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  • #16
    "What % of your patients sign on after hearing the spiel? And what % stick with it to the point of making a significant improvement in their health? It sounds very intimidating."

    To be blunt: I don't think my approach would work with "normal people". I think it works primarily because of who my patient base is.....

    My average patient has been NIDDM for about 20-30 years, often longer. They are sent to me because someone has recommended at least a consult on whether their diabetes has caused so much damage in their eyes that they require surgery.

    In medical-lingo, this is what we refer to as "end-organ damage" of diabetes, meaning that it has begun to compromise actual parts of the body. On some of my patients, this is NOT the only place this has occurred. At least 20% of my patients can no longer walk, have diabetic boots on, are on liver treatments, etc. I don't deal with your normal diabetic. I deal with someone that has, by the numbers, about a 90% chance of being dead in 5 years.

    Not everyone that I see is THIS sick, but a good deal are, others realize it is down the road. I often say that I don't have to do any scary stuff or say much: I just have to give them some graphs of what their situation looks like, statistically....I don't do this, but they know the realities.

    In other words, for many of my patients, literally "change or die". I use those 3 words with probably 60% of my patients. I think I said to a man earlier, "My job isn't to put you on a magazine cover. It's to keep you looking down at the ground instead of up at it." I am not a sexy-maker trainer. I am trying to keep people alive, and if fully successful, on a full turn around.

    So far, I have about an 85% buy in rate. I make nothing by doing the diet part. It is revenue neutral by the time my expenses are paid....but doing it any other way is not responsible, or realistic to me.

    As for success, I have my OWN binder I show them (while they bring theirs). In it are, as of last month when I updated it, 226 names. Most have seen the proof in one form or another. It's not hard to do what I do. You just have to be really, REALLY, honest with people
    "The soul that does not attempt flight; does not notice its chains."

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    • #17
      Originally posted by TheyCallMeLazarus View Post
      To be blunt: I don't think my approach would work with "normal people". I think it works primarily because of who my patient base is.....

      My average patient has been NIDDM for about 20-30 years, often longer. They are sent to me because someone has recommended at least a consult on whether their diabetes has caused so much damage in their eyes that they require surgery.

      In medical-lingo, this is what we refer to as "end-organ damage" of diabetes, meaning that it has begun to compromise actual parts of the body. On some of my patients, this is NOT the only place this has occurred. At least 20% of my patients can no longer walk, have diabetic boots on, are on liver treatments, etc. I don't deal with your normal diabetic. I deal with someone that has, by the numbers, about a 90% chance of being dead in 5 years.
      That's the key, I guess. Seeing your body disintegrate out from under you will get your head in a different place in a big hurry.

      How often do Drs. who deal with "end-organ damage" aggressively address the causes of diabetes with their referrals? I've never heard of such a thing - though I don't personally know anyone who has progressed beyond a prescription for Metformin.
      50yo, 5'3"
      SW-195
      CW-125, part calorie counting, part transition to primal
      GW- Goals are no longer weight-related

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      • #18
        Originally posted by TheyCallMeLazarus View Post
        "change or die".
        What my wife (a nurse) said to me.

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        • #19
          "How often do Drs. who deal with "end-organ damage" aggressively address the causes of diabetes with their referrals? I've never heard of such a thing - though I don't personally know anyone who has progressed beyond a prescription for Metformin."

          I would say not very often. I have found that I have little to no competition in providing nutritional guidance to my patients, and seeing as many patients are VERY interested, it gets me a lot of referrals I wouldn't otherwise get just doing surgery.

          You are actually touching on a very sore spot for me in how modern medicines views NIDDM. I would say that, very generally speaking, it goes like this:

          1) "Borderline" => A lot of times this is the most dangerous, because many times only their fasting BG is being used to make this call. Because of this a lot of underlying, often severe disease progression occurs, often without the patient believing they have to change much. Most docs will do the normal "diet and exercise" spiel, but it lacks much punch.

          2) After Dx, waiting period and metformin => Many docs give metformin as your first line, almost as a rule. Again here though, the tone to most patients is tentative....even when they are young, and would otherwise still have a lot of tools to turn things around. They are told that metformin will handle it, again more generic dieting guidelines, and move on. Many patients stay in this phase for years.

          3) 2nd line therapies => Once the above fails, other meds are added. My this point that tone goes more to "well, you have it. Try to manage it."

          4) Emergent care, insulin, end-organ damage => These are my people....I guess I left out one very big thing about diabetes: generally speaking, it is a time-dependent disease. In short, the longer you have it, the more complications you get. This is true for eyes, liver, kidneys, etc. A 20 year DM has much higher odds of end-organ damage than a 15 year, and so on.

          Now, at what point there was the CAUSE really ever attacked? I mean full out warfare on metabolic syndrome. Not DASH, not a vague guideline, a full on "we are going to defeat this" mentality? The answer is never. The drugs are our crutches, nothing more. Teaching them to walk again is not really taken as the first line treatment, in reality.

          For me, ALL patients showing signs of metabolic syndrome onset, and by that I mean the cascade of toxic effects caused by prolonged states of high insulin, should have doctors that demand complete overhaul of their diets.....the time to do it is THEN, not after 20 years of carnage and my lasers zapping the bleeding in their eyes. A lot of times I am the guy called in the bottom of the 9th inning, down ten runs, with my job being to help them mount a comeback. It's a shame and it's all malpractice in my view, but it is the reality of how it is handled.
          "The soul that does not attempt flight; does not notice its chains."

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          • #20
            Originally posted by TheyCallMeLazarus View Post
            I would say not very often. I have found that I have little to no competition in providing nutritional guidance to my patients, and seeing as many patients are VERY interested, it gets me a lot of referrals I wouldn't otherwise get just doing surgery.

            You are actually touching on a very sore spot for me in how modern medicines views NIDDM.
            ...
            A lot of times I am the guy called in the bottom of the 9th inning, down ten runs, with my job being to help them mount a comeback. It's a shame and it's all malpractice in my view, but it is the reality of how it is handled.
            Well, I hope you are getting considerable satisfaction from the work you are doing, because there are millions more who could use the kind of guidance you are providing and they are screwed by living miles from VT.
            50yo, 5'3"
            SW-195
            CW-125, part calorie counting, part transition to primal
            GW- Goals are no longer weight-related

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            • #21
              I've got nothing but observation of one human. My mother was obese and TypeII. She listened mostly to her CW doctor. Oatmeal every day for breakfast dontcha know. Dead at 74.

              Normally I would think not to get advice from an online forum for something serious. However, we do have Laz, and I have the utmost respect for his advice. And CW doctors will kill you.

              I'm not obese, and I don't have TypeII, but my blood pressure rises when I get over 160 pounds (and my ego slumps 'cuz it's just not pretty). The one thing I believe: everything the govt and CW doctors have been telling us about nutrition in the last 40 years is a BIG FAT LIE.
              "Right is right, even if no one is doing it; wrong is wrong, even if everyone is doing it." - St. Augustine

              B*tch-lite

              Who says back fat is a bad thing? Maybe on a hairy guy at the beach, but not on a crab.

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              • #22
                To: TheyCallMeLazarus: Hi, I posted the orig. question, & I can't express how much I appreciate your time and help. (I've been MIA, settling my Son W/ Asperger's into college). Wish I lived near Vermont! (I'm near Dallas, TX). I have 2 sets of July labs on my Husband. One fasting, one not. (Some of The designations seem to vary from what you asked for, so I'll post the stand-outs). These are all from 7/25/13 Fasting: Glucose Serum: 134 (previous week was 135), BUN: 25, BUN/ Creatinine Ratio: 23, Bilirubin total:1.4, TTL Cholesterol: 127, Triglycerides: 197, HDL: 34 (on 1000 mg. Niaspan), He has small particulate LDL from past testing, I don't know why this M.D. didn't test for that (!). TSH: 5.070. Under "CBC with Differential/ Platelet", the standouts are: WBC: 3.1, Neutrophils: 35, Lymphs: 51, Neutrophils Absolute 1.1 (If this is TMI, I apologize)!

                All Non Fasting: (Coincidently, done @ a work wellness screening also on 7/25/13) Standouts: Glucose: 112, A1c: 5.7, VAP Lipid Panel: (Direct Measured Cholesterol Panel): Total LdL: 52 with dense size pattern B, Total HDL: 31 (HDL2 is 8, HDL3 is 22), Total VLDL: 37 (VLDL 1+2 is 20.4, VLDL 3 is 16), Total Cholest is 119. Triglycerides: 269. Apolipoproteins: Apo Al is 113. Homocysteine: 12.2, C-reactive Protein, hs is 1.4. Bilirubin Total: 1.4, Hgb A1c with eAG Estimation Hemoglobin A1c: 5.7. (Again, sorry if TMI)! We will find somewhere to get a water body fat test and do the photo op. I may have to strong arm him on those photos!

                Can you help me understand why Ketosis may not be beneficial for him? He doesn't fast and gorge; he has 3 meals a day, typical is very low carb like organic 12 lettuce salad with salmon, or eggs w/ organic butter, onion, mushrooms, jalapeno. He has a p.m. snack of heavy cream. We started to cut back on the protein a bit & increase healthy fats, since he hasn't hit more than the edge of ketosis in 3 weeks of low carb according to Ketostix (I hear they're not a very good gage. His blood meter will arrive soon). The only time he did hit more than trace ketosis was after more than 2 hours of busting it on his mountain bike. (He's Motivated! I'm so proud & impressed)! He was well hydrated.

                His brother had type 2 Diabetes that he didn't take enough self responsibility for (+ many additional health issues) and died last year @ the young age of 55. Doctors could not determine cause of death, except that it was not heart attack or stroke. If it wasn't for his Mother's help, he probably would have died sooner. It's very sad, and definitely Not happening to my Husband.

                Bty, I don't find your style intimidating at all (referencing someone else's post). Do you have anyone you can refer us to in the Dallas, Tx area who has an approach like yours? Or, ideas on how to find a doc like you? I don't have enough faith in our family internal medicine m.d. His "solution" was a metformin script, but my husband said he wanted to do lifestyle changes instead. Our Doc said "Fine, watch what you eat, exercise, lose weight & we'll check you in 2 months". That was it, not very helpful. I'm guessing I should start by looking for an endocrinologist that espouses low carb?

                Thank you SO much for helping us, and clearly many others in your practice and Marks Daily Apple. I wish more M.D.'s had your approach, sense of sharing information and responsibility!

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                • #23
                  I would highly suggest consulting one of the various Paleo or Primal RDs for some chow advice, if you can afford it. Given what is at stake and the health issues to take into consideration, I think it would incredibly useful to get a custom meal plan drawn up which would also help with your cooking.

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                  • #24
                    7/25/13 Fasting: Glucose Serum: 134 (previous week was 135), BUN: 25, BUN/ Creatinine Ratio: 23, Bilirubin total:1.4, TTL Cholesterol: 127, Triglycerides: 197, HDL: 34 (on 1000 mg. Niaspan), He has small particulate LDL from past testing, I don't know why this M.D. didn't test for that (!). TSH: 5.070. Under "CBC with Differential/ Platelet", the standouts are: WBC: 3.1, Neutrophils: 35, Lymphs: 51, Neutrophils Absolute 1.1 (If this is TMI, I apologize)!

                    All Non Fasting: (Coincidently, done @ a work wellness screening also on 7/25/13) Standouts: Glucose: 112, A1c: 5.7, VAP Lipid Panel: (Direct Measured Cholesterol Panel): Total LdL: 52 with dense size pattern B, Total HDL: 31 (HDL2 is 8, HDL3 is 22), Total VLDL: 37 (VLDL 1+2 is 20.4, VLDL 3 is 16), Total Cholest is 119. Triglycerides: 269. Apolipoproteins: Apo Al is 113. Homocysteine: 12.2, C-reactive Protein, hs is 1.4. Bilirubin Total: 1.4, Hgb A1c with eAG Estimation Hemoglobin A1c: 5.7


                    Whew....ok, so here is my take and what I would do if he were my patient. First of all, the main outlier numbers and what they mean:
                    Fasting glucose of 134 => Just barely over threshold of NIDDM Dx of 126. I don't give this one that much sway as to the overall picture though.

                    Trigly of 197, HDL of 34 => I don't like either of these numbers, but also know that these 2 are both very movable and very slow to react. During the first 2 phases of the program I do, I tell patients that these will be moving around a lot. I see them more as endzone numbers than midfield numbers, to use a Texas-relatable football analogy

                    A1c of 5.7% => I am very hopeful because of this number, for reasons I will articulate in a bit.

                    HDL2 of 8, HDL3 of 22
                    VLDL 1+2 is 20.4, VLDL 3 of 16
                    Pattern B predominating => To be perfectly blunt, as is my medical style, I am very concerned over these numbers. For starters, the HDL that predominates in him is the less protective kind, whereas the HDL2, the most protective, is very low. Also, the VLDL 3, often high in diabetics, is concerning in regards to coronary disease. The fact that pattern B is dominant, or the more dense and dangerous kind, is also of concern.

                    Overall Assessment: I am more concerned over the coronary impacts of his metabolic syndrome than the insulin-based fluctuation markers. For many people, the blood sugar aspect is very dominant, and I have found that attempting to treat anything prior to anything else is an exercise in futility. In short, when the insulin resistance itself is profound, it is the first beast that must be slain to accomplish much of anything else....in the case of your husband though, the amount of insulin resistance itself, manifested by the fasting glucose and more so by A1c, are not all that poor. He is a borderline diabetic, in other words.

                    The downside is that he is a full-bore metabolic syndrome patient, with lipid profiles and triglyceride profile of marked disease. Much of this may or may not be genetic, but that is not relevant to the treatments themselves. We beat the monster, regardless of how it arrived on the scene Another downside is that metformin will not do very much to affect the primary concern, that being atherosclerotic disease.

                    Plan: Ketosis, or very low carb dieting, is a misdirected approach at this point. The main concern is that of his lipid panels in respect to metabolic syndrome, and simply keeping starches low takes a lot of discipline that could better be directed elsewhere. Most of all, keep his intake of PUFAs and of course sucrose, very low. In regards to carbs, I have no problem with slow digestion carbs that will allow him to feel more energetic and exercise. I would take the approach that these must be "earned" by exercise.

                    Keep the intake of all PUFA to an absolute minimum. Ghee will be your best friend....another upside is that given his blood sugar, there is a probability that he can fast without any dangers. In my own practice I use a 100g glucose test to fully assess this, but I cannot imagine a sub-6% A1c getting BG cliffs from fasting....Putting it all together, it would look like this:

                    High-activity days: 75-100 carbs as a max, depending on how hard he is working out. I would allow slow carbs, no pure sucrose. Keep protein at about 200g a day (this will be an adjustment), and get the rest from non-PUFA fats. Try fasting for 12 hours, then increase by 2 hours, up to a 16 or 18 hour window, once he acclimates. 12 is not hard and 9 of it happens automatically for most.

                    Rest-days: No more than 50g carbs, same protein limits, all non-PUFA fat. The hard part will be NOT being too hypocaloric on this plan, but that is a problem we can handle a lot easier than insulin resistance....when possible, have him eat his carbs either after a workout or after a fast, when he will be most insulin sensitive. If this ONE rule is done well, that being to TIME your carbs rather than just blindly limit them, I have seen very fast A1c turn around.

                    In regards to meat, it will have to be pretty lean for awhile unfortunately. He is not primal...he is trying to not be sick, SOON to be primal Stick to lean stuff, grass-fed beef if possible, and no mixed meats. Those lipid profiles must get better. On one end it is being fought with his carbs and fasting program, the other with cutting out all PUFAs.

                    Please review and let me know what you think. I will write more when I have time. About to head home after a full work week
                    "The soul that does not attempt flight; does not notice its chains."

                    Comment


                    • #25
                      Lazarus, thanks for posting such detailed info. It is helpful to many more of us than just the OP. I wish I could find a doctor in my area who understands nutrition as you do.

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                      • #26
                        Amen! It's refreshing to see this lone sane voice in the primal wilderness. It's now somewhat acknowledged that ketosis isn't for everyone. Does it then perhaps suggest that ketosis may not even be ideal for diabetics either? I know many diabetics who tried the Bernstein diet and came away with the same side effects and glucose deficiency symptoms that Paul Jaminet talks about. Granted, these people have to limit their carbs. But it can be done above the ketogenic level. Unless you're a type 1 diabetic on insulin or a severely beta-cell depleted T2 diabetic, you do not have to do the insane Bernstein diet. Most of Bernstein's patients, by the way, have Hashimoto's. Bernstein freely acknowleges this during his monthly telecasts.

                        It's alarming to hear this as a reflexive advice when it's clear that the person has never even tried the Bernstein diet. If you're diabetic, you MUST try the Bernstein Diet!!!! As if the advisor is in fact diabetic and has tried himself.

                        Look, get with it folks. The Bernstein 6-12-12 is ipso facto ketogenic. It's not for everyone. No, not even for diabetics. Bernstein himself has severe immune problems and has recently undergone surgery -- all I suspects due to his years of sticking to 6-12-12. I don't think he'll be around much longer. Many of his disciples have severe health problems, mostly autoimmune-related. They have excellent blood sugar control, this I cannot deny. But health is more than blood sugar. That's why Jennry Ruhl no longer believes in the Bernstein diet. Thank God for Paul Jaminet and the sanity he brought to the Paleo world. Without him, we would all be thinking ketogenic is the way.

                        Originally posted by otzi View Post
                        I don't understand why you are so bent on getting him in ketosis. Ketosis is not needed in the least for
                        control of T2D or PreT2D.

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                        • #27
                          Originally posted by choppedliver View Post
                          Amen! It's refreshing to see this lone sane voice in the primal wilderness. It's now somewhat acknowledged that ketosis isn't for everyone. Does it then perhaps suggest that ketosis may not even be ideal for diabetics either? I know many diabetics who tried the Bernstein diet and came away with the same side effects and glucose deficiency symptoms that Paul Jaminet talks about. Granted, these people have to limit their carbs. But it can be done above the ketogenic level. Unless you're a type 1 diabetic on insulin or a severely beta-cell depleted T2 diabetic, you do not have to do the insane Bernstein diet. Most of Bernstein's patients, by the way, have Hashimoto's. Bernstein freely acknowleges this during his monthly telecasts.

                          It's alarming to hear this as a reflexive advice when it's clear that the person has never even tried the Bernstein diet. If you're diabetic, you MUST try the Bernstein Diet!!!! As if the advisor is in fact diabetic and has tried himself.

                          Look, get with it folks. The Bernstein 6-12-12 is ipso facto ketogenic. It's not for everyone. No, not even for diabetics. Bernstein himself has severe immune problems and has recently undergone surgery -- all I suspects due to his years of sticking to 6-12-12. I don't think he'll be around much longer. Many of his disciples have severe health problems, mostly autoimmune-related. They have excellent blood sugar control, this I cannot deny. But health is more than blood sugar. That's why Jennry Ruhl no longer believes in the Bernstein diet. Thank God for Paul Jaminet and the sanity he brought to the Paleo world. Without him, we would all be thinking ketogenic is the way.
                          I don't like this review of Dr. Bernstein and his diet at all (big surprise right). I'm not saying this to OP or trying to convince one person or another that its right for them. But lets be fair to the man at least. He and his recommendations have literally saved lives. Is it for every person and every diabetic? Perhaps not, but its quite disingenuous to elude that his diet is responsible for Hashimotos or other autoimmune disorders unless you have something more than assumptions.

                          Something you should recognize is that Type I Diabetes is associated with genetic markers HLA DR2, DR3, and DR4. Would you like to hazard a guess as to what other autoimmune diseases are associated with these same markers? So don't be so quick to blame his diet for all their health problems. Its quite likely just making the best of a bad situation for his patients.

                          And if the man is in poor health right now.... your comment is bad form. No two ways about it. The man has lived with type I diabetes himself for over 64 years! That is no easy accomplishment. He sets an absolutely outstanding example in walking the talk IMO and he should be commended. http://www.diabetes-book.com/book/mylife.shtml
                          Last edited by Neckhammer; 08-23-2013, 07:44 PM.

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                          • #28
                            Let me refute you directly and your spurious claim of being disingenuous. Dr. B sees both T2 and T1 patients. In order to become his patient, you have to be on his 6-12-12 diet. To be accepted as his patient, you have to fax your food log so that he can check your carb intake and verify your "worth" as his patient. All of his patients are VLCing and virtually all of them are ketogenic. During his telecasts, he casually comments that he hasn't seen a single patient who doesn't have at least 1 autoimmune disease. These are his T2s and T1s who're ketogenic, not just his T1s. He's also said that 90-95% of his patients have Hashimoto's. We're not talking about T1s here who, on average, could be afflicted with 4-6 autoimmune issues. Now, T2s often have autoimmunity as well. But Hashimoto's to the degree you see in Dr. B's patient population? Does low FT3 ring a bell with you at all? He actually wonders aloud why that's the case; he really does not know. And his acolytes won't bother telling him why that might be so.

                            Dr. B has done a lot of good in restoring BG control for many. That is true and he deserves a lot of credit. However, he's done that at the cost of significant health issues that are quite disturbing, if you realize the extent of the problems his patients are afflicted with. Aside from various autoimmune isssues, every telecast, his listeners compalin about gout, constipation, weakness and dizzy spells, nausea. Well, he doesn't know much about gout; his answer is, lose weight. His answer for constipation is, it ain't constipation if you're going to the bathroom twice a week. What about pellet stool? He says not to worry about them. For long-term constipation, he recommends a fiber supplement from Oz called Phloe, which is completely unhelpful if your constipation stems from glucose deficiency and your colon is bone dry. In fact, Phloe will cause fecal impaction and you'll be sent to an emergency room if you ever tried it while suffering from the mucosal deficiency which PHD so helpfully elucidates in exposing the problems of a ketogenic diet. He has no answer for anemia like symptoms which are so characteristic of glucose deficiency. He won't even acknowlege them. He thinks LDL skyrocketing for some on VLCing is always due to thyroid, not genes. He's never heard of physiological insulin resistance. He belives in the anthropologcial myth that we were all hunters and all we ate were meats, fish, eggs and poultry; he's never heard of the term, gatherer. In fact, he tells his patients to not eat any vegetables if they don't want to, not even any green leafies because they have carbs. He counts every carb and does not take into account fiber. He thinks "net carbs" is a scam; tell that to anyone who ever ate an avocado. So at 6-12-12, your carbs aren't coming from any starch but really from liver, leafies, non-starchy veggies. It's not a 30g carb diet; it's a zero carb diet.

                            I used to believe in Dr. B because I felt that blood sugar control was of paramount importance. Of course it is. But it is not all there is to health. The man is isolated and has a siege mentality which pits him against the world, the ADA, the Evil Empire. Which is understandable, especially given his age and his outsider status within conventional medicine. And I do admire him for that. However, in the near future, we'll have a serious debate about the propriety of his diet and its susceptiblity to autoimmunity and other problems, specifically, in relation to intestinal permeability. Yes, I believe low-carbing is necessary for diabetics. But ketosis is not required. In fact, for some, it could be downright unhealthy and lead to problems more insidious than diabetes.
                            Last edited by choppedliver; 08-23-2013, 09:36 PM.

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                            • #29
                              I really don't see where you have successfully refuted anything I wrote? So I suppose the crux of your issue is:

                              1. You believe everything Paul says is correct about dietary glucose insufficiency. I don't. So on to two.
                              2. You think his diet causes more harm than good. I disagree.
                              3. His diet isn't necessary for all diabetics. Yeah, I agree and actually said so in my first response.

                              I would actually love to see a multifaceted study of his patient base put up against the ADA's recs (or non Bernstein diet diabetics in general). Would be really interesting. You could probably guess my predictions in such a case, so we can just agree to disagree. Does that mean I have to agree with everything the man has ever said or done?
                              Last edited by Neckhammer; 08-23-2013, 09:12 PM.

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                              • #30
                                You keep misrepresenting the issue. I never said I support the ADA and I'm for low-carbing, just not ketogenic VLCing. It's my folly to argue with you since you are not interested in a rational discourse. A group of Bernstein dieters with a group that did low-carbing but not VLCIng? Who will have better A1cs? Probably Bernstein's? Who's arguing with that? But which group wouldn't be hobbled by autoimmunity and other incorrigible health problems associated with ketogenic dieting? Hands down the other group. I believe you have the critical intelligence and discernment to grasp the import of this argument, if you try. But just like Bernstein, you just have too much skin in the game to admit this.
                                Last edited by choppedliver; 08-24-2013, 12:25 AM.

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