Ask Dr. Vernon

WELL, WELL. UPDATES FROM THE AMERICAN DIABETES ASSOCIATION

Here’s news. Tight control of diabetes using medications causes high rates of illness (what doctors call morbidity) and often death (what doctors call mortality). And using drugs to control blood sugar levels doesn’t stop the progression of the underlying disease process. I completely agree with these earth shaking findings (earth shaking if your business is selling drugs, it’s not good news that the drugs are often harmful and don’t stop the problem that kills the customer.). Controlling blood sugar levels with drugs does not stop the underlying destructive process of blood vessel damage. That’s why I spent the last 10 years of my professional life working to help patients with this diagnosis fix the problem. Not cover up the symptoms-fix the problem.

The blood sugar elevation in Type 2 diabetes is not just the problem-it’s a marker for an underlying deranged biochemistry.  When your body takes in carbohydrates, a entire cascade of biochemical changes occur automatically.  The dietary carbs trigger the secretion of insulin (and other hormones as well).  These hormonal signals tell your liver what types and how much cholesterol to make, as well as signaling the processing of these carbohydrates into a fat (trigycerides) that is transported in the blood stream  for the other cells in the body to use, if they can.

Now, the level of carbs that can be eaten before these destructive changes start is different from person to person.   I think of the whole situation the same way I think of sunburn.  This is an analogy I often use with patients. 

Clearly, there is a large difference in the amount of sun exposure that human individuals can tolerate. I actually know some people who can be out in the sun all day and not have sunburn. Then there’s me. As a child I was never allowed to swim between 11 am and 4 pm if the pool was in the sunlight. I wore long sleeves, hats and sunscreen if I would be exposed to the sun. No such thing as tanning-more sun just meant more sunburn. No amount of moral rectitude improved my sun tolerance.  That’s because, as we now know, skin pigmentation is inherited and not altered by moral fiber.   Of course I thought this was socially crippling as a child and teen.  I did live through those times, and I can now actually vacation on the beach.  I use coping strategies.  I still wear hats, long sleeves and sunscreen.   I work indoors in the middle of the day and play or work outdoors in the early morning or late afternoon. 

So the moral of this tale is:  I have a genetic predisposition to sunburn easily.  When my genetics interact with a sunny environment, then I have sunburn and skin damage.  Can I change my genetics?  No.  Can I manage my environment?  Yes.

Many people have a genetic predisposition to make a large insulin signal when they eat carbs.  (Of course, just like my fair-skinned Northern European ancestors may have benefited from their pale skin because they easily obtained enough Vit D from even brief sun exposure in the winter, rapid and effective transformation of dietary sugars and starches into stored body fat eaten when the harvest was available helped those folk’s ancestors make it through famine and long winters with minimal shelter.)  This large insulin signal moves sugar rapidly from the blood stream into processing for fat stores.  I’m telling you, we Midwesterners really understand this-because this is how animals used for meat are fed to “finish them for market”.  Feed the grain to the beef and the meat is marbled with fat.  Feed the grain to us and the same things happen.  Our livers become stuffed with fat they can’t ship out to the rest of the body, just like feeding geese corn to make fois gras.  The amount of carbohydrate needed to trigger these changes varies from person to person.  Can you change your genetics? No.  Can you change the amount of carbs you eat? Yes.

On with the story.  So you eat carbs and make an insulin burst and then the sugar is moved from your blood stream into your fat stores. Insulin has two major jobs-trigger sugar storage (as fat) and stop fat burning.  When dietary carbs are enough to trigger your personal insulin burst, then you store fat and you don’t burn it until the insulin level drops down again. Some people can store some fat and then burn it and no problems result.  It’s when the storage is chronic and the body never burns the stored fat that the cascade of problems occurs.  It’s not just the blood sugar rise, it’s the chronic inflammation that accompanies unmitigated fat accumulation that tears up the blood vessels all over the body.   The blood vessel damage that gives you a heart attack or a stroke, or causes blindness or kidney failure-all the same process, just occurring in many places.  There is probably some individual variation in response that causes one person to have kidney failure and another to have a heart attack.  Diabetes is a disease of inflammation and the dietary carbs drive this.  Dr. Volek and Dr. Phinney published a wonderful paper showing that the inflammatory chemical markers decrease in patients on a low carb ketogenic diet.  They show some additional biochemical information that indicates that the cell walls (membranes) are probably less damaged on a low carb ketogenic diet.  That’s what I’m talking about.  Fix the underlying metabolic problem (the problem with the fuel mix to your cells) and you will impact the disease.

Now, sometimes the destruction has progressed to the point where complete repair or recovery of the body can’t take place.  Even so, stopping the on-going destruction is very helpful.

Taking a medication to lower the blood sugar just lowers the blood sugar.  (Do you ever wonder where that sugar goes?  Is this like Star Trek, and we’ve “beamed up” the excess glucose, maybe to the Klingons?)  The blood sugar gets moved out of the blood stream into the fat stores.  You get fatter faster!  Read the side effects of these meds-almost all of them list weight gain as a side effect.  What did I just tell you about fat?  That accumulation of fat is associated with increased inflammation.  I’ll tell you something else-it is not just the fat.  The burning of carbs as fuel causes more inflammation than the burning of fat as fuel.  So a high carb, fat storing diet increase inflammation.  A fat burning (low carb/ketogenic) diet decreases inflammation and it’s destruction of your blood vessels and other body structures.

Now you can understand why I was not a bit surprised by the study reported at the ADA-that heart attacks and strokes don’t decrease when you control diabetes with meds.  I know this.  I’ve seen too many patients who were doing exactly what they’d been told to do.  They had their Hgb A1C less than 7, they took their medications, and they didn’t improve.  I’m not guaranteeing that a low carb ketogenic diet can fix everyone.  It can be the key for most, though.

So Dr. Buse, of the ADA, says concentrate on your lipids and blood pressure to avoid heart attacks. I say, your lipid changes, elevated blood pressure and blood vessel destruction are driven by the same process that elevates your blood sugar.  Control that process and then everything falls into place.

The ACCORD study was an attempt to show improved outcomes for patients who controlled their diabetes more intensively using drugs.  The intensive control part of the study was stopped early because the treated patients were dying at a higher rate than the untreated ones.  You can’t control blood sugar within the normal range with medications without the risk of the severe blood sugar drops known as hypoglygemia. These are killer events.

http://www.nutritionandmetabolism.com/content/pdf/1743-7075-5-10.pdf

Another study (an analysis of diabetes patients on oral medications) indicated that about half of the diabetes patients taking pills to control their blood sugar were able to stay on oral meds rather than progress to taking insulin.  Is this good?  I don’t think so.  We just reviewed how the medications don’t stop the progress of the disease.  So does this mean that the patients died before they got put on insulin?  Patients like this, because most people prefer not to give themselves shots.  But how can this be good news, when the disease still progresses? 

I want to fix the problem at the source.  Match the dietary carb intake to the metabolism of the patient, and 99% of the time the blood sugars, blood pressure and lipids return to normal.  Then no meds are needed.  No statins with their attendant risks of memory impairment and dissolving muscle.  No ACE inhibitors with the increase in cough and asthma associated with those drugs.  No diuretics with the increase in dehydration and impairment of kidney function.  No need for the pills to lower the blood sugar-your blood sugar (in most cases) can be normal.  The average cost of the cheapest medications above on a monthly basis?  $500.00 all together.   That’s $6000/year at a minimum.  Most of the time the meds cost much more, even with insurance.  Save your pocketbook and your health.   Use carbohydrate restriction to manage and control these issues. 

DEJA VU, IF ANYONE WAS LISTENING THE FIRST DOZEN TIMES?

The media is once again jumping up and down that science has confirmed what Dr. Atkins had been shouting from rooftops for so many years.  It seems that everytime science confirms what has already been confirmed, everyone is yet again surprised.  Perhaps if more Americans were following Atkins' rules, our collective memory would begin to function.

So once again, the low carbohydrate approach to weight and metabolism looks good. And the low carb arm of the study got these results in spite of the diet being changed after 2 months to allowing more carbs per day than I eat in a week!

The low carb dieters ate 20 grams of carb/day for the first 2 months. Sure enough, the outcomes look like all the other low carb studies. Weight loss and metabolic parameters like lipids were all much better on low carb. After 2 months, the low carbers were increased to 120 gram of carb/day. That’s not low carb in my book-and the outcomes showed it! Keep eating in the 20-50 grams of carb/day range and those excellent initial results will persist.

One of the comments about this study is that the counseling to avoid animal fat was what helped get the good results-which I say would have been even better if the participants had actually maintained the lower carbohydrate intake.

But let’s look--the findings of this study generally repeat the pattern seen before in the low carb studies, so I’m thinking the type of fat didn’t make a significant difference. That would be what I see in practice when I treat vegetarian patients. When carbs are low, the lipids change not because of the fat you eat, which was never the driver of your cholesterol and other blood fats in the first place, but because the hormonal signal to your liver changes. Drop the insulin levels and the liver makes the healthier lipid profile. This is a marker of your improved health as well. So eat a low carb vegetarian diet (yes I have done this with patients) or eat a low carb animal protein diet as you like. If you restrict the carbs, you’ll get the benefit.

Here’s another fun point. The author believes these people were helped by support. To which I say YES YES YES. That is why having a trained physician who can help you get to your metabolic best is very important. That is why I have worked with the American Society of Bariatric Physicians to help provide this information for physician. You can do your best work with an educated coach.

Dean Ornish, who now thinks good cholesterol (HDL) is bad for you, needs to get over it, as my kids would say. The association with favorable heart risk and HDL is statistical. So no matter what the HDL is doing, higher HDL is associated with better heart outcomes.

A paper by Marshall published in the American Heart Journal in Feb 2006 said that an ultralow-fat diet as a component of a comprehensive lifestyle intervention induces reductions in HDL-C and the emergence of a dyslipidemic lipid profile. Aerobic exercise only partially mitigates this effect. (Am Heart J 2006;151:484- 91. Translated, this says the diet recommended by Dr. Ornish is associated with increased heart disease risk, and that exercise doesn’t fix these changes. I say let’s hold low fat to the same standard of proof to which low carb has been held. Do the studies and show us the results. We did it and the studies that did it the way the low carb clinicians described got the outcomes the low carb clinicians described.

I agree with the authors of the Israeli study about one point, though. The best results are obtained when patients have an individualized plan working with a physician who is trained in this area. If we could fix this problem with a glossy pamphlet or wall chart, we’d already have this national issue solved. Individually tailored interventions based in sound science can get the patient great results. Let’s put this potent tool of carbohydrate restriction to use making ourselves healthier.

On another note.

I have just learned that the results of my patient follow up study with data from patients for as long as 377 days is accepted for presentation this fall at The Obesity Society meeting. Stay tuned for those results!

MORE OF MARY TO GO AROUND

Whew. It’s been a whirlwind couple of months--but here's the latest update.

Earlier this year, I started offering Web based educational seminars. These are great fun for me because the groups are purposely kept small so that I can answer questions. I don't provide individual patient advice in these sessions--for that an appointment is needed.  Even so, helping patients understand the disease process helps them to use the tools we can offer to improve their health. If you haven't tried one of these, you might consider signing up once to see if you find these seminars helpful.

In early February, I joined a physician group that shares my interest in nutrition and metabolic health. This group, Women's and Family Care, has offices in the Kansas City Metropolitan area (Shawnee, Kansas) and in Lawrence, Kansas (in the Neu Physical Therapy building). The contact telephone number is 913-643-0075. I am seeing patients in both locations. This is helpful for my Kansas City patients who used to make the drive to Lawrence. I still see patients in Lawrence as well; and I am in Lawrence as much as I was before.

Tracy Clark, a colleague in this group, is a nurse practitioner who studied with me in Lawrence. Her interest in metabolic health has already helped many patients. She continues to work with me. This is a great benefit to my patients when I travel out of town to give presentations. Someone who knows their situation is still in the area to help, if needed. Of course, for those of you who have seen Melissa, she is still available, and working hard.

Dr. Gordon Clark (yes, he and Tracy are married) is an OB/GYN with an interest in carbohydrate restriction as it applies to women who suffer from metabolic and hormonal imbalance due to hyperinsulinemia and insulin resistance. We have begun a consultation clinic focused on women with these problems. One of the most common diagnoses we work with is PCOS (polycystic ovarian syndrome). Often, irregular periods, infertility, weight gain, gestational diabetes and excess facial hair are related to insulin levels. We work with all of these problems using a comprehensive, whole patient approach. We have a full range of diagnostic testing available, including in-office ultrasound, bone density testing and of course laboratory testing if appropriate.

While all of this was happening, I was named finalist (one of five) in the "Diabetes Educator of the Year" contest sponsored by American Diabetes Wholesalers. The final vote was in February-and March 3rd I found out I was the first runner up.

I am honored to have been recognized by my patients in this national contest. (Here is a little joke I'm telling on myself--when this company first contacted me to tell me I was a finalist, I thought they were kidding. I kept telling the nice person who called that I didn't need any supplies right now. He finally convinced me to go to their web site and see the information about the contest.)

On another front, I was recently in Washington DC speaking to members of Congress and to the USDA (Dr. Brain Wansink) and to the Office of Disease Prevention and Health Promotion (called U dip hip for short) about building healthy diets. I presented the evidence for normal blood sugar values (without medication) obtained when diabetic patients use dietary carbohydrate restriction. Even though this information has been published in the medical literature, it often appeared to be new and eye-opening information for those we had the opportunity to meet. I guess you can't cover this information too frequently. Dr. Westman, Dr. Volek and Dr. Robert Lustig were also part of the group providing information to these individuals and agencies.

Finally, on March 11, I appeared on a Canadian documentary, My Big Fat Diet, the story of an entire community that needed to control it's weight and diabetes. Yes, we saw the same benefits there that I have published about before. Looks like this works no matter no matter where one lives.

So  now I am back at work. It is working with patients that teaches me about the benefits of nutritional intervention. I love this. I'm having a great time with my colleagues who want to help patients in the same way I do.

Mary Vernon, MD, CMD

DR. VERNON GOES LIVE ONLINE

Because of my interest in educating patients, I am beginning a series of Internet-based educational presentations. These will be limited to small groups of about 10 participants at a time. You’ll log in to a web site and call in to a conference call line-so you can see the information I present on your computer screen, hear me discuss the information and be part of the question and answer session.

This is not an individual medical consultation-and no information of that sort will be discussed, but this is an opportunity to understand how your body works, what the progression is from early changes in blood sugar control to diabetes, and how changing what you eat can change what happens in your body.

The cost is $100 for each 30 minute session (20 minute presentation, 10 minute Q&A.).  For now, you’ll need a PAYPAL account, computer and telephone to participate.  This is an introductory price.  Email info.mvernonmd@yahoo.com and our educational coordinator will communicate with you.

For now, I will personally run these sessions but in the future I plan to add guest lecturers as well.  Keep checking this blog for updates.

Additionally, I will be providing educational programs for your physicians as well.

After the jump, you'll find a letter that you can print out and share with your physician.  This gives you, the patient, the opportunity to play a very active role in your own health care.

HAS THE AMERICAN DIABETES ASSOCIATION SPARKED YET ANOTHER ATKINS REVOLUTION?

EDITOR'S NOTE:

Some four years after the death of famed nutrition pioneer, Dr. Robert C. Atkins and some three years after the publication of Atkins Diabetes Revolution by Dr. Mary Vernon, colleague of Dr. Atkins and immediate past President of the American Society of Bariatric Physicians, the American Diabetes Association has reversed it's position on the Atkins Diet and the role of carbohydrate control in diabetes.

Dr. Atkins used to say"  "One day the medical and nutrition community will catch up to me." Apparently that has finally happened.

DR. VERNON COMMENTS:

After decades of relentlessly vilifying Dr. Robert C. Atkins and those of us who long ago turned to the research and the facts, the American Diabetes Association (ADA) is coming on line today, December 28, 2007, to say that carbohydrate restricted diets are effective for weight loss.

I suppose, at this time of year, I should be overwhelmed with gratitude that the ADA is finally catching up with the science.

Sorry, I am underwhelmed.  Make that underwhelmed x 2.

Oh, I am glad that patients, whose physicians use the ADA recommendations, will now have access to this potent and effective tool. Up until now, many patients were steered away from this method simply because the ADA was “waiting for the evidence”. (Strangely, the evidence the ADA is using to say that carbohydrate-restricted diets are safe and effective for a year was published in 2003).  Patients deserve access to the information-not patronizing advice.

I am most saddened by the lack of understanding. Carbohydrate restriction and the resulting control of insulin secretion is much more than weight loss. It’s not the weight-it’s the metabolic state your body is in, that generates disease or well-being.  I supppose we'll have to wait another 5-10 years before the ADA catches up with the rest of the science, science well understood by researcher from Harvard, Duke and even the National institutes of Health--but not yet the ADA.  Again, strange.  Of course, perhaps not so strange to the highly profitable processed foods, refined carbs and low-fat industries.

I’ll try to explain. Your body has two choices regarding fuel-store it or spend it. How is this decision made? By the type of food you eat. Sugars and starches (dietary carbohydrates) stimulate insulin secretion and release. This process begins the moment you put the food in your mouth-and maybe even before that. Insulin goes up--fat storage is triggered and fat burning comes to a proverbial screeching halt. (I do mean screeching--very small changes in insulin levels can stop fat from being moved into the mitochondria, your cell’s furnace.)  Protein may cause a tiny bump in insulin levels-and dietary fat does not stimulate insulin release at all. So pull the sugars and starches out of the diet and the signal to store fuel is gone--POOF!--as if David Copperfield had been waving a handkerchief.

If the signal to store is insulin, and insulin levels are now back to normal, because the signal that generated the excessive level is gone, your body naturally turns to it’s fat stores for energy.  Any fat you eat is also burned for energy--your liver is an equal opportunity metabolic unit for energy production. No sugar or starch around ? No problem.  The liver cheerfully begins burning stored and dietary fat to produce energy. Do you lose weight?  You can, if you need to. But you can change your risk factors and not lose a pound. I see this happen all the time-I have some 90 lb patients who started with triglycerides in the 300’s whose weight didn’t change but who now have normal triglyceride and HDL numbers--just by taking the carbs out. Often, even though they are weight stable, their body composition will have changed. I had a patient go from 35% body fat to 29% body fat in one year without changing a pound on the scale. Of course, the cholesterol and glucose numbers returned to normal, as well. It is not the weight.  The weight is a marker for the metabolic problem. Yes, the weight can make the problem worse. But to say that low carb diets are as effective as low fat diets for weight loss over one year is looking at the minimum outcome this dietary approach can generate.

So, ADA, congratulations on finally giving patients an option they can use effectively. It is way past time.  Now please catch up with the rest of the science and honor your commitment to help stem the tide of the nation's out-of-control diabetes epidemic.

SURVIVING DIABETES: LOOKING PAST THE NEW YORK TIMES!

The NYTimes had an article by Gina Kolata which rendered me speechless for almost 12 hours. I have now recovered.

The article focused on how diabetics aren’t aware of the need to lower cholesterol and blood pressure in addition to controlling their blood sugar numbers. (Most diabetics die from heart disease.)

Ms. Kolata accurately reports the standard medical line-therefore take drugs-one or two for each problem! Reader please note-a recent American Diabetes association Presidential Address seriously proposed the one-a-day combo pill approach for all Americans. Put a blood sugar drug (metformin), a cholesterol drug (statin), a little aspirin and maybe some B vitamins in a pill and everybody could take one a day. Cheap!

Some bullet points:

The newsflash that we need to get the medical establishment to understand is that the cause of the cholesterol problem most of the time is the glucose metabolism problem. This is not the chicken and the egg circular thing. There is a starting point and that staring point is glucose metabolism. Return glucose metabolism to normal and the blood pressure goes down and the cholesterol normalizes. Oh yeah-and the triglycerides plummet and the good cholesterol (HDL) goes up.

I can point to many articles in the medical literature which clearly show the relationship between cardiac arterial disease and abnormal glucose metabolism. This relationship extends to the early stages of blood sugar problems-stages known as metabolic syndrome, hyperinsulinemia, impaired fasting glucose and impaired glucose tolerance (pre-diabetes). Many times a patient has their glucose metabolism problem diagnosed when they go to the hospital with chest pain or a heart attack. If doctors were educated to look for the glucose problem so that it was diagnosed in the early stages, the blood vessel disease could be treated or avoided.

More newsflashes! The medications prescribed don’t fix the destructive process of the abnormal blood sugar metabolism. The medications cover up the evidence of the problem, but the destruction often continues. If you fix the blood sugar metabolism so that the blood sugar (and insulin) numbers are normal without medication, then I have seen evidence in patients that blood vessel disease actually improves. Just give the medicines, and the medical dogma that the diabetes inevitably worsens and progresses turns out to be true.

Whoa! (We say that in Kansas.) The medications often have side effects. Take a look at the book written by Duane Graveline called “Lipitor, Thief of Memory”. Dr. Graveline is an MD and was a NASA astronaut. Just do a Google search for the side effects on any of the medications recommended for treating diabetics. You’ll find a significant list for most meds.

Now, that doesn’t mean you shouldn’t take these meds if you need them. They may help you, if you need them. But what should happen first and foremost is to control your metabolism using nutritional change. For Type 2 diabetics, this means using carbohydrate control to get the best blood sugar control possible. After your blood glucose numbers are normal without medication, your cholesterol numbers will usually be well within the recommended range. Cholesterol numbers often change during the active stage of metabolic change-so don’t make decisions about your personal outcomes until you are stable for a while.

Here is the disclaimer. If you are a Type 2 diabetic on medications, you need a physician trained in using this approach to help you taper your medications. Carbohydrate control is so powerful a tool that your medications for blood sugar control may need to be decreased very rapidly to avoid low blood sugar (hypoglycemia.) Of course, that is the great thing about carbohydrate control. In many cases, when dietary carbs are controlled, patients are able to decrease or completely stop medications to control blood sugar. The blood sugar numbers become normal without medication. Cholesterol levels normalize for most patients and blood pressure returns to normal as well.

Ok, I’ve calmed down. Read “Atkins Diabetes Revolution” for a more complete discussion of these issues, as well as the references. Dr. Atkins knew how effective this method is. He spent his professional life trying to help patients benefit from using this method.

I have been lucky enough to experience how effective this treatment is for patients in my own medical practice. It is from the practical experience of watching patients improve that I learned how effective this nutritional treatment can be. I can continue to hope that other physicians begin to learn the benefits this method can offer patients.

(You can read Ms. Kolata's full article after the break.)

ATKINS FOR DIABETES: IT'S NEVER TOO LATE TO CHANGE BAD HABITS

Ron of Sarasota, Florida asks:

I have been a type one diabetic since November of 1982. In 2003, I had a quadruple cabg. My blood numbers are good except for a low (30) HDL. My LDL in in the low 50s, my total cholesterol is at 103 and my triglycerides are in the 70's.

I have basically been on the ADA carbs merry-go-round: Eat carbs/take insulin (Humalog and Lantus, injecting 3 times per day. I exercise regularly, plus bowling in three leagues per week plus one other day of bowling.

I am very interested in the practice of medicine and volunteer at the local hospital almost 1,000 hours a year.

My questions are these:

How could I receive benefits from your practice on a direct basis,including coming to Kansas, or is there a doctor near Sarasota who is on the same page as you?

My A1c is 6.6 and I want to live a long time and stay active. Ii am 72 years of age.

And Dr. Vernon answers:

The closest physician to your location who is helping patients using this method is Eric Westman at Duke. You are, of course, welcome to visit me in Kansas. I do see patients who travel from all over, so my practice is accustomed to working with patients at a distance after I have seen them at my office for an evaluation.

In my experience, all patients with blood glucose problems (whether Type 1 or Type 2) benefit from controlling carbohydrate intake. Many Type 2 diabetics no longer need medication to control their blood sugar-their blood sugar measurements become normal when they follow the dietary plan. Type 1 diabetics benefit by avoiding the ups and downs in their blood sugar readings. If a Type 1 diabetic takes enough insulin to keep their blood glucose normal when it would be high based on what they ate, then their blood sugar drops too low if they do not eat that way all the time. If they do eat in such a way as to have elevated blood sugars all the time, the amount of insulin they take to control the blood sugar numbers in conjunction with the excess carbs causes weight gain. So it is almost functionally impossible for Type 1s to avoid hypoglycemia and weight gain unless they control carbs carefully.

Many of my Type 1's do very well on 2 injections of a 12 hour insulin preparation a day. They use no more than the amount of insulin equal to the amount your body secretes to keep glucose available and glucagon in check. This basal amount is about 1 unit/hour. My patients using insulin pumps do very well, too, as long as they decrease the pump amount rapidly enough when they begin controlling carbs.

The real trick to all this is having the advice and guidance of a physician knowledgeable about these various insulin preparations and the effect of carb control, to guide you safely through the transition from the ADA roller coaster to the smooth sailing of carb control. (How's that for a mixed metaphor?) Most physicians have never experienced the need to decrease medication-so they are tentative about tapering insulin, anti-hypertensives and diuretics rapidly. When carb control is initiated the need for blood glucose ,and blood pressure lowering decrease rapidly-some Type 2's go from needing 100 units of insulin/day to needing no insulin/day in 3 days or less. You can imagine that without expert guidance patients changing their diet but not their meds could be dangerously ill from too much medicine. I'll share a story to illustrate this very important point.

In my family medicine practice several years ago, I had a brilliant and busy university professor of computer science. He was on 3 different medications for his blood pressure, which wasn't very well controlled even with that much medication. He had the Santa Claus profile and his blood sugars were starting to rise above normal levels. We discussed these issues and he asked me if doing the Atkins diet was safe. I said it was--but you'll need to do it with my help because of your meds. He thought that plan did not meet his time-line, so he began on his own. On day 3 of dietary carb restriction he had to lie flat on the floor to keep from fainting-his blood pressure was so low he would faint if he lifted his head. He called 911 from flat on the floor using his cell phone.  He was off of all of his blood pressure medications right then--but it took 3 days of medical care in the hospital for him to be able to stand up and not be dizzy. This was not a problem with the diet, it was a case of potent medication no longer needed. I'd have guided him on how to taper the meds to avoid the flat on the floor episode. He has a great sense of humor, though. He was sheepishly apologetic when I saw him in the hospital, joking that he guessed the diet worked as well as I said it did. He has done well since. He only needed one experience like that

PHISHMAN ASKS FOR THE WORLD AND GETS IT

A demanding reader, Phishman from Maine asks some very big questions:

First off, let me say that I was just recently introduced to your blog and find it very useful. Hopefully you have a minute or two to respond to this email, or post your answers on your web site.

I have been living a low-carb lifestyle on and off for about 2.5 years now, and absolutely love it. Not only do I do it for weight management, but it also helps with energy levels, building muscle, working vegetables and healthy fats into the diet, cures any symptom under the sun from a bad diet (over-eating, heartburn, etc). In other words, no one need to convince me that this is among some of the more healthy nutrition plans known to the human body.

It seems that between 2002 and 2003 low-carb dieting, specifically Atkins, was at its peak. You could find their food everywhere, LC eating was getting a bunch of positive press, and people really started changing their minds. Then, the death of an overweight, heart-troubled Robert Atkins was plastered all over the media, as well as a disastrous comment by one of their spokespeople about saturated fat, and since then Atkins has filed Chapter 11, their advertising campaign is almost non-existent, and at least up here, their food is all but impossible to find.

I’ve seen nothing defy typical common sense for the lay-person when it comes to nutrition the way Atkins’ philosophy does, and I always find myself battling with people, and constantly citing the very small handful of studies that have gained enough notoriety to prove his position in the world of nutrition.

With all of this mind, I’d love to play devil’s advocate for a moment, and give you the most common critiques of the diet that even I, a staunch supporter, have trouble defending at times. I would love for you to take a moment to respond to these common criticisms of low carb eating:

1. No one, and I mean NO ONE is arguing the fact that people can loose weight  quickly and significantly on Atkins. No one is even arguing that certain fats aren’t good for you such as those from nuts/vegetable oils. However, almost every single nutritional study to date suggests that saturated and trans fats are harmful, and cause drastic increases of bad cholesterol. To simplify, are we to believe that it’s the crust in pizza that’s raising our cholesterol levels and not the cheese, or the potato, not the butter melting on it?
2. Everyone knows that a balanced diet is key. No one building block of food (carbs/protein/fat etc) should be over or under-emphasized. What do you say to those who recommend balance?
3. Don’t low carb diets deny us the vitamins and minerals of so many important fruits and even some vegetables that simply can’t be replaced by supplements?
4. Isn’t it dangerous to deprive our bodies, especially our brains of glucose and natural sugars?
5. Don’t carbohydrates play a vital role in exercise, energy, and muscle growth? Could you honestly recommend, for example, that someone run a 10k race on only 20-50 carbs each day for several weeks beforehand?

I’d love to hear your response so I can respond a little better to some of the ‘water cooler’ critics who are honestly using little more than normal intuition to come to their conclusions. Feel free to publish this on your blog.

Ok phishman, you asked for it, Dr. Vernon responds:

Robert Atkins was a champion of the truth. He was also a brilliant witty entreprenuer with enough intestinal fortitude to face multiple attacks including a Senate hearing to defend what you have already experienced-keep the sugars and starches out of the diet and health improves. His cardiologist stated in a televised interview that during a cardiac catheterization a year or two before his death, his arteries did not require any intervention. I hope I can say that about myself at age 72.

Dr. Atkins died of a head injury sustained from a fall. His heart kept going for weeks. (Again, I should have such a heart at that age.) His brain was injured. I don't know of anything about low carb that protects one from accidents like slipping on ice. Of course the sequelae of two brain surgeries and the best American medicine had to offer was fluid retention from medications to decrease brain swelling and maintain blood pressure in the presence of such an injury. As a result a comatose Dr. Atkins bloated and swelled. 

Speaking of attacks-after his death, a physician associated with a radical animal rights group asked for Dr. Atkins records-and the City of New York sent these records without a release!  This same physician/group then crafted a press release calculated to generate in the media exactly the message you took home by releasing half truths. So there.  Dr. Atkins "obesity" was caused fluids related to life-saving measures and this was delivered to the media as evidence of the failure of low carb eating. This was dishonesty and misinformation at its most vile.

Next: What a relief. Can I really believe you when you say that no one argues that one can lose weight using this approach? It seems I still fight this battle. I am glad that the common sense is now that carbs and gain of fat are linked. It is true.

You will need to tell me what nutritional studies show that saturated fats are harmful in the absence of carbohydrates. I know of none that show this. All the saturated fat studies so far have had lots of carbs. DO FAT AND SUGAR TOGETHER TRIGGER FAT STORAGE? YES.

Now, pay attention, because some brilliant scientists have been working on answering this question.

In the fall of 2006, at the annual meeting of the North American Association for the Study of Obesity (NAASO), Dr. Steve Phinney and Dr. Jeff Volek presented a poster. I am quoting directly from the abstract conclusions: The absolute concentration of total SFA in plasma TG was reduced by 57% after the VLCKD, compared to 21% after the low fat diet. We conclude that a VLCKD reduces both the % and absolute amount of SFA in plasma TG to a greater degree than the low fat diet, despite the relatively high proportion of fat and SFA consumed with the VLCKD. The abbreviation SFA=saturated fatty acids, and VLCKD means very low carbohydrate ketogenic diet, ie-Atkins induction.

Here is the translation for those who don't want to wade through the science talk: The saturated fat in the blood stream went way down on a diet high in saturated fat and low in carbs. Know what else they found? The type of fat your body makes when it is actively storing fat went way down as well. Wait! I think Dr. Atkins said something like that-you store less fat when you eat fat if you leave out the carbs! So in response to your question-eat the butter and cheese on the pizza, and ditch the crust.

What I say to the people who recommend balance is that the Emperor is naked.  Balance is as balance does.  Is balance equal volume measures (cups of food), equal energy amounts (joules) or is balance what someone writes down without any knowledge of the consequence of that recommendation in an individual person? As a bariatric physician, I learned that template solutions for complex problems don't work. Dropping down to 20 grams of carbs/day from leafy green vegetables and eating the remainder of your energy needs from meat and fat, then adding low glycemic carbs back in slowly (after you have attained metabolic health) allows each person to find their own balance. If that is 20 grams of carbs from leafy greens every day for the rest of their life, then that's what it is.

The best analogy to explain this is sun exposure. Should all humans have the same amount of sun exposure? No. (Duh). I wear a hat, long sleeves and sunscreen and avoid the outdoors between 11 am and 4 pm. All the time and even on the beach. I have friends who just get tan and never burn. DO what fits you and your metabolism.

And while I am ranting about this, Here is my personal soapbox issue:

Individuals who maked dietary recommendations based on what they think instead of what really happens in patients. This certainly happened with the low fat recommendations. See Gary Taubes article "The Soft Science of Dietary Fat".

The problem has not stopped with low fat vs high fat-but continues on when lay press diet books give all sorts of advice about healthy fats without at least some patient evidence. Dr. Atkins observed the benefits of the carb control approach in himself and in his patients-then he wrote about their outcomes.He didn't just decide what should happen and then write a book about his opinion. He knew what happened because he saw it happen. I had the same experience.

On to question # 3)

The answer to your question is "No".

This has acutally been analyzed and representative low carb 20 gram menus are perfectly fine in this regard. Leafy greens as recommended are the enzymatic powerhouse of the plant and have these vitamins in abundance.  They also have the other substances you mention that may contribute to health.Remember what I said above? That individualization is key to diet and health? Same here. Why not take a multiple vitamin to cushion the individual dietary preferences and metabolic differences?

4) If eating a low carb diet deprived your body and brain of glucose you'd be dead. You are not. Therefore, it does not deprive your body or your brain of anything. Now for the fun explanation:

When scientists calculate the minimum amount of fuel needed to keep you alive if you just lay still and breathe, it is the equivalent of about 100 grams of glucose a day. Your brain is perfectly happy to use a fuel called ketones to fulfill its energy needs. Only your red blood cells, a few parts of your eye and maybe a couple of other cells can use only glucose as an energy source. If you add up the energy needs of cells that only use glucose their energy requirement is about 30 grams of glucose/day. Your liver and kidneys (yes your kidneys) can easily make that much glucose from other sources: amino acids from protein and glycerol from your fat.

The other cells in your body, like muscle cells, can use fatty acids and ketones as fuel.  So no problem on a low carb ketogenic diet.  You eat protein and fat, both of which can be used to make the minimal amount of glucose needed on a daily basis.  There is no minimum daily requirement for dietary carbohydrate.

Here is a conundrum:

Children with seizures are treated with a ketogenic diet much stricter than even Atkins induction. This approach is nearly miraculous in many cases in decreasing seizures. In other words, their brains work better using ketones for fuel. I don't have seizures, but my brain works better on a low carb ketogenic Atkins Induction type diet, too.

Another smart scientist (Eric Kossoff at Johns Hopkins) tried the induction approach on kids with seizures and found that it worked great. Here is the Pub Med abstract and the link.

A modified Atkins diet is effective for the treatment of intractable pediatric epilepsy.

Kossoff EH, McGrogan JR, Bluml RM, Pillas DJ, Rubenstein JE, Vining EP.

John M. Freeman Pediatric Epilepsy Center, Departments of Neurology and Pediatrics, the Johns Hopkins Medical Institutions, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MS 21287-1000, U.S.A. ekossoff@jhmi.edu

PURPOSE: The Atkins diet may induce ketosis as does the ketogenic diet, without restrictions on calories, fluids, protein, or need for an inpatient fast and admission. Our objective was to evaluate the efficacy and tolerability of a modified Atkins diet for intractable childhood epilepsy. METHODS: Twenty children were treated prospectively in a hospital-based ambulatory clinic from September 2003 to May 2005. Children aged 3-18 years, with at least three seizures per week, who had been treated with at least two anticonvulsants, were enrolled and received the diet over a 6-month period. Carbohydrates were initially limited to 10 g/day, and fats were encouraged. Parents measured urinary ketones semiweekly and recorded seizures daily. All children received vitamin and calcium supplementation. RESULTS: In all children, at least moderate urinary ketosis developed within 4 days (mean, 1.9). Sixteen (80%) completed the 6-month study; 14 chose to remain on the diet afterward. At 6 months, 13 (65%) had >50% improvement, and seven (35%) had >90% improvement (four were seizure free). Mean seizure frequency after 6 months was 40 per week (p = 0.005). Over a 6-month period, mean serum blood urea nitrogen increased from 12 to 17 mg/dl (p = 0.01); creatinine was unchanged. Cholesterol increased from 192 to 221 mg/dl, (p = 0.06). Weight did not change significantly (34.0-33.7 kg); only six children lost weight. A stable body mass index over time correlated with >90% improvement (p = 0.004). CONCLUSIONS: A modified Atkins diet is an effective and well-tolerated therapy for intractable pediatric epilepsy.

Oh, yeah, and low carb ketogenic diets help migraines in many patients. Dr. Kossoff is working on a study on this, I think.

Again, the short answer to your question is that you don't need carbs. Now, for the fun explanation:

Want to know about carb restriction and exercise? Look up a study done by Dr. Stephen Phinney on trained bicycle racers.

The human metabolic response to chronic ketosis without caloric restriction: preservation of submaximal exercise capability with reduced carbohydrate oxidation.

Phinney SD, Bistrian BR, Evans WJ, Gervino E, Blackburn GL.

To study the effect of chronic ketosis on exercise performance in endurance-trained humans, five well-trained cyclists were fed a eucaloric balanced diet (EBD) for one week providing 35-50 kcal/kg/d, 1.75 g protein/kg/d and the remainder of kilocalories as two-thirds carbohydrate (CHO) and one-third fat. This was followed by four weeks of a eucaloric ketogenic diet (EKD), isocaloric and isonitrogenous with the EBD but providing less than 20 g CHO daily. Both diets were appropriately supplemented to meet the recommended daily allowances for vitamins and minerals. Pedal ergometer testing of maximal oxygen uptake (VO2max) was unchanged between the control week (EBD-1) and week 3 of the ketogenic diet (EKD-3). The mean ergometer endurance time for continuous exercise to exhaustion (ENDUR) at 62%-64% of VO2max was 147 minutes at EBD-1 and 151 minutes at EKD-4. The ENDUR steady-state RQ dropped from 0.83 to 0.72 (P less than 0.01) from EBD-1 to EKD-4. In agreement with this were a three-fold drop in glucose oxidation (from 15.1 to 5.1 mg/kg/min, P less than 0.05) and a four-fold reduction in muscle glycogen use (0.61 to 0.13 mmol/kg/min, P less than 0.01). Neither clinical nor biochemical evidence of hypoglycemia was observed during ENDUR at EKD-4. These results indicate that aerobic endurance exercise by well-trained cyclists was not compromised by four weeks of ketosis. This was accomplished by a dramatic physiologic adaptation that conserved limited carbohydrate stores (both glucose and muscle glycogen) and made fat the predominant muscle substrate at this submaximal power level.

Ok, here is what Dr. Phinney did.  He took trained bicycle racers and fed them a very low carbohydrate ketogenic diet long enough for them to adapt to using fat as an energy source. (at least 2 weeks at a minimum, but he fed them this way for a month).  He tested them for performance and did all sorts of other tests including muscle biopsies for glycogen. 

You can read it for yourself-the racers did as wells on the diet as before. Although they had less muscle glycogen stored, their glycogen dropped less when they were keto-adapted. They didn't need to use their glycogen because they were so good at burning fat.

I have depleted my brain ketones writing all this so I am going to go find some fat. Take that to the water cooler. Thanks for asking.

DEAN ORNISH: SCIENCE BE DAMNED, SELF-INTEREST BE SERVED

As always, Dean Ornish and the media put aside science in favor of headlines and self-interest.  The following editorial was rejected by NEWSWEEK, TIME, the Journal of the American Medical Association and others.  However, Ornish was allowed exclusivity on the playing field.  And who pays the price yet again?  The American consumer and the millions suffering from obesity, diabetes and heart disease.  Dear reader: write to your local media, the national media, phone, email and demand that Dr. Vernon and other experts who follow the trail of science be given a voice.

More Science and Less Zealotry, Please.

The controversy over which diet is best for all has again made headlines with the publication of the Stanford University study in the Journal of the America Medical Association March 7, 2007. Since the results are favorable to the low-carbohydrate Atkins diet, the usual criticism can be expected to follow.

Predictably, Dean Ornish has launched a tirade in which he manipulates the study findings to find fault with the low-carb approach and to deflect criticism away from his ultra low-fat diet which did not perform well in the study. Unfortunately, this is an argument based on dogma and not on science. The science speaks for itself.

As scientists and clinicians, we believe that no one dietary approach is going to be ideal for everyone. There is no doubt that, for some, an ultra-low-fat approach may be appropriate. Unlike Dr. Ornish, we recognize that there is no one-size-fits-all approach to the enormously complex problem of obesity and related conditions. Unfortunately, other authoritative sources like the US dietary guidelines also recommend a single lowered fat high-carbohydrate diet approach and have been doing so over the decades that this epidemic has grown.

Gratuitous attacks on the Atkins diet that imply it involves abandonment of wholesome vegetables and fruit for “bacon and brie” are simply wrong. Even in the most restrictive phase it meets the recommended daily guidelines for vegetables and fruits. As one advances through the phases, low-glycemic fruits, more vegetables, legumes and even whole grains are introduced based on an individual’s metabolic tolerance for these foods. One survey found that people who follow the Atkins plan over the long term eat more vegetables than they did before. Another study found that rather than increase the intake of fat and protein to compensate when carbohydrates were reduced, people simply ate less.

The unfortunate reality of today is that too many Americans are eating potato chips and fries and drinking sugar-sweetened beverages. We support the idea that wholesome foods such as meat, fish, cheese and eggs along with vegetables and low glycemic fruits constitute a healthier diet than chips and fries and sodas.

While this study examined four popular dietary approaches, what is clear is that whatever approach one takes to healthy eating, success will depend on how well you can stick to it. In this case, and in many earlier studies, it is clear that the Atkins diet is the one most people can maintain. On the other hand, the extremely low-fat diet advocated by Dr. Ornish is very difficult to follow. In this study, the subjects who were supposed to reduce their fat intake to his recommended intake of 10% could not reach that target.

Another important aspect of this and earlier studies is the beneficial effect that reducing carbohydrates has on metabolic markers. In his criticism, Dr. Ornish states that the LDL-cholesterol level fell in response to his diet, but does not mention that none of the differences in LDL-C in this study were statistically significant. This is therefore not a scientifically valid criticism. On the other hand, it is widely recognized that elevating the HDL-C, the good cholesterol, is an important factor in reducing cardiovascular risk. In this study there was a highly significant 10% rise in HDL-C in the Atkins group but no such change among those who followed the very high-carbohydrate Ornish diet.

In the same vein, the Atkins group demonstrated a significant (both statistically and clinically) greater reduction in systolic and diastolic blood pressure than the other three diets. A difference in mean arterial pressure of 5 mm Hg is about the response we would expect to see with a first-line pharmaceutical in the clinical setting. Any objective observer would acknowledge this as a major beneficial effect of the Atkins diet.

Dr. Ornish suggests that the positive findings of research such as this that supports the Atkins diet will cause problems, and that “many people may go on a diet that harms them based on inaccurate information.” This is a wildly irresponsible statement, given the consistency with which a reduction in important metabolic and cardiovascular risks are achieved by lowering carbohydrate consumption. It is simply preposterous to suggest that an approach that leads to significant risk factor reduction is unhealthy.

The seriousness of the accelerating epidemic compels us to think outside the box to find new solutions where the status quo has failed. The only approach that will be successful is one that people can actually follow. This study adds to the mounting evidence that the Atkins diet is a healthy choice which should be supported as a viable way to lose weight and improve metabolic and cardiovascular risk factors.

The Real Atkins Lifestyle

Before there was research on the Atkins diet it was commonly criticized in the belief that it would elevate cholesterol, ruin one’s kidneys and bones and cause heart disease. None of this has been borne out by the research.

What is clear from this JAMA study, and others like it, is that cardiovascular risk factors actually improve when controlling carbs. The scientific studies of this approach have shown numerous times that a pattern of rising HDL-C and falling triglycerides is the hallmark of carb restriction and that this benefit occurs even in the absence of weight loss.

Research also shows that rising HDL-C (good cholesterol) and falling triglycerides is correlated with larger LDL-C particles which are less likely to cause heart disease. Even the much touted statin drugs do not deliver this kind of improvement in LDL-C particle size. On the other hand, the research shows that eating a high-carb diet and cutting fat intake results in small dense LDL-C particles that are linked to an increased risk of heart disease.

Importance of Fat

There are other problems associated with extremely low fat diets, as well. Cutting fat intake can lead to deficiencies in fat soluble vitamins, depletion of essential fats such as EPA and DHA, and decreases in the absorption of nutrients. Studies also show that people with cholesterol levels that are too low become prone to depression, suicide and cancer and have higher overall death rates than those who have higher cholesterol levels.

When all is said and done, it behooves us to remember that the diet debate is not a horse race where there is only one winner. We know there is a great variability in metabolic and genetic factors that will determine what dietary approach is best for each individual person. Although, in this and many other studies the Atkins diet worked better for more people, it is also evident that other dietary approaches will work for some people as well. The most important thing we have learned from dietary research is that people need to find the approach that will deliver healthy outcomes for them individually. And, just as the proof of the pudding is in the eating, the proof of a diet's effectiveness is whether it can sustain those benefits over the long haul. Hopefully, the weight of the evidence will now allow the Atkins diet to be recognized and supported as a legitimate option for people who want to improve their health through better nutrition.

On a final note, Dr. Ornish’s repugnant attempt to undermine Dr. Atkins’ credibility by perpetuating the myth that he had heart disease is unconscionable. It is unbecoming of any honorable person to make ad hominem attacks on those who are departed. Enough is enough. Dr. Atkins died of a head injury. He is no longer with us, but the line of scientific inquiry that he started continues to vindicate his dietary approach. And no amount of unfounded criticism will alter the fact that this study, and the 60 others before it, clearly demonstrate that what Dr. Atkins had been telling us all along was right.

• Jacqueline A. Eberstein, R.N. Co-author, Atkins Diabetes Revolution, President, Controlled Carbohydrate Nutrition
• Stephen D. Phinney, M.D. Ph.D Emeritus Professor, Department of Medicine, UC Davis, Elk Grove, Cal
• Mary C. Vernon, M.D., CMD, Co-author, Atkins Diabetes Revolution, President, American Society of Bariatric Physicians
• Eric C. Westman, M.D. M.H.S, Associate Professor of Medicine, Duke University Medical Center
• Jay Wortman, M.D, Department of Health Care & Epidemiology, Faculty of Medicine, University of British Columbia

A LITTLE BIT DIABETIC AND THE COMPLICATED ISSUE OF A1C LEVELS

Cindy asks:

My understanding of A1c levels is that it gives an average of the blood glucose levels over a few months time.

I've read that an A1c or 6.0 means an average blood sugar of about 135, and A1c of 7.0 would be an average blood sugar of 170. (Are these accurate numbers?). Recently when I talked to my sister, who is diabetic, she said her A1c was 6.8. She also went through a bunch of her readings and most were in the 130-140 range, but several were also 160, 180 and even higher. This leads me to believe that she's also had lower levels, but just not when she checked it? (she only tests a few times a week, being told by her doc to "not get obsessesed about it")

Now, if I understand this correctly, that means that someone who has frequent or regular episodes of LOW blood sugar may have a lower A1c, even though along with the episodes of low blood sugar they also may be having much higher levels than the A1c would indicate?

So....if someone who is "mildly diabetic" (kinda like being a little bit pregnant?) or even pre-diabetic by A1c readings, but also having frequent episodes of hypoglycemia, may in fact be more out of control than the A1c would indicate?

I'm thinking about someone I know who has been told she is "mildly diabetic" and "controls" her blood sugar with diet only. Unfortunately, she eats a much higher carb intake than even the ADA recommends, and frequenstly eats white sugar, flour, etc. The only time she checks her blood sugar is when she has "symptoms", which are usually hypoglycemic episodes. Her blood sugars have been as low as the low 70s, but she's not concerned, and neither is her doc, because her A1c is only 5.8, which is considered "withint normal limits".  Fasting blood sugars are almost always (when checked by doc) in the 120-125 range.

Do I have reason to be concerned about my friend? Or do I have this all wrong?

Dr. Vernon responds:

You are correct in thinking that the HgbA1C is a more complicated measurement than you have been led to believe.

What this test measures is the percent of hemoglobin (the oxygen carrying protein in the red blood cells) that has glucose (irreversibly) stuck to it.  When the blood glucose is in what is (currently) considered the normal range, a small percentage of hemoglobin has glucose stuck to it, and that's the normal range of HgbA1C.  The higher the blood sugar, the more hemoglobin has glucose stuck to it.  Here is what complicates the picture:  red blood cells are broken down at about 120 days.  That's the usual lifespan for a red blood cell.  So if you have an episode of high blood sugar yesterday, then that episode may have more impact on the HgbA1C level than an episode of elevated blood sugar 2 months ago, due to the life span of the red blood cells.

Because the glucose is irreversibly bound to the hemoglobin, then even if the blood sugar is too low, the HgbA1C doesn't decrease.  So to simplify-it can go up, but not down.

Now, should you worry about your friend?  Absolutely.  I worry about everyone whose pancreas can't keep their blood sugar in line.  I worry about the stage before that-with elevated insulin levels and controlled blood sugar.  I worry about everyone in the stage before that-metabolic syndrome, hyperinsulinemia and reactive hypoglycemia.  I worry about everyone whose glucose metabolism isn't normal.  Why?  because I know that the blood vessel damage is occurring through all of these stages.  Just because one can't feel the damage doesn't mean the there is no harm done.

All of this is covered extensively in the book I wrote with Jacqueline Eberstein, RN., called Atkins Diabetes Revolution.