Very Low Carbohydrate Diets for Diabetes (ADA 2018)
By Maria Muccioli Ph.D.
June 26th, 2018
A crowd overfilled the ballroom this Sunday afternoon at the ADA 78th Scientific Sessions to hear two presentations about very low carbohydrate diets (VLCD) for diabetes.
In the first presentation, Dr. Jeannie Tay from the University of Alabama at Birmingham summarized the current knowledge on VLCD for type 2 diabetes (T2D) patients and presented new clinical trial results. In the second presentation, Dr. Martin I. de Bock of Princess Margaret Hospital discussed the limited data on VLCD for children with type 1 diabetes (T1D), including the benefits, hypothetical concerns, and areas for additional follow-up.
Study Demonstrates Health Benefits for Patients with T2D
Dr. Tay began her presentation by summarizing the available data on very low carbohydrate diets (VLCD) for patients with T2D. She defined VLCD as that containing between 20-70 grams of carbohydrate per day.
She evaluated results from randomized controlled trials (RCTs) that followed patients for at least six months and highlighted that some data showed greater A1c improvements with the approach. The researcher noted that patients also experience an increase in HDL-C levels, a reduction in triglyceride levels, and improved insulin resistance.
Dr. Tay explained that while some studies showed an increase in LDL-C levels in patients following a VLCD, other studies did not find this. She addressed that LDL-C is becoming a controversial metric to assess cardiovascular disease risk and that context is important when discussing its relevance as a risk factor. Dr. Tay noted that it is generally believed that LDL-C increases may be a result of the higher saturated fat content of some VLCD.
Dr. Tay and colleagues set out to determine how a VLCD that is also low in saturated fat (LCLSF) compares against a high carbohydrate (HC) diet for the metabolic management of patients with T2D.
RCT of HC vs. LCLSF Diet for T2D
The researcher enrolled 115 adults with T2D and obesity with a mean A1c level of 7.3 +/- 1.1% and excluded patients with pre-existing renal conditions. The patients used a variety of methods to control their diabetes, including oral agents and/or insulin. They assigned the participants to either follow a HC diet (53% carbohydrate) or a LCLSF diet (14% carbohydrate, <10% saturated fat). Importantly, the diets were identical in calorie content.
All participants followed the same exercise program and their adherence to the diet was closely followed via food logs, regular meetings with a dietician, as well as urinalysis for ketones and urea/creatinine.
The researchers compared numerous parameters between the groups, including weight, body composition, A1c and markers for cardiovascular disease risk. Furthermore, they also used CGM technology to evaluate post-prandial blood glucose control and glycemic variability. The patients were followed for two years.
Main Study Outcomes
The drop-out rate (~50%) was not significantly different between the two groups, and the researchers confirmed that the remaining participants adhered to the prescribed diets.
While the data showed a comparable reduction in A1c (~1%), weight, and similar body composition, the participants in the LCLSF group:
Lowered their medication use by more than two-fold compared to the HC group
Experienced a greater than two-fold reduction in glycemic variability parameters compared to the HC group
Experienced a greater reduction in triglycerides than the HC group
Both groups experienced comparable decreases in blood pressure, insulin use, insulin resistance, and c-reactive protein levels (a marker of inflammation).
The researchers also performed a very comprehensive evaluation of renal function and cognitive performance in the subjects following the low carbohydrate approach. The researchers found no difference between the HC and LCLSF groups in any of the measured outcomes, demonstrating its safety with regard to renal function and cognitive performance.
Also, the researchers did not observe a significant difference in the LDL-C levels between the groups. Notably, the HC group experienced a significant drop in HDL levels during the study, while the HDL levels remained unchanged in the LCLSF group.
Dr. Tay stated that a very low carbohydrate diet offers a considerable advantage over a high carbohydrate approach for patients with type 2 diabetes.
She noted that reducing medication use is not only cost-effective but can also safeguard from the considerable side effects of some second-line medications. She also explained that achieving less glycemic variability, which may be an independent risk factor for the development of diabetes-associated complications, is “of great clinical importance.”
“It is a good diet to have if you have diabetes, and the data support that,” she concluded.
Endocrinologist Discusses Considerations for Children with T1D
Dr. de Bock began his presentation by describing what he believes to be the current political climate in discussing very low carbohydrate (VLC) approaches for children with T1D. “[It is] thorny, polarizing, and controversial,” he remarked. The speaker went on to explain that while he is no way against VLC approaches for children, the main purpose of his presentation was to identify putative concerns and areas that require additional study.
“I am not a denier. One can get exceptional glycemic control on a very low carbohydrate diet,” he stated, also remarking that frequent blood glucose monitoring and dosing adjustments were key to achieving the results.
Dr. de Bock believes that it is also possible to get “good control” on a high carbohydrate diet. To support this, he presented very limited blood glucose records for one teenage patient who consumes more than 300 g of carbohydrate per day, and also showed some data on pediatric A1c levels. Notably, while the A1c levels were below the average for that age group with T1D, they were still above normal.
Dr. de Bock identified five areas that he believes to be of relevance regarding the potential concerns regarding children eating a VLCD: 1) growth; 2) long-term metabolic profile; 3) bones; 4) exercise and 5) psychosocial impact and conflict. As published data specific to VLCD in children with T1D is limited, the speaker presented some data from animal studies, case studies, and children with epilepsy who followed a ketogenic diet.
Dr. de Bock did not define the specific nutrient distribution of VLCD and the data that he presented on varied greatly in the carbohydrate content, from “ketogenic” to “30% carbohydrate” for one particular case.
Since data on the exact diet composition or on glycemic control for the case study subjects that experienced adverse outcomes was not presented, it was impossible to gauge whether these could be attributed to suboptimal glycemic control or the specific macronutrient distribution.
Dr. de Bock stated that the available data on pediatric growth on a low-carb diet is contradicting and requires further investigation. His main theoretical concern is that those on a VLCD may use less insulin, and insulin is very important for numerous physiological processes, including growth. However, he did not discuss the administration of insulin to account for protein consumption, which is an important consideration. Dr. de Bock also addressed the importance of identifying any nutritional deficiencies, in particular, iron.
Long-Term Metabolic Profile
Dr. de Bock presented some data about elevated LDL-C levels in individuals on a VLCD, although the study results were variable. He stated that for those individuals who experience an uptick in LDL-C, it is unclear whether the improved glycemic control mitigates the LDL-C increase. Notably, the LDL-C metric is a controversial one and needs to be considered in the context of triglycerides, HDL, and other metabolic parameters.
Dr. de Bock pointed to some studies on children with epilepsy who followed the ketogenic diet and exhibited low bone density. He noted that individuals with T1D are prone to low bone density, so it is an important parameter to follow. Dr. de Bock did not mention the relevance of optimizing glycemic control, as chronic hyperglycemia is a relevant factor in low bone density in patients with T1D.
The speaker stated that the exercise capacity of children following a VLCD appears to be variable. He noted that some individuals do not have any problems, while others may experience fatigue. He believes the data on the subject is “inconclusive.” Careful assessment of the specific nutrient distribution of the diet to ensure appropriate nutrient intake may be at the heart of the matter.
Psychosocial Impact and Conflict
The speaker focused heavily on the potential mental and emotional implications of following a “restrictive” diet. He suggested that children (unlike adults) do not yet have the “executive thought” to make a rational decision to eat a VLCD. As such, he believes that children on a VLCD may feel deprived or resentful.
“We are a society that celebrates with food,” de Bock pointed out, as a photograph of excited children gathered around a birthday cake appeared on his presentation slide. He stated that eating cake “may or may not result in a postprandial blood glucose excursion,” depending on the management, and did not discuss that low-carbohydrate dessert recipes are widely available.
He also attempted to draw parallels between the perfectionism and idealism associated with the pursuit of very tight glycemic control on a VLCD and how these qualities are common to individuals who are at an increased risk for developing eating disorders. However, while there is no evidence to support that children on a VLCD are specifically at an increased risk for anxiety and eating disorders, there is evidence to suggest that these issues are more common in people with type 1 diabetes, in general, suggesting that they are likely related to glycemic control.
Dr. de Bock did not address the tangible concerns of suboptimal blood glucose management in pediatric patients, or the potential psychological impacts of increased anxiety, depression, and resentment that may arise from frequently abnormal blood glucose levels and the associated physiological consequences.
Dr. de Bock does not deny that a VLCD for children with type 1 diabetes can help to achieve exceptional glycemic control, as recently demonstrated in a study showing normal average A1c levels in a large cohort of patients. The speaker remarked that the patients in that study had very low glycemic variability.
He believes that more research needs to be conducted to evaluate the relevance of the potential concerns that he outlined. Until then, he advises parents of children who follow a VLCD to work closely with their medical care providers to monitor growth, cardiac, nutritional, and mental/emotional parameters.
Undoubtedly, very low carbohydrate diets for the management of diabetes have been gaining popularity and acceptance in recent years. It is difficult to deny that they constitute an effective and important tool for optimizing glycemic control for both type 1 and type 2 diabetes patients.
This symposium received considerable attention at the meeting and in social media channels. As always, we welcome your comments on the topic and hope that this review has been useful in summarizing the key points and relevant considerations in the broader context of the discussion.
Just keeping up appearances (for myself more than anyone else).
Yesterday I finally went back to my band GP for a fill. Whilst have (generally) been doing well on Optifast again, after a bad week last week, I realise that when I am "bad", I am eating way too much for somebody with a band, as well as getting those hunger pangs between meals. So I bit the bullet and decided I need to be utilising my resources like I did in the beginning of my journey, and start seeing my band doctor regularly again for accountability.
He put in about 0.75ml - to make an even 6ml. I didnt look at my weight as I only weigh once a month now and it's not weigh day! But I WILL be going back in a month's time to show him the progress I have made, and perhaps get another half a mil put in.
I took a naked selfie (from the back) after the gym the other day and realised I should be focussing more on my weight training than cardio - particularly on toning those areas that bother me.
My stomach bothers me and I know I need to build my core strength with planks etc to help reduce that, but for now my focus is on my back! I genuinely HATE those rolls under the bra strap. In my limited 45minute gym time each day, I'm now focussing on the leg press (squats for my bum and lower back muscles), kettlebell deadlifts (lower back muscles), and lat pulldowns/support row machine (for my upper/side back muscles). If I focus for now on those areas that both me the most and see results in a few weeks (months), I can then move on to other problem areas such as my stomach and inner thighs.
Has anybody ever used a waist trainer and had any joy with it? I'm tempted to try it to train in but feel like it might just bee another money-making weight loss gimmick that you dont actually need. Might provide some back support though if I am to focus on those exercises.....
So I've only got 6 more sleeps to go! It's finally single digits!! I've been shopping and bought a small suitcase on wheels, pjs, jumpers, knickers and last time I bought things like slippers. Next step is make soup. I've got a few things like Powerade zero and herbal teas but I will need soup. I'm so excited as well as scared. Anaesthesia always scares me.
I couldn't be happier about my decision. I've run into some family drama regarding my decision and what will be my new way of eating. It's my life and if their world revolves around food then I just won't catch up with them. Typical Europeans where it's all about eating until you're stuffed.
Im excited about the way my life and body is going to transform. I can get out of leggings and track pants back into jeans and fashionable clothes. Right now I'm confined to my bedroom while my husband helps our kids make something for Mother's Day. I'm really looking forward to seeing everything they are planning to surprise me with. Until Thursday I will continue counting down.
I haven't actually logged onto this site for god knows how long. Years.
Once upon a time...I was 112kg at my heaviest. Size 18..almost 20 if I'm 100% honest. It was 12months after my first child was born, and I was heavier than when I was pregnant with him! I underwent the gastric banding in Nov 2012. I stuck to the rules, ate the right foods, in the right portions, and did the right exercise. I managed to shed 37kg over the next 18months, to my lowest ever weight of 75kg (size 12), and I couldn't have been happier. I couldn't seem to get under that to reach my goal weight of 65kg but I was happy anyway.
Unfortunately when I went back to fulltime work, an admin role, the weight started to creep back up. Juggling working fulltime as a FIFO mum was exhausting and I was become much less active. Sitting at a desk all day, indulging in the staff birthday cakes or treat lunches. I became complacent and put on about 10kg the first year I was there. Fast forward to Oct 2016 - I gave birth to my second child, and began a year-long battle with severe post-natal depression. Unfortuntely this resulted in the breakdown of my marriage as well, another reason for me to comfort-eat and not wanting to get out of bed. Between my depressive symptoms, having fill taken out (and not put back in) for my pregnancy, and various medications I was on, I piled the weight back on and I've found myself more or less back where I started.
It's been a really rough 12 months. My youngest is now 18months old. Unfortunately I am separated (although not giving up hope), and I'm learning how to put myself first for a change.
I joined a gym close to work late last year, and I go (amlmost) every lunchbreak for an hour during the week. I joined ParkRun - a 5km run (or walk) every Saturday morning, and I want to start learning how to run! My goal is to just beat my time every week, even if it's only by a minute. I applied and enrolled into university, something I never got to do after highschool, and come July, I will be starting a bachelor degree in Psychology. I'm so excited about this and see it as an investment in my future. I also am considering moving back to my home-state (WA) to be with my family again, after 7 years of living in Adelaide with my husband. I am hoping we will work things out and he'll come with me, but I'm preparing to go on my own (with the kids) if he won't.
All of the above sounds like a lot to handle at once but I'm determined to make it happen. It's going to be the year of ME, and I'm trying to find myself again. I'm following my heart, feeding my mind and trying my hardest to regain my fitness. I'm starting over today on Optifast, 3x a day for 12 weeks for that kickstart I so desperately need. I'm also planning to make an appointment and reconnect with my banding doctor, have a bit more fill put in and work with him to lose the weight again.
Most importantly, I've rejoined this community to find the support and encouragement I've been missing he last few years as I struggled to control my weight on my own.
This is Day 1....107kg, size 18
Me - female, 153.5 cm tall (short!), turning 55 next month (how did that happen??).
Sleeved 02.02.2015 by Dr Stephen Watson at SJOG Murdoch Perth, weighed 82.5 kg at my heaviest in 2002 - BMI 35, weighed 74 kg at pre-op appt - BMI 31.4 , and weighed ??70.4 kg BMI 30 immediately pre-op. Lightest I got down to was 41.3 kg, BMI 17.5 in 2015 (I had a gut infection).
I had plastic reconstructive surgery - 1/2 bodylift and arm lift at the end of 2015. My blog is on bandingtogether.com, same username.
Not working, heaps of medical problems not obesity related, on Disability Pension. Health-wise, I do best on a gluten-free, low FODMAP, LCHF diet.
Recent heaviest weight was 22.03.2018 54.88 kg, BMI 23.29. My only consolation is that when I last weighed this, in May 2015, I had more body fat (I have scales which also measure hydration and body fat %). Dietitian's long-term goal for me was 50-53 kg, so I am over my goal weight. My original goal eight was 50 kg. I desperately want to get back to 46 kg, BMI 19.5 - my happy weight.
Following another Campylobacter gut infection last year, i ceased some prescribed medication as I simply could not face taking it. Then inadvertently went through seven months of hideousness with Cymbalta Withdrawal Syndrome, had no energy, was hideously fatigued, no appetite control, and ate and ate and ate. I am now back on Cymbalta for Fibromyalgia/ME/CFIDS nerve and soft tissue pain. For me, a bonus of Cymbalta is one of it's known side effects - diminished appetite! Yay!
Negatives for me are: Still feeling very fatigued and drained with post-exertional malaise (ME/CFS), feel great in the mornings until after I walk the hounds and then it's downhill from there. As far as my "energy/wellness/health budget" go, I either spend it on walking the dogs, or other activities such as housework. Walking the dogs wins out ....
Positives/strategies for me are:
Involvement in a group of like-minded supportive folk, i.e. this forum!
I continue to follow a LCHF diet, and have made the effort over the last couple of days to chew more and to take a break between mouthfuls.
I have found doing the 20, 20, 20 does slow my eating down, and therefore I fill up/reach satiety faster! I am not doing any other activity while I am eating, and quite frankly, it is quite boring, so I don't stretch the time period out more.
I continue to use small crockery and cutlery.
I have been back and looked at the guidelines given to me by my dietitian post-op. I had consulted her at every stage - pre-op, and then at every progression post-op, and have found a very basic guide for a plan for getting in protein when on full diet.
I continue to walk briskly minimum 3.4 km daily with two houndies.
I have identified areas that I personally for me need to work on, these are in italics.
Slow down your eating pace. If you have a gastric band, you may need to wait up to 90 seconds between each swallow.
Chew well and clear the mouth between small forkfuls (spoonfuls). There’s no need to rush when the meal is small.
Skip energy-laden drinks, such as sugar-drinks (soft drinks, cordials, energy drinks) and drinks containing alcohol (beer, wine, spirits, cider, liqueurs).
Choose nutrient rich foods including protein rich foods. Protein is nature’s natural appetite suppressant.
Stick with a smaller serving size that is just enough to take your hunger away without either making you feel over-full or leaving you hungry soon after - a fine balance that takes time to to discover. Serve more and you’ll attempt to eat more - human nature at work! Serve too little and you will slip into a less helpful grazing and snacking pattern.
Learn to recognise the differences between true tummy hunger and head hunger. Head hunger is driven by social occasion, desire, emotions, or mood. Respond to head hunger with something other than food.
Stop grazing and random snacking. Between meal eating and drinking is easy to forget and accounts for stalled weight loss and weight regain in many. http://www.foodtalk.com.au/contents/en-us/d136_The_Pouch_Reset_Test_Diet__does_it_really_work_.html
I am now in the first stages of meal planning and looking at recipes.
I've gone through some of my resources here at home, and had a good browse through "Curb the carb. The safer way to diet. The healthy low-carbohydrate weight loss programme" by Amanda Cross. It's not bariatric, but has good recipes with macros and meal planning. Also goes through three stages of weight loss - fast, slower, maintenance. A lot of the recipes are 1-2 serves for folk who haven't had weight loss surgery, so it's easy enough to split the meal up into servings appropriate for me and know what the macros are for each serve.
I am going to source a LCHF dietitian in Perth - and see them under a Chronic Disease Management Plan. I am really confused about how much my daily protein should be, there is a lot of conflicting info, and also whether or not I should have snacks *sigh*.
I was approved the other day! I just need to get my drivers license certified to post in with my letter of approval and withdrawal form. So how did all this happen? It started when I fell pregnant with my daughter and ballooned from 70kgs to triple digits. After she was born I dropped around 20kgs and then the weight started creeping on. The doctor wouldn't take me seriously (I've now got a really great gp) and it turns out I've got Hashimoto's Disease.
I recently had a son and I'm ready to lose weight and gain my life back. I looked into the lapband as I had no private health insurance at the time and had enough in my super to cover the surgery but not sleeve (also sleeve was a newer operation back then). After a surgeon telling me 70% will require a reoperation within 5 years I was turned off. Frustrated I put everything on the back burner and was clucky. Sadly I suffered a missed miscarriage with my second pregnancy. I blamed my weight, the fact I coloured my regrowth and because I had hoped for a boy a horrible thought of what if my baby had been a girl and died all because of my selfish thoughts of hoping for a boy.
In 2017 I unexpectedly fell pregnant. I was ecstatic! I gained little weight which is just as well as I was now the heaviest I had ever been. I had a gorgeous healthy boy in November. Now was the time to do something about losing the weight. I had my appointment in the public system where your choice is sleeve or lapband only to be told there's a 2 year weight. I've been waiting since 2013 to lose this weight! I spoke to hubby who was surprisingly on board with me accessing my super (any questions just pm me or start a thread). It started with finding a surgeon and one of the gps at the doctors surgery I go to recommended Dr Ravi Rao in Mount Lawley. I sat in his waiting room so nervous but he immediately put me at ease. He's a lovely man. A straight shooter but kind.
The next step is to confirm my date when the money clears and see him again, complete my admission paperwork and see the dietician. I'll cut this short as I tend to talk a lot. As mentioned I will be having the SIPs bypass. I am nervous. I've had dreams of the surgery. Last night I dreamt I had had the surgery and could feel soreness in my dream. I was also sipping apple juice. Very random I know. I look forward to this journey. Optifast will be the next step and I feel it will be tough as I am hungry an awful lot. Until next time, thanks for reading.
So today I submitted my paperwork for early release of super. Hubby is about to book in his dates. This is all getting so real.
My hubby wants to take our little boy swimming tomorrow and I'm filled with dread. I'm so embarrassed to wear bathers. I refuse to miss out though.
Hoping to have an answer soon. My surgeon wrote a letter asking them to give priority to me due to the severity of my weight. Am I scared? Yep! But you know what scares me even more? The way I'm described on paper - morbidly obese. Those words terrify me.
Ruben Meerman, researcher,
Andrew J Brown, professor
1School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, 2052, Australia
Correspondence to: R Meerman firstname.lastname@example.org
Accepted 14 November 2014
Ruben Meerman and Andrew Brown explain why the answer might not be what you expect
When somebody loses weight, where does the fat go?
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7257 (Published 16 December 2014)Cite this as: BMJ 2014;349:g7257
Considering the soaring overweight and obesity rates and strong interest in this topic, there is surprising ignorance and confusion about the metabolic process of weight loss among the general public and health professionals alike. We encountered widespread misconceptions about how humans lose weight among general practitioners, dietitians, and personal trainers (fig 1⇓). Most people believed that fat is converted to energy or heat, which violates the law of conservation of mass. We suspect this misconception is caused by the “energy in/energy out” mantra and the focus on energy production in university biochemistry courses. Other misconceptions were that the metabolites of fat are excreted in the faeces or converted to muscle. We present a novel calculation to show how we “lose weight.”
Fig 1 Responses of a sample of doctors, dieticians, and personal trainers to the question “When somebody loses weight, where does it go?” (Correct answer CO2)
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Weight we want to “lose”
Excess carbohydrate or protein in the diet is converted to triglyceride and stored in the lipid droplets of adipocytes. Excess dietary fat needs no conversion other than lipolysis and re-esterification. People who wish to lose weight while maintaining their fat-free mass are, biochemically speaking, attempting to metabolise the triglycerides stored in their adipocytes.
The chemical formula for an average triglyceride molecule can be deduced from fatty acid composition studies. In 1960, Hirsch and colleagues published data that yield an “average fatty acid” with the formula C17.4H33.1O2.1This 50 year old result is in remarkable agreement with more recent data.2 Three “average fatty acids” esterified to the glycerol backbone (+3C, +6H) give an “average triglyceride” with the formula C54.8H104.4O6. The three most common fatty acids stored in human adipose tissues are oleate (C18H34O2), palmitate (C16H32O2), and linoleate (C18H32O2),1 2 which all esterify to form C55H104O6.
The complete oxidation of a single triglyceride molecule involves many enzymes and biochemical steps, but the entire process can be summarised as:
Stoichiometry shows that complete oxidation of 10 kg of human fat requires 29 kg of inhaled oxygen producing 28 kg of CO2 and 11 kg of H2O. This tells us the metabolic fate of fat but remains silent about the proportions of the mass stored in those 10 kg of fat that depart as carbon dioxide or water during weight loss.
To calculate these values, we traced every atom’s pathway out of the body. The carbon and hydrogen atoms obviously depart as CO2 and H2O, respectively. The fate of a triglyceride molecule’s six oxygen atoms is a conundrum solved in 1949 by Lifson and colleagues.3 They used labelled heavy oxygen (O18) to show that the oxygen atoms of body water and respiratory carbon dioxide are rapidly exchanged through the formation of carbonic acid (H2CO3). A triglyceride’s six oxygen atoms will therefore be shared by CO2 and H2O in the same 2:1 ratio in which oxygen exists in each substance. In other words, four will be exhaled and two will form water.
The proportion of a triglyceride molecule’s mass exhaled in CO2 is the proportion of its molecular weight (daltons) contributed by its 55 carbon atoms plus four of its oxygen atoms:
(661 Da (C55)+64 Da (O4))/(861 Da (C55H104O6))×100=84%
The proportion of mass that becomes water is:
(105 Da (H104)+32 Da (O2))/(861 Da (C55H104O6))×100=16%
These results show that the lungs are the primary excretory organ for weight loss (fig 2⇓). The water formed may be excreted in the urine, faeces, sweat, breath, tears, or other bodily fluids.
Fig 2 When somebody loses 10 kg of fat (triglyceride), 8.4 kg is exhaled as CO2. The remainder of the 28 kg total of CO2produced is contributed by inhaled oxygen. Lungs are therefore the primary excretory organ for weight loss. (This calculation ignores fat that may be excreted as ketone bodies under particular (patho)physiological conditions or minor amounts of lean body mass, the nitrogen in which may be excreted as urea)
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Lifting the veil on weight loss
At rest, an average 70 kg person consuming a mixed diet (respiratory quotient 0.8) exhales about 200 ml of CO2 in 12 breaths per minute.4 Each of those breaths therefore excretes 33 mg of CO2, of which 8.9 mg is carbon. In a day spent asleep, at rest, and performing light activities that double the resting metabolic rate, each for 8 hours, this person exhales 0.74 kg of CO2 so that 203 g of carbon are lost from the body. For comparison, 500 g of sucrose (C12H22O11) provides 8400 kJ (2000 kcal) and contains 210 g of carbon. Replacing one hour of rest with exercise that raises the metabolic rate to seven times that of resting by, for example, jogging, removes an additional 39 g of carbon from the body, raising the total by about 20% to 240 g. For comparison, a single 100 g muffin represents about 20% of an average person’s total daily energy requirement. Physical activity as a weight loss strategy is, therefore, easily foiled by relatively small quantities of excess food.
Our calculations show that the lungs are the primary excretory organ for fat. Losing weight requires unlocking the carbon stored in fat cells, thus reinforcing that often heard refrain of “eat less, move more.” We recommend these concepts be included in secondary school science curriculums and university biochemistry courses to correct widespread misconceptions about weight loss.
Cite this as: BMJ 2014;349:g7257
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare
Provenance and peer review: Not commissioned; externally peer reviewed.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Hirsch J, Farquhar JW, Ahrens EH, Jr, Peterson ML, Stoffel W. Studies of adipose tissue in man. A microtechnic for sampling and analysis. Am J Clin Nutr1960;8:499-511.
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Hodson L, Skeaff CM, Fielding BA. Fatty acid composition of adipose tissue and blood in humans and its use as a biomarker of dietary intake. Prog Lipid Res2008;47:348-80.
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Lifson N, Gordon GB, Visscher MB, Nier AO. The fate of utilized molecular oxygen and the source of the oxygen of respiratory carbon dioxide, studied with the aid of heavy oxygen. J Biol Chem1949;180:803-11.
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Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR, Jr, Tudor-Locke C, et al. 2011 Compendium of physical activities: a second update of codes and MET values. Med Sci Sports Exerc2011;43:1575-81.
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I had my consult yesterday and was given the choice of the sleeve or SIPS. I am choosing SIPS. It's a sleeve however the intestines are also bypassed while preserving the plyrus. I've send my paperwork off to super to change to my married name. I'm just waiting on the quotes and completed paperwork from the surgeon before I see my gp for his paperwork.
Not much else to report except can I keep saying how excited I am? Ask me the week before op how I'm feeling though when I've given up coffee. Will keep everyone updated as I make the transition from boganlicious to glamorous. Not that there's anything wrong with being boganlicious but I'm sick to death of trackies and leggings since not much else fits. Also I'm in denial of my size I think. I can get away with 18 if stretchy but if I was to wear jeans, etc I'd say I'm bigger. That and I don't like much of what's on offer in my size. Can't wait to go from the plus size sections to shops such as ICE and Valley Girl, Dotti, Cotton On.
2018 I'm going to be a successful transformation story.
A 4-Week Preoperative Ketogenic Micronutrient-Enriched Diet Is Effective in Reducing Body Weight, Left Hepatic Lobe Volume,and Micronutrient Deficiencies in Patients Undergoing BariatricSurgery: a Prospective Pilot Study
Here I am back again. I was banded in 2011, really successfully. I was so happy with it, I lost a heap of weight and got into fitness in a big way. A couple of years ago, now that I look back on it, my band slipped. Certainly I was having symptoms of it. I ignored it for way too long. For some reason I felt that the slippage was my fault and convinced myself that I had failed. (Isn't that strange?). Anyway, after a few really bad episodes of pretty much complete obstruction, I saw a new surgeon who gave me a (loving and kind) kick up the arse.
I regained a lot of weight in that time. Eating over those years had become a real nightmare. And, though I became a bit averse to food, and eating in front of people, I still managed to gain weight because I was HUNGRY and only refined foods would be able to get in. I can absolutely say that the maladaptive eating syndrome is real, and can corrupt the most intelligent of minds.
My band came out in November. Apparently there was quite a mess in there. Though I was fearful of losing my beloved (!) band it wasn't a bad thing. I finally could eat salads, other green things and I have really learnt to be able to eat again. Of course I've regained weight, as I think there's more to bariatric surgery than just the restriction. But I feel that this 3 months has enabled me to reconcile my relationship with fresh and whole foods, all of which were not in my repertoire with a slipped band.
I'm on optifast again now - 10 days to sleeve surgery. I really thought I couldn't do it again, but I'm thriving. And finally, I KNOW that my band slippage was not my fault and that I should have admitted it so much earlier. The moral of my story? Stick with your follow ups, they're right when they say we're more successful if we stay connected and, also, don't let self recrimination get in the way of your success (and health).
Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes.
The results are not surprising.
Nutr Diabetes. 2017 Dec 21;7(12):304. doi: 10.1038/s41387-017-0006-9.
Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes.
Saslow LR1, Daubenmier JJ2, Moskowitz JT3, Kim S4, Murphy EJ4, Phinney SD5, Ploutz-Snyder R6, Goldman V4, Cox RM7, Mason AE4, Moran P4, Hecht FM4.
Dietary treatment is important in management of type 2 diabetes or prediabetes, but uncertainty exists about the optimal diet. We randomized adults (n = 34) with glycated hemoglobin (HbA1c) > 6.0% and elevated body weight (BMI > 25) to a very low-carbohydrate ketogenic (LCK) diet (n = 16) or a moderate-carbohydrate, calorie-restricted, low-fat (MCCR) diet (n = 18). All participants were encouraged to be physically active, get sufficient sleep, and practice behavioral adherence strategies based on positive affect and mindful eating. At 12 months, participants in the LCK group had greater reductions in HbA1c levels (estimated marginal mean (EMM) at baseline = 6.6%, at 12 mos = 6.1%) than participants in MCCR group (EMM at baseline = 6.9%, at 12 mos = 6.7%), p = .007. Participants in the LCK group lost more weight (EMM at baseline = 99.9 kg, at 12 mos = 92.0 kg) than participants in the MCCR group (EMM at baseline = 97.5 kg, at 12 mos = 95.8 kg), p < .001. The LCK participants experienced larger reductions in diabetes-related medication use; of participants who took sulfonylureas or dipeptidyl peptidase-4 inhibitors at baseline, 6/10 in the LCK group discontinued these medications compared with 0/6 in the MCCR group (p = .005). In a 12-month trial, adults with elevated HbA1c and body weight assigned to an LCK diet had greater reductions in HbA1c, lost more weight, and reduced more medications than those instructed to follow an MCCR diet.
Ketogenic diet beats low fat in study of patients with prediabetes and type 2 diabetes
Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors
so itsnow 4 days since having my band removed, still feeling tender like i have done hundreds of situps! each day is getting easir to move although its painful to cough and when i breath deeply,plus i still feel bandy but taking it easy starting solids again. not really felt starving hungry yet so thats a plus.
9 weeks to wait now till i go in for sleeve.
Well, it's now August and I am down to 72 kilos. I feel so much better: my feet and knees have stopped hurting and I've just started a weightlifting program at the gym to strengthen up. It's taken a while to get to the 'green zone' but I'm there now and finding I usually consume around 1000 calories a day (healthy ones mainly, apart from the occasional chocolate). I have also stopped drinking alcohol. This is one of the things I've noticed with the band - my addictive drivers (food, alcohol, coffee) are all much reduced. As I've previously had breast cancer, which is my primary motivator for losing weight, stopping drinking can only help (it's another risk factor).
I want to get down to business and lose this last 7-8 kilos, so I'm starting to record my food intake again. The fact that I've lost so much weight already, without really trying, highlights how effective the band is. The only side-effect I've had is gas - because it's harder to burp, I find that by the end of the day I can have quite a bit of wind buildup, which can cause pain in my shoulder. I'm going to start having peppermint tea to see if that helps. It's well worth it though, for the payoff.
has anyone heard about NERIUM body contouring cream
apparently its an alternative to get rid of saggy skin that's having huge results
I had my band years ago the best thing ive ever done life changing I lost 45 kg in my first year and have managed to maintain it
the only thing is I want to look as good as I feel but am to scared to go tummy tuck or plastic surgery but have heard this
cream is amazing and fantastic so just want to know if anyone else has tried it before I dish out my money
feed back would be hugely appreciated to save me and give me an option instead of surgery
Finally the waiting is basically over.
Yes I still have 18 days to go before my surgery but I have started my pre-op phase so I finally feel like I am doing something.
I have also paid the rest of my out of pocket expensive and it seems I over budgeted and I have a spare $500 so I am very happy about that.
As for my Optifast diet I am officially four days in and I finally feel like I am getting into a routine with it all.
Lunch - Bar
Dinner- Chicken and vegetable stir-fry (type of thing)
It's been hard though, no matter how prepared I thought I was. I did not realised how many habits and patterns I had developed around food. Thankfully catching myself when I attempt to fall back on these habits is getting easier and it is interesting to assess the reasons or causes behind these habits.
I have lost almost 3 kgs so far which I am very happy about but I am worried I am falling into a bit of an obsessive behavior in regards to weighing myself. Already I am weighing myself multiple times a day and I can't help but wonder if I am like this before the op what will I be like afterwards. I guess that is something I will have to tackle as it comes along.
Next step is the actual operation......so bring it on!!!!
Been a while since I have updated in here. Seems diet isn't the only thing i get slack on.
LONG WINDED BACK STORY and then some other faffing in there, so bare with me.
So as some may know i had many problems with my sleeve, namely it being kinked and everything coming up. Basically it was similar to having a stuck moment with a band but there was no way to push things down as the usual techniques a bandit would use just let to more vomiting. in about April/May this year I had a solid barium contrast which showed that the bottom of my stomach was twisted around etc and so was pushing everything up. This lead to bad reflux(40mg Nexium twice a day and even then I often needed some gaviscon or quickeze to help in between) I have felt faint, though BP is fine, don't even have a postural drop which i suspected. i pretty much have lived off coffee(yes i know that doesn't help reflux but i also have a toddler and was finishing nursing studies). Pretty much two bites in no matter how well chewed and things came up. and it would hurt. Even puree soup and that came up. my surgeon told me he had only had one patient have similar symptoms to me about 8 years ago and that she had scar tissue attach to her liver when healing which caused her kink. she was an original sleever not a redo like me(band to sleeve). i gotta say i'm a tad pissy as I even waited 9 months after my band out to convert to sleeve to give my stomach extra time to heal. Anywho, i had a gastroscopy start of June for my surgeon to check what the issue was causing the kink and see if we can work the best option to fix it. Best case was dilation. Worst case full gastric bypass, and then a few options in between them. So after the gastroscopy the good news was I just needed a dilation. Problem being my surgeon hasn't done this type before so referred me to a colleague of is. This colleague has done this procedure a few times and is familiar with the technique. This dilation process is called Achalasia Balloon Dilation. Basically with the procedure they put the gastroscope down my throat(while i'm asleep obviously) then place another instrument down along side the gastroscope(this instrument is too big to go down the gastroscope). It goes down to the part of my stomach where the kink is. for me mine is caused by the stomach scar tissue being healed on each other, so there is a balloon at the end of this instrument which they slowly blow up to burst open the scar tissue. They leave it blown up for 2 to 3 mins at a time until they have done enough. That is the procedure I had done yesterday.
So I woke in recovery just a tad groggy. Apparently I had fentanyl in theatre so I wouldn't be in pain. I managed to have a coffee and it didn't come up my throat. almost cried. This is something which basically since i got my sleeve I struggled with. yes even fluids struggled to go down and not come up. I have had only occasionally small stomach cramps. haven't had to take anything for it. I really hope this procedure has worked. today i have had nibbles of food here and there and even had a salad. yes even salad didn't go down before. prior to surgery the surgeon did advise me this may not be a permanent fix and I may still need to switch to a bypass later. He told me has has a patient who was sleeved and had same symptoms as me and stomach was almost identical to mine. He did the dilation last year and slowly the symptoms have come back and he needs to dilate again. If this ends up being the case he said I'll get to a point where I am sick of it and want the bypass so I no longer suffer. i really don't want a bypass. That will be the 3rd weight loss surgery in an attempt to be "normal" and "healthy". i'm aware the risks increase each time we have surgery and am so worried i will actually die from it. Surgeon did a whole bunch of bloods as well as he thinks i would be deficient in a few things such as thiamin due to not eating but also I have been experiencing what i can only describe as feeling like i caught dementia. have had trouble getting words out, like on the tip of my tongue but can't say them, pins and needles in fingers, extreme exhaustion, forgetful etc. it's worse than mummy brain. Anyways was tested for many many things (8 tubes of blood taken) and i'm deficient in nothing. even my vitamin d is higher than the norm for summer time and I have barely taken my multivitamins because i forget. though this last week i've been good. So no idea what is causing my extreme brain farts but seems pathologically i am healthy as an ox so to speak. So really at this stage i guess we wait and see how it goes and hope for the best. Although I love the weight loss i've had, emotionally the sleeve has taken a toll on me especially with all the vomiting. never being able to eat just a small amount while out, without needing the loo very quickly after because food is sitting in my throat or in my mouth. i hope now I can eat and get back on track. I'm not far off goal weight. I don't even know what that is but i guess maybe another 10kg and i should be done. Will be nice to maybe workout too if i feel like it. again lazy i am good at but i literally have not had the energy to when not eating so yea. let's hope it works. i don't want the bypass but if i had to vomit every day, after every meal and have discomfort even from drinking I don't know how long i would tolerate that for.
Hopefully this will be the last such surgery i have to have and can get on with my life. Just want to feel normal and get on with things instead of always having my body and my attempt to be normal and healthy get in the way. Onwards and upwards hopefully.