CHAPTER 6 How Not to Die from Diabetes
A few years ago, Millan, a member of the NutritionFacts.org community, was kind enough to share her story with me. When she was thirty years old, she was diagnosed with type 2 diabetes. Millan had struggled with obesity all her life and suffered through the highs and lows of years of yo-yo dieting. She had tried nearly every fad diet she could find but, not surprisingly, would quickly gain back whatever weight she’d lost. Diabetes wasn’t a stranger to her. Millan’s parents, brothers, and aunt were all diabetic, so she figured that her own diagnosis was inevitable. It’s age related. It’s genetic. There was nothing she could do. Or so she thought. Millan’s initial diagnosis was back in 1970, and she lived as a diabetic for two decades. Then, in the 1990s, she switched to an entirely plant-based diet and completely turned her life around. Today, her energy levels are better than ever, she looks and feels younger, and she’s finally been able to maintain a healthy weight. More than four decades after being diagnosed as a diabetic, Millan, now in her seventies, is fit as a fiddle. She even teaches high-intensity Zumba classes! She didn’t find some wonder drug or trademarked diet. She simply decided to eat healthier food.
The disease called diabetes mellitus comes from two words: diabetes (Greek for “to pass through or siphon”) and mellitus (Latin for “honey sweet”). Diabetes mellitus is characterized by chronically elevated levels of sugar in your blood. This is because either your pancreas gland isn’t making enough insulin (the hormone that keeps your blood sugar in check) or because your body becomes resistant to insulin’s effects. The insulin-deficiency disease is called type 1 diabetes, and the insulin-resistance disease is called type 2 diabetes. If too much sugar builds up in your blood, it can overwhelm the kidneys and spill into your urine. How did people test urine before they had modern laboratory techniques? They tasted it. Diabetic urine can evidently taste as sweet as honey. Hence the name. Type 2 diabetes has been called the “Black Death of the twenty-first century” in terms of its exponential spread around the world and its devastating health impacts. Instead of the bubonic plague, though, the pathological agents in obesity and type 2 diabetes are identified as “high-fat and high-calorie diets,” and instead of fleas and rodents, the causes are “advertisements and inducements to poor lifestyle.” 1 More than twenty million Americans are currently diagnosed with diabetes, a tripling of cases since 1990.2 At this rate, the CDC predicts that one in three Americans will be diabetic by midcentury. 3 Currently in the United States, diabetes causes about 50,000 cases of kidney failure, 75,000 lower extremity amputations, 650,000 cases of vision loss, 4 and about 75,000 deaths every year. 5 Your digestive system breaks down the carbohydrates you eat into a simple sugar called glucose, which is the primary fuel powering all the cells in your body. To get from the bloodstream into your cells, glucose requires insulin. Think of insulin as the key that unlocks the doors to your cells to allow glucose to enter. Every time you eat a meal, insulin is released by your pancreas to help shuttle the glucose into your cells. Without insulin, your cells can’t accept glucose, and, as a result, the glucose builds up in your blood. Over time, this extra sugar can damage the blood vessels throughout the body. That’s why diabetes can lead to blindness, kidney failure, heart attacks, and stroke. High blood sugar can also damage your nerves, creating a condition known as neuropathy that can cause numbness, tingling, and pain. Because of the damage to their blood vessels and nerves, diabetics may also suffer from poor circulation and lack of feeling in the legs and feet, which can lead to poorly healing injuries that can, in turn, end as amputations. Type 1 diabetes, previously called juvenile-onset diabetes, represents approximately 5 percent of all diagnosed diabetes cases. 6 In most people with type 1 diabetes, the immune system mistakenly destroys the insulin-producing beta cells in the pancreas. Without insulin, blood sugar rises to unsafe levels. Type 1 diabetes is therefore treated with injections of insulin, a type of hormone-replacement therapy, to make up for the lack of production. The exact cause of type 1 diabetes is unknown, though a genetic predisposition combined with exposure to such environmental triggers as viral infection and/ or cow’s milk may play a role. 7 Type 2 diabetes, previously known as adult-onset diabetes, accounts for 90– 95 percent of diabetes cases. 8 In type 2 diabetes, the pancreas can make insulin, but it doesn’t work as well. The accumulation of fat inside the cells of your muscles and liver interferes with the action of insulin. 9 If insulin is the key that unlocks the doors to your cells, saturated fat is what appears to gum up the locks. With glucose denied entry into your muscles, the primary consumer of such fuel, sugar levels can rise to damaging levels in your blood. The fat inside these muscle cells can come from the fat you eat or the fat you wear (i.e., your body fat). The prevention, treatment, and reversal of type 2 diabetes therefore depends on diet and lifestyle. The CDC estimates that more than twenty-nine million Americans are living with diagnosed or undiagnosed diabetes— that’s about 9 percent of the U.S. population. Out of one hundred people you know, chances are six of them already know they are diabetic and about three have diabetes but haven’t yet been diagnosed. More than one million new cases of type 2 diabetes are diagnosed each year. 10 The good news: Type 2 diabetes is almost always preventable, often treatable, and sometimes even reversible through diet and lifestyle changes. Like other leading killers— especially heart disease and high blood pressure— type 2 diabetes is an unfortunate consequence of your dietary choices. But even if you already have diabetes and its complications, there is hope. Through lifestyle changes, you may be able to achieve a complete remission of type 2 diabetes, even if you’ve been suffering with the disease for decades. In fact, by switching to a healthy diet, you can start improving your health within a matter of hours.
What Causes Insulin Resistance?
The hallmark of type 2 diabetes is insulin resistance in your muscles. As we’ve learned, insulin normally enables blood sugar to enter the cells, but when the cells are resistant and don’t respond to insulin as they should, it can lead to dangerous levels of sugar remaining in the bloodstream. What causes insulin resistance in the first place? Studies dating back nearly a century note a striking finding. In 1927, researchers divided healthy young medical students into multiple groups to test out the effects of different diets. Some were given a fat-rich diet composed of olive oil, butter, egg yolks, and cream; others were given a carbohydrate-rich diet of sugar, candy, pastry, white bread, baked potatoes, syrup, bananas, rice, and oatmeal. Surprisingly, insulin resistance skyrocketed in the fat-rich diet group; within a matter of days, their blood sugar levels doubled in response to a sugar challenge, far more than those on the sugar and starch diet. 11 It took scientists another seven decades to unravel the mystery of why this happened, but the answer would provide the key to what causes type 2 diabetes. To understand the role of diet, we must first understand how the body stores fuel.
When athletes talk about “carb loading” before a competition, they’re referring to the need to build a fuel supply in their muscles. Carb loading is a more extreme version of what you do every day: Your digestive system breaks down the starch you eat into glucose, which enters your circulatory system as blood sugar and is then stored in your muscles to be used for energy as needed. Blood sugar, though, is a little like a vampire: It needs an invitation to come into your cells. And that invitation is insulin, the key that unlocks the front door of your muscle cells so glucose can enter. When insulin attaches to insulin receptors on a cell, it activates a series of enzymes that escort in the glucose. Without insulin, blood glucose is stuck out in the bloodstream, banging on your cells’ front door, unable to enter. Blood sugar levels then rise, damaging vital organs in the process. In type 1 diabetes, the body destroys the insulin-producing beta cells of the pancreas, so very little insulin is present to let blood sugar enter your cells. But with type 2 diabetes, insulin production isn’t the problem. The key is there, but something has gummed up the lock. This is called insulin resistance. Your muscle cells become resistant to the effect of insulin. So what’s jamming up the door locks on your muscle cells, preventing insulin from letting glucose enter? Fat— more specifically, intramyocellular lipid, the fat inside your muscle cells. Fat in your bloodstream, either from your own fat stores or from your diet, can build up inside your muscle cells, where it can create toxic breakdown products and free radicals that block the insulin-signaling process. 12 No matter how much insulin you produce, your fat-compromised muscle cells can’t effectively use it. This mechanism by which fat interferes with insulin function has been demonstrated by either infusing fat into people’s bloodstreams and watching insulin resistance shoot up13 or by removing fat from people’s blood and seeing insulin resistance drop. 14 We can now even visualize the amount of fat in the muscles using MRI technology. 15 Researchers are now able to track the fat going from the blood into the muscles and watch insulin resistance rise. 16 One hit of fat, and within 160 minutes, the absorption of glucose into your cells becomes compromised. 17 Researchers don’t have to give their study subjects fat through an IV, though. All they have to do is feed them. Even among healthy individuals, a high-fat diet can impair the body’s ability to handle sugar. But you can lower your insulin resistance by lowering your fat intake. Research has clearly shown that as the amount of fat in your diet becomes increasingly lower, insulin works increasingly better. 18 Unfortunately, given the current diets of American children, we’re seeing both obesity and type 2 diabetes occur earlier and earlier in life.
Prediabetes in Children
Prediabetes is defined by elevated blood sugar levels that are not yet high enough to reach the official diabetes threshold. Commonly found among those who are overweight and obese, in the past, prediabetes was regarded as a high-risk state that presaged diabetes, but it was not thought to be a disease in itself. However, we now know that prediabetic individuals may already be experiencing organ damage. Prediabetics may already have sugar damage to their kidneys, eyes, blood vessels, and nerves even before diabetes is diagnosed. 19 Evidence from numerous studies suggests that chronic complications of type 2 diabetes begin occurring during the prediabetic state. 20 To prevent diabetic damage, therefore, we need to prevent prediabetes— and the earlier, the better. Thirty years ago, virtually all diabetes in children was assumed to be type 1. But since the mid-1990s, we’ve started to see an increase in type 2 diabetes among kids. 21 What was once called “adult-onset diabetes” is now known as type 2 diabetes because children as young as eight are developing the disease. 22 This trend can have devastating consequences: A fifteen-year follow-up study of children who were diagnosed with type 2 diabetes found an alarming prevalence of blindness, amputation, kidney failure, and death by the time these kids had reached young adulthood. 23 Why the dramatic rise in childhood diabetes? It’s likely due to the dramatic rise in childhood obesity. 24 Over recent decades, the number of American children considered to be overweight has increased by more than 100 percent. 25 Children who are obese at age six are more likely than not to stay that way, and 75– 80 percent of obese adolescents will remain obese as adults. 26 Childhood obesity is a powerful predictor of adult disease and death. For example, being overweight as a teenager was found to predict disease risk fifty-five years later. Such individuals may end up with twice the risk of dying from heart disease and a higher incidence of other diseases, including colorectal cancer, gout, and arthritis. Researchers have found that being overweight as a teen could be an even more powerful predictor of disease risk than being overweight as an adult. 27 To prevent childhood diabetes, we need to prevent childhood obesity. How do we do that? In 2010, the chair of the nutrition department at Loma Linda University published a paper suggesting that giving up meat entirely is an effective way to combat childhood obesity, pointing to population studies demonstrating that people eating plant-based diets are consistently thinner than those who eat meat. 28 To study body weight, we usually rely on body mass index (BMI), which is a measure of weight that also takes height into account. For adults, a BMI over 30 is considered obese. Between 25 and 29.9 is considered overweight, and a BMI between 18.5 and 24.9 is considered “ideal weight.” In the medical profession, we used to call a BMI of under 25 “normal weight.” Sadly, that’s no longer normal. What’s your BMI? Visit one of the scores of online BMI calculators or grab a calculator and multiply your weight in pounds by 703. Then divide that twice by your height in inches. For example, if you weigh 200 pounds and are 71 inches tall(five foot eleven), that would be (200 × 703) ÷ 71 ÷ 71 = 27.9, a BMI indicating that you would be, unfortunately, significantly overweight. The largest study ever to compare the obesity rates of those eating plant-based diets was published in North America. Meat eaters topped the charts with an average BMI of 28.8— close to being obese. Flexitarians (people who ate meat more on a weekly basis rather than daily) did better at a BMI of 27.3, but were still overweight. With a BMI of 26.3, pesco-vegetarians (people who avoid all meat except fish) did better still. Even U.S. vegetarians tend to be marginally overweight, coming in at 25.7. The only dietary group found to be of ideal weight were the vegans, whose BMI averaged 23.6.29 So why aren’t more parents feeding their kids plant-based diets? There’s a common misconception in America that their growth will be stunted. However, the opposite may be true. Loma Linda University researchers found that children who eat vegetarian diets not only grow up leaner than kids who eat meat but taller, too, by about an inch. 30 In contrast, meat intake is associated more with horizontal growth: The same researchers found a strong link between consumption of animal foods and increased risk of being overweight. 31 Developing diabetes in childhood appears to cut life expectancy by about twenty years. 32 Who among us wouldn’t go to the ends of the earth to enable our kids to live two decades longer?
THE FAT YOU EAT AND THE FAT YOU WEAR
Carrying excess body fat is the number-one risk factor for type 2 diabetes; up to 90 percent of those who develop the disease are overweight. 33 What’s the connection? In part, a phenomenon known as the spillover effect. Interestingly, the number of individual fat cells in your body doesn’t change much in adulthood, no matter how much weight you gain or lose. They just swell up with fat as the body gains weight, so when your belly gets bigger, you’re not necessarily creating new fat cells; rather, you’re just cramming more fat into existing ones. 34 In overweight and obese people, these cells can get so bloated that they actually spill fat back into the bloodstream, potentially causing the same clogging of insulin signaling one would experience from eating a fatty meal. Doctors can actually measure the level of freely floating fat in the bloodstream. Normally, it’s between about one hundred and five hundred micromoles per liter. But people who are obese have blood levels between roughly six hundred and eight hundred. People eating low-carb, high-fat diets can reach the same elevated levels. Even a trim person eating a high-fat diet can average eight hundred, so that sky-high number isn’t exclusive to obese patients. Because those eating high-fat diets are absorbing so much fat into their bloodstreams from their digestive tract, the level of free fat in their blood is as high as someone who’s grossly obese. 35 Similarly, being obese can be like gorging on bacon and butter all day even if you are actually eating healthfully. That’s because an obese person’s body may be constantly spilling fat into the bloodstream, regardless of what goes into the mouth. No matter the source of fat in your blood, as fat levels rise, your ability to clear sugar from the blood drops due to insulin resistance— the cause of type 2 diabetes. People who eat a plant-based diet, on the other hand, have just a small fraction of the rate of diabetes seen in those who regularly eat meat. As you can see in figure 1, as diets become increasingly plant based, there appears to be a stepwise drop in diabetes rates. 36 Based on a study of eighty-nine thousand Californians, flexitarians appear to cut their rate of diabetes by 28 percent, good news for those who eat meat maybe once a week rather than every day. Those who cut out all meat except fish appear to cut their rates in half. What about those eliminating all meat, including fish? They appear to eliminate 61 percent of their risk. And those who go a step farther and drop eggs and dairy foods too? They may drop their diabetes rates 78 percent compared with people who eat meat on a daily basis. Why would this be? Figure 1 Is it just because people eating plant-based diets are better able to control their weight? Not entirely. Even at the same weight as regular omnivores, vegans appear to have less than half the risk of diabetes. 37 The explanation may lie in the difference between plant fats and animal fats.
Saturated Fat and Diabete
Not all fats affect our muscle cells in the same way. For example, palmitate, the kind of saturated fat found mostly in meat, dairy, and eggs, causes insulin resistance. On the other hand, oleate, the monounsaturated fat found mostly in nuts, olives, and avocados, may actually protect against the detrimental effects of the saturated fat. 38 Saturated fats can wreak all sorts of havoc in muscle cells and may result in the accumulation of more toxic breakdown products (such as ceramide and diacylglycerol) 39 and free radicals and can cause inflammation and even mitochondrial dysfunction— that is, interference with the little power plants (mitochondria) within our cells. 40 This phenomenon is known as lipotoxicity (lipomeaning fat, as in liposuction). 41 If we take muscle biopsies from people, saturated fat buildup in the membranes of their muscle cells correlates with insulin resistance. 42 Monounsaturated fats, however, are more likely to be detoxified by the body or safely stored away. 43 This discrepancy may explain why individuals eating plant-based diets are better protected from diabetes. Researchers have compared the insulin resistance and muscle-fat content of vegans versus omnivores. Because people eating plant-based diets have the advantage of being so much slimmer on average, the researchers recruited omnivores who weighed the same as the vegans they were studying so that they could see whether plant-based diets had a direct effect beyond the indirect benefit of pulling fat out of the muscles by helping people to lose weight. The result? There was significantly less fat trapped in the deep calf muscles of vegans than in those of comparably slim omnivores. 44 Those eating plant-based diets have been found to have better insulin sensitivity, better blood sugar levels, better insulin levels, 45 and even significantly improved function of their beta cells— the cells in the pancreas that produce insulin in the first place. 46 In other words, people eating plant-based diets appear to be better at both producing and using insulin.
Preventing Diabetes by Eating More
Many population studies have shown that people who eat significant amounts of legumes (e.g., beans, split peas, chickpeas, and lentils) tend to weigh less. They also have slimmer waists, less obesity, and lower blood pressure compared to people who don’t eat many legumes. 47 But couldn’t these benefits be due not to the legumes themselves but to the fact that people who eat more legumes may eat a healthier diet in general? To tease out the connection, researchers used the most powerful tool in nutrition research: the interventional trial. Instead of just observing what people eat, you change their diets to see what happens. In this case, they put legumes to the test by comparing extra legume consumption head-to-head against calorie restriction. Reducing belly fat may be the best way to prevent prediabetes from turning into full-blown diabetes. Though calorie cutting has been the cornerstone of most weight-loss strategies, evidence suggests that the majority of individuals who lose weight by portion control eventually regain it. Starving ourselves almost never works long term. So wouldn’t it be great if instead we could find a way to eat more food to get the same weight-loss benefit? The researchers divided overweight subjects into two groups. The first group was asked to eat five cups a week of lentils, chickpeas, split peas, or navy beans— but not to change their diets in any other way. The second group was asked to simply cut out five hundred calories a day from their diets. Guess who got healthier? The group directed to eat more food. Eating legumes was shown to be just as effective at slimming waistlines and improving blood sugar control as calorie cutting. The legume group also gained additional benefits in the form of improved cholesterol and insulin regulation. 48 This is encouraging news for overweight individuals at risk for type 2 diabetes. Instead of just eating smaller portions and reducing the quantity of the food they eat, they can also improve the quality of their food by eating legume-rich meals. Saturated fats may also be toxic to the cells in the pancreas that produce insulin. At around age twenty, the body stops making new insulin-producing beta cells. After that, if they are lost, they may be lost for good. 49 Autopsy studies have shown that by the time type 2 diabetes is diagnosed later in life, you may have already killed off half your beta cells. 50 The toxicity of saturated fats can be demonstrated directly. If we expose beta cells to saturated fat51 or to LDL (“ bad”) cholesterol in a petri dish, the beta cells begin to die. 52 The same effect is not observed with the monounsaturated fats concentrated in fatty plant foods, such as nuts. 53 When you eat saturated fat, both insulin action and insulin secretion are impaired within hours. 54 The more saturated fat you have in your blood, the higher your risk may be for developing type 2 diabetes. 55 Of course, just as everyone who smokes doesn’t develop lung cancer, everyone who eats excessive saturated fat doesn’t develop diabetes. There is a genetic component. But for those who already have a genetic predisposition, a diet with too many calories and rich in saturated fat is considered a cause of type 2 diabetes. 56
Losing Weight with a Plant-Based Diet
As noted earlier, even if you don’t eat extra fat, the extra fat you wear may cause the spillover effect— the tendency for overstretched fat cells to spill fat into the bloodstream. The advantage of a whole-food, plant-based approach to weight loss is that there may be no need for portion control, skipping meals, or counting calories, because most plant foods are naturally nutrient dense and low in calories. Fruits and vegetables, on average, contain about 80– 90 percent water. Just as fiber can bulk up the volume of foods without adding calories, so can water. Experiments have shown that people tend to eat the same amount of food at a meal, regardless of calorie count— probably because stretch receptors in the stomach send signals to the brain after a certain volume of food has been ingested. When much of that volume is a zero-calorie component like fiber or water, that means you can eat more food but gain less weight. 57 Figure 2 shows the amounts of broccoli, tomatoes, and strawberries that contain one hundred calories, compared with the quantities of one hundred calories of chicken, cheese, and fish. You’ll notice that even though the calorie content is the same, the volume of these foods is different. So it makes sense that one hundred calories of the plants would be more likely to fill you up, while the same one hundred calories from animal or processed foods may leave you half-empty. That’s why whole-food, plant-based diets are great for people who like to eat, since you can basically eat as much as you want without worrying about counting calories. A head-to-head randomized clinical trial found that a plant-based diet beat out the American Diabetes Association’s recommended diet for weight loss. This occurred without restricting portions the subjects ate and without requiring calorie or carb counting. 58 Moreover, a review of similar studies found that, in addition to weight loss, individuals consuming plant-based meals experienced improved blood sugar control as well as reduced risk of cardiovascular disease compared with people who followed diets that included more animal products. 59 Such are the benefits of a plant-based diet. Diabetics are more likely to suffer from strokes and heart failure. 60 In fact, diabetic patients without a history of coronary heart disease may have the same risk of heart attack as nondiabetic individuals with confirmed heart disease. 61 In addition to improving insulin sensitivity better than conventional diabetic diets, the plant-based approach can also lead to a significant drop in LDL cholesterol, thereby reducing risk of the number-one killer of diabetics, heart disease. 62 But how do people feel about making such a major shift in their diets? As Dr. Dean Ornish has quipped, are we all going to live longer, or is it just going to seem longer? 63 Apparently, most people who switch to a plant-based diet are happy they did. One of the reasons there’s been such great compliance with plant-based dietary interventions is that people not only tend to get measurably better, they also tend to feel much better. In a recent randomized, clinical weight-loss trial, diabetics were split into two groups. Half were put on the conventional diabetic diet as recommended by diabetes organizations; the other half were prescribed a plant-based diet consisting mostly of vegetables, grains, legumes, fruits, and nuts. At the end of six months, the plant-based group reported both a significantly better quality of life and significantly higher mood scores than those assigned to the conventional diet. Patients consuming the plant-based diet also felt less constrained than those consuming the conventional diet. Moreover, disinhibition decreased, meaning patients eating vegetarian food were less likely to binge, and the plant-based folks tended to feel less hungry as well— both of which could help these subjects sustain this way of eating in the long run. 64 So not only do plant-based diets appear to work better but they may be easier to adopt long term. And with the improvement in mood they seem to bring, there may be benefits for both physical and mental health. (See chapter 12 for more on this topic.) When it comes to maximally lowering diabetes risk, does it matter if you eat just a little meat? Researchers in Taiwan sought to answer that question. Traditionally, Asian populations have enjoyed very low rates of diabetes. In recent years, however, diabetes has emerged on a near-epidemic scale, coinciding with the Westernization of Asian diets. Rather than compare vegetarians to modern-day omnivores, these researchers compared vegetarians to those eating a traditional Asian diet, which customarily included very little fish and other meat. The women ate the equivalent of just a single serving of meat each week, while the men had a serving every few days. 65 Both the vegetarian and traditional Asian diet groups were following healthy diets, avoiding soda, for example. Despite the similarities in diet among the four thousand study subjects and after accounting for weight, family history, exercise, and smoking, the researchers found that the vegetarian men had only half the odds of diabetes as the occasional meat eaters. The vegetarian women had 75 percent lower odds of diabetes. Those who avoided meat altogether appeared to have significantly lower risk of both prediabetes and diabetes than those who ate plant-based diets with an occasional serving of meat, including fish. The researchers were unable to compare the diabetes rates of the more than one thousand vegetarians in the study to the sixty-nine vegans in the group, however, because the prevalence of diabetes among those eating strictly plant-based was zero. 66
The dramatic rise in obesity has been blamed squarely on overeating and inactivity. But could there be something else about the food we’re eating that’s plumping us up? Scientists have begun identifying “obesogenic” chemical pollutants released into the environment that may disrupt your metabolism and predispose you to obesity. Contaminated food is the main source of exposure to these chemicals, and 95 percent of that exposure may come through the consumption of animal fat. 67 What’s the big deal? A nationwide study found that people with the highest levels of pollutants in their bloodstreams had an astounding thirty-eight times the odds of diabetes. 68 Harvard University researchers identified one chemical in particular, hexachlorobenzene, as a potent risk factor for the disease. 69 Where is this toxin found? Apparently, at the grocery store. In a supermarket survey of a variety of foods, canned sardines were found to be the most heavily tainted with hexachlorobenzene, though salmon was found to be the most contaminated food overall. Two dozen pesticides were detected in the salmon fillets. 70 Farmed salmon may be the worst, containing ten times more of a class of toxic chemicals called PCBs than wild-caught salmon. 71 Industrial toxins like hexachlorobenzene and PCBs were largely banned decades ago. So how could they account for any of our increasing rates of diabetes? The answer to this paradox may be our obesity epidemic. The association between these toxic chemicals and diabetes was much stronger among obese subjects than in lean subjects studied, raising the possibility that your own fat stores are acting as reservoirs for these pollutants. 72 Overweight individuals may be effectively carrying around a personal toxic waste dump on their hips. Without significant weight loss, people whose bodies contain salmon pollutants may take between fifty to seventy-five years to clear the chemicals from their bodies. Do those who avoid meat completely get enough nutrients? To find out, researchers looked at a day in the life of thirteen thousand people all across America. They compared the nutrient intake of those who ate meat to those who didn’t. The study found that, calorie for calorie, those eating vegetarian diets were getting higher intakes of nearly every nutrient: more fiber, more vitamin A, more vitamin C, more vitamin E, more of the B vitamins thiamin, riboflavin, and folate, as well as more calcium, magnesium, iron, and potassium. Furthermore, many of the nutrients that are so rich in plant-based diets are among the very ones that most Americans normally don’t get enough of— namely, vitamins A, C, E, not to mention fiber, calcium, magnesium, and potassium. At the same time, people who avoided meat also ingested fewer harmful substances, such as sodium, saturated fat, and cholesterol. 74 In terms of weight management, those eating meat-free diets consumed an average of 364 fewer calories daily. 75 That’s about what most people on traditional weight-loss programs strive to cut out, meaning a meatless diet could be considered an all-you-care-to-eat version of a calorie-restricted weight-loss diet, without having to count calories or restrict portion intake. Those who eat plant-based diets may even have an 11 percent higher resting metabolic rate. 76 That means vegetarians could be burning more calories even in their sleep. Why? This could be because vegetarians have a higher gene expression of a fat-burning enzyme called carnitine palmitoyltransferase, which effectively shovels fat into the mitochondrial furnaces in your cells. 77 So a calorie may not be a calorie when it comes to meat. A massive study with an equally massive name, the European Prospective Investigation into Cancer– Physical Activity, Nutrition, Alcohol, Cessation of Smoking, Eating Out of Home, and Obesity— commonly known as EPIC-PANACEA— was comprised of hundreds of thousands of men and women who were followed for years. It’s the largest study ever to investigate eating meat and body weight, and it found that meat consumption was associated with significant weight gain even after adjusting for calories. This means that if you had two people eating the same number of calories, it appears the person eating more meat would, on average, gain significantly more weight. 78
What About Drugs and Surgery?
As noted earlier, those with type 2 diabetes are at elevated risk for such serious health problems as heart disease, premature death, blindness, kidney failure, and amputations, as well as fractures, depression, and dementia. And the higher people’s blood sugar levels, the more heart attacks and strokes they tend to have, the shorter their life spans are, and the higher their risk of complications are. To see if these outcomes could be averted, a study was performed in which ten thousand diabetics were randomized into one of two groups, the standard therapy group (in which the goal was just to lower blood sugar levels) and an intensive blood-sugar-lowering group (in which the researchers put the diabetics on up to five different classes of oral drugs at the same time) with or without insulin injections. The goal was not just to drive down blood sugars, as is the case with standard therapy, but to drive them down consistently into the normal range. 79 Considering that type 2 diabetes is a disease of insulin resistance, high blood sugar is just a symptom of that disease, not the disease itself. So even by artificially forcing down blood sugars by any means necessary, we aren’t actually treating the cause— just like blood pressure– lowering drugs aren’t actually treating the cause. By lowering one of the disease’s effects, however, scientists hoped they could prevent some of its devastating complications. The results of this study, published in the New England Journal of Medicine, sent shock waves through the medical community. The intensive blood-sugar-lowering therapy actually increased subjects’ mortality, requiring the researchers to halt the study prematurely for safety reasons. 80 The drug combinations may have been more dangerous than the high blood sugars they were trying to treat. 81 Insulin treatments themselves may accelerate aging, worsen diabetic vision loss, and promote cancer, obesity, and atherosclerosis. 82 Insulin can promote inflammation in the arteries, which may help explain the increased death rate in the intensively treated group. 83 So rather than trying to overcome insulin resistance by brute force— just pumping in more and more insulin— isn’t it better to treat the disease itself by eliminating the unhealthy diet that caused it? That reminds me of people who undergo bypass surgery for clogged arteries. If they keep eating unhealthfully, their bypasses will eventually get clogged too. It’s better to treat the cause than the symptoms. How about surgery for diabetes? Gastric bypass surgery— which effectively reduces the size of the stomach by 90 percent or more— is one of the most successful treatment methods for type 2 diabetes, with reported long-term remission rates of up to 83 percent. These results had led to the suggestion that gastric bypass surgery improves diabetes by somehow altering digestive hormones, but this interpretation ignores the fact that patients are placed on a severely limited diet for up to two weeks following the procedure to recover from the surgery. Extreme calorie restriction alone can reverse diabetes. So is the success of surgery the result of the operation itself or due to the restrictive diet? Once again, researchers designed a study to uncover the answer. 84 They compared diabetics placed on the same postoperative diet before and after they actually had the surgery. Amazingly, they found that the diet alone worked better than the surgery even in the same group of patients: The subjects’ blood sugar control was better in the absence of the operation. This means the benefits of major surgery may be obtained without you ever having to go under the knife and getting your internal organs rearranged. 85 The bottom line: Blood sugar levels can normalize within a week of eating six hundred calories daily, because fat is pulled out of the muscles, liver, and pancreas, allowing them to function normally again. 86 This reversal of diabetes can be accomplished either by voluntary calorie restriction87 or involuntarily, by having most of your stomach removed, a form of compulsory food restriction. Undergoing surgery may be easier than starving yourself, but major surgery carries major risks, both during the operation and afterward. These risks include bleeding, leakage, infections, erosions, herniation, and severe nutritional deficiencies. 88 Surgery or starvation? There’s got to be a better way, and, in fact, there is. Instead of changing the quantity of food you eat, it’s possible to reverse diabetes by changing the quality of that food.
Does Eating Obesity Cause Obesity?
The EPIC-PANACEA study, which found that meat consumption is associated with weight gain even independent of calories, identified poultry as potentially the most fattening meat, 89 a finding that has since been confirmed in another study. Men and women eating even a single ounce of chicken a day (think two chicken nuggets) had a significantly greater gain in body mass index over the fourteen-year follow-up period than those who consumed no chicken at all. 90 Perhaps this news shouldn’t be surprising, considering how fat chickens themselves are now genetically manipulated to become. According to the U.S. Department of Agriculture, about one hundred years ago, a single serving of chicken may have contained only sixteen fat calories. Nowadays, one serving of chicken may have more than two hundred calories of fat. The fat content in poultry has ballooned from less than two grams per serving a century ago to up to twenty-three grams today. That’s ten times more fat. Chicken now contains two to three times more calories from fat than from protein, leading nutrition researchers to ask, “Does eating obesity cause obesity in the consumer?” 91 As the beef industry is proud of pointing out, even skinless chicken can have more fat, and more artery-clogging saturated fat, than a dozen different cuts of steak. 92
Reversing Diabetes with Food
We’ve known since the siege of Paris in 1870 that type 2 diabetes can be reversed by an extreme reduction in food intake. Parisian doctors documented how glucose disappeared from their patients’ urine after people went weeks without food. 93 Diabetes specialists have long known that iron-willed patients who are able to lose up to one-fifth of their body weight can reverse their diabetes and bring their metabolic function back to normal. 94 Instead of starving by eating less food, though, what if diabetics just ate better food, as in a 90 percent or more plant-based diet of all-you-can-eat greens, lots of other vegetables and beans, whole grains, fruits, nuts, and seeds? In a pilot study, thirteen diabetic men and women were told to eat at least one big salad every day, as well as veggie-bean soup, a handful of nuts and seeds, fruit at every meal, a pound of cooked greens, and some whole grains; to restrict their animal product consumption; and to eliminate refined grains, junk food, and oil. Then, the researchers measured their hemoglobin A1c levels, considered the best measure of how poorly blood sugars have been controlled over time. At the onset of the study, the diabetics had A1c levels averaging 8.2. An A1c level under 5.7 is considered normal, between 5.7 and 6.4 is considered prediabetic, and above 6.5 is considered diabetic. However, the American Diabetes Association’s target is just to get most diabetics down below 7.0.95 (Recall that intensive blood-sugar-lowering trials using drugs, which tried to push A1c levels under 6.0, unfortunately ended up pushing many diabetics six feet under.) After about seven months of eating a diet centered on whole plant foods, the subjects’ A1c levels dropped to a nondiabetic 5.8— and this was after they were able to stop taking most of their medications. 96 We’ve known diabetes can be reversed with an extremely low-calorie diet. 97 Now we know that it can also be reversed with an extremely healthy diet, but is that because it was also low in calories? The study subjects lost about as much weight on the vegetable-packed, plant-based diet as people who went on semistarvation diets based on liquid meal replacements. 98 But even if this type of diabetes reversal was just about calorie restriction, which would be healthier? Subsisting on mostly diet shakes made out of sugar, powdered milk, corn syrup, and oil, or eating a plant-based diet where you can enjoy real food and lots of it? Surprisingly, even participants who temporarily didn’t lose weight on the plant-based diet, or who actually gained weight, still appeared to improve their diabetes. In other words, the beneficial effects of plant-based diets may extend beyond weight loss. 99 However, the study described just a handful of people, had no control group, and included only those who could stick to the eating plan. To prove plant-based diets could actually improve diabetes independent of weight loss, researchers would need to design a study in which they switched people to a healthy diet but forced them to eat so much that they didn’t lose any weight. Just such a study was published more than thirty-five years ago. Type 2 diabetics were placed on a plant-based diet and weighed every day. If they started losing any weight, they were made to eat more food— so much that some of the participants actually had trouble eating it all! The result: Even with no weight loss, subjects on the plant-based diet saw their insulin requirements cut by about 60 percent, meaning the amount of insulin these diabetics had to inject dropped by more than half. Furthermore, half of the diabetics were able to get off insulin altogether, despite no change in body weight— just by eating a healthier diet.
This wasn’t over the course of months or years, either. This was after eating a plant-based diet for an average of only sixteen days. Some of the subjects had been diabetic for two decades and had been injecting twenty units of insulin a day. Yet within two weeks of eating a plant-based diet, they were off insulin altogether. One patient was on thirty-two units of insulin per day at the onset of the study. After eighteen days, his blood sugar levels plummeted so low that insulin injections were no longer necessary. Even at approximately the same body weight, he had lower blood sugars on a plant-based diet using no insulin than when he had been on a regular diet using thirty-two units of insulin daily. 101 That’s the power of plants.
Curing Diabetic Neuropathy
Up to 50 percent of diabetics eventually develop neuropathy, or damage to their nerves. 102 Neuropathy can be very painful, and that pain is frequently resistant to conventional treatments. No medical treatment is considered effective for the condition. 103 We doctors are left with only steroids, opiates, and antidepressants to try to ease our patients’ suffering. But then a remarkable study was published, entitled “Regression of Diabetic Neuropathy with Total Vegetarian (Vegan) Diet.” Twenty-one diabetics who had been suffering from painful neuropathy for up to ten years were placed on a whole-food, plant-based diet. After years and years of suffering, seventeen out of the twenty-one patients reported that they felt complete relief from their pain— within days. Their numbness noticeably improved too. And the side effects were all good: The diabetics lost an average of ten pounds, their blood sugar levels dropped, their insulin needs dropped in half, and, in five of the patients, not only was their painful neuropathy cured, so was, apparently, their diabetes. After having been diabetic for up to twenty years, they were off all blood sugar drugs in less than a month. 104 On top of that, the diabetics’ triglyceride and cholesterol levels improved on average as well. High blood pressures dropped by so much that half of the subjects also appeared cured of their hypertension. Within three weeks, the subjects’ need for high blood pressure medications dropped by 80 percent. 105 (This is why it is critically important to work with your doctor when radically improving your diet, because if they don’t reduce or eliminate your medications accordingly, your blood sugar levels or blood pressure may drop too low.) We’ve long known that plant-based diets can reverse diabetes106 and hypertension, 107 but reversing nerve damage pain with diet was new. This study involved a live-in program in which patients were provided meals. What happened after they were sent home, back into the real world? These seventeen subjects were followed for years, and in all cases but one, the relief from their painful neuropathy continued— or improved even further. How were the researchers able to achieve such a high degree of dietary compliance even in an uncontrolled setting? “Pain and ill health,” the researchers wrote, “are strong motivating factors.” 108 In other words: Because plant-based diets work. Think about it. Patients walk in with one of the most painful, frustrating, and hard-to-treat conditions in all of medicine, and three-quarters of them were cured in a handful of days using a natural, nontoxic treatment— namely, a diet composed of whole plant foods. This should have been front-page news. How could nerve damage pain be reversed so suddenly? It didn’t appear to involve the improvement in blood sugar control. It took approximately ten days for the diet to control the diabetes itself, but the pain was gone in as few as four days. 109 The most interesting speculation was that trans fats naturally found in meat and dairy could be causing an inflammatory response in the patients’ bodies. The researchers found that a significant percentage of the fat under the skin of those who ate meat, or even just dairy and eggs, was composed of trans fats, whereas those who had been on a strictly whole-food, plant-based diet had no detectable trans fat in their tissues.
The researchers stuck needles into the buttocks of subjects who had been eating different diets and discovered that people who had been on a whole-food, plant-based diet for nine months or more appeared to have removed all the trans fat from their bodies (or at least from their butts!). 111 But their neuropathy pain didn’t take nine months to get better. It improved in closer to nine days. It’s more likely that this amazing reversal was due to an improvement in blood flow. 112 Nerves contain tiny blood vessels that may become clogged, depriving the nerves of oxygen. Indeed, biopsies of leg nerves in diabetics with severe progressive neuropathy have shown arterial disease within the sural nerve in the leg. 113 However, within days of eating healthier meals, blood flow may improve to the extent that neuropathy disappears. 114 Within an average of two years of eating a plant-based diet composed mostly of rice and fruits, even diabetic vision loss can be reversed in as many as 30 percent of patients. 115 So why didn’t I learn about any of this in medical school? There’s little money to be made from prescribing plants instead of pills. The neuropathy pain reversal study was published more than twenty years ago, and the blindness reversal studies more than fifty years ago. As one commentator wrote, “The neglect of this important work by the broader medical community is little short of unconscionable.”
WHtR Versus BMI
The body mass index (BMI) is a better predictor of disease than body weight alone, as BMI takes height into account. But BMI has long been criticized for not considering the location or the nature of your weight. Bodybuilders, for instance, have extremely low body fat but can have off-the-chart BMIs, because muscle is heavier than fat. Today, it’s generally accepted that health risks can be determined as much by the relative distribution of body fat as by its total amount. 117 What’s the worst kind? Abdominal fat— the kind that builds up around your internal organs. Having a potbelly may be a strong predictor of premature death.
Both the men in figure 3 have the same BMI, but the distribution of weight is different. People with the so-called apple shape, with body fat concentrated in the abdominal region, may have the lowest life expectancy. 119 Fortunately, there may be an even better tool than BMI that we can use to gauge the health risks of body fat. It’s called Waist-to-Height Ratio, or WHtR. 120 Instead of a scale, grab a simple measuring tape. Stand up straight and take a deep breath, exhale, and let it all hang out. The circumference of your belly (halfway between the top of your hip bones and the bottom of your rib cage) should be half your height— ideally, less. If that measurement is more than half your height, it’s time to start eating healthier and exercising more regardless of your weight.
Type 2 diabetes in the United States is reaching epidemic proportions. The CDC estimates that 37 percent of U.S. adults— and 51 percent of adults over sixty-five— have prediabetes. That’s eighty-six million people, 122 most of whom will become full-blown diabetics. 123 But type 2 diabetes can be prevented, arrested, and even reversed with a healthy-enough diet. Unfortunately, doctors don’t tend to educate their patients about diabetes prevention. Only about one in three prediabetic patients reports ever being told by their doctors to exercise or to improve their diets. 124 Possible reasons for not counseling patients include a lack of insurance reimbursement for the extra time spent, a lack of resources, a lack of time, and a lack of knowledge. 125 We’re just not training doctors how to empower the people they serve. The current medical education system has yet to adapt to the great transformation of disease from acute to chronic. Medicine is no longer about just setting broken bones or curing strep throat. Such chronic diseases as diabetes are now the principal cause of death and disability in America, consuming three-quarters of the nation’s health care budget. Medical education has yet to recognize and respond to the changing nature of disease patterns, which now requires a focus on prevention and lifestyle change. 126 How far behind the times is the medical profession? A report by the Institute of Medicine on medical training concluded that the fundamental approach to medical education has not changed since 1910.127 Not long ago, I received an e-mail that helps sum up where we are. Tonah, a sixty-five-year-old Native American, had been on insulin for type 2 diabetes for the last twenty-seven years. He was told by his doctor that Native Americans were “genetically predisposed” to the disease. He just had to live with it, including the excruciating nerve pain, three heart stents, and erectile dysfunction. After watching my “Uprooting the Leading Causes of Death” video on NutritionFacts.org, his granddaughter convinced him to try a plant-based diet. It wasn’t easy, since the nearest store with fresh food was fifty miles away.
Nevertheless, in less than two weeks, he turned his life around. His nerve pain diminished dramatically, to the point where it no longer kept him up at night. He lost thirty pounds in a matter of months and no longer needed insulin. His own doctor couldn’t believe this was possible and ordered a CT scan to check for tumors. There weren’t any. Now he feels better than he has in years. “I’m grateful that my granddaughter has stopped seeing me as a sick old man,” Tonah concluded his note. “I feel young again, Doc.”
Greger MD, Michael; Stone, Gene. How Not to Die: Discover the Foods Scientifically Proven to Prevent and Reverse Disease (pp. 139-140). Flatiron Books. Kindle Edition.