Diabetes

MAHA Fact and Fiction

We have all lately heard a lot about MAHA (Make America Healthy Again) from Robert F Kennedy Jr. Some of the things he is advocating probably would improve the health of Americans, but many would not only not improve health, but would make it worse. In this post I’m going to try to identify the good parts and debunk the rest.

Food Dyes

Kennedy wants to eliminate “synthetic” food dyes except for “natural” ones. Food dyes have no nutritional value and many have never been adequately tested in humans. That does not mean they are toxic or cause disease. The only food dye that has been shown to be possibly toxic to humans is red dye #3 also known as erythrosine. It has already been banned in food and cosmetics. For other food dyes we simply do not know how safe they are for human consumption. . The FDA has recently approved 3 plant based food dyes:

  • Galdieria extract blue, a blue color derived from the unicellular red algae Galdieria sulphuraria.
  • Butterfly pea flower extract, a blue color that can be used to achieve a range of shades including bright blues, intense purple, and natural greens. This dye is produced through the water extraction of the dried flower petals of the butterfly pea plant
  • Calcium phosphate, a white color approved for use in ready-to-eat chicken products, white candy melts, doughnut sugar, and sugar for coated candies.

We don’t know any more about the safety of long term use of these plant-based dyes in food than we know about synthetic dyes. Just because they are extracted from plants does not make them safer. The drug digoxin was originally extracted from the foxglove plant. Taking too much of that can kill you. The most conservative thing to do is to ban food dyes, period. That would take congressional action, which is most unlikely in the current congress.

There is no evidence, by the way, that any currently used food dyes cause cancer or other diseases. There is just very little evidence about whether they are safe or not.

Emulsifiers

Emulsifiers are added to foods to prevent separation of oil and water in foods. They also can increase shelf life. Some are natural products like guar gum and some are synthetic. Emulsifiers are not new and have been used for hundreds of years. There is some evidence that certain emulsifiers may adversely affect the gut microbiome. Most of this work has been done in mice, so it is not clear whether emulsifiers have the same effect in humans. Emulsifiers are used most extensively in processed and ultra-processed foods. Unprocessed foods do not contain emulsifiers. Once again, the jury is out on whether emulsifiers have adverse effects in humans, but they might have an effect on the gut microbiome and promote inflammation and they might not. Kennedy is opposed to all emulsifiers in food. This is not exactly a nuanced perspective, as is the case with all his recommendations and obsessions.

Other Food Additives

There are hundreds of substances added to foods. Here is a link to an FDA list of all substances added to foods that are approved by the FDA or are GRAS (generally recognized as safe): Substances Added to Food. This list is 80 pages long! I have to say that I agree with Kennedy on this one. Already, all of these additives have to be listed on the contents label. If there are more than three things on the contents label that you don’t recognize, leave it on the shelf!

Seed Oils

Kennedy (who is a lawyer, not a health expert, by the way) parrots many so called “natural” food advocates who say that seed oils have toxic by products and the wrong ration of omega 6 to omega 3 fatty acids. They maintain that seed oils cause inflammation and thus increase the risk of heart disease and other conditions like obesity and diabetes. The evidence does not support these claims.

What are seed oils anyway?

  • Canola (rapeseed) oil
  • Corn oil
  • Cottonseed oil
  • Soybean oil
  • Sunflower oil
  • Safflower oil
  • Grapeseed oil
  • Rice Bran oil

All of these are polyunsaturated (as opposed to saturated oils like animal fats, palm oil and coconut oil , which are not good for you in more than moderate amounts). They are more refined than cold pressed oils and a chemical process is used in the refining process. These chemicals, including hexane are volatile and completely evaporate during the refining process. There are no toxic by products in refined seed oils.

Health effects of seed oils – The evidence

Seed oils contain linoleic acid which is an omega 6 fatty acid. Multiple studies show that linoleic acid intake decrease the risk of heart disease and decreases , not increases inflammation. The best way to use these or any oil as a beneficial part of a healthy diet is stir frying vegetables, oven roasting fish, or crafting homemade salad dressings.

The correct ration of omega 6 to omega 3 fatty acids is not clear. To get both eat omega 3 fatty acids which are found in high amounts in walnuts and fatty fish. A good summary of the evidence on the good health effects of seed oils can be found on this Massachusetts General website: Seed Oils: Facts and Myths.

Beef Tallow

Kennedy thinks that using beef tallow for frying is healthier than seed oils. While beef tallow does make for delicious french fries, it is 100% saturated fat. Saturated fat can be healthy as a small part of your total fat intake, but eating exclusively animal fat vs unsaturated fat markedly increases the risk of heart disease, obesity and diabetes. Multiple studies over the years have confirmed increased risk from eating exclusively or large quantities of saturated fats. Kennedy has a video of him frying a whole turkey in beef tallow while saying that this is cooking the MAHA way. Here is a link to that video. In my opinion this is the height of irresponsibility.

Water Fluoridation

Kennedy cites studies that show decreased IQ in children who are exposed to fluoridated water. I have a previous post about the safety of water fluoridation. See this link. The bottom line is that these studies were done in countries and locales that had very high natural fluoride levels. There was no effect in these studies on the very low fluoride levels that are used in water supplies to prevent cavities in children. Banning water fluoridation will lead to excess tooth decay in the most vulnerable children.

Limiting foods that can be purchased with SNAP benefits

SNAP stands for Supplemental Food Assistance Program. It used to be called the food stamp program. Benefits are applied to a card that can be used like a credit card to purchase food. As of now households whose gross income is 130% or less of the federal poverty and whose net income is below the federal poverty level are eligible for SNAP benefits. The amount is determined by the number of people in the household. The federal government pays all of the benefits and 50% the administrative costs. The state pays the other half of the administrative costs. The Big Beautiful Bill Act will make substantial cuts to the SNAP program. More about that later.

People can use their SNAP benefits to purchase food, but not alcohol or cigarettes. Texas and Louisiana have just passed laws that also prevent using SNAP benefits to purchase soft drinks or candy. Kennedy has praised these new state laws. While it is true that soft drinks and candy are not healthy foods, excluding these from SNAP benefits is just a way to make lawmakers feel virtuous about limiting the food choices poor people make. It is not going to improve their nutrition because like non-SNAP households foods households buy on SNAP benefits tend to be ultra-processed foods. Healthy unprocessed foods are more expensive and require time to prepare and cook as well as requiring working appliances and cooking equipment. Families at or below the poverty level, who are often renting sub-standard housing are unlikely be able to afford to purchase or to have the time, and equipment to prepare and cook unprocessed foods. Non-SNAP households don’t do much better. See this link from the USDA: Foods typically purchased by SNAP households .One more MAHA recommendation that will likely not improve health!

What makes this even worse are the cuts to the SNAP program in the Big Beautiful Bill Act. Here is a summary of the cuts and when they will kick in:

  • Shifting SNAP costs to states by:
    • Requiring states to pay a portion of SNAP benefits for the first time in program history, up to 15%, based on their payment error rates, beginning in October 2027. Final negotiations in the Senate resulted in a temporary implementation delay for up to two years for states with high error rates. 
    • Increasing the state’s share of administrative costs from 50% to 75%. 
       
  • Restricting future adjustments to the Thrifty Food Plan, which will include cuts to SNAP benefits as well as benefit levels for The Emergency Food Assistance Program (TEFAP), SUN Bucks/Summer EBT benefits, and the Nutrition Assistance Program block-grant to Puerto Rico. 
     
  • Increasing the number of individuals subject to time limits on their SNAP benefits, including, for the first time ever, parents of school-aged children over 14 and older adults age 55 through age 64 by expanding work requirements and restricting waivers. 
     
  • Adds a time limit on benefits for veterans, currently homeless individuals and former foster care youth.
  • Eliminating funding for the SNAP Nutrition Education program. 

SNAP is (or was) the most effective hunger relief program in the U.S.

All of the above information on the changes to SNAP benefits comes from the Harvesters Community Food Network .

Vaccines

With no evidence whatever, the MAHA report calls current childhood vaccination schedules “overmedication.” It emphasizes exceedingly rare adverse effects of vaccines and promises to do “randomized trials” of current vaccine schedules. Randomized trials are routinely done before new vaccines are approved and repeating them will be inordinately expensive and delay vaccine approval. The result of this MAHA policy will mean that we will see serious childhood diseases again, some of which will result in hospitalization and some totally avoidable childhood deaths. We have already seen a resurgence of measles cases in 40 states. See my previous post about Vaccine risks in perspective.

Bottom Line

Kennedy has legitimate concerns about the unhealthy ultra-processed foods that most Americans eat. The concerns about food additives are also reasonable but overblown. These legitimate concerns are mixed in with conspiracy theories about toxic byproducts in seed oils, health benefits of beef tallow, and vaccines as a cause of autism. He completely ignores the fact that most poor people cannot afford to buy, prepare or cook healthy unprocessed foods. He is overall a danger to public health.

Inflammation: Pathway to Chronic Diseases

Inflammation is activation of the immune system in response to threat or injury to the body. Acute inflammation mobilizes the immune system to repair an injury or fight an infection. Once healing takes place the immune system goes back to baseline. Chronic inflammation, however, involves long term activation of the immune system caused by some ongoing stress to the body. More and more, researchers are beginning to show that chronic inflammation is the common pathway to many diseases. There are multiple causes of chronic inflammation. In this post I will write about the causes of chronic inflammation. I will also do a series of posts about the many diseases that chronic inflammation causes. These posts will be based on the structure of an excellent book: Inflamed – Deep Medicine and the Anatomy of Injustice. It is not easy to read because it is disturbing but I highly recommend it. I will also write about a test to measure chronic inflammation. I will write about things you can do to decrease chronic inflammation if you have it and how to prevent it if you don’t. There are many causes of chronic inflammation that have to do with the structure of our society. These are things an individual cannot control. These societal causes will take ongoing efforts by all of us to change some of the toxic structures of society.

The Process of Inflammation

The inflammatory process starts with damage or threat of damage to the body. That can be an infection, a wound, or perceived threat of such. The immune system mobilizes white blood cells called macrophages to the injured area or site of infection. The cells of the immune system also release a cascade of messenger molecules called cytokines that amplify inflammation. These include interleukin 1ß, interleukin- 6 and tumor necrosis factor -α. The liver also releases a protein called c-reactive protein. When the threat is neutralized the immune system helps the body start to heal by releasing anti-inflammatory cytokines including interleukin (IL)-1 receptor antagonist, IL-4, IL-10, IL-11, and IL-13.

In chronic inflammation the pro-inflammatory cytokines continue to predominate and the c-reactive protein continues to be elevated.

Causes of Chronic Inflammation

Causes an individual can do something about

  • Low levels of physical activity.
  • Having a BMI at or above 30 , especially when excess weight is deep within your belly (visceral fat). The best way to measure belly fat is to use a tape measure to measure your waist at the widest point. Increased belly fat is greater than 35 inches for women or greater than 40 inches for men
  • An imbalance of healthy and unhealthy bacteria in your intestine (dysbiosis). Dysbiosis can be caused by antibiotics and by eating foods low in soluble fiber.
  • Regularly eating foods that cause inflammation, especially highly processed foods, or foods high in sugar or salt
  • Inadequate sleep
  • Using tobacco products.
  • Regularly drinking too much alcohol
  • Periodontal disease (gum infection) and tooth decay
  • Perceived stress

Societal Causes

  • Experience of racism (structural or personal)
  • Poverty
  • Homelessness
  • Worry about debt
  • Work stress
  • Exposure to air pollution
  • Exposure to chemicals (pesticides and herbicides for farm workers, glyphosphate (RoundUp) for everyone, microplastics in our bloodstreams for everyone. Every day, we are surrounded by thousands of synthetic chemicals. They are in our food, clothes, tools, furniture, toys, cosmetics and medicines. We know the health effects of only a few of these).

Diseases caused by chronic inflammation

  • Cardiovascular Disease (coronary artery disease, heart attacks, congestive heart failure)
  • Strokes
  • Type 2 diabetes
  • Cancer (multiple types)
  • Inflammatory bowel disease (crohns disease, ulcerative colitis)
  • Rheumatoid Arthritis
  • Lupus and similar autoimmune diseases
  • Asthma
  • COPD
  • Pulmonary fibrosis
  • Depression

Tests to measure chronic inflammation

All of the inflammatory cytokines can be measured but those are expensive tests. A simple inexpensive test that measures inflammation, both acute and chronic is high sensitivity CRP. It will also be high with an acute infection or injury, but will return to normal after the infection or injury have resolved. If it remains elevated when you are not sick or injured it is a sign of chronic inflammation. It may be worth asking your doctor to order this test if you have any of the individual or societal risk factors for chronic inflammation. A normal hs-CRP is less than 0.55 mg/dl in men and less than 1.0 mg/dl in women. If your hs-CRP is high in the absence of acute infection or injury, that can serve as motivation to make lifestyle changes to decrease your chronic inflammation and put you in a population that has less risk of developing any of the diseases associated with chronic inflammation.

Anti-inflammatory lifestyle

  • Exercise regularly. The CDC recommends 30 minutes of moderate exercise (walking briskly) for 30 minutes at least 5 days a week.
  • Eat mostly unprocessed or minimally processed foods and avoid sugary drinks or foods with added sugar or high fructose corn syrup. Also include foods with high soluble fiber such as beans, carrots, sweet potatoes, nuts, berries and most fruits (not fruit juice). Organic foods, while more expensive, have no residual pesticides or herbicides. If you eat meat buy grass fed beef, and pasture raised chicken and pork. Eat more plant-based foods than meat.
  • Avoid taking antibiotics as much as possible
  • Sleep. Average at least 8 hours a night
  • Floss your teeth daily, brush twice a day and see your dentist every 6 months
  • If you don’t smoke, don’t start and if you do smoke quit.
  • It is better not to drink alcohol at all, but if you do limit it to 1 drink a day or less.
  • Learn meditation or self hypnosis to manage stress. There are good books and videos, but an in person course is best if it is available.
  • Drink only filtered water and not bottled water in plastic bottles
  • Gas stoves cause significant indoor air pollution. If possible switch to an electric stove. Induction type burners actually heat more quickly than gas. If you have to use a gas stove, be sure to turn the ventilator fan on and open a window if possible.

Bottom Line

Chronic inflammation is the common pathway for many chronic diseases. There are many individual strategies that reduce or prevent chronic inflammation. Many of these strategies are not possible for people with socioeconomic problems. The stress black people experience from structural and individual racism, homelessness or inadequate housing, anxiety over debt, exposure to environmental synthetic chemicals, and exposure to air pollution are societal problems that we all have a responsibility to address.

My next post will deal with chronic inflammation and cardiovascular disease.

Update on Diagnosis and Treatment of Alzheimers Disease

There are some new developments in the diagnosis of Alzheimer’s disease. These developments mean more people may be eligible for the new treatments for Alzheimer’ disease. In this post I will write about the new blood tests for Alzheimer’s disease and also revisit the available treatments. This will be an update of my previous post New Treatment for Early Alzheimer’s Disease – What You Need to Know.

Blood tests for Alzheimer’s disease

The monoclonal antibody treatments for Alzheimer’s disease only work if patients have evidence of amyloid proteins in their brains. Prior to the new blood tests, the only way to tell if patients had the amyloid protein was either to measure it in spinal fluid (which means a spinal tap) or to see it on a PET scan (which is a very expensive type of scan). The FDA has approved a new blood test that has been shown to work as well as a spinal tap or PET scan. It measures a protein called ptau217. The test is called the ALZpath ultra-sensitive pTau217  test. Because it requires just a blood sample, that means a lot more people will get the test and if positive will be eligible for treatment with the new monoclonal antibody treatments. This is a somewhat mixed blessing as I will outline below.

Theories of the cause of Alzheimer’s disease

On November 3, 1906, a clinical psychiatrist and neuroanatomist, Alois Alzheimer, reported “A peculiar severe disease process of the cerebral cortex” to the 37th Meeting of South-West German Psychiatrists in Tubingen, Germany. He described a 50-year-old woman whom he had followed from her admission for paranoia, progressive sleep and memory disturbance, aggression, and confusion, until her death 5 years later. His report noted distinctive plaques and neurofibrillary tangles in the brain at autopsy. In 1909 he presented two more patients with a similar history and pathology in the brain after death. These were all relatively young patients, so the name Alzheimer’s disease originally was applied to patients who developed dementia in their 50’s and 60’s (it was also called “pre-senile dementia.”

In later years it was discovered that many people who developed dementia at any age, including advanced age had the same plaques and neurofibrillary tangles when their brains were examined after they died. It turned out that 90 % of people who had dementia had these plaques and neurofibrillary tangles in their brains found at autopsy..

The Toxic Protein Hypothesis

The composition of the plaques turned out to be a protein called amyloid protein and the neurofibrillary tangles were composed of another protein called tau. The theory was that accumulation of these proteins was toxic to brain cells and that this toxic effect caused dementia. Because dementia is associated with age, it was hypothesized that in predisposed individuals gradual accumulation of these proteins in brain cells over many years eventually results in dementia.

There is one problem with this hypothesis. Several studies have followed aging people over time and measured the presence or absence of dementia. People in all these studies have agreed to have their brains studied after they died. In all of these studies anywhere from 12% to 30% of people who never had dementia during their long lifetimes (many were in their 80’s or older when they died) had plaques and neurofibrillary tangles that met the criteria for Alzheimer’s disease. It appears that the accumulation of amyloid and tau proteins is associated with Alzheimer’s dementia, but not necessarily the main cause of it.

Treatments based on the toxic protein hypthesis

There are three monoclonal antibodies now approved by the FDA for the treatment of Alzheimer’s disease. They newest ones are lecanemab and donanemab. They both target the amyloid beta protein that accumulates in people with Alzheimer’s disease. They are both used in people with mild cognitive impairment and they do reduce the beta amyloid protein as shown by follow up spinal fluid testing and/or PET scanning. Unfortunately, they only have a modest effect on slowing progression from mild cognitive impairment to Alzheimer’s disease. The cognitive test used in the studies of both drugs is called the Clinical Dementia Rating–Sum of Boxes. The range of this test is 0-18. Only people with mild cognitive impairment were included in the trials. The treatment group in the lecanemab trial got lecanemab, which has to be given by iv infusion every two weeks for 18 months. The placebo group got a saline infusion every two weeks. In both the placebo group and the treatment group, the scores on the dementia test got worse by 18 months, but the dementia scores for the treatment group did not increase as much as the placebo group. The absolute difference in the scores was about 14%. This was a statistically significant difference in slowing the progression of mild cognitive impairment to Alzheimer’s disease, but it’s not a very big difference.

Side effects of monoclonal antibody treatment

Both approved monoclonal antibody treatments attack the amyloid beta protein and produce an inflammatory response in the brain. This resulted in brain edema and/or micro hemorrhages in 17% of the treatment group vs 9% of the placebo group. Also nearly a quarter of the treatment group had reactions to the infusion. Most of the people with brain hemorrhages or edema did not have symptoms but some had headache, visual disturbance and confusion.

Expense of monoclonal antibody treatment

Lecanemab, which goes by the trade name Leqimbi is priced by the manufacturer at $26,500 per year. The other approved monoclonal antibody, aducanumab is priced at $28,200 per year. The UK has not approved either of these drugs because they don’t feel the modest benefit justifies the cost. The UK also points out that we have no idea what the long term effects of either one of these drugs might be.

Other treatments for Alzheimer’s disease

The other major class of drugs that has been used for Alzheimer’s disease are the cholinesterase inhibitors. The theory behind using these drugs is that nerve cells that produce a neurotransmitter called acetyl choline are diminished in Alzheimer’s disease. The cholinesterase inhibitors have the effect of increasing levels of acetyl choline in the brain because they inhibit the enzymes that break it down. These drugs are donazepil (Aricept), rivastigmine (Excelon), memantine in combination with donazepil (Namzeric), galantamine (Razadyne) and tacrine (Cognex).

These medicines don’t work very well Fourteen out of 100 patients with mild to moderate Alzheimer’s disease have some improvement in thinking skills. Side effects, especially nausea and vomiting are common. None of these medicines has been shown to work any better than the others in the class.

Genetics

There is no specific Alzheimer gene. Almost 80 genetic sequences have been identified that either decrease or increase the risk of Alzheimer’s disease. If you have a first degree relative who has had or has Alzheimer’s disease, then your risk is increased somewhat. Each of these sequences has only a minimal effect by itself, so you would have to have a lot of them to substantially increase the risk of Alzheimer’s disease. It is estimated that genetics accounts for less than 5% of Alzheimer’s disease.

Integrated theory of cause of Alzheimer’s disease

In doing research for this post, I discovered a very interesting paper by Richard Armstrong that reviews current theories of the cause of Alzheimer’s disease and proposes a new integrated theory that accounts for everything we know about Alzheimer’s disease so far. Here is a link to that paper if you would like to read the whole thing: Review article: What causes alzheimer’s disease?. It is from a Polish neurological journal, but the article is in english.

On the basis of current evidence Dr Armstrong believes that the primary factor in Alzheimer’s disease is an age-dependent breakdown of anatomical systems and pathways within the brain and the consequent loss of synapses. The degree of this aging effect depends on the amount of lifetime stress (also called allostatic load). The brain is the ultimate recipient of stress through hormonal changes resulting from high blood pressure, diabetes, cardiovascular disease, and immunological problems. The result of all this is gradual disconnection of synapses, degeneration of nerve cells, and the expression of genes determining various reactive and breakdown products such as Aβ and tau. The brain has a protective mechanism that removes breakdown products, and this protective mechanism continues to function and prevents the accumulation of Aβ and tau. As a person enters old age and the effects of excessive body stress accumulate, then senile plaques and neurofibrillary tangles begin to form as the brain’s protective systems get overwhelmed. In this theory, accumulation of Aβ and tau are the result of loss of synapses and connections in the brain rather than the cause. By the time these proteins can be detected in the spinal fluid or blood, the process of brain degeneration is already well underway. It is no wonder that targeting these proteins with monoclonal antibodies only modestly slows but does not reverse the progression of mild cognitive deficit to full blown Alzheimer’s disease.

If Doctor Armstrong’s theory is correct, then we should see a markedly increased risk of developing Alzheimer’s Disease with aging in people with certain chronic conditions. Here are some numbers:

Metabolic Syndrome

Metabolic syndrome is defined by having at least three of the following five conditions:

  1. Excess abdominal fat (Waist circumference greater than 40 inches for men or 35 inches for women)
  2. High blood pressure (Systolic greater than 140 or diastolic greater than 90)
  3. High blood sugar (fasting blood sugar greater than 100 mg/dl)
  4. high blood triglycerides (fasting triglycerides greater than 150 mg/dl)
  5. Low HDL cholesterol (less than 40 mg/dl)

People with metabolic syndrome have 11.5 times the risk of developing Alzheimer’s disease as they age as people without metabolic syndrome. About one in every three adults in the US has metabolic syndrome.

Type 2 diabetes

A recent review of the literature found that type 2 diabetes increases the risk of eventually developing Alzheimer’s disease by 56%.

Coronary artery disease

People with coronary artery disease, especially at a relatively young age have a 26% increased risk of eventually developing Alzheimer’s disease.

Sedentary Lifestyle

In a study from the UK the more hours a person spent sedentary, the higher the risk of all cause dementia. Since Alzheimer’s disease accounts for the vast majority of dementia, we can assume that the more hours per day you spend on the couch, the greater the risk of eventually developing Alzheimer’s disease.

Social Networks

Many longitudinal studies show that maintenance of supportive social networks (family, friends) decreases the risk of development of Alzheimer’s disease. Conversely loneliness increases the risk of developing Alzheimer’s disease

Heavy alcohol consumption

Light to moderate alcohol consumption (2 drinks a day for men and 1 drink a day for women actually decreases the risk of developing Alzheimer’s disease. Heavy alcohol consumption (4 drinks a day or greater for men and 3 drinks a day or greater for women) increases the risk of developing Alzheimer’s disease by 300%!

Bottom Line

The new blood tests help diagnose people with mild cognitive impairment who are at high risk of progressing to Alzheimer’s disease. This is only helpful if there are good treatments to prevent progression to Alzheimer’s disease. Unfortunately, the best current treatments modestly slow the progression from mild cognitive impairment to Alzheimer’s disease but do not reverse or prevent the progression. These monoclonal antibody treatments have significant side effects that include microhemorrhages and brain edema. At present there is no medical treatment to reverse or prevent Alzheimer’s disease.

Dr. Armstrong has proposed a theory that the non-hereditary form of Alzheimer’s disease results from loss of synaptic connections in the brain from chronic lifetime body stress and that the amyloid protein accumulations are the result rather than the cause of loss of synaptic connections in the brain. This theory is supported by the fact that people with lifestyle related chronic diseases (metabolic syndrome, diabetes, heart disease, sedentary lifestyle, lack of meaningful mental activity, loneliness, heavy alcohol intake) have a markedly increased risk of developing Alzheimer’s disease as they age.

The best treatment for Alzheimer’s disease is prevention. Risk of developing Alzheimer’s disease with age is decreased by maintaining normal body weight, eating mostly unprocessed foods, exercising regularly, staying mentally active, maintaining supportive social networks, and avoiding heavy alcohol intake.

Artificial Sweeteners: Evidence for Benefit and Harm

It is expected that in 2024, 144 million people in the US will be using artificial sweeteners daily. The rationale for using non caloric or low caloric artificial sweeteners is of course to be able “to have your cake and eat it too.” That is, the sweet tooth can be satisfied without the known ill effects of sugar consumption. You can reduce your calories and therefore lose weight while still getting all the sweetness you crave. Is this true? Are artificial sweeteners safe? Do they help people lose weight? Are there ill effects from consuming artificial sweeteners over a long time? The answers to some of these questions are far from clear, but there is evidence to answer some of them.

There are six different sweetener compounds approved as food additives by the FDA. The FDA also approves the use of three plant and fruit based sweeteners as safe. To complicate things further, there are six FDA approved sugar alcohols (which have slightly less calories than sugar, but are metabolized differently). Below is a table listing all these sweeteners and their brand names. Scroll to the right to see the nutritive sweeteners in the table. Here is a link to the article containing the table

Non-nutritive sweetenersNutritive Sweeteners
NamesAspartameAcesulfame-KSaccharinSucraloseNeotameAdvantameSteviosidesMannitolXylitolSorbitolErythritol
Brand namesNutraSweet®, Equal®, othersSunett®, Sweet One®Sweet’N Low®, Sweet Twin, Sugar Twin®, Necta Sweet®Splenda®Used as ingredient in food products.Used as an ingredient in food and beverage productsStevia®, Truvia™, Sun Crystals®, PureVia™, Sweetleaf Sweetener™Used as ingredient in food products.XyloSweetUsed as ingredient in food products.Zerose

The only thing all these compounds have in common is that they stimulate the human sweet taste receptor. Some are absorbed in the small intestine and some are not absorbed. They have (or may have) different effects on metabolism. Some of them are 2000 times as sweet as sugar and some (the sugar alcohols) are as sweet or half as sweet as sugar.

In this post I’m going to write about the pro and con evidence for each of these different classes of sweeteners. I’m also going to write about the effects of using honey, maple syrup and agave as sweeteners.

Human Taste

Humans have only five kinds of taste buds, mostly on the tongue, but some on the roof of the mouth and the throat. They are sweet, sour, bitter, salt and umami (spicy). All tastes are combinations of activity of these five kinds of receptors. Artificial sweeteners stimulate primarily the sweet taste buds. A few of them in larger quantities stimulate the bitter taste buds as well.

Do artificial sweeteners increase the risk of cancer?

The answer to this question is almost certainly no. There were some early studies of aspartame in rats that showed an increased incidence of bladder cancer. This turned out to be related to physiology specific to rats and not humans. There is no evidence at present to suggest that any artificial sweeteners increase the risk of cancer in humans. Obesity does increase the risk of cancer and many overweight people use artificial sweeteners. There is no evidence that the sweeteners themselves increase the risk of cancer.

Do artificial sweeteners help with weight loss?

The answer to this question is no. Almost all human and animal studies to date show no effect on weight loss or weight gain for any of the artificial sweeteners.

Do artificial sweeteners increase the risk of cardiovascular disease?

The answer to this question is probably yes. A large study in France showed that consumption of artificial sweeteners was associated with cardiovascular disease. The main ones consumed were aspartame, acesulfime potassium and sucralose. Apartame was associated with increased risk of stroke. Consumption of  acesulfame potassium and sucralose was associated with an increased risk of coronary disease. Here is a link to that study in the British Medical Journal.

Do artificial sweeteners increase the risk of type 2 diabetes?

The answer to this question is complicated. The large study in France did show some increase in type 2 diabetes in the group that took the largest amount of artificial sweeteners. Some studies suggest that this effect may be due to the artificial sweeteners’ effect on the microbiome. Only sucralose, saccharine, and the sugar alcohols seem to affect the composition of the gut microbiome. It appears that people with certain kinds of composition of their microbiome are at risk of developing diabetes.

Other side effects of artificial sweeteners

People with irritable bowel syndrome may have increased symptoms from artificial sweeteners. People with inflammatory bowel disease (such as ulcerative colitis or crohn’s disease may have exacerbation of their symptoms from artificial sweeteners.

What about using honey, maple syrup, or agave as sweeteners?

Honey and maple syrup have some antioxidants that may be good for you, but they also have as much sugar as regular table sugar. Agave has mostly fructose as opposed to glucose, so it tends to make your blood sugar higher for longer. It also is only metabolized in the liver, and too much fructose can lead to fatty liver. Any of these in small amounts not too frequently is fine. The same is true for sugar.

Bottom Line

There are no health benefits to using any of the artificial sweeteners, including the ones derived from plants and fruits, and including the sugar alcohols. Evidence is accumulating that many of them may cause harm by increasing the risk of cardiovascular disease and adversely affecting the microbiome. You are much better off to use small amounts of sugar, honey, or maple syrup no more than a few times a week. You should avoid foods advertised as sugar free if any of the artificial sweeteners are listed on the label. Refer to the table at the beginning of this post to see what they are called.

New Drugs for Weight Loss – What are the Risks and Benefits?

Most people know these new effective weight loss drugs by their trade names: Ozempic, Wegovy and Mounjaro. Ozempic and Wegovy are different names for semaglutide. Mounjaro is the trade name for tirzepatide. All of these drugs are in the same class. They are called GL-P1 agonists. They mimic the action of a hormone called glucagon-like peptide. These drugs were developed to treat type 2 diabetes. They lower blood sugar by causing insulin release and also by delaying stomach emptying, which delivers less glucose to the bloodstream. The slowing of emptying from the stomach decreases appetite and causes an increased feeling of fullness. People on these drugs tend to reduce their calorie intake fairly markedly and that is how they work for weight loss.

Common Side Effects

The most common side effects of all these long acting medicines are nausea, vomiting, abdominal pain and diarrhea. These side effects usually disappear within a few weeks, and are less likely to happen if they are started at a low dose and increased gradually. Occasionally they are persistent. Some somewhat less common side effects include headache, fatigue, dizziness, constipation, heartburn, bloating, belching and flatulence (passing gas). People with diabetes can sometimes get low blood sugar. Again, most of these side effects usually go away within a week or two. Occasionally they can be persistent.

Rare Side Effects

These side effects are rare, but much more serious and can result in hospitalization. They include severe allergic reaction, acute pancreatitis, gall stones, acute kidney injury, suicidal thinking, and cancer of the thyroid.

Long Term Effects

The evidence so far is that stopping these medicines results in weight gain back to the original weight. That means that people are likely to have to stay on these medicines to maintain the weight loss. We know that the medicines are relatively safe when taken for two years, but we have no idea what long term side effects might be, or even if the medicines will continue to work past two years.

How well do they work?

The medicines are given by injection once a week and they work very well. These are the most effective medicines for weight loss that we have ever had, and there are some new ones in the pipeline that may even work better. As with any medicine, there are risks as I have documented above as well as benefits. You would not want to take one of these medicines unless the benefit exceeds the risk.

Who should take these medicines and who should not?

Obesity increases the risk of diabetes, heart disease and cancer, especially colorectal cancer. The best predictor of risk of disease from obesity is the waist circumference. Just take a tape measure and measure your waist at the level of the belly button. If you are female your risk of cancer starts to increase if your waist circumference is more than 31.5 inches. Your risk of cancer, especially colorectal cancer increases 5% for every inch above 31.5 inches. Above 35 inches the risk of diabetes, and cardiovascular disease starts to go up. For men the numbers are 37 inches for the risk of cancer going up and 40 inches for the risk of diabetes and cardiovascular disease.

The best treatment for obesity is prevention. That means eating unprocessed foods and regular exercise. If you are already overweight or especially if you are obese, it is very hard to lose weight and keep it off. Once you lose weight, your body thinks it is starving and all kinds of hormones and body changes kick in to try to get the weight back.

If your waist circumference is over 31.5 if your are female and 35 if you are male, then you are a candidate for one of these new weight loss medicines. For you the benefit likely outweighs the risk. If your waist circumference is less than those values, then the risk of taking these medicines is much higher than the potential benefit.

Cost

If your insurance does not cover medicines for weight loss the cost of these medicines may be prohibitive.

Wegovy costs $1,349.00 a month without insurance.

Ozempic costs $892.00 a month without insurance.

Muanjaro costs $1,300 a month without insurance.

Unfortunately many insurance plans do not cover weight loss medicines.

Diet and Heart Disease – Not as Simple as We Thought

We have all been told for years that the main dietary risk factor for heart disease and stroke is how much saturated fat we eat. We have also been told that eating foods high in cholesterol also increases risk of heart disease and stroke. Evidence is accumulating that consumption of saturated fat increases risk of heart disease and stroke little if at all. Since your body makes cholesterol itself, eating cholesterol rich foods has almost no effect on serum cholesterol. Other aspects of diet have a much greater effect on increasing the risk of heart disease and stroke. In this post I will summarize the evidence and spend some time discussing things we eat and drink that do substantially increase the risk of heart disease, stroke and other chronic diseases.

The Seven Country Study

The most famous study that led to the saturated fat hypothesis was carried out by Ancel Keys. The study started in 1956 and was published in 1978. He looked at the dietary patterns of 7 different countries. The countries included Finland, Greece, US, Italy, Yugoslavia, Netherlands and Japan. He found that saturated fat intake was correlated with increased risk of heart attack and stroke. The country with the lowest saturated fat intake was Crete in Italy, which also had the lowest incidence of heart disease and stroke of the 7 countries. The diet of Crete is the basis for the famous Mediterranean Diet.

Diets of free living humans are notoriously difficult to measure. Keys did his best to accurately determine diet. He had a subset of his subjects in each country weigh their food for a number of days, which is considered the gold standard for dietary studies. The problem with any population study like this is that populations in different countries differ in lots of other ways besides diet. Also diets are complex, so some other factor or factors in diet could account for the low heart disease incidence in Crete. Another problem was that diet was measured in Crete during Lent, when most people did not eat meat. All Keys could really say was that saturated fat intake was associated with heart disease, but he could not say that saturated fat caused heart disease.

People who adhered to the Mediterranean Diet did reduce their population risk of heart disease, but there is a lot more to the Mediterranean Diet than reduced saturated fats. It also includes little added sugar, lots of vegetables and fruit and mostly unprocessed foods. It is not clear that reduction in saturated fat is responsible for the health benefits of the Mediterranean Diet.

The Framingham Study

The next big population study was the Framingham Study. A large group of people in Framingham Massachusetts was followed over many years with surveys about diet, activity, smoking and laboratory measurements of total cholesterol, LDL, HDL and triglyerides among other measurements. Heart attacks, strokes, death from either of these things and death from any cause were recorded in the study group. This was the first large study that implicated cigarette smoking as a cause of cardiovascular disease and cancer. It was also found that the higher the total cholesterol and especially the higher the LDL (low density lipoprotein) the higher the risk of cardiovascular disease. It was also one of the first studies that showed that the higher the blood pressure, the greater the risk of cardiovascular disease. This was a tremendously important and well done study.

The Diet-Heart Hypothesis

The diet-heart hypothesis is that saturated fat is the main dietary cause of cardiovascular disease. It has been very influential over 60 years and is still promoted by the American Heart Association and many cardiologists. Here is the train of thought. The 7 country study implicated saturated fat as associated with cardiovascular disease. It has been found through multiple studies that saturated fat intake raises LDL (so called bad cholesterol). The Framingham study showed that increased LDL was a major risk factor for cardiovascular disease. Since saturated fat raises LDL, therefore saturated fat must cause cardiovascular disease.

That makes perfect sense, so many randomized trials were carried out to nail down the diet-heart hypothesis. Unfortunately, as is often the case with beautiful theories, further randomized trials did not consistently show the expected increase in heart disease from eating saturated fat. The other part of the hypothesis was that eating polyunsaturated fats would decrease the population risk of heart disease. That was based on the observation that consuming polyunsaturated fats decreased LDL levels. Randomized trials have generally failed to consistently show that eating polyunsaturated fats reduces the risk of cardiovascular disease.

Reduced Risk of Cardiovascular Disease in US

Heart disease was epidemic in the US, peaking in the 60’s. Since then, the incidence of heart disease in the US and most other developed countries has decreased by 60%! Scientists debate the cause for this decline. Although saturated fat consumption decreased some, Americans still eat much more saturated fat than the 5% of fat recommended by the American Heart Association. So the fact that we eat somewhat less saturated fat does not explain the remarkable decline in heart disease over the last 60 years. What else changed?

Cigarette Smoking

In the 1940’s half of all Americans said they smoked cigarettes. Smoking began to decline in the US in the 60’s and today only 11.5% of Americans smoke tobacco! This has to be a major factor in the decline of cardiovascular disease (and lung cancer).

High Blood Pressure

High blood pressure is a major risk factor for heart disease. The number of people with high blood pressure successfully controlled on medicine has more than doubled since 1960. This is clearly another major factor in the decline of cardiovascular disease

Trans Fats

The rise of trans fat consumption was an unintended consequence of the heart-diet hypothesis. Because animal fat (mostly saturated fat) was postulated to cause heart disease, the food industry started figuring out how to use vegetable oil to replace lard and butter, which were high in saturated fats. They needed something that would be solid, not liquid at room temperature. They discovered that if they partially hydrogenated vegetable oil, then it would be solid at room temperature and could substitute for lard and butter. They marketed these products as healthier because they were only partially saturated fats, not saturated fats. The medical establishment bought this story and recommended margarine as a substitute for butter and Crisco (the most successfully marketed shortening substitute) as healthier alternatives. I have been unable to find statistics on trans fat consumption in the US, but it was very large.

It turns out that consumption of trans fats markedly increased the risk of cardiovascular disease. For every 2% increase in the consumption of trans fats, heart disease increased by 23%. This is a shocking number! The consumption of trans fats certainly contributed to the epidemic of heart disease in the 50’s and 60’s. The FDA essentially banned the addition of trans fats to food in June of 1978. The elimination of trans fats is almost certainly another major factor in the decline of heart disease.

Interesterification

Since trans fats have been banned, food companies have come up with a new way to make vegetable oil solid and spreadable. It is called interesterification. It is complicated, but the simplest explanation is that it involves changing the arrangement of fatty acids on a glycerol backbone. These are fully hydrogenated fats, so are not trans fats. We know very little about how these new industrial fats affect human health, but the information we do have suggests that these new products may be just as bad for you as trans fats. You would do best to avoid them until we know more. More about how to do this later in this post.

Do we need to limit red meat consumption?

The main risk of consumption of any food is eating too much of it. It is total calorie intake that makes us fat, and being fat increases the risk of cardiovascular disease, diabetes and some cancers. Eating red meat by itself is very unlikely to increase your risk of heart disease as long as your total calorie intake is equal to the calories you burn up. So there is very little health risk to you in eating red meat, but there is a big risk to the environment. Cattle raising worldwide contributes about 16% of greenhouse gas emissions. Here is a link to a balanced discussion of greenhouse gas emissions from cattle raising: Livestock Don’t Contribute 14.5% of Global Greenhouse Gas Emissions.

The other thing to think about when consuming any meat product, including chicken is that almost all the meat you buy in the grocery store comes from giant factory farms, where animals are treated very inhumanely. That in itself is bad enough, but raising all those animals together increases risk of spreading disease to the people who eat them. Antibiotics are used in many factory farms to keep animals from getting sick. This contributes to the evolution of bacteria that are resistant to most antibiotics.

If you are not willing to give up eating meat entirely, try to find locally raised beef, pork and poultry. Farmer’s Markets are a good place to find meat from locally raised animals. It may be a little more expensive, but likely a lot safer.

What about eating fish?

If you are at high risk of cardiovascular disease or have cardiovascular disease then eating oily fish (salmon, sardines, anchovies, herring, mackerel, tuna, swordfish) twice a week reduces your risk of a heart attack by 50%. If you are at average risk, these fish don’t have unusual health benefits but if you like them, it’s fine to eat them. Because most of these fish contain some mercury they should probably be avoided by pregnant women and children. If you get canned tuna, get Pacific Island Tuna at Walmart. It is sustainably caught. Here is a link to an article from the Nature Conservancy about it: The Nature Conservancy. By the way taking fish oil is not nearly as good for you as eating fish.

Highly Processed Foods

There are convincing data that consumption of lots of highly processed foods leads to health concerns ranging from increased risk of obesity, high blood pressure, breast and colorectal cancer, to dying prematurely from all causes.These foods all also contain additives whose health effects have never been adequately tested. How do you recognize them? Just look at the label where the ingredients are listed. If there are more than two things you don’t recognize, put it back on the shelf. Here is an example of an ingredients list from a loaf of bread!

This is not bread you would want to eat! If you mostly stay out of the central aisles of the grocery store you will avoid most highly processed foods. Just be sure to look at the ingredients label before you buy anything.

It is all well and good for me to make these recommendations, but highly processed foods and factory farmed meat are cheap. People who are poor cannot afford to buy anything else. This is only one of the things that have led to the major health inequities that are present in this richest country in the world.

Foods that decrease risk of cardiovascular disease

Fiber

Increased dietary fiber has been shown to decrease risk of cardiovascular disease. This may well have to do with promoting a healthy microbiome in the intestine. Sources of fiber that promote growth of healthy gut bacteria are ones that contain inulin. The highest sources of inulin are leeks, asparagus, onions, wheat, garlic, chicory, oats, soybeans, and Jerusalem artichoke. Sourdough bread (no added sugar, honey, or high fructose corn syrup) is also a good source of fiber. Whole grains, fruits, nuts and vegetables are also good sources of fiber.

Fresh Fruits

Fresh fruits are a good source of fiber and also contain many beneficial nutrients including vitamins and antioxidants. Data from multiple studies show that eating fresh fruit daily reduces risk of cardiovascular disease.

Nuts

Eating a handful of nuts per day reduces your risk of heart disease by 20%. Peanuts are technically of legume, not a nut, but legumes reduce the risk of cardiovascular disease as well. Unsalted nuts are better for you than salted.

Whole grains

Whole grains are also a good source of fiber and other beneficial nutrients. Eating whole grains most days is associated with decreased obesity, diabetes and heart disease. Examples of whole grains are

  • Barley.
  • Bulgur, also called cracked wheat.
  • Farro.
  • Millet.
  • Quinoa.
  • Black rice.
  • Brown rice.
  • Red rice.
  • Wild rice.
  • Oatmeal.
  • Popcorn.
  • Whole-wheat flour.
  • Whole-grain breakfast cereals.
  • Whole-wheat bread, pasta or crackers.

Make sure to read the ingredients label for cereals and crackers. Don’t buy anything that has more than two ingredients you don’t recognize.

Fresh Vegetables

Fresh vegetables are also a good source of fiber. Sorry folks, but potato chips and french fries do not count as fresh vegetables! Once again eating fresh vegetables daily significantly lowers your risk of cardiovascular disease.

Bottom Line

Eating red meat and saturated fats does very little to increase your risk of heart disease, but it also does not reduce your risk. Raising livestock on factory farms causes significant harm to the environment and puts people at risk of infectious disease. Eating meat from locally raised animals is safer.

Eating high fiber foods, whole grains, nuts, fruits and vegetable does substantially reduce your risk of cardiovascular disease as well as cancer.

Eating highly processed foods, and this includes the new industrial fats made by interesterfication increases your risk of cardiovascular disease and cancer. The biggest risk of these is probably because they encourage people to eat more calories than they need and have almost certainly led to the epidemic of obesity.

The most concise recommendation for a healthy diet comes from author Michael Poulin: “Eat food (food is anything your grandmother would have recognized as food), mostly plants, not too much.”

Type 2 Diabetes Mellitus: Anatomy of an Epidemic

This begins a series of posts on chronic diseases. Nearly half of Americans suffer from at least one chronic disease. Chronic diseases include diabetes mellitus, high blood pressure, cancer, stroke, heart disease, respiratory diseases, arthritis, obesity, and oral diseases. Chronic diseases are responsible for 7 out or every 10 deaths in the United States. Almost of these diseases can be prevented or managed successfully.

Type 2 Diabetes mellitus has reached epidemic proportions in the United States. One in every ten people in the United States has type 2 diabetes mellitus. It is the 7th leading cause of death in the U.S. In this post I will talk about the causes of type 2 diabetes mellitus, how it can be prevented, and how it can be treated by diet and exercise modification.

Terminology

The correct terminology for excesssive blood sugar is diabetes mellitus.The greek word from which the word diabetes comes means ”a large discharge of urine.” Mellitus comes from the greek word meaning “sweet.” There is another kind of diabetes (large discharge of urine) called diabetes insipidus, which is a completely different disease. Diabetes insipidus is caused by a deficiency of a hormone called vasopressin that is secreted at the base of the brain.

There are two types of diabetes mellitus and they both cause high blood glucose but they have completely different causes. Type 1 diabetes mellitus is an autoimmune disease that destroys the beta cells in the pancreas, which are the cells that produce insulin. It usually occurs in childhood, often following a viral infection. It is much less common than type 2. People with type 1 diabetes mellitus have high blood glucose because they produce no insulin at all and have to be treated with insulin. People with type 2 diabetes mellitus make plenty of insulin, at least in the beginning of the disease. Their bodies are resistant to insulin, and even though their insulin levels are high, the insulin can’t carry glucose into the body’s cells like it is supposed to and the blood glucose rises. In the rest or this post I’m going to talk exclusively about type 2 diabetes mellitus.

Causes of type 2 diabetes mellitus

Type 2 diabetes mellitus is caused by a complex interaction between genetics and environment.

Heredity

Type 2 diabetes mellitus tends to run in families. The lifetime risk of developing type 2 diabetes mellitus is 40% for individuals who have one parent with type 2 diabetes (I will leave off the mellitus from here on out for the sake of brevity) and 70% if both parents are affected. We know some of the genes that are associated with risk of developing type 2 diabetes but they only account for about 20% of the heredity, so there are a lot more genes to find. Genetic risk is not destiny, though. Environment plays a huge role in the development of type 2 diabetes.

Causes of Insulin Resistance

Insulin resistance is the hallmark of type 2 diabetes. Insulin resistance starts well before the onset of diabetes. At first your pancreatic beta cells make enough extra insulin to keep your blood sugar normal. Eventually, though, they can’t keep up and blood sugar starts to rise. A number of things can lead to insulin resistance, which I will outline below.

Abdominal body fat

Increased waist circumference (greater than 40 inches for men and 35 inches for women) is a marker for what is called visceral fat, which means fat around the internal organs. Visceral fat is one of the main causes of insulin resistance. Just being over fat in general is also a cause of insulin resistance.

Sedentary Lifestyle

Lack of regular exercise causes insulin resistance. I will talk more about exercise later on when I discuss preventing and treating type 2 diabetes.

Diet

A diet high in processed foods with starchy carbohydrates and sugar (or high fructose corn syrup) causes increased insulin release and can eventually lead to insulin resistance.

Microbiome

The microbiome refers to the 100 trillion bacteria that live in our intestinal tracts. The bacteria in the microbiome help digest our food, regulate our immune system, protect against other bacteria that cause disease, and produce vitamins including B vitamins B12, thiamine and riboflavin, and Vitamin K, which is needed for blood coagulation. It turns out that the microbiome may also promote or reduce insulin resistance depending on what kinds of bacteria live in our intestine. Research about this is just beginning, but here is what we know so far. People with type 2 diabetes have a lower diversity of bacterial species in their gut. They specifically lack bacterial species that produce something called butyric acid. Increased bacterial diversity in the microbiome and especially bacteria that produce butyrates are associated with lower insulin resistance. At this point we don’t know if changing the microbiome will help treat or prevent diabetes, but this is an exciting possibility.

Prediabetes

When genetic predisposition and environment interact, insulin resistance starts to develop. There is a condition called prediabetes. It develops up to ten years before people develop frank type 2 diabetes. There are two tests used to diagnose prediabetes (or actual type 2 diabetes). One is called fasting blood glucose. The blood glucose is tested after fasting overnight. Another test is called hemoglobin A1C. It turns out that glucose in the blood forms a molecular bond with the hemoglobin in red blood cells. This molecular bond lasts for the life of the red cell, which is about 90 days. The amount of hemoglobin that is bonded to glucose is proportional to the average blood glucose level over the 90 day life of the red cell. We can measure the amount of hemoglobin bonded to glucose and that gives us a pretty good measure of the average blood glucose over the last 3 months.

Prediabetes is defined as a fasting blood glucose of 100-125 and/or a hemoglobin A1C of 5.7%-6.4%. If either one of these values is higher, then that makes the diagnosis of type 2 diabetes.

The importance of finding prediabetes is that by making diet and lifestyle changes people can prevent the onset of type 2 diabetes. It is much easier to prevent type 2 diabetes than it is to treat it once you already have it.

How to prevent or reduce insulin resistance (whether you have prediabetes or have progressed to frank type 2 diabetes).

  • Reduce body fat especially if you have excessive abdominal fat. Refer to my previous post (The Psychology of Eating and How to Use It Your Advantage) for tips on how to do this sustainably.
  • Increase your exercise. The CDC recommends 150 minutes a week of moderate exercise (brisk walking for 30 minutes, 5 days a week, for example) or 75 minutes per week of vigorous exercise (jogging or running for 25 minutes 3 days a week for example).
  • Avoid highly processed foods with added sugar, honey, maple syrup and especially high fructose corn syrup. Replace them with fresh fruit, fresh vegetables, fish and poultry.
  • Increase the soluble fiber in your diet. Soluble fiber promotes growth of diversity in your microbiome. Here is a link to an article from Healthline.com that identifies the top 20 foods with soluble fiber: Top 20 Foods High in Soluble Fiber
  • Eat fermented foods with live bacteria in them such as plain yogurt (sweeten with added fruit or berries, not sugar) sauerkraut, or kimchi. These add healthy bacteria to your microbiome. Here is another link to Healthline.com that lists a number of fermented foods that are good for you: 8 Fermented Foods and Drinks to Boost Digestion and Health.

Dietary Treatment of Type 2 Diabetes

If you already have type 2 diabetes you can do all of the things listed above to decrease insulin resistance, which means you may be able to get by on less or no medicines. If you are on any diabetic medicines other than metformin, you should let your doctor know of any changes you plan to make in your diet or exercise. He or she may want to reduce your medicines so you don’t get your blood sugar too low.

There are some additional dietary changes that may help your blood glucose be under better control and reduce or eliminate your diabetic medicines. These are things you definitely need to check with your doctor before you try them.

Ketogenic Diet

There is good evidence that a ketogenic diet is very good for people with type 2 diabetes.

What are ketones?

Normally your body uses glucose for energy for the brain and other body functions. Insulin carries the glucose into cells so they can use it for energy. If you don’t take in enough carbohydrates to produce glucose for energy, then your body starts to mobilize fat. Fat cannot be broken down to glucose, but it can be broken down to something called ketones. Your body and brain can switch over to using ketones for energy. Ketones require little or no insulin to get into cells.

What do you eat on a ketogenic diet?

A ketogenic diet is a very low carbohydrate high fat diet. That sounds unhealthy and it can be if you eat mostly saturated fats. A good ketogenic diet uses mostly healthy unsaturated fats. Here is a link to another Healthline.com article that discusses ketogenic diets for type 2 diabetes: How the Ketogenic Diet Works for Type 2 Diabetes. Do not start a ketogenic diet without checking with your doctor first!

Intermittent Fasting

Intermittent fasting means exactly that. Fasting means not taking in any calories for certain periods. There are all sorts of ways to do intermittent fasting. Most commonly, people fast for 24 hours every other day or they eat all their meals within a limited time period, between 7AM and 3PM for example. There is increasing evidence that intermittent fasting improves control of type 2 diabetes over and above the fat loss that results. Here is a link to a recent review article about the benefits of intermittent fasting for type 2 diabetes: Intermittent fasting: is there a role in the treatment of diabetes? A review of the literature and guide for primary care physicians.

It is important to drink plenty of water when doing intermittent fasting. If doing fasting for longer that 24 hours, one needs to drink liquids with electrolyes rather than plain water. People with type 2 diabetes should NOT start an intermittent fasting program without checking with their doctor.

Further Reading

If you want to read more about diet and lifestyle treatment of type 2 diabetes, here is a link to an excellent book by Dr. Jason Fung: The Diabetes Code: Prevent and Reverse Type 2 Diabetes Naturally.

The Biology of Fat Gain and Fat Loss

Fat storage is a way for mammals to manage energy allocation. Fat cells are not simple storage depots, but are metabolically very active. They respond to and produce hormones and other messenger molecules. A certain amount of body fat is essential for mammals, especially humans who have to maintain a large brain which uses a lot of energy. In adult humans 20% of basal metabolism is devoted to maintaining the brain. For infants, that number is closer to 80%. Fat storage gives humans the flexibility to manage environmental stresses such as variation in food supply.

In most of human history there was a balance between energy intake (eating) and energy output. Energy output includes energy to keep the body intact (basal metabolism), energy required to digest food (thermic effect of food) and exercise. Some of the energy from eating goes into fat storage, but the quantity of body fat is also kept in balance. This balance of energy intake, fat storage, and energy output is maintained by a complex feedback system. Most of the research into how energy balance happens has been done in animals, and we still don’t understand exactly how that translates to humans, but we are able to sketch the broad outlines of how the system works. This system involves messenger chemicals and the reward system in the brain. I won’t go into all the complexities here (It is so complicated it would make your eyes cross) but I will give you the simple version.

Leptin

Fat cells produce a hormone called leptin. The amount of leptin they produce is proportional to the amount of fat storage. Leptin decreases appetite and increases satiety (feeling that we have had enough to eat).

Ghrelin
When the energy output is greater than the energy input fat storage decreases and leptin decreases. The stomach makes a hormone called Ghrelin, which increases appetite. We then eat more food until the body fat gets back to the balance point.

The brain reward system

Humans evolved to find sweet high calorie density foods intensely pleasurable. That is probably because such foods were rare or at least seasonal for our hunter-gatherer ancestors. These kinds of foods cause dopamine release in the brain. This is the same system that makes drugs of abuse pleasurable. Eating in general stimulates this system to some extent. From an evolutionary standpoint eating being pleasurable has obvious survival benefit.

How fat storage gets out of balance

Our hunter gatherer ancestors took in lots of calories, but they also burned lots of calories in the hunting and gathering part. In our modern society we don’t have to exercise very much to get our food, so our daily calorie expenditure is a lot less on average than our hunter gatherer ancestors. Moreover, we have the big food industry which has learned very well about the kinds of foods that stimulate our brain reward system the most. The more calories we eat, the bigger their profits. The foods that maximize their profits are calorie dense processed foods with lots of sugar and starchy carbohydrates. We live in what the scientists call an “obeseogenic” environment. The easy (and cheap) availability of high sugar, high carbohydrate foods maximally stimulate the brain reward centers and overwhelm the rest of the energy and fat regulatory system. The result is that many of us increase fat storage up to the point that the extra calories it takes to move our large bodies around get most of us into balance again, but at a much higher level of body fat. Some unfortunate people continue to gain fat until they become disabled by the huge amount of body fat they carry. As I discussed in the previous post, that increased percentage of body fat increases the risks for heart disease, diabetes and cancer.

Addressing the epidemic of overfatness

While I intend to focus later on what individuals can do to lose fat permanently the thing that all of us need to do is to work at a political and social level to change the ”obeseogenic” environment. That will include things that increase the expense of high sugar high carbohydrate foods (like voting for taxes on sweetened beverages) and decrease the expense of healthy unprocessed foods like fresh fruits and fresh vegetables (like allowing food stamps to be used at farmers markets). It is unconscionable that ”food deserts” exist in some communities so that the only foods available are at convenience stores that sell only obeseogenic foods. We also need to work toward changing the exercise environment so that all communities (not just the wealthy ones) have safe walking trails and exercise facilities. All of us, fat or thin, need to do what we can to change the food and exercise environment.

The biology of fat loss

The only way to lose fat is for the calories we eat to be less than the calories we burn. That is a truism, but it is not very helpful in creating strategies for successful fat loss. So what does the body do when we change our energy balance to less energy in than energy out?

The first thing that happens when we have a negative energy balance is that leptin, the satiety hormone secreted by fat cells goes down. It actually goes down before we lose any fat. Ghrelin, the appetite enhancing hormone goes up.

As the body starts to lose fat several other things happen. The basal metabolic rate decreases. Muscles get more efficient, so the calories we burn per minute of exercise goes down as well. All these changes decrease energy output to try to match the decrease in energy input. This means that fat loss starts to slow down and eventually stop, even though we are eating the same number of calories that caused fat loss in the beginning. Not only does energy output decrease, the body sends powerful signals that increase appetite that make it more and more difficult to keep from increasing our calorie intake. The end result is that 90% of people who lose a lot of fat gain most or all of it back eventually, most within a year. Even more depressing, the low metabolic rate persists even after the fat is regained. Contestants in show The Biggest Loser still had low metabolic rates 6 years after the show, when almost all of them had gained back the fat they lost. In fact, their basal metabolic rates were even lower than when they lost the fat.

I’m sure at this point after hearing all this you are depressed and are saying to yourself, ”what is the point of even trying to lose fat.”

Bad News and Good News

The bad news is that all these mechanisms that operate to make you regain the fat you lost are proportional to the amount of fat you lose. Very fat people who lose enough fat to get close to ideal body fat have an almost impossible time staying there. The body mechanisms that work to bring the body back to the original amount of body fat are just too powerful to resist.

The good news is that permanent fat loss of around 10 percent of your body weight is possible by making permanent changes in your eating and exercise habits. The other good news is that modest fat loss makes a big difference in your risk of high blood pressure, diabetes, heart disease and cancer.

In the next post I will talk about the unconscious mechanisms that contribute to over eating. I will also talk about setting reasonable goals for weight loss and how to go about making permanent changes in your diet and exercise.

Why is the United States So Fat and What to do About It

I’m going to take a break from the series of posts on healing relationships for a while and start a new series of posts about the epidemic of fatness in the U.S. This is an especially opportune time to talk about the epidemic of overfatness in the U.S.. Many people have gained fat during the last few years of the pandemic, and the holidays always make it worse. In this series I will talk about the causes of the epidemic, how to measure body fat, some common myths about fat loss and then discuss the science behind fat loss and fat gain. Finally I will give some practical suggestions for losing fat and keeping it off.

The epidemic of fatness

I use the term fatness on purpose, rather than overweight or obesity. It is really too much fat that causes bad health consequences. The CDC defines obesity as a BMI (body mass index) of 30 or higher. I will talk later about the problems of using BMI as a measure of fatness, but when the BMI is 30 or higher it is a pretty good indicator of fatness and health risks. In 2018 (the last year we have complete data) 42.4% of adults in the U.S. had a BMI of 30 or greater. That means nearly half of adults have all the health risks associated with overfatness! These include heart disease, stroke, cancer and diabetes. More than 10% of adults have type 2 diabetes. In the 1950’s only 10% of adults in the U.S. had a BMI of 30 or greater and less than 1% had type 2 diabetes. We see the same trends in children and adolescents. What happened?

In 1980 there was a scientific consensus that dietary saturated fat caused heart disease. The evidence was flawed, but that will be a subject for another post. The US dietary guidelines for that year recommended lowering dietary fat to 30% of calories. People reduced their fat intake modestly, but the food industry substituted sugars for fats in processed foods. This increased total calorie intake. There were other factors as well. The average restaurant meal is four times larger than it was in the 1950’s. The size of American manufactured dinner plates increased from 9.6 inches to 11.8 inches. Average physical activity for both adults and children has decreased as well. The result of all of these factors has resulted in a 24% increase in average daily calorie intake.

Type 2 diabetes is caused not by insufficient insulin, but by resistance to the insulin your body makes. The most common cause of insulin resistance is being too fat. Thus the epidemic of diabetes parallels the epidemic of fatness.

Are you too fat?

The most common measure of how fat you are is called BMI (body mass index). The BMI is your weight in kilograms divided by your height in meters squared. The easiest way to calculate your BMI is to use a BMI calculator app that lets you enter your height in inches or feet and your weight in pounds. Here is a link to one BMI calculator.

Although BMI is easy to calculate it is not a very good measure of body fat. It is most useful at the extremes. If your BMI is over 30 then there is a 95% chance that you have an unhealthy amount of fat. If your BMI is less than 18 then your body fat percentage is likely to be too low to be healthy. In between these extremes, BMI is not very good as an estimate of unhealthy body fat. For people who have a high amount of muscle mass (professional athletes for example) BMI can significantly overestimate body fat. For others, particularly the elderly, BMI significantly underestimates per cent body fat.

Other ways to estimate body fat

Ideal body percent body fat varies by sex and age. Below is a table of ideal body fat percentage from Beth Israel Lahey Health Winchester Hospital.

AgeHealthy Body Fat % (Women)Healthy Body Fat % (Men)
20-3921%-32%8%-19%
40-5923%-33%11%-21%
60-7924%-35%13%-24%

Electrical impedance

There are a number of consumer grade scales that advertise that they measure weight and per cent body fat. They use something called electrical impedance to do this. A small imperceptible electric current is passed through your body. Fat and bone have more resistance than muscle and body water. The machine uses a formula to calculate per cent body fat. The formula uses age, sex and height. These values are usually entered through some sort of smart phone app.

Most of these scales use only two electrodes, one for each foot. These are not very accurate. Scales that use four electrodes, one for each foot and one for each hand, are considerably more accurate. Most of the four electrode models cost thousands of dollars, but I did find one that sells for $349. Here is a link to that scale’s website.

Skin fold calipers

Measurement of per cent body fat using skin fold measurements is quite an accurate way to measure body fat. Skin fold calipers are not particularly expensive but it takes a lot of experience to use them correctly. The skin folds have to be measured in seven different places. Some trainers at gyms have been trained to do skin fold measurements. This is not a practical method to use at home.

Other methods for measuring body fat

There are some very accurate ways to measure body fat including a special kind of x-ray and being immersed in a tank of water to see how much water you displace. Both of these methods require expensive specialized equipment. These methods are mostly used in research and are not even available at most hospitals.

Waist circumference

The biggest health risk is the amount of fat inside the abdomen around the intestines and organs. This is called visceral body fat and it is easy to measure. Get a cloth tape measure and measure your waist circumference. The correct way to do this is to feel for the top of the pelvic bone on both sides and measure just above this. That will be about at the level of your belly button. For women if your waist circumference is greater than 35 inches you have triple the risk of diabetes, heart disease and cancer. Women with a waist circumference of 31.5 inches to 35 inches have a lower risk, but still moderately elevated. Women who have a waist circumference of less than 31.5 inches have the lowest risk. For men the equivalent numbers are: High risk: greater than 40.2 inches. Moderate risk: 37 to 40 inches. Low risk: less than 37 inches.

Fat around the hips and buttocks is not associated with any significant health risk. In other words, pear shaped is better than apple shaped!

Losing Fat

Lets say you have calculated your BMI, measured your waist circumference and perhaps measured your body fat percentage using one of the impedance devices. You have determined that you have an unhealthy amount of body fat. The next post will discuss myths about fat loss strategies as well as what we know about the science of fat loss and fat gain. For those of you who want to get a little preview, you can review the brief post I did in 2015 called How to Lose Weight and Keep It Off.