In January 2013, I had blood work drawn and to my shock and dismay I was diagnosed with metabolic syndrome. My fasting blood sugar was elevated and I had atherogenic dyslipidemia. In hindsight, the results of the lab should not have been a surprise as I not only had a strong family history of metabolic syndrome but I had also been displaying subtle signs of insulin resistance and diabetes. For example, I had gradually gained weight despite maintaining a robust exercise regimen. I was consistently fatigued and tired. Like most other people, I had ascribed these to an exhausting work schedule rather than any objective biomedical processes. Nevertheless, the results of the lab were eye opening and a clear indicator of biological dysfunction. Furthermore as an ER physician, I was a firsthand witness to the downstream ravages of metabolic syndrome but was wholly unprepared to deal with the disease itself.
As it was presented to me, my choices were two fold. Either to go on a lifelong regimen of cholesterol lowering and blood sugar controlling medications or to change my diet to adhere to a low fat, “healthy” carbohydrate diet with the goal of losing weight and decreasing my triglycerides and LDL cholesterol. I was hesitant to start medications, so I decided to try to diet route. Six months into my experiment, I was realizing that I was not making any impact on my disease burden. I had not lost any weight and my fasting blood sugars were still elevated.
During this time, I increasingly start to come across literature on the effects of carbohydrate restriction. I read about the results Dr Atkins had achieved in reversing insulin resistance and inducing weight loss with carbohydrate restriction. Additionally, I learned about the physiology of nutritional ketosis and its role as a dormant but potentially advantageous metabolic pathway. Lastly, I read an interesting quote by Jared Diamond. He states, “If each hour on clock represents 100,000 years…[and] the history of the human race began at midnight, then we would now be almost at the end of our first day. We lived as hunter-gatherers for nearly the whole of that day, from midnight through dawn, noon, and sunset. Finally, at 11:54 p. m. we adopted agriculture.” In other words, we as a human species have been eating carbohydrates sourced from grain, corn, and rice for 10,000 years of an existence of 2.4 million years. It showed me historically that grain, corn, and rice have not been a necessary component for a substantial portion of our evolution but currently roughly two thirds of caloric consumption is sourced from these three “staples.” These scientific and historical observations served as reasonable proof that carbohydrates in large quantities are not an essential macronutrient.
The last piece of the puzzle was uncovered by my genomic analysis. I personally have a very strong family history of normal weight diabetes and was beginning to think that I was metabolically under suited to metabolize carbohydrates. I verified this inkling via SNP analysis. My odds ratio for developing diabetes was significantly higher than the average population. Despite a relatively “healthy” lifestyle and not being clinically obese, I had become a diabetic mostly due to my decreased ability to effectively metabolize carbohydrates. At that point, I decided to self-experiment with carbohydrate restriction.
Although, I was never disciplined to enter nutritional ketosis, I have limited my carbohydrate intake between 50-100g with periodic lapses (but never for more than a few days). We now fast forward two years into my ‘n of 1’ experiment and I have been able to achieve dramatic results. My HgA1c is normalized, my triglycerides have dropped to normal level, and my cholesterol profile has improved. Additionally, I have lost 40 pounds and am at an optimal BMI. Over the last year since I have achieved my target weight, I have added lots of fat into my diet as a calorie source. I usually do not feel hungry and enjoy most of my meals (butter has a way of doing that).
My two years journey is not an isolated or uncommon experience. The web is plentiful with stories of carbohydrate restriction in terms of weight loss. Currently, two in three adults qualify as overweight, and one in three adults is clinically obese. More than 33% have metabolic syndrome, 25% have impaired fasting glucose, and approximately 11% of the population has type -2 diabetes. I would speculate that a vast majority these people are physiologically under-equipped to optimally metabolize large amount of carbohydrates (from any source). However, the ADA recommends a diet that sources 45% of its calories from carbohydrates. Why is carbohydrate restriction not even mentioned as a possible alternative in any of the authoritative nutritional guidelines. On the contrary, the ADA states that, “low-carbohydrate diets (restricting total carbohydrate to <130 g/day) are not recommended in the treatment of overweight/obesity. The long-term effects of these diets are unknown…” However, the above statement is false because the body shifts to a safe alternative pathway of energy metabolism – nutritional ketosis – in the absence of glucose. Furthermore, historically there has been a geographically diverse group of populations ranging from the Masai in Kenya to the Inuit Indians in Alaska who flourished for thousands (maybe millions) of years on low carbohydrate/high fat diets.
In reality, what perplexes me (as a physician and a patient) is the ‘one size fits all’ approach taken by the leading authorities such as the American Diabetes Association, American Heart Association, and the USDA. These organizations set dietary guidelines for 300 million Americans based on equivocal results from a small subset of the population. However, by most metrics, these guidelines have failed miserably. In my opinion, an individual diet must be designed for each person based on his or her ‘-omics’, lifestyle, environment, climate, and season. Furthermore, it is not only the type of food alone that is relevant; the entire process from food production to digestion is essential. We must consider how, where, and when the food is grown or raised, how it is prepared, how and when it is consumed, and finally the body’s response to the food. We might currently not be at that granularity, however, we must seek out and identify significant subsets of populations who will thrive with “alternative” nutritional guidelines. These dogmatic and often scientifically unsubstantiated guidelines have already taken and continue to take a substantial toll on the health of population. As Nina Teicholz recently stated in The Big Fat Surprise, “if we combine the lessons of both science and history” with our personal and cultural relationship with food “we may be able to make enlightened decisions about how to start down the path towards curing ourselves of chronic disease.”