Abnormal lipids, probably as a result of abnormal glucose metabolism (insulin resistance or pre diabetes) are a significant factor in the development of cardiovascular disease. There are proven dietary and life style strategies that are proven to help pts with severe vascular disease (prior MI, stroke, etc.), so it would seem safe to speculate that the same strategies would be beneficial for everyone (but especially if they had undiagnosed insulin resistance). The current presumption is that this "prediabetic" condition can be present for years before full fledged diabetes with an elevated blood sugar is diagnosed - and the entire time blood vessel damage is ongoing.

Here is another way to look at this. There are multiple risk factors:

• Aging
• Obesity
• Genetics
• Sedentary lifestyle

• Dyslipidemia (decreased HDL, increased LDL and triglycerides)
• Hypertension
• Atherosclerosis

In reviewing the literature, it is extremely common to note that certain dietary changes improve both the risk of DM and risk of heart disease in the same direction and by the same relative amount. Again, strong suggestive evidence that it is insulin resistance that is the common factor for both development of overt diabetes mellitus and cardiovascular disease. In fact, I heard one lecturere say that if one followed all the dietary and life style recommendations that follow, the chances of developing diabetes type 2 were almost nil.

The dyslipidemia CV risk factors include

• an increase in the LDL (or bad cholesterol) levels
• a decrease in HDL - HDL functions to clear cholesterol from the periphery and transport it back to the liver. (a 1 mg/100ml increase in HDL = 2-4% lower risk of a cardiac event)
• and an increase in triglycerides.

Many of these dietary recommendations are elements of the Mediterranean diet (actually Cretan diet as that island is the locale where it is eaten most consistently). The Med Diet stresses increasing the intake of fruits, vegetables, whole grains, olive oil, omega 3 fatty acids, nuts, beans/legumes, and minimizing saturated and trans fats.

Does the Mediterranean Diet work? The EPIC study (NEJM 2003:348:2599-608) followed 22, 0423 people over 44 months. Adherence to a Med Diet was rated on a scale of 0 to 9. For each 2 point improvement in adherence, there were 33% fewer deaths from heart disease and 24% less from cancer.

Why do we think a Mediterranean diet is so effective in decreasing cardiovascular and cancer risk factors?

• The increase in omega 3 fatty acids Circulation 2002:105:1874-5
• Its anti-inflammatory effect (lower CRP) JAMA 2004:292:1440-1446
• By improving endothelial function JAMA 2004:292:1440-46
• By minimizing insulin resistance and lowering the serum insulin levels, it reverses early metabolic syndrome JAMA 2004:292:1440-46

• Mediterranean Diet Cookbook (Harmon-Jenkins)
• Whole food weight loss eating plan from Texas Tech

• Avoid rapidly absorbed carbohydrates
  • These are foods with a high glycemic index and include sweets, potatoes, white flour, white rice, and potatoes
• Fiber
  • Will lower LDL levels
  • Eggplant 200 gm every other day or okra 100gm every other day (viscous fiber)
  • Psyllium fiber 10gm day = 7% lower LDL (Am Jr Clin Nut 2000:71:472-9
  • Oat Bran 4 - 8 Tablespoons/day 10-26% decrease in LDL (JACN 1998:17:601-608)
• Whole grain diet
  • The coarser the better. Pumpernickel rye is good!
  • Sterols and stanols - present in whole foods
    • 2 gm/day will lower LDL by 10%
  • essentially absent in most breads, bagels, pastries, pasta. If it doesn't say 100% whole grain, it probably isn't.
  • 1 serving of whole grains per day decrease cardiac death rate by 30% AJCN 1998:68:218-19, 248-57
  • demonstrated decrease in the risk of DM on a whole grain diet Diabetes Care 1997:545-550
• Smoking - not good for anything
• Alcohol
  • From 3 alcoholic drinks per week up to 2 drinks per day provide a 20-50% cardiac risk reduction. JAMA 2001:285:2004-2005
  • 5 - 10 drinks per week have lowest risk of developing DM Diabetes Care 2000:26:18-22 (type of alcohol didn't matter in this study)
  • Resveratrol which is in red wine has a CV protective effect.
    • More in Cabernet Savignon than in Pinot Noir
    • Also present in cranberry juice - a glass a day will increase your HDL levels
• Fuits and vegetables
  • increase fruits and vegetables - 5 to 9 servings a day
  • fruit juices generally bad because of free sugar.
• Fats - the focus should be on replacing satuated fats and trans fats with unsaturated fats (read more about fats).
  • Mono unsaturated (olive oil and nuts) are the best. Will improve the lipid profile with lower LDL and lower TG. JAMA 1994:271:1421-8, Am J Clin Nut 1998:67:577S, Diabetes Care 1999:22:889
  • extra virgin olive oil or canola oil are good fats
    • 40 gm of olive oil per day led to a 48% decrease in daily antihypertensive med dose Ann Int Med 2000:160:837-42
  • oil from nuts 5 oz/wk 35% decrease in IHD risk BMJ 1998:317:1341-345
  • Trans fats - partially hydrogenated vegetable oils used in many baked foods and margarines. 2-10 x worse than saturated fats for IHD risk. Increases risk of DM by 40%
  • more fish (omega 3 fats) light tuna in water, wild salmon, herring, sardines, mackerel and less preserved meats
    • 30 grams of fish per day = 50% reduction in cardiac mortality NEJM 1985:312:1205-9
    • 5 times per week = 31% less heart disease in diabetic pts Circulation 2003:107:1852-57
  • Volunteers fed a 60% CHO, 25% fat diet versus 40% CHO, 45% fat with Calories equal had lower HDLs without a change in LDL questioning the idea of substituting CHO for fat to lower risk. Am J Cardiol 2000:85:45-48
  • When used in a diet, a 33% fat diet was more effective in achieving weight loss than a 20% diet. Int J Obesity 2001:25:1503-1511
• Nuts - preferred are raw almonds, pecans, hazelnuts, Brazil nuts.
  • Less DM, even peanut butter 5z/week JAMA 2002:288:2554-60
  • Almonds improve metabolic syndrome versus pasta 84g/day Int J Obesity 2003:27:1365-72
  • Raw almonds 2 handfuls (73 gm) LDL down 9% (Circulation 2002:106:1327-32)
• Cheese - aged cheeses are better than processed cheese.
• Beans - 4x/wk = 19% lower Ischemic Heart Disease (IHD) risk
• Coffee >6 cups per day had 30-50% decrease in risk of DM
  • Catechins 50 mg/day = 25% decrease in CHD mortality
    • Black tea also contains catechins
    • 5 cups of coffee per day lowered LDL 7.5 - 11.5% (Davies Jr Nut 2003:133:3298S-3302S)
    • 1 -2 cups of coffee per day loweed relative risk of heart disease and stroke J. Epid 1999:149:162-7)
    • Chocolate (also high in catechins)
      • Aim for >70% dark chocolate when you buy it
      • 20 gram per day
• Vitamins/minerals/supplements
  • Magnesium increases insulin sensitivity JAMA 2004:291:1056-57
    • In green vegetables, nuts, cereals, beans, chocolate
  • Higher Vit D = less insulin resistance 800 units per day JACN 2004:79:820-5
  • Niacin - a 5 to 25% reduction in LDL as well as increasing the HDL (one of the few things that will do so)
  • Garlic 1.8 gm/day lowered total cholesterol 9% (Ann Int Med 1993:119:599-605)
  • Cinnamon 1g/day with decrease in FBS of 18-29%, triglycerides 23-30%, LDL 7-27% Diabetes Care 2003:26:3215-18

There is evidence that carbohydrates eaten at night will form fat more easily than those eaten at noon (when you are still more active). It is reasonable to speculate that as you are using CHO for energy, they are selectively metabolized (over glycogen stores) in the afternoon, while at night instead of replacing glycogen stores, absorbed carbohydrates are converted into fat. Emphasize lean meat and vegetables at night - carbs in the morning or midday.

Life style Issues

• Regularly eating breakfast decreased risk of DM 37-55%
• Exercise
  • walk 30 min daily - LDL particles changed in size and become less atherogenic
  • exercise 1 hr 4x a week increases HDL 10%
  • Being fit is better than being thin JAMA 2004:292:1179-87
• Less than 6 hrs sleep per night = 1.6 to 2.5 risk ratio to get DM

1. Eat breakfast
2. Eat the bulk of your carbohydrates at breakfast and lunch
3. Take those vitamins with a glass of cranberry juice
4. Take a multivitamin daily - and be sure it has have 800 units of vitamin D; add in 1 gram of fish oil as a capsule and also magnesium supplements
5. Eliminate as much as reasonable all white flour, white rice, and potatoes - use brown rice and whole grain breads.
6. Eat a cooked whole grain cereal or steel rolled oats when possible for breakfast (cold cereals are not comparable, even granolas).
7. Use only low fat milk
8. Peanut butter on a piece of 100% whole grain toast is a quick breakfast
9. A couple of cups of coffee a day can be a good thing - even three or four
10. A snack during the day might be a handful of almonds (raw or at least not roasted in transfats)
11. 1 alcoholic drink a day - make it red wine if possible
12. Use olive oil whenever feasible (canola is second)
13. The more vegetables the better.
14. Sweets only for special occasions - grab the dark chocolate if you have it handy
15. Have fish as often as possible (see below)
16. Blue cheese and other aged cheeses are better than processed cheeses
17. Fat Calories are not necessarily bad - even if you want to loose weight - and may be better than an equivalent number of CHO calories

The Mukilteo Diet

I was a gastroenterologist, seeing patients with liver and other digestive tract complaints for 35 years. (And for those of you wondering about the name of the diet, I live in Mukilteo.) Over the years, I noticed a dramatic increase in the number of patients referred with the diagnosis of "fatty liver". A fatty liver refers to the increase of fat in the liver cells which in turn can produce inflammation and ultimately scarring (cirrhosis) in a small percentage. Fatty liver is seen in metabolic syndrome and pre-diabetes/diabetes, both more common in overweight individuals. By some estimates fatty liver now affects upwards of 25% of the population. Fatty liver, diabetes, and obesity overlap in their underlying physiology and are all impacted (both positively and negatively) by diet. When I explained this to patients, that a change in diet was a simple start to impact the liver fat accumulation, the next question was predictably "what can I do ?" The following summary of my answer to them is not only a reasonable first step in treating these 3 conditions, but also a set of guidelines for healthy eating.

Although the traditional dietary approach to "too much fat" has been an emphasis on losing weight, it is not quite that simple. Carbohydrates, and the insulin release they stimulate, are a more important factor than previously suspected. Thus the source of one's daily calories (carbohydrate versus fat) and when they are eaten during the day are equally as significant as the total daily calorie balance.

These five factors all play a role in any healthy diet but need special attention in any comprehensive dietary approach to the weight loss as well as the treatment of glucose intolerance and fatty liver (steato-hepatitis).

• Caloric Balance - if weight loss is a goal, then you will need to eat fewer calories a day than you will use. It is the mantra that is the basis os all weight loss plans. It is simple to understand and each diet then goes on to explain how you can easily eat less with their program. A negative caloric balance will ultimately translate into fat loss. As there is individual as well as day to day variability in water retention, it may not show an immediate effect on the scale. And when you go into negative caloric balance, the body will slow its metabolism a bit to compensate, so the loss may not be as dramatic as hoped. But in the end if you eat fewer calories than you expend, you will lose weight. If you have achieved your goal weight, then stepping on the scale every morning before breakfast will reinforce that you are remaining on track.
  • If you want to lose weight, eat fewer calories than you expend.

• When you eat - When you eat your calories is just as important as the caloric balance. You should eat the bulk of your calories early in the day (before 2 PM). Aim for a 25-50-25 split for breakfast Ð lunch- dinner. Any calories, especially carbohydrates, eaten early in the day are preferentially used by your active muscles during the subsequent 3 or 4 hours rather than being stored as fat (in the liver as well as fat cells) for later use when the muscles are not active (evening, sleeping).

  If you do cut back on your evening calories Ð and for double bonus points focus on a plant based, low carbohydrate meal Ð you are moving towards an intermittent fast as described by Dr. Mirkin. A fast does not need to be a total elimination of calories. His post has references as well as a list of identified benefits.

  To quote directly from Dr. Mirkin: "Intermittent fasting" does not mean complete avoidance of foods and drinks. Instead, you markedly reduce your intake of food during certain periods. The benefits of intermittent fasting can be seen as long as you significantly reduce your total caloric intake during those periods. Intermittent fasting appears to work by

  • increasing the body's sensitivity to insulin and reducing an overactive immunity, called inflammation (Cell Metabolism, Feb, 2014;19(1932-7420):181Ð92).
  • lower blood pressure (British Journal of Diabetes and Vascular Disease, April 2013)
  • lower cholesterol and triglycerides (Am J Clin Nutr, Nov 2009;90(5):1138-43)
  • reduce body fat (Int J Obes (Lond), May 2015;39(5):727-33)
  • lower insulin (Am J Clin Nutr, Jan 2005;81(1):69-73)
  • lower blood markers of inflammation (Free Radic Biol Med, March 2007;42(5):665-74)
  • increase speed and endurance in athletes (Med Sci Sports Exerc, April 2016;48(4):663-72)

  A decrease in your evening carbohydrates will directly increase the use of body fat metabolism and use. My blog post Optimizing The Use of Body Fat As An Exercise Energy Source - train high, sleep low reviews the physiology and logic. It is even more effective if you exercise just prior to deplete muscle glycogen stores and "force" or stimulate fat metabolizing pathways. The results are clear. The subjects on a post exercise carbohydrate restriction burned 8.7% of their total body fat while the control group lost just 2.6%. Both were on equi-caloric daily diets so this was not just fat loss from calorie restriction.
  • Move to a daily 25-50-25 distribution of calories (breakfast-lunch-dinner).
  • Minimal carbohydrates for the evening meal Ð bonus points for a plant based meal.
  • Maximize the effect with an afternoon exercise session.

• What you eat (cabs versus fats/protein) and glycemic load - there is a growing body of evidence that a healthy diet (especially if you are trying to lose weight or treat fatty liver or a pre-diabetic tendency) means a decrease in the percentage of total daily calories provided by carbohydrates.

  When carbohydrates are absorbed from the intestinal tract, they elevate the blood sugar level which in turn stimulates insulin release from the pancreas. Insulin is required to move glucose (the absorbed form of the carbohydrates) into the muscle cells where it is used for energy or stored (in the form the carbohydrate glycogen or fat). A carbohydrate with a high glycemic INDEX is more rapidly absorbed and the blood glucose rise higher which provides an extra stimulus to insulin secretion. Some foods contain only a small amount of carbohydrate per serving (a carrot is an example) which is rapidly absorbed, so the idea of glycemic LOAD as a measure of the glucose surge makes more physiologic sense as a measure of pancreatic stimulation. Here is a nice summary of glycemic index versus glycemic load and a quick link to a list which compares glycemic index and glycemic load of common foods.

  As mentioned, insulin facilitates movement of carbohydrate into muscle and fat cells. And if it is not immediately use by a working muscle, after an evening meal or a bedtime snack, it is converted into fat. To decrease carbohydrate fueled fat production you could a) decrease the total percentage of carbohydrates in your diet, b) eat foods that contain low glycemic load carbohydrates which will decrease the production of insulin to facilitate the movement into fat cells, or c) eat more of your carbohydrates early in the day or just before/while exercising. With vigorous exercise, glucose will move into the muscle cell without insulin (it is insulin INDEPENDENT) and any blood sugar spike is blunted. Thus the idea of glycemic load is less important if carbohydrates are eaten just before or during exercise.

  • Carbohydrate calories should be a smaller part of your total daily calories.
  • Low glycemic load carbohydrate containing foods are preferred.
  • The bulk of your daily carbohydrates should be eaten in morning or before 2 PM.

• Exercise - adding exercise to your diet program provides 3 benefits.
  • First, it increases the total calories you will be using during the day both for the exercise itself as well as from a persistent elevation in total calories metabolized per hour in the few hours post exercise.
  • Second, while exercising, blood glucose will move into the muscles cells without the need for insulin which blunts the blood sugar spike seen after eating a high glycemic index food.
  • Third, when exercising, you decrease your muscle glycogen stores. Then, if you limit your post exercise carbohydrates, you stimulate fat metabolizing pathways to refill the glycogen storage deficit in the muscle. This magnifies or leverages the benefits of a low carbohydrate diet.

    The exercise can be as simple as an afternoon walk - which only has to be 20 minutes to be of benefit - or as complex as a rigorous training program. There are a number of programs out there - here is a short video. And a recent study shows that even a few minutes of intense exercise in a 10 minute exercise program will provide these benefits. So lack of time is not an excuse.

    • 20 minutes of exercise a day will magnify the benefits of a lower carbohydrate diet.

  • Microbiome (colon bacteria) - The bacteria in our colon were traditionally considered as "outside our body" and irrelevant to health. But we now understand that products of bacterial metabolism of the food we eat are actually absorbed and impact metabolism. Here is an intriguing article that illustrates the point.

    And the colon's bacterial balance will change in a matter of days based on our diet.

    I feel certain that we will find that colon bacteria play a significant role in the development of fatty liver and glucose intolerance or pre-diabetes - most likely via the production of intermediate chemical products from the metabolism of the foods we eat. And that it is the microbiome that is involved in the weight loss benefits we see with a shift to a plant based diet.

    • No sugar supplements.
    • Decrease the amount of meat in your diet relative to plant based protein sources.

    To summarize, these are the components of my Mukilteo diet. And if you want a go slow approach, I put them in what I think is their relative order of importance.
    1. Move towards a daily 25%-50%-25% distribution of calories (breakfast-lunch-dinner).
    2. Decrease the percentage of daily calories from carbohydrates - low glycemic load foods preferred.
    3. The bulk of daily carbohydrates to be eaten by 2 PM. Minimize carbohydrates in the evening meal - bonus points for a plant based dinner.
    4. As protein is increased, increase the amount that is from plant based protein sources.
    5. 20 minutes of exercise a day will magnify the benefits of a low carbohydrate diet.
    6. If you want to lose weight, eat fewer calories than you expend.

    
    Reader's Questions

    Q.You suggest eating fish as much as possible. I ate tuna 4 times a day until I heard about murcury. You should mention eating lower mercury fish more often (eg: sardines), and higher mercury fish less often (eg: tuna). - CR

    A.You make a good point. This is particularly an issue for women who are prgnant or are considering becoming pregnant as mercury is a toxin on the developing fetal nervous system. The same may be true in young children. Less is known about the potentially harmful effects of mercury on men (or women who are not interested in having children) as an adult's nervous systems is felt to be much less sensitive to the effects of mercury.

    There is a significant variation in the mercury content of fish, and even in tuna there are some forms which are safer than others from the perspective of mercury levels (light tuna is better than white tuna, for example). And perhaps the safest approach of all is to use fish oil capsules daily.

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