Perspectives on Low-Carb, I: Dr. Kurt Harris

Posted by on October 6, 2011 154 comments

Last week in An Anti-Cancer Diet (Sep 28, 2011), I recommended that cancer patients eat 400 to 600 carb calories per day, but combine it with a program of daily intermittent fasting plus longer “ketogenic fasts” and periods of ketogenic dieting or low-protein dieting to promote autophagy.

The recommendation to eat some carbohydrates, plus my statement that it was possible for cancer patients to develop a “glucose deficiency” which might promote metastasis and the cancer phenotype, seems to have stirred a bit of a fuss.

In addition to making @zooko sad, it led Jimmy Moore to reach out to a number of gurus to ask their opinion. On Twitter, Jimmy says:

Working on an epic blog post today about @pauljaminet and his “safe starches” concept. Input from numerous #Paleo and #lowcarb peeps.

I’m excited to have this discussion. As Jimmy later tweeted:

Should be fun to hash all this out publicly for ALL of us to understand better about your concepts. Here’s to education.

So far, I have seen responses from Dr. Kurt Harris and Dr. Ron Rosedale. On PaleoHacks, there is an extensive discussion on a thread started by Meredith.

UPDATE: Jimmy’s post is up: Is There Any Such Thing as “Safe Starches” on a Low-Carb Diet?.

I think this discussion is wonderful. With so many people putting effort into this, I have an obligation to respond. I’ll start with Kurt’s perspective today, then Ron Rosedale’s early next week, then whoever else participates in Jimmy’s epic post.

PHD and Archevore: Similar Diets

Kurt and I have essentially identical dietary prescriptions. However, our reasoning sometimes works from different premises. Kurt observes:

My arguments are based more on ethnography and anthropology than some of Paul’s theorizing, but I arrive at pretty much the same place that he does.

An example of a point of agreement is Kurt’s endorsement of glucose-based carbs:

[I] see the human metabolism as a multi-fuel stove, equally capable of burning either glucose or fatty acids at the cellular level depending on the organ, the task and the diet, and equally capable of depending on either animal fats or starches from plants as our dietary fuel source …

We are a highly adaptable species. It is not plausible that carbohydrates as a class of macronutrient are toxic.

I think that if there is no urgency about generating ATP then fatty acid oxidation is slightly preferable to glucose burning. But essentially, I share Kurt’s point of view. Our ancestors must have been well adapted to consuming high-carb diets, and necessity surely thrust such diets upon some of our ancestors. Certainly there’s no reason why consuming starch per se should be toxic.

Kurt and I also agree on which starches are safe:

These starchy plant organs or vegetables are like night and day compared to most cereal grains, particularly wheat. One can eat more than half of calories from these safe starches without the risk of disease from phytates and mineral deficiencies one would have from relying on grains.

White rice is kind of a special case. It lacks the nutrients of root vegetables and starchy fruits like plantain and banana, but is good in reasonable quantities as it is a very benign grain that is easy to digest and gluten free.

We agree that safe starches are a more useful part of the diet than fruits and vegetables:

[E]ating starchy plants is more important for nutrition than eating colorful leafy greens …

I view most non-starchy fruit with indifference. In reasonable quantities it is fine but it won’t save your life either. I like citrus now and then myself, especially grapefruit. But better to rely on starchy vegetables for carbohydrate intake than fruit.

We agree on the optimal amount of carbs to eat:

I personally eat around 30% carbohydrate now and have not gained an ounce from when I ate 10-15% (and I have eaten as high as 40% for over a year also with zero fat gain) If anything I think even wider ranges of carbohydrate intake are healthy.

One can probably eat well over 50% of calories from starchy plant organs as long as the animal foods you eat are of high quality and micronutrient content.

I think being slightly low-carb, in the sense of eating slightly below the glucose share of energy utilization which I estimate at about 30% of energy, is optimal. However, I think we are metabolically flexible enough that a very broad range of carb intake may be nearly as good. I would consider 10% a minimal but healthy intake of carbs, and 50% a higher-than-optimal, but still healthy, intake so long as the carbs are “safe” and the diet is nourishing.

Differing Origins of Our Ideas

Kurt mentions that his ideas are more derived from ethnography and anthropology than mine.

I give great weight to evolutionary selection as an indicator of the optimal diet, and am friendly to ethnographic and anthropological arguments. If I don’t give tremendous weight to such arguments, it’s because I think some other lines of argument give us finer evidence about the optimal diet.

Here, from a paper by Loren Cordain et al [1], are representations of hunter-gatherer diets:

The top graph shows plant food consumption by calories, the bottom graph animal+fish consumption by calories. The numbers are how many of 229 hunter-gatherer societies ate in that range. Typically, hunter-gatherers got 30% of calories from plant foods and 70% of calories from animal foods.

I think the Cordain et al data supports my argument that obtaining 20% to 30% of calories from carbs is probably optimal. However, it’s hardly decisive. There is considerable variability, mainly in response to food availability in the local environment. Inuits, who had few edible plants available, ate hardly any plant foods; tropical tribes with ready access to starchy plants, fruits, and fatty nuts sometimes obtained a majority of calories from plants.

Hunter-gatherer diets, therefore, are a compromise between the diet that is healthy and the diet that is easy to obtain. A skeptic could argue that hunter-gatherers routinely ate a flawed diet because some type of food was routinely easier to obtain than others, and thus systematically biased the diet.

I believe evidence from breast milk is both more precise about what diet is optimal, and much harder for skeptics to refute. Breast milk composition is nearly the same in all humans worldwide, and it has been definitely selected to provide optimal nutrition to infants.

So breast milk, I think, gives us a much clearer indication of the optimal human diet than hunter-gatherer diets. It is an evolutionary indicator of the optimal diet, but it is not ethnographic or anthropological.

There are other evolutionary indicators of the optimal diet — mammalian diets, for instance, and the evolutionary imperative to function well during a famine — which, as readers of our book, we also use to determine the Perfect Health Diet. So, while I think ethnographic and anthropological findings give us important clues to the optimal diet, I think there are plenty of other sources of evidence to which we should give weight. Fortunately, all of these sources of insight seem to be consistent in supporting low-carb animal-food-rich diets — a result which is gratifying and should give us confidence.

Food Reward and Obesity

Kurt seems to have been more persuaded than I am by Stephan Guyenet’s food reward hypothesis (which is, of course, not of Stephan’s creation – it is the dominant perspective in the community of academic obesity researchers). Kurt writes:

Low carb plans have helped people lose fat by reducing food reward from white flour and excess sugar and maybe linoleic acid. This is by accident as it happens that most of the “carbs” in our diet are coming in the form of manufactured and processed items that are simply not real food. Low carb does not work for most people via effects on blood sugar or insulin “locking away” fat. Insulin is necessary to store fat, but is not the main hormone regulating fat storage. That would be leptin.

I agree with Kurt in rejecting what he calls the carbohydrate-insulin hypothesis of obesity, but I am uneasy at the confident assertion that “reducing food reward” is the mechanism by which excluding flour, sugar, and omega-6 fats helps people lose weight.

Let me say first that there is no doubt that the brain has a food reward system that regulates food intake, and also an energy homeostasis system that regulates activity and thermogenesis, and that these systems are coupled. The brain is the coordinating organ of metabolic activity. And the brain’s food reward and energy homeostasis systems are altered in obesity.

But the direction of causality is unclear. Is “reducing food reward” the best strategy against obesity, or is “maximizing food reward with nourishing food” the best strategy?

Some data may illustrate what I mean. Here’s an investigation of how the food reward system in rats controls appetite to regulate protein and carbohydrate consumption. The data is from multiple studies and was collected by Simpson and Raubenheimer [2].

Rats were given a chow consisting of protein and carbohydrate in varying proportions. The figure below shows how much of the protein-carb chow they ate.

I’ve drawn a kinked blue line to show what a “Perfect Health Diet” analysis would consider optimal. Protein needs consist of a fixed amount of protein, around 70 kJ, to meet structural needs, plus enough protein to make up any dietary glucose deficiency via gluconeogenesis. Glucose is preferable to protein as a fuel. Glucose needs in rats are in the vicinity of 180 kJ. When dietary glucose intake falls short of 180 kJ, rats eat extra protein; they seek to make carb+protein intake equal to 250 kJ so they can meet both their protein and carb needs, with gluconeogenesis translating the dietary protein supply into the body’s glucose utilization as necessary.

As the data shows, the food reward system in rats seems to organize food intake to precisely match this:

  • When the chow is low-carb, the food reward system directs rats to eat until carb+protein intake is precisely 250 kJ – then they stop eating.
  • When the chow is high-carb, the food reward system directs rats to eat until protein intake is precisely 70 kJ – then they stop eating.

I interpret this to show that the food reward system evolved to optimize our health, and in healthy animals does an excellent job of getting us to eat in a way that achieves optimal health.

Note that if the chow is high-carb, rats eat more total calories. Is this because their diet has “high food reward”? No, it is because it is malnourishing. It is protein deficient.

Now, a diet of wheat, sugar, and omega-6 fats is malnourishing. There are any number of nutrients it is deficient in. So the food reward system ought to persuade people to eat more until they have obtained a sufficiency of all important nutrients, and rely on the energy homestasis system to dispose of the excess calories in one way or another. But if the energy homeostasis system fails to achieve this, then obesity may be the result.

If this picture is correct, then what is the solution to obesity? Is it to eat a diet that is bland and low in food reward? I don’t think so; the food reward system evolved to optimize our health. Rather the diet that defeats obesity will be one that is efficiently nourishing and maximally satisfies the food reward system at the minimum possible caloric intake.

A good test of these two strategies is the severely calorie (and nutrient) restricted diet. It would be hard to conceive of a diet lower in food reward than one with no food at all. Yet severe calorie restriction produces temporary weight loss followed by regain – often to even higher weights. This “yo-yo dieting” cycle may be repeated many times. I think this proves that at least some methods of “reducing food reward” – the malnourishing ones – are obesity-inducing.

So I would phrase the goal of an anti-obesity diet as achieving satisfaction of the food reward system, rather than as reducing food reward; and would say that wheat, sugar, and seed oils are obesogenic because they fail to provide genuine food reward, and thus compel the acquisition of additional calories.

Conclusion

Jimmy Moore is friends with the smartest people in the low-carb movement, so this discussion is sure to be interesting. I’m grateful that he’s persuaded people to comment on Shou-Ching’s and my ideas, and I’m eager to hear what Jimmy’s experts have to say.

One thing I’m sure of, the discussion will help us understand the many open issues in low-carb science. It should be a lot of fun!

References

[1] Cordain L et al. Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-gatherer diets. Am J Clin Nutr 2000 Mar;71(3):682-92. http://pmid.us/10702160.

[2] Simpson SJ, Raubenheimer D. Obesity: the protein leverage hypothesis. Obes Rev. 2005 May;6(2):133-42. http://pmid.us/15836464.

Bone Broth Revisited; and Pumpkin Soup

Posted by on October 3, 2011 200 comments

We’d like to thank Shilpi and Amit Mehta for hosting the potluck dinner last night. My talk was on “Common Pitfalls of Paleo,” and it was a pleasure to meet so many Paleo enthusiasts, including people we knew from PaleoHacks, email, comments, and Facebook.

We brought pumpkin soup to the potluck, and that will be our food post this week. But we’ve had some questions about bone broths, so let’s revisit that first.

Making a Tasty Broth

Earlier, we discussed making a broth from ox feet (Ox Feet Broth, Miso Soup, and Other Soups, Jan 2, 2011). The advantage of feet (ox feet, chicken feet) or tails (ox tail) is that they have a lot of connective tissue, so they make a gelatinous broth full of nourishing collagen.

However, you can make a good broth from any bones, and it’s possible to find marrow bones that also have some connective tissue. With longer cooking, you can extract collagen and minerals from the bone itself, and get a good broth from these larger bones.

We’ve found, on limited data so far, that bones from grass-fed animals from local farms seem to produce a tastier broth than supermarket bones. I’d be curious to hear if others have had the same experience.

A few other tricks can help make a tasty broth. One tactic that seems to work is to discard and replace the cooking water at an early stage.

Here’s what we do. In this case, we started with a mix of beef and pork bones:

As you can see some blood comes out of the bones, especially the pork bones, almost immediately. This may be responsible for the poor taste some experience.

We put the heat on very low and let the water warm up gradually. Before it reaches a boil, after an hour or less, it looks like this:

At this point we drain and discard the liquid, adding new water. It now looks like:

You can see the marrow inside the pork bones, which will fall out before we’re done, and the ligaments and tendons in the joints, which will produce a nourishing gelatin. Bits of meat and fat will also be released.

After some hours of cooking, all the meat and fat and most of the marrow and connective tissue will have fallen off the bones. It will look something like this:

At this point you can pour out the broth into a container and use this fatty, meaty broth for rich soups. Seaweed, vegetables like tomatoes and onions, and thinly sliced beef, tendon, or pork bellies go well with this broth. We often use it for Pho (Vietnamese Noodle Soup) (Feb 27, 2011).

Add water and acid and continue cooking. This second round of broth will mainly contain minerals and some collagen, and will need longer cooking.

In the second and later rounds of cooking, we add an acid to help extract minerals from the bones and expose the collagen matrix. Lime juice, lemon juice, and vinegar all work well. We especially like the juice of a lime, and rice vinegar, which gives a slightly sweet taste; others seem to like apple cider vinegar, which is more acidic.

Here are our beef and pork bones early in the process:

And here they are later:

The bones will be obviously softening by this point, as you can tell by poking them with the tine of a fork.

If you wish, you can once again collect the broth, add new water and cook again. Every successive broth will be lighter. In the third round, with long enough cooking, the broth becomes white, like this:

I have heard that in earlier times, when food was costly but fuel cheap, that bones would get cooked until all the nutrients had been extracted – for as long as a month.

Pumpkin Soup

Pumpkins are abundant in New England in October, and we love pumpkin soup.

Here are the ingredients – garlic, onion, and pumpkin:

On very low heat, gently cook the garlic and onion in 3 tbsp butter:

Then add the diced pumpkin and enough bone broth to cover:

Bring to a simmer but don’t boil. When the pumpkin is cooked, after about 20 minutes, use a hand blender to puree the pumpkin-onion-broth mixture in the pot. It will look like this:

Add salt, pepper, cinnamon, and nutmeg to taste, and 1 tbsp rice syrup for a touch of sweetness. Add curry, or other spices, if you like a more flavorful soup. Serve hot, adding a dollop of sour cream if you like a richer, fattier taste:

A delicious autumn appetizer! It can even serve as a meal by adding meat and vegetables to the soup.

Around the Web; Curing Constipation Edition

Posted by on October 1, 2011 37 comments

Shou-Ching and I will be speaking tomorrow to the Living Paleo in Boston group, at a potluck dinner hosted by Amit and Shilpi Mehta, on the topic of “Common Pitfalls of Paleo.” We’re excited to meet everyone. Kamal Patel has already promised a question about “the philosophical and emotional aspects of glycogen.”

Also, Paul will be appearing on Patrick Timpone’s The Morning Show on Thursday, Oct 13, at 11 am EST/10 am CST.

[1] Book Reviews and Cures: Several mentions of our book came to our attention this week:

Larry Carter of Dan’s Plan included us in his “Five Slightly Different Flavors of the Paleo Diet.” (The other flavors: Cordain, Wolf, de Vany, and Sisson.)

Steve Omohundro called our book, “My favorite reference … I’ve read it twice and am still learning lots from it.”

Sean at Prague Stepchild offered kind words:

What’s cool about this book is that it is sort of the health aficionado’s health book, yet at the same time extremely accessible. So accessible that my wife has pretty much been monopolizing it since it arrived more than a month ago. This is especially notable because my wife’s native language is Czech, and while her English is excellent, she’s not crazy about reading books in English. In fact she just plain doesn’t do it.

Jennifer Fulwiler of Conversion Diaries gives the best review ever:

I love the subject of nutrition. My fascination with it began when I was 18, and for the past 16 years I’ve read tons of books on the subject, from pop diet paperbacks to heavy textbooks…. I have found a book that is head and shoulders above everything else I’ve ever read on the subject … It’s called The Perfect Health Diet, and it is awesome. (To give you an idea how good it is, I stayed up late reading it in the hospital the night after the baby was born because I couldn’t put it down!)

There you go: We keep moms awake even better than their newborns!

Gratifyingly, a couple of cures were reported on the constipation thread. First, Anna:

I’m so grateful to you for this information. I’ve been suffering for weeks but I took the recommended supplements and did nothing else — and experienced relief the second day. In a world full of useless and confusing information, having a good source is such a godsend. Thank you for all that you do.

Then, Vincent reported his constipation is almost cured with our anti-fungal diet:

After a few weeks of little improvement, I experienced my first normal bowel movement in a long time (years?).  After more changes to my regimen, I now have normal stools on most days.  The greatest improvements coincided with the times I added fermented tubers and (later) ThreeLac.  I also think that cranberries, turmeric, increased amounts of safe starches, the Now Foods anti-fungal, and removal of my beloved coconut oil were all quite helpful.  My victory is not complete — I still get diarrhea fairly easily and the occasional hard stool — but the improvement is incredible.

Many thanks, Paul, for helping me fix a problem that has plagued me for a long time.  I wish you, Shou-Ching, and all your readers the great health and happiness you deserve.

Sincerely,

Vincent

Our sincere thanks to everyone who reports results. It’s such a pleasure to hear from you!

[2] My Research for Kamal’s Question:

Via Andrew Day on Facebook.

[3] Interesting Items This Week: Kurt Harris is one of the most respected authorities in the Paleo movement, and Jimmy Moore asked his thoughts on our advice to eat a certain amount of “safe starches.” Kurt’s discussion is excellent. His diet advice is essentially identical to ours, although the reasoning by which we reach our conclusions differs in a few respects.

Over at Dallas and Melissa Hartwig’s blog, a great “Whole9 success story”: How Jessica O cured trichotillomania and seizures with a Paleo diet.

Beth Mazur explains why she’s the Weight Maven (“A Maven is someone who wants to solve other people’s problems, generally by solving his own.”) and links to a cool cartoon showing the significance of a Ph.D.

Robb Wolf backs ever so slightly away from low-carb: “In years gone by I’d have staunchly recommended a low carb paleo diet as THE best intervention but I can’t in good faith recommend that anymore.”

Perhaps he was influenced by this study. Bix at Fanatic Cook passes on results from a large population-based study (27,140 participants) in Sweden:

  • A high-protein intake was associated with an increased risk for type 2 diabetes.
  • Replacing protein with carbohydrate … was associated with a lower risk for type 2 diabetes.

Stephan Guyenet is starting a series on the mechanisms underlying food reward. I think this is much needed, and I’m in the group he’s targeting (“skeptics” and “scientifically inclined people who want mechanism”). (Note: I’m not skeptical that food reward exists, or that addictive-like wanting is an important factor in many cases of obesity. I’m skeptical over the origins of addictive-like wanting, and over the universality and importance of this factor – whether it is the cause, or a symptom; whether bland food is curative, or merely a means of symptomatic relief. I’m wondering whether there will be compliance to an unrewarding diet.)

Peter at Hyperlipid conducts a trial to prove that chocolate is more rewarding than bananas. On another thread at Peter’s, Jenny Ruhl points out an interesting fact about obesity and diabetes:

The number of people with diabetes in the overall population stays fairly close to 9% but the number of obese and insulin resistant people keeps growing to where it is somewhere between 1/2 and 2/3rds of all older adults.

So whatever is causing the obesity epidemic, it doesn’t promote diabetes.

Stan the Heretic gives us a study from Sweden claiming that gene expression is optimized on a 1/3 carb 1/3 fat 1/3 protein diet:

“Both low-carb and high-carb diets are wrong,” says Johansen. “But a low-carb diet is closer to the right diet. A healthy diet shouldn’t be made up of more than one-third carbohydrates (up to 40 per cent of calories) in each meal, otherwise we stimulate our genes to initiate the activity that creates inflammation in the body.”

Dr. Briffa discusses a study showing that B12 deficiency is linked with brain shrinkage in later life.

Chris Masterjohn shows evidence that dietary protein protects against cancer by raising glutathione levels.

Via Julianne Taylor on Twitter, CoQ10 maintains fertility in older women.

ScienceDaily links to a new Nature paper showing that fat cells in obese people store fats more easily and shed fats less easily than fat cells in normal people. A study author says “this is the first time that someone has demonstrated that the metabolism of fat in the fat cells differs between healthy and obese individuals.” If something so basic had never been demonstrated, it’s no wonder the blogosphere can’t agree on what causes obesity.

More manipulation of mammals by germs: From The Scientist, A Lactobacillus rhamnosus strain reduces anxiety and depression in mice, and may do the same in people, according to a new paper in PNAS.

While fermentation of vegetables produces very healthful foods, fermentation of meat tends to culture germs that can digest us, and is a very risky activity. Melissa McEwen points out that the lore of how to do it safely has largely been lost.

Wired.com has some neat graphics on the gut microbiome. Most striking to me was this chart of how long it takes people who don’t eat kimchi to refresh their gut flora:

[4] More music: We’re so classy, classical music isn’t good enough unless wine glasses are involved. Here’s Bach’s Toccata and fugue in D minor:

[5] The 2011 Ig Nobel Prize for Medicine has been awarded: For demonstrating that people make better decisions about some kinds of things, but worse decisions about other kinds of things, when they have a strong urge to urinate.

Via Peter Klein.

[6] Cute animal photo: From Logan Pass, Glacier National Park, Montana:

Via EarthPorn by way of Lance Strish.

[7] Best Comments This Week (not about constipation):

Jana had a great comment on the relentless pressure on cancer patients to be “upbeat,” and the harm it may do.

Majkinetor guides us to a paper showing that a maternal protein-deficient diet can promote high blood pressure and impaired glucose metabolism in offspring, but that this effect can be rescued by folate supplementation. Vitamins B6, B12, and choline are even better.

Lance Strish had a very informative discussion of toxicity from AGEs and ALEs.

[8] Shou-Ching’s Photo Art:

[9] “Little Miss Muscle”: Was spindly 7th-grader April Atkins the world’s strongest teenager?

Via Instapundit.

An Anti-Cancer Diet

Posted by on September 28, 2011 163 comments

Our cancer series resumes today with some tentative advice for cancer patients. (Note: This post is designed for solid tumor cancers, not blood cancers. However, most of the advice would also be applicable to blood cancers.)

This series began with Toward an Anti-Cancer Diet (Sep 15, 2011). There we advocated trying to shift cells away from the cancer phenotype via 8 anti-cancer strategies.

Future posts will explore in detail how to implement those strategies via diet and lifestyle. Today, I’m just going to give a general overview of what I would do if I had cancer.

Eat the Perfect Health Diet

This may sound self-serving, but it’s my best advice. Our diet is designed to optimize health generally, and that’s exactly what you want to do against cancer.

I said in the introduction that cancer is a disease in which cells lose their “humanness” – their proclivity to collaborate with other human cells to create a human organism. Instead, they lose recently evolved features and “remember” an identity similar to that of our distant evolutionary ancestors from the early days of multicellular life. This regression is possible because we retain the genes of our primitive evolutionary ancestors, and silencing of only a few hundred genes may cause a human cell to resemble, genetically, bacteria or fungi.

Many gut bacteria can take on two modes of behavior – a commensal or harmless phenotype, or a virulent harmful phenotype – depending on whether their environment is benign. In beneficial environments, bacteria tend to be cooperative with their host; in harsh environments, bacteria begin to look out for their own interests “selfishly,” and begin to display virulence traits which harm their host but help them move to a better environment.

Something similar may happen with “proto-cancer” cells. In a healthy environment, they are pleased to cooperate with their host – to retain their “humanness.” But in a harsh environment, they are more likely to withdraw from their neighbors and go their own way. An abused cell is more likely to become a cancer cell.

This may sound like anthropomorphization, but the metaphor is probably sound. Bruce Ames has remarked upon the fact that almost every compound is a carcinogen in large enough doses. Why? Because any unbalanced environment is harsh, and any harsh environment makes the cell more likely to develop the cancer phenotype.

It’s not only by discouraging “cancer virulence” that a good diet helps. A healthy diet also optimizes immune function.

Immune function is highly variable. Under stress, we suppress immunity so that all the body’s resources are available to meet “fight or flight” needs. Contrariwise, peaceable happiness is stimulating to immune function. A nutrient-rich diet, savory meals, happiness, calm, restful time spent in conversation – all of these things tell the body it has no pressing concerns and that available resources can be devoted to immunity and healing.

After cancer diagnosis, from a similar medical condition, those who are under stress tend to succumb to cancer, while those who are happy, cheerful, and sociable tend to recover from it. It is believed that this difference is primarily due to improved immune function in those under less stress.

I believe that a healthy, tasty diet is also a stimulant for immune function. Make your food nourishing and enjoyable.

Specific Dietary Aspects

A few aspects of an anti-cancer diet deserve special mention. Let’s look at the PHD Food Plate:

Some aspects I would emphasize for cancer patients:

  • Safe starches. I recommend obtaining 400 to 600 glucose calories a day, mainly from safe starches. I believe it is important to avoid a glucose deficiency, since glycosylated proteins are the means of intercellular coordination, and defects in glycosylation are characteristic of the cancer phenotype. (See, eg, this paper.) You don’t want to aggravate this with a self-induced glucose deficiency.
  • Low omega-6 meats. Omega-6 fats can be very damaging to mitochondria and can promote metastasis. Our needs for them are minimal, and they are everywhere. It’s important to choose foods that minimize omega-6 levels. Among meats, prefer seafood, shellfish, and red meats; obtain eggs, milk, and organ meats from pastured and naturally raised animals. Eat tropical plant oils like coconut and palm.
  • Omega-3 and omega-6 balance. The diet should include some marine sources of omega-3 fats, like salmon or sardines.
  • Bone broth soups and gelatin (cooked collagen). Collagen is 30% of our body’s protein and forms much of the extracellular matrix scaffolding which is crucial to maintainance of tissue health. The extracellular matrix is broken down in cancer. An anti-cancer diet should be rich in cooked joint tissue, such as can be found in Ox Feet Broth soups. Vitamin C and sulfur, discussed below, are also required for collagen formation; be sure you’re not deficient in these.
  • Fermented vegetables, yogurt, and acids. A diverse portfolio of gut bacteria can be helpful to the fight against cancer by several mechanisms. Probiotic flora from fermented  foods help shield against the entry of cancer-promoting pathogens to the body through the gut; they generate by-products, like short-chain fats and vitamin K2, which have anti-cancer effects; and they can modulate immunity in a favorable direction. Acids such as vinegar and lemon juice can also favorably modify gut bacteria.
  • Vegetables, herbs, and spices.Fiber is probably beneficial against cancer. Butyrate, which is produced by gut bacteria from the digestion of many types of fiber including “resistant starch” from safe starches, has anti-cancer properties. Moreover, many vegetables and traditional herbs and spices have been shown to have anti-angiogenic effects. Foods with anti-angiogenic properties include:
    • Garlic.
    • Tomato.
    • Green tea.
    • Dark chocolate / cocoa.
    • Maitake mushroom.
    • Bok choy.
    • Kale.
    • Many berries.
    • Cherries.
    • Ginseng.
    • Turmeric.
    • Oregano.
    • Parsley.
    • Polyphenol-rich extra virgin olive oils.
  • Organ meats and egg yolks. It’s important to be well nourished, and organ meats like liver and egg yolks tend to be rich in micronutrients. They are much better than plant foods for compounds like phospholipids. In particular, choline (and its phospholipid form phosphatidylcholine) is important for methylation status and epigenetic functioning – an important element in cancer prevention.
  • Sea vegetables, sea salt, and seafoods. These are good sources of trace minerals such as iodine, which is a critical anti-cancer nutrient.

In general cancer patients should focus on the foods in the apple of the PHD Food Plate more than the “pleasure foods.” However, there’s nothing wrong with some berries, dark chocolate, pistachios, and whipped cream for dessert, and some red wine with dinner. Above all, it’s important to enjoy your food. Try to obtain from every meal a sense of pleasure and well being!

Supplements

Much more could be said on this topic than I’m going to say today. One could make a very long list of supplements that might help against cancer (also a long list of those that hurt). However, the crucial five from my point of view are in our recommended supplement list:

  • Vitamin D
  • Vitamin K2
  • Iodine
  • Selenium
  • Magnesium

The tricky one here is the iodine. Iodine dosage should be built up very slowly from a low level, so as not to disrupt thyroid function. (Hyperthyroidism can strongly promote cancer, and hypothyroidism can inhibit immune function and healing, so any thyroid dysfunction is a serious risk.) Start at 500 mcg or less, and increase the dose no faster than a doubling per month. If you get either hypothyroid or hyperthyroid symptoms from an increase in dose, back off a bit (eg instead of going directly from 500 mcg to 1 mg per day, go to 500 mcg and 1 mg on alternate days). Be patient, but try to build up to 12 mg/day over a 6 month period. Then stay there. Be sure to get 200 mcg/day selenium along with the iodine.

I also recommend a multivitamin, for general nourishment; and make sure there is no deficiency of vitamin C, zinc, copper, or chromium. Also, when it comes to antioxidants, more is not better. Avoid most antioxidant supplements other than glutathione, vitamin C, selenium, zinc, copper, and manganese.

For magnesium, I recommend taking a 200 mg oral supplement of magnesium citrate or a magnesium chelate. Epsom salt baths might not provide magnesium, but they can be a useful source of sulfur (in the form of sulfate) which assists collagen formation.

Vitamin C is an unusual case. It supports collagen formation, and for this purpose and to avoid a deficiency I strongly suggest taking 1 g per day. In higher doses, vitamin C may be helpful because it has anti-viral properties (see Fighting Viral Infections by Vitamin C at Bowel Tolerance, Sep 26, 2010), and most cancers are probably viral in origin. Linus Pauling, of course, advocated high doses of vitamin C – either taken orally to bowel tolerance, or intravenously. However, there are arguments on the other side. Vitamin C can protect cancer cells from immune attack, and also makes them resistant to chemotherapies. Clinical trials have not yet proven high-dose vitamin C therapy, but it may help against a subset of cancers caused by viruses sensitive to vitamin C therapy.

If sufficient amounts are not obtained from diet, then choline should be supplemented.

Intermittent Fasting, Intermittent Ketosis, Intermittent Protein Restriction

This is an extremely important cluster of strategies that are probably highly effective against cancer.

Their common trait is that all three promote autophagy, or “self-eating,” which is both a means for cells to cope with resource scarcity and a central part of the intracellular immune response.

When resources are abundant, cells allow aged organelles and junk proteins to accumulate. When resources are scarce, they turn on autophagy and digest unnecessary components, recycling the resources.

Autophagy is the dominant innate immune mechanism inside cells – the primary way cells kill bacteria and viruses.

Autophagy also recycles damaged mitochondria, which can be digested, enabling remaining healthy mitochondria to multiply. The result is a healthier mitochondrial population.

Since viruses and damaged mitochondria promote cancer, autophagy helps transform cells from the cancer phenotype back to the normal human phenotype.

Fasting, by inducing resource scarcity, promotes autophagy. Scarcity of amino acids, which can be achieved by a protein restricted diet, also promotes autophagy. And ketosis, which is part of the metabolic profile of starvation, also promotes autophagy.

Note in my section heading the shared word: “intermittent.” We don’t want to sustain fasts or protein scarcity too long; that could create malnourishment and cause more harm than good. Permanent ketosis may promote fungal infections. The most helpful course is probably to follow these strategies intermittently:

  • Engage in daily intermittent fasting: eat only within a 6 to 8 hour window each day. Within the fasting period, eat some coconut oil or MCT oil to promote ketosis.
  • Eat high protein for a few weeks while engaging in resistance exercise to build muscle; then low protein for a few weeks.

A Note on Ketogenic Diets

Since we wrote our book, we’ve become a bit less excited about the therapeutic potential of ketogenic diets.

Ketogenic diets have demonstrated effectiveness in brain cancers, and several considerations suggest that they would be helpful against all cancers:

  • Cancer cells are dependent on glucose metabolism, a phenomenon called the Warburg effect. In ketosis, blood glucose levels can be decreased – a fall from 90 to 65 mg/dl is achievable – and reduced glucose availability should retard cancer growth.
  • Mitochondria do well on ketones, and some studies had shown that provision of ketones can restore the ability of mitochondria to trigger apoptosis, or the programmed cell death of cancer cells.

It’s too early to judge, but a few scraps of data published recently have made ketogenic diets seem a bit less exciting then hoped.

First, the group of Michael Lisanti has published work suggesting that tumors can evade the metabolic restrictions of a ketogenic diet by manipulating neighboring normal cells. The idea (here is an overview) is that cancer cells release hydrogen peroxide, which causes a stress response in neighboring cells, stimulating them to release lactic acid, which the cancer cells can metabolize. This process can happen nearly as well on a ketogenic as on a normal diet, so the effectiveness of a ketogenic diet in starving the cancer cells is reduced.

The Lisanti group results are hardly conclusive – indeed so far as I know no other group has supported their claims – and there are plenty of skeptics. Jimmy Moore gathered responses from a panel of low-carb experts.

Second, clinical experience with ketogenic diets has not yet shown them to be highly effective. The sort of data we have is well represented by a recent report in Nutrition and Metabolism. Sixteen patients with advanced metastatic cancer were put on ketogenic diets. The results:

One patient did not tolerate the diet and dropped out within 3 days. Among those who tolerated the diet, two patients died early, one stopped after 2 weeks due to personal reasons, one felt unable to stick to the diet after 4 weeks, one stopped after 6 and two stopped after 7 and 8 weeks due to progress of the disease, one had to discontinue after 6 weeks to resume chemotherapy and five completed the 3 month intervention period.

The conclusion: a ketogenic diet “has no severe side effects and might improve aspects of quality of life and blood parameters in some patients.”

Clinical trials with control groups and more statistical power are needed to evaluate whether ketogenic diets have therapeutic effect. For now, I think the most prudent course is intermittent ketosis and intermittent ketogenic fasting, rather than a continuously ketogenic diet.

UPDATE: Mario makes a great point in the comments: fasting prior to chemotherapy reduces toxicity to normal cells but increases toxicity to cancer cells. It is quite likely that a ketogenic diet might have the same effect during chemotherapy. So the combination of intermittent ketogenic dieting with chemotherapy should be given consideration.

Circadian Rhythm Enhancement

Many diseases become more likely, or more severe, if circadian rhythms are disrupted. Enhancement of circadian rhythms may be therapeutic for these diseases.

I’ve blogged about circadian rhythm therapies for hypothyroidism (“Intermittent Fasting as a Therapy for Hypothyroidism,” Dec 1, 2010) and for sleep disorders, psychiatric disorders, neurodegenerative disorders, and obesity (“Seth Roberts and Circadian Therapy,” Mar 22, 2011).

Well, cancer is another disease for which circadian disruption may be damaging. The International Agency on Research on Cancer (IARC) has recently classified “shiftwork that involves circadian disruption” as “probably carcinogenic to humans.”

It’s plausible that circadian enhancement may be therapeutic for cancer. Tactics that enhance circadian rhythms include:

  • Exposure to mid-day sunlight.
  • Sleeping in total darkness during hours of darkness.
  • Confining eating to daylight hours.
  • Socializing – especially, looking at faces and talking – during daylight hours. Seth Roberts found that looking at images of human faces can substitute for actual socializing.
  • Exercising during daylight hours. Even low-level activity – like standing instead of sitting – helps.
  • In people who are melatonin deficient due to a brain immune response, supplementation of melatonin just before bedtime.

Curiously, circadian rhythm disruption seems to make chemotherapy more effective. Also, timing treatments to match circadian rhythms may double their effectiveness.

Exercise and Other Lifestyle Factors

A number of lifestyle factors are important for cancer recovery. David Servan-Schreiber’s Anti-Cancer has an excellent overview of the evidence.

A recent study in the Lancet found that every additional 15 min of daily exercise beyond 15 min a day reduced all-cancer mortality by 1%. Exercise appears to be therapeutic even for late stage cancers. A meta-review found that two and a half hours of exercise a week could lower a breast cancer patient’s risk of dying or cancer recurrence by 40 percent, and could reduce a prostate cancer patient’s risk of dying from the disease by about 30 percent.

However, exercise should not be exhausting. Rather, it should be restful and relaxing; or build muscle. Resistance exercise on the “Body by Science” model of one intense workout per week, with more time spent in restful recovery than in stress, is probably a good strategy. Long walks outdoors in nature, and relaxing exercises like yoga or tai chi, are also great approaches to cancer therapy.

Being sociable, happy, calm, and optimistic are all important factors for cancer recovery. Those who have companions they love, and a purpose for living that makes them happy, have the best prognosis. Be grateful for what you have, and make your body understand that life is worth living.

Dealing with Anorexia and Nausea

Anorexia and nausea can seriously impair the ability of cancer patients to eat a nourishing diet and maintain their strength.

I haven’t had time to research this aspect of the disease yet, but there do seem to be some dietary and lifestyle interventions that help.

For instance, exercise can correct anorexia.

Among dietary interventions, ginger has been reported to reduce chemotherapy-induced nausea, reducing incidence in one study from 93% to 55%. (Hat tip: Healthy Fellow.)

Ginger teas are a traditional Asian folk remedy. Slice some ginger root in water, boil it on the stove, add some rice syrup for sweetness, and drink up!

Under-Utilized Therapies

There are a few therapies which are rarely prescribed, but might be more helpful than chemotherapies in treating cancer:

  • Low-dose naltrexone.
  • Anti-viral drugs.
  • Anti-fungal therapies.

Low-dose naltrexone is taken at night before bed. It temporarily blocks opioid receptors, which leads the body to increase production of endorphins and enkephalins – immune compounds which interact with opioid receptors. The following day, the naltrexone is gone and the opioid receptors are working again, but the endorphins are still around. Taking LDN thus increases endorphin levels. Endorphins inhibit cancer proliferation, and may enhance anti-cancer immunity. Here is a recent paper on anti-proliferative effects of LDN against ovarian cancer: http://pmid.us/21685240. Here is a recent paper on LDN plus alpha lipoic acid as a therapy against pancreatic cancer: http://pmid.us/20042414. For a general overview, see http://lowdosenaltrexone.org/.

Viruses cause or contribute to most cancers, and thus anti-viral drugs have great potential. A few cancer-causing viruses are famous, such as the Human Papilloma Virus for which there is a vaccine; however, most of the viruses that cause cancer remain unknown, though we know they exist because genetic mutations that impair viral immunity greatly increase cancer incidence.

Mario Renato Iwakura recently sent me a link to a paper that nicely illustrates the potential of antiviral therapies against cancer. Cytomegalovirus, also known as human herpes virus 5, is a common virus that infects 40% of adults worldwide and 50% to 80% of Americans. However, it is found in almost 100% of human tumors. It seems to be difficult to get cancer if you haven’t been infected by cytomegalovirus.

From the paper abstract:

Medulloblastomas are the most common malignant brain tumors in children…. Human cytomegalovirus (HCMV) is prevalent in the human population and encodes proteins that provide immune evasion strategies and promote oncogenic transformation and oncomodulation…. Remarkably, all of the human medulloblastoma cell lines that we analyzed contained HCMV DNA and RNA and expressed HCMV proteins at various levels in vitro. When engrafted into immunocompromised mice, human medulloblastoma cells induced expression of HCMV proteins. HCMV and COX-2 expression correlated in primary tumors, cell lines, and medulloblastoma xenografts. The antiviral drug valganciclovir and the specific COX-2 inhibitor celecoxib prevented HCMV replication in vitro and inhibited PGE2 production and reduced medulloblastoma tumor cell growth both in vitro and in vivo.

Tumor growth declined by 72% when treated with Valcyte (valganciclovir) and an NSAID drug. A press release notes that these drugs have “relatively good adverse effect profiles” and that “antiviral drugs are selective and largely affect infected cells.”

Yet another antimicrobial approach that may be helpful against cancer is antifungal therapy. Most cancer patients develop systemic fungal infections, and fungal infections such as Candida promote metastasis and tumor growth, and may also suppress anti-cancer immunity. An effective antifungal therapy may significantly retard cancer progression.

Conclusion

Much more remains to be said, and it’s certain that we’ll refine these suggestions after more thoroughly studying the literature. But I think this basic approach to an anti-cancer diet can’t be too far wrong.

Our prayers and best wishes go out to all those who are battling cancer.