The Doctor: “Have You Started an LCHF Diet, Or Something?”

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Many people with obesity or diabetes experience amazing health improvements with fewer carbohydrates in their diets. But you may still feel a little nervous at that follow-up appointment. What will the tests show?

A reader e-mailed me a story about what can happen.

“Have you started an LCHF diet, or something?” was the first thing the doctor said:

The Email

Hi,

I just want to say thank you for a great blog and great work and to leave yet another testimony here.

I have PCOS and have had insulin resistance and a fluctuating blood sugar for the past 25 years. I’ve had annual check ups for “diabetes type 2” for twenty years and have struggled with my weight, but have not been able to maintain it by eating less. Blood pressure, lipid profiles and liver tests have always been off and I’ve been recommended medication like Metformin. In the winter of 2012, more than a year ago, they wanted to put me on Januvia. I was heavy and miserable. But I didn’t want to start taking meds, so instead I began eating a low-glycemic index/LCHF diet.

I did some kind of moderate LCHF, i.e. ate complex and fewer carbohydrates, and increased the amount of both polyunsaturated fat and saturated fat. More vegetables and a lot of fish. But also a lot of eggs, full-fat dairy products and keeping the fat on the meat. No low-fat products. But some fruit.

I was very unsure of what my numbers would look like and had no idea how this would affect my cholesterol and my liver, I’ve had a fatty liver for almost 20 years!

Over a year later… To sum up – when the doctor saw my new numbers she looked sternly at me and said “Have you started an LCHF diet, or something”?

A little scared I confirmed that I had significantly cut back on carbs.

She gave me a print out of my numbers. They were completely normal and even on the good side. My fatty liver is normalized. Cholesterol numbers better than ever and all other numbers good.

My liver is now without excess fat for the first time in 19 years!

My HbA1c is perfect. I’m down 22 lbs (10 kg), and more than 3 inches (8 cm) around my waist. There it is – it works!

I can hardly believe it. I have to admit that I was skeptical and a little afraid when I had eaten my fat yogurt, butter, fatty fish and meat without removing the fat. But it really worked!

The doctor told me to continue with what I was doing, and I asked her if they recommend LCHF and GI to their diabetic patients now. She said something like: “Now we may, as the authorities have changed their recommendations.” Then she warned me against eating too much saturated fat and red meat, and recommended vegetables, complex carbohydrates, fish and to reduce the amount of dairy products for a happier digestive system. And then she said that “We have seen this for a long time, with the carbohydrates, but couldn’t say anything”.

I will continue my moderate LCHF. When I eat simple carbohydrates my blood sugar rises again, so I’m not “cured” from my underlying problem. But I’d rather keep away from carbohydrates than take medications! And if nothing else, I now have the doctor’s confirmation on this!

So, thank you to you and all others.

And I do hope doctors will start recommending a low-carb diet.

Sincerely,

A 44 year-old woman

Congratulations on your health improvements!

One would wish that more people got similar help from the health care system, instead of having to find the information on their own. Right?

Addition

A few small objections to an otherwise encouraging story:

The advice from the doctor about saturated fat is, of course, outdated. There’s no scientific support that it would be anything but harmless. Red meat is also likely completely safe to eat.

But on the whole, one has to say that this doctor was open to new knowledge. So in a year or so maybe she’ll be even better informed.

Previous stories

“Hello LCHF – Goodbye Type 2 Diabetes”

Another Diabetic Healthier and Leaner with LCHF

More

LCHF for Beginners

How to Lose Weight

More weight and health stories

How to Normalize Your Blood Sugar

“LCHF Challenging Health Care’s Poor Dietary Guidelines”

33 Comments

Top Comments

  1. Tom Welsh
    “We have seen this for a long time, with the carbohydrates, but couldn’t say anything”.

    If that is really her attitude, she should have resigned. How can a doctor practice while giving her patients information she knows to be wrong? There is no possible excuse.

    Replies: #4, #18
    Read more →
  2. Murray
    You fail to appreciate that physicians can be financially punished, sued, professionally sanctioned or even lose their licence for failing to follow official guidelines.

    My wife, who has narrow hips, had an especially difficult labour with our daughter, resulting in an emergency C-section. (After a long, long day with complications, I asked the chief obstetrician what were the alternatives--"death.") The doctors were encouraging her to try VBAC (vaginal birth after Caesarian) for our second. We did a lot of research and, based on my wife's lithe figure and general health, concluded that VBAC was not the best option. Eventually she told her doctor she wanted Caesarian. Her doctor said that is what she would do as well, but the health guidelines forced her to push for VBAC. (Our son was born 10 pounds 12 ounces, two pounds more than our daughter, so another emergency C-section would have been most likely.)

    Then, as chronicled here, there was the physician in Sweden who was brought before the supervising regulatory body on a complaint because she was advising low carb. My recollection is that the process took over two years. Although she was ultimately vindicated, two years of enduring persecution and uncertainty of outcome is quite a toll to ask any practitioner. Who wants to risk their career and livelihood, to earn income to raise their family, just to be a test case?

    Dr. Cate Shanahan in her book Deep Nutrition reports how the insurance companies punish physicians financially for failing to prescribe statins.

    I have had good discussions with a dietician I have consulted. She said she agreed with most all of my observations but said that she could not recommend them to patients or advocate them publicly or she would be disciplined in her profession.

    So a health professional is constrained by the guidelines that are established by the health bureaucracies in response to various commercial, political-ideological and budgetary agendas. What is good for the agendas at the macro level is not necessarily what is good for the individual. In most healthcare systems, the health professional is constrained by the diktats of herd management and has limited discretion in assessing the particular needs of the individual.

    Reply: #5
    Read more →

All Comments

  1. Lisa
    I'm sure the doctor has to say that as a "CYA".
  2. Tom Welsh
    “We have seen this for a long time, with the carbohydrates, but couldn’t say anything”.

    If that is really her attitude, she should have resigned. How can a doctor practice while giving her patients information she knows to be wrong? There is no possible excuse.

    Replies: #4, #18
  3. JD
    This reminded me of a Jimmy Moore blog post.

    http://livinlavidalowcarb.com/blog/the-dilemma-of-the-way-modern-medi...

    If you don't want to read the whole thing, it's about a reader's email who doesn't want to be put on a statin, and here is the highlight:

    "After I told him this, my doctor sighed and looked up at me stating that if it was him, he probably wouldn’t take the statin drug either. Then he shifted his attention to his computer screen and said something that he probably didn’t mean to say in front of me. “With health markers like yours, nobody would ever win a malpractice suit against me just because you aren’t taking a statin.”

    Needless to say, that shocked me. He didn’t really disagree with me not wanting to take a medication I didn’t want to take. But he knew that if he didn’t follow the ‘standard of care’ that requires him to prescribe a statin, then he would be putting himself at risk"

  4. Murray
    You fail to appreciate that physicians can be financially punished, sued, professionally sanctioned or even lose their licence for failing to follow official guidelines.

    My wife, who has narrow hips, had an especially difficult labour with our daughter, resulting in an emergency C-section. (After a long, long day with complications, I asked the chief obstetrician what were the alternatives--"death.") The doctors were encouraging her to try VBAC (vaginal birth after Caesarian) for our second. We did a lot of research and, based on my wife's lithe figure and general health, concluded that VBAC was not the best option. Eventually she told her doctor she wanted Caesarian. Her doctor said that is what she would do as well, but the health guidelines forced her to push for VBAC. (Our son was born 10 pounds 12 ounces, two pounds more than our daughter, so another emergency C-section would have been most likely.)

    Then, as chronicled here, there was the physician in Sweden who was brought before the supervising regulatory body on a complaint because she was advising low carb. My recollection is that the process took over two years. Although she was ultimately vindicated, two years of enduring persecution and uncertainty of outcome is quite a toll to ask any practitioner. Who wants to risk their career and livelihood, to earn income to raise their family, just to be a test case?

    Dr. Cate Shanahan in her book Deep Nutrition reports how the insurance companies punish physicians financially for failing to prescribe statins.

    I have had good discussions with a dietician I have consulted. She said she agreed with most all of my observations but said that she could not recommend them to patients or advocate them publicly or she would be disciplined in her profession.

    So a health professional is constrained by the guidelines that are established by the health bureaucracies in response to various commercial, political-ideological and budgetary agendas. What is good for the agendas at the macro level is not necessarily what is good for the individual. In most healthcare systems, the health professional is constrained by the diktats of herd management and has limited discretion in assessing the particular needs of the individual.

    Reply: #5
  5. Galina L.
    That is why it is so important that the professionals, like LC dietitian Franziska Spritzler, RD, CDEhttp://www.lowcarbdietitian.com/blog.html, who recommend LC diets officially, exist.
  6. murray
    Non-calorie restricted high-fat very-low-carb diet (keto!) outperforms calorie-restricted medium-carb, low-fat diet---again!

    The village verificationist science is slowly catching up to the critically interpretive science and clinical experience.

    http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.00...
    "A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabetes"

  7. granny gibson
    I had no idea that I was causing possible repercussions by declining the statin my doctor (and his PA) offered me at every opportunity for three solid years when I became a diabetic. If I had known, I would have taken the piece of paper and thrown it away.

    I have Met Syndrome, including PCOS. When I was much younger, I was on a low carb diet (not labeled, but it was) and was able to conceive and have a normal pregnancy. Didn't know until twenty years that it was probably because of my diet at that time, which included weight loss as well.

    When I crossed over into T2 diabetes I went back to low carb, whole foods and after twenty years, I am managing it with no meds.

  8. Jo TB
    Murray, I am with you on this. A medical doctors livelihood is at stake if he/she doesn't comply with treatment guidelines. I live in Holland and doctors have to adhere to treatment protocols laid down by the medical board. I don't want to take a statin and I won't. Should my doctor get into trouble over this, then by all means prescribe the medication, but they CAN'T FORCE ME TO TAKE THE TABLETS. I'll just flush them down the toilet.
  9. Kat
    Flush them down the toilet? Why waste money filling the prescription at all? I regularly simply fail to fill prescriptions or follow up on completely idiotic blood tests (If a doctor orders 400 tests for things for which you have no symptoms, you'll test positive for something.).
  10. Jennie
    Flush them down the toilet?
    Won't they eventually get back into the water system? We'll all be taking them then!
  11. FrankG
    Whether you agree with your Doctor or not, I don't think it is a good idea to be dishonest with them... if (as I'd recommend) you see the same MD each time (for consistency) they will need to know the full story; in order to offer their best advice. While I completely agree that advice offered may be tainted by policy and is not always perfect, it will still be better than if you are deceiving them. Ultimately you should still get to make an informed decision as to the treatment on offer.
  12. Kat
    Frank, I understand what you're getting at, but if your doctor is insisting on total BS, then pacifying him by nodding your head and doing what you want is often the best strategy. Doctors can get pretty officious and often throw up their hands and refuse to think much about a patient who won't comply with their "lordly" wisdom. At that point you should probably get a new doctor, but it's not always that easy. It's not unheard of for patients to do it their own way and then show up having achieved better results without meds and confessing to their stunned doctor. That said, of course it's much better if one can be honest.
  13. Galina L.
    I asked my doctor to place the fact I am eating a LC diet in my medical history. He is generally supportive.
  14. Molly
    Hah ! I FIRED 8 doctors until I came across a competent one. None of this nodding and agreeing - straight up "I don't agree with you, I'm getting another opinion"...

    I'm in Australia, and we have the freedom to do this - mind you, my current doctor had a run in with the AMA and endured four days of grilling, before winning :(

    I pity them - the money doesn't get you through all that training and general gore - I'd say 99% of them get into it because they genuinely want to help and heal others. How painful it must be for them to have to recommend things they know don't work, and to see their patients sicken and die as a result.....

  15. Sandra
    i have to say that the LCHF diet has worked for me in terms not only of weight loss, but also for my IBS. If I stick to 50gm a day carbs (of any sort) I get little to no flatulence. My bowel movements have become 'normal' the spasms and pain has gone.

    I have started my mother on LCHF and in less than a week her blood sugar has stabilised around the 6 mmol mark. This was following hospitalisation where it had troughs of 2 and peaks of 11+, whenever it dropped they administered sweets and sandwiches, when it was raised they ignored it.

    thank you for getting the message 'out there'

  16. Kat
    I've been lucky(ish) and strong-willed. I was not overweight when my doctor diagnosed me with PCOS (I had other symptoms), but she did say at the time (almost 20 years ago) that studies were showing that a low-carb diet could alleviate symptoms and that I could try that if I chose. At the time Atkins was treated like a pariah, so I stupidly decided against trying it. As I gained weight and my IBS got out of control in middle age despite a grueling training schedule and "eating right", I finally gave in and moved to LCHF and solved all of my problems almost instantly. Since my biomarkers are awesome, my doctors are willing to say that whatever I'm doing is working. But, the thing is....I don't seem to rely on them for advice. I do my own research and then show up healthy so that they just say "whatever you're doing, it's working. Keep it up."

    Basically, doctors are human beings and subject to limitations and we have to take our health into our own hands. My uncle had a long career as a surgeon and he agrees with my approach. He marvels at how much guessing doctors have to do because we actually don't know a lot of very important things about disease. Pharmacology, on the other hand is very advanced - so advanced that my uncle says we can now poison our patients with meds without ever really knowing what's wrong with them or if we're merely masking the underlying disease.

  17. Andrew
    I have been on LCHF since February. I am a triathlete and things have been great. I'm very lean. I burn fats for energy and do not need to supplement my training with gel or sports drinks. I haven't been hungry while staying on the LCHF. Unfortunately my lipid profile came back today. My cholesterol and LDL has doubled (they were high to begin with and I thought LCHF would help). I have a family history of CVD/CAD. I am completely at a loss of what to do next. This was working well for me, but the risks of continuing seem to outway the benefits. As a sidenote, people should look at their lipid profile. Apparently some people (me) internally produce too much cholesterol.
  18. Laura
    Andrew, what is the level of your HDL? it is the ratio between the LDL and HDL that is important. Our bodies are designed to make cholesterol, it is required by every cell.

    As a new qualified health professional I have to agree with Tom's initial comment. I am finding it extremely difficult to give advice following the guideline but against my personal research and opinion supporting LCHF. Due to my hesitancy in consultations my supervisors have viewed this in a lack of knowledge and although I have passed my placement by concealing my beliefs I know I would not be able to continue to practice in this way.

    I would like to join forces with other like minded health professionals and continue evidence based practice which includes, full testing of biomarkers and then with consent, collate the resulting data to help support the LCHF recommendations or not depending on the individual and their specific needs.. The only problem is this health care would have a financial cost as there would be no funding body (i.e. the UK's NHS) to support the care and that's where I'm currently at. Any opinions?

  19. Kat
    Laura, I think you meant that the ratio of triglycerides to HDL are much more important than the total LDL number. As for your other concern I don't know how to address it directly except to point to Tim Noakes's prediction that the internet will be doctors' undoing. Unable to achieve results via outdated imposed guidelines, your patients will seek answers on the internet and essentially drag the profession into the guidelines it ought to have. Professional organizations are very bad at staying on top of a dynamic world and that's true of all professional organizations.

    Andrew, cholesterol is not very well correlated to heart disease. Of the people who develop heart disease half have high cholesterol and half don't. What's important is what happened to your triglyceride/HDL ratio (fewer triglycerides relative to HDL is better) and the particle size of LDL. Particle tests aren't given unless you ask for them. It's more accurate because it's a direct test rather than the standard, which can seriously miscalculate LDL levels in the presence of either very high or very low HDL. Typically, diets change the particle size of LDL (and diet is the only known method, btw. Statins don't do a thing). LCHF diets tend to encourage large particle over small and large particle LDL isn't dangerous. Small particle certainly is. High carb diets tend to increase the proliferation of small particle LDL, so even if your total LDL number is smaller, you might end up with more small particle LDL if you go back to high carb. So, before you change anything, I'd ask your doctor for a direct measure of cholesterol that measures particle size. You may need to make changes after all, but at least you'll know the whole story about your cholesterol and will be able to make an informed decision.

  20. Andrew
    Thank you for your comments. My first set of numbers was in 2010. I was very active and lean, but not doing any endurance related exercise like I am now. Total: 231; HDL: 73; LDL: 143; trigly: 73; VLDL: 15. Six month later in January 2011 (bad month for me after Thanksgiving and Christmas) Total: 249; HDL: 73; LDL:160; trigly:85; VLDL:16.

    Two days ago these are my numbers after close to 3 months of LCHF diet. I'm very lean and my performance has never been better. Total: 342; HDL: 105; LDL: 226; trigly: 55; VLDL: 11. When I first saw the numbers I thought I should not exert myself because I might keel over and die from a heart attack. I was very surprised that they were so high. My doctor emailed me that he was concerned and that this happens to some people on LCHF because the internally produce too much cholesterol. I'm genetically wired that way.

    Any thought? I have already decreased my fat intake, but really have no idea how to proceed.

    Replies: #22, #25, #33
  21. bill
    Andrew said:

    "I have already decreased my fat intake..."

    What?

    Have you read anything on this site?

  22. Kat
    Andrew,

    I'm not your treating physician, just someone commenting on the internet, so I wouldn't expect you to change your actions based solely on my advice. However, I think it would be to your benefit to consider the following issues and discuss them with your doctor and perhaps insist on some further tests.

    1.) Note that HDL is a far better predictor of heart disease. Further, your TG/HDL ratio is a strong predictor of insulin resistance and heart disease. Predictably, your HDL increased significantly on LCHF and your triglycerides, dramatically improving your TG/HDL ratio.

    2.) Your total LDL cholesterol number has increased, but since that number fails to account for the heterogeneity of LDL cholesterol, it says nothing about your risk of heart disease.

    3.) The LDL test is likely to be inaccurate. Typically, cholesterol analysis employs the Friedewald equation to back into an LDL number. Unfortunately, at very high levels and very low levels of triglycerides, this test is highly inaccurate. You should insist on a direct measure to assess particle size in order to account for LDL particle size.

    4.) In the absence of a direct measure of cholesterol, TD/HDL-C is a pretty effective proxy for LDL particle size. A ratio over 3.5 indicates you probably have predominance of small particle size - which is dangerous. Note that not only did you not breech that ratio but on LCHF you have reduced that ratio from 1 to 0.52.

    With those kinds of numbers and the direction they moved in, I wouldn't be so eager to change my diet. If I were you, I'd get a direct measure of my cholesterol first. That LCHF raises total LDL cholesterol is a favourite talking point in the medical profession and especially critics, but it is misleading to look only at total LDL numbers arrived at by the indirect Friedewald equation.

  23. Kat
    for some reason the edit doesn't work. frustration.

    So, VLDL (readily converted to small-particle LDL) is also lower. The lower VLDL and TG and higher HDL mean you've likely decreased your risk of heart disease and increased your LDL particle size. Those are good things. If you increase your total LDL but decrease the number of small particle LDL while raising the large particle LDL, then you've actually improved your health and insulin resistance (which wasn't high to begin with, judging by your TG/HDL ratio below 3.5). I would very much hesitate to shift my diet back toward the one that worsened my VLDL and TG/HDL ratios until I got a particle test.

  24. Laura
    Lol I don't know what Kat does for a living but from the literature I have read I am in total agreement with what she is saying and ask Andrew to consider her comments.
  25. Zepp
    Tot/HDL=risk factor.

    231/73=3,16

    342/105=2,37

    Should be 6 or less, better if its 5 or less, very good if its 4 or less.

    http://www.docsopinion.com/2013/12/15/10-pitfalls-of-using-ldl-choles...

  26. Andrew
    Thank you everyone for your comments. I continued to research ratios, large particles and alternative lipid profile tests. All with the plan to present a case to my doctor. I thought, if he didn't know much about LCHF then I would give him something to research.

    The good news is that he gets it. As I began to lay out my case he already had his in mind. He looked at the same ratio and looked at a "risk calculator." It should despite my high total and LDL, I'm still only at 3% risk. He said he had no reason for me to stop LCHF. He said he wanted to wait 3 weeks before running another test (I stopped LCHF because of my lipid profile) that would directly measure LDL particle size.

    I couldn't be happier! I've felt like crap this past week. I'm very excited to get back on LCHF tomorrow. Thank you all again!

  27. Laura
    That's great news Andrew, I'm excited for you!
  28. deborahkrueger
    Andrew,

    It is you ratios that count and they are all ideal (terrific)-good grief what could be better?

    Anytime you want to check you figures go here: http://www.hughcalc.org/chol.php

    RATIOS:
    Your Total Cholesterol/HDL ratio is: 3.26 - (preferably under 5.0, ideally under 3.5) IDEAL
    Your HDL/LDL ratio is: 0.467 - (preferably over 0.3, ideally over 0.4) IDEAL
    Your triglycerides/HDL ratio is: 0.571 - (preferably under 4, ideally under 2) IDEAL

  29. Andrew
    So I got the NMR my doctor requested and my initial thought was that it was not good. My doctor looked at my figures and consulted with his partners. They all felt the risk was too high and I should start taking a Statin. After looking at everything, I'm beginning to rethink that they look bad. The only think that is not good is my LDL-P. Everything else looks better than "good," they looked optimal!

    LDL-P:1730
    Trig: 51
    Chol LIpo ELP: 313
    HDL-P: 46.8
    Small LDL-P: 107
    LDL size: 22.2
    LP-IR: <25

    Everything but LDL-P looks awesome. But LDL-P is the predictor for CVD.

    Any opinions out there?

  30. Karon
    Hi I am a 45 year old woman, and triathlete. I have been following a LCHF diet for 5 weeks now and have managed to put on weight and body fat. I train 11-14 hours a week swimming running and riding. I also work full time at a desk job. Where I love this diet as my energy is good, I can't keep putting ON weight, I must have my macros or calories wrong. I am now 5 weeks out from race day and instead of losing weight I have put it on. I purchased a ketonix and blow red 90% of the time, I just don't know what I'm doing wrong.
    I currently weight 64kg height is 153cm. I wanted to get down to 57kg for race day but now would be happy with 59kg.
    Can you please help me.

    Many Thanks
    Karon

    Reply: #32
  31. Patricia
    Perhaps you have added protein to your diet instead of fat, that is usually a common mistake in the beginning. And remember you are just in the beginning! Let your body get used to LCHF at a slow pace. Good luck with your race!
  32. Geraldine D. Kuss
    You should INCREASE your fat intake. LCHF= LOW carb HIGH FAT!

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