Tag Archives: hunter-gatherer diet

Short-Term Paleo Diet Improves Glucose Control in Obese Type 2 Diabetes (the Masharani Study)

Posted on April 6, 2015 | 3 comments
UCSF is here

UCSF is here

A three-week Paleolithic-style diet improved blood sugars and lipids in obese type 2 diabetics, according to researchers at the University of California—San Francisco. This is the Lynda Frassetto study I’ve been waiting over a year for. The first named author is U. Masharani, so I’ll refer to this work in the future as the Masharani study. Sorry, Lynda.

To understand the impact of this study, you need to know about a blood test called fructosamine, which reflects blood sugar levels over the preceding 2–3 weeks. You may already be familiar with a blood test called hemoglobin A1c: it tells us about blood sugars over the preceding three months. Blood glucose binds to proteins in our blood in a process called glycation. The higher the blood glucose, the more bonding. Glucose bound to hemoglobin molecules is measured in HgbA1c. Glucose bound to plasma proteins (predominantly albumin) is measured as fructosamine. It probably has nothing to do with fructose. Fructosamine is a generic name for plasma ketoamines.

If you’re doing a diabetic diet study over over 2–3 weeks, as in the report at hand, changes in glucose control will mostly be detected in fructosamine rather than HgbA1c levels.

How Was the Research Done?

Twenty-five obese diabetics in the San Francisco Bay area were randomly assigned to either a paleo-style diet or one based on American Diabetes Association (ADA) guidelines. They followed the diets for three weeks, with various measurements taken before and after intervention.

Participants were aged 50-69; you have to guess the sex breakdown. Average body mass index was 34. Over half (63%) were White/European American; there were three each of Asian, African American, and Hispanic ethnicity. They had normal blood pressures and diabetes was well controlled, with hemoglobin A1c’s around 7% and fructosamine levels close to normal. Four subjects were on no diabetes medications; 14 were taking metformin alone, five were on metformin and a sulfonylurea, one was on long-acting insulin and a sulfonylurea. No drug dosages were changed during the study.

Both intervention diets were designed for weight maintenance, i.e., avoidance of weight loss or gain. If participants lost weight, they were instructed to eat more. All food was prepared and provided for the participants. Three meals and three snacks were provided for daily consumption.

Fourteen subjects completed the paleo diet intervention. They ate lean meats, fruits, vegetables, tree nuts, poultry, eggs, canola oil, mayonnaise, and honey. No added salt. No cereal grains, dairy, legumes, or potatoes. Calorie percentages from protein, fat, and carbohydrate were 18%, 27%, and 58%, respectively. Compared to the ADA diet, the paleo diet was significantly lower in saturated fat, calcium, and sodium (under half as much), while higher in potassium (twice as much). These dieters eased into the full paleo diet over the first week, allowing bodies to adjust to higher fiber and potassium consumption. The paleo diet had about 40 grams of fiber, over twice as much as the ADA diet.

[I wonder why they chose canola over other oils.]

Ten subjects completed the ADA diet, which included moderate salt, low-fat dairy, whole grains, rice, bread, legumes, and pasta. Calorie percentages from protein, fat, and carbohydrate were 20%, 29%, and 54%, respectively (very similar to the paleo diet). I don’t have any additional description for you. I assume it included meat, poultry, eggs, and fruit.

Diet compliance was confirmed via urine measurements of sodium, potassium, pH, and calcium.

What Did the Researchers Find?

Both groups on average lost about 2 kg (4-5 lb).

Compared to their baseline values, the paleo group saw reductions in total cholesterol, HDL cholesterol, LDL cholesterol, HgbA1c (down 0.3% absolute reduction), and fructosamine. Fructosamine fell from 294 to 260 micromole/L. [The normal non-diabetic range for fructosamine is 190-270 micromole/L.]

Compared to their baseline values, the ADA diet group saw reductions in HDL cholesterol and HgbA1c (down 0.2% absolute reduction) but no change in fructosamine, total cholesterol, and LDL cholesterol.

Comparing the groups to each other, the difference in fructosamine change was right on the cusp of statistical significance at p = 0.06.

Within each group, insulin resistance trended down, but didn’t reach statistical significance. However, when they looked at the folks who were the most insulin resistant, only the paleo dieters improved their resistance. By the way, insulin resistance was measure via euglycemic hyperinsulinemic clamp instead of the short-cut HOMA-IR method.

Blood pressures didn’t change.

The authors don’t mention hypoglycemia at all, nor alcohol consumption.

They note that some of the paleo dieters complained about the volume of food they had to eat.

Errata

I found what I think are a couple misprints. Table 1 has incorrect numbers for the amount of sodium and potassium in the ADA diet. See the text for correct values. Table 2 give fructosamine values in mg/dl; they should be micromoles/L.

Final Thoughts

This particular version of the paleo diet indeed seems to have potential to help control diabetes in obese type 2’s, perhaps even better than an ADA diet, and despite the high carb content. Obviously, it’s a very small study and I’d like to see it tested in a larger population for several months, and in type 1 diabetics. But it will be years, if ever, before we see those research results. Diabetics alive today have to decide what they’ll eat tomorrow.

I wish the researchers had explained why they chose their paleo diet macronutrient breakdown: calorie percentages from protein, fat, and carbohydrate were 18%, 27%, and 58%, respectively. Perhaps they were trying to match the ratios of the ADA diet. But from what I’ve read, the average ancestral paleo diet carbohydrate energy percentage is 30-35%, not close to 60%. My experience is that reducing carb calorie consumption to 30% or less helps even more with glucose control. Reducing carbs that low in this study would have necessitated diabetes drug adjustments and increased the risk of hypoglycemia.

The authors wonder if the high fiber content of the paleo diet drove the lowered glucose levels.

High HDL cholesterol is thought to be protective against coronary artery disease and other types of atherosclerosis. Both diet groups here saw reductions in HDL. That’s something to keep an eye on.

The ADA diet group saw a drop in HgbA1c but not fructosamine. I can’t explain how HgbA1c goes down over three weeks without a change in fructosamine level.

You have to wonder if the paleo diet results would have been more impressive if the test subjects at baseline had been sicker, with poorly controlled blood pressures and HgbA1c’s of 9% or higher. And it sounds like some of these folks would have lost weight if not forced to eat more. The paleo diet is more satiating than some.

The article was well-written and a pleasure to read, in contrast to some I’ve suffered through recently.

Steve Parker, M.D.

Reference: Masharani, U., et al. Metabolic and physiologic effects from consuming a hunter-gatherer (Paleolithic)-type diet in type 2 diabetes. European Journal of Clinical Nutrition, advance online April 1, 2015. doi: 10.1038/ejcn.2015.39

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My Critique of the Joslin Critique of the Paleo Diet

Posted on March 16, 2013 | 3 comments
paleo diet, Paleolithic diet, hunter-gatherer diet

Huaorani hunter in Ecuador

The Joslin Diabetes Blog yesterday reviewed the paleo diet as applied to both diabetes and the general public.  They weren’t very favorably impressed with it.  But in view of Joslin’s great reputation, we need to give serious consideration to their ideas.  (I don’t know who wrote the review other than “Joslin Communications.”)

These are the main criticisms:

  • diets omitting grains and dairy are deficient in calcium and possibly B vitamins
  • you could eat too much total and saturated fat, leading to insulin resistance (whether type 1 or 2 diabetes) and heart disease
  • it’s not very practical, partly because it goes against the grain of modern Western cultures
  • it may be expensive (citing the cost of meat, and I’d mention fresh fruit and vegetables, too)

Their conclusion:

There are certainly better diets out there, but if you are going to follow this one, do yourself a favor, take a calcium supplement and meet with a registered dietitian who is also a certified diabetes educator  to make sure it is nutritionally complete, isn’t raising your lipids and doesn’t cause you any low blood glucose incidences.

Expense and Practicality

These take a back seat to the health issues in my view.  Diabetes itself is expensive and impractical.  Expense and practicality are highly variable, idiosyncratic matters to be pondered and decided by the individual.  If there are real health benefits to the paleo diet, many folks will find work-arounds for any expense and impracticality.  If the paleo diet  allows use of fewer drugs and helps avoid medical complications, you save money in health care costs that you can put into food.  Not to mention quality of life issues (but I just did).

Calcium and B Vitamin Deficiencies

This is the first I’ve heard of possible B vitamin deficiencies on the paleo diet.  Perhaps I’m not as well-read as I thought.  I’ll keep my eyes open for confirmation.

The potential calcium deficiency, I’ve heard of before.  I’m still open-minded on it.  I am starting to wonder if we need as much dietary calcium as the experts tell us.  The main question is whether inadequate calcium intake causes osteoporosis, the bone-thinning condition linked to broken hips and wrists in old ladies.  This is a major problem for Western societies.  Nature hasn’t exerted much selection pressure against osteoporosis because we don’t see most of the fractures until after age 70.  I wouldn’t be surprised if we eventually find that life-long exercise and adequate vitamin D levels are much more important that calcium consumption.

With regards to calcium supplementation, you’ll find several recent scientific references questioning it.  For example, see this, and this, and this, and this, and this.  If you bother to click through and read the articles, you may well conclude there’s no good evidence for calcium supplementation for the general population.  If you’re not going to supplement, would high intake from foods be even more important?  Maybe so, maybe not.  I’m don’t know.

If you check, most of the professional osteoporosis organizations are going to recommend calcium supplements for postmenopausal women, unless dietary calcium intake is fairly high.

If I were a women wanting to avoid osteoporosis, I’d do regular life-long exercise that stressed my bones (weight-bearing and resistance training) and be sure I had adequate vitamin D levels.  And men, you’re not immune to osteoporosis, just less likely to suffer from it.

Insulin Resistance

Insulin resistance from a relatively high-fat diet is theoretically possible.  In reality, it’s not common.  I’ve read plenty of low-carb high-fat diet research reports in people with type 2 diabetes.  Insulin levels and blood glucose levels go down, on average.  That’s not what you’d see with new insulin resistance.  One caveat, however, is that these are nearly all short-term studies, 6-12 weeks long.

If you have diabetes and develop insulin resistance on a high-fat diet, you will see higher blood sugar levels and the need for higher insulin drug doses.  Watch for that if you try the paleo diet.

Are High Total and Saturated Fat Bad?

Regarding relatively high consumption of total and saturated fat as a cause of heart or other vascular disease: I don’t believe that any more.  Click to see why.  If you worry about that issue, choose meats that are leaner (lower in fat) and eat smaller portions.  You could also look at your protein foods—beef, chicken, fish, eggs, offal, etc.—and choose items lower in total and saturated fat.  Consult a dietitian or online resource.  Protein deficiency is rarely, if ever, a problem on paleo diets.

In Conclusion

I think the paleo diet has more healthful potential than realized by the Joslin blogger(s).  I’m sure they’d agree we need more clinical studies of it, involving both type 1 and 2 diabetics.  I appreciate the “heads up” regarding potential vitamin B deficiencies.  My sense is that the Joslin folks are willing to reassess their position based on scientific studies.

I bet some of our paleo-friendly registered dietitians have addressed the potential adverse health issues of the paleo diet.  Try Amy Kubal, Franziska Spritzler (more low-carb than paleo) or Aglaée Jacob.  I assume the leading paleo diet book authors have done it also.

If you’re worried about adverse blood lipid changes on the paleo diet, get them tested before you start, then after two months of dieting.

Steve Parker, M.D.

PS: The paleo diet is also referred to as the Stone Age diet, caveman diet, Paleolithic diet, hunter-gatherer diet, and ancestral diet.

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Low-Carb Research Update

Posted on February 9, 2013 | 4 comments
Grain-based high-carb Neolithic food

Grain-based high-carb Neolithic food

The paleo diet averages about 30% of total calories from carbohydrates, with a range of about 22 to 40%.  That 30% average is much lower than the standard 50–60% in the developed world.  Is that lower percentage healthy or not?  It depends on the quality of the carbs and the remainder of the diet.  It most certainly can be healthy.

As much as possible, I base my nutrition and medical recommendations on science-based research published in the medical literature.  In the early 2000s, a flurry of scientific reports demonstrated that very-low-carb eating (as in the style of Dr. Robert Atkins) was safe and effective for short-term weight management and control of diabetes.  Eighty hours of literature review in 2009 allowed me to embrace low-carbohydrate eating as a logical and viable option for many of my patients. The evidence convinced me that the relatively high fat content of many low-carb diets was nothing to worry about long-term.

I’d like to share with you some of the pertinent low-carb research findings of the last few years.

Low-Carb Diets

  • Low-carb diets reduce weight, reduce blood pressure, lower triglyceride levels (a healtlhy move), and raise HDL cholesterol (another good trend).  These improvements should help reduce your risk of heart disease.  (In the journal Obesity Reviews, 2012.)
  • Dietary fat, including saturated fat, is not a cause of vascular disease such as heart attacks and atherosclerosis (hardening of the arteries).  (Multiple research reports.)
  • If you’re overweight and replace two sugary drinks a day with diet soda or water, you’ll lose about four pounds over the next six months.  (American Journal of Clinical Nutrition, 2012.)
  • United States citizens obtain 40% of total calories from grains and added sugars.  Most developed countries are similar.  Dr. Stephan Guyenet notes that U.S. sugar consumption increased steadily “…from 6.3 pounds [2.9 kg] per person per year in 1822 to 107.7 pounds [50 kg] per person in 1999.  Wrap your brain around this: in 1822 we ate the amount of added sugar in one 12-ounce can of soda every five days, while today we eat that much sugar every seven hours.”
  • A very-low-carb diet improves the memory of those with age-related mild cognitive impairment. Mild cognitive impairment is a precursor to dementia.  (University of Cincinnati, 2012.)
  • High-carbohydrate and sugar-rich diets greatly raise the risk of mild cognitive impairment in the elderly. (Mayo Clinic study published in the Journal of Alzheimers’ Disease, 2012.)
  • Compared to obese low-fat dieters, low-carb dieters lose twice as much fat weight.  (University of Cincinnati, 2011.)
  • Diets low in sugar and refined starches are linked to lower risk of age-related macular degeneration in women.  Macular degeneration is a major cause of blindness.  (University of Wisconsin, 2011.)
  • A ketogenic (very-low-carb) Mediterranean diet cures metabolic syndrome (Journal of Medicinal Food, 2011.)
  • For type 2 diabetics, replacing a daily muffin (high-carb) with two ounces (60 g) of nuts (low-carb) improves blood sugar control and reduces LDL cholesterol (the “bad” cholesterol). (Diabetes Care, 2011.)
  • For those afflicted with fatty liver, a low-carb diet beats a low-fat diet for management. (American Journal of Clinical Nutrition, 2011.)
  • For weight loss, the American Diabetes Association has endorsed low-carb (under 130 g/day) and Mediterranean diets, for use up to two years. (Diabetes Care, 2011.)
  • High-carbohydrate eating doubles the risk of heart disease (coronary artery disease) in women.  (Archives of Internal Medicine, 2010.)
  • One criticism of low-carb diets is that they may be high in protein, which in turn may cause bone thinning (osteoporosis).  A 2010 study shows this is not a problem, at least in women.  Men were not studied.  (American Journal of Clinical Nutrition.)
  • High-carbohydrate eating increases the risk of developing type 2 diabetes (American Journal of Clinical Nutrition, 2010.)
  • Obesity in U.S. children tripled from 1980 to 2000, rising to 17% of all children.  A low-carb, high-protein diet is safe and effective for obese adolescents.  (American Journal of Clinical Nutrition, 2010.

Steve Parker, M.D.

PS:  The paleo diet is also referred to as the caveman diet, Paleolithic diet, hunter-gatherer diet, Stone Age diet, and ancestral diet.

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Ideas For A Paleo Diabetic Diet

Posted on February 3, 2013 | 5 comments
Sirloin steak, salad, cantaloupe, 3 raspberries

Sirloin steak, salad, cantaloupe, 3 raspberries

I’ve been thinking about a paleo-style diabetic diet for over a year.  Here are some miscellaneous ideas for your consideration.

A paleo diabetic diet will have the following major food groups:

  • vegetables
  • fruits
  • nuts and seeds
  • proteins (e.g., meat, fish, eggs)
  • condiments

A paleo diabetic diet could (should?) emphasize salads and low-carb colorful vegetables and only (?) low-carb or low-glycemic-index fruits.

Calories

Total calories?  Probably in the range of 1,800 to 3,000 calories daily with an average of 2,000.  Remember that 85% of type 2 diabetics are overweight or obese. Calorie restriction—regardless of macronutrient ratios (% carb, protein, fat)—tends to improve or normalize blood sugar levels.  Weight loss will likely entail some caloric restriction, whether consciously or not.

Type 1 Versus Type 2 Diabetes

Type 1 and type 2 diabetics have many pathophysiologic differences.  Could a single paleo diabetic diet serve both populations equally well?  That’s the goal.

Carbohydrates

Diabetics have trouble metabolizing carbohydrates, so a paleo diabetic diet should probably be lower-than-average in digestible carbs.  100 g/day?  30 g/day?  I’m leaning toward 60 g ± 25%, so 45–75 g.  Smaller, less active folks could eat 45 g/day; larger, more active guys eat closer to 75 g.

Is there a role for very-low-carb or ketogenic eating patterns?  For most folks, that’s less than 50 g of digestible carbohydrate daily.  Under 30 g for some.  Use that only for those needing to lose weight?  Start everybody at  very low carb levels then increase carbs as tolerated?  On the other hand, there’s a lot to be said for simplicity.  It might be best to avoid very-low-carb (ketogenic) eating entirely.  Anyone not losing the desired amount of fat weight could cut portion sizes, especially carbohydrates.

Fish

I encourage fish consumption twice a week, diabetes or no.  Cold-water fatty fish have more of the healthy omega-3 fatty acids than other fish.

Nuts

I’d encourage 1–2 ounces (28–56 g) of nuts or seeds daily.  Any more than that might crowd out other healthful nutrients.  Nuts are protective of the heart.

Proteins

Protein-rich foods can definitely raise insulin requirements and blood sugar levels, but not in an entirely predictable way, and not to the extent we see with carbohydrates.  Should insulin users dose insulin based on a protein gram sliding scale?  I’m leaning towards simply recommending the same amount of protein at each meal, perhaps 4–8 ounces (113–229 g).

Fruit and Starchy Vegetables

Could a paleo diabetic diet even be “paleo” without fruit?  The problem with classic fruits is that they spike blood sugars too high for many diabetics.  To prevent that, Dr. Richard Bernstein outlaws all classic fruits (and other starchy carbs), even limiting tomatoes and onions to small amounts.  E.g., a wedge of tomato in a salad.  He doesn’t allow carrots either, unless raw (lower glycemic index than when cooked).  A paleo diabetic diet eater may be able to get away with eating lower-carb, lower-GI (glycemic index) fruits such as cantaloupe, honeydew, strawberries and other berries.  Some paleo diabetic dieters will tolerate half an apple twice a day.

Different diabetics will have different blood sugar effects when eating starchy vegetables and higher-carb fruits.  Type 1 diabetics will tend to be more predictable than type 2s.  Both may just need to “eat to the meter”: try a serving and see what happens to blood sugar over the next hour or two.

Starchy vegetables—potatoes and carrots, for example—may well have to be limited.  Again, eat to the meter.

Gluten

This is looking to be gluten-free.  How trendy!  It’s a paleo celiac diet.

Use “natural” stevia as a sweetener?  If you read about how the product on your supermarket shelf  is made, it’s not at all natural.

Omega-6/Omega-3 Fatty Acids

A strict focus on omega-6/omega-3 fatty acid ratio will not appeal to many folks, even if it’s important from a health viewpoint.  Reserve this for advanced dieters who have mastered the basics?  Modern Western diets have an omega-6/omega-3 ratio around 10 or 15:1.  Paleolithic diets were closer to 2 or 3:1.  So we have an over-abundance of omega-6 fatty acid or deficiency of omega-3 that may be unhealthy.

Implementation

To get dieters started, I’d design a week of meals based on 2,000 to 2,200 calories.  If still hungry, eat more protein, fat, and low-carb vegetables (and fruits?).

What do you think?

Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.  

PS: See Dr. Bernstein’s “no-no” foods on page 151 of his Diabetes Solution book.

PPS: The paleo diet is also known as the Paleolithic diet, Stone Age diet, caveman diet, hunter-gatherer diet, and ancestral diet.

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Two Month Recap of the Parker Paleo Diet Trial

Posted on December 9, 2012 | 1 comment
soup, home-made, potato, chicken, paleo diet, meal, Stone Age diet, recipe

Potato chicken soup

I’ve completed my two-month paleo diet trial.  I’m proud to say I’ve been fairly compliant with it, although certainly not 100%.  Perhaps 95%.

My major transgressions have been:

  • three diet sodas
  • a bottle of wine around Thanksgiving holiday
  • two or three pies around Thanksgiving (I couldn’t stand throwing them out)
  • other grain and refined sugar products around Thanksgiving
  • four servings of salad dressing made with industrial seed oils when I had no good alternative
  • a Blizzard (thick milk shake) from Dairy Queen
  • on 10–15 days I’ve exceeded my 2-ounce (60 g) limit on nuts

Results and Overall Impressions of Paleo Eating

It’s fairly easy, even when dining out or away from home.  Nevertheless, it requires some discipline and willpower.

My sense is that my meat, poultry, egg, and nut consumption stayed about the same as my baseline, pre-paleo levels.  I eliminated cheese and didn’t miss it much.  I ate more vegetables and fruit.

paleo diet, paleo meal, recipe, stone age diet, paleo food, hunter-gatherer food

I took my lunch meals to the hospital

My wife says paleo eating is at least a little more expensive than my prior eating habits, mostly related to fresh vegetables and fruit.  Grain products like bread, pasta, and rice are cheaper calories.  On the other hand, we saved money by not buying wine even though I don’t drink expensive wine.

I don’t miss grain products much at all.  I had already cut back on them over the last couple years as part of my experimentation with low-carb eating.  I do enjoy whole grain breads but could live a happy life without them if necessary.

I miss sweet items like cinnamon rolls, other pastries, cake, pie, ice cream, diet soda, and candy bars.  I don’t care for sugary soda pop and fruit juices.

I didn’t do this to lose weight, yet went from 171 lb (77.7 kg) down to 164 lb (74.5 kg).  So an unexpected loss of 7 lb (3.2 kg).  I hovered between 162 and 166 lb for the last few weeks so I don’t think I’ll keep losing weight if I stay with the program.

Do I feel any different eating this way?  No.  I’m blessed with good health, so wasn’t looking for any upgrades.  I have noticed more sweetness in a few foods, such as nuts and carrots.

I take nothing away from those who report more energy, better sleep, improved digestion, increased strength, less joint pain, etc., from paleo-style eating.  Undoubtedly, some of those apparent improvements are placebo effect, some are coincidental, and some are bona fide results of the paleo lifestyle.

Steve Parker, M.D.

PS: The paleo diet is also called the Paleolithic diet, hunter-gatherer diet, Stone Age diet, caveman diet, or ancestral diet.

Update December 16, 2012:  I wondered if lack of alcohol for the last two months had any effect on my weight loss.  For the last week I ate my usual paleo diet but added 3 fl oz (90 ml) of whiskey daily.  Weight today 163 lb (73.9 kg), so no real change over the short run.  That’s enough whiskey for a while.

Update December 27:  After three days of unrestrained Holiday eating, my weight is up 8 lb to 171 lb (77.7 kg).  Mostly thanks to pie, cookies, and candy.  I’m sure some of that extra weigh is glycogen, water, and intestinal contents, rather than fat.  Back on the paleo diet today, a low-carb version.

Update December 29:  Weight is down 5 lb to 166 lb (75.5 kg).  Amazing.

Pace salsa, paleo diet, Parker paleo diet

The contents of this salsa jar are all paleo-compliant

paleo diet, Parker paleo diet, canned pumpkin

Pure paleo contents unless there’s BPA in the can liner

pumpkin pie, paleo diet, Parker paleo diet

Definitely non-paleo pumpkin pie

wine bottle, red wine, paleo diet, meal,

Wine is not “paleo” by most definitions

paleo diet, paleo food, hunter-gatherer diet, macadamia nuts

L. Cordain likes the low omega-6/omega-3 ratio of macadamia nuts

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Day 1 of My Paleo Diet

Posted on October 8, 2012 | 14 comments

Why do it?

  • Direct experience with implementation obstacles
  • Potential health benefits

My first Parker Paleo Diet meal: sautéed mixed veggies and pan-fried chicken breast

I’m not doing this to lose weight, although I wouldn’t mind losing 10 lb (4.5 kg).  I weigh 171 lb (77.7 kg, BMI 23.4).  Regarding health benefits, I’m just going to monitor how I feel.  No blood work.  My blood pressure’s normal already.

My current version of paleo is not designed for someone with diabetes or prediabetes.  That may come in the future (Dr. Frassetto, when can we see your latest research results?).  By “current version,” I mean I’ll quite likely tweak it over the coming months.  One of my major issues is whether to keep or delete potatoes.

Here’s what I’ll eat (or not) on the Parker Paleo Diet:

FORBIDDEN FOODS: Grains (e.g., corn, wheat, rice), Dairy, Legumes (peanuts, beans, peas, green beans), Industrial Vegetable Oils (soybean, corn, safflower, etc.), Alcohol, Refined Sugars.

PROTEINS: Meat, fish/seafood, eggs, poultry, and wild game.  Bacon OK; minimize other processed meats.

NUTS & SEEDS: Especially walnuts, macadamia, cachews, almonds.  Limit to 1-2 oz/day.

FRUITS: Limit 2 pieces/day?

VEGETABLES:

Lower-Carb: Greens (lettuce, spinach, chard, collard, mustard geen, kale), radicchio, endive, bok choy, herbs, celery, radishes, mushrooms, cabbage, jicama, avocado, asparagus, okra, cucumbers, cauliflower, broccoli, peppers, summer squash, zucchini, Brussels sprouts, green onions, tomatoes, eggplant, tomatillos, eggplant, artichokes, turnips, rutabagas, spaghetti squash, carrots, onions, leeks, water chestnuts (small serving).  This list generally starts with the lower carb items and gradually increases to higher carb grams.  All these have 5 or fewer carbs per serving; most are  much less.

Starchy, Higher-Carb: Beets (6 g, GI 64), winter squashes (acorn, butternut), water chestnuts, parsnips (9 g, GI 97), potatoes (35 g, GI 87), sweet potatoes, (20 g, GI 61), cassava (37 g), taro (21 g), plantains.  Some categorize carrots as starchy.

HERBS & SPICES: Cilantro, parsley, basil, rosemary, thyme, etc.  Salt (minimal), pepper, vinegar.

OILS: Extra virgin olive, canola, flax, avocado.

CONDIMENTS: Olive oil vinaigrettes, mayonnaise from olive oil & egg yolk, and ?

LIQUIDS: H2O, coffee, tea

I’m not counting calories, fat grams, or carb grams.  I’ll eat until full or satisfied, not stuffed.  This is a two-month trial, excluding 24 hours around Thanksgiving.

Steve Parker, M.D.

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What Exactly Is the Paleo Diet?

Posted on October 7, 2012 | 9 comments

Pure paleo

Let’s be realistic: There’s no way to eat a Stone Age diet these days unless you live off the land, hunting, fishing, and gathering from what’s naturally available in the wild.  Few can do that, although it’s not impossible.  I’m going to specify my version of the paleo diet because I’m starting a paleo diet trial soon—a first for me.

How long has man had fire?  Biological anthropologist Richard Wrangham estimates hominins tamed fire and started cooking with it 1.8 million years ago.  So I’m cooking my paleo foods if I wish.

As with my beloved Mediterranean diet, definitions of the paleo diet vary.  The following guidelines are influenced by my review of blogs or websites by Loren Cordain, Julianne Taylor, Robb Wolf, and Kurt Harris.  The first three are closely affiliated with each other, so expect lots of overlap.  It’s simplest to define paleo by what’s not allowed.

What’s NOT Paleo?

Industrial vegetable oils (e.g., soybean, corn,safflower), legumes, dairy, refined sugars, grains, alcohol, and high salt consumption.

What Is Paleo? 

The focus is on minimally processed, in-season, locally available foods.  Many favor pastured, grass-fed beef, free-range chickens, “organic,” and the like.  I guess that’s fine if you can afford it; I choose to spend my money elsewhere.

Proteins

Meat, fish/seafood, eggs, poultry, and wild game.  Most paleo proponents favor lean meats over fatty ones; it’s debatable. Undoubtedly, our domesticated feedlot animals are fattier than wild game, generally.  Processed meats such as bacon would not be pure paleo, but many paleo advocates allow it.

Nuts and Seeds

Favor those with the best omega-6/omega-3 ratio (2 or 3:1), such as walnuts, almonds, macadamia, and cashews.  Modern humans eat way more omega-6 fatty acids compared to ancient hunter-gatherers.

Fruits and Vegetables

It’s probably best to favor those with lower glycemic index.  Examples are berries, melons, cauliflower, tomatoes, onions, and broccoli.  Most modern fruits and veggies  have been bred for large size and good looks.  Ancient fruits and veggies were smaller and had much more fiber per serving.

Tubers, Roots, Bulbs

These are OK per Cordain, and I agree.  Examples include potatoes, cassava, taro root, onions.  Some paleo proponents exclude potatoes.

Oils

Cordain favors oils such as canola, flax, olive. Others mention avocado oil.  Aim for a good omega-6/omega-3 ratio.  Lard is probably OK although obviously processed.

Herbs and Spices

Many of our favorites should be OK.  Wolf says balsamic vinegar is allowed, although processed, like all vinegars.  Vinegar is “natural,” as you might have noticed if you ever walked through an apple orchard with rotting fruit on the ground; you can smell the vinegar.

Condiments

Undecided.  Note that you can make mayonnaise from olive oil and egg yolk.

Miscellaneous

Olives?  They’re processed, but I’m inclined to keep them in the mix.  Coffee?  Not paleo, but I ain’t givin’ it up.  Consider limiting nuts to one ounce daily since most of them are high in omega-6 fatty acids.  Fresh foods are more purely paleo than canned or frozen, but I’ll not exclude canned and frozen.  Limit fruit?  Probably: in most environments, they’re available only seasonally.  Diet sodas?  Clearly not paleo, but I enjoy one now and then and don’t see any drawbacks to low consumption.

Steve Parker, M.D.

Update October 8, 2012

I learned today that my version of paleo, by coincidence, is similar to the Hartwigs’s Whole30 plan.  But they allow clarified butter or ghee, green beans, and snow peas.  I include potatoes, but Whole30 doesn’t.

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Does the Paleo Diet Cause Kidney Stones?

Posted on August 19, 2012 | 1 comment

MedPage Today in May, 2012, reported a substantial increase (70%) in the prevalence of kidney stones in the U.S. over the last two decades. Stone prevalence rose from 5.2% to 8.8% of the population.  Prevalence was based on the periodic National Health and Nutrition Examination Survey, which asked participants, “Have you ever had kidney stones?”

Starting a hundred-yard DASH

Stone prevalence began rising even earlier.  Again according to the third NHANES, prevalence increased from 3.8 percent in the period 1976 to 1980 to 5.2 percent in the years 1988 to 1994.

Older studies estimated that one in 10 men and one of every 20 women will have at least one painful stone by the age of 70.

What are kidney stones make of?  

Three out of four patients with kidney stones form calcium stones, most of which are composed primarily of calcium oxalate or, less often, calcium phosphate.  Pure uric acid stones are less than 10 percent of all stones.

Why the increased stone prevalence?  Does diet count?

Unfortunately, the article doesn’t offer any reasons or even speculation as to why kidney stones are more prevalent.  Kidney stones have a genetic component, but our genes have changed very little over just two decades.  I have to wonder if diet plays a role.

UpToDate.com reviewed diet as a risk factor for kidney stones.  Some quotes:

There are several dietary factors that may play an important role in many patients: fluid, calcium, oxalate, potassium, sodium, animal protein, phytate, sucrose, fructose, and vitamin C intake. Lower intake of fluid, calcium, potassium, and phytate and higher intake of sodium, animal protein, sucrose, fructose, and vitamin C are associated with an increased risk for calcium stone formation. The type of beverage may also influence the risk. The effect of calcium intake is paradoxical, with a decreased risk with increased dietary calcium and an increased or no change in risk with calcium supplements.

The combination of dietary factors may also have a significant impact upon stone risk. As an example, the Dietary Approaches to Stop Hypertension (DASH) diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein. Based upon an analysis of three large cohorts, adherence to a DASH-style diet lowered the risk for kidney stones among men, older women, younger women, high body mass index (BMI) individuals, and low BMI individuals. Thus, the DASH diet is a reasonable option in the attempt to reduce the risk of stone recurrence.

Higher sucrose [table sugar] intake is associated with an increased risk of stone formation in younger and older women.
The statements above link both low sucrose and high sucrose consumption to kidney stones, so I’m going to ignore sucrose.  The paleo diet, of course, does’t supply much sucrose.
I thought I read somewhere that the paleo diet is potentially deficient in calcium, but I can’t find the reference.  Dr. Cordain at his website suggests that the formal recommended dietary allowance is set too high in any case.  If the diet’s low in calcium, it could predispose to stones. On the other hand, most paleo diet versions are low in sodium and rich in potassium, which may protect against stones.
In Cordain’s 2002 Paleo Diet book, he writes:
In virtually every dietary permutation [of the paleo diet] the levels of vitamins and minerals exceed governmental recommended RDAs.
So does the paleo diet cause kidney stones?  Sorry, but I don’t know.  I tend to doubt it.  I’m not aware of any scientific studies comparing the prevalence of kidney stones in those eating paleo-style with an otherwise similar population.
What about stone prevalence in modern hunter-gatherer cultures?  I bet those data exist, but searching “urolithiasis AND hunter-gatherer” got me nothing at PubMed.  Comparing those cultures with modern Western ones is probably a fool’s errand anyway: too many other uncontrolled variables besides diet.
Standard advice to prevent initial and recurrent kidney stones is to avoid low urine output.  Do that by drinking plenty of fluid.
Although I pay $400 a year for access to UpToDate, they offer free public access to some of the website.  Here’s the UpToDate poop sheet on kidney stones.
Extra credit:  Medical conditions that predispose to kidney stones include primary hyperparathyroidism, obesity, gout, diabetes, and medullary sponge kidney.
For SEO: The paleo diet is also called Stone Age, Old Stone Age, Paleolithic, caveman, and hunter-gatherer, and ancestral diet.

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Can A Christian Be A Paleo Advocate?

Posted on July 18, 2012 | 16 comments

If you’re squeamish about discussions of religion and God, read no further! What follows is controversial and much of it not subject to scientific investigation.

In case you’re wondering, I’m a Christian.  This simply means I believe I was given life by God, that His son Jesus became a man and died for my sins, and that I will have everlasting life in heaven for believing on this.  I strive to live the way God would want me to live, as written in the Holy Bible.  I was brought up in the Catholic faith, even attending parochial school in grades 1-8, but I’m Protestant now.  I went through an agnostic period between the ages of 19 to about 38—I’m glad I made it through that alive!

I’ve been learning more about paleo eating over the last year since it overlaps a fair amount with low-carb eating. (Paleo-style eating is also referred to as ancestral, Old Stone Age, hunter-gatherer, or the caveman diet.) The Paleolithic Era covers about 1.5 to 2 million years of human evolution, admitting that there probably hasn’t been much genetic change over the last 50,000 years (debatable). The cornerstone of paleo eating is that we should eat the things we are evolutionarily adapted to eat. We’ll be healthier that way. We didn’t have corn chips, soda pop, and candy bars 20,000 years ago, so we shouldn’t be eating them now.

Sounds reasonable, doesn’t it? Various species of animals thrive on certain foods and not others. My horses eat three meals a day – all hay; you and I couldn’t survive on that.

I have a college degree in Zoology, so I was thoroughly indoctrinated in Charles Darwin‘s evolutionary theory, at least the version current in the mid-1970s. Darwin’s theory requires no God, or didn’t include a role for God or gods. How Darwinians answer the question of Creation, I don’t know.

Many proponents of evolutionary theory seem to be atheist or agnostic. Natural selection determines who lives or dies, not the hand of God. Some brands of Christianity, but not all, reject the idea of human evolution in its entirety. They believe God created us just as we are about 6,000 years ago. So can a Christian be a paleo diet advocate?

(I don’t know where Judaism, Islam, and other major religions stand on evolution.)

Human evolution is central to paleo diet theory. A religious person may reject the idea of human evolution; can he nevertheless participate in the modern “paleo community”?

I believe God made us and the universe. There’s no proof – it’s a matter of faith. I don’t know if He made us 6,000 years ago or two million.  The bulk of the science speaks clearly against 6,000 years ago.

Our bodies are made to thrive on certain foods and not others.  That’s true for all animals.  If you find an injured bird in your yard and hope to nurse it back to health,  you better find out what it eats naturally and provide it, or you’ll fail.  The range of foods humans can thrive on is pretty broad. Whether the optimal way of eating is determined by godless evolutionary processes or by the intelligent design of a Creator doesn’t matter so much if you’re looking at it from a purely nutritional viewpoint.

From an “everlasting life” viewpoint, it matters.  Big time.

The paleo guys might be right about the best way to eat. Science continues to accumulate evidence one way or the other.

Christianity and paleo diet theory are not mutually exclusive. A Christian can ignore the possiblity of a million years of evolution, believing instead that God made our bodies in such a way that we’d be healthier eating certain foods and not others. Those foods may be the components of the paleo diet, whatever that is.

Steve Parker, M.D.

Further reading:

Carl Drews has written extensively on Christianity and Evolution, including his essay on Theistic Evolution.

Phil Porvaznik’s article on theistic evolution and the Roman Catholic Church.

Wikipedia: Catholic Church and Evolution.

Can a Christian follow a paleo low-carb diet? at Jimmy Moore’s Livin’ La Vida Low-Carb blog.

A few questions for the atheists.  Where did the universe come from?  Was it created? By whom or what?  What if God exists, and he made us for a reason and wants us to live a certain way?

Consider this excerpt from Walter Isaacson’s book, “Einstein: His Life and Universe”:

One evening in Berlin, [Albert] Einstein and his wife were at a dinner party when a guest expressed a belief in astrology. Einstein ridiculed the notion as pure superstition. Another guest stepped in and similarly disparaged religion. Belief in God, he insisted, was likewise a superstition.

At this point the host tried to silence him by invoking the fact that even Einstein harbored religious beliefs.

“It isn’t possible!” the skeptical guest said, turning to ask Einstein if he was, in fact, religious.

“Yes, you can call it that,” Einstein replied calmly. “Try and penetrate with our limited means the secrets of nature and you will find that, behind all the discernible laws and connections, there remains something subtle, intangible and inexplicable. Veneration for this force beyond anything we can comprehend is my religion. To that extent, I am, in fact, religious.”

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Random Thoughts On Paleo Eating For People With Diabetes

Posted on February 18, 2012 | 16 comments

Not really pertinent, but I like buffalo

I was interviewed  yesterday by Amy Stockwell Mercer, author of Smart Woman’s Guide to Diabetes.  All I knew beforehand was that she was interested in my thoughts on the paleo diet as applied to diabetes.

In preparation, I collected some random thoughts and did a little research.

What’s the paleo diet?

Fresh, minimally processed food.  Meat (lean or not? supermarket vs yuppiefied?), poultry, eggs, fish, leafy greens and other vegetables, nuts, berries, fruit, and probably tubers.

Non-paleo: highly processed, grains, refined sugars, industrial plant/seed oils, legumes, milk, cheese, yogurt, salt, alcohol.

Is the paleo diet deficient in any nutrients?

A quick scan of Loren Cordain’s website found mention of possible calcium and vitamin D deficits.  Paleoistas will get vitamin D via sun exposure and fish (especially cold-water fatty fish).  Obtain calcium from broccoli, kale, sardines, almonds, collards.  (I wonder if the Recommended Dietary Allowance for calcium is set too high.)

What About Carbohydrates and Diabetes and the Paleo Diet?

Diabetes is a disorder of carbohydrate metabolism.  In a way, it’s an intolerance of carbohydrates.  In type 1 diabetes, there’s a total or near-total lack of insulin production on an autoimmune basis.  In type 2 diabetes, the body’s insulin just isn’t working adequately; insulin production can be high, normal or low.  In both cases, ingested carbohydrates can’t be processed in a normal healthy way, so they stack up in the bloodstream as high blood sugars.  If not addressed adequately, high blood glucose levels sooner or later will poison body tissues .  Sooner in type 1, later in type 2.  (Yes, this is a gross over-simplification.) 

Gluten-rich Neolithic food

If you’re intolerant of lactose or gluten, you avoid those.  If you’re intolerant of carbohydrates, you could avoid eating them, or take drugs to help you overcome your intolerance.  Type 1 diabetics must take insulin.  Insulin’s more optional for type 2’s.  We have 11 classes of drugs to treat type 2 diabetes; we don’t know the potential adverse effects of most of these drugs.  Already, three diabetes drugs have been taken off the U.S. market or severely restricted due to unacceptable toxicity: phenformin, troglitazone, and rosiglitazone. 

Humans need two “essential fatty acids” and nine “essential” amino acids derived from proteins.  “Essential” means we can’t be healthy and live long without them.   Our bodies can’t synthesize them.  On the other hand, there are no essential carbohydrates.  Our bodies can make all the carbohydrate (mainly glucose) we need.

Since there are no essential carbohydrates, and we know little about the long-term adverse side effects of many of the diabetes drugs, I favor carbohydrate restriction for people with carbohydrate intolerance.  (To be clear, insulin is safe, indeed life-saving, for those with type 1 diabetes.)

That being said, let’s think about the Standard American Diet (SAD) eaten by an adult.  It provides an average of 2673 calories a day (not accounting for wastage of calories in restaurants; 2250 cals/day is probably a more accurate figure for actual consumption).  Added sugars provide 459 of those calories, or 17% of the total.  Grains provide 625 calories, or 23% of the total.  Most of those sugars and grains are in processed, commercial foods.  So added sugars and grains provide 40% of the total calories in the SAD.  Remember, we need good insulin action to process these carbs, which is a problem for diabetics.  (Figures are from an April 5, 2011, infographic at Civil Eats.)

Anyone going from the SAD to pure Paleo eating will be drastically reducing intake of added sugars and grains, our current major sources of carbohydrate.  Question is, what will they replace those calories with? 

That’s why I gave a thumbnail sketch of the paleo diet above. Take a gander and you’ll see lots of low-carb and no-carb options, along with some carb options. For folks with carbohydrate intolerance, I’d favor lower-carb veggies and judicious amounts of fruits, berries, and higher-carb veggies and

Will these cause bladder cancer? Pancreatitis?

tubers.  “Judicious” depends on the individual, considering factors such as degree of residual insulin production, insulin sensitivity, the need to lose excess weight, and desire to avoid diabetes drugs.

Compared to the standard “diabetic diet” (what’s that?) and the Standard American Diet, switching to paleo should lower the glycemic index and glycemic load of the diet.  theoretically, that should help with blood sugar control.

A well-designed low-carb paleo diet would likely have at least twice as much fiber as the typical American diet, which would also tend to limit high blood sugar excursions.

In general, I favor a carbohydrate-restricted paleo diet for those with diabetes who have already decided to “go paleo.”  I’m not endorsing any paleo diet for anyone with diabetes at this point—I’m still doing my research.  But if you’re going to do it, I’d keep it lower-carb.  It has a lot of potential.

Are There Any Immediate Dangers for a Person With Diabetes Switching to the Paleo Diet?

It depends on three things: 1) current diet, and 2) current drug therapy, and 3) the particular version of paleo diet followed. 

Remember, the Standard American Diet provides 40% of total calories as added sugars and grains (nearly all highly refined).  Switching from SAD to a low-carb paleo diet will cut carb intake  and glycemic load substantially, raising the risk of hypoglycemia if the person is taking certain drugs.

Drugs with potential to cause hypoglycemia include insulin, sulfonylureas, meglitinides, pramlintide, and perhaps thiazolidinediones.

Who knows about carb content of the standard “diabetic diet”?  Contrary to popular belief, there is no monolithic “diabetic diet.”  There is no ADA diet (American Diabetes Association).  My impression, however, is that the ADA favors relatively high carbohydrate consumption, perhaps 45-60% of total calories.  Switching to low-carb paleo could definitely cause hypoglycemia in those taking the aforementioned drugs.

One way to avoid diet-induced hypoglycemia is to reduce the diabetic drug dose.

A type 2 overweight diabetic eating a Standard American Diet—and I know there are many out there—would tend to see lower glucose levels by switching to probably any of the popular paleo diets.  Be ready for hypoglycemia if you take those drugs.

Paleo diets are not necessarily low-carb.  Konner and Eaton estimate that ancestral hunter-gatherers obtained 35 to 40% of total calories from carbohydrates.  I’ve seen other estimates as low as 22%.  Reality likely falls between 22 and 65%.  When pressed for a brief answer as to how many carbohydrate calories are in the paleo diet, I say “about a third of the total.”  By comparison, the typical U.S. diet provides 50% of calories from carbohydrate.

Someone could end up with a high-carb paleo diet easily, by emphasizing tubers (e.g., potatoes), higher-carb vegetables, fruits, berries, and nuts (especially cashews). Compared with the SAD, this could cause higher or lower blood sugars, or no net change.

A diabetic on a Bernstein-style diet or Ketogenic Mediterranean Diet (both very-low-carb) but switching to paleo or low-carb paleo (50-150 g?) would see elevated blood sugars.  Perhaps very high glucoses.

Any person with diabetes making a change in diet should do it in consultation with a personal physician or other qualified healthcare professional familiar with their case.

Steve Parker, M.D.

Fun Facts!

  • A typical carbonated soda contain the equivalent of 10 tsp (50 ml) of sugar.
  • The typical U.S. adult eats 30 tsp  (150 ml) daily of added sweeteners and sugars.
  • U.S total grain product consumption was at record lows in the 1970s, at 138 pounds per person.  By 2000, grain consumption was up by 45%, to 200 pounds per person.
  • Total caloric sweetener consumption (by dry weight) was 110 pounds per person in the  1950s.  By 2000, it was up 39% to 150 pounds.
  • Between 1970 and 2003, consumption of added fats and oils rose by 63%, from 53 to 85 pounds.  [How tasty would that be without starches and sugars?  Not very.]
  • In 2008, “added fat” calories in the U.S. adult diet were 641 (24% of total calories).

Fun Facts provided by the U.S. Department of Agriculture. 

(The paleo diet is also referred to as the Paleolithic, Old Stone Age, Stone Age, Ancestral, Hunter-Gatherer, or Caveman diet.)

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