Check out my new diet calculator--completely revised and updated

I spent some time last week rewriting the nutrition calculator that used to tell people how much protein they should be eating on a ketogenic low carb diet. Now it isn't restricted to ketogenic diets and provides several other new features. You'll find the calculator at:

http://www.phlaunt.com/lowcarb/DietMakeupCalc.php

I've revised it to do the following:

• Calculate caloric needs based on either total body weight or lean body mass by providing the ability to enter body fat percentage. This gives a much more accurate result for heavy people whose extra weight is largely contributed by fat which doesn't require much protein to sustain it.
• Provide the ability to specify how much fat-related weight you'd like to lose each week. The calculator will also flag unrealistic weight loss goals including those that would require cutting protein down to unhealthy levels.
• Allow any carbohydrate intake level to be entered. If the carbohydrates entered exceed 120 grams a day, the calculator changes its recommendation of fat and protein levels to match the nutrient intakes that appear to be the healthiest, based on the research I reviewed for my new book.

The calculator continues to account for the additional protein required by people on very low carb, ketogenic diets. But it also makes it clear that as carbs rise and the diet continues past the first few weeks when the body adjusts to the ketogenic state many people will need far less protein than they might think. Cutting out that excess protein is often the easiest way to break a low carb weight loss stall--and to eliminate diet-associated dragon breath.

I found that when I calculated my own caloric needs by entering my body fat percentage as measured by my Tanita scale first thing in the morning, the calorie and protein levels that the calculator came up with matched exactly the caloric intake and protein levels my food logging had shown to lead to continuing weight loss and, when I reached goal, successful maintenance.

This had not been the case when I calculated my nutritional needs using other online calculators that asked only for my total body weight. Most interestingly, entering my body fat percentage along with my total body weight into the new calculator provided a new daily calorie level that was a couple hundred calories higher than that provided by other calculators.

This eliminated the caloric difference that in the past I had attributed to the "metabolic advantage" of a ketogenic diet. It turns out that the only reason I could lose weight on a ketogenic diet at a higher caloric intake than suggested by the formulas beloved by nutritionists is that I have more lean body mass for my size than their whole-body based formulas assumed so I burn more calories.

This is in line with much of what I learned doing my research. I'd love to hear from you as to how the calculator's estimates match your own experience maintaining your current weight or achieving weight loss. Post in the comments section of this post and we'll keep the discussion going there.

Is Red Meat Dangerous?

An epidemiological study published a few weeks ago linked the consumption of red meat to a higher risk of death from all causes, cancer, and heart disease. You can read a good summary of it (with a link to the article at the bottom) here:

Science Daily: Red Meat Consumption Linked to Increased Risk of Total, Cardiovascular, and Cancer Mortality.

The study used data from "37,698 men from the Health Professionals Follow-up Study for up to 22 years and 83,644 women in the Nurses' Health Study for up to 28 years who were free of cardiovascular disease (CVD) and cancer at baseline. Diets were assessed through questionnaires every four years."

The study found that "One daily serving of unprocessed red meat (about the size of a deck of cards) was associated with a 13% increased risk of mortality, and one daily serving of processed red meat (one hot dog or two slices of bacon) was associated with a 20% increased risk."

This isn't the first study to link health problems with red meat so we shouldn't be too quick to dismiss its findings. However, given the methodology it used, we also shouldn't be too quick to blame the red meat for the problems it reveals.

Was it the Meat or What's IN the Meat?

The first problem is with the way the nutritional questionnaires are designed that were used in these studies. They ask questions about people's food habits, along the lines of "How many times in the past month did you eat red meat?" and then give multiple choice options for answers like "Less than 5 times" or "6 to 10 times."

What they don't ask is "Where did you eat your red meat?" "Was your Red Meat filled with MSG?" "Was your red meat fried on a grill covered with damaged oils?" "Was Your Red Meat full of pink slime?"

This is important, because you'd have to be delusional to argue that the red meat sold in most chain restaurants is anything but toxic. People who get a daily serving of red meat from a fast food hamburger probably are shortening their lives. Not because of the meat, but because of what else is in the substance they've been sold as "meat."

Did You Get Fries with That?

The second problem with the questionnaires is that they don't ask "what did you eat WITH your red meat? None of us would question that a "red meat" meal that is made up of 3 ounces (cooked) of pink slime on a bun covered with ketchup, sugary pickles, mayo made out of the cheapest oils, and served with a big side of fries cooked in damaged fat, washed down with a 32 oz sugary soda is likely to have severe health consequences, too. But that's how most people at their meat. And if that is the case, the combination of damaged oils and lots of carbs can explain the negative health consequences without any need to demonize red meat.

The Ambivalent Role of Iron

But even so, other research has turned up some significant problems with iron which may also play a part, though as we'll see, we may not be getting the damaging iron from meat since there are other sources of dietary iron to consider.

Iron is essential to life. Without it our blood couldn't transport oxygen to our cells. But too much iron seems to gum up the works. For more than a decade numerous studies have linked higher than normal levels of iron in the brain to the development of Alzheimer's. Too much iron also damages the beta cell, which is why people who have a genetic condition called hemochromatosis where their iron stores grow abnormally large develop diabetes. But high levels of iron also damage the beta cells in people who don't have this gene.

You can read a good review of how iron can cause or worsen diabetes in this article, which also points out that high iron levels contribute to some complications:

The Role of Iron in Diabetes and Its Complications. Sundararaman Swaminathan. Diabetes Care July 2007 vol. 30 no. 7 1926-1933

What Raises our Iron Stores?

So what raises our blood iron stores? Three ounces (cooked) of hamburger are listed as containing 15% of a typical person's daily need for iron. So you'd have to eat a lot of burgers each day to exceed the iron RDA.

Four ounces of rare roast beef contain 43% of your daily need, so if you are eating 12 ounces of roast beef a day, yes, you are eating what could be dangerous amounts of iron if you were doing this day after day.

But it turns out there is almost twice as much iron in a serving of kidney beans as there is in roast beef. (You can find a good listing of the iron content of various foods HERE) And to keep vegetarians from feeling smug, 3 oz of Tofu contains more iron than three ounces of roast beef.

But that's not where the dangerous amounts of iron are coming from, as the link just cited makes plain. Because it also tells us that a cup of "Oatmeal, fortified instant, prepared" contains two and a half times as much iron as a hefty serving of roast beef, clocking in at 10 mg per serving where the 4 oz of roast contains only 4.2 mg.

The key word to note here is "fortified." Because it isn't just your packaged oatmeal that has extra iron in it. Breakfast cereals do. Cheap breads do, too. And of course, you get 100% of your daily iron RDA in any multivitamin not markets as being for "seniors." More iron is absorbed from your food if you consume a lot of vitamin C either from fruits or vitamin pills. The latter fact may have something to do with why large studies have shown that supplementing with vitamin C for a long time raises the risk of death.

But not all the iron in your body comes from your food. You will also get more iron in your food if you cook it in cast iron pans. And cans made out of steel may also contribute iron to your diet, especially if they contain acidic foods. (Details HERE.)

In short, it's very likely that high iron consumption is dangerous. But most of the iron you consume is not coming from the red meat you eat. It might be informative to run a few day's worth of food consumption through some nutritional software to see exactly how much iron you are taking in each day. (This won't, of course account for iron coming in from pans or cans.) If you are consuming a lot of iron, cut back. It might help lower your blood sugar over time.

If your iron intake is high, you might also ask your doctor to measure your ferritin level at your next physical. The hemochromatosis gene is fairly widespread in European populations with 1 in 8 to 12 carrying it and 5 in 1,000 having the two copies that cause damagingly high levels of iron in the blood

it would also be a very good idea for all of us to limit our consumption of red meat to quality meats, avoiding the chemical-laden patties sold in restaurants.

No, WLS Does NOT Cure Diabetes--Study By Doctor with Conflict of Interest

The PR people from the Cleveland Clinic sent me a fact sheet about the study that was all over the news yesterday, which is being headlined as if Weight Loss Surgery was a cure for diabetes.

The facts presented in the sheet were slightly different and more informative than the summary presented in the New England Journal of Medicine research report.

Here's the research report: NEJM: Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes.

Here are extracts from the press release sent to me by the Cleveland Clinic's PR team. 150 patients participated in a 1 year-long trial. 50 had gastric bypass surgery, 50 had gastric banding, and 50 got the usual crap treatment from doctors including, undoubtedly, the advice to eat low fat/high carb diets. Here's what they report.

"After 12 months, a normal HbA1c (less than 6.0) was achieved in 42.6 percent of patients who underwent gastric bypass and 36.7 percent of patients who underwent sleeve surgery..."

Translation, 56.4% of those who had chunks of their stomachs amputated still ended up with blood sugar far from "cured" or even normal. The NEJM report says the average A1c for those having bypass was 6.4±0.9% that means, many still had A1cs up to 7.3%.

Those with gastric banding did even more poorly. 63.3% of them had A1cs over 6.0% The NEJM report says that their Average A1c was 6.6±1.0%, meaning that some still had A1cs of 7.6%.

Many of us can get A1cs under 6.0% just by cutting carbs. I have heard from hundreds of people, some of whom started out with A1cs well over 10.0% who did just that.

The study continues:

"The study authors reported some complications of surgery, but most were not serious. However, four patients did require a second operation. The study authors caution that the favorable results were observed after a relatively short follow-up period (12 months) and that long-term studies are needed to determine the durability of the findings."

Translation: 4 out of 100 people who had surgery ended up with a "complication" like their incisions opening internally that required them to be rushed to the hospital. The rest of the complications aren't detailed, but while not disturbing to the doctors, they may have been tough on the patients. Some complications of WLS can be projectile vomiting whenever people eat, severe mineral deficiencies caused by malabsorption syndrome, and surgical site infections that heal poorly.

It's important to note that this study only lasted 1 year and that previous studies of WLS find that the participants uncure themselves pretty quickly as time goes by. I blogged about earlier results claiming similar cure rates. You can read that post HERE.

This study reports, "There were no deaths." The current kill rate for this surgery ranges from 1 to 6 per thousand, so with only 100 people having the surgery, the fact that no one died doesn't mean its safe. If the kill rate is 1 per thousand and 150,000 people have the surgery, that's 150 people dead.

You can see the death rates for the surgery on this surgeon-created site. Bariatric Surgery Source: Gastric Bypass Surgery Deaths Note that surgeons only list the deaths that happen immediately after the surgery. Not those that occur from malnutrition and other longer-term surgically-caused problems.

To read more about the actual death rate associated with WLS when people are tracked more than 1 year, read the post I made two years ago HERE..

WHAT WASN'T MENTIONED IN THE COVERAGE

Here's the kicker, which appeared at the bottom of the press release: "This study was funded by Ethicon Endo-Surgery, Inc., a subsidiary of Johnson & Johnson, which is a company that designs and manufactures medical devices and surgical instruments. Dr. Schauer is a paid advisory board member of Ethicon, and is in complete compliance with all Cleveland Clinic COI policies."

Dr. Shauer is the first author listed on the NEJM paper. The disclosure, which didn't make it into any of the press coverage, makes it clear that he profits from the sale of the devices used for these weight loss surgeries. This is not research folks, this is a business promotion.

Do you really want to risk your life for a surgery that would give you results no better than you could get by getting serious about cutting down on your carbs? The same people who warn you it is "dangerous" to lower your A1c by cutting your carbs urge you to have this potentially fatal surgery to "cure" your diabetes. Shame on them!

If that's a cure, I'll stick to the disease. My A1cs have been far better than that for longer than 5 years, and so have those of many of you. (Post them in the comment section if you're inclined to.)

When To Test? A New Study Pinpoints Timing

One of the most common questions people email me is when exactly they should start measuring the "hour after eating" at which I suggest they should test their blood sugar. Does that hour start after the first bite or at the end of the meal?

Luckily for us, an obscure paper published last year give us a definitive answer. Luckily for me, that answer is identical to the advice I've been giving people who have asked me this question for the last five years. (I based my answer on a previous study and the reports of people posting about when they tested on online discussion groups.)

The study used used data collected from people with both Type 1 and Type 2 Diabetes, using insulin, who were wearing continuous glucose monitors. You can read it here:

Peak-time determination of post-meal glucose excursions in insulin-treated diabetic patients. Daenen S, et al. Diabetes Metab. 2010 Apr;36(2):165-9. Epub 2010 Mar 11.

For insight into why this study is so useful you have to keep in mind that the whole point of testing at one hour is to find the highest blood sugar reading after the meal.

This study found that the average blood sugar peak after breakfast was found at 72 minutes after the start of the meal, with most people's values falling between 49 minutes and 95 minutes.

However, one person in five saw a peak after 90 minutes from the start of the meal. The researchers observe that "Peak time correlated with the amplitude of postprandial excursions, but not with the peak glucose value." I.e. A rise of 100 mg/dl to 170 mg/dl from a starting value of 70 mg/dl would take longer than a rise of 30 mg/dl from 140 g/dl to that same 170 mg/dl, which makes sense.

Since many of us spend about 15 minutes eating a meal, this explains why many people will do just fine if they test hour after finishing their meal.

But not everyone gulps down their meals, so how fast we eat along with several other factors, including how fast our digestion works and what kinds of foods we eat, will also influence when that blood sugar peak occurs.

For example, some people find that meals heavy in fat digest more slowly than those that are made up mostly of starches and sugars. Large meals of any composition may produce a slightly delayed spike. And meals heavy in protein may, under some conditions, produce a rise in blood sugar at the next meal because dietary protein can be converted into blood glucose over a period of six hours.

So what we can take from this is that, as is so often true with anything to do with blood sugar, the only way we can know for certain when our own blood sugar is likely to peak is by testing at various times after eating the exact same meal and discovering when we see the highest reading for that meal.

If you always see the peak a lot earlier or later than the average person would, adjust your testing schedule. But don't make yourself crazy about it. A rough approximation of an hour after the end of the meal or an hour and fifteen minutes after the first bite will give you a reading that for most people will be informative enough.

Given the poor accuracy of meters, a reading in the middle 100 mg/dl range could easily be 15 mg/dl higher or lower strictly due to meter variation so once you've determined that your highest readings aren't occurring significantly later than average--two hours after you start your meal, for example, don't fret about exact timing.

The other important piece of information we look for when we test after eating is how fast our blood sugar is coming down after that peak because the longer blood sugars stay over 140 mg/dl, the more damage they do. (Details on what researchers have found about wht blood sugar levels cause damage can be found HERE.)

When you take a second reading is up to you and depends on how many strips you have and what previous tests have taught you about how your blood sugar works. Most of us will find it informative to test an hour after the peak occurs to see how fast our blood sugar is dropping from its peak.

In this particular study people's blood sugar dropped on average 0.82 mg/dL per minute or 49.2 mg/dl per hour. But the actual range of how fast their blood sugar dropped was very large, with the range in which most readings clustered extending from 7 mg/dl per hour to 91 mg/dl per hour and some outliers dropping not at all or even faster.

If you see only a very small drop in your own blood sugar an hour after its peak, or a rise, you should check in another hour. If the usual pattern you see is for your blood sugar to stay high for two hours or more after peaking, it's time to cut back on the carbohydrate in your meals, since carbohydrates are what raise blood sugar.

If cutting carbohydrates doesn't get your blood sugars rising less and dropping faster, it's time for a visit to the doctor to discuss adding a safe medication would be advisable. (Metformin and insulin are by far the safest choices. You can read about all the drugs doctors prescribe to drop blood sugar HERE.)

If you start using insulin at meal times you should also test your blood sugar towards the end of the insulin's period of activity. How long the insulin stays active varies both with the kind of insulin you use and the dose.

Regular Human Insulin (R insulin) which is sold as Humulin or Novolin, is active for a period that can extend as long as 6 hours, so testing at 4 or 5 hours can warn you if you are in danger of a hypo.

For Humalog, Novolog (Novorapid), and Apidra, which have shorter times of duration, testing at 3 or 4 hours is wise until you determine you aren't in danger of a hypo.

If you see a low value at any time when your insulin still has more time left to work, take some glucose to raise your blood sugar and adjust your dose the next time you eat that meal or a one with similar amount of carbohydrate.

If your doctor hasn't taught you how to adjust your dose of fast acting insulin to match your carbohydrate intake, ask for that kind of training. If you can't get it, educate yourself by reading John Walsh's book, Using Insulin or Dr. Bernstein's Diabetes Solution by Dr. Richard K. Bernstein.

Yet another poll! What Are Your Work Horse Foods?

The participation on these polls has been great, and I've heard from quite a few people who say they've learned a lot from them. So here's another question for you:

Whatever diet you're eating, what are the foods you have come to rely on the most when you don't feel like doing fancy cooking or being creative?