VASCULAR FUNCTION.

An early event in heart disease, vascular dysfunction is now considered part of metabolic syndrome because of its likely origins in insulin resistance in cells that line the interior artery walls.39 An ultrasound technique that measures the ability of an artery in the arm (the brachial artery) to dilate detects the proper functioning of blood vessels. An ultrasound technique that measures the ability of an artery in the arm (the brachial artery) to dilate detects the proper functioning of blood vessels.40 In previous studies, a high-fat meal has been shown to temporarily impair dilation of the brachial artery. In previous studies, a high-fat meal has been shown to temporarily impair dilation of the brachial artery.41 The adverse effects of single meals high in fat, especially saturated fat, on lipid levels after a meal The adverse effects of single meals high in fat, especially saturated fat, on lipid levels after a meal42 and on vascular and inflammatory functions have been used as evidence to discourage low-carbohydrate diets. The test subject's prior diet history, however, has a fundamentally important effect on the metabolic response to meals. For example, research has repeatedly shown that adaptation to a very-low-carbohydrate diet results in a substantial reduction in the triglyceride response to a high-fat meal. and on vascular and inflammatory functions have been used as evidence to discourage low-carbohydrate diets. The test subject's prior diet history, however, has a fundamentally important effect on the metabolic response to meals. For example, research has repeatedly shown that adaptation to a very-low-carbohydrate diet results in a substantial reduction in the triglyceride response to a high-fat meal.43 This means that studies that show short-term harmful effects of a high-fat meal on vascular function may show very different results after subjects are adapted to a low-carbohydrate diet. This means that studies that show short-term harmful effects of a high-fat meal on vascular function may show very different results after subjects are adapted to a low-carbohydrate diet.

When the effects of a high-fat meal on vascular function are a.s.sessed in subjects with metabolic syndrome who consumed a high-fat, very-low-carb diet,44 there is a marked decrease in the triglyceride response to the high-fat meal. In contrast, control subjects consuming a low-fat diet showed little change. After twelve weeks on a very-low-carbohydrate diet, subjects showed improved vascular function after a high-fat meal compared to a control group of subjects who consumed a low-fat diet. there is a marked decrease in the triglyceride response to the high-fat meal. In contrast, control subjects consuming a low-fat diet showed little change. After twelve weeks on a very-low-carbohydrate diet, subjects showed improved vascular function after a high-fat meal compared to a control group of subjects who consumed a low-fat diet.

THE ATKINS DIET IS GOOD MEDICINE.

A series of low-carbohydrate-diet studies show that improvement in metabolic syndrome is intimately connected with controlling carbohydrate consumption.45 Although metabolic syndrome can manifest in various ways, the nutritional benefits of a low-carbohydrate diet hold the promise of improving Although metabolic syndrome can manifest in various ways, the nutritional benefits of a low-carbohydrate diet hold the promise of improving all all the syndrome's features. Most physicians would treat each symptom individually, with the result that an individual might be taking multiple medications, increasing both the expense and the chance of developing side effects. Because having metabolic syndrome means you're on the fast track to diabetes and heart disease, getting all of its components under control is a unique benefit of the Atkins Diet. In the next chapter, you'll learn that these same dietary modifications can also reduce the likelihood of developing type 2 diabetes or even reverse its course, as evidenced by our final Success Story. the syndrome's features. Most physicians would treat each symptom individually, with the result that an individual might be taking multiple medications, increasing both the expense and the chance of developing side effects. Because having metabolic syndrome means you're on the fast track to diabetes and heart disease, getting all of its components under control is a unique benefit of the Atkins Diet. In the next chapter, you'll learn that these same dietary modifications can also reduce the likelihood of developing type 2 diabetes or even reverse its course, as evidenced by our final Success Story.

SUCCESS STORY 10.

WHEN PROFESSIONAL AND PERSONAL WORLDS COLLIDE.

His self-diagnosis of diabetes launched the Canadian physician Jay Wortman on a personal odyssey of discovery and recovery. It also spurred a professional quest to push the boundaries of diabetes management at a time when the disease is becoming a global health crisis.

VITAL STATISTICS.

Current phase: Lifetime MaintenanceDaily Net Carb intake: 2030 gramsAge: 59Height: 5 feet, 9 inchesBefore weight: 185 poundsCurrent weight: 160 poundsWeight loss: 25 poundsCurrent blood sugar: Under 6 mmol/Ll (108 mg/dL)Current HbAlc: 5.5%Former blood pressure: 150/95Current blood pressure: 130/80Current HDL cholesterol: 91 mg/dLCurrent LDL cholesterol: 161 mg/dLCurrent triglycerides: 52.4 mg/dLCurrent total cholesterol: 272 mg/dLCurrent C-reactive protein: 0.3 mg/dL What is your background?

As a physician who has focused on aboriginal health, I was acutely aware of the high rates of diabetes, as well as obesity and metabolic syndrome, in this population. These epidemics were devastating aboriginal communities and incurring huge costs for health care services. When I traveled to the affected communities, there was almost a feeling that the situation was hopeless. Even in communities with extra resources and research programs, we weren't able to reverse the terrible trend.

Did you have a family history of diabetes?

I grew up in a small village in northern Alberta, Canada. Some of my ancestors were settlers in the Hudson Bay area and had intermarried with aboriginal peoples. Both my maternal grandparents developed type 2 diabetes, as did my mother and other close relatives. The aboriginal genetic tendency toward this disease had slowly snaked its way up through my family tree to bite me.

How did you react to this realization?

I was stunned. As a physician, you somehow believe that you're going to be immune to the diseases that you diagnose and treat in others. This, coupled with the fact that I had a very young son, made my self-diagnosis doubly shocking. Of all the concerns about serious health problems and a shortened life expectancy, however, the prospect of not seeing my two-year-old son grow into maturity was the thing that disturbed me most.

I had taken extra training in diabetes in my last year of family medicine residency and knew about the diabetic diet and how lifestyle change was supposed to be the cornerstone of diabetes management. I also knew that, for the most part, newly diagnosed type 2 diabetics went on drug therapy immediately because of the ineffectiveness of lifestyle interventions and that, even then, most tended to struggle and fail in their attempts to maintain normal blood glucose values. Further complicating my situation was the fact that I abhorred the use of medication.

Did the diabetes occur out of the blue?

Clearly, I'd been in denial. I'd put on some weight and was fatigued all the time. I struggled through bouts of afternoon drowsiness. I got up at night to urinate, was constantly thirsty, and needed to squint to see the television news. My blood pressure was also rising into the zone that would require treatment. I rationalized all these developing problems as the natural and inevitable effects of aging until it suddenly dawned on me that I had the typical symptoms of diabetes. I tested myself and confirmed that my blood sugar was way too high. In order to buy time while I looked at the recent science and formulated a management plan, I decided not to eat anything that would exacerbate my soaring blood sugar. I immediately stopped eating sugar and starchy foods, but at the time I didn't have a clue about low-carb diets.

What was the result of your dietary s.h.i.+ft?

Almost immediately, my blood sugar normalized, followed by a dramatic and steady loss of weight-about a pound a day. My other symptoms swiftly vanished, too. I started seeing clearly, the excessive urination and thirst disappeared, my energy level went up, and I began to feel immensely better. I bought an exercise bike and started riding it for thirty minutes every day as I continued to avoid starches and sugars. It was my wife who pointed out that I was on the Atkins Diet. She had struggled to lose weight after the birth of our son and had tried various diets. I recall that when she brought home an Atkins book I was dismissive, suggesting that it was just another of the fad diets and that it probably wouldn't work over the long haul. As I read the book, I realized that I wasn't actually following Dr. Atkins's phased approach to carb restriction, I was simply avoiding all carbs.

How did your personal situation impact your practice?

As I began to realize that my simple dietary intervention was rapidly and effectively resolving my own diabetes, I naturally started to look at the broader aboriginal diabetes epidemic through this lens. In my travels to First Nations communities, I started to question people, especially the elders, about their traditional ways of eating. It was common, especially in coastal communities, to consume traditional foods like salmon, halibut, and sh.e.l.lfish. Inland, one would eat moose, deer, and elk. It was also common to eat modern fare, such as potato and pasta salads with the salmon and moose, cakes and cookies for dessert, all chased with juices and soda pop.

I began to understand that the traditional diet didn't have a significant source of starch or sugar. People ate berries, but the vast majority of calories came in the form of protein and fat. A number of seasonal wild plants, akin to modern greens, were all low in starch and sugar. The traditional diet was looking very much like a modern-day lowcarb diet in terms of its macronutrient content.

How did you test your theory?

Around this time a medical journal published a study in which a group of overweight men were put on the Atkins Diet and followed it for six months. The men lost significant weight and experienced an improvement in their cholesterol levels. I suggested to my two community medicine specialists that we design a similar study for a cohort of First Nations subjects.

I had started speaking to First Nation audiences about my ideas of a link between their changing diet and the epidemics of obesity and diabetes. Ultimately, the Canadian government agreed to fund a trial study to look at the effects of a traditional low-carb diet on obesity and diabetes. I was also able to spend two years on research leave at the University of British Columbia Department of Health Care.

How is your health today?

For about seven years, I've adhered to the diet and continue to maintain normal blood sugar and blood pressure and a weight loss of about 25 pounds. After the first six months, I had my cholesterol checked. I'd become accustomed to eating lots of fatty foods, including my own wickedly delicious low-carb chocolate ice cream recipe. I have to admit I was afraid. I'd been taught that a diet high in saturated fat would lead to an unhealthy lipid profile. Much to my surprise and relief, I had excellent cholesterol. I was clearly on the right track.

My most recent blood tests continue to demonstrate excellent results. Although my total cholesterol and LDL cholesterol are above normal limits, I know from reading the scientific literature that this is not a concern given that the important markers for cardiovascular risk, HDL and triglycerides, are well within normal limits and my C-reactive protein is exceptionally low. With a pattern like this, although I have not tested for small, dense LDL, I can a.s.sume that my LDL is of the healthy variety. I am convinced that my health is better than it has ever been. I have learned an enormous amount in an area of science that physicians, unfortunately, tend to ignore: nutrition.

Has your research been published yet?

At this point, we're collecting data. After statistical a.n.a.lysis, we'll write the paper and submit it for publication in a scientific journal. Meanwhile, the study and how it affected the people of the Namgis First Nation and other residents of Alert Bay is the subject of the doc.u.mentary My Big Fat Diet. My Big Fat Diet.

(For more information, see www.cbc.ca/thelens/bigfatdiet.)

Chapter 14 MANAGING DIABETES, AKA THE BULLY DISEASE.

Diabetes now affects more than 18 million people in the United States alone, but because the early stages can be completely silent, as many as 8 million of them are unaware that they have the disease.

The Atkins Diet is more than just a healthy lifestyle. As you've learned in the previous chapter, this way of eating can significantly reduce your chances of developing heart disease and metabolic syndrome. Now you'll learn that the Atkins Diet is also an extremely effective tool to manage diabetes. We've previously pointed out that dietary carbohydrates act like a metabolic bully, demanding that they be burned first and pus.h.i.+ng fats to the back of the line, which promotes the buildup of excess fat stores. Just as an individual who has been bullied for years may stop fighting back, some people's bodies eventually give in to the ongoing stress of too much sugar and other refined carbohydrates. The result is type 2 diabetes, which occurs when the body loses its ability to keep blood sugar within a safe range. When this happens, the swings in blood sugar-sometimes too low, but mostly too high-start to do their damage.

ONE NAME, TWO DISEASES.

Though most people know that diabetes has something to do with insulin, they're generally confused about exactly what that means. That's not surprising, considering that two different conditions (type 1 diabetes and type 2 diabetes) share the name. Both types involve insulin, the hormone that facilitates the movement of glucose into cells to be burned or stored. Simply put, type 1 diabetes reflects a problem in insulin production that results in low insulin levels. Type 2, on the other hand, reflects a problem in insulin action (insulin resistance), which results in high insulin levels. Type 2 occurs mainly in adults and is the much more common form, representing 85 to 90 percent of all cases worldwide. Type 1 is more common in children, but thanks to the rapid increase in obesity among younger people, tragically this age group is also now developing type 2 diabetes.

If you've already been diagnosed with type 2 diabetes and have been testing your blood sugar after meals-or you live with someone who does-you've probably noticed that foods rich in carbohydrates drive blood sugar higher than those composed mostly of proteins and fats. If so, this chapter will confirm your suspicions that a healthful diet should limit carbohydrates to an amount that doesn't elevate blood sugar to the level that can inflict damage. And for the rest of us who don't (yet) have diabetes, it will soon become apparent that the best way to prevent this illness is by reducing dietary carbs to the point where they no longer function as a metabolic bully.

A "SILENT" DISEASE ... BUT AN ENORMOUS EPIDEMIC About one-third of people with type 2 diabetes in the United States are unaware that they have this disease. Fortunately, diagnosing diabetes is as simple as checking a small amount of your blood for its blood sugar (glucose) level or your blood level of hemoglobin Alc (HbAlc), which indicates your blood glucose level over the last several months. Your health care provider can perform either of these tests at a routine checkup, and many employers provide workplace screening (see the sidebar "Understanding Blood Sugar Readings" for more on testing). Because diabetes is so common and checking for it is so easy, if you don't know if you have diabetes, there's no reason not to find out as soon as possible.

Understanding the role of carbohydrate restriction in the prevention and treatment of diabetes is especially important because of the enormous scope of the diabetes epidemic. Despite the best efforts of the traditional medical approach, which is based upon aggressive use of drugs, the tide of this disease continues to rise. According to the American Diabetes a.s.sociation, the disease now affects 18.2 million people in the United States, but because the early stages of diabetes can be completely silent, 8 million of them are unaware that they have the disease. Nor are the numbers likely to improve soon. As other nations adopt a diet high in sugar and processed carbohydrates, the epidemic has escalated to involve 246 million people worldwide, with projections of 380 million by 2025.

UNDERSTANDING DLOOD SUGAR READINGS.

The amount of glucose (sugar) in your blood changes throughout the day and night. Your levels vary depending upon when, what, and how much you have eaten and whether or not you've exercised. The American Diabetes a.s.sociation (ADA) categories for normal blood sugar levels follow, based on how your glucose levels are tested.

Fasting blood glucose. This test is performed after you have consumed no food or liquids (other than water) for at least eight hours. A normal fasting blood glucose level is between 60 and 110 mg/dL (milligrams per deciliter). A reading of 126 mg/dL or higher indicates a diagnosis of diabetes. (In 1997, the ADA changed it from 140 mg/dL or higher.) A blood glucose reading of 100 indicates that you have 100 mg/dL. This test is performed after you have consumed no food or liquids (other than water) for at least eight hours. A normal fasting blood glucose level is between 60 and 110 mg/dL (milligrams per deciliter). A reading of 126 mg/dL or higher indicates a diagnosis of diabetes. (In 1997, the ADA changed it from 140 mg/dL or higher.) A blood glucose reading of 100 indicates that you have 100 mg/dL.

"Random" blood glucose. This test may be taken at any time, with a normal blood glucose range in the low to midhundreds. A diagnosis of diabetes is made if your blood glucose reading is 200 mg/dL or higher and you have such symptoms of the disease as fatigue, excessive urination, excessive thirst, or unplanned weight loss. This test may be taken at any time, with a normal blood glucose range in the low to midhundreds. A diagnosis of diabetes is made if your blood glucose reading is 200 mg/dL or higher and you have such symptoms of the disease as fatigue, excessive urination, excessive thirst, or unplanned weight loss.

Oral glucose tolerance. After fasting overnight, you'll be asked to drink a sugar-water solution. Your blood glucose levels will then be tested over several hours. In a person without diabetes, glucose levels rise and then fall quickly after drinking the solution. If a person has diabetes, blood glucose levels rise higher than normal and don't fall as quickly. A normal blood glucose reading two hours after drinking the solution is less than 140 mg/dL, and all readings in the first two hours must be less than 200 mg/dL for the test to be considered normal. Blood glucose levels of 200 mg/dL or higher at any time indicate a diagnosis of diabetes. After fasting overnight, you'll be asked to drink a sugar-water solution. Your blood glucose levels will then be tested over several hours. In a person without diabetes, glucose levels rise and then fall quickly after drinking the solution. If a person has diabetes, blood glucose levels rise higher than normal and don't fall as quickly. A normal blood glucose reading two hours after drinking the solution is less than 140 mg/dL, and all readings in the first two hours must be less than 200 mg/dL for the test to be considered normal. Blood glucose levels of 200 mg/dL or higher at any time indicate a diagnosis of diabetes.

Hemoglobin A1c (HbA1c). This is a substance that goes up as a result of high blood glucose levels, and, once elevated, it stays up for a couple of months. Because blood glucose levels bounce around a lot depending on diet and exercise, the HbA1c test offers the advantage of smoothing out a lot of this variability. A level below 5.5 is considered good; a level above 6.5 indicates a diagnosis of diabetes. This is a substance that goes up as a result of high blood glucose levels, and, once elevated, it stays up for a couple of months. Because blood glucose levels bounce around a lot depending on diet and exercise, the HbA1c test offers the advantage of smoothing out a lot of this variability. A level below 5.5 is considered good; a level above 6.5 indicates a diagnosis of diabetes.

As of this writing, the American Diabetes a.s.sociation is intending to adopt the HbA1c test as a diagnosis for diabetes.

DIABETES AND INFLAMMATION: A CHICKEN-AND-EGG SITUATION?.

The underlying cause of type 2 diabetes is a controversial topic. In general, diabetes is a disorder of carbohydrate metabolism caused by a combination of hereditary and environmental factors. The latter includes the composition of the diet, obesity, and inactivity. However, many people eat a poor diet and are sedentary but never develop obesity or diabetes. Similarly, some obese, sedentary people have normal blood sugar levels. Nonetheless, overall, obesity and inactivity increase an individual's risk of developing diabetes, but some individuals seem more protected than others. This indicates that genetics play an important role in the development of the disorder. Another important factor is age: your body may tolerate bad behavior at age 30 but not necessarily at 60.

Your body uses the hormone insulin to trigger the movement of blood sugar into the cells, but, as you learned in the previous chapter, at high levels insulin also promotes metabolic syndrome, including excess fat storage, inflammation, and the formation of plaque in your arteries. Inflammation has increasingly become a topic of interest because people with type 2 diabetes typically have increased blood levels of inflammation biomarkers such as C-reactive protein (CRP), and this biomarker in turn accurately predicts who will later develop such complications of type 2 diabetes as heart disease, stroke, and kidney failure.1 More important, however, when large populations of adults without diabetes are screened for CRP levels and then followed for five to ten years, the quarter of the population with the highest levels has two to four times the likelihood of subsequently developing diabetes.2 What this means is that inflammation comes before the overt signs of diabetes develop. In other words, inflammation looks less like an effect of diabetes and more like an (if not the) underlying cause. Coming back to our a.n.a.logy of carbohydrate as a bully, it's simple but appealing to think that dietary carbohydrates repeatedly "bruise" the body. Further, it would seem that some people respond to this bruising by becoming inflamed, and this inflammation eventually results in damage that causes cells to become insulin-resistant and organs to eventually fail. What this means is that inflammation comes before the overt signs of diabetes develop. In other words, inflammation looks less like an effect of diabetes and more like an (if not the) underlying cause. Coming back to our a.n.a.logy of carbohydrate as a bully, it's simple but appealing to think that dietary carbohydrates repeatedly "bruise" the body. Further, it would seem that some people respond to this bruising by becoming inflamed, and this inflammation eventually results in damage that causes cells to become insulin-resistant and organs to eventually fail.

So how does this simple a.n.a.logy help us understand something as complex as the underlying cause of type 2 diabetes? Well, take away the bully, and the bruising stops. Right? In the previous chapter we gave you strong evidence that carbohydrate restriction in people with metabolic syndrome (aka prediabetes) results in a sharp reduction in the biomarkers of inflammation. Now we'll show you that type 2 diabetics consuming a low-carb diet experience improvements in blood sugar, blood lipids, and body weight-sometimes dramatically so.

A LOOK AT THE RESEARCH.

There are several different types of studies used to understand the effect of eating different foods on human health. In previous decades, scientists tended to rely on observational studies of what people ate and how that affected their long-term health (nutritional epidemiology), but prospective clinical trials are considered more accurate. Studies on individuals in an "inpatient" clinical research ward provide tight control over what people eat, but they tend to be limited to a week or two, during which research subjects remain hospitalized, with a few notable exceptions.

In other studies, researchers give subjects food to take home to eat. However, there's no a.s.surance that people won't eat other food in addition to the supplied meals. Finally, another type of research involves instructing people to buy and eat certain foods and return for instruction and support-often over a period of several years. These "outpatient" or "free-living" studies tell us a lot about whether a certain diet is sustainable in the "real-world" setting. But the interpretation of such studies is limited because people don't necessarily follow the dietary instructions. Here are some examples of studies that have shown that the Atkins Diet is a safe and effective treatment for type 2 diabetes.

INPATIENT STUDIES.

In a pioneering study done thirty years ago, seven obese type 2 diabetics were placed on a very-low-calorie ketogenic diet, first as inpatients and later as outpatients.3 Initially, these subjects had fair-to-poor blood glucose control despite the fact that they were already taking 30 to 100 units of insulin per day. Within twenty days of starting the low-carbohydrate diet, all the subjects were able to discontinue their insulin injections. Nonetheless, their blood glucose control improved, as did their blood lipid profiles. The authors noted that blood glucose control improved much more rapidly than did the rate at which they lost weight, indicating that carbohydrate intake was the primary determinant of glucose control and insulin requirement rather than obesity itself. Initially, these subjects had fair-to-poor blood glucose control despite the fact that they were already taking 30 to 100 units of insulin per day. Within twenty days of starting the low-carbohydrate diet, all the subjects were able to discontinue their insulin injections. Nonetheless, their blood glucose control improved, as did their blood lipid profiles. The authors noted that blood glucose control improved much more rapidly than did the rate at which they lost weight, indicating that carbohydrate intake was the primary determinant of glucose control and insulin requirement rather than obesity itself.

In a 2005 inpatient study ten obese people with type 2 diabetes were fed their usual diet for seven days, followed by a low-carbohydrate diet (the Induction phase of Atkins) of 20 grams of carbs a day for fourteen days.4In both cases, subjects were allowed to choose how much they ate, so the only change after the first week was eliminating most carbohydrate foods. Because this study took place in a research ward, the researchers were able to doc.u.ment the subjects' total food intake. They found that when subjects followed the low-carb diet, they continued to eat about the same amount of protein and fat as before, even after two weeks of carb restriction and although they could have eaten more protein and/or fat to make up for the missing carbohydrate calories if they desired. This means that they naturally ate fewer calories when carbs were restricted. In addition to losing weight, the subjects also showed improvements in their blood glucose and insulin levels. Many were able to eliminate their medications, and their insulin sensitivity improved by 75 percent on average, similar to the observations of the 1976 study cited above. More important, this recent study showed that instructing people to limit their grams of carbohydrate (without restricting calories or portion size) resulted in their eating less food and rapidly improving their insulin sensitivity.

OUTPATIENT STUDIES.

A recent outpatient study compared a low-carbohydrate diet to a portion-controlled, low-fat diet in seventy-nine patients over a three-month period.5 After three months, subjects in the low-carb group were reportedly consuming 110 grams of carbohydrate per day (the upper range of the Atkins Lifetime Maintenance phase). Compared to the low-fat group, the low-carb group had improvements in glucose control, weight, cholesterol, triglycerides and blood pressure. In addition, more people in the low-carb group were able to reduce medications than those in the low-fat group. After three months, subjects in the low-carb group were reportedly consuming 110 grams of carbohydrate per day (the upper range of the Atkins Lifetime Maintenance phase). Compared to the low-fat group, the low-carb group had improvements in glucose control, weight, cholesterol, triglycerides and blood pressure. In addition, more people in the low-carb group were able to reduce medications than those in the low-fat group.

Another, very recent outpatient study compared the Induction phase of Atkins (20 grams of carbohydrate daily) to a reduced-calorie diet (500 calories a day below their previous intake level, low in fat and sugar but high in complex carbs) over a six-month period.6 They found greater improvements in blood sugar levels and greater weight loss in the Atkins Induction group. What was especially exciting, however, was that individuals who were taking insulin often found the beneficial effects of the low-carb diet quite powerful. Subjects taking from 40 to 90 units of insulin before partic.i.p.ating in the study were able to eliminate insulin altogether, while also improving glycemic control. These results were similar to the inpatient studies described above. They found greater improvements in blood sugar levels and greater weight loss in the Atkins Induction group. What was especially exciting, however, was that individuals who were taking insulin often found the beneficial effects of the low-carb diet quite powerful. Subjects taking from 40 to 90 units of insulin before partic.i.p.ating in the study were able to eliminate insulin altogether, while also improving glycemic control. These results were similar to the inpatient studies described above.

And finally, the Kuwaiti low-carb study cited in chapter 1 chapter 1 included thirty-five subjects whose blood glucose was elevated at the start of the study. The average value for this group returned into the normal range within eight weeks of following the low-carb diet, and at fifty-six weeks, this group's average fasting blood glucose had been reduced by 44 percent. included thirty-five subjects whose blood glucose was elevated at the start of the study. The average value for this group returned into the normal range within eight weeks of following the low-carb diet, and at fifty-six weeks, this group's average fasting blood glucose had been reduced by 44 percent.

In summary, these five studies, in a variety of settings, all showed dramatic improvements in blood glucose control and blood lipids in type 2 diabetics consuming a low-carb diet. When these studies included a low-fat, high-carb comparison group, the low-carb diet consistently showed superior effects on blood glucose control, medication reduction, blood lipids, and weight loss. Weight loss is particularly important because treatment goals for patients with type 2 diabetes always emphasize weight loss if the individual is overweight, yet the drugs used to treat diabetics almost all cause weight gain. So let's look at this briefly, as the ability to deliver improved blood sugar control and and weight loss distinguishes a low-carb approach from all other nonsurgical treatments for type 2 diabetes. weight loss distinguishes a low-carb approach from all other nonsurgical treatments for type 2 diabetes.

WEIGHING THE OPTIONS: COMMON SIDE EFFECTS OF MEDICATION.

On its surface, the management of type 2 diabetes seems pretty easy: just get your blood glucose back down into the normal range. But insulin resistance characterizes this form of diabetes; put simply, the glucose level "doesn't want to go down." This means that the body is less responsive to the most powerful drug used to treat it: insulin. So the dose of insulin that most type 2 diabetics are prescribed is very high. Moreover, because insulin not only drives glucose into muscle cells but also accelerates fat synthesis and storage, weight gain is usually one side effect of aggressive insulin therapy.7 Other pills and injected medications have been developed to reduce this effect, but on average, the harder one tries to control blood glucose, the greater the tendency to gain weight. Other pills and injected medications have been developed to reduce this effect, but on average, the harder one tries to control blood glucose, the greater the tendency to gain weight.8 The other major side effect of attempting to gain tight control of blood sugar is driving it too low, causing hypoglycemia, which causes weakness, shakiness, confusion, and even coma. If these symptoms appear, the advice is to immediately eat a lot of sugar to stop the symptoms, which jump-starts the blood sugar roller coaster all over again. Interestingly, once type 2 diabetics complete the first few weeks of the Atkins program, they rarely experience hypoglycemia. That's because of the body's adaptation to burning fat for most of its fuel during carb restriction, in concert with the ability to reduce or stop most diabetic medications (including insulin) within a few days or weeks of starting the Atkins Diet. The other major side effect of attempting to gain tight control of blood sugar is driving it too low, causing hypoglycemia, which causes weakness, shakiness, confusion, and even coma. If these symptoms appear, the advice is to immediately eat a lot of sugar to stop the symptoms, which jump-starts the blood sugar roller coaster all over again. Interestingly, once type 2 diabetics complete the first few weeks of the Atkins program, they rarely experience hypoglycemia. That's because of the body's adaptation to burning fat for most of its fuel during carb restriction, in concert with the ability to reduce or stop most diabetic medications (including insulin) within a few days or weeks of starting the Atkins Diet.

So why isn't it good enough just to cut back on one's calories without cutting back on carbs? It's true that going on a diet and losing weight typically improve diabetes control. Well, first of all, dieting won't necessarily result in weight loss, and any weight loss may not be sustained. Second, even weight loss is usually not enough to significantly reduce medication dosage. Finally, since diabetic drugs still produce side effects and appet.i.te stimulation, losing weight on a standard diet is a difficult tightrope for a diabetic to walk.

Once you understand this tightrope of weight loss during drug treatment-some would call it a Catch-22-it's easier to appreciate the advantage of using the Atkins Diet to manage type 2 diabetes. When you remove added sugar, significantly reduce carb intake overall, and confine your consumption primarily to the foundation vegetables allowed in Induction, your insulin resistance rapidly improves, and blood glucose control improves-usually dramatically. Additionally, most people find that they can stop or substantially reduce their diabetes medications. As a result, the path to meaningful weight loss changes from a tightrope to a wide road. As long as you stay within your carb tolerance range, you should be able to navigate your way to health.

IF AND WHEN TO EXERCISE.

You might be familiar with many of the potential health benefits of exercise, but you probably don't know that exercise has insulinlike effects. This is relevant for type 2 diabetics with insulin resistance, because performing just a single bout of exercise improves insulin resistance for several hours. A number of studies have shown that regular exercise improves blood sugar control, even if it doesn't significantly improve weight loss.9 Because weight loss is so difficult for people with type 2 diabetes and because doctors have little else to offer (other than drugs) in the way of effective remedies, exercise is always near the top of the list of official guidelines. Because weight loss is so difficult for people with type 2 diabetes and because doctors have little else to offer (other than drugs) in the way of effective remedies, exercise is always near the top of the list of official guidelines.

Given this information, simple logic dictates that we should tell everyone with diabetes to get out and exercise. But not so fast. First, exercise holds an exalted position in diabetic treatment because the usual diets almost always fail. We need to consider what role exercise should play if the tables are turned and you have access to a diet like Atkins that almost always "works" and that simultaneously causes insulin resistance and blood sugar control to improve significantly. Unfortunately, we don't yet have the perfect answer. Yes, we've proved that once people adapt to the Atkins Diet, they're capable of lots of exercise. But no one has done a study of diabetics on Atkins in which some of them exercise and some of them don't, to prove that adding exercise to an already successful diet improves blood sugar control or increases weight loss enough to justify the added effort.

Second, if you're diabetic, you're at increased risk for heart attack, and most people with type 2 diabetes are overweight (at least, before they start Atkins). So if you were offered the choice of either starting the program and exercising at the same time, or alternatively starting Atkins first, getting your blood sugar under control, reducing or stopping medications you might be taking for diabetes, and getting some weight off your ankles, knees, hips, and lower back, which would you choose?

Clearly, the key question is not really if if but but when. when. The Atkins Diet opens the door for you to exercise, and exercise has a lot of benefits other than weight loss (and may even improve your blood sugar control). As we've said previously, if you're already physically active, keep it up, being careful not to overdo it while you're adapting to fat burning in the first few weeks. But if it's been a while since you did much of anything vigorous, consider giving yourself a few weeks or months to unburden your heart and joints before taking on a 10K run or trying to burn out the treadmill or pump iron at the gym. The Atkins Diet opens the door for you to exercise, and exercise has a lot of benefits other than weight loss (and may even improve your blood sugar control). As we've said previously, if you're already physically active, keep it up, being careful not to overdo it while you're adapting to fat burning in the first few weeks. But if it's been a while since you did much of anything vigorous, consider giving yourself a few weeks or months to unburden your heart and joints before taking on a 10K run or trying to burn out the treadmill or pump iron at the gym.

THE CURRENT OFFICIAL GUIDELINES.

Okay, we've explained how Atkins offers unique benefits to someone with type 2 diabetes. So why isn't everyone with the disorder doing it? The answer is that the low-fat-diet fad of the last forty years, backed by the food industry and government-sanctioned committees, has taken a long time to run its course. Only with the recent research we've cited in the last few chapters has the mainstream medical community begun to be receptive to the value of low-carbohydrate diets. Standard treatment guidelines are beginning to reflect this change. This is where we stand today.

The goal of medical nutrition therapy for type 2 diabetes is to attain and maintain optimal metabolic outcomes, including: - Blood glucose levels in the normal range or as close to normal as is safely possible to prevent or reduce the risk for complications of diabetes- Lipid and lipoprotein profiles that reduce the risk for blood vessel disease (i.e., blockage of blood flow to your heart, brain, kidneys, and legs)- Blood pressure levels that reduce the risk of developing vascular disease The American Diabetes a.s.sociation (ADA) has acknowledged the use of a low-carbohydrate diet in achieving these goals in its 2008 guidelines, which include:10 - Modest weight loss has been shown to improve insulin resistance in overweight and obese insulin-resistant individuals.- Weight loss is recommended for all overweight individuals who have or are at risk for the disease.- Either low-carbohydrate or low-fat calorie-restricted diets may be effective for weight loss in the short term (up to one year).- Patients on low-carbohydrate diets should have their lipid profiles, kidney function, and protein intake (for those with kidney damage) monitored regularly.- To avoid hypoglycemia, patients following a low-carb diet who are taking blood sugar-lowering medications need to have them monitored and adjusted, as needed.

PRACTICAL POINTERS.

How can those of you who are diabetic translate all of this information into action to transform your health? Here are three practical considerations: 1. The focus of this chapter has been on type 2 diabetes because it's usually a.s.sociated with being overweight, and also because most type 2 diabetics probably won't need insulin injections if they can find and comply with their threshold for carbohydrate tolerance (CLL or ACE). Type 1 diabetics will always need some insulin, making its management much more technical on a carb-restricted diet. Though some doctors are now using the Atkins Diet for selected type 1 diabetics, instructions on how to do this safely are beyond the scope of this book. If you've been diagnosed with type 1 diabetes, or if you've ever been diagnosed with diabetic ketoacidosis, you should not try the Atkins Diet on your own. And if you do try it under medical supervision, be sure that you're being instructed and closely monitored by a doctor familiar with Atkins.2. Second, if you're taking medications to control blood sugar (diabetic drugs) or drugs for high blood pressure, be sure to work closely with your doctor, particularly in the first weeks and months of the diet. It's during this time that diabetes and blood pressure improve rapidly, which usually requires reducing or stopping the medications used to treat these problems. This should always be done with your doctor's knowledge and consent.3. Be consistent about sticking with the program. While we advise this for everyone following a low-carb diet-whether your problem is weight, diabetes, high blood lipids, or high blood pressure-consistency is of the greatest importance if you start out with diabetes. This is because type 2 diabetes represents the highest level of insulin resistance, so if you break the diet, your body's return to carbohydrate intolerance will be rapid and the swings in blood sugar wide. If you've gotten off of most of your diabetes or high-blood-pressure drugs in the first two weeks of the diet and celebrate this victory by three days of eating everything in Vegas, the metabolic bully will beat you up and you'll return home with these problems once again out of control. (In this case, what happened in Vegas won't stay in Vegas!) Yes, as you lose weight, your underlying tendency to be insulin-resistant often improves. But most diabetics still remain somewhat insulin-resistant even after substantial weight loss, so staying at or under your carbohydrate threshold has greater importance for you in order to avoid the long-term medical problems caused by poorly controlled diabetes.

A CHALLENGE THAT'S WORTH THE EFFORT Using the Atkins Diet to manage type 2 diabetes is probably the most potent use of this powerful tool, but it's also the most demanding. Make sure that you (and your doctor) are ready to apply the time and energy necessary to be successful-both in the near term and for years to come. To that end, we have provided a combination of scientific and practical information in this chapter so that both you and your physician can be a.s.sured that this use of the Atkins Diet can be safe and effective.

Acknowledgments.

We are like dwarfs on the shoulders of giants, so that we can see more than they, and things at a greater distance, not by virtue of any sharpness of sight on our part, or any physical distinction, but because we are carried high and raised up by their giant size.

-Bernard of Chartres, 1159 For a quarter century, as an academic physician doing research on low-carbohydrate metabolism, my life ran parallel to that of Robert C. Atkins. Sadly, our paths never crossed. About a decade ago, however, two leaders of a new generation of medical scientists contacted me. Building a bridge between the heretofore separate realms of academic research and the clinical brilliance of Dr. Atkins, Dr. Eric Westman and Dr. Jeff Volek have forged the scientific foundation of the New Atkins. As a result of their efforts and the support of the Atkins Foundation, there has been a resurgence of scientific interest in the Atkins Diet. It has been my very great pleasure to collaborate with them, first on current research studies and now on the creation of this book.

I also wish to thank Drs. Ethan Sims, Edward Horton, Bruce Bistrian, and George Blackburn for teaching me to subject standard dietary practices to scientific scrutiny. Their guidance helped to shape my life and my career. I also owe a debt of grat.i.tude to my many patients and research subjects for opening my eyes to unantic.i.p.ated results. And, most important, thanks to my lovely family-Huong, Lauren, and Eric-for their unquestioning support and their tolerance of my cooking.

-Stephen D. Phinney I must first thank those people who have shaped my scientific thinking and specifically contributed to a line of research on carbohydrate restriction. Dr. William J. Kraemer initially sparked my interest in science and has offered unwavering support for almost twenty years as we have continued to collaborate on research and become best friends. I'm not sure if he qualifies for MENSA, but my coauthor Dr. Stephen Phinney is a bona fide nutritional genius. In 1994, I first read his enlightening papers on experiments he conducted in the early 1980s on metabolic adaptations to very-low-carbohydrate diets. A decade later I'm fortunate to consider him a close friend and colleague. Several other colleagues have significantly influenced my views of nutrition and positively impacted my research. Drs. Maria Luz Fernandez, Richard Feinman, and Richard Bruno are all brilliant collaborators on past and current research projects whose relations.h.i.+ps I treasure. I have also been privileged to work with several tireless and talented graduate students over the years, all of whom dedicated countless hours to conducting more than a dozen experiments aimed at better understanding how low-carbohydrate diets improve health.

It's been a pleasure working with Eric Westman and Stephen Phinney. It is also necessary to acknowledge Dr. Robert C. Atkins, who had a remarkable and permanent impact on my life. His recognition of the importance of science to validate his dietary approach and his generous philanthropy has been a major reason I was able to conduct cutting-edge research on low-carbohydrate diets over the last decade.

I am forever grateful to my selfless mother, Nina, and my father, Jerry, for their unconditional love and support, and all the sacrifices they have made in order to make my life better. My two cherished boys, high-spirited Preston, who recently turned two, and Reese, who was born during the writing of this book, give me a deep sense of purpose and perspective. Coming home to them is the perfect antidote to a stressful day of work. Most important, thanks to my beloved wife, Ana, who keeps me balanced and makes life infinitely more fun.

-Jeff S. Volek I acknowledge first the enthusiastic love and support of my wife, Gretchen, and our children, Laura, Megan, and Clay. I learned to tilt at windmills from my parents, Jack C. and Nancy K. Westman, and brothers, John C. Westman and D. Paul West-man. Innumerable friends, colleagues, and data-driven academic environments enabled this book-and the science behind it-to materialize.

Thanks to Dr. Robert C. Atkins and Jackie Eberstein for having the openness to invite me to visit their clinical practice. Thanks to Veronica Atkins and Dr. Abby Bloch of the Robert C. Atkins Foundation for continuing his legacy. Thanks also to the doctors and researchers who allowed me to visit their practices or collaborate on research studies with them: Mary C. Vernon, Richard K. Bernstein, Joseph T. Hickey, Ron Rosedale, members of the American Society of Bariatric Physicians, William S. Yancy, Jr., James A. Wortman, Jeff S. Volek, Richard D. Feinman, Donald Layman, Manny Noakes, and Stephen D. Phinney.

-Eric C. Westman As a team, we wish to acknowledge the Herculean effort expended in bringing together all the components of this book by project editor Olivia Bell Buehl and Atkins nutritionist Colette Heimowitz. Dietician Brittanie Volk developed the meal plans. Thanks also to Monty Sharma and Chip Bellamy of Atkins Nutritionals, Inc., for their insight on the importance of publis.h.i.+ng this book and their patience as it took on a life of its own.

Glossary ACE: See See Atkins Carbohydrate Equilibrium. Atkins Carbohydrate Equilibrium.

Aerobic exercise: Sustained rhythmic exercise that increases your heart rate; also referred to as cardio. Sustained rhythmic exercise that increases your heart rate; also referred to as cardio.

Amino acids: The building blocks of protein. The building blocks of protein.

Antioxidants: Substances that neutralize harmful free radicals in the body. Substances that neutralize harmful free radicals in the body. Atherosclerosis: Atherosclerosis: Clogging, narrowing, and hardening of blood vessels by plaque deposits. Clogging, narrowing, and hardening of blood vessels by plaque deposits.

Atkins Carbohydrate Equilibrium (ACE) : The number of grams of Net Carbs that a person can consume daily without gaining or losing weight. The number of grams of Net Carbs that a person can consume daily without gaining or losing weight.

Atkins Edge: A beneficial state of fat-burning metabolism, caused by carbohydrate restriction, that makes it possible to lose weight and maintain weight loss without extreme hunger or cravings; a metabolic edge. A beneficial state of fat-burning metabolism, caused by carbohydrate restriction, that makes it possible to lose weight and maintain weight loss without extreme hunger or cravings; a metabolic edge.