80 mg of atorvastatin, an unexplained foolishness that probably has something to do with the drug companies.

      Maybe the last trial with placebo was the West of Scotland (WOSCOPS) trial which is now a classic in medical statistics. I discussed this in the blogpost “Damned statistics and the nutrition literature”.

      The bottom line was that the the press release said: “People with high cholesterol can rapidly reduce… their risk of death by 22 per cent by taking…pravastatin.”
      but when you looked at the paper, the deaths with placebo were 41 per thousand. Pravastatin was able to reduce this to 32 per thousand which is suddenly not so great. In fact, when you calculate absolute risk reduction, 41/1000 – 32/1000, you get 9/1000, or 0.9 %. Using the number needed to treat (1/abs risk reduction), you would have to treat 111 people to save one life. This doesn’t actually seem like enough to throw out the placebo comparison.

  19. Gretchen says:

    I recently posted a blogpost related to this issue: (http://www.healthcentral.com/diabetes/c/5068/163018/diets-bg-levels/3?ic=2602) although it doesn’t specifically address health risks.

    It basically provides N =1 evidence that a person *without* diabetes can do well on a high-carb diet, but a formal study showed that for people *with* diabetes, in order to achieve what seems to be the most reduction in insulin resistance on an oral glucose tolerance test, they must eat a diet that sends their blood glucose (BG) levels over 200 after meals, levels high enough to cause complications in the long term.

    I find proven high BGs riskier than theoretical risks of a LC diet.

  20. Paula says:

    As to constipation, we should be taking Magnesium daily for lots of other reasons – ‘even ‘ mainstream doctors (not just the Eades in their “Magnesium Miracle” chapter in Protein Power Life Plan) recommend this.

    Interesting is to consider are pp. 115-116 and p. 205 of Life Without Bread: How a Low Carbohydrate Diet Can Save Your Life (Christian B. Allan, Ph.D. with Wolfgang Lutz, M.D.) copyright 2000.

    p. 116 Here is mention of constipation clearing up in “…1-2 days in children; in young adults, one or two weeks; and in order persons, a few months; but undoubtedly, as has been observed in hundreds of people from Dr. Lutz’s practice, the evacuation process will normalize. The problem here is that THE MUSCLES RESPONSIBLE FOR PUSHING THE STOOL THRU THE DIGESTIVE SYSTEM BECOME WEAK IN HIGH-CARBOHYDRATE EATERS BECAUSE EXCESS CARBOHYDRATES TEND TO ‘POISON’ THE GUT, WHICH INCREASES BOWEL MOVEMENTS WITHOUT THE NEED FOR MUSCLE ACTION [emphasis mine]. Adoption of a low-carbohydrate diet eventually will strengthen the muscles, but some time may be necessary.” (p. 205 mentions “…under the influence of carbohydrates, it is the pancreatic polypeptide hormones that speed up passage through the bowel…”)

    pp. 116-117 on carbs, constipation, and Diverticulosis:

    “Dr. Lutz found that diverticulosis could be treated very successfully with a low-carbohydrate diet. This can still be a high-fiber diet since the truly high-fiber foods mentioned above (broccoli, cauliflower, celery, lettuce) are actually low in carbohydrates. In cases of diverticulosis, the prevention of initial constipation through the regular application of cleansing enemas is particularly important. After a few months, there will be normal stools and no further complaints relating to diverticulosis. The existing diverticula will not disappear, but no new ones will form. Most importantly, the inflammation, which very often exists in the gastrointestinal canal of people on normal [i.e. SAD] diets, and which spreads to the diverticula, will heal. Finally, the bowel musculature will strengthen and the original cause of the diverticula; namely, the muscular weakness with the enlarged spaces between the bundles, disappears.”

  21. Paula says:

    “Tergiversation” – that’s the word that occurred to me tonight so I looked it up, figuring it meant dodging or waffling of some sort: “Evasion of a straightforward action or clear-cut statement – equivocation; shuffle, circumlocution.”

    “The ADA / AMA / etc. once more engaged in tergiversation…”

    • rdfeinman says:

      That’s the word that I was looking for. Of course, when you look at their work it is all eisegesis = the process of interpreting a text or portion of text in such a way that it introduces one’s own presuppositions, agendas, or biases into and onto the text. This is commonly referred to as reading into the text. The act is often used to “prove” a pre-held point of concern to the reader and to provide him or her with confirmation bias in accordance with his or her pre-held agenda.

  22. Marilyn says:

    “You mean there will never be another placebo-controlled study.” Thank you. Yes. I remembered your “Damned statistics. . .” blogpost when I went back and read it. That’s surely where I got the “unethical” business.

    Statins, of course, are not the only drugs that are overrated. “Hyertension/High blood pressure causes strokes” is plastered all over the internet, in most cases, with no particular definition of “hypertension.” But a systolic blood pressure (SBP) of 201, I’d think, would carry more risk than 141, although both are considered hypertension. I went looking for more information, and was surprised at what I found on the Framingham Heart Study:

    http://www.framinghamheartstudy.org/risk/

    If I’m reading their chart correctly, for my age group, 71-73, an untreated SBP of 156-167 carries no more risk than a treated SBP of 132-139 — a +6. A +6 indicates a 3% risk of stroke over the next ten years. I think I’ll spend my time doing something other than going to doctors and drugstores and taking pills every day for the rest of my life.

  23. Margaretrc says:

    Excellent post! I despair of doctors ever really giving low carb a chance. My husband’s doctor diagnosed him as pre-diabetic the last time we visited him (FBG 110). He handed my husband a “low fat, heart healthy diet” pamphlet. I thought, “Oh great. That will turn him into a full blown diabetic fast. No thanks.” and dumped it into the trash. Not too long after, we both went LCHF and haven’t looked back. Oh, yeah, the doctor wanted to talk about a Statin on the next visit. We never went back. The hubby dubbed him “Dr. Doom.”

    Re the comments about Paul Jaminet and The Perfect Health Diet: Until I see some RCT study data (not anecdotal) that this mucin problem is really a problem of “carbohydrate deficiency,” I remain unconvinced and will stick to my VLC diet. If anything, my own digestive issues are much improved on VLC.

  24. Marilyn says:

    I was just reading one of your earlier contributions:

    Low-carbohydrate nutrition and metabolism

    http://ajcn.nutrition.org/content/86/2/276.full

    There the statement was made:

    “Only one of the clinical trials has assessed symptomatic side effects of an LCKD (55). In that study, subjects following an LCKD were more likely to experience constipation, headache, muscle cramps, diarrhea, weakness, and skin rash than were those following a low-fat diet.”

    In my opinion, none of these can be taken seriously unless the persons experiencing them had ONLY reduced their carbohydrates from their previous diets — nothing else. But so often, when people go on low-carb diets, especially those eager to lose weight, they go whole-hog, using prepared low-carb foods, making low-carb versions of their favorite high-carb foods by replacing flour with fiber for breads, replacing potatoes with cauliflower, using sugar alcohols to create their favorite sweet treats. . .

    So who’s to know whether the “side effect” was from eating fewer carbs, or from eating something that would have given them grief even on their previous high-carb low fat diet?

    • rdfeinman says:

      Quite right. And, as the point of the post, those things are trivial if they occur beyond the normal incidence. My excuse for including them at all was that back in 2007, when we were young and naive, we thought that including all the pluses and minuses was appropriate and that there was possibility of compromise with the lipophobes, but it is basically a battle and some come over to our side but cooperation is not in the cards.

  25. Marilyn says:

    “. . . that is where you have a bunch of weak studies, most of which have shown nothing or very little and you average them on the assumption that many wrongs make a valid scientific conclusion.”

    OT: That reminded me of a statement in the 1951 International Harvester “How to Freeze Foods” book my brother just gave me: “Remember, freezing does not improve the quality of anything; it merely . . . maintains whatever quality the food has at the start.” :-)

  26. David says:

    Lipophobia is irrational in the face of evidence yet I suspect it is secretly maintained by many, though not admitted to, being in a similar category to the fear of chickens. It seems the constipation issue may be a red herring, sorry that is too fatty, since it may well be due not to LC but due to a combination of LC-LF, with the LF part being unspoken. A number of contributors have indicated constipation went away when fat was added to the diet. Presumably fat was previously mostly absent. The Inuit live on a high fat diet. Just because they eat only flesh does not make it high protein; its all about ratio. The flesh they eat is drawn from a very low temperature environment which evolution has determined should be high in fat for reasons of survival. Think seal blubber. Lipophobia may actually be the hidden target here.

  27. Queen Lab Rat reporting: In a n=1 study, I can state that a LCHF/Mediterranean combined diet has no negative side effects nor health risks of any nature. Quite the opposite in fact has been the case, as shown by two blood tests and loss of adipose fat tissue. My doctor, an Internist, is quite impressed with these results & approved no meds (Metformin, Pravastatin) for 3 months. Fasting BS are ranging 88-98 so expect will see same successful lab results in December.

    I have had no constipation, but then I eat a lot of fibrous veggies on the LCHF/Mediterranean combined diet. People have noticed that I’ve lost weight & my skin tone glows.

    Forget the naysayers ~ “the proof is in the pudding” is still true. Results will convince people & their doctors & spread one at a time. I have sent links to this blog & a summary of “Dr. Berstein’s Diabetic Solution” to at least 10 people (8 are T2D and 2 are T1D) so they have good information to learn how our cells actually use nutrients first. If they just want to lose weight, I tell them to get the latest whiz-bang diet book… or simply eliminate simple carbs except on rare occasions. (!,!)

    To the good Professor ~ cheers! Your Lowly Lab Rat ~ Hugs, Moms aka Eve

    • rdfeinman says:

      Excellent story and it is wonderful to have a successful Homo Rodenta study. And I like n=1. As I always tell students, if you do 2 experiments, you’re going to have to do 3.

  28. Raphi789 says:

    “40 years of federal nutrition research fatally flawed”

    University of South Carolina study shows flaws in NHANES data.

    Four decades of nutrition research funded by the Centers for Disease Control and Prevention (CDC) may be invalid because the method used to collect the data was seriously flawed, according to a new study by the Arnold School of Public Health at the University of South Carolina.

    The study, led by Arnold School exercise scientist and epidemiologist Edward Archer, has demonstrated significant limitations in the measurement protocols used in the National Health and Nutrition Examination Survey (NHANES). The findings, published in PLOS ONE (The Public Library of Science), reveal that a majority of the nutrition data collected by the NHANES are not “physiologically credible,” Archer said.

    These results suggest that without valid population-level data, speculations regarding the role of energy intake in the rise in the prevalence of obesity are without empirical support, he said.

    The NHANES is the most comprehensive compilation of data on the health of children and adults in the United States. The survey combines interviews of self-reported food and beverage consumption over 24 hours and physical examinations to assess the health and nutritional status of the US population. Conducted by the CDC and the U.S. Department of Agriculture, the NHANES is the primary source of data used by researchers studying the impact of nutrition and diet on health.

    The study examined data from 28,993 men and 34,369 women, 20 to 74 years old, from NHANES I (1971 – 1974) through NHANES (2009 – 2010), and looked at the caloric intake of the participants and their energy expenditure, predicted by height, weight, age and sex. The results show that — based on the self-reported recall of food and beverages — the vast majority of the NHANES data “are physiologically implausible, and therefore invalid,” Archer said.

    In other words, the “calories in” reported by participants and the “calories out,” don’t add up and it would be impossible to survive on most of the reported energy intakes. This misreporting of energy intake varied among participants, and was greatest in obese men and women who underreported their intake by an average 25 percent and 41 percent (i.e., 716 and 856 Calories per-day respectively).

    “Throughout its history, the NHANES survey has failed to provide accurate estimates of the habitual caloric consumption of the U.S. population,” Archer said. “Although improvements were made to the NHANES measurement protocol after 1980, there was little improvement to the validity of U.S. nutritional surveillance.”

    These limitations “suggest that the ability to estimate population trends in caloric intake and generate public policy relevant to diet-health relationships is extremely limited,” said Archer, who conducted the study with colleagues at the Arnold School.

    “The nation’s major surveillance tool for studying the relationships between nutrition and health is not valid. It is time to stop spending tens of millions of health research dollars collecting invalid data and find more accurate measures,” he said.

    http://dx.plos.org/10.1371/journal.pone.0076632 link to study from the Arnold School of Public Health @ University of South Carolina

  29. […] health, biochemistry professor Dr. Richard Feinman’s thought-provoking column entitled “Health Risks of Low Carbohydrate Diets,” and so much more! You know what to do by now–pull up a chair, grab a cup of coffee and […]

  30. Wenchypoo says:

    As far as the fears of constipation, I’m doing a ketogenic 4:1 diet (the one for epileptics), and haven’t experienced ANY constipation–my gastroenterologist asked me how many times a day I go right before my last colonoscopy, because even HE was concerned. FAT is the stool mobilizer, not fiber, and if you’re well and truly fat-adapted, there is no constipation problem whatsoever.

    As far as VLCD messing people up. my husband did experience physiologic insulin resistance from doing strict VLCD for too long, but carb back-loading fixed him. He does “carb night” once weekly, and it keeps his blood sugar in the 80-90 range all week. The reason why he only does it once weekly is because he’s a genetic diabetic–this means his entire paternal line is diabetic (both types), but he is so far the only male in his family NOT on insulin or drugs.

    Yes, some people experience thyroid problems, physiologic insulin resistance, brain fog, and all sorts of other things, but each can be overcome with the right diet tweaking. Sometimes all it entails is just taking a short break from VLCD.

  31. Cheryl says:

    @ Raphi789
    This post at the blog Mostly Meat Is What I Eat addresses the mucus deficiency: issue:http://mostlymeatiswhatieat.blogspot.fr/2012/10/mucous-not-glucose-deficiency.html

  32. C McFarland MD says:

    Dr Feinman, it’s been a while since your last post. Can we expect another one soon? I’ve found your posts to be very instrumental in teaching my anesthesiology residents how to evaluate what they read in the medical literature. Next month our journal club will be discussing yet another prospective RCT analyzed on an intent-to-treat basis….
    Thanks for the work you’ve done and made available to us through your blog.

  33. Marilyn says:

    Sounds like a new year’s resolution to me. I look forward to the fruits thereof!

  34. Chris says:

    I’m now two months in ketosis and I was really looking forward to finding this. By the way, constipation may occur, but it is extremely easy treatable. Just eat your leefy green carbohydrates and drink enough water…and it’s gone…

    Constipation is no problem to people in ketosis. It is only a problem for those who stigmatize ketogenic lifestyles.

    Really wonderful article. It is a reference to me!

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