Mendosa Interview with Dr. Balart

Interview with Luis A. Balart, M.D.

This interview with Luis A. Balart, M.D., one of the authors of Sugar Busters!, was conducted by telephone on May 25, 1998, with Rick Mendosa, a freelance writer specializing in diabetes who was writing an article about Sugar Busters! for Diabetes Interview magazine. That article was published in the September 1998 issue.

RM: Is there anything you wanted to say specifically before I ask my questions?

LB: No. The only thing is that when we wrote this book we wrote it as a way to get people to lose weight and feel better. We were very happy when we began getting feedback from diabetics. We had not really realized the full implications of this way of eating for diabetics until we started hearing from people that were able to get off of oral hypoglycemic agents, or lower their insulin doses, or in some cases get off insulin. We were very happy to see this happening. Professionally it has been a very gratifying thing to see people do well.

RM: I would like to have a sidebar to my article about sugars. You mention in various places the types of sugars you don’t want people to eat or eat small amounts of. But there are really lots of others that you don’t mention. Would you be the one to help me pull that together?

LB: Let me take a crack at it.

RM: I think this is important. I don’t think the book has covered it in an organized fashion. You say basically no refined sugar, corn syrup, molasses, honey, sugared colas, and beer on page 7. Later on you say only small amounts of Maltodextrin, malted barley, polydextrose, maltitol, sorbitol, or sugar alcohol. I think in some other place you mention high-fructose corn syrup. And somebody says, "The authors also frown on crystalline fructose." What about fruit sugars like date sugar?

LB: Is that a product in a crystalline form?

RM: I don’t know. And I see in the supermarket date puree and something called datem. I have no idea what that is.

LB: I don’t either. On that one I would pass to Dr. Andrews.

RM: On the Sweetalk list people use the term legal so often. You use it once or twice in the book. It is a little off-putting to me.

LB: It is. We didn’t want that to mushroom too much. You are right. There aren’t any things that are really theoretically bad for you. It is just the way that people eat them primarily. We don’t want to promote that business of "legal" or "illegal." The best way to say it is, is this part of the way of eating or not?

RM: Someone wrote to me that after she finished reading the book she was totally confused about how much the different food types -- protein, fat, carbohydrates -- you recommend per meal. I wrote her back that I doubt if anybody was going to give you a recommendation per meal, but maybe they would give a general recommendation.

LB: You are absolutely right. The general recommendation, say for a 24 hour period or a day, is that we should follow the general accepted guidelines, which basically break down to somewhere around 40 of carbohydrates, 40 of protein, and maybe 30 or less of fat. You can do that and still get a good balanced meal. If you look at this way of eating, the natural inclination will probably be to eat a little more protein. So you might be eating a tiny bit more protein than normal. We think that would still be within a good balance. This is not like an Atkins, say, a very severe carbohydrate-restricted diet. And the other important message that we try to bring to people is that we are not saying no carbohydrates. We are saying choose the correct carbohydrates and you are still going to be eating a good solid number of carbohydrates in a 24-hour period. But they are just going to be the ones that are better for you. And so we are sticking with the traditional 40-40-30 or 40-40-25. You are going to have to be somewhere around there, because that is a good balance.

RM: "Smoking cessation provides major non-medical ways to accomplish this reduction of circulating insulin." Unless I’m missing something, the book doesn’t explain how insulin production is affected by smoking.

LB: We actually did not address that on purpose, because the amount of relevant scientific data is skimpy. The same thing for caffeine. We found some studies that show that caffeine raises the insulin levels. But then we found others that said it really doesn’t do it. So when we re-wrote the book, we were a little less certain about the caffeine connection. I don’t doubt that there are studies that show that cigarettes can do that, but we just didn’t feel like there was enough data there for us to get into it. And if there is better data at a later date, that certainly could be part of it. There are enough compelling reasons to give up cigarettes that we don’t need to include it!

RM: I am a non-smoker. I am not hoarse because of smoking.

LB: I started out life smoking. I quit. I don’t like it and I don’t condone it, particularly my patients, where I see them with problems.

RM: Let me ask you about cereals. Why isn’t Special K recommended or suggested in the 14-day meal plan along with oatmeal?

LB: When we made the meal plan up, we had so many choices. But we definitely should have put it in there. It is one of my favorites. It has a very low glycemic index to it. I believe that Special K is probably in the 40s. I wanted it in there, but I lost out to my colleagues, who like some of the other ones. I am sorry that that happened, but we couldn’t include everything. It is a very good one -- even though, as you will read on the label -- it has a little sugar.

RM: That was my reaction [to that person’s question]. I said that you doctors were considering both the glycemic index and their sugar contents.

LB: Right.

RM: For example, they don’t like regular All-Bran, because it has sugar, even though it has a low GI. Getting off sugar is the key. Do I have that correctly?

LB: Right. That is a key part of it, exactly. That has so many good effects on your taste buds and other things. You can undo the whole thing if you have a great cereal with a lot of fiber and you put a lot of sugar on it. It wouldn’t work.

RM: [Someone wrote that] the 14-day meal plan seems to violate some of the principles of the diet. For example, light mayonnaise eaten with fruit eaten with the meal, and some of cereals have illegals in them.

LB: The reason that the meal plan is in there is that there were so many requests for it. We had so many people who wanted to be told what to eat. Basically, what we have in there is a maintenance meal plan. One that would be able to maintain your ideal body weight. What we are telling patients, and perhaps we are not doing as good a job as we should have in the book is that if you need to lose weight or if you have a need to control your blood sugar even more than most people then you need to have more severe avoidance of some of these items. You get to the point where if you are at a steady state you can actually eat a few of these things and maintain your body weight. So we tried to reach a meal plan that would be a happy medium.

RM: Some of these items to avoid you mean the various types of sugars?

LB: Exactly.

RM: Someone else asked along the same line, but thinking very differently, and I don’t think she is right, "If weight loss is slow, as it is for me, should red meats be restricted or eliminated?

LB: No.

RM: She is also asking about restricting cheese and carbohydrates?

LB: If you are having a real hard time losing weight, they you may want to restrict even the moderate glycemic carbohydrates. So you would go down to your very low ones. Fortunately, cheese is low. So that would be okay. Even some of the whole-wheat breads that look real good, they are going to have a modest glycemic index. So if you are losing weight, I would avoid even those and get yourself to an ideal body weight.

RM: A couple of days ago I went through the supermarket looking through all the fine micro-bakery breads and I didn’t see one that was satisfactory on this diet.

LB: No. I’ll tell you. We are intensively investigating that issue right now. One good bit of news is that we found a baker located in New York. It is a German bakery. And what they do is they developed mixes. So you can bake the mix locally in New Orleans or California. They have made some samples up for us and we have tasted them and they are excellent breads and real high quality whole grain. One of the ones that we tested was a six-grain bread. Very high-end product. When you look at it and taste it you know, you have that feel. So we are hoping that maybe we can develop that ourselves and say that this is "a Sugar Busters!-approved bread" so people can know. I don’t know how far we can get along with this idea, but we are working on it. Because you are right, some times you go to the stores and they don’t have much of anything. And even the stuff that is brown isn’t really good, because it is make with whole-meal flour and that is about it.

RM: Is bread the main thing that you think you may have to start making?

LB: Oh, yeah. Because that is where you see so much variation from store to store, city to city. I was in Portland, Oregon, a couple of weeks ago and they have some wonderful breads. They told me, we have some bakers here that are really into this European, German-type bread. Every community is going to be a little different depending on what the traditions are and who the bakers are. Here in New Orleans the demand has always been traditionally been for French bread. And French bread is just atrocious for the glycemic index. So we are working on that and hopefully we will have something that will be good for them.

RM: I understand that you are working on follow-up books, perhaps a cookbook. Any comment on when that will be available.

LB: Probably some time in the fall.

RM: These are the next steps: cookbook, products, licensing maybe?

LB: Yes. There are things that could be made locally that we could license. Obviously we are doctors and are busy. We have our practices and we really don’t want to leave those. Mr. Steward is a real busy man. I think that what we would like to do in order to bring some uniformity to this and also to give people the idea that this is really good and we stand behind it in licensing some products throughout the country that we feel comfortable with, and we are not going to do it to make money, but because this is a good product. For instance, we were approached by a guy who wants to make a chip. I had problems with that. I said, I am not so sure that chips are good for you in any way, shape, or form. So we have to be very careful in how we approach any licensing.

RM: That could be the same person who approached me for GI testing. He makes a sweet potato chip.

LB: Yes.

RM: I put him in touch with Jennie Brand Miller in Australia.

LB: I would have to see the data and what kind of oil he used and we may say, yeah, that looks good. But as a matter of priority I think we need to put our interest into things we know, cereals and breads and things like that that are very important to nutrition and are keys to success in this way of eating. So that is what we are going to do.

RM: Someone else writes about cereal, "I found the list of legal carbs very confusing and obscure. In various places I have seen Grapenuts, Cheerios, Shredded Wheat, and other cereals listed as legal. I am almost sure that Cheerios and Shredded Wheat are listed in the new book, and Grapenuts was mentioned in a question-and-answer session with one of the authors, yet if you look at the GI for any of these, it is quickly recognizable that they should be avoided."

LB: Cheerios out of that group would be the one to avoid. But you know there is a whole-wheat Cheerio, which is much better. The confusion may be as to which type of Cheerio it is. Grapenuts are actually pretty low.

RM: Shredded Wheat is pretty high.

LB: Which brand? There are two or three varieties. It may be in the 50s or 60s, so you are right, it is moderate. The glycemic index information that is available, a lot of it comes from Australia and their cereals are not exactly like ours.

RM: That’s right There have been three studies of Shredded Wheat. One in Australia, that was 58 (when glucose = 100), another one that Jenkins did in his original study was 67, and then the Shredded Wheat, Nabisco Brands of Toronto, was 83. The mean is 67.

LB: So that is a moderate one. So you are right. Again, we have to sort of reach a happy medium and anybody who wants to lose a lot of weight probably should avoid the moderate ones as well. It’s like the bread and the crackers and the pasta. A lot people who have approached us have wanted to lose only say between 10 and 15 pounds. They can obviously do this at a different level from those who want to lose 20 or 25 pounds or beyond that. That to me, Rick, is the difficult thing to impart to patients: look, you can fine-tune this thing yourself. When we wrote the first book we avoided the meal plan because my idea was let’s communicate the knowledge to the reader in a way that they can understand it. Let the reader adapt this way of life, way of eating, to their own particular needs. That sounded really good, but as we got feedback from folks, they all wanted, "we need a meal plan; you need to tell us what we can eat." People somehow have to be sometimes led to do things and so we put that it there. And it was difficult because the meal plan doesn’t apply to everybody. You have different levels of what that applies to and in a way I am still attracted to my idea, which is that we need to tell everybody how this works and why, and then let them do their own thing. But we had to settle for some things. That’s why you will see some things in there that normally if you really needed to lose a lot of weight for instance you should probably avoid that. So if you can impart that in your message it is a very important thing.

RM: There is an interesting and related question that someone asked. "Could you also ask if you doctors have a specific recommendation for Sugar Busters! for weight loss versus Sugar Busters! purely for blood glucose control? There must be some differences," this person writes. Are there?

LB: I think there probably are. Again, it would depend on how high your blood sugar would be. If you are an insulin-dependent diabetic then of course you have some variables there. For the majority of diabetics, as you well know, 80 percent of them or even more are overweight. So while achieving weight loss you are also achieving blood glucose control. There is going to be a gray zone for some of the patients who are insulin dependent who may not be obese and how you can achieve blood sugar control and not necessarily have to lose a lot of weight, because many of those patients don’t need to lose weight, would be a little tricky. And that’s what we are telling patients that this is something that you need to do under the control of your physician. Because, for instance if somebody is taking 20 units of NPH or 30 or 40 and now your blood sugar starts coming down a bit, you need to know how much to cut back. There are so many variables here that it needs to be done under a more controlled environment than just losing the weight. For diabetics, in particular for insulin-dependent diabetics, it’s going to be a little tricky. But the short answer to your question is yes, both things can be achieved at different levels. You could probably not lose a lot of weight but control your sugar in some cases, but in most cases because most folks [who have diabetes] are overweight and have high blood sugar because of insulin resistance, you are going to achieve both at the same time.

RM: A lot of diets say that you can’t have salted nuts. This person says, "Are salted nuts acceptable? Or is it necessary to stick to plain right-out-of-the shell nuts like our ancestors ate? I much prefer salted, but this may be why my weight is slow to drop?"

LB: The problem with salt will be with many patients who also have hypertension and who may have a tendency to develop hypertension. So I think that salt should be consumed in moderation. To the extent that nuts are good for you, I always tell my patients to try the unsalted or lightly salted nuts and not necessarily the high-octane salt where you can see it in the naked eye you know you are in trouble.

RM: My wife and I mix packages of salted and unsalted nuts to get it sort of half salted.

LB: Yes, exactly. That’s a perfect way to do it. That achieves the right mix. Because sometimes there is a lot of salt in there, and if you have high blood pressure or a tendency to that, that would definitely worsen it. So we don’t want to promote that. I will tell you this though. This is my own observation of my own body and I don’t know if I can apply this to everybody, because everybody is a little different. I have always been partial to salty things. But I also like sweets. I have found that as I was on this way of eating of avoiding the sugars I could feel my body changing. I do think there is a bit of a craving for salt that one has to be careful with. That is my own observation that I haven’t researched. So I think that if anybody out there would have a tendency to eat a little more salt than they should, they should definitely be careful with it. We don’t want to go overboard.

RM: Finally, I noticed that there are several differences in the GI factors that you list and the ones in Jennie Brand Miller’s book. Not too many. I brought one to the attention of Mr. Steward. I think it is clearly based on a misprint in Jennie’s book.

LB: Which one is it?

RM: Specifically, fresh apricots, where you say are 10. You were rounding from her book and it had a misprint. She wrote 7, and it should have been 57. It has been corrected in a later edition. Mr. Steward says that will be corrected [in a subsequent printing of Sugar Busters!.

LB: It would make more since for me for it to be in the 40s or 50s like other similar fruits.

RM: I don’t know how to explain this, though. You say the GI of barley is 45 and it is pretty clear from the Canadian studies reported in her book that it is 25. Barley has a very low glycemic index, far lower than any other. Where did you get the number of 45. Where did you get that number?

LB: We got that from The G.I. Factor book.

RM: No, that’s what I have in my hands. It says 25.

LB: That could be a misprint. Does it say pearled barley? Because pearled is the lowest one.

RM: Ah. That’s right. You may be putting together the cracked barley and the rolled barley [with the pearled barley].

LB: The pearled is the lowest one.

RM: That’s right. Pearled barley is 25 and the cracked and the rolled increases it.

LB: Maybe what we did at the request of the editor was to lump them together. Listen, I have got to go do an endoscopy.

RM: Thank you very much, Dr. Balart.