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Chris Dikmen has some great advice on staying on plan during a cruise:

So when preparing for a low-carb cruise, there are really two things that you have to keep in mind:

1. Define a plan for limiting the carbs during your cruise.

2. Accept that cruising without carbs can be enjoyable. You don’t have to have the pies, cakes and breads to have a great time on a cruise. Look at it this way, it is better to be on a low-carb lifestyle and on a cruise than on a low-carb lifestyle and be at home!

He has specifics in the post, and you can tell he’s a pro at this; he has had more than 15 cruises since starting a low carb lifestyle back in 2002.

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I’ve avoided the show The Biggest Loser on purpose, but Dr. Doug McGruff happened upon it in the break room between patients in the emergency ward:

I have never watched this show, as I assumed it would be ridiculous. I was shocked how much I had underestimated. I could not believe the amount and types of exercise these poor people were being put through. They even showed one contestant collapsing on a treadmill and being spit off the back of the machine by the spinning tread. Then there were multiple scenes of the contestants being screamed at by that Gillian lady in the tank-top/midriff shirt (talk about narcissistic) and some sadistic guy with tattoos all over his arms. The instructors’ contempt for the obese was obvious as they spewed insults (and saliva) in the faces of the contestants. I don’t care how fat or desperate I was, if someone did this to me I would punch them in the face and storm off the set. I checked in on the show between patients. The diet and exercise shown were prescriptive for ravenous hunger and ultimate failure. As I continued to work, I kept thinking about the importance of biologic signaling, and why it does not have to be this hard.

Dr. McGruff graduated from the University of Texas Medical School at San Antonio in 1989 and studied Emergency Medicine at the University of Arkansas in Little Rock, where he served as Chief Resident. He is one of the “smart guys” I like; not a researcher in some academic office running computer queries to do some fancy meta analysis, but a practicing physician who sees real people with real problems every week.

Every person who has struggled with a “diet and exercise” program to lose weight knows the problem Dr. McGruff identifies:

Overtraining (especially in the obese) triggers cortisol and other stress hormones. A low fat, high carbohydrate diet signals insulin release. These signals defend a high level of stored fat and drive huger…a true prescription for misery and failure.

Theories abound in what passes for dietary science. The ones based on science rather than just observation appeal to me the most. Dr. McGruff explains why a short high intensity workout is better than the Biggest Loser’s cardio-based workouts:

The key to turning around these sorts of metabolic disasters is to send the correct biologic and hormonal signals. If the correct signals are given, there is a disproportionate improvement in the metabolic state and body composition. This disproportionate response is courtesy of a second messenger system. Most hormones do not act directly on their target organ or tissue.

The cell wall protects the cell; most hormones cannot pass through the cell wall easily. Instead, the hormone’s fat soluble receptors bind the hormone on the outside of the cell wall and transmit the signal to a messenger inside the cell itself. I always think of the way an amplifier can take the puny signal from an iPod, process it, and play it through big, power hungry speakers. And in this case, amplification does indeed happen. The second messenger, on the inside of the cell, amplifies the signal:

The unique thing is that the second messenger then activates a chemical cascade that multiplies the signal at the target. This way a single molecule of primary messenger can produce thousands of second messenger signals at the target.

In other words, your cellular stereo amplifier is set on “10″ (or “11″ if you are a This is Spinal Tap fan).

This is why a proper signal is so important…the beneficial effect is hugely magnified. A brief, but intense workout that fatigues the musculature activates growth hormone, testosterone and adrenaline which all signal to empty glycogen and fat, both short and long-term. A hunter-gatherer diet creates a low insulin signal which triggers the body to defend a lower body fat set point.

The fact is, you don’t need a skinny person who has never fought a weight battle yelling at you to lose weight or become healthier. And chances are, even after that ordeal, your weight problems will return:

On camera, Zwierstra seemed giddy and brash, interrupting host Caroline Rhea, hollering at her friends in the audience, tipsy on her 3-inch heels. Secretly, she was woozy, having dehydrated herself by avoiding liquids, baking in a sauna and fasting for days to skim off those last few pounds.

The studio audience went wild as the cameras panned in. Zwierstra stepped on the scale. Rhea hollered, “Your current weight is …”

The scale heightened the tension: Beep. Beep. Beep.

144 pounds!

She’d lost 45 percent of her body weight.

But it wasn’t enough.

In the end Erik Chopin, a New York deli owner, took home the big check, losing more than 200 pounds from a starting weight that topped 400.

In January he appeared on Oprah to describe how he’d gained half of it back.

The top two contestants of The Biggest Loser’s third season have not solved their problems. The impossible standard set by the program’s extreme exercise program won’t work for them, or for many people. At its heart, The Biggest Loser uses the “calories in / calories out” principle, comparing the human body to a gas engine rather than to a metabolic organism. It is rooted in the 19th century science that measures food content in how much heat it gives off when burned in a furnace, rather than using modern science to understand how the human body actually works.

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Dana Carpendar at Hold the Toast blog recaps the results of an interesting study in the Archives of Internal Medicine:

47% of the low carb group had their blood pressure medication discontinued in the course of the study, as compared to 21% of the low fat group. Dr. William Yancy, who ran the study, said the difference in the two groups might have been even greater had subjects remained on their blood pressure medication, but they instead took people off medications as their readings normalized.

The study started the low carb group at the true low carb level promulgated by the Atkins diet, 20 grams per day. Far too often, studies comparing low carb diets to low fat diets use 100 or more grams per day of carbohydrate. The study lasted nearly a year, long enough for true differences in the diets to be seen. For the low fat diet group, the study added a common diet drug, orlistat, a drug that sequesters fat so it can be eliminated before being absorbed by the body.

Weight loss for the two groups is statistically insignificant, even though some low carbers have pointed to the results proudly. The small sample size and small difference in the number of pounds lost between the two groups just doesn’t lend itself to proclaiming any victory for the low carb diet. But the study does show the low carb diet is the equal of a low fat diet in nearly every respect. The study’s Abstract points this out.

No matter what you read, the main benefit of a low carb diet in this study was that it matched the low fat diet in nearly all areas, and was superior in controlling high blood pressure:

Conclusion: In a sample of medical outpatients, an LCKD [low carb ketogenic diet] led to similar improvements as O + LFD [orlistat plus low fat diet] for weight, serum lipid, and glycemic parameters and was more effective for lowering blood pressure.

It would be interesting to see how the participants felt about their low carb or low fat diet. My experience has been that the low carb diet is much easier to maintain, as I rarely struggle with hunger even while losing weight.

And, I love bacon.

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Dr. James Carlson is a board certified family physician with multiple degrees … biochemistry and molecular cellular biology from Cornell University, an MBA from Regis University, and a Juris Doctorate from Concord University. And that’s in addition to his medical education at the NY College of Osteopathic Medicine. Dr. Carlson is one of those smart guys I like, one that, like Dr. Eades, has actually had a medical practice with real patients and real mysteries to solve.

His blog post today covers a subject that many low carb dieters wonder about: for some reason, they stop losing weight, even though they have not increased their carb intake. In forums, these people are often told they are “cheating”, perhaps without knowing it. But I’m always struck with how much this kind of “advice” resembles the justifications for the failed low-fat diet: if you can’t stay on the diet, its your fault.

Dr. Carlson does a good job of describing a situation where protein can be made into glucose:

Ok, so back to protein. Yes, one can definitely over consume protein, allowing the glucogenic amino acids to be converted to glucose, this can cause a sugar rise, subsequent release of insulin and that is what is causing your weight loss stall or possibly weight gain.

There’s a lot more there about a topic most low carbers have heard, gluconeogenesis, and one they probably haven’t, glyceroneogenesis. Follow the link to read it all.

So why would a careful low carber, who has been losing steadily and eating all the right things, suddenly stop losing? Nothing has changed, right? Wrong.

No, the dieter isn’t necessarily cheating. The dieter has lost 20 or 30 pounds. I have lost 30 pounds, about 13% of my pre-diet body weight. And when I started the diet, I calculated my protein requirement based in large part upon … my weight. That’s what has changed.

So, for the low carb dieter who has lost weight, its back to the tables and charts to re-calculate what their protein requirement is; for most people, it will be less than before. While weight lifters may have more lean body mass, most of us will have less calculated lean body mass. I don’t think we are actually losing muscle. And while I’m not absolutely certain on this point, I think the charts and measurements we use have a built-in variation that gets more and more accurate as we reduce our body fat percentage.

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I noticed when I adopted the The Protein Power Lifeplan
way of eating that I was finally able to eat regularly spaced meals without getting hungry between them. Prior to that, I can’t remember a time in my life when I wasn’t fighting the urge to snack between meals.

In dietary circles, the ability of food to satisfy your hunger is referred to as the satiety factor. Some researchers claim satiety is tied to the feeling of fullness you get from bulkier foods, but my experience is that high fiber foods do not necessarily satisfy my hunger. They make me feel full, but still hungry. There’s always room for another slice of that fiber-rich pumpkin pie.

Low carb advocates often cite the satiety factor of their diet, as I have done in the first paragraph. Some point to the higher percentage of fat in the diet than the typical low-fat diet emphasized by most doctors, making the claim that you cannot gain weight if you eat a low carb diet with plenty of fat. But some people do gain weight that way, so something else may be at work.

When I started Protein Power, I calculated my daily minimum protein requirement, as the book recommends. I was surprised at how much food I could eat. With 25 – 30 grams of protein per meal as a minimum, that meant a hearty bacon and eggs breakfast of 3 eggs (18 grams) and 3 slices of bacon (9 grams). My usual breakfast routine was a toasted bagel, then a snack before lunch because by 10 AM I was very hungry. But after eating the eggs and bacon mentioned above … I was full, and remained so until lunch time.

As the title of the book suggests, Protein Power is about getting the right amount of protein as well as reducing carbohydrates. It works for me. And it may be the protein that satisfies, rather than just the increased fat.

Nutritional ecologist Professor David Raubenheimer of New Zealand’s Massay University, recently conducted a study on primate eating habits in collaboration with other experts. Studying the Bolivian rainforest spider monkey, Professor Raubenheimer found the monkey’s food intake increased when low protein food sources were the only ones available.

The findings, published in the latest issue of the journal Behavioural Ecology, reinforce the theory that humans and other primates are physiologically predisposed to maintain a constant level of protein in their diets. But when the range of foods available to them is low in protein (yet high in fats and carbohydrates) they are compelled to eat greater quantities in order to maintain correct protein levels.

I think this explains the satiety issue better, and gives an indication of why some people experience weight gain even on a low carb diet. If they aren’t meeting their body’s protein requirements, they will be hungry. And hungry people eat more.

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Stunning statistics from a study published in the December issue of Diabetes Care, as reported by Health Day News:

The number of people with diabetes in the United States is expected to double over the next 25 years, a new study predicts.

That would bring the total by 2034 to about 44.1 million people with the disease, up from 23.7 million today.

At the same time, the cost of treating people with diabetes will triple, the study also warns, rising from an estimated $113 billion in 2009 to $336 billion in 2034.

The increase is from adult onset, or type II diabetes. Health Day attributes the increase to obesity:

Factors driving the increase in diabetes cases include the aging population and continued high rates of obesity, both of which are risk factors for type 2 diabetes, in which the body does not produce enough insulin or the cells don’t use it correctly. In the study, the researchers assumed that the obesity rate would remain relatively stable, topping out at about 30 percent in the next decade and then declining slightly to about 27 percent in 2033.

The problem is that the official stance towards this problem has little hope of solving the underlying issue: our addiction to carbohydrates. While the general consensus is that people would not be diabetic if they lost weight, telling people to lose weight has proven to be a dismal failure. The reason is that very few people will starve themselves voluntarily.

The standard American diet is one rich in refined, processed foods (i.e., carbs). The “optimum” diet recommended by nutritionists is one that is low in dietary fat and eschews refined, processed foods in favor of “complex carbohydrates, such as whole grains, cereal, rice, pasta, potatoes, dry beans, carrots and corn”, with calorie reduction necessary to lose weight. It doesn’t work because you are always hungry on that diet.

Hungry people eat. And if they eat “complex carbs” that are “low in fat” they never feel sated, and will never stop eating.

Try this experiment … go to the sugar bowl and spoon out a scoop of sugar onto the counter. Then another. And another. Keep going, and when you have 22 spoonfuls of sugar on the counter, you have the average American’s intake of sugar. But what if you cut out all the added sugar found in soft drinks, cookies, candy and other snacks (even low fat ones)?

If you follow the various guidelines by the USDA, American Heart Association, et. al., you’ll limit fat to 20% of your dietary intake, and get adequate protein, making up the rest of your diet with those complex carbohydrates. Let’s take an example of a 2,000 calorie diet, and see how that works out in grams of each micro nutrient:

• Fat, 44g at 9 calories each = 20% of calories
• Protein, 100g at 4 calories each = 20% of calories
• Carbohydrates, 300g at 4 calories each = 60% of calories

Carbohydrates turn to sugar (glucose) in your gut in a very short time, within 2 to 4 hours. Even “complex carbs” turn to sugar.

Spoon out another 75 teaspoons of sugar onto your counter. That is the amount you are asking your body to metabolize when you eat 300g of carbohydrates per day.

Here’s a layman’s explanation of what is happening: The body needs sugar to run, but if it can’t use it in a very short time, it is stored as fat. Blood sugar spikes in 2 to 4 hours after eating carbs, and the body reacts by releasing insulin to drive the sugar into the cells so they can use it for energy. If the cells have enough, they refuse insulin’s prompting, and the sugar is stored as fat. As you abuse this system by overloading it with sugar, the cells become more and more resistant to insulin, and the body sends out more and more. When the sugar is pushed into fat cells, your blood sugar level drops, and hunger returns even though you ate only a few hours ago. So you eat again, and start the process all over again (if you eat a diet “rich in complex carbohydrates”). Sound familiar?

The emphasis on low fat, high carbohydrate diets has caused our expanding waistlines, and emphasizing that people should continue to eat this way but reduce calorie intake is counter intuitive. Survival depends on getting enough to eat, and your body will betray you if it thinks it is starving.

A better approach is to limit carbohydrates to about 1/3 of all calories if you are at your goal weight and otherwise healthy. For a 2,000 calorie diet, that’s about 167 grams of carbs. The rest of your calories can come from fat and protein. It is best to calculate your minimum protein requirement, usually calculated at about a half gram per pound of lean body weight. “Lean body weight” is your weight minus your fat (take your body fat percentage times your weight, and deduct that from your total weight to get your “lean body weight”). The book The Protein Power Lifeplan has this approach as a “maintenance diet”, and people can tolerate it for life … because you don’t get hungry.

And if you need to get to your goal weight, the first phase of the diet can help you do that without getting hungry. You can short-circuit the vicious cycle of carb intake, insulin response, fat storage and premature hunger by eating a diet that is tuned to your needs.

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Tom Naughton deconstructs the “obesity epidemic” at his blog Fat Head:

But what I found most interesting was the data on who’s “overweight” and by how much. Here are the numbers:

• More than 50 pounds overweight: 6%
• 21-50 pounds overweight: 17%
• 11-20 pounds overweight: 15%
• 1-10 pounds overweight: 24%
• At ideal weight: 18%
• 1-10 pounds underweight: 7%
• 11-20 pounds underweight: 3%
• More than 20 pounds underweight: 1%
• Undesignated: 9%

As we noted in our post Does Being Overweight Harm Your Health, all-cause mortality studies show that you have a 17% less chance of dying if you are in the “overweight” BMI (as compared to being “normal weight”). Even being “obese” was statistically even with being “normal weight” in these studies. The absolute worse thing you can do is be “underweight”, with a stunning 73% greater risk of dying than a “normal” weight person.

We have also noted our belief that individuals have to assess their own health needs and identify their individual risk factors, rather than focusing on a “society wide goal”. If your risk factors lean more towards developing diabetes II, then controlling blood sugar levels may be more important than being within 10 pounds of some goal weight. And as McNaughton notes, adult onset diabetes is at epidemic levels:

A different Gallup poll underscores another point I made in the film: there is a genuine epidemic out there, and it’s called diabetes. More than 11% percent of Americans adults have diabetes now, and more than 90% of those have type 2 diabetes, which is mostly preventable. The rate has more than doubled in the last decade alone. Among senior citizens, the numbers are even more harrowing: nearly one-quarter have diabetes. Just think of all the physical damage that’s causing. And even those numbers don’t count the pre-diabetics.

Nutritionists tend to focus on the weight end of the scale (so to speak), but they are missing the point. You can’t push a string. People are overweight because of their blood sugar levels (i.e., hyperinsulinemia, insulin resistance and related disorders leading to diabetes). They are not suffering from high blood sugar levels because of their weight. As Naughton sums it up:

The constant drumbeat about the obesity epidemic and the emphasis on losing weight is sending the wrong message. We need to tell people to get their blood sugar checked and keep it under control with the proper diet. If we do that, the 10 pounds will take care of itself. And if it doesn’t, well … so what? A bit of belly won’t kill you if it’s not the result of high blood sugar.

If your blood sugar is elevated, the way to get it under control is by adopting a low carb eating lifestyle. You will lose weight, but the most important thing is that you will live longer. And living longer is the goal.

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Statins are a class of drugs that lower cholesterol levels, and, the reasoning goes, should reduce the risk of heart attack. But the reality has been less illuminating than the promise. This morning word of another study showing that the popular statins containing ezetemibe, Vytorin and Zetia, do not lower the risk of heart disease. As the LA Times reports:

For the second time in as many years, a large clinical trial has found that the key ingredient in the heavily advertised drug Vytorin provides little or no benefit in preventing heart disease compared to a competing product. The ingredient is ezetemibe, which blocks the absorption of cholesterol in the intestines. It is sold alone under the brand name Zetia or in combination with the cholesterol-lowering drug simvastatin under the brand name Vytorin. The combination of drugs has been shown to reduce cholesterol more than simvastatin alone, but that apparently does not translate into a lower risk of heart disease.

Statins are often credited with a number of unpleasant side effects, including uncomfortable muscle aches. And evidence is mounting that while they may lower LDL cholesterol numbers, they aren’t providing the reduction in heart attacks that “should” result.

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With the usual caveat that I am not a medical professional, I want to propose an idea for your consideration. I would encourage you to discuss this idea with your doctor before embarking on any diet plan.

I think it makes sense to first identify your individual risk factors for the things that kill us. The Centers for Disease Control (CDC) publishes charts showing the leading causes of death for men and for women. Looking at the charts you see that heart disease is the leading cause of death at about 27% of all deaths. We tend to focus on those stats and work to minimize our chances of dying from heart disease. That’s certainly the approach taken on a society-wide level with the low-fat diet recommendations (the low fat diet is thought to reduce serum cholesterol levels leading to less heart disease, although many of us find that it increases cholesterol instead.) What I think we are ignoring is that our individual risk factors may be for something entirely different. Remember, that heart disease is not the cause of death for a majority of the people … 73% of them, in fact. Are we increasing our risk of dying early by trying to reduce our risk for heart disease?

The American Heart Association (AHA) identifies the risk factors for heart disease in two categories, those you can change and those you cannot. The categories are a mistake, in my view. It is the risk factors you cannot change that may be the most susceptible to changes in diet: age, sex and heredity. 83% of the deaths due to heart disease happen after age 65, so time is on your side if you are younger than that. Males are more susceptible to heart disease, and have a higher incidence of dying younger than that age 65 statistic. And family history, including race, plays a factor.

The factors you “can change”, according to the AHA, are things like tobacco use, obesity, high blood pressure, serum cholesterol levels, activity levels, and diabetes.

The standard treatment to reduce risk factors for heart disease is a low fat, relatively high carbohydrate diet and prescription drugs to lower cholesterol. The prescription drugs are necessary because many people find a low fat, high carbohydrate diet raises cholesterol (especially triglycerides). Low carb diet advocates challenge this view, and note that many people find a low carb diet improves their lipid profile without the use of prescription drugs (as well as improving weight, high blood pressure and other factors).

The problem is that there is no easy way to score these factors. Do you check off each factor, and if you have more than three, start to worry? Or is family history such an important factor that it, by itself, compels you to work to reduce your risk? Certainly, if your parents and all your siblings died of heart attacks, you probably realize it “runs in your family.” But for most of us, even getting the full list of risk factors isn’t enough to tell us if we, personally, are at risk.

The place to start is a doctor who knows your medical history. Ask him point blank: what do you think I’m going to die from? The answer will be about risk factors for the diseases on those CDC charts, and which one your history indicates the greatest risk for you. Heart disease and cancer are at the top, by a large margin. But as you read down the list, you see stroke, respiratory disease, and diabetes.

Its interesting that diabetes is a risk factor for heart disease, and diabetes itself is the 6th leading cause of death.

My largest risk factor, given my family history and age, sex and physical condition is diabetes. Several people in my family, a brother and my mother, have adult-onset diabetes. I’m male, over 50, and have more than two of the markers for “metabolic syndrome” (pdf file from CDC on metabolic syndrome). In contrast to that, I have very little heart disease in my immediate family.

My doctor recommended a low carb diet to reduce my high triglyceride level; success is shown by lowering triglycerides from 462 to 113 on my last blood test. I’m staying on it to lower my weight and blood glucose level, as well as meet the other cholesterol goals (HDL, LDL, etc., as shown on the About Page).

The term “diet” is often associated with a reduced calorie, temporary eating regimen that you abandon after reaching a weight goal. The problem with this approach is that it ignores the very real impact your diet has on your health. The real goal should be to live longer, not simply to lose weight and “look good”. A pretty corpse is still dead.

Your diet should reflect the best bet to protect against your individual risk factors, and not to fulfill a broad societal goal.

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Ever wonder just how they determined what a dietary calorie is, and how they know how much energy you get from it? Like many things in dietary science, the answer is surprising.

They burn it and measure the calories (a unit of heat energy) the food gives off. Sort of. A scientist in the 1800’s figured this out, and we’ve been using his system ever since.

Except it doesn’t work. Your body does not “burn” food, it digests it. So there are problems with the method. But as New Scientist notes, there is resistance to changing the flawed system:

“There will be errors, but not very serious errors, and nobody can do their calories anyway so what difference does it make?” says Marion Nestle, a nutritionist at New York University.

Gotta’ love those nutritionists.

The article gives a real-world example that is worth noting. Two foods may have similar calorie counts but end up being utilized (DIGESTED!) by the body in different ways. A brownie, filled with refined starches and sugars, may have a calorie rating of 250 and a “healthy” snack bar with “complex carbs” a rating of 300, yet the body will extract more calories from the brownie. The dieter counting calories is fooled by the system. But, it doesn’t really matter to nutritionists; no one does it right anyway, right?

After the not-so-compelling browning/muslei bar example, the article actually talks about real food. What you quickly see is that trying to count calories becomes incredibly complex, and as our expanding waistlines have told us, does nothing to help reduce obesity.

For my money, counting what you can’t count accurately doesn’t make a lot of sense. Paying attention to what you eat, and not just how much, seems more consistent with human health.

Unless you think you really are a bonfire. Then burn, baby, burn.