Saturday, July 27, 2013

The Ignorance Continues! A Very Important Question...or, Shame On You Grandma!

I was reviewing my comment sections and came across this recent question regarding the Paleo lifestyle. I'll post the question first then my reaction....ummm, I mean response. I must admit when I read this question my immediate visceral response was a vehement "Are you kidding me!!??"  directed at the profoundly ignorant biological grandmother, who represents, unfortunately, the abysmally and continually ignorant majority. Any ways, here's the question;

Dr. Carlson,

My question was about feeding a 3 year old child a low carb paleo diet. My girlfriend and I follow a low carb paleo diet, not for weight loss purposes but rather for overall health and wellness. Our diet consists mainly of meat (chicken, beef, pork, turkey, fish), non-starchy vegetables (broccoli, cauliflower, carrots, cabbage and so forth), eggs, nuts (raw mixed nuts), cheese (usually aged cheddar), low sugar fruits (mostly berries), and the occasional dessert (dark chocolate, ice cream). Naturally, my girlfriend's child eats the same food that we do.

Based on the research I have done this type of diet is ideal not only for adults but children as well. However, the child's biological grandmother is alleging that the diet we feed the child is a form of child abuse because it restricts, among other things, whole grains. She has stated an intention to make it an issue in family court and has already contacted CPS. Accordingly, I am feeling a pressing need to contact a low carb pediatric expert and get advice on the diet that we follow.

I understand that without seeing the child in person you couldn't make any pronouncement about the child's health but I was hoping to get a statement on the safety of the diet for a child in general. Again, it isn't for weight loss purposes, but only overall health. It is our desire to instill healthy eating habits into the child while he is young and to ensure that he develops into a healthy adult who will avoid things like diabetes, obesity and other problems associated with the standard American diet in the long run.

Thank you very much for your time sir.
Hello There,
Sorry it took me so long to respond but when I finally got to your question it invoked a ton of deep emotions in me, I had to make a Blog post of my answer. Let me cut to the chase; DO NOT EVER STOP FEEDING YOUR CHILD THE WAY YOU ARE FEEDING THEM!!!!
I hope the bolded locked caps emphasized my point. Hey, when you're right, you're right and you are right! You're research led you down the correct path to understanding the proper way to eat and I congratulate you. Both you and your girlfriend are feeding your children exactly the way they should be eating. OK, I'm not much of a carrot fan because of the high sugar content, but I really cannot complain much because all the other food is right on track.
So the biological grandmother is going to make an issue of how you're feeding your child in family court, and has already contacted CPS because you're not feeding the kid whole grains?
Really? Really?? Really!!!???
Holy WOW!
It's obviously apparent this grandma has no idea that sugar is sugar is sugar. That cholesterol and fat production starts with sugar; both glucose and fructose. She has no idea of the glycolytic pathway and how acetyl coenzyme A, derived from sugar, will ultimately be transformed into both cholesterol & fat. But then again, why would she? Most physicians, dieticians and nutritionists also have no clue as to the correct way to eat, so why would grandma?
To make the suggestion or even the slightest innuendo that whole grains are good for us is just plain wrong! The fact is that the consumption of whole grains, multi grains, seven grains, whole wheat pasta, brown rice, yogurt, oat meal and fruit ARE THE REASONS HEART DISEASE IS THE NUMBER ONE KILLER; WHY WE AMERICANS ARE GETTING FATTER AND FATTER AND WHY THE PREVALENCE OF TYPE 2 DIABETES IS SKY ROCKETING!!!!
So for those of you who think these aforementioned foods are OK, go ahead and eat them and make the drug companies richer. Because the end result is just that; you're going to need a ton of medications to treat the diseases you'll bestow upon yourself by eating those poisons. So congratulations! And don't you dare suggest to those of us who understand the correct way to eat to eat whole grains because YOU are wrong, not us!
No, I am not a low carb pediatric expert, but I am a Board Certified Family Physician in practice for over 20 years, with prior undergraduate training in biochemistry and molecular cellular biology. I have been placing patients of all ages on a low carb Paleo way of eating for over 16 years. I have lost track of the success stories over this time frame but what I do know is the following;
If you want heart disease follow how the American Heart Association tells you to eat. If you want diabetes or to have your diabetes poorly controlled, follow how the American Diabetes or American Dietetic Association(s) tell you to eat; and finally, if you want to increase your risk for cancer follow how the American Cancer Society tells you to eat. And no, the National Institutes of Health, the National Heart Lung & Blood Institute, the ridiculous 'My Plate' campaign, the Surgeon General and Dr. Oz will not escape my wrath because all of you are incorrect as well.
The foolishness has got to stop!
From the misinterpreted rabbit study to the manipulated seven country study up to and including the ignorant McGovern report, our country has been brainwashed into thinking whole grains and fruit are good for us and that we need to avoid that nefarious, pernicious grass feed cow. And don't even think about eating those cage, antibiotic and hormone free eggs, because you will die a horrific, tragic and almost immediate death!
The answer is that we all need to be eating and feeding our children exactly the way this individual is eating and feeding his child! And even though my blog posts are not intended to diagnose, treat, cure or prevent any illness, I will be happy to testify on your behalf in Family Court and even in front of the CPS if you wish. It would be my honor! You just have to provide the steak and eggs :-)
My final words, SHAME ON YOU GRANDMA!  I should contact child and adult protective services on you for making the suggestion anyone should eat whole grains.
And so my rant for today has finally come to an end. Enjoy your weekend everyone!
dr jim :-)

Tuesday, May 28, 2013


Took me awhile but I finally created the Kindle version! Yay!

dr jim :-)

Monday, May 6, 2013


Here was a great question sent to me in regards to ketosis;
I’ve had a great deal of difficulty finding a straight answer regarding ketosis. Not ketone production; but specifically what the levels really mean – what to look out for – and do you really need to be in ketosis? Let alone, all the time?

More important to me though, is not being able to find studies / info that talk to Low Carb and young children. LC is so 'taboo' in American society; people seem to be fearful to say its ok for kids too. It should be though, am I right? (All those years of brain washing by industry have left me doubtful - could I be hurting my children by having them avoid excessive carbs? - Stevia is great - but is Splenda ok for them?) The other day I walked into my son's Beaver Scout meeting to see the "dreaded" Canadian Food Guide on the wall (don't even get me started). Turns out teachers don’t appreciate it when a 6 year old advises the information is incorrect. *laughing to myself*. I want to be sure that my kids have the right information on how-to-eat so that they will always be able to make informed decisions. I want to know if ketosis is a state that is ok for children. Can levels ever be too high? Does it need to be monitored? I very sincerely appreciate any insight.

Your loyal reader/follower ~

Physicians who are first learning about low carbs will often confuse benign dietary ketosis with the life threatening diabetic ketoacidosis. Benign dietary ketosis is just that, benign, and it has nothing to do with diabetic ketoacidosis. In fact, the only similarity between the two is that both have the 4 letters 'keto' shared among the terms, but that's where the similarity ends. Oh, and a 'sis' and a 'di' and a couple t's etc....
Benign dietary ketosis occurs when one is using free fatty acids for the creation of the universal energy source ATP. Not that I want to get too biochemical on anyone, but notice I am refraining from using the word 'burn', i.e. as in 'burning' fat for fuel. There is absolutely no burning of anything going on here. What is occurring is that the free fatty acid is being broken down by enzymes which cleave off 2 carbon fragments at a time from the fatty acid. These two carbon fragments are referred to as acetylCoA, which then enter a pathway referred to as the Kreb's cycle, where ATP is produced. Of course there is creation of other biomolecules e.g. FADH, NADH, but I want to limit our discussion to where the term ketosis applies. The term used in biochemistry to describe the whittling away of fatty acids to create ATP is referred to as beta oxidation.
It is when our bodies use the beta oxidation pathway to create ATP that ketones are created. Ketosis simply means we are creating ketones because we are using free fatty acids for the creation of energy. Here are a few interesting points; in order for the 2 carbon fragments to enter the Kreb's cycle, some carbs need to be consumed. This is because the acetylCoA molecules neeed to combine with another molecule called oxaloacetate in order to get into the Kreb's cycle. Since our bodies can only make oxaloacetate from sugar (glucose and/or fructose), some carbs need to be consumed in order to keep the cycle going. This is why I often will repeat to my patients to not do no carbs and try to get at least 20 to 30 grams of carbohydrates a day. Another interesting point is that our bodies can use ketones for fuel e.g. heart, kidney (renal cortex), respiratory muscles and brain. (Berg, Biochemistry,7th. edition, pp 654-655.)
Now I know the question wasn't really asking me about how ketones are produced,  I just wanted to provide a brief run down on how and why ketones appear in our blood; and I also want to point out that I am not talking about diabetic ketoacidosis, I will discuss that condition further below; here I am focusing on benign dietary ketosis only.
So what do the levels mean?
The level of ketosis can be measured by performing blood work or by checking the urine. There are strips on the market which check for ketones in the urine and a lot of people who start low carbs purchase these strips. The problem with these strips is that some people, even if they are in the beta-oxidative pathway and losing weight, may test negative. This is because some people's physiologies are better at utilizing ketones than others, resulting in a negative result on the ketostix and causing confusion. I generally tell my patients to not get these strips because if they are losing weight they have to be utilizing fat for the creation of ATP, so it's a waste of time and money to get them.
So basically I don't even have my patients check their ketone levels at all, so I'm not concerned about how high (or low) the levels are. Those of us eating more fat and less carbs will tip the biochemical scales in favor of ketone creation and again, I'm not concerned about the level in benign dietary ketosis. We can generally remain in ketosis for our whole lives and I remember reading somewhere  Eskimos (Inuit?) eating their native diet stay in ketosis their entire lives. As far as if we really need to be in ketosis my answer is that you will be, so long you are eating more fat and less carbs, it's a biochemical certainty. Remember that when we are eating lower carbs and more fat we are also secreting less insulin and influencing enzymes (HMG-CoA, acetyl CoA carboxylase, Hormone sensitive lipase) to utilize fat for energy production, lower production of cholesterol and will keep the body in a beta oxidative mode, hence perpetuating the ketotic state.
You're correct, low carb is a taboo when it comes to children and even more of a taboo when it comes to  pregnant moms. Children should absolutely be eating low carbs and it is safe for them to be in ketosis. I have had the privilege to work with thousands of pregnant moms who I have, and I might add, very safely placed them on low carbs, and yes they were eating more fat and cholesterol and protein and they all did fantastic! Especially moms with a histroryof gestational diabetes, pregnancy induced hypertension, preeclampsia etc; do exceptionally well and most do not need to take any medicine at all once started on low carbs. An interesting side note is that the biggest chapter in my groundbreaking, whistle-blowing, soon-to-be-number-one-globally book Genocide:How Your Doctor's Dietary Ignorance Will Kill You! is my chapter on pregnancy; go figure....
But getting back to children, they absolutely should be in a ketotic state i.e. eating low carbs and more cholesterol, fat and protein. And no, don't even get me started on the ridiculous My Plate campaign (we had to convert to descriptive circles here in America, I guess the pyramid was too complicated), so I am soooo with you on the 'Canadian' food guide.
I personally have never tried Stevia, but I can comment on both splenda and equal as sweeteners. I can also comment on Stevia come to think of it, it's safe so no worries. Splenda's ingrediants are actually dextrose, maltodextrin and sucralose. I learned from Judy Barnes Baker ( an expert who has written low carb cookbooks, and yes, you too Dana Carpender, another low carb cookbook expert, I think she has like 13 now, showoff :-) over the summer that when splenda is used for baking purposes that there could be an appreciable increase in the carb amount. This is due to the dextrose, maltodextrin ingrediants, not the sucralose, so we need to be cautious when using splenda to bake with. As a side note, there exists a few products that are liquid sucralose only, which one can use for cooking and provides zero carbs in the finished product.

Since sucralose is chlorinated sucrose, there have been some concerns as to its safety. I have come across no studies showing any danger with the use of sucralose. Yes, I have come across anecdotal reports written by non-scientists voicing concerns over sucralose, but from a biochemical perspective I have seen no ill effects. I want to emphasize that the vast majority of my patients do low carbs, use splenda to cook with and their blood work as far as liver, kidneys, etc. have all been normal, so I personally have no issues with it.

Equal's first 2 ingredients are the same as splenda, but the sweetener in equal is the dreaded aspartame. Let me assure you that for most people aspartame is a safe sweetener. the only people who have to worry about aspartame (which is really just 2 amino acids linked together) are people who lack the enzyme necessary to break down aspartame; they are referred to as phenylketonurics or PKUs for short.

LOL! No, teachers do not appreciate being corrected by anyone, let alone a 6 year old. It reminds me when my daughter was in, I believe third grade and the following question was on her nutrition quiz; 'What is the healthiest snack?'

A. apple
B. candy bar
C. potato chips
D. cookie.

So what does my daughter do, she writes in E. none of the above; and yes, she failed that test.

So yes, ketosis is ok for children of any age;  and, no, don't bother checking or monitoring the levels.

Now the above conversation pertained to benign dietary ketosis. Diabetic ketoacidosis is a life threatening medical condition seen in Type 1 diabetics and is the reason most physicians counsel their patients, especially the ones on a low carb diet, to avoid ketosis on any level. These doctors are confusing the two different types of ketosis and because of this, these docs will often give contradictory advice. We discussed above a little bit about how we get into dietary ketosis, by utilizing fatty acids for the production of energy. Once we are in the beta-oxidative pathway we will create ketones, period. So here's the conundrum; when a doctor suggests to a patient they need to lose weight, but also tells them to not go into ketosis. This is a contradictory state of affairs because the only way to lose weight (excepting liposuction) is for the body to get into ketosis; that is, to lose fat stores, hence to lose weight, occurs by utilizing the fat for the creation of ATP and requires the body to be in ketosis; there is no other way! These docs might as well be telling their patients to jump in a pool naked, but don't get wet!

An interesting side note and a very important one for Type 1 diabetics, is when a Type 1 diabetic follows a low carb diet, their sugars become easily manageable and they don't see the highs and lows as the Type 1's eating too many carbs. A great book for any diabetic is Dr. Bernstein's Diabetes Solution by Richard K. Bernstein M.D. a must have if you or a loved one suffers from diabetes. My comment to my patients about Dr. Bernstein's book is that for Type 1's it's a solution, for type 2's, it's a cure.

Hope this helps!

dr jim :-)

Genocide: How Your Doctor's Dietary Ignorance Will Kill You!
Soon to be available on Kindle!

The answers to these questions are for informational purposes only and are not intended to prevent, diagnose, treat or cure any illness. They are, however, meant to hopefully eradicate the profound persistent nutritional ignorance of most medical professionals;
Dr. Jim

Friday, April 26, 2013


For you Zombie fearfuls creating your safe houses and  underground bungalows fear not the Zombie apocalypse for it violates the 3 Laws of Thermodynamics! Yes, I am an avid viewer of The Walking Dead and have myself conjured up many a ways to protect myself and my loved ones lest the inevitable occurs.

About 2:32 this AM I awoke with the startling realization of why a Zombie Apocalypse could never occur; THE LAWS OF THERMODYNAMICS, THE LAWS OF THERMODYNAMICS, THE LAWS OF THERMODYNAMICS!!!!! I screamed at the top of my lungs and instantaneously received a kick from my wife Bruce Lee would be proud of, startled my sleeping dogs into a barking frenzy and immediately fell back to sleep hoping this true Eureka! moment would still be with me upon my awakening.

Fortunately, it stayed with me and now I must relate to all why a Zombie apocalypse (do I really need to capitalize Zombie, dunno, but I'll continue  out of respect for the Zombies of course) can never occur due to strict violations of the laws of thermodynamics. What this also means is that if a Zombie apocalypse does ever occur we must find and eliminate the energy source behind it, before it's too late for us all. Due to the unerring laws of thermodynamics the only way a Zombie apocalypse could occur is if we humans (or is it 'us humans' whatever, I'm not being graded) or possible extraterrestrial beings, supply an outside energy source to fuel the Zombie resurrection. OK, so let's look at each of the laws of thermodynamics and analyze why they will save us from a Zombie demise;

The first law of thermodynamics states that 'the total energy of a system and its surroundings is constant.' (Biochemistry, 7th Edition, Berg et. al.) Or said another way, energy is neither created nor destroyed, it just changes forms. Ah ha you say! That's it! There can be a Zombie uprising because it's just the energy changing forms part that allows Zombies to resurrect.

Not so fast. We need to analyze this law a bit further. The first thing we need to calculate is the total amount of people who have died. This is difficult because we can only do this within recorded history. So, using what we know from recorded history 99,000,000,000, that's 99 billion people have died throughout the known recorded history of the world. That number is going to be higher, much higher. Right now an interesting thought just occurred to me "In a Zombie apocalypse, is it just humans in the Homo sapiens species which will become a Zombie? What about H. floresiensis, H. neanderthalensis, H. rhodesiensis, H. heidelbergensis, H. paleohungaricus, or H. erectus (my personal favorite) all the way back to H.  australopithecus?" (BTW, I left about 8 or so genuses out, but I think you get my point) Oh yeah, that part of the discussion only applies if you, ummmm, 'believe' in evolution.

Anyway, will other primates become Zombies as well; you know like gorillas, monkeys, chimps etc. What about other animals? Since we never see anything other than human Zombies I guess we can assume the term Zombie only applies to those of the Homo sapiens variety.

Getting back to why a Zombie apocalypse violates the first law of thermodynamics and using the more formal definition of the law, that is, 'the total energy of a system and its surroundings is constant', it would take a large amount of energy to awaken, in a Zombie sense, those 99 billion people. That's a tremendous energy input. Where's this energy coming from? Is it from other parts of our galaxy, our universe? Is it energy which traveled through a wormhole perhaps (right now I'd love to have a hot line to Stephen Hawkings)? And that's just to get the 99 billion known dead into a Zombie transition.

I know, I know, now you're thinking that Dr. Jim is a fool. Everyone knows it's a virus that is causing the Zombies to rise and that's where the extra energy is coming from. The problem with this line of reasoning is that viruses are neither alive or dead, they are either activated or inactivated. Viruses must rely on living cells to become activated. But we all know Zombies are already dead (really referred to as the living dead, but that's not an oxymoron I am about to tackle here, right now I'm battling the laws of thermodynamics), so the cells are dead, ergo these cells cannot activate viruses. So forget the virus theory contributing to the Zombie apocalypse.

So again I ask; where is all the energy coming from to allow the Zombies to become Zombies. Heck, we all know they can walk, appear to move all intact extremities and can easily eat brains (and apparently digest them, I guess) when presented to them. Getting back to the intact extremities; another first law thermodynamic problem is that when a Zombie limb is severed (and even a head), the extremity still moves or the head still moves etc. Is the energy allowing this motion related to the initial intact Zombie or is it fueled separately from the same source that originally fueled the Zombie in the first place. This brings up a whole new set of problems with our first law, but the question is the same; if energy is neither created nor destroyed, if the energy of a system and it's surroundings is constant, where is all this extra energy coming from to create, cause, allow etc the Zombie apocalypse? As a side note, do Zombies digest? They never show a Zombie urinating or using the bathroom for that matter, so like how is the stuff they eat, ummmm, digested? Is it digested? Does it just sit in the Zombie belly and cause bloating? But a Zombie's already dead so is it safe to assume that the esophagus, stomach, intestines and all digestive organs & enzymes are dead too, or are they still working? And why the craving for brains? Anyone who understands the correct way to eat will immediately have the answer to that, 'Zombies eat brains because brains are mainly fat and Zombies obviously instinctively know the correct way to eat.' Bottom line; Zombies are following a low carb diet and they know more about the correct way to eat than most physicians, nutritionists and dietitians! (Sorry, I just couldn't resist)

So the take home message as to why a Zombie apocalypse violates the first law of thermodynamics is; Because there is a constant amount of energy in our universe and that energy is neither created nor destroyed and since one cannot create energy out of a vacuum (forget the whole Big Bang thing for now, it just muddies my hypothesis); to have a Zombie apocalypse would require more energy than is currently available in our universe! Can't happen, no way, no how! Phew! OK, on to the second law;

The second law of thermodynamics states; 'the total entropy of a system plus that of its surroundings always increases.' (same reference as above) The second law deals with a concept known as entropy or the fact that our universe favors towards disorder. An easy way to visualize this is if you have a child, go clean their room, don't clean up after them for a month; then check their room. The result; entropy!

The second law deals a lot with heat exchanges as well, referred to as enthalpy, but I wont touch upon that here, all we need to remember is that systems tend toward disorder, not order. In a Zombie apocalypse to rise from the dead would require the creation of some type of, say, order. I don't want to use the term heat because I do not know the temperature of a Zombie. I'm assuming they'd be at room temperature (which, as an aside, raises an interesting question; could a Zombie exist without proper attire in Antarctica or the South Pole? Wouldn't they just freeze? Assuming I'm wrong about this thermodynamic stuff and a Zombie apocalypse actually happens, shouldn't we all just move to a much colder climate? After all, all the Zombies I've ever seen were in warm environments, OK, back to our discussion).

So to have a Zombie Apocalypse would require the creation of more order in our universe, much more order (remember the 99 billion plus number); since this goes against the second law of thermodynamics and directly violates entropy (think of a room cleaning itself by itself with no outside influence, just cannot happen) a Zombie apocalypse is impossible. Phew! That made sense. Now on to the third law;

The third law of thermodynamics states that 'the entropy of a perfect crystal at absolute zero is exactly equal to zero.' (This definition I just remember from chemistry so I'm the reference.) This is an easy law of thermodynamics to apply to Zombies because IT HAS NOTHING TO DO WITH ZOMBIES BECAUSE THEY WONT BE ABLE TO MOVE BECAUSE THEY'LL BE FROZEN!!!!!! Duh! They'll be at zero degrees Kelvin or something like that...

In conclusion; from my erudite discussion above one can conclude that a Zombie Apocalypse cannot occur as it will be in violation of all three laws of thermodynamics.

Caveat; in the event I'm wrong, someone, or more frighteningly, something, will be supplying the energy necessary to create the energy needed to increase order to allow the Zombies to come after us. We'll need to find that energy source and destroy it. Barring that, buy yourself a Northface or Patagonia or just a really warm coat and get to the nearest, most coldest climate and good luck!

Have a great weekend all!

dr jim


Monday, April 15, 2013


High Fruit Low fat is the way to go. This man is a nutcase. Our body runs on simple sugar.
All the don't eat list he mentions is correct: Refined starchy carbs. But then he puts fruit in with that. And he recommends a high fat diet that means you will get high blood sugar because your blood is full of fat and it prevents insulin from working. He is insane.


Wednesday, March 20, 2013

Another Diabetic Discussion

I'm currently involved in training as part of a Care Management team approach, which will help prepare me for the implementation of the Patient Centered Medical Home. This is the concept that...wait for it...wait for it....physicians actually ask the patient what we as clinicians can do to help them care for themselves better. Call me crazy but doctors are actually being taught they have to talk to their patients and then really, truly actually listen to what they have to say...A concept whose time, ummmmm, should've already come.

This weeks discussion was on diabetes and I had alot to say, but kept it short, for, uh, brevity's sake. First off, who is brevity and second off, it wasn't short....


Remember, my blog posts are for informational purposes only and are not intended to diagnose, treat or cure any diseases. However, they are intended to hopefully eradicate the nutritional ignorance of the medical profession...

Diabetes Forum;

As a family physician with a profound concern for the diagnosis and correct treatment of diabetes, and having been directly involved with the management and care of thousands of diabetics over my 20 years of practice; I can state without reservation that the current standards of care for diabetics is wrong. Unfortunately, organizations like the American Diabetes Association, American Dietetic Association, American Heart Association, American Cancer Society, the National Institutes of Health, the National Heart Lung & Blood Institute, the Surgeon General, TV personalities such as Dr. Oz and even the White House’s new My Plate campaign, all have it wrong as far as the correct way to eat is concerned.

My direct clinical experience has taught me that in order to correctly treat diabetics, carbohydrate  (carb) restriction is mandatory. The current ADA guidelines recommend that diabetics go no lower than 139 grams of carbs per day. This is wrong. Experience has shown me that when I reduce the carb count to 20 to 40 grams of carbs a day, dramatic sugar control becomes immediately apparent. Yes, you read that correctly; I did state that I reduce my diabetic pt’s carb intake to 20 to 30 grams a day.

This reduction is simple in a newly diagnosed Type 2 diabetic who is not on any medications; but if I get a diabetic already diagnosed on meds, the clinical approach needs to change. For instance, if I see a diabetic who is on insulin (and this can be a type 1 or 2 ) and I get the impression that they are serious about lowering their carbs to help lower their meds; I will immediately stop any short acting insulin (e.g. Humulog) and cut in half the long acting insulin they may be on. Also, meds like Byetta (a hormonal incretin analog which increases GLP-1 secretion) and Januvia (a dipeptidyl peptidase type 4 inhibitor which allows incretin analogs to stay in system longer) will be stopped as will any sulfonylurea (e.g. glimeprimide and glipizide, which work by stimulating an already fatigued pancreas to secrete more insulin hence facilitating B cell burnout and the eventual need for insulin).

The insulin can be stopped and adjusted and the meds can be d/c’ed because once a diabetic reduces their carb amount these meds are no longer needed. I have a big issue with any Type 2 being started on any sulfonylurea due to their mechanism of action. As a side note, if anyone has seen the black box warnings on sulfonylureas it includes ‘increased risk of cardiovascular mortality’ and that it ‘should not be used for prolonged therapy,’ a fact that most clinicians have either forgotten or had no idea about, because I still get diabetics in my office on these meds; usually for many years.

Getting back to adjustments and d/cing of meds, when one dramatically lowers their carb intake there will not be a large increase in post prandial serum blood sugar; therefore the short acting insulin (which is used to lower post prandial blood glucose) will not be needed. Meds like Byetta & Januvia also work by helping lower postprandial blood glucose and they will not be needed as there will be no large increase in post prandial blood glucose because of the carb lowering. The most dangerous of these meds are the sulfonylureas. These meds need to be stopped immediately once a pt implements low carbs. This is because the sulfonylureas will continue to force the pancreas to secrete insulin, irrespective of the blood glucose readings and dangerous life-threatening hypoglycemia can result. I have counseled many a pt who started a low carb regimen on their own, without stopping the sulfonylurea, and subsequently woke up in the hospital after their syncopal event. What’s even worse is that the ER doctor or nutritionist who sees the patient tells the patient they should never have lowered their carb intake; not understanding that is the wrong approach and the pt should have stopped the medicine, not increased their carb intake. Why? Because the pt was no longer consuming large amounts of carbs and does not need the med any longer. This would also be true of Byetta, Januvia, and short acting insulins.

Let’s take some time to discuss insulin and its role in the treatment of diabetics. There are four types of diabetics; Type 1 DM whose pancreas’s no longer can make insulin so they need to take it exogenously; the Type 2 DM whose pancreas is actually hyper-secreting insulin and represents the most common type. This hyper-secretion can go on for years which is why eventually the B cells can burn out (a process facilitated by sulfonylureas and assuaged somewhat by the use of exogenous insulin). This hyper-secretion is also the reason the cellular insulin receptors become resistant due to receptor down regulation as one of the contributors; and this is also the main reason we should never, ever use a sulfonylurea to treat a type 2 diabetic, as their pancreas is already overworking and these meds facilitate its demise. There is also a less recognized type of diabetes known as type 1 and a half or type 3 diabetes. This type of diabetic is one who is insulin requiring, but now has developed resistance to exogenous insulin, a situation we are seeing more of as more clinicians are using insulin in the initial treatment of even type 2 diabetics (a treatment I do agree with but with some caveats). The fourth type is gestational diabetes and these pts do very well with carb restriction which is safe in pregnancy, so long the pt is eating more fat, cholesterol and protein. Some authors have argued there are at least two more types (drug induced diabetes as one sees with steroid use and Juvenile onset type 2 diabetes, which is self-explanatory) but for brevity’s sake we’ll limit our discussion to the 4 types above.

Now let’s get back to insulin. We all learned in nursing or medical school that insulin helps to lower serum blood sugar. This is done via a second messenger system specifically the Inositol 1-4-5 triphosphate, e.g. IP3 and the diacylglycerol or DAG molecules. This fact was learned when we took biochemistry but unfortunately was quickly forgotten. Analyzing this second messenger system further and looking specifically at the DAG molecule, we need to note that one of the ‘acyl’ groups is arachidonic acid which when metabolized releases pro-inflammatory mediators (Click Here for more on Arachidonic Acid). It is these mediators that can and do cause a cellular apoptosis. What’s even more of a concern is that some of these mediators have been shown to be oncogenic. The possible end result of allowing our cells to see too much insulin is the eventual death of the cell. Said another way, not only does the elevated blood sugar cause cellular damage, but so too insulin can cause cellular damage or death (culminating in organ damage) and this is a point missed by most clinicians. Therefore I disagree with the intensive insulin therapy and do agree with lowering the carb intake in our 60 yo female pt.

While some may be thinking it difficult to lower the carb intake so strictly, I must state that the majority of my patients are very happy to have this option to treat, an option too few doctors even know about. As far as motivational interviewing is concerned it really is a treatment that sells itself. Most pts do not want to take meds and they especially do not want to take insulin as this requires a needle. I have successfully treated thousands of diabetics with a low carb approach with success nothing short of miraculous. The only problem is that most clinicians, dieticians, nutritionists, and politicians do not even understand the correct way to eat.

I want to get back to insulin a little while longer because it is such an important hormone to understand. When a healthcare professional is asked to describe the effects of insulin secretion, all will correctly state that it helps lower serum blood sugar; but insulin has many more effects biochemically which I want to discuss further, as it directly affects diabetes care. Insulin also increases the activity of HMG Coenzyme reductase as well as acetyl Coenzyme A carboxylase. The first enzyme catalyzes the rate limiting step in cholesterol biosynthesis; the second enzyme catalyzes the start of the biosynthesis of fatty acids. Therefore, any increase in the secretion of insulin which occurs via the consumption of carbs, will also increase the biosynthetic rate of both cholesterol and fatty acid synthesis. The end result is progression of atherosclerosis, elevation of triglycerides, lowering of HDL, and increases in weight all of which contribute to the manifestation of ‘the metabolic syndrome’ which culminates in development of overt type 2 diabetes. In fact, the treatment and reversal of not only type 2 diabetes but of the entire metabolic syndrome is so easy; it should be an embarrassment to the medical community that we haven’t been able to do this yet on a widespread scale. As a side note, there is a website that lists doctors who understand the importance of low carbs in the treatment of disease, just go to

Now it is easy to say we need to dramatically lower our carb intake to experience better and ultimate sugar control, but we aslo have to analyze further what exactly carbs are and this is where it can become controversial. Everyone knows that cakes and candies are bad for us as well as the white starchy foods; but what about whole grains, muti-grains, whole wheat pasta, brown rice, yogurt, oatmeal and fruit? Are these foods safe for a diabetic to eat? Well, let’s analyze those foods further. Diabetics are often told that they can eat whole grains and the like, and that fruit is fine to eat too. This is false. Whole grains are complex carbs and as such contain many sugar molecules (one grain contains 6 x 10 exponent 1017 molecules which is a 6 times 10 to the 1017 power!) and one slice of whole grain bread may contain even more carbs (even after subtracting the fiber) than its white counterpart. The body will break down these complex carbs into simple sugars and that’s where the trouble starts. One may not see an immediate rise in blood sugar for an hour or so after consuming complex carbs, but it will happen if one keeps checking blood glucose levels. Another side note is that blood sugar should always be normal, it should never be elevated. This sounds like a tautology but let me explain further. I use a normal range of 80-100 and I warn my diabetics they should always be in that range. That any increase in blood sugar will create cell damage and is dangerous to their organs. I am confused as to why the ADA allows a post-prandial increase in blood sugar and considers this to be ‘normal.’ It is not and any rise above 100 should be evaluated. In fact, I tell my patients who are going to get their labs drawn to not fast, as fasting is cheating and changes the blood chemistry into what it truly isn’t and we want to see what the blood normally looks like. Another fact is that a simple 6 hour fast (and a lot of clinicians tell their pts to fast 12-14 hours) can normalize blood sugars and triglycerides, and the clinician will not know a pt is over consuming carbs and cannot counsel the pt effectively. Another reason blood sugar should always remain normal is that the attachment of glucose molecules to cells in our organs occurs via a nonenzymatic pathway, referred to as nonenzymatic glycosylation. What this means is that glucose attaches to the cells in a concentration dependent manner and no intermediaries are needed for this to happen. This glycosylation process is what leads eventually to end organ damage and the only way to prevent this is by having normal blood sugars all the time.

Getting back to the whole grains (and this goes for any grain, oatmeal etc.) once they are metabolized to simple sugars, insulin will be secreted form the pancreas and this will facilitate persistent insulin resistance as well as increase the biosynthesis of cholesterol, free fatty acids, help to lower HDL, encourage weight gain, & create pro-inflammatory mediators via the second messenger system. This cascade of events will occur with any glucose molecule. The glucose released from complex carbs is not ‘special’ in any sense. To think that at the level of the cell a cell can ‘recognize’ a glucose molecule as being from whole grains, oatmeal, white starchy food or a chocolate bar is wrong. Cells are not cognizant of where a glucose molecule comes from, they just do biochemically what they’re programmed to do when glucose enters them; make us fatter, create plaque forming deadly cholesterol and of course elevate blood glucose serum levels.

And now a word about fruit. I tell my diabetics that fruit is a poison and they should stay away from it. Any diabetic who actually checks their blood sugar level after eating fruit knows this. I am utterly confused as to why the organizations as delineated above refuse to understand this. Another biochemical fact is our cells use both glucose and fructose to make cholesterol and fat and that fructose is actually transformed into cholesterol & fat faster than glucose. This means that when one eats a piece of candy and piece of fruit, the fructose in the fruit will be converted more quickly into fat & cholesterol, than the glucose in the piece of candy will be. This is a biochemical fact. Why? Quite simply because fructose enters the glycolytic pathway about a third of the way in and needs to be modified less than glucose. So, no, diabetics should not be eating fruits as allowed by the ADA guidelines.

I want to take time out now to dispel a few myths about glucose. Glucose is not the primary energy source of the body. I know this is a controversial statement but let me explain further.  The fact is that our skeletal muscles, renal cortex and myocardium all prefer free fatty acids for fuel, not glucose. Also, when given the choice the brain prefers ketone bodies for fuel over glucose. Interestingly enough, the breakdown products of fatty acid metabolism (in a process referred to as beta-oxidation) are ketone bodies. Another interesting point is that some will claim that the only way glycogen can be stored (in the liver and muscles) is by the consumption of carbs, which allows glucose to be stored as glycogen. This is not true. We can also make glucose from the glucogenic amino acids as well as the glycerol backbone chain found in triglycerides. The utilization of free fatty acids for energy comes from shuttling 2 carbon acetyl fragments into the Kreb’s cycle then onto the oxidative phosphorylation pathway, not by creating glucose (this is the beta oxidative pathway).

Another misconception I wish to clear up is the whole ‘burning of fat’ or ‘burning of calories’ notion. When we catabolize or breakdown macronutrients (fat, carbohydrates or protein) this is not a combustion process, it is a digestive process. For example, the breakdown of carbohydrates begins when a carb is ingested. If it is a complex carb, it will be acted upon by different enzymes (mono & disaccharidases) to release a glucose molecule(s). This glucose molecule will then enter the cell and be shuttled into the glycolytic pathway. The end result of this pathway is the creation of a molecule (actually 2) of pyruvate which then will be transformed to Acetyl CoA. I often refer to Acetyl CoA as a pivotal biomolecule because its fate depends upon how much carbohydrate one has consumed. If there is an overabundance of carbs ingested, the Acetyl CoA will be shuttled into the cholesterol and fatty acid biosynthetic pathway. If there is not an overabundance of carbs consumed it (Acetyl CoA) will then move into the Kreb’s cycle and then finally into the oxidative phosphorylation pathway (the final step in the oxidation of glucose.) It is important to stress that nothing is burned because it creates a misunderstanding of what really is happening biochemically. Glucose is metabolized to create either ATP (the energy currency of our bodies) or is used to make cholesterol or fat, there is no actual burning. The same is true of fat and protein digestion, they are not combustion processes. This is so germane to a diabetic (and anyone) because we are told to count calories. This is wrong. We often hear the phrase ‘I need to burn up my calories,’ and this, too, is wrong. We are not burning any calories or fat. We metabolize fat, protein and/or carbs to either create biomolecules and/or to create ATP. Again, there is no combustion going on here.

Now the process to determine how many calories are in an item of food is indeed a combustion process. We’ve all come across the calorimeter; a cylindrical metal device containing water, a thermometer, a lid and a heat source. To determine the amount of calories we simply place an item of food inside, heat it to reduce it to carbon, and record the temperature rise of the thermometer. The temperature rise is how we actually measure calories. In fact, the definition of a calorie takes all this into account; i.e. a calorie is the amount of heat needed to raise the temperature of 1 gram of water by 1 degree Celsius. All this is very important to understand when caring for a diabetic. Only by realizing that the calorie is irrelevant in human nutrition, that the burning of anything from a nutritional standpoint is a fallacy, can we better care for our diabetics. The bottom line is that we need to be counting grams of carbs, not calories. Also, by focusing on calories and suggesting they be lowered, will often deprive the pt of important sources of fat & cholesterol in the diet.

With this introduction I will now move onto the questions for this week’s forum;

1)    What might you assume is causing the patient’s blood sugar variability?

We have here a 60 yo female suffering from diabetes for 8 years, stated as non-compliant, with concomitant diagnoses of CVA, HTN and depression; she’s also stated to be ‘maxed’ out on oral meds. My first encounter with this pt would consist of an in depth discussion with the pt about her diabetes, determine exactly why pt is experiencing difficulty with blood sugar control and ascertain how much her depression contributes to her ‘non-compliance.’ I put non-compliance in quotes because I have seen many a pt whose sole reason for non-compliance was a lack of understanding about their disease and not a voluntary attempt to disregard the advice of the physician or nurse.

I would also address the 2 other medical conditions (HTN & CVA) and discuss with pt that many people experience depression with having only one medical condition e.g. diabetes, but she is dealing with 2 more, greatly increasing her risk for depression. I would then add that many pts can get depressed from the simple act of taking meds on a daily basis; this increased risk of depression (& frustration) increases the more meds one has to take. It also needs to be ascertained exactly what type of CVA pt suffered and if (depending on area of brain involved) the location of CVA is contributing to depression e.g. deep limbic system, pre-fontal cortex, anterior cingulate gyrus, basal ganglia &/or temporal lobes. It should be noted that evidence based studies have shown antidepressants to be ‘modestly beneficial’ with ‘adverse events significantly more common.’ (Hackett, Anderson, House; Cochrane Database Syst Review 2008.)  Also, psychotherapy was shown to have ‘no evidence of benefit.’ (Ibid). Another trial revealed ‘that a care management program, which included depression education, antidepressant treatment guided by algorithm, and monitoring of therapy was more effective than usual care’ i.e. discretionary use of antidepressants. (Stroke. 2007;38(3):998) Further studies go on to state an ‘eight-week psychosocial-behavioral intervention plus antidepressant therapy was superior to antidepressant treatment alone.’ (Stroke. 2009;40(9):3073) With all this conflicting data it is easy to see why the treatment of depression of this pt that’s post-CVA can be a challenge. That said, a care management approach, which is exactly what these tutorial sessions are teaching us, appears to be the best approach.

After discussing with pt her individual med conditions and assessing where her knowledge base is at, I would then go over her medications with her, again asking what she takes and how she takes it. For my own edification, I also review the med list from a pharmacodynamic and pharmacokinetic perspective.

The med list appears to only list the diabetic meds and it immediately became apparent to me that meds the pt may be taking for her HTN or CVA could be contributing to her depression; for brevity’s sake I will only focus on the diabetic meds. The first med listed is metformin. This is a safer med for diabetics to take as its mechanism of action is to help increase a cell’s sensitivity to insulin and also decreases gluconeogenesis in the liver; this has the effect of more effective utilization of circulating insulin and diminished ‘dumping’ of blood sugar into the serum. This is a medication that does not (usually) cause a precipitous drop in blood glucose, so I can safely allow my pts to continue this drug when starting a low carb regimen. Both glimeprimide & glipizide are sulfonyl ureas and stimulate an already overworked pancreas to secrete even more insulin. As mentioned above, but it bears reiterating, this will have the effect of increasing insulin resistance (despite the package insert’s contradictory comments), increasing the likelihood of beta-cell burnout, increasing the intracellular production of both cholesterol & triglycerides (which directly increased cardiovascular morbidity & mortality), increasing cellular apoptosis via the use of the second messenger system, and slowing down and/or preventing weight loss by its inhibitory action on hormone sensitive lipase; this is not an exhaustive list but I will stop here.

Now the next 2 meds, Byetta and Januvia are an interesting combination and it appears the prior physician was using them for their complimentary actions. Januvia was the dipeptidyl peptidase type 4 inhibitor which interestingly enough,  would prevent the Byetta from being metabolized, allowing Byetta to exert its physiological effects longer (increasing glucose dependent insulin secretion, decreasing glucagon secretion, slowing gastric emptying…) As a side noted, studies have shown Byetta to reduce the HgA1c by 0.5-1%,( immediate release) to 1.5-1.9% (sustained release), which would reduce our pt’s HgA1c to 12.0 (sustained release), which is a negligible lowering of average blood sugar. In addition, post-marketing studies have shown increased risk of pancreatitis with Byetta use.

After review of her med list. I would immediately begin counseling on carb counting and would gauge pt’s motivation for starting. If I sensed she would seriously consider starting to lower her carbs, I would stop the glimepiride, glipizide, Byetta and Januvia.

I agree with the start of Insulin therapy, but I would need clarification of what ‘intensive insulin therapy’ means. The orders do not reveal if we are adding Insulin in addition to or are we eliminating any meds once starting insulin? These orders immediately reminded me of a study I read a few years back which suggested that tight HgA1c control (<6 .5="" 3="" about="" all="" am="" amp="" and="" answer="" as="" associated="" be="" better="" blood="" bolt="" came="" certainly="" death="" disease="" end-organ="" equates="" finally="" greater="" i="" in="" into="" less="" me="" morbidity="" morning="" mortality.="" of="" one="" over="" read="" regulation="" researchers="" sat="" seeing="" so.="" so="" study.="" study="" style="mso-bidi-font-style: normal;" sugar="" sure="" t="" taught="" that="" the="" this="" tissue="" to="" upright="" was="" wasn="" we="" were="" weren="" why="" with="" would="">the increased morbidity & mortality was not due to the tight control of the HgA1c
, it was due to all the meds the pts were on to get the HgA1c lower. The pt’s blood sugars were not being controlled through the correct way to eat, but through the use of these medications and the pts were suffering because of this.
Getting back to my pt, I would stop the meds as described and start solely on long acting insulin (assuming pt allows), and yes, using the pens makes it much easier (some insurances wont allow), discuss the importance of low carbs, and have the pt call my office on a daily basis with blood sugar results. Now some may immediately become concerned at me stopping 4 PO meds and starting on just long-acting insulin stating (correctly) that the pt’s blood glucose will almost certainly rise. That is correct, but it is OK. Hypoglycemia is more dangerous in the short term than hyperglycemia, so I’m ok allowing my pt to run a little higher as we figure out the correct dose of insulin. Another couple points about insulin. Once we take more than 20 units at once (some authors say 10 units), there can be erratic absorption so it is best to ‘split’ the dose above, say, 30 units; i.e. give 20 units SQ in one area and 10 units SQ in another. Also, we run the risk of creating more insulin resistance by using increasing doses of insulin; thus the pt runs the risk of developing type 3 diabetes. This is where metformin is helpful because it helps maintain insulin sensitivity.

In 1 week pt will return with both a sugar and food diary (remember she was in contact with me daily all week) and we will discuss the results.

As far as what’s causing the blood reading variability, it is because pt most likely received inadequate diabetic teaching (or more importantly, the incorrect diabetic training) and may possibly be ‘afraid’ to use the insulin; this is why it’s important to have pt come back with not only a sugar diary, but a food diary as well and we would want to ask exactly how she is taking insulin.

Looking at pt’s labs reveals a diabetic nephropathy as microalbuminuria is elevated with an elevated Cr. I would like to stress that the correct approach is to not restrict protein intake, but encourage increased consumption of protein, fat and cholesterol and to lower the carb intake. What is happening in diabetic nephropathy (as well as all the other end-organ damaging effects) is that the aforementioned non-enzymatic glycosylation is occurring at the glomerular level and this impairs the filtration mechanism of the nephron. This impaired filtering mechanism, with the subsequent increased proteinuria, is not from the consumption of protein, but from the overconsumption of sugar. Eating more protein will not create more kidney damage as is commonly thought. In fact it’s beneficial. I have seen microalbuminurias in the 100 range (highest 800) revert to normal upon eating the correct way. This is a reversal of the nephropathy. In addition, other end organ damage (eye and nerve) can also reverse when a pt begins to eat the correct way. A quick note about the lipid profile; the triglycerides are elevated. These will also lower once the pt lowers their carbs and begins to eat more fat, cholesterol & protein.

2)    What would your next steps include in care-managing this pt?

A full discussion of diabetes including the correct way to eat; recommended reading: my favorite is Dr. Bernstein’s Diabetes Solution by Richard K. Bernstein (2007).; I would have anyone on my care management team read this book and keep it as a handy reference; training of my support staff as to the correct way to eat for counseling our pts….

I have so much more to say, but I think this is a good primer for continued study J

Saturday, January 26, 2013


Yes, I did, much to my chagrin.....So we're eating these delicious MISSION CARB BALANCE 'Whole Wheat Tortillas' when my wife starts to read the ingredient list....and we can all guess where this is going... "Jim, what's interesterified soybean oil?" Yes, the tortilla I was currently masticating fell out of my mouth (but I managed to save the meat part)....

"Goshdarnit!!" I exclaimed. And yes, I really did say goshdarnnit...I immediately recognized that type of soybean oil as I had done a radio show on it a few years back. Interesterification is a process that switches around the fatty acids on a triglyceride molecule. Remember that a triglyceride molecule contains 3 (the tri part) fatty acids connected to a glycerol backbone chain. These fatty acids are connected to the glycerol backbone chain through what are known as 'ester' linkages; hence the 'ester' part of inter'ester'ification. Now, vegetable fats generally have specific fatty acids at the 1 and 3 position of the glycerol backbone (stearic & palmitic which are saturated) and an unsaturated fatty acid (oleic or linoleic) at the 2 position. The interesterification process will remove the # 2 fatty acid and replace it with a more saturated one.

Ok, I can hear some of you saying "So what's the problem with that? Now you have a triglyceride that's completely saturated and haven't you been saying all along Dr Jim that saturated fats are better for us than mono and polyunsaturated?"

Yes, you are correct in your understanding that saturated fats are the safest & healthiest fats to consume (I can hear the gasps of incredulity from anyone new reading my Blog who doesn't understand the correct way to eat; and btw, I broke 45,000 views this month, woo hoo, there goes my ego again....or is it superego....or the id? Aw heck, what did Freud know anyway...:-)

Ok, so back to that newly created saturated fat from the interesterification process; the first problem is that we are creating a fatty acid that our bodies may not have seen naturally before. What this means is that like trans fats where our bodies do not have the necessary enzymes to break them down, resulting in the buildup of free radicals; so too is my concern that we may not have the necessary enzymes to break down this 'new' fat created by the interesterification process; will this result in the creation of free radicals as well?

There have been studies looking at the effects of the interesterified fats on human blood chemistry and while the number of subjects were low, the results were cause for concern. One study revealed that the HDL (our good cholesterol) lowered and that insulin levels dropped dramatically causing blood sugars to raise by about 20%. It is important to note that this study looked specifically at postprandial blood levels not fasting blood levels (postprandial simply means after eating). Other studies revealed no changes in blood sugar, but this study was reporting the effects on fasting blood sugar only. Now it needs to be stressed that fasting blood levels do not truly reveal what's going on in our bodies. Labs analyzed after a 12-14 hour fast do not reveal the true biochemistry of our blood; it is what I call cheating. We should always measure non-fasting labs if we want a true idea of what is really happening in our bloodstreams.I immediately recognized that fact when I saw the researchers had performed the analysis under a fasting state, this is not telling us what is really going on with our blood biochemistry.

If all of this isn't enough , a quick review of how an interesterified fatty acid is created should be enough to scare the fecoliths out of ya.... This is, once again, a highly industrialized process using bleaching detergents, carcinogenic solvents, dangerous metallic alloys, and deodorizing. This last step, referred to as deodorizing, can actually cause trans fats to appear in the mix; ummm, not good.

So the moral of this story is please read your side packaging ingredient list; you'd think I would've learned my lesson with the whole Green Giant debacle....And no, I'm not eating the rest of those tortillas. An interesting side note is that not all Mission low carb wraps have the interesterified fatty acids; so again, my mistake was that I assumed that because I had read through the ingredients before and didn't see partially or interesterified fats, that I was ok......and let's all remember what happens when we assume...

Have a great rest of your weekend everyone! And thanks to everyone who helped me break the 45,000 view mark!

dr jim :-)