The Mukilteo Diet - a healthy diet (and treatment for metabolic syndrome).

I was a gastroenterologist (specialist in liver and digestive diseases) practicing in the Mukilteo, Washington, area for 35 years. Over that time, I noticed a dramatic increase in the number of patients referred to me for the diagnosis of “fatty liver”. A fatty liver results from an accumulation of fat in individual liver cells which in turn provokes inflammation in a significant number of patients. Of those with inflammation, a small percentage go on to develop scarring (cirrhosis) as the end result.

Fatty liver is seen in metabolic syndrome (the clinical triad of prediabetes, high blood pressure, and fatty liver), in patients with pre-diabetes/diabetes, and in some individuals with only obesity as a risk factor. And in a rare case, fatty liver can be seen in individuals without any risk factors. By some estimates fatty liver now affects upwards of 25% of the population.

Fatty liver, diabetes, and obesity overlap in their underlying physiology (abnormal glucose/insulin metabolism) and are all impacted (both positively and negatively) by the patient's diet. When I explained this to patients, that a change in diet was the first step to begin their work on diminishing the amount of liver fat accumulation, the next question was predictably “what kind of diet changes?” The following is a summary of my answer to them. It is not only a reasonable first step in the treatment of all three of these conditions, but is also a set of guidelines for healthy eating.

Although the traditional dietary approach emphasizes losing weight as the key factor to success, it is not quite that simple. Carbohydrates, and the insulin release they stimulate, are more important than previously suspected. Thus the source of one's daily calories (carbohydrate versus fat) and when carbohydrates are eaten during the day are equally as significant as the daily caloric balance.

The following five factors are important in any healthy diet but are particularly important in a comprehensive dietary approach to weight loss (where they work together with a decrease in total daily caloric intake) as well as in the treatment of glucose intolerance and fatty liver (steato-hepatitis).

I. Caloric Balance – if weight loss is a goal, then you will need to eat fewer calories a day than you will use. It is the mantra that is the basis os all weight loss plans. It is simple to understand and each diet then goes on to explain how you can easily eat less with their program. A negative caloric balance will ultimately translate into fat loss. As there is individual as well as day to day variability in water retention, it may not show an immediate effect on the scale. And when you go into negative caloric balance, the body will slow its metabolism a bit to compensate, so the loss may not be as dramatic as hoped. But in the end if you eat fewer calories than you expend, you will lose weight. If you have achieved your goal weight, then stepping on the scale every morning before breakfast will reinforce that you are remaining on track.

• If you want to lose weight, eat fewer calories than you expend.

II. When you eat – When you eat your calories is just as important as the caloric balance. You should eat the bulk of your calories early in the day (before 2 PM). Aim for a 25-50-25 split for breakfast – lunch- dinner. Any calories, especially carbohydrates, eaten early in the day are preferentially used by your active muscles during the subsequent 3 or 4 hours rather than being stored as fat (in the liver as well as fat cells) for later use when the muscles are not active (evening, sleeping).

If you do cut back on your evening calories – and for double bonus points focus on a plant based, low carbohydrate meal – you are moving towards an “intermittent fast” as described by Dr. Mirkin. A fast does not need to be a total elimination of calories. His post has references as well as a list of identified benefits.

To quote directly from Dr. Mirkin: "Intermittent fasting" does not mean complete avoidance of foods and drinks. Instead, you markedly reduce your intake of food during certain periods. The benefits of intermittent fasting can be seen as long as you significantly reduce your total caloric intake during those periods (http://www.ncbi.nlm.nih.gov/pubmed/16529878).

Intermittent fasting appears to work by increasing the body's sensitivity to insulin and reducing an overactive immunity, called inflammation (Cell Metabolism, Feb, 2014;19(1932-7420):181–92).

Various programs of intermittent fasting have been shown to:

• lower blood pressure (British Journal of Diabetes and Vascular Disease, April 2013) 
• lower cholesterol and triglycerides (Am J Clin Nutr, Nov 2009;90(5):1138-43) 
• reduce body fat (Int J Obes (Lond), May 2015;39(5):727-33) 
• lower insulin (Am J Clin Nutr, Jan 2005;81(1):69-73) 
• lower blood markers of inflammation (Free Radic Biol Med, March 2007;42(5):665-74) 
• increase speed and endurance in athletes (Med Sci Sports Exerc, April 2016;48(4):663-72) 

A decrease in your evening carbohydrates will directly increase the use of body fat metabolism and use. My blog post “Optimizing The Use of Body Fat As An Exercise Energy Source - train high, sleep low” reviews the physiology and logic. It is even more effective if you exercise just prior to deplete muscle glycogen stores and “force” or stimulate fat metabolizing pathways. The results are clear. The subjects on a post exercise carbohydrate restriction burned 8.7% of their body fat while the control group lost just 2.6%. Both were on equi-caloric daily diets so this was not just fat loss from calorie restriction.

• Move to a daily 25-50-25 distribution of calories (breakfast-lunch-dinner).
• Minimal carbohydrates for the evening meal – bonus points for a plant based meal.
• Maximize the effect with an afternoon exercise session.

III. What you eat (cabs versus fats/protein) and glycemic load – there is a growing body of evidence that a healthy diet (especially if you are trying to lose weight or treat fatty liver or a pre-diabetic tendency) means a decrease in the percentage of total daily calories provided by carbohydrates, and especially simple carbohydrates.

When carbohydrates are absorbed from the intestinal tract, they elevate the blood sugar level which in turn stimulates insulin release from the pancreas. Insulin is required to move simple carbohydrates (the absorbed form of all carbohydrates) into the muscle cells where it is used for energy or stored (in the form the carbohydrate glycogen or fat). A carbohydrate with a high glycemic INDEX is more rapidly absorbed and the spike in the blood glucose rise higher, providing an extra stimulus to insulin secretion. Some foods contain only a small amount of carbohydrate per serving (a carrot is an example) which, although rapidly absorbed, gives a lower blood spike spike than other foods with more glucose that might be absorbed more slowly. Thus the idea of glycemic LOAD (which reflects total sugar content AS WELL AS the rate of absorption) as a measure of the glucose surge makes more physiologic sense as a measure of pancreatic stimulation. Here is a nice summary of glycemic index versus glycemic load: http://www.fammed.wisc.edu/files/webfm-uploads/documents/outreach/im/handout_glycemic_index_patient.pdf
Here is a quick link to a list which compares glycemic index and glycemic load of common foods. http://www.health.harvard.edu/diseases-and-conditions/glycemic_index_and_glycemic_load_for_100_foods

As mentioned, insulin facilitates movement of carbohydrate into muscle and fat cells. And if it is not immediately use by a working muscle, after an evening meal or a bedtime snack, it is converted into fat. To decrease carbohydrate fueled fat production you could a) decrease the total percentage of carbohydrates in your diet, b) eat foods that contain low glycemic load carbohydrates which will decrease the production of insulin to facilitate the movement into fat cells, or c) eat more of your carbohydrates early in the day or just before/while exercising. With vigorous exercise, glucose will move into the muscle cell without insulin (it is insulin INDEPENDENT) and any blood sugar spike is blunted. Thus the idea of glycemic load is less important if carbohydrates are eaten just before or during exercise.

And recently there has been evidence that fructose as a simple sugar may be more detrimental to ideal blood sugar control than sucrose or glucose (https://www.ncbi.nlm.nih.gov/pubmed/27669460). This study suggests that fructose specifically activates a liver enzyme that then in turns  a) increases the resistance of the liver to the effects of insulin as well as b) increasing the production of additional  glucose from the liver cells - a positive feedback loop. In essence a prediabetic state. There is additional evidence that this negative effect is blunted if the fructose is ingested as intact fruit where it is bound to fiber and subsequently absorbed more slowly.(http://nutritionfacts.org/video/juicing-removes-more-than-just-fiber/ )

• Carbohydrate calories should be a smaller part of your total daily calories.
• Low glycemic load carbohydrate containing foods are preferred (avoid simple carbohydrates).
• The bulk of your daily carbohydrates should be eaten in morning or before 2 PM.
• Avoid drinks that are high in fructose (fruits are just fine).

IV. Exercise – adding exercise to a dietary program adds 3 benefits.

First, it increases the total calories you metabolize during the day. Additional calories expended for the actual exercise period as well as a slight rise in the basal metabolism rate for a few hours post exercise.

Second, while exercising, blood glucose moves into the actively contracting muscles cells without using insulin. And this insulin independent effect blunts the blood sugar spike (and stimulation of insulin release) seen after eating a high glycemic index food.

This New York Times article (http://well.blogs.nytimes.com/2015/01/23/ask-well-the-best-time-of-day-to-exercise/) refers to a study that shows us how to use the timing of exercise to blunt insulin release. In this study, exercising BEFORE eating blunted the negatives of excess daily dietary carbohydrate calories, while exercising a few hours AFTER eating provided a lesser (but still definite) benefit. Exercising before a meal appears to shunt post exercise calories directly into muscles and divert them from fat storage (throughout the body and liver). And as the process is insulin independent, it takes the pressure off the pancreas to provide additional insulin to move the glucose into the cells.

Third, when exercising, you will decrease your muscle glycogen (glucose) stores to provide energy to the muscles. Then, if you limit your post exercise carbohydrates, you stimulate fat metabolizing pathways to refill that glycogen storage deficit in the muscle. This magnifies or leverages the benefits of a low carbohydrate diet to reduce overall body fat stores.

The exercise can be as simple as an afternoon walk – which only has to be 20 minutes to be of benefit - or as complex as a rigorous training program .(http://cptips.com/hit.htm). There are a number of programs out there – here is a short video: http://www.nytimes.com/video/health/100000001515630/the-20-minute-workout.html  And a recent study shows that even a few minutes of intense exercise in a 10 minute exercise program will provide these benefits. So lack of time is not an excuse.

• 20 minutes of exercise a day provides further health benefits (magnifying the positives of a low carbohydrate diet).
  
• Exercising BEFORE a meal is a plus.

V. Microbiome (colon bacteria) – The bacteria in our colon were traditionally considered as “outside our body” and irrelevant to health. But we now understand that products of bacterial metabolism of the food we eat are actually absorbed and impact metabolism. Here is an intriguing article that illustrates the point. http://www.nytimes.com/2013/09/06/health/gut-bacteria-from-thin-humans-can-slim-mice-down.html.  And here is another easy to understand explanation: http://www.drmirkin.com/nutrition/two-clues-to-the-obesity-epidemic.html
And the colon's bacterial balance will change in a matter of days based on our diet – http://nutritionfacts.org/video/how-to-change-your-enterotype/

I feel certain that we will find that colon bacteria play a significant role in the development of fatty liver and glucose intolerance or pre-diabetes - most likely via the production of intermediate chemical products from the metabolism of the foods we eat. And that it is the microbiome that is involved in the weight loss benefits we see with a shift to a plant based diet.

• No artificial sugars.
• Decrease the amount of meat in your diet relative to plant based protein sources.

To summarize, these are the components of my Mukilteo diet. And if you want a go slow approach, I put them in what I think is their relative order of importance.

1. Move towards a daily 25%-50%-25% distribution of calories (breakfast-lunch-dinner).
2. Decrease the percentage of daily calories from carbohydrates – low glycemic load foods preferred.
3. The bulk of daily carbohydrates to be eaten by 2 PM. Minimize carbohydrates in the evening meal – bonus points for a plant based dinner.
4. As protein is increased, increase the amount that is from plant based protein sources.
5. 20 minutes of exercise a day will magnify the benefits of a low carbohydrate diet.
6. If you want to lose weight, eat fewer calories than you expend.