The skeptical cardiologist reserves the exclusive and unimpeachable right to censor reader comments he deems inappropriate, nasty or unhelpful.
There’s a good chance if you attack me personally, I won’t post your comment. On the other hand, if I find your attack particularly amusing there is a good chance I’ll include it in a blog post.
Here’s an ad hominem attack I really enjoyed:
You may be an MD, but you are no doctor. That requires a doctorate, which I have, and I can smell the bias from the other side of the Earth. Your “skepticism” is a front for your cynicism, and you yourself are the very thing you hate when denigrating people like Esselstyn as “evangelists”. Get a doctorate degree and learn science before attempting to analyse it.
There is so much to unpack and ponder in this paragraph! I love it.
The reader says that I am “no doctor.” This, it appears, requires a doctorate (which, coincidentally my reader has). The reader advises me to “get a doctorate degree” before attempting to analyse science.
If we assume the reader is going by the Cambridge English definition, and my title of doctor of medicine doesn’t count as a doctorate, let’s see what does.
Wikipedia lists a ton of different types of doctorates. My reader didn’t specify what kind. Would a Doctor of Music qualify me to analyse science? If so, sign me up for the coursework.
My newly-minted mother-in-law has a doctorate in English, is she more qualified than me to analyse science?
The reader left his comment on my post about the death of Robert Atkins, so I’m not even sure what bias I am accused of, but I love this sentence:
“I can smell the bias from the other side of the earth”.
In my defense it should be pointed out that the entire Robert Atkins post is a precise analysis of his medical history and doesn’t really touch on science. Perhaps the bias my reader smells from so far away is my bias to seek the truth.
Finally, I have to say the killer sentence in my reader’s comment is the most brilliant ad hominem attack I have ever encountered:
Your “skepticism” is a front for your cynicism, and you yourself are the very thing you hate when denigrating people like Esselstyn as “evangelists”.
It is so deep and piercing that I am incapable of defense and I can only say “mea culpa” and I yield to your doctoral brilliance.
By the way, this whole PhD versus MD debate brings up the burning question of who one should be referring to as doctor. Should I address my mother-in-law as Dr. Perkins since she has a Ph. D. in English Literature? And, by the way, although she is my go-to person for questions about D.H. Lawrence, Hemingway and Shakespeare, I don’t think her scientific analytic skills are up to mine even with her doctorate.
The skeptical cardiologist spent an interesting week in ketoland, counting carbs, and turning ketostix purple, but ultimately decided this was not a world he wanted to inhabit long term.
During that week I paid 1.99$ to download William Banting’s “Letter on Corpulence”(available here for free.) Banting, writing in 1869, first popularized a low carb, high fat diet for obesity with this pamphlet. He starts it off with these words:
“OF all the parasites that affect humanity I do not know of, nor can I imagine, any more distressing than that of Obesity, and, having emerged from a very long probation in this affliction, I am desirous of circulating my humble knowledge and experience for the benefit of other sufferers, with an earnest hope that it may lead to the same comfort and happiness I now feel under the extraordinary change,—which might almost be termed miraculous had it not been accomplished by the most simple common-sense means.”
The pamphlet was enormously popular and sold over 60,000 copies. Banting donated his 225 £ of profit to various charities, including:
To The Printers’ Pension Society, at the
Anniversary Dinner, in March, 1864,
per Chas. Dickens, Esq. .. .. 50 0 0″
In my last post, I closed with a paragraph describing the benefits I had experienced of consuming a really high fat, very low carb diet: more energy, less sleep needed, asthma cured, wrinkled skin “melting away. This was supposed to be a humorous parody of how enthusiastic supporters of fad diets feel after they have jettisoned their bad eating habits but apparently most readers, unaware of my dry sense of humor (or perhaps not familiar with David Cronenberg’s The Fly) took this seriously.
Certainly, if I had felt significantly better on the Atkins diet I, like William Banting, would still be on it. Alas, if anything, I felt worse.
My sleep was unaffected. Unllike, Robert Atkins, who noted his sleep requirements went from 8 hours a night to 5 hours a night, my sleep patterns were unchanged.
Energy levels in the morning were good but periodically in the afternoon, especially after even minor exertion but particularly after an intense workout, I would feel uncharacteristically exhausted.
Although my weight dropped 3-4 pounds this is typically what happens if I cut out alcohol from my diet for a week so it’s hard to say what the independent role of the extremely low carb intake and ketosis was.
My blood pressure dropped during the week and I had to cut back on my blood pressure medications to avoid dizziness. There were too many other variables occurring simultaneously that week (weight loss, lack of alcohol consumption) to know if this was independently associated with the ketogenic diet, however.
To be fair, supporters of ketogenic/Atkins diets warn us that during the initial weeks, we may feel worse, experiencing the so-called “low carb flu.” To fully test it I should have stayed on it for 3-6 weeks and entered a maintenance phase in which I could have consumed more carbohydrates.
However, after a week of having to analyze in detail the carb or net carb content of everything that I consumed, I realized this was not something I wanted to do long term.
For the significantly obese like William Banting who struggle to achieve weight loss the ketogenic/Atkins diet is likely to be a much better experience than for someone like me who is not overweight. Banting’s diet prior to his “miraculous change” consisted primarily of bread, milk and beer and it is likely that cutting out the bread and beer alone would have had a dramatic effect on his weight and well-being.
It would nice if we had some sort of genetic test that would tell us what diet is perfect for us. Unfortunately, until that is developed, trial and error is the only viable approach. Some, like William Banting, Robert Atkins and the lady at zerocarbizen.org will thrive on very low carbs whereas others, like Dean Ornish and Nathan Pritikin prosper on a very low fat diet.
Most individuals will be served best by a diet of real, minimally processed food with lots of different vegetables growing both above and below ground and eaten in moderation.
N.B. Here, in a nutshell, in Banting’s own words ,is the essence of the Banting diet:
“I never eat bread unless it is stale, cut thin, and well. toasted. I very seldom take any butter, certainly not a pound in a year. I seldom take milk (though that called so, in London, is probably misnamed), and I am quite sure that I do not drink a gallon of it in the whole year. I occasionally eat a potato with my dinner, possibly to the extent of 1 lb. per week. I spoke of sherry as very admissible, and I am glad of this opportunity to say, that I have since discovered it promoted acidity. Perhaps the best sherry I could procure was not the very best, but I found weak light claret, or brandy, gin, and whisky, with water, suited me better; and I have been led to believe that fruit, however ripe, does not suit me so well taken raw as when cooked, without sugar. I find that vegetables of all kinds, grown above ground, ripened to maturity and well boiled, are admirable; but I avoid all roots, as carrot, turnip, parsnip, and beet. ”
In the name of research and inspired by reading a biography of Robert Atkins, a few days ago the skeptical cardiologist embarked on an ultra low carb diet designed to put him in a state of ketosis.
Robert Atkins, the “cardiologist” who popularized the ultra low carbohydrate, high fat diet (LCHF) with his 1972 book “Dr. Atkins Diet Revolution,” admonished his patients: “Now remember, happiness is a purple stick!”
When the body shifts to utilizing fat for energy rather than glucose, the result is the production of ketone bodies which can be detected in the urine by use of a ketostick. When your urine turns the stick purple, you have become ketotic and have successfully kept your carbohydrate intake low.
Entering ketoland, as I like to term it, is not for the faint of heart. It requires a fanatical devotion to the LCHF pope, a steely determination, and meticulous monitoring of your food for anything that resembles a dreaded carb.
Nutritional Ketosis versus Diabetic Ketoacidosis
My first experience of ketosis was as a third year medical student on the vast, communal wards of St. Louis City Hospital. Here, the teeming indigents, the IV drug abusers and the criminals of the city came to share graciously their noxious diseases with we innocent disciples of Hippocrates.
Amongst the patients with AIDS and endocarditis, pheochromocytoma and Mallory-Weiss syndrome, there were many insulin-dependent diabetics who, for themselves, poorly did care or who had decompensated due to infection.
Emanating from their mouths and other orifices, I, not uncommonly, noted a peculiar odor. It smelled like pear drops or ripe apple or perhaps, (had I been familiar with it at the time) nail polish remover, and was quite distinctive. Most of my fellow students could not smell it and relied on blood or urine tests to confirm what I had already detected-KETONES!
These diabetics had gone into diabetic ketoacidosis (DKA), a life-threatening complication and I was smelling acetoacetic acid.
Peter Attia has written eloquently and interestingly about the difference between DKA and nutritional ketosis here. You can only get the dangerous type of DKA if you are unable to produce insulin like type I diabetics.
Attia tells this embarrassing story:
“I remember exactly where I was sitting in a clinic at Johns Hopkins in 2002 explaining to (admonishing, really) a patient who was on the Atkins diet how harmful it was because of DKA. I am so embarrassed by my complete stupidity and utter failure to pick up a single scientific article to fact check this dogma I was spewing to this poor patient. If you’re reading this, sir, please forgive me. You deserved a smarter doctor. “
I’m pretty sure that,to this day, there are many doctors who only think of DKA when they hear the term ketosis.
The ketoland I have entered is not pathological: Atkins and, increasingly in the last decade, evidence-based and academic nutrition scientists, believe that ketosis may be a healthier state for our body to be in, free of wildly fluctuating, inflammatory insulin cycles.
The cost of admission, however, is eschewing all bread, pasta, rice, potatoes, sugar-sweetened beverages, pastries, processed foods and, obviously, candy…that’s right out.
The tantalizing part of the diet is that it does not restrict your intake of fat in any way. In fact, to have your ticket punched into ketoland you must seek out fat in as pure a form as possible.
This morning, for example, I made myself a cup of coffee and adulterated it with heavy whipping cream (0 carbs, 50 calories of fat). Before leaving the house I took two boiled eggs and mixed them with mustard and safflower oil mayonnaise (30 grams of fat, no carbs) to eat later in the day.
I eat burgers, no fries, no buns, and I carry with me macadamia nuts, sunflower seeds, and almonds. I bought a huge jar of coconut oil and eat it by the teaspoon.
Ketoland is foreign territory for most of us. I had to enter foods into the myfitnesspal app to help me determine what the carbohydrate contents were. I found myself paying close attention to portion size, not for the calories, but to help me better estimate how many carbs I was consuming.
For example, I thought that cauliflower would be a good snack, but 4 pieces of cauliflower cost me almost 5 carbs.
Happiness Is A Purple Stick
After 12 hours, during which I consumed 123 grams of fat, and only 26 grams of carbohydrates, my ketostick turned purplish.
What is it like in ketoland? Well, for one thing I only need 4 hours of sleep. Asthma, which has plagued me all my life, is now nonexistent. Wrinkles have melted from my face, like wax from a burning candle. I have boundless energy. The best comparison I can come up with is the transformation Jeff Goldblum underwent in David Cronenberg’s (1986) The Fly. Come to think of it, he was probably also on a LCHF diet. Hopefully, I won’t experience his complete transformation.
****Warning. The above paragraph is an attempt at humor. None of it is true. Warning******
Seriously, I think it is too early to tell whether the tediousness of this diet will be worth it for me, but if I can last for a few weeks, I will have some good anecdotal short-term data to share with my patients on the diet’s effects on weight, energy, hunger, and personality.
If you are wondering why we make ketones, here’s a simple answer from Peter Attia.
For starters, it’s a vital evolutionary advantage. Our brain can only function with glucose and ketones. Since we can’t store more than about 24 hours worth of glucose, we would all die of hypoglycemia if ever forced to fast for more than 24 hours. Fortunately, our liver can take fat and select amino acids (the building blocks of proteins) and turn them into ketones, first and foremost to feed our brains. Hence, our body’s ability to produce ketones is required for basic survival .
If you’d like to watch a very well done 11 minute video on low carb high fat diets click here. You have to give an email address, which will send you Andreas Eenfeldt’s Diet Doctor updates. His site is very well done, free of ads and free of any industry influence.
You should be able to watch his diet revolution video, full of Swedish humor here.