Saturday, July 12, 2008

Post-Low-Carb Meal 5-Hour Glucose Tolerance Test Produces Rather Odd Results

My arm had so much blood sucked out of it for these tests

I just returned late on Thursday from my 3-hour trip up I-85 North to Durham, North Carolina to spend some time with the Triangle (and Beyond) Low-Carb Meetup group there as well as seeing a great low-carb doctor from Duke University named Dr. Eric Westman to conduct some tests and talk about my recent blood sugar woes and pesky 30-pound weight gain in 2008 that won't come back down again no matter what I do. It was a good time away although I missed blogging and updating you about the healthy low-carb lifestyle. And I'll be leaving again on Tuesday to go see my brother Kevin in Pensacola, Florida for at least a week where I will have ZERO Internet access besides my iPhone (and, no offense, but I ain't up for blogging on that thing with the hunt and peck typing!), so I'll be trying to squeeze in as many posts as I can before then. It's gonna stay busy for me the next couple of months.

But so many of you have been wondering about how my visit with Dr. Westman went that I wanted to make sure I provided an update, especially with the results from my five-hour glucose tolerance test (GTT) following a low-carb meal which was conducted on Monday. If you thought my home testing of my blood sugars was interesting enough, just wait until I tell you what happened during the GTT. Unbelievably crazy! I'll share more about that in a moment.

First, let's look at the bazillion other tests Dr. Westman ran for me to see if there are other culprits going on with my health. A few of these I requested done because Dr. Keith Berkowitz (who I will be sharing a special two-part follow-up podcast interview with the first week in August about this answering your questions), who espouses the "reactive hypoglycemia" theory for long-term low-carbers, suggested I have them run.

Here were the results:

Vitamin B-12--529 (normal)
Cortisol--8.9 (surprisingly normal)
Homocysteine--6.7 (normal)
25-Hydroxyvitamin D3--42 (normal)
HbA1c--5.0 (a little low, but normal)
LDL particle number--1453 (borderline high)
Small LDL particle number--30 (low is less than 600!)

By all accounts of these tests, I'm one extremely healthy guy! My thyroid function was all fine and so was my liver function. So it's good we can rule those out as culprits. I was quite frankly shocked to see my cortisol levels in the good range considering all the stress I've experienced lately, but this just confirms my body handles it all very well apparently. The A1c number was also encouraging since it is so spectacular and out of the diabetic range completely (although Dr. Berkowitz thinks it is a little low--a sign of the reactive hypglycemia according to him).

My LDL and total cholesterol are higher than normal as I've previously blogged, but look at the particle number of the dangerous "small" LDL--a measly little 30! That's just 0.02 percent of my total LDL particle other words, quite negligible and protective considering over 95 percent of my LDL particle size is the large, fluffy kind. :D I'm not at all worried about my lipid profile with my HDL at 65 and triglycerides at 77. That's an HDL/triglycerides ratio I'd put up against anybody else's every day of the week.

Alright, so what the heck is going on with my blood sugars? And, more importantly, what is happening with my insulin levels when my blood sugar drops even after a low-carb meal? Inquiring minds, myself included, sincerely want to know. Here are the results of my GTT after eating a low-carb breakfast consisting of eggs and cheese with a chicken breast from Chick-Fil-A:

30 MIN--89--13.7
1 HOUR--78--11.1
2 HOUR--78--9.0
3 HOUR--89--5.1
4 HOUR--87--5.0
5 HOUR--89--4.7

Fascinating test, huh? And it's just about what I expected was happening. My fasting glucose and insulin levels are perfect, but within a half hour of eating even a low-carb meal I'm seeing a TRIPLING in my insulin levels to keep my blood sugars in check. This would be a typical response if my insulin then came back down again within the first hour or two, but it doesn't.

As you can see, the insulin sustains at that higher level for two hours lingering at 13.7 then slowly dropping to 11.1 and then hitting 9.0 before dropping back down significantly in the third hour to get closer to baseline. During this time of elevated insulin, my blood sugar falls below fasting down about 10 points before rising back to where it started once the insulin comes down again. A normal response would show blood sugars going up quickly and then falling quickly, but not for Jimmy Moore. Lucky me, eh?

So what am I to make of this and what plan of action does Dr. Westman and his colleagues suggest I implement to limit this insulin response so that maybe I can get my recent weight gain to come back down again? I wish I could tell you it's a pretty cut and dry "do this and all will be well" solution, but it's not. The reality is I need to tweak this slowly by only changing one thing at a time. That one thing for me will include eating LESS protein than I have been and watching my specific portions of protein and overall intake just to see if it makes a difference.

Yes, I know cutting portions and even counting calories is almost taboo to talk about within low-carb circles and I'm not interested in that debate right now because I'm not fully convinced of it. Only time will tell. I haven't once counted calories or measured out my portion sizes in the past four and a half years of livin' la vida low-carb, so this is a tough sell for me. But I'm certainly game for doing something different to get my weight to come back down again, especially that little bit that has come back to my midsection.

Interestingly, Dr. Westman suggested I cut back on the amount of protein I have been consuming because it is possible that my body through gluconeogenesis is converting much of the dietary protein I have been consuming into glucose/sugar/carbs which COULD be the reason why I haven't been able to get my weight back down again. And this theory certainly has some merit since I consciously increased my protein intake when I started lifting weights for the first time in December 2007 shortly before my weight gain.

Sure, I also took creatine in the first six weeks and that may have had some impact on the weight gain. But consuming more protein-based foods in an effort to help with my muscle growth could have sabotaged my weight maintenance efforts somewhat. Although I have experienced quite an increase in the amount of muscle on my body after six months of training, it's not implausible that upwards of half of that weight gain is indeed muscle mass. The rest of the 15 or so pounds of weight I have put on over this period of time may be the result of excess glucose from protein.

Beginning yesterday, I started adding in more fat and deliberately trying to eat less total protein (not as a percentage, but overall) to see if it makes a difference. One way I'm doing this is to make sure any protein source I am eating is offset by an addition of more fat. For example, if I'm eating a chicken breast that is basically all protein and little fat, I'll slather it in butter and add cheese on top. Cheese in the form of brie or other fatty ones as a meal will also be a way to increase my fat while decreasing my protein. Cooking eggs in butter and adding cheese also will help with this. Nuts, coconut oil, heavy cream, and other high-fat foods will become more and more prevalent in my low-carb menus.

Since I already eat most of those foods anyway, this shouldn't be difficult to implement. Simply cutting back on protein could be as simple as eating half a steak or only one burger patty or chicken breast. Making sure I contribute fat and fiber to my meals will keep that ratio of fat to protein at the 3-1 ratio I am hoping to attain. Carbs, of course, will remain reduced to basically non-starchy, green leafy veggies.

What do you think about all of this? I'd love to know what you think about the results of my GTT. I'm also frightened to think what would happen if I did a traditional GTT with a glass of sugar water--EEEK! My insulin would go even MORE berserk! Your thoughts as always are welcomed. :)

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Blogger Aaron said...

Hmm- is it possible that a little bit of carbs now and then might actually allow your body to better process insulin? The kind of results people like mark sisson are getting on a 20-25% protein, 20-25% carb, and 60-65% fat are starting to show up all over the net. Low blood sugar doesn't mean much if your insulin is going out of hand everytime you eat. Also, certain saturated fat foods have been shown to increase insulin secretions over foods high in monounsaturated fats- you may want to watch your ratios (and rememeber, i'm not sayign saturated fats are bad- just watch the ratios). You may just need to consume some more nuts like macadamias, almonds, hazelnuts! You lose the most weight insulin output and sensitivity in stablized.

7/12/2008 5:48 PM  
Blogger Jimmy Moore said...

THANKS for your comments, Aaron! But I don't understand how ADDING carbohydrates is gonna help at all. Would you mind elaborating on the specific foods that you are suggesting I should consume to give me 20-25% of my daily intake of calories from carbs? I'm assuming you are referring to non-starchy, green leafy veggies but enlighten me and the rest of us on specifically what you mean.

As for saturated fat, every respectable researcher I have spoken with about this issue says that it has NO impact on insulin secretion...just carbs and protein through gluconeogenesis. Fat is passive on blood sugar and insulin spikes. What evidence are you referring to when you make these claims?

I do love nuts and specifically the ones you listed and eat them quite often. My goal is certainly to stabilize the BG and insulin, so I appreciate your input. :)

7/12/2008 6:01 PM  
Blogger JD said...

Your blood sugar curve matches that of some obese children in Dr. Lutz's book 'Life w/o Bread'. That is they had a flat glucose curve and a bit of hypoglycemia at 2 hours compared with a normal glucose response curve which is bell shaped and never shows hypoglycemia at 2 hours. The flat response is high insulin levels according to Dr. Lutz.

Since most charts of blood glucose don't show insulin I am assuming 3x is pretty high. Do you happen to know what a normal insulin level would be at these time markers? Just curious.

Since you have already lost a ton of weight and you weight lift (reducing insulin resistance) I just wonder what else you can do other than limit the protein and add fat as you are doing. Cutting protein is one of Dr. Bernstein's recommendations to lose weight.

7/12/2008 6:08 PM  
Blogger Jimmy Moore said...

I dunno what a typical insulin response would be, JD, but I wouldn't think it would be MORE than double the fasting level for a normal response. Perhaps someone else will chime in with more about this.

7/12/2008 6:18 PM  
Blogger OnPoint said...

Jimmy, I went through this last fall. I basically switched from Atkins to Groves, which is basically what you are doing now - higher fat ratios and controlling protein. It did NOT help me at all. In fact, I gained weight (on INDUCTION).

I'll let Charles speak for himself (and I know he will), but I recall him saying on your old discussion board that the body does not continually convert protein through gluconeogenesis, but just enough to meet its daily needs.

Having said that, I hope this works out for you. I'm not convinced this is the problem though. You're a substantial man who works out with weights. You also ate lots of whole eggs fried in coconut oil (yuk!), cheese, sausages, and other foods that had sufficient fat to protein. Considering who you are and what your diet has been, I'm not so sure this particular tweak is the one that will make a difference.

I do applaud you for sharing this journey. Before you point it out, I DID take note that you said you will have to make your tweaks one at a time until you figure this thing out.

Several days ago, on your menus blog, you mentioned that a former Atkins Nutritionals employee had told you to add more fibrous carbs to keep your body from overproducing glucose through gluconeogenesis. I never understood the reasoning behind that - you didn't explain the principle behind her recommendation - but maybe it ties into what Aaron said.

Now that I think of it . . . Maybe the Atkins employee said to eat a few more fibrous carbs to keep your body from manufacturing glucose at all, since you can't control how much your body produces? I dunno . . .

Other than the whacky theory above, I have another thought. Maybe zero carb is the answer. I REALLY do NOT want to go there, but Charles has said repeatedly that weight loss problems are hormonal, and further, that if low carb doesn't solve them, then zero carb might be what's necessary.

I'm going in for my yearly checkup soon, and I will be discussing these things with my doctor, b/c I suspect I am also having a problem similar to yours. I've had all the benefits of low carbing EXCEPT weight loss.

Off to the net to do some research. However, it IS good to have the problem clarified, isn't it?

7/12/2008 6:21 PM  
Blogger Kent said...

I have no words of wisdom other than to say thank you for letting us along for the journey.

7/12/2008 6:26 PM  
Blogger Me said...

Have you thought of trying a fat fast?

That would be 40-50 grams of protein and all the rest of your calories from fat.

I assume you are familiar with the HyperLipid blog but here's the link anyway:

7/12/2008 6:40 PM  
Blogger Jimmy Moore said...

THANKS for your words, OnPoint. This is a journey and I'm trying to find the answers one by one. When I do, LOOK OUT! :D

Kent, thank you for your support. I'm happy to share my struggles for the benefit of others. It's not always as cut and dry as we think it is unfortunately.

Susan, the fat fast did come up in my discussion with Dr. Westman. It's the next step I will take if the reduction in the protein does not work.

7/12/2008 7:40 PM  
Blogger sal said...

Hi Jimmy!

Was just wondering why they did not do the standard OGTT?
I had one in May..thats where they determined I was insulin resistant.

All of this is foreign to me. I'm reading Dr. B's book, staying on extended induction (I've lost 40# so far), walking a couple miles every day. and YOU have really brought me out of some pretty low times when I felt like throwing in the towel. So thanks so very much for all you do for me and others also.
God made someone special when he made you!

7/12/2008 7:48 PM  
Blogger Jimmy Moore said...

THANKS so much for your super kind remarks, Sal! You're the BEST! :)

The reason the didn't do a traditional GTT is because we wanted to know what happened after a low-carb meal which is all I ever eat. I don't typically consume high-carb meals anymore, so we wanted to know what was happening after low-carb.

Now the next step in this process would be to do a GTT after drinking the glucose water to see how far off the charts my insulin would go, but for now this showed us exactly what we wanted to see.

7/12/2008 7:51 PM  
Blogger Unknown said...

Jimmy, Mike Eades says that on a good low-carb diet you can't gain weight, but sometimes you can't lose weight unless you have a caloric deficit. For this reason I would say don't overdo it on the fat increase. Cut your protein (and your total intake) and don't go out of your way to replace it calorically. This works for me when I have difficulty losing. Sometimes I can achieve this by eating breakfast and a late lunch/dinner – two meals a day. I know it sounds onerous to others, but I get used to it. I'm not hungry doing this.

7/12/2008 8:21 PM  
Blogger Lauren said...

I'll be interested to see how your fat fasting turns out! That part of DANDR was always intriguing. I hope you get this issue resolved, Jimmy. Dr. Westman sounds like the go to guy for us low-carbers. Thanks for keeping us updated on who's who in the low carb world.

7/12/2008 8:50 PM  
Blogger Jimmy Moore said...

THANKS Gary! Dr. Westman was the first to bring up the "c" word and I'm looking at that, too. First things first is getting my protein reduced while keeping my fat up. If I can master that, then I can pay attention to calories a little.

I appreciate it, Lauren. I'm tempted to try the fat fast now, but Dr. Westman said to take things one at a time so you know what's working and what isn't. If you do it all at once, you'll never know. He is a great doctor and I'm listing more of them at m new low-carb doctors blog.

7/12/2008 8:59 PM  
Blogger JD said...

I was rereading this blog and wondered since your insulin goes so high and stays so high if there isn't a tweek to be made regarding the number of times you eat per day. With a large number of small meals I wonder if your insulin doesn't go high and stay high. I wonder if there isn't a balance between number of meals and giving your insulin time to come down so it doesn't stay high all day. Just a thought.

7/12/2008 11:01 PM  
Blogger Jimmy Moore said...

I thought of that, too, JD. That's why you'll notice my menus contain LESS meals than before. :)

7/12/2008 11:25 PM  
Blogger Aaron said...

It's late and i'm not on an article finding tour- but i seem to recall that small amounts of carbs seem to enhance insulin sensitivity. Now if your body is already trying to create carbs from glucogenesis- why not just give it the carbs in the form of non-starchy vegetables (or even the occasional fruit <---OMG) i'm sure you already know that fat doesn't create an insulin response (but protein and carbs do) Also, not that i'm telling you to do this (i'm not) but on a high carb diet- the body also seems to clear insulin better (but over time it gets wreaked from this too often!!!) (which i'm seeming to say that too much fat all the time seems to create a slight insulin resistance (which also seems to slighty be the case) <---- which is ok if you stay lower carb (40g to 150g daily)- not no carb). Now on the saturated fat issue, your body does contain desaturase enzymes that can turn saturated fat into mono-unsaturated fats and so on <--- and does a good job of this when your insulin levels are low <----interesting!!!! (considering your your insulin has been jumping around even while your glucose is great!)

Why not try to just duplicate the levels of fats that you already have in your tissues which is something like around 50%+mono and 40%+ saturated and minimal poly (around these figures).

I really think you may be on to something great if you up your monounsaturated fats -- make sure to keep polyunsaturated fats low with an occasional intake of omega 3 and do<--- consume saturated fats in lower amounts.

Lower the amount of protein in your diet and up your amount of veggies <--- doesn't sound too bad does it?

7/12/2008 11:51 PM  
Blogger Jimmy Moore said...

I'm tinkering with it little by little, Aaron! THANKS for sharing your thoughts. I'm curious what kind of carbs you think would be helpful to enhance insulin sensitivity. What's been your experience?

7/13/2008 1:18 PM  
Blogger Jimmy Moore said...

By the way, if you look at my menus blog, then you'll see I eat a good share of non-starchy, green leafy veggies already. :)

7/13/2008 1:19 PM  
Anonymous Anonymous said...

It's curious to me that even though millions of people get their blood tested, there's no clear way to know what it means.

Eric Westman gives you high marks cause you don't hardly have any small ldl, Dr. Solis (?) that you interviewed this week thinks the ratio between total cholesterol and hdl is what matters, in which case you better not go to the blood marker championships in Beijing, save your money on those plane tickets. Then there's the guy that you interviewed that thinks it's all about triglycerides and hdl, maybe better get those tickets after all, thouh Ornish that you interviewed said triglycerides aren't reliable, in fact he thinks markers in general aren't reliable, and Taubes agrees with Ornish on that (though not that much else). Wish these docs would get it figured out. Meanwhile I guess we should each trust whoever says we're healthy.

7/13/2008 1:27 PM  
Blogger Jimmy Moore said...

Perfect illustration, Peter, of just how much we DON'T know about health and risk factors. But the way we are doing it right now is obviously not working, so I'm open to other theories that might actually make a difference (like HDL/triglyceride ratio). It's difficult for the average non-medical person to grasp who is right, so some semblance of consensus based on science should apply here. So far it hasn't.

7/13/2008 1:36 PM  
Anonymous Anonymous said...

I would remember the experimental pizza meal after you first discovered the hypoglycemia you get after eating a low-carb meal. You didn't get a headache after the pizza, you felt fine. Yes, you responded when I mentioned this, but what about the weight gain? But your body, especially as you have been building up your muscles, wants to restore glycogen, and restoring glycogen causes a temporary weight gain as the muscles take up water along with the carbohydrate. You have achieved good health with potentially good carbohydrate metabolism, so that periodically, while eating low-carb for most meals, you can have a large meal of starch and some sugar to restore glycogen. And it will go to glycogen, not fat, because you have corrected your carbohydrate intolerances. This is the cyclical ketogenic diet that so many of us have found optimal. We have tried strict low-carb for a long time and have come to the conclusion that glycogen restoration is not incompatible with the other health benefits of low-carb--although it is incompatible with the strict low-carb ideology.


Jim Jozwiak

7/13/2008 5:11 PM  
Blogger Jimmy Moore said...

That seems to make sense to me, Jim. I guess my question would be how often should I do such a meal and what should that meal look like? I've heard both sides of the debate over carb cycling and just haven't become convinced fully of it yet.

7/13/2008 5:43 PM  
Blogger Sue said...

Maybe do that high carb meal post workout. Not sure what in the high carb meal but not junk carbs. I'm interested in hearing more about restoring insulin sensitivity with the occasional high carb meal. Does everyone need to do this after been a low-carber for ages??

7/13/2008 7:07 PM  
Blogger JD said...

Jimmy if you are serious about carb loading and weight lifting, then you have no better source about how often and what to eat than what is laid out in the TNT book by Volek & Campbell.

7/13/2008 8:58 PM  
Blogger Jimmy Moore said...

I'll do one step better...I'll see if Dr. Volek will come on my podcast show to talk about it. :)

7/13/2008 9:00 PM  
Anonymous Anonymous said...

Since you are inviting speculation on your condition, here are my thoughts:

1. According to Bernstein's book, your A1C is not normal. 5.0 means your average glucose is 105.

2. Elevated insulin levels result from excessive carbs and/or insulin resistance at the cellular level. Perhaps insulin resistance is your problem.

3. Perhaps you developed overt diabetes prior to the weight loss and while greatly improved, you still suffer from its effects. That last mile of fat around your belly may be the source of insulin resistance.

4. Since you are looking for options perhaps you could try a therapeutic trial of metformin or some other diabetes meds that reduce insulin resistance and help with weight loss.

5. Now might be a good time to study Dr Bernstein's book deeply and look for some strategies. Better yet, contact him or ask Dr. Westman to consult with him on your behalf.

Just food for thought. Best of luck and never give up!

7/13/2008 9:34 PM  
Blogger Jimmy Moore said...

THANKS Barry. My average blood glucose according to the A1c test was 92. I'm not eating too many carbs, so perhaps the cellular level explanation is accurate and causing some insulin resistance. I've often wondered if all of those years of eating poorly would catch up to me despite my healthy eating in recent years. One of the last options we discussed was having me take metformin since it basically stops gluconeogenesis from happening. I'd make an exception to my "no drugs" rule with that one if I had to. I'd love to work with Dr. Bernstein on getting this under control. THANKS for your comments!

7/13/2008 9:50 PM  
Anonymous Anonymous said...

Bodybuilders frequently have a day or two of high-carb and then eat low-carb the rest of the week. I am not a bodybuilder, and it works better for me to have a single high-carb meal every other day. The meal has about 250 grams of net carbs, such as a big plate of spaghetti, some milk and some dried fruit. I had to experiment to find how often I could have a high-carb meal to restore glycogen while maintaining insulin senstitivity without inflammation, fatigue, poor mood, etc.

Jim Jozwiak

7/14/2008 1:00 PM  
Anonymous Anonymous said...

I wouldn't be at all surprised if the problem fixes itself before you figure out what the problem is.
Lee in Nashville

7/14/2008 1:08 PM  
Anonymous Anonymous said...

I think Dr. Westman has it it spot on about lowering intake of protein a bit. Protein does promote insulin secretion. Are you familiar with the work of Dr. Jan Kwasniewski? He's considered the "Polish Atkins" but recommends less protein and more fat than Atkins. I've also heard that even Dr. Wolfgang Lutz of "Life Without Bread" fame has switched to less protein and more fat after meeting with Dr. Kwasniewski fact-to-face. "Food for thought" - no pun intended.(<:

7/15/2008 10:31 AM  
Anonymous Anonymous said...

Now, don't freak out or anything, but your insulin resistance/reactive hypoglycemia combination strongly reminds me of PCOS (which I have). There has been some talk in the PCOS community about a "male" version of PCOS, but no hard data I can point you to. At ant rate, maybe it's time for a full endocrine workup, with testosterone and related hormones, plus the more detailed thyroid stuff, T3, reverse T3, etc.?

As well, I have also heard that insulin resistance increases with age, and the only way to fight that is with exercise and antioxidants.

And I can see why you would want to put in some more fats, but have you tried an olive oil/vinegar combo instead of butter? The olive oil has lots of good stuff as I'm sure you know, and the vinegar is supposed to slow down the digestive process somewhat, so as to moderate the insulin reaction. Good luck.

7/15/2008 5:31 PM  
Blogger Unknown said...

Jimmy, I've never been able to eat "anything" I want. Maybe because I'm short. Maybe something else. But, I do constraint my calories. Not a lot, just to make sure I go to bed a little hungry. When I do that, I lose weight. If not, I maintain.

I find that with my weight training, I am gaining muscle and losing weight a little more rapidly. I don't take anything as a supplement for weight training; I just take my normal vitamins and supplements.

Good luck.

7/16/2008 6:08 PM  
Anonymous Anonymous said...

I am surprised that in 32 comments thus far, no one has mentioned insulinotrophic foods as a possible cause. Milk consumption causes a greater spike in insulin output than is expected by its carb and protein content, not only at the meal consumed but at the next meal, too. A number of high protein and carb foods are insulinotrophic alone and in combination with certain other foods. There is one excellent research study listing the insulinotrophic effects of more than 100 different foods. The researcher was an Australian who was unable to do follow-up studies because of a lack of funding. She believes that looking at insulin levels, not just glucose levels, is key to understanding health and disease. Alas, I do not have a link. :(

7/16/2008 9:15 PM  
Anonymous Anonymous said...

I'd love for you to post your thyroid levels.
Your B12 AND Cortisol levels are not "normal"-- they are within normal range, but that doesn't mean Jack, concerning some results.

Thanks for posting what you did.

I'm sure it helps a lot of people out.

7/21/2008 5:48 PM  
Blogger Jimmy Moore said...

I'll have to get the numbers from Dr. Westman.

7/21/2008 6:14 PM  
Blogger Jimmy Moore said...

Here are the thyroid numbers Whitney:


THYROXINE,FREE 0.71 ng/dL [0.52-1.21]

TRIIODOTHYRONINE, FREE 2.84 pg/mL [2.20-3.80]

7/23/2008 8:27 PM  

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