Amy Nett: The first question I have is from Amy, and Amy asks, “How would you recommend responding to someone who has been told to follow the ADA or AHA diet?” So following the American Diabetic Association or American Heart Association dietary recommendations. She says, “I frequently encounter newly diagnosed diabetics and/or those who recently had heart attacks that have been told to follow the ADA or the AHA guidelines. What are your or Kresser Institute’s thoughts on the current guidelines?Would you encourage and recommend the Paleo template alternatively, and most importantly, how do you approach re-education or alternative thoughts on these highly-promoted guidelines?”
This is a great question. Admittedly, I think at CCFM we’re a little bit spoiled in that more than 95 percent of our patients are probably coming to us already familiar with a Paleo template approach, and I think a lot of people that we’re actually seeing at CCFM have already bought into this. For the most part, admittedly, it is easier for us, but no, we really don’t follow the ADA dietary recommendations. I mean, I think they still include some carbohydrates as I recall. So no, for a lot of our diabetics, we will actually use keto. I would say, in answer to would be recommend or encourage a Paleo template, absolutely. I think that there are a lot of variations within that Paleo template and to figure which approach, meaning, do you want to go Paleo/keto? Do you want to do a Mediterranean Paleo diet? There are a lot of variations within that theme, and I think you do need to pick which is most appropriate. For a lot of diabetic patients, I am going to tend, probably if they have pretty severe insulin resistance, I am going to tend towards a ketogenic/Paleo approach, at least initially maybe not long term, but I more often favor a ketogenic diet that’s based on using olive oil or sometimes MCT oil or coconut oil. I actually don’t use a dairy-centered ketogenic diet for most of my patients, and often keto is focused on cheese, butter. You will see a lot of those saturated fat, but I in general, I really favor unsaturated fats. That’s kind of my personal preference and just where I’m at right now in terms of feeling comfortable with a fat-heavy diet.
If you’re seeing somebody who’s recently had a myocardial infarction, again, with cardiovascular disease, I stick with a Paleo template, but there I’m going to favor a Mediterranean Paleo diet. I also often look at genetics, so I look at ApoE. I’m trying to see whether a patient is ApoE2, and, of course, they carry two copies of this, so are they ApoE2/2, ApoE3/3, ApoE3/4, or ApoE4/4 because an ApoE4/4 carrier, I’m going to go a lot lower on all fat even including some of the fish oil sand the unsaturated fat because we know that lipids effect—and remember ApoE4 is a genetic predisposition increasing your chances of both Alzheimer’s disease and cardiovascular disease. In my ApoE4 patients, I’m going to be a lot stricter in terms of how we’re approaching this diet, what types of fat we’re using, how much fat we’re using, and I am going to opt—with the ApoE4/4 I think, again, different schools of thinking. You could either do a keto approach so that you’re getting someone to eat just about twice per day, again, focusing on unsaturated fats both mono and polyunsaturated fats, but some of the thinking too in terms of ApoE4/4 is that you probably want to do a low-fat diet.
This is somewhat of a long answer to say, “Yes, I would recommend the Paleo template,” but you really need to think about with which variation or which flavor of Paleo you want to use and what’s appropriate. In terms of re-education, this depends on how motivated your patient is to read and learn because there are so many different resources out there that they listen to podcasts, point them to podcasts. If they like reading books, there are books that are written on this. Kind of figuring out where your patient is, what their interest level is and if this is somebody who just wants to know, “Look, tell me what to do. I want to make sure that I’m being reasonable in terms of my approach to this.” Then, I think it’s fair to present the data in terms of “Look, this this is the older way of thinking but you know…” Maybe you want to explain some of the basics around where some of the dietary guidelines came from that there was a lot more in in the way of sort of lobbying and politics than there was in terms of science when you look at where the food pyramid came from and really where the ABA and AHA guidelines came from. I think just you know explaining some of the mechanisms and why you’re wanting to go lower carb, what you’re trying to do with the gluten-free diet – lowering inflammation, increasing phytonutrients. I think those are all reasonable places to start in terms of the re-education. Hopefully that gives you some ideas in terms of where to start.