Guest post written by: Amy Berger
Dr. David Perlmutter’s appearance on episode 200 of the Paleo Solution podcast stirred up a bit of controversy. It was disconcerting to hear one of the premier clinicians in the field of neurology present a hardline stance concerning carbohydrate consumption. With many of us consuming higher amounts of carbohydrates to fuel athletic performance, lighten the food budget, or simply enjoy a little more variety in our diets, hearing a medical expert draw a line in the sand against seemingly all carbohydrates left a few of us anxious, worried, and starting to question what we’re feeding ourselves and our children.
In light of that, I think it would be useful to present some thoughts about all this. It’ll be a pretty high-level view of things, or, as Robb might put it, “the 30,000 foot view”. On the way up from the ground, we’ll get to see lots of pretty, individual trees, but once we reach cruising altitude, there’s a heck of a beautiful forest to take in, too.
The Big Question
What will prevent mental and physical degeneration? What are the exact actions we could take that will have each and every one of us winning 100-yard dashes and chess tournaments well into our nineties? In case you’re pressed for time, let me spoil the ending for you right here and now: we don’t know. We can’t say with absolute certainty precisely what types and amounts of physical activity will keep us agile and strong. We can’t say exactly how many grams of fat, protein, and carbohydrates will keep every single one of us healthy, pain-free, and firing on all cognitive cylinders for the rest of our lives. Sorry kids, but that’s the truth. For all the studies that have been done, all the programs and protocols that exist, and all the logical sounding theories, the scary fact is: We. Don’t. Know.
If you think this lack of definitive answers gives you free rein to toss back as many boxes of donuts and barrels of soda as you want, from the comfort of your horizontal perch on the couch where you spend ten hours a day, guess what? You already had that. You’ve had it all along. Because diet and lifestyle recommendations—whether they come from the Paleo side of things or somewhere else—are not laws. They’re not commandments. They’re simply information, for you to apply to your own life as you see fit.
Just because we aren’t absolutely sure of everything doesn’t mean we don’t have some pretty good working assumptions. So yes, the bad news is, we don’t have all the answers. And even when we think we have some answers, we often have to go back and revise them in light of new data. But the good news is, even though we don’t know—and really, can’t know—everything, we’ve developed a darn strong framework to help us make informed choices about what we eat and how we live. It’s called ancestral health. (Maybe you’ve heard of it…) We don’t have an iron-clad, step-by-step procedure for guaranteeing we’ll all be intellectual and physical ninjas until we drop dead from happiness as we reach the top of Mt. Kilimanjaro at age 112. But what we do have is the most sensible and most comprehensive approach to all this that we’re currently aware of, based on research that has been done and is still being done by some very brilliant people across a wide variety of disciplines.
So we have an ancestral framework, not a historical reenactment, right? That’s why some of us go running barefoot, but still sleep in a bed. Or why we eat bone marrow but also have Facebook accounts. These things aren’t mutually exclusive. In keeping with this 30,000-foot view, we could ask ourselves what the environmental and dietary inputs are that we’ve evolved to expect, and what are the likely consequences when we spend most of our lives without these inputs?
Again, we can’t know these answers with absolute certainty. But we have some fairly educated speculation that we can use to take action and hedge our bets, rather than throwing our hands up and doing nothing because of “paralysis by analysis.” And the framework we have can offer some insights that might help us make sense of Dr. Perlmutter’s stance on carbs, and decide how we want to proceed in our own lives.
…And the Possible Answers
As we get into this, let’s remember the patients Dr. Perlmutter likely deals with: they are demented, inflamed, in chronic pain, and otherwise suffering the effects—or so we presume—of diets & lifestyles out of sync with what evolution has conditioned our bodies and brains to expect. To put it bluntly, these people are broken. So while it’s important to know how to “fix” these people, perhaps even more important is to figure out how to not break in the first place. And we think the ancestral health approach offers some pretty great guidelines for this—probably better than anything else currently on offer. Will we be proven wrong? Only time will tell. Time, and a seriously huge prospective study that will likely never be done. (Anyone got an extra couple hundred million dollars lying around?)
But just because we can’t know everything for sure doesn’t mean we don’t have some suspicious looking smoking guns. For the purpose of not “breaking” in more ways than there’s room to mention here, one of the most powerful things we can do for our health—or so we currently believe, based on an exponentially expanding body of research—is maintain insulin sensitivity and keep blood glucose levels in check. One effective way to do this is to keep our carbohydrate intake at levels suitable to our individual physiology. This is where things get gnarly. (Or, as Robb might say, where people’s panties start bunching.) People get very anxious when this topic comes up, and for good reason. Some people are perfectly content to eat less than 30g of carbs a day for the rest of their lives, but others prefer some sweet potato hash now and then, a handful of berries, some butternut squash, and maybe even some grain-free dessert splurges made with maple syrup and dried fruit. But one thing we probably all agree on is that none of us wants to end up a financial and emotional burden on our loved ones. If poor health is scary, poor neurological health is downright terrifying. And it seems like this is where most of the trepidation regarding carbohydrate consumption comes from. Are we doing ourselves and our children a disservice by consuming vegetables and fruits that have been part of the human diet for millennia?
What is the exact amount of carbohydrate that, when consumed over a day, a week, a year, or a lifetime, could potentially bring about diabetes or Alzheimer’s? Would that amount be different for a librarian and an NHL player? How about a 5’2” Korean woman and a 6’4” pureblooded Cherokee man? The mere nature of those questions should show us how difficult it is to posit answers. Is a once-a-month ice cream bender in an otherwise lower-carb diet going to cause us to become insulin resistant? How about a post-workout whey protein & banana smoothie? Will a ketogenic diet prevent all illnesses related to blood glucose dysregulation? If so, is that true for every single human being? And if that’s so, would the ketogenic diet need to be followed for an entire lifetime? We just don’t know. No one can tell any of us the exact number of carbohydrate grams that each of us, as individuals, can consume with no adverse effects on long-term health.
But looking at this through the evolutionary lens and combining that with what we know about physiology and biochemistry can give us a good sense of how to feed and water ourselves. Good enough to prevent every single illness, wrinkle, and moment of forgetfulness we would otherwise encounter sixty years from now? We can’t say. And if you’re looking for someone who can tell you that their approach is THE way, the best way, and the only way, for every human being on the planet, I encourage you to make sure your BS meter is expertly calibrated and fully charged.
Informed by Evolution & Anthropology
Most of the conditions Dr. Perlmutter regularly treats are the results (or so we currently believe) of insulin dysregulation, mitochondrial dysfunction, gluten intolerance, and autoimmunity. So in order to “not get broken,” we would want to avoid foods and activities that could potentiate these things, and include things that are supportive of health at the macro and micro levels. This matches up with the Paleo template of eating real, whole foods, restoring and maintaining lifelong insulin sensitivity, and preventing or reversing leaky-gut induced conditions by avoiding foods that are problematic for us almost as nicely as Africa and South America fit together according to the theory of continental drift. Based on our evolutionary framework, as general guidelines for keeping ourselves in good working order for as long as possible, we can list sleeping when it’s dark out, getting physical movement the way Mark Sisson describes it (lots of low-level activity like walking; lifting heavy things a couple times a week; and going all-out on speed & effort once in a while), getting some sunlight on our bare skin, not sterilizing and irradiating every molecule we come in contact with, and managing stress levels (feelin’ groovy as much and as often as possible, but with occasional periods of pants-wetting fear, limb-tearing anger, and/or stomach-churning anxiety).
And then, of course, there’s diet. Like I said in my comment on the podcast post, “just because ketogenic/VLC diets seem to do a stunningly fantastic job of healing in some conditions for which conventional pharmaceuticals have largely failed or even made things worse, doesn’t mean every single one of us needs to be on a ketogenic diet our entire lives to prevent these conditions.” I used the metaphor of an insect infestation: That “calling an exterminator and having him fumigate your house kills your ant infestation doesn’t mean setting off bug bombs in your house is required to prevent the infestation in the first place. You can use other, less drastic measures to ensure you don’t need the more extreme solution later on. (Better insulation on doors & windows, not leaving food out, etc.)”
So what are the less drastic measures we can implement when it comes to diet? Since poor glucoregulation seems to be one of the larger issues (if not the largest) behind several metabolic and degenerative conditions, the carbohydrate question is especially important—and particularly vexing. In light of us not being able to say much of anything with 100% certainty, it’s impossible to define the amount of carbohydrate that will and will not lead to insulin resistance and related health complications. There are just too many factors at work to be able to make blanket statements that apply to the ethnically, geographically, and physiologically diverse species that is Homo sapiens. In the oft-cited Kitavans and Inuit, we have two populations that remained robust and healthy on radically different diets. Does this mean a Kitavan would thrive on whale blubber and an Arctic dweller would remain her strong, healthy self on starchy tubers and fruit? From lactase gene persistence to skin pigmentation, we assume certain physiological adaptations have occurred through the millennia. Why should carbohydrate tolerance be any different? We shouldn’t dismiss the possibility that groups of people with certain ethnic and geographic origins can consume more carbohydrates than others long term without ill effect. And based on studies of traditional populations (by Drs. Price, Lindeberg, Eaton, etc.), it’s safe to say that consuming carbohydrates, per se, does not cause the myriad health problems we see today. Context matters. Can I say that again? Context matters. (Or so I think. In the proud tradition of responsible scholars, I reserve the right to revise my position if necessary.)
But let’s stick with our big picture focus: if we try to stay guided by combining common sense with our evolutionary lens, it’s possible that 200 grams of carbohydrate from potatoes, parsnips, yams, and beets have a different metabolic effect than 200 grams from Mountain Dew and Oreos. It’s also possible that those 200 grams—regardless of where they come from—have a different effect in someone who was born with compromised insulin sensitivity and digestive function, and someone who, for reasons of sunlight exposure, sufficient sleep, good stress management, reasonable levels of physical activity, previous generations’ nutrition, and, for all we know, Venus rising in Aquarius the day they were born, are able to process much more carbohydrate than their next-door neighbor.
Is there a difference between eating some honeydew or a sweet potato now and then, versus fruit cocktail canned in heavy syrup eaten for breakfast every morning along with whole wheat toast and a 20oz glass of orange juice? Nutritionally speaking, yes, of course there’s a difference. Biochemically, in the non-metabolically broken, there also seems to be a difference. But the broken people—the ones who fail to process most carbohydrate properly—would likely do well to avoid both options, at least while they’re still in the process of repairing themselves. Some people will be able to repair themselves to the point where they can increase the amount of carbohydrate they eat. Some won’t. Some might have done so much damage for so long that they’ve backed themselves into a metabolic corner and the only way to keep it from getting worse is through medication and/or a drastic diet.
Would Dr. Perlmutter’s recommendations for everyone, across the board, to follow a lifelong low-carb diet largely prevent “the diseases of civilization”? Probably not all of them, but it would likely go a long way in the right direction. Does that mean a low-carb diet is required to prevent them? Maybe not, but what is probably required is lifelong good glucoregulation—whatever that means for YOU. Maybe it means under 50g of carbs a day, maybe it means under 150. Maybe it means 200 on the days you have a tough workout, but 40 when you go a couple days being sedentary. You can’t know unless you pay attention to your own body. (For anyone who thinks the original Atkins diet was nothing but bunless double bacon cheeseburgers, I encourage you to read his earlier books, because the much-maligned Dr. A was a strong proponent of finding your own individual level of carbohydrate tolerance. For some people, that might be 200g and leaves room for rice and fruit. For others, it might be 50g, in which case they’re better off sticking with broccoli and eggplant.)
Let’s bring this back to what we’re all after here: not getting broken.
In my original comment, I said that if we smell the smoke long before the fire gets out of control, we can spare the house from burning down. Our bodies are only too happy to give us smoke signals all the time. Do we get irritable if meals are skipped or delayed? Do we want to maim, torture, or kill everyone in sight until we get fed if it’s been a few hours since our last meal? (Kudos to whoever came up with the word “hangry.” It’s golden.) Do we have times throughout the day when we feel fuzzy-headed or forgetful? These can be indicators of blood glucose gone awry. And you don’t need a fancy test or even a doctor’s appointment to interpret these smoke signals and find out what’s going on. How about a $20 meter from the corner drugstore? We wouldn’t go on a cross-country drive without occasionally glancing down at the gas and oil gauges. Why should we drive through our lives without checking the numbers once in a while? When we see fasting blood glucose, A1C, and triglycerides inching upward over the years, that could be a sign we’re eating more carbohydrates than our body can handle appropriately. (With the understanding that A1C might not be an ideal marker for healthy people already following Paleo or low-carb diets.) We don’t have to wait for full-blown diabetes to come knocking on the door and we’re all but forced into cutting carbohydrates (or dosing up the insulin, along with all the great things that can lead to). We can self-check now and then to see where we are and do modest repairs before the wheels completely fall off the wagon.
That’s the good thing about these numbers. Unlike a smoke detector that only goes off when there’s already smoke—and possibly a fire—in the house, some of the biomarkers we believe offer clues about our health start moving unfavorably long before we’re diagnosed with anything. Overt symptoms sometimes take years to manifest, and they only show themselves when the problem has existed unchecked for so long and has become severe and/or widespread enough that the body can no longer compensate for or hide it. So keeping an eye on some of these markers over time can be a kind of metabolic GPS, telling us when we need a course correction.
But let’s remember that even these numbers are imperfect guides. If fasting blood glucose at 100 mg/dL makes someone “pre-diabetic,” how different is that from someone at 99? Or what about cholesterol? If a doctor pushes statins on someone with total cholesterol of 200mg/dL, does that mean the person at 199 is totally in the clear? (Just an example. I’m fully aware that 200 is not high and the way the “treatment” of cholesterol has been medicalized is beyond ridiculous.)
Okay, that’s all well and good, but WHAT ABOUT CAAARBZZZ???
Let’s remember that humans are nothing if not opportunistic omnivores. We eat what we can, when we can. If we think about this from our ancestral/evolutionary viewpoint, it makes sense that we would have made use of the flexibility to be sugar burners or fat burners seasonally. That is, consuming fruit and sweeter vegetables in summer to “fatten up” for the relatively leaner period of winter, when we would have been closer to a ketogenic diet, accompanied by less physical activity and more rest. Almost like a human hibernation period. But there are other factors at play besides our carbohydrate consumption: considering the amount of darkness during winter away from the equator, we likely would have gotten a lot more sleep. Our ancestors weren’t waking up at 4:30 or 5:00 in the morning every day, all year long, to go to work or hit the gym, whether it was light or dark out, hot or freezing cold. Our modern diets & lifestyles have made it so neither the famine nor the darkness ever comes. These environmental inputs we’ve presumably evolved to expect are absent from our 21st Century lives. We have to intentionally impose these conditions upon ourselves because they no longer occur naturally for us. But it’s not difficult to do. It’s as simple as implementing periods of ketosis, fasting, or low-carb once in a while (if you don’t do it as your baseline anyway), and sleeping in the dark. (It also couldn’t hurt to get outside in the fresh air now and then, preferably in a green, woodsy area, but that is a whole separate topic.)
So back to carbs. Dr. Perlmutter likely deals with younger people who’ve been eating the SAD all their lives, or, in the case of baby boomers, for enough years that their health is completely, totally compromised. It makes sense that people who are quite far gone would need a strict, no-nonsense dietary intervention as a therapy. They don’t have the luxury to play around with dipping their toes in the water to test things out. They need to do a cannonball into the deep end. But this is what makes the most sense after the damage is already done and we’re trying to reverse it, stop it, or at least slow it down a little. This does not automatically translate to this same dramatic protocol being required to prevent the damage from occurring in the first place.
If you stumbled upon Paleo-style eating early enough in your life (or your children’s lives) to understand the basic approach of keeping omega-6 consumption low, staying away from gluten, eating the best quality meat & produce you can afford, and eating real, whole food carbohydrates to match your individual metabolic sensitivity to them or to satisfy your physical performance goals, then there’s a good chance you’re not going to accumulate this lifetime of extreme damage. You will accumulate some damage, though, make no mistake about that. The glycated proteins and advanced glycosylation end products (AGEs) Dr. Perlmutter mentioned are normal, natural parts of aging. But they’re supposed to happen slowly, over a very long period of time. We’re all going to get old and die. We can’t change that. But what we can change are obese first-graders, 35-year-olds sidelined by rheumatoid arthritis, and 65-year-olds (still young!) with dementia so severe they require live-in care.
After Dr. Perlmutter’s interview aired, people started questioning their carbohydrate intake, and some wondered whether it was safe to feed their children fruit. If you’re feeding your children a Paleo diet most of the time, they get outside and run around regularly, and you aren’t hosing them down with antibacterial gel every time they come and go from the house, they are likely WAY ahead of the curve and it’s hard to imagine that a bit of fruit or starch here and there would derail their long-term health. We might never know exactly what prehistoric man ate, but we have a pretty good idea of what he didn’t eat. (Pop-Tarts and gas station cappuccinos come to mind.) The basic ancestral dietary framework—including carbohydrates—will get us, say, 85% of the way there. The extras—better sleep, intelligent exercise, lower stress, some sunlight and fresh air—will maybe get us to 96%. As for the last 4%, it should be weighed against our quality of life—against the simple pleasures of dining out with friends, going apple picking in October and eating some of the apples, or sleeping in on a Saturday morning during a blizzard instead of scraping ice off your windshield in the dark so you can make your 6am workout.
You are the one walking around in your own body and in your own life. Everything has a cost/benefit associated with it, from the volume and frequency of the exercise we do, to the amount of omega-6 in the nuts & seeds we eat, to the amount of fruit we consume. We have to make these choices and tradeoffs for ourselves. We can live to be 114, but how much will we enjoy those years if we spend the last 75 of them never, ever dining out with friends because …*gasp*… something might have been cooked in canola oil? Or we become so afraid of fructose that every summer for the rest of our extra-long, long lives passes without the juice of a ripe peach running down our chin?
The good news!
This post started off with the bad news—that we don’t have all the answers. So let’s end it on a better note. One thing we do know is that the human body is remarkably, stunningly resilient. Given proper care and feeding—and thanks to the glorious process of cellular turnover—our bodies are capable of staggering acts of healing and regeneration. The testimonial section of this and other Paleo sites are repositories of personal accounts detailing seemingly miraculous turnarounds of arthritis, diabetes, heart disease, obesity, lupus, MS, digestive disorders, infertility, anxiety, acne, depression, and more. So while we can’t say with certainty exactly how many grams of carbohydrates each of us should be eating to cruise into old age happily and healthfully, I’d say we just might be on to something here.
Amy Berger, M.S., is owner of Tuit Nutrition. A proud U.S. Air Force veteran, Amy spent years doing “all the right things,” but failed to see the expected improvements in her health and fitness. By shifting to nutrient-dense, unprocessed foods (especially some of the things we’ve been told not to eat!), she transformed her health and physique, and now shares the lessons learned with those still struggling. She is especially passionate about showing people that losing weight and achieving vibrant health do not require starvation, deprivation, or living at the gym— and that real men and women need REAL FOOD, not lettuce!