Low-Carb "instead-of's"

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 - Obesity affects about 30% of Canadians

- As a physician, I begin to worry about the effects of obesity on my patient's health when the waist measurement (measured 1 finger breath above the side hip bone) is larger than the hip measurement (measured over widest part of hips)

--- This is called "Central Obesity" and predicts other health problems, often already present or that will likely come to pass over the next few decades

  - In younger, otherwise healthy seeming patients, central obesity is associated with fatty liver disease, elevated cholesterol, blood sugar and blood pressure. As time progresses, sleep apnea, type 2 diabetes and poor blood sugar control in type 1 diabetics may develop. Polycystic ovarian syndrome including heavy/irregular periods, infertility and male-pattern facial hair growth may affect pre-menopausal women. In middle age and older adults, after several decades of harm, the previously mentioned problems can contribute to various types of organ dysfunction affecting the heart, brain, liver and kidneys.

 Obesity occurs because of a combination of factors:

- Some medications prescibed by doctors and nurse practitioners can put patients at risk of developing obesity

- Some health problems, such as low thyroid, can cause obesity. I usually check for this problem with lab work at the initial visit for obesity but rarely find it is the cause.

- Your enviroment: 1) The foods and drinks you had growing up inform what you think is normal and appropriate food as a teenager and adult, 2) And as a teenager and/or adult, the foods and drinks you have in your household now - whether bought by you or someone else, predicts what you will eat and drink next. So if there are sugary drinks and sugary/starchy foods in your kitchen, you are much more likely to consume them. 

- Your dietary pattern: sugar and starch is turned into 'stored engery' (fat) by your liver for use later. To be clear, sugar and startch are the building blocks of centrally stored fat.

- Your exercise pattern: a sedentary lifestyle means that that 'stored energy' or fat, is never being used. So it just stays there and accumulates, mostly around the central organs/waist line. 

- Your alcohol intake pattern: alcohol consumption in excess of 3 standard drinks per week (a standard drink is 325 mL of beer, 1.5 oz of 40% alcohol and 5 oz of wine)

 1. Address medical problems: a) with medical supervision, consider stopping problematic medications, and b) treat organ problems like low thyroid

2. Lifestyle based: a) exercise more, b) dietary restriction: adopt a low-carb or low-calorie eating pattern

3. Medication treatments

4. Bariatric surgery

 - Carbohydrates are one of the three categaries of "macronutrients", or molecules that the body can use to make energy from food.

- While carbodydrates come in many forms with many names (bread, buns, begals, breakfast cereal, pasta, potatoes, rice, corn products, fruit, desserts and sugary drinks), the digestive tract breaks them all down into just 3 molecules: glucose and fructose (from startches and sugar) and galactose (from dairy products).

- Unlike protein and fat, glucose, fructose and galactose trigger the pancreas to release insulin, a hormone which causes these sugars to  be stored away in the liver and muscle as glycogen and in the adipose tissue as fat.

- Humans do not need to eat any carbohydrate to maintain normal body function.

--- In the absense of carbohydrate intake, the body will make glucose from protein to keep blood sugar levels between approximately 4 and 6 mmol/L (which will provide glucose to the few cells types that are dependent on glucose, such as the red blood cells) and otherwise, the body will make "ketone bodies" from fat to fuel the remainder of the body's cells.

- "Keto" refers to the presence of ketone bodies in the blood, urine and/or breath.

- Ketone bodies are made by the liver from dietary or stored fat through a natural, normal, non-harmful process caused "beta-hydroxylation". 

- Ketones travel through the blood stream to cells where they are taken-up and used by cell's mitochondria (the power plants of cells) to make energy for the body. The majority of the cells in the body (including the brain!) can use ketones to generate energy.

- Most people following a diet with a mix of fat, protein and carbodyrate will begin to make ketones about 4-6 hours after their last meal.

- All diets, be they low-carb or low-calorie, that result in weight loss, are "ketogenic"; that is to say, they result in weight loss by causing fat to flow out of the fat cells, to the liver, where it is converted into ketones and eventually burned by the body's cells as energy.

- Since all dietary patterns that result in weight loss are ketogenic, the ideal diet for a patient depends mostly on what one can maintain for the long-term.

- Over the last 10 years, I have formed the opinion that the low-carb approach is more sustainable and effective than a low-calorie approach.

- My main criticism of a low-calorie dietary patterns comes from observating patients fail to maintain it due to complaints of hunger and low energy. 

---That is not to say that patients do not fail at maintaining low-carb. But low-carb does not fail due to hunger or fatigue, it fails due to complaints of missing carbs/household patterns of eating and lack of variety. I feel all these concerns can be addressed with proper formuation and lots of "Instead-of's".

LCHF stands for 'Low-Carb, High Fat' and it does not mater what the diet is called: if it results in carbydrate restriction to less that 20 g of net carb per day, it will physiologically result in mobilization of stored fat for energy and ketone production.

But the fomuation of the low-carb dietary pattern does matter for health.

- Low-carb is the engine of this weight loss approach. Physiologically, the choice to reduce carbohydrate intake to no more than 20 net carbs per day results in sustained ketone body generation and weight loss. So any ad lib diet that has no more than 20 g of net carb per day is ketogenic and will likely result in weight loss. 

- But that does not mean I recommend you eat meat all day! Interestingly, if you read Dr. Atkins original 1973 text, he advocates for a diet high in protein and animal fats but speaks to some of the health consequences from this such as increased episodes of gout.

- Where 'Low-Carb' refers to what you don't eat (carbs), 'Formulation' refers to what you do eat.

- I recommend a low-carb dietary pattern formulation to be 1) high in 'low-carb' vegetables, high in fibre, high in naturally occuring fats (like animal/dairy fat, olive oil, coconut oil, avocado oil), 2) moderate in protein, up to 4 oz of anmial protein, up to 3x per day (reduce to 3 oz, 2-3x per day if diabetic) or plant-based proteins like legumes and/or lentils and 3) low in sugars and startches.

- It is true that a plant-based protein approach will result in higher net-carb intake. A vegetarian or vegan may even exceed 100 g of net carb per day. That said, for reasons I don't fully understand, it does not seem to matter if a vegetarian consumes more than 20 of net carb per day in an effort to consume plant based proteins from lentils, legumes or quinoa. I have observed vegetarian patients do very well with weight loss, despite the higher net-carb intake. I think it is actually advantageous for all patients following a low-carb dietary pattern to emphasize plant-based proteins, be they vegetarian or not.

- Please see my one-pager on low-carb below, called the "MetabolicHealth Minute", for some important fomulation pointers. Please note information about supplements.

Net-carb is total carb content of the serving of food, minus the fibre content.

- Low carb meals are delicious: flavourful (fat caries the flavour), savory (yes - you get to have salt on your food with keto - in fact, you must) and filling (no portion restiction). 

- Patients almost never complain of hunger and seem to have lots of energy when following a low-carb approach

- The problem is that carbs (sugar and startch) are such an abundant/filling 'staple' (potatoes, pasta or rice as a side dish), ingredient (shapards pie has a starchy potato topping) or additive (sugar is often added to yogurt), that patients have not learned how to avoid them. Favorite and familiar foods are loaded with carbs - carbs are all many of my patients have ever known! 

- Patients who 'fall off the wagon' will complain that they were board of eating the same low-carb foods all the time. Maybe they got into a rut of only eating eggs for breakfast. They missed their old 'favs'. Somewhere along the way, despite weight loss and success with blood sugar control, they got a taste of potato or bread again and the cravings for them came roaring back.

- Therefore, to be successful with low-carb for the long-term, one needs to educate him or herself on the "Instead-Of's". One must unlearn old favorites and find new ones.

 - Thankfully, there are more and more ideas out there all the time - there are now hundreds of low-carb cookbooks and websites and some fabulous commerical low-carb products that make long-term keto a much easier transition to make. 

- Don't cheat!

- One must make a sustained effort to abstain from bread, buns, begals, breakfast cereal, muffins, pasta, potatoes, rice, corn, fruit (with the exception of small servings of berries), sweet drinks and desserts.

--- As a comparison, imagine the best advice for someone trying to quit smoking? Best not to dabble at all! 

- As hard as this sounds, it gets dramatically easier after just a few days (to a few weeks). Just a few days of abstaining from these sugars and statches and one finds self-control that was previously unknown. 

- If one 'falls off the wagon' and has a cheat, it will be hard for a few days - cravings for all carbs return with a vengeance - but that state of control is just around the corner, if only one can again abstain for a few days.