By Marika Sboros
A century ago, doctors looked on in awe as patients with type-1 diabetes responded to life-saving insulin therapy. These days, Israeli endocrinologist Dr Mariela Glandt feels “the same awe” watching her type-2 diabetes patients get off insulin.
Glandt, who trained at Harvard Medical School and Columbia University in the US, lives and practises in Israel. She is on a mission. Glandt has started a revolution in Israel against mainstream medical treatment for type-2 diabetes (T2D). She hopes it will spread more widely through orthodox medicine globally.
Her first salvo was Israel’s first low-carb, high-healthy-fat (LCHF), ketogenic (very LCHF) conference on type 2 diabetes treatment, held in Tel Aviv in November 2019.
Billed as Metabolix 2019, Bringing You The Science Of Keto, it brought together speakers from across the globe. They included top medical doctors and nutrition researchers locally and internationally. Their target was the current medical worldview on metabolic disease and health.
The conference was a success. More than 500 people signed up to attend. On the day, organisers had to expand the venue to accommodate 600 participants. More than a third were medical doctors, including endocrinologists, nutritionists and diabetics.
Time for change, says Glandt
There were signs that low-carb is already seeping into the mainstream in Israel for T2D. That’s not surprising in a country that is acknowledged globally for innovation in medical science. One sign was conference support from the Israeli Diabetes Association. Kupat Holim Meuhedet, Israel’s third-largest health-care insurer network was also on board.
Estimates are that there are 429-million people with diabetes worldwide. The vast majority have T2D. T2D rates are rising rapidly in Israel, along with obesity levels.
Israel also has a high rate of the use of bariatric (stomach) surgery to treat obesity. The treatment is can speedily reverse symptoms of T2D. However, it is invasive. And experts point to the high life-threatening complication and failure rate.
“It’s time for change,” Glandt told the conference in her opening statement. “Diabetes doctors face a painful day of reckoning.”
Doctors can no longer ignore the evidence that conventional drug treatment for T2D does not work long-term, Glandt said. “A lot of our advice and treatment can make patients fatter, sicker and coming back for more drugs.”
Presenting the evidence
Speakers presented the scientific evidence for low-carbohydrate, high-healthy-fat (LCHF), ketogenic (very LCHF) diets to treat type 2 diabetes and related medical conditions. These include metabolic conditions such as insulin resistance (IR), obesity and T2D diabetes that are all now epidemic in many countries.
T2D, in particular, significantly increase the risk of cardiovascular disease (CVD, heart attack and stroke), kidney and liver disease, blindness, limb amputation, cancer and dementia. Dementia is so common that doctors often call it type-3 diabetes because of the documented link with diet and declining cognitive function.
The conference showed that controversy still swirls around LCHF and keto globally. It exposed the real meat (pun intended) of that controversy. It’s not so much about low-carb content any longer as the high-fat and animal-foods content.
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That’s despite little consensus on how low-carb or high-fat to go for maximum therapeutic benefit. It’s also despite compelling evidence on safety and efficacy of animal products, including red meat, in treating and preventing disease.
No echo chamber
The conference was not an LCHF echo chamber and there were dissenting voices. Speakers showed that it is possible to be vegetarian on LCHF and keto. Even vegan but only if you really know what you’re doing and preferably only under medical supervision.
A conference focus was on the genesis of conventional medical “wisdom” of treatment for T2D for two decades. That put the spotlight on the influential US dietary guidelines – that many other countries slavishly follow. Israel is among them.
The US launched the guidelines in the 1970s. Despite tweaks in the intervening years, the guidelines that still essentially promote low-fat, high-carbohydrate diets, including for diabetics.
UK public health researcher Dr Zoë Harcombe presented evidence showing that the guidelines had no evidence from randomised controlled trials (RCTs), the so-called “gold standard” of modern medical science, backing them up when the US first launched them. Nor was there epidemiological evidence (that shows association, not causation) to support the guidelines.
That status quo remains
In his presentation, British GP Dr David Unwin showed how his practice saves the UK’s National Health Service (NHS) £50,000 annually in unprescribed insulin for T2D patients.
Unwin was similarly withering about the guidelines. He joined speakers who criticised advice that dietitians still dish up to diabetics to eat carbs moderately. Speakers also demolished the conventional idea that diabetics need to “graze” – snack on carb foods throughout the day.
That prompted one of my favourite of Unwin’s quotes: “Telling patients with diabetes to eat carbs moderately just leaves them moderately poisoned”. And another of my favourite quotes from Harcombe: “Don’t graze – unless you are a cow or want to be the size of one.”
Not surprisingly, sugar was a major focus of conference presentations.
The sugar problem
US science writer and prolific author Gary Taubes spoke on the “problem of sugar”. Taubes’s latest book is The Case Against Sugar. showed that while science can’t prove it definitively and the industry vehemently denies it, the sweet stuff really can kill.
Another conference focus was optimum diet for health and longevity. That was based on foods that humans evolved to eat over two million years.
A highlight was Tel Aviv University paleo-anthropologist Dr Miki Ben-Dor’s talk. Ben-Dor presented evidence from palaeontology and archaeological finds, many of them in Israel. It comes down solidly in favour of animal foods.
“Humans are undoubtedly omnivores,” he said. However, humans evolved over two million years to become “highly carnivorous” or “hypercarnivores”.
Humans continue to “retain a biologic adaptation” to “high-level trophic carnivory” (where humans sit on the food chain).
Plant v animal food
Ben-Dor isn’t against plant foods – nor was anyone else at the conference.
On the contrary, he said there was “no doubt that humans ate plants for all of history”. The only question was “how much plant food they ate”. The answer, according to the evidence that he outlined in his presentation was: “Not much.”
As hypercarnivores, humans evolved to eat 70% to 100% of their energy source from animals, said Ben-Dor
“That means lots of protein but also lots of fat.”
‘Fat hunters and lovers’
Humans have always been “fat hunters” and “fat lovers”, he said. Ample ethnographic – archaeological and biological – evidence points to “human dependence on and preference for animal fat as a food (and energy) source”.
Authoritative sources show that “it may be fat rather than protein that drives the desire for meat in many foraging societies”. The importance of fat is also evident in its use as symbols of fertility, sacredness, wealth, health and even life itself in recent traditional societies’ rituals, linguistics and mythology, he said.
The scientific evidence supports safety for humans to consume a high portion of their diet from animal protein, “possibly to the tune of 30% to 40% of daily calories”, Ben-Dor said. And to include lots of healthy fats, including saturated.
“Not many alternatives foods can claim nearly two million years of safe consumption”, he said.
Revealing ‘ancient secret’
Israeli-tech entrepreneur Dael Shalev is author of The Ancient Secret. The book is a best-seller in Israel and currently available only in Hebrew (Hasod Hakadmoni).
Shalev showed that there’s really no rocket nutrition science behind optimum diet. The most nutrient-dense food, he said, is simply “real food”. By that, he means anything that comes without a package or a barcode”. In other words, food from animals, animal products, vegetables, nuts, berries and other fruits.
An intriguing presentation came from Dr Eran Segal, professor in the Department of Computer Science and Applied Mathematics at the Weizmann Institute of Science. Segal heads a lab with a multi-disciplinary team of computational biologists and experimental scientists working in the area of computational and systems biology.
The group’s research focuses on the microbiome, nutrition, genetics, and their effect on health and disease. The scientists initiated the Personal Nutrition Project. They describe as a “large-scale nutrition initiative that aims to help people make food choices that are better for their health and well-being”.
It forms the basis of what scientists have called the Day Two Diet. It is based on a personalised algorithm in an app that predicts the individual’s glycemic response to specific foods.
The conference also neatly and unequally divided into detractors and supporters of the diet-heart hypothesis that saturated fat causes heart disease.
One one side, the detractors were in the majority. They said that the diet-hypothesis is unproven, terminally ill and deserves a decent burial for its spawn – conventional, low-fat, high-carb diets.
On the other side, supporters said that hypothesis is alive and well and low-fat diets are “heart-healthy”. Their reasoning: unlike LCHF and keto, low-fat don’t increase CVD risk by raising “bad” LDL-cholesterol.
Both sides claimed data for their positions.
It’s true that LCHF and keto diets often do raise LDL levels. In his presentation, US physician Dr Stephen Phinney explained why that’s really nothing to fear.
Phinney is an emeritus professor of internal medicine and specialist in clinical nutrition, co-founder. He is also head of Virta Health, a US research-based program assessing how doctors can reverse “millions of cases of T2D”.
He said that raised LDL is mostly a “transient effect”. It’s a result of “mobilisation” of pre-existing cholesterol in the circulation system from fat cells after weight loss.
In those for whom LDL levels remain high long-term, he would have “no inhibition” in adding a statin (cholesterol-lowering drug).
What about T1 diabetes?
Israeli endocrinologist Dr Roy Eldor was adamant that doctors must worry about raised LDL. Eldor is a researcher and director of the Tel Aviv Sourasky Medical Centre Diabetes Unit Institute of Endocrinology, Metabolism and Hypertension.
He said that doctors cannot know for sure that raised LDL is not doing harm by causing atherosclerosis. That’s the medical term for arterial plaque build-up that can rupture, causing heart attack and stroke).
“The data isn’t there,” Eldor said.
Few CVD biomarkers have “more merit than LDL-cholesterol”, he said. Statins for elevated LDL are one of modern medicine’s “most evidence-based” life-saving interventions in terms of “hard outcomes” (lives saved).
If he had to give one drug or medical intervention to a diabetic patient with high LDL levels on a desert island, it would be a statin, Eldor said. He based all his medical decisions on data and said that all doctors should “humbly” do the same.
Paediatric endocrinologist Prof Ram Weiss was only slightly more muted but vocal on data primacy.
Weiss is professor at the Technion School of Medicine and head of paediatrics at Ruth Children’s Hospital, Rambam Medical Centre, Haifa. His conference presentation was on low-carb for type 1 diabetes (T1D). (There is growing and compelling evidence internationally to show that not just low-carb but LCHF/keto diets work as well for T1 as for T2D.)
Evidence for LDL risk may not be “as strong as everyone thinks it is” but it still is significant, Weiss said.
“You can’t argue with the data. The truth, even when it’s painful, is still the truth.”
Those sentiments brought spirited and evidence-based rebuttals from Phinney, US physicians Eric Westman and Jeffry Gerber (“Denver’s Diet Doctor”) and Irish engineer Ivor Cummins. They made it clear that the data is there to show that the LDL risk is over-hyped. All it requires is willingness to see.
In her conference presentations, Glandt said that doctors have long known – or should know by now – that T1D is a condition of too little insulin and T2D a condition of too much insulin.
They should also know by now that carbohydrate foods cause the most insulin release. Meat and other animal foods with protein and fat, on the other hand, do not, she said.
They cause minimal insulin release, including through a process known as gluconeogenesis, in safe amounts compared to carbohydrate foods.
Conference speakers made clear that carbohydrate foods are not the only reason for the failure of conventional T2D treatment.
“Fat phobia intervened,” Glandt said.
For decades, doctors and dietitians demonised dietary fat, particularly saturated fat on the basis of failed diet-heart hypothesis that saturated fat causes heart disease. That made many people “fat-phobic” across the globe, she said.
“It paralysed us (doctors) and made us scared of using powerful, natural and safe weapons that we have: LCHF and keto.”
Four years ago Glandt began to see something seriously wrong with the logic of giving more insulin to type 2 diabetes patients who already had higher than normal insulin levels.
The thought occurred to her: “Why not just tell patients to cut the foods that cause their blood sugar levels to spike in the first place?”
Why not, indeed.
Glandt changed her practice and started advising her patients to cut the carbs and eat more healthy fats, including saturated. Results exceeded expectations.
Glandt’s take-home message
Many patients have lost significant amounts of weight on LCHF and keto diets and kept it off. They have significantly reduced or come off all diabetes drugs, Glandt said. Many also speedily reversed all symptoms of type 2 diabetes quickly and have been able to come off all drugs.
Those results became the take-home message of hope from the conference: T2D is no longer the life-threatening, life sentence doctors once thought it was. Dietary change can often reverse all T2D symptoms without resorting to drug use.
These messages echoed in Glandt’s clarion call for a revolution in orthodox medical treatment for diabetes, both type 1 and 2 worldwide.
Glandt is already planning the next low-carb, keto conference in Israel in March 2021.