ABOUT THE AUTHOR
Dr. Mark Cucuzzella, MD
I am a family doctor working in West Virginia, the state with the highest obesity and diabetes rates in America. I started my medical training in the 1980s, and since 1990, the incidence of both of these conditions have tripled: we now have an adult rate of type 2 diabetes close to 20% and obesity (BMI >30) well north of 40% in my state (with other states not far behind). Early in my career, until 2012, I was aware of these increasing rates but felt helpless and hopeless in how to help. The advice I was giving — eat less, exercise more, reduce fat, increase medications — often led to poor outcomes. As clinicians, we often viewed it as the patient's fault for not "complying." This was embedded in our training. The drugs I prescribed at best poorly managed these problems. I left the office fatigued and often felt as if we both had failed — myself and the patient.
A six month assignment in 2012 with the U.S. Air Force to re-design the running program changed my life. Realizing that obesity was a large driver of fitness test failures, I traveled to dozens of military bases asking whether anyone in the room had lost 50 lb and kept it off for a year. Usually a handful (or two out of about 100) would volunteer, and I would query what they did. From base to base, the answer was very similar: they had given up all bread and sugar or had done a paleo-type diet, which in those days was not paleo junk food. The food was mostly eggs, meat, fish, and vegetables, and a few even had the courage to say they had done “Atkins.”
I started reading about the history of obesity as well as the science. The early works of Gary Taubes in Good Calories, Bad Calories opened my mind to new ideas. These ideas were confirmed by the premier scientist Dr. Timothy Noakes in South Africa as we did a couple of courses together in his country. Paradoxically, at the same time, my blood glucose was in the prediabetic range since I was developing an insulin insufficiency type of diabetes. For many years I had been a runner, eating the traditional runner's diet of high carbohydrate and low fat. So I started a low-carb lifestyle myself. A short experiment with a continuous glucose monitor showed the dramatic response my body had to any form of carbohydrate whether it was fruit, starchy veg, cereal, any bread product, and undoubtedly the low-fat frozen yogurt. At the time I did not realize they were all basically the same thing: turned into sugars once they hit my system. For the last eight years I have enjoyed every day free of medication, staying below the threshold for full diabetes.
I came back to my hospital at West Virginia University after this tour and immediately started implementing a low-carb option for patients with diabetes as we monitored their blood sugars in the hospital. The results were instantaneous and dramatic, and many staff started changing their own lifestyle and eating patterns. We even got sugary drinks out of the hospital for all patients, staff, and visitors. Since this time, millions around the world have been adopting a low-carb lifestyle, including many of my patients. These amazing people are not just managing the diabetes but rather putting it into remission and coming off their medications safely. Many other medical conditions such as blood pressure, lipid problems, joint pains and swelling, headache conditions, fatigue, skin and respiratory conditions, as well as a multitude of gastrointestinal symptoms, also seem to improve with this way of eating.
I’m often asked if this is an expensive way of eating. The short answer is definitely not. The first thing to look at is the savings you will have from all the junk food and fast food that tends to end up in your shopping cart and through your car window. Seasonal vegetables, especially the ones on sale, and local produce at the farmers market or from your own garden, are very affordable. We have a program here that doubles the value of SNAP (Supplemental Nutrition and Assistance Program) at Farmers' Markets.
Extremely nutrient-dense natural foods high in essential fatty acids and proteins are not expensive if you can learn how to shop and cook. Look for less expensive varieties of chicken, pork, ground beef, and fish if you live near the sea. Eggs or cheese are incredibly nutrient-dense and inexpensive. Try new things and be a bit adventurous in your shopping and cooking. Break out of old patterns and see the effect in how you feel and the effects on health conditions. Imagine a life without dieting. It’s easy if you try.
Note of Caution: When you reduce the carbohydrates in your diet, your blood sugar and blood pressure tend to improve rapidly and often dramatically, so if you are on medications for these conditions, please consult your physician about adjusting them. If you live near me, I am available to help at the West Virginia University Center For Diabetes And Metabolic Health.
To Restoring Your Health!
Mark Cucuzzella, MD FAAFP
Professor, West Virginia University School of Medicine
WVU Center for Diabetes and Metabolic Health
Dr. Kristie Sullivan, PHD
Kristie Sullivan is passionate about helping others learn how to follow and sustain a low-carb lifestyle. Her passion is fueled by her personal experience with obesity, which started in childhood. Kristie began a strict low-carbohydrate lifestyle in 2013. As a result, she has lost over 100 lbs and significantly improved her health.
Because of her personal success, she began helping others, who also struggled as she did. Kristie established a popular YouTube channel, Cooking Keto with Kristie. She has also authored five best-selling books: Journey to Health: A Journey Worth Taking, Low-carb Living Day by Day, Keto Gatherings, Crazy Busy Keto, and Growing Up Keto. Kristie focuses on a clean-eating approach to a very low-carbohydrate diet.
At Diet Doctor, Kristie focuses on creating content through recipes, videos, and guides as well as building community. Kristie believes that enjoying low-carb foods is a significant factor in long-term success, so she also has two seasons of cooking videos available for members. Season two of Cooking Keto with Kristie features her in the kitchen with low-carb leaders, researchers, and physicians chatting about various topics and creating delicious recipes. Lastly, Kristie also contributes feature articles to help inspire or motivate those who might also struggle with obesity.
Kristie holds a Ph.D. in Educational Research and Policy Analysis from North Carolina State University and enjoyed a 30-year career in higher education before joining Diet Doctor full time. She lives in the beautiful Sandhills region of North Carolina with her husband David and their two children, Grace and Jonathan. David, Grace, and Jonathan also follow a very low-carb diet. Kristie has a Facebook page, "Simply Keto Kristie Sullivan", and a closed Facebook group, "Low-carb Journey to Health (Cooking Keto with Kristie)". She has a website called Cooking Keto with Kristie. You can also find her on Twitter, Instagram, and Pinterest.
You can contact Kristie at email@example.com or join her on social media.
A NOTE ON THE RECIPES AND COOKING
With the recipes, we want you to develop an instinctive relationship with the ingredients and the flavors. This helps you keep creative and eat with the seasons. Low-carb eating makes this style even more important since you are working with a determined range of ingredients. When shopping, you will learn to buy the foods that are healthy for you and often decide what to make with them when you get home.
Some will plan a week’s meals in advance and shop accordingly. Some will do a big weekend cook-up and eat off of that for the whole week. Flexibility and knowledge, mixed with a little creativity and adventurous spirit to try new things, makes this fun. Involve your family in the cooking and have a willingness to fail every now and then.
The approach of this book is like a starter instruction manual. We provide some easy basic meals, simple and available ingredients, as well as being budget-friendly. The recipes allow for variability in tastes and liking. Be resourceful and try different things with different amounts and varieties of spices. You can make swaps with the low-carb veggies and mains (meats/fish/eggs). This way of eating can be adopted to vegetarian patterns also.
We are here to give you hope and joy, not despair.
—Mark and Kristie
Prevalence of Diabetes and Prediabetes
- The prevalence of prediabetes and type 2 diabetes has increased dramatically over several decades in parallel with the increasing prevalence of obesity (which now is over 40% of adults, across all ages).
- Over half of Americans have prediabetes (hemoglobin A1c 5.7–6.4%) or type 2 diabetes (hemoglobin A1c ≥6.5% or on diabetes medication). These numbers have tripled since 1990.
- Obesity, prediabetes and type 2 diabetes are all risk factors for cardiovascular disease (CVD), and their increasing prevalence is now leading to an increase in the prevalence of CVD.
- A low-carb diet is powerful for improving Type 2 Diabetes, Metabolic Syndrome, High Blood Pressure, and Obesity.
- If done correctly, low-carb nutrition is healthy since it can improve blood pressure, blood sugar, and metabolism. Consult your physician before starting a low-carb diet to review whether medication changes are necessary.
Basics of Low-carb
- Eat: Meat, fish, eggs, most vegetables growing above ground, and natural fats.
- Avoid: Bread, pasta, rice, beans, and potatoes, and other sugary and starchy foods. Also avoid refined, processed vegetables and seeds such as canola, soybean, and margarine.
Eat only when you’re hungry and stop when you’re satisfied. Foods with protein and fat create satiety (the feeling of being full).
Vitals and Basic Testing EssentialsIt is important to keep track of your progress and vital signs while following low-carb nutritional approaches. This log can also be shared with your healthcare provider at each visit.
Weight and Waist Circumference
- Start at the top of the hip bone, then bring the tape measure all the way around your body, level with the umbilicus. You can hold the beginning of the tape measure at the umbilicus and rotate 360° in front of you to accomplish this.
- Make the tape snug but not tight and record the measurement right after exhalation. Note: if waist circumference multiplied by two is greater than your height, then risk is higher for metabolic syndrome. Use the same unit of measurement for both (e.g., inches).
Blood Pressure and Heart Rate
- You should be seated, relaxed, and rested for five minutes prior to measurement. Use an appropriately sized cuff since a cuff that is too small falsely elevates the reading. Note: Many individuals with diabetes have stiff arteries, which can cause a falsely elevated blood pressure reading.
- While not tracked at every visit, it’s also important to keep a log of the following:
- Lipid panel, including: Total cholesterol, HDL, LDL, and triglycerides
- Thyroid-stimulating hormone (TSH)
- Hemoglobin A1c (HbA1c)
- Vitamin D
TESTING BLOOD GLUCOSE
Testing Blood Glucose is Empowerment and a Behavior Modification Tool
Standard Glucometer versus Continuous Glucose Monitor (CGM)
Testing your blood glucose before and after meals as well as with exercise is essential to figure out how your body works. In the authors' opinion, there is nothing more powerful than seeing your own response to food and glucose curve and correspond to how you feel. The technology has become more accessible, affordable, and user friendly in the last year with the Freestyle Libre as an entry level CGM. Watch for reactive hypoglycemia.
Large post-meal spikes are a big issue with patients who have standard high carbohydrate dietary patterns, are insulin-resistant, and in later stage T2D with beta cell insufficiency. The CGM shows these patterns as well as a resolution of patterns with an individualized approach.
Is Low-carb Right for Me?
- Do you have obesity, diabetes or another metabolic problem (high blood pressure, fatty liver, PCOS, cardiovascular disease, sleep apnea)?
- Are you interested in losing belly fat, halting or reversing diabetes, and/or lowering your likelihood of cardiovascular diseases?
If you answered “YES” to any of the above, low-carb may be right for you!
- Do you have any acute, unstable medical conditions?
- Are you currently pregnant or breastfeeding?
- Are you taking any medication for diabetes or high blood pressure?
DESCRIPTION OF APPROACHES
Table 1. Low-carb Eating Patternsa
|Eating Pattern||Total Carbs|
|Meat||Poultry||Fish and Shellfish||Eggs||Tofu|
|Very Low-carb Keto||≤30c||No Limitd||No Limitd||No Limitd||No Limitd||—|
|Low-carb Keto||30–50c||No Limitd||No Limitd||No Limitd||No Limitd||—|
|Mediterranean||50–150||No Limitd||No Limitd||No Limitd||No Limitd||No Limitd|
|Paleoe||50–150||No Limitd||No Limitd||No Limitd||No Limitd||—|
|Primale||50–150||No Limitd||No Limitd||No Limitd||No Limitd||—|
|Vegetarian||100–150||—||—||—||No Limitd||No Limitd|
|Eating Pattern||Total Carbs|
|Non-Starchy Veggies||Starchy Veggiesb||Leafy Greens||Berries||Fruit||Grains|
|Very Low-carb Keto||≤30c||1 cup||—||2 cups||—||—||—|
|Low-carb Keto||30–50c||2 cups||1 cup||2 cups||1/2 cup||1 cup||—|
|Mediterranean||50–150||3 cups||1 cup||No Limitd||1 cup||1 cup||2 svgs|
|Paleoe||50–150||3 cups||1 cup||No Limitd||1/2 cup||1/2 cup||—|
|Primale||50–150||3 cups||1 cup||No Limitd||—||—||—|
|Vegetarian||100–150||No Limitd||No Limitd||No Limitd||1 cup||1 cup||4 svgs|
Note: "No Limit" does not mean "eat to excess". Enjoy these foods, eat slowly and mindfully, but you do not need to count servings or grams.a This table is based on the most common approaches, and some variants of each nutritional approach may differ slightly from the table.
b Examples are potatoes, corn, peas, beans/legumes, acorn or butternut squash, carrots, parsnips.
c Suggest a minimum of 15 grams total carbs daily in the form of non-starchy vegetables.
d May be consumed to satiety. While no limit is specified for these foods, consuming them excessively or beyond satiety can adversely impact weight management.
e Paleo/Primal food quality emphasized: grass-fed beef, grass-fed butter, limiting omega-6 fatty acids (vegetable oil, seed oil). Major difference between the two is that Primal allows dairy, nightshade vegetables, and legumes.
Figure 1. Reading a Nutrition Facts Label
There are two ways to count carbs: TOTAL CARBS or NET CARBS
- Look at the serving size and total carbohydrate sections.
In this example, 4 grams carbohydrate = 4 total grams of carbohydrate per 1 cup of cauliflower.
- TOTAL CARBS is used when individuals are trying to lose weight most effectively.
- Look at the serving size, total carbohydrate, and dietary fiber sections.
- Subtract dietary fiber from total carbohydrate to get the "net carbs".
In this example, 4 grams carbohydrate − 2 grams fiber = 2 grams "net carbs" per 1 cup of cauliflower.
- NET CARBS is more often used for individuals trying to lose weight more gradually or maintain body weight.
- Packaged or processed low-carbohydrate foods often contain sweeteners called sugar alcohols (e.g., erythritol, maltitol, xylitol, isomalt) that are carbohydrates. Some people think sugar alcohols can be subtracted similar to fiber when calculating "net carbs," but most of them contain about half the calories per gram that carbohydrates contain.