Fat Chance, by Dr. Robert Lustig

Just came across “Fat Chance:  Beating the Odds Against Sugar, Processed Food, Obesity, and Disease,”  by Dr. Robert Lustig.

Dr. Lustig is a pediatric endocrinologist and the Director of the Weight Assessment for Teen and Child Health Program at the University of California San Francisco’s Benioff Children’s Hospital.  Dr. Lustig came to the issue of weight and obesity via a start caring for children who had survived brain tumors.  The therapy to get rid of the tumor often damaged the hypothalamus.  Some of the kids developed hypothalamic obesity, because the neurons in the hypothalamus that sense the leptin signal are all dead.  ”Even if these kids eat only 500 calories a day, they gain weight.” Why?  ”Leptin is a protein made and released by fat cells.  It circulates in the bloodstream, goes to the hypothalamus, and signals the hypothalamus that you’ve got enough energy stored up in your fat.”   If the hypothalamus can’t hear the signal, the person will continue to store, not burn, energy.

So Dr. Lustig knew years ago that weight was not only about “calories in, calories out.”  His book argues forcefully that obesity is not a “choice” or the result of bad individual decisions.  He recounts the stories of obese 6 month and 1 year olds, and the fact that some kinds of infant formula have roughly the same amount of sugar per serving as coca-cola.  Did the 6 month old or the 1 year old make “bad choices?”

He would like to see a public health attack on what he believes are the true sources of obesity:  sugar, especially fructose, and processed food of all kinds.  He notes that many individuals, children among them, have no practical control over what they eat either because of lack of access to real food–in urban “food deserts,” for example, or because of poverty.  Nutrition programs that support low income people, such as Women, Infants, and Children (WIC) are not first and foremost nutrition programs but rather ways of disposing of federally-subsidized agricultural surplus crops.

Perhaps the most interesting part of the book for me, however, as the parent of a teenager who has tried most everything (except a starvation diet) to bring her weight down to a healthy level, is his estimation that in his practice, 60% of kids can resolve their weight issues by eliminating unhealthy carbohydrates such as sugar, flour etc., but 40% CANNOT.  They need additional support in the form of supplements, or drugs that do things such as improve insulin sensitivity, and even bariatric surgery.

This is the FIRST place I have ever seen a 40% failure rate for a low carb eating plan.  In Life Without Bread, about which I’ve written before, Dr. Wolfgang Lutz, practicing in Germany from about 1960 on reported 100% success with a low carb eating plan for his pediatric patients within a year except in very extreme cases, which might take longer to resolve, or in cases where it was subsequently learned patients hadn’t actually followed the plan.  And failure is too strong a word–there is no question that a low carb eating plan has vastly improved Juliana’s quality of life–she weighs less; she has far more energy, and a more positive and more stable mood on a low carb eating plan.  But she’s not all the way to a healthy weight and remains at risk for metabolic syndrome and diabetes.

In fact, in Fat Chance there is a description of something called acanthosis nigricans.  In all my low carb reading, I’d never heard of it.  It is a darkening, or thickening, and ridging of the skin at the back of your neck, armpits, and knuckles.  People think it’s dirt, or on the neck “ring around the collar.”   In fact, it is excess insulin working on the skin.  It can’t be washed off.  Juliana has had this on her neck, even after months on a low carb eating plan, and after her fasting insulin level was tested at an excellent “3″.  Even though her fasting insulin level is fantastic, I suspect there is still something else going on with her non-fasting insulin response–her hormonal response to food.

I wonder whether the difference between Dr. Lutz’s clinical experience and Dr. Lustig’s clinical experience is literally the change in the world in the past 50 years.  When Dr. Lutz began his practice, endocrine disruptive chemicals were not everywhere.  Now they are.  It is practically impossible to avoid exposure.

Oh, and is it any surprise, that Dr. Lustig is a buddy of my hero Gary Taubes, whose work first led us to try a low carb eating plan?

Naturopath #2

The mother of a friend of Juliana’s at school who has had terrible skin issues recommended another naturopathic doctor to me.  The Mom described the doctor as a “detective,” she just keeps asking questions and investigating until she figures it out.  She was able to vastly improve the teen’s skin problems, and is still working on it.

I had an introductory phone call.  These phone calls are usually for people who don’t know anything about naturopathy, so that they don’t show up at the appointment expecting the standard 10 minute office visit and an Rx.  I explained to Dr. Seddig that I knew all about naturopathy, and was calling her because the naturopathic physician we were working with seemed to be out of ideas.  I briefly explained Juliana’s history and asked her if she knew of other things that might be causing Juliana’s issues that hadn’t yet been identified.  She said yes, she could think of lots of other things to investigate that hadn’t been tried yet.

Our intake appointment was two hours long.  Questions included a battery of chemical smells, such as “new car smell;” gasoline; cigarette smoke; and nail polish and whether Juliana liked them, disliked them, or didn’t care.  She asked about Juliana’s circadian rhythm and whether she was tired after eating any of her meals.  She asked about pregnancy or birth complications–at first I couldn’t think of any but then remembered that Juliana had had an unusual blood level of something for which they whisked her away for a transfusion after birth.  I had to go look up the diagnosis and the procedure–don’t know yet if Dr. Seddig will find any clue there.

She concluded by saying that Juliana clearly has some hormonal issue.  She ordered an adrenal function test and a glucose tolerance test.  Juliana had her blood tested before and after eating a meal of a McDonald’s pancake, 1 syrup, and 1 hash brown square.  (Needless to say, she felt sick after the meal and had to lie down for a few hours).  The adrenal function test collected spit specimens four times a day at particular times of day and at a certain amount of time after waking and before eating.

We don’t have the results in yet.  As I wait, I found another fascinating and relevant book, that I’ll review next.

 

We try a fat fast

So after all that reviewed in the last few posts, we decided to try a fat fast.  Why?  We wondered whether Juliana was actually getting more carbs than she could tolerate just from the vegetables she eats.

A “fat fast” is a very last ditch technique described by Dr. Atkins in his original books (and not retained in the updated version by Phinney and Volek).  In this eating plan, you attempt to attain 90% of your daily calories from fat.  The theory is that such an eating plan will move the most resistant body into ketosis, where it is burning fat, rather than carbohydrates, for fuel.  Dr. Atkins emphasized that such an eating plan was dangerous to a non-resistant individual because the rate of weight loss was too fast to be safe.  More than a pound a day was an unsafe rate.

Here’s the thing about the fat fast–it’s high fat, but it is also ultra low carb–less than 10 grams of carb per day, depending on what you eat.

Juliana had been eating essentially what she is eating today on the fat fast, except including large portions of low carb vegetables.  So 3 ounces of protein/fat at a meal, with several cups of roasted cauliflower.  3 eggs with 2 cups of sauteed broccoli.  And so forth.  Now we’ve eliminated the vegetables.  And what have we found?  She is more satiated on a high-fat, relatively low-calorie regimen with minimal fiber than she was on a high-fat, high-fiber (from vegetables), and relatively low calorie regimen.  But fiber is supposed to fill you up, right?  Well, maybe not if it has a significant positive carb value.

The vegetables she is now NOT eating had negligible calories–two cups of broccoli; three cups of cauliflower?  Who cares?  BUT they had a high carb count for someone who can’t tolerate more than 10-15 grams of carbs per day.   On the “fat fast” regimen–about 1000 calories per day, fewer than 10 grams of carbohydrate, she did lose a few pounds, without hunger.

Let me emphasize again:  WITHOUT HUNGER.  A 1000 calorie per day eating plan consisting of a “balance” of fats, protein and carbohydrate would be a starvation diet.  The Atkins fat fast of 1000 calories per day with 90% of calories coming from fat is a satiation diet.  The five small meals per day can be a little strange:  two ounces of cream cheese, for example, but there is NO HUNGER.

Books I like a lot, like Jonny Bowden’s, emphasize eating fiber to help “feel full.”  But if that fiber contains carbohydrates, it may not have that effect in very sensitive individuals. Instead, the carbohydrates in the fiber foods may make them feel “more hungry.”  Since Juliana has exhibited symptoms of carbohydrate intolerance almost from the time she started eating solid food as a toddler, I think we can safely say that she is very sensitive.

However, she isn’t supposed to stay on the fat fast for more than a few days.  Weight loss stopped when she resumed a low carb eating plan with vegetables.  Since she’s not going to stop eating vegetables for the rest of her life, there must be another solution.

 

 

 

 

How to do an elimination diet

In a previous post, I described how Juliana tested positive for various food intolerances, and that we had begun a test by eliminating every food to which she had a measured reaction.

But something was bothering me.  What if she was intolerant of something to which she hadn’t had a measured reaction?  In particular, to dairy?  Dairy is one of the “sensitive seven,” also including wheat, sugar, peanuts, soy, eggs and corn.  Furthermore, Jonny Bowden writes, you might want to expand the milk category to include cheese, and the wheat category to include all grains. Living Low Carb, p. 340.  And what if she was reactive to something else not on the sensitive seven list, like tomatoes, or citrus?

There are two distinct reasons why a substance might not have shown a reaction in the test.  First, she is reactive, but the test didn’t pick it up; and second, she is reactive but the testing was done incorrectly at the lab.  The opposite is also true:  she may not be reactive but a test could show that she is for either reason.  I was afraid that by only cutting out the foods to which the blood tests showed a reaction, we could still be missing something important. But I wasn’t sure how to proceed.

In a fascinating new book, with the terribly undescriptive title “Six Secrets of Successful Weight Loss,” Dr. John Mansfield, a physician from Britain, details the problems he encountered with various types of testing for food reactions in 30 years of clinical practice treating people for food intolerances.  He regards blood testing as next to useless.  His method, instead, puts people on a restricted eating plan that includes only about 40 foods for seven days.  Only foods with a very low likelihood of causing a reaction, in his clinical experience, are on the list.  After seven days, foods are tested, one by one, to see if they provoke a reaction.

There are two types of possible reactions.  One, a host of possible physical and mental symptoms:  migraine, stomachache, digestive issues, skin rashes, fatigue, low energy, depression, etc.  All the various symptoms that can be the result of food intolerances that are often thought to be psychosomatic because no clear causal pattern seems to exist to explain them.  Two, weight gain.  Sudden weight gain, such as 4 or 5 pounds over the course of a day or overnight.  Very interestingly, Dr. Mansfield treats weight gain itself as a food intolerance reaction.  He has found that the only symptom many people have of food intolerance is weight gain, and that when the offending food or foods are eliminated, normal weight is restored.

Since she eliminated grains and fruit, Juliana hasn’t had fatigue and low energy.  Her only remaining “symptom” was stalled weight loss.  Dr. Mansfield offers a protocol to investigate that symptom.  Interestingly, the approximately 40 foods that are allowed in stage 1 of the elimination diet include fruits like peaches, pears, and plums, and starchy items like sweet potatoes and turnips.  Juliana and I decided to try it.

She stuck it out for a week.  It wasn’t as hard for her as you might imagine, since she got to eat all sorts of things she has been avoiding for months, including fruit and starchy tubers.  Those were big treats.  At the end of a week, if you haven’t lost a significant amount of weight (5+ pounds), Dr. Mansfield would conclude that you don’t have food intolerance and you should  abandon the elimination diet.  So what happened?  Juliana gained 6 pounds.  (As an aside, there is no way that she ate an excess of 21,000 calories in one week.  Do we really need more evidence that weight is not a function of calories in, calories out?)

What does this tell us? Well, it certainly tells us, again, that she is very sensitive to carbohydrate.  The fruit and starchy tubers she ate sent her weight right back up. To get the most information, however, we cut out all the fruits and starchy carbs so she hopefully wouldn’t gain any more weight, and then we added back each food she had been avoiding, one by one, and watched for a reaction.

The first was broccoli, then lemon, pork, garlic, cauliflower, beef.  Juliana weighs herself on waking in the morning, and before eating dinner.  We test one new food or drink in the morning, and one in the evening.  A significant weight gain overnight or during the day–more than the normal variation we observed prior to starting the plan–is a reaction, and indicates an intolerance to the food.

Juliana hasn’t had a reaction to anything.  If she does have a reaction, we will have to wait for the reaction to die down before testing another food.

Dr. Mansfield offers an important lesson–that you can’t trust blood-test results.  His book goes on to recommend that if you don’t lose weight on the elimination diet, the next thing to do is to attack a systemic yeast (candida) infection, and the last thing to do is try a low-carb eating plan.  On the one hand, this is fascinating.  It’s the only place I’ve ever seen a detailed protocol for discovering whether food intolerances and yeast overgrowth, that are hinted at all over the low carb literature as possible problems, are actual problems.  But Dr. Mansfield, in my view, still doesn’t have it quite right.

For individuals who know they are carb-sensitive, have gone low-carb, and are still having trouble losing weight, try Dr. Mansfield’s diet, but a low-carb version.  Granted this doesn’t leave you much to eat, but it’s only for a few days.

 

 

What about yeast (candida)?

So what’s the story on systemic yeast infection and weight gain or inability to lose weight?  Dr. Robert Atkins considered it a significant and usually unexplored cause of weight problems.  It’s featured prominently in an interesting book called The Harcombe Diet.  A systemic candida infection causes carbohydrate cravings because the yeast in your body wants to be fed.  The only way to get it under control is to stop feeding it, but sometimes even that isn’t enough.  Various supplements can further help kill off the overgrowth and restore better gut balance.

But is this for real?  I remember in the late 80′s a long list of ailments were blamed on systemic yeast infection and I knew lots of people on yeast elimination eating plans.  And I had a phone consultation with a regular doctor, but one who was at least conversant with low carb eating, who told me that the only people he’d ever seen with systemic yeast infections were AIDS patients at an advanced stage of the disease.

Well, it turns out that that doctor is correct as far as the allopathic model of medicine goes–yeast issues are not acknowledged in that model until they reach the extreme of an AIDS patient or other patient with a severely compromised immune system that allows the yeast to multiply to the point that it is visible.  However, naturopathic physicians routinely treat what an allopathic physician would consider a sub-clinical yeast infection–one that doesn’t show up on standard testing–but nonetheless causes significant problems for the patient, and they observe that those patients improve when the yeast condition is treated.

In Juliana’s case, she is severely allergic to mold.  Yeast and mold are co-reactors; being allergic to mold suggests she is also sensitive to yeast.   She had already been on a low carb eating plan that should have “starved the yeast,” but what if she needed more?  I talked the naturopathic physician into beginning a protocol of supplements to attack yeast.  But Juliana couldn’t tolerate the supplements–in addition to being hard to swallow, she had bad tasting reflux and burps from them for hours afterward.

We decided to try a test to see if we could identify a measurable sub-clinical yeast problem.  If we could, then we’d try a single supplement to attack it rather than the multiple supplement protocol she had been taking, and see if she tolerated that better.  There is a blood test and an accompanying stool test.  Unfortunately, we weren’t able to complete the stool test before she left for summer camp.  (Now I know that stool tests have to be delivered to the lab before the morning fedex cutoff so that they can be overnighted to the testing facility, and only on a Monday through Thursday morning.  It would be helpful if they put that information on the test itself).  So for the moment, we’re not working on yeast.