Low-Carb Mediterranean Diet

© 2010 Steve Parker, M.D.

After a year of intense research and analysis, version 2.0 of the Low-Carb Mediterranean Diet is ready.  It’s a work in progress that may be improved periodically.  Check back for updates.

Precautions and Disclaimer

The ideas and suggestions in this document are provided as general educational information only and should not be construed as medical advice or care.  Information herein is meant to complement, not replace, any advice or information from your personal health professional.  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.  Steve Parker, M.D., and pxHealth disclaim any liability or warranties of any kind arising directly or indirectly from use of this diet.  If any medical problems develop, always consult your personal physician.  Only your physician can provide you medical advice.  You should not follow this diet if you are a child, pregnant or lactating, have alcoholism or history of alcohol abuse, have abnormal liver or kidney function, or have gout or a high uric acid blood level.  If you take medications for high blood pressure or diabetes, they may need to be stopped or reduced by your personal physician.

 

Introduction

The Low-Carb Mediterranean Diet is designed specifically for people who have one or more of the following conditions:

Diabetes and prediabetes always involve impaired carbohydrate metabolism; metabolic syndrome and simple excess weight often do, too.  Over time, excessive carbohydrate consumption can turn overweight and metabolic syndrome into prediabetes, then type 2 diabetes. 

The key feature of the Low-Carb Mediterranean Diet is carbohydrate restriction, which directly addresses impaired carbohydrate metabolism naturally.   

Why “Mediterranean”?  The traditional Mediterranean diet is widely recognized for its promotion of health and longevity.  Many of its components are compatible with low-carbohydrate eating.   

The foundation of the Low-Carb Mediterranean Diet is the Ketogenic Mediterranean Diet.  If you’re not familiar with the Ketogenic Mediterranean Diet (KMD), review it here.  The KMD and the document you’re reading now constitute the Low-Carb Mediterranean Diet. 

The Ketogenic Mediterranean Diet is simply the initial or conversion phase of the Low-Carb Mediterranean Diet.  The KMD is a conversion phase because your body is switching to an energy metabolism based on fats and proteins instead of carbohydrates.  Or we could call it a watershed phase since a watershed is “a critical point that marks a division or a change of course; a turning point.” 

Some may stay on the KMD long-term, so it’s free-standing. 

But others will move on to a long-term balance phase, hereafter referred to as the Low-Carb Mediterranean Diet (to distinquish it from the Ketogenic Mediterranean Diet).  It’s a move from very low-carb to low-carb eating.  The Low-Carb Mediterranean Diet (LCMD) adds more plant-based nutrients to the foundational KMD, balancing the benefits of plants against their potential adverse effects on blood sugar levels and weight. 

Eighty-five percent of people with type 2 diabetes carry excess weight.  The Ketogenic and Low-Carb Mediterranean Diets will help with that issue.  But just as importantly, they lower and smooth out the elevated blood sugars characteristic of diabetes and prediabetes, regardless of weight.

I assume readers of this document have been following the Ketogenic Mediterranean Diet for at least a couple weeks, if not for several months or more.  I recommend at least 8–12 weeks.  Most followers—diabetic or not—wanted to lose some excess weight with a Mediterranean-style diet.  Others, already at healthy weights, just wanted better control of blood sugars.

At this point you’re ready for a change either because you’ve reached your weight-loss goal or you want a greater variety of carbohydrates (“carbs”).  Stay familiar with the KMD because it is the basis for everything that will follow.  You’re not really done with it; you’re adding to it. 

Perhaps you’ve been losing weight steadily with the KMD and are not yet at your goal weight but need more food variety.  Many continue to lose excess weight with their expansion to the Low-Carb Mediterranean Diet.  If weight loss stalls, just return to the KMD.

The KMD may be perfectly healthy long-term; we just don’t know for sure.  On the other hand, there is at least some evidence that additional carbohydrates—as in the LCMD—may be even healthier.  For example, fruit and vegetable consumption is linked with lower rates of cancer, stroke, and coronary heart disease.  [Other studies find no benefit.]  Whole grain consumption is associated with lower rates of cardiovascular disease, including heart attacks and strokes.  Legumes are a great source of fiber to counteract the constipation common with very low-carb diets like the KMD.  Fruits and vegetables as components of the Mediterranean diet seem to contribute to longevity. 

And many carbohydrates just plain taste good!

Nearly all the studies linking fruits, vegetables, whole grains, and legumes—all prominent in the Mediterranean diet—with improved health were done in general populations, not specifically in diabetics.  Whether diabetics benefit is not entirely clear.  If such consumption raises blood sugar levels too much, then health outcomes will be worse.

A quick reminder for readers here for the first time: Low-carb eating has the potential to drop blood sugar levels dangerously low in people with diabetes who take certain medications to control blood sugar.  If this applies to you, you must work closely with your personal physician and review “T2 Diabetes and Low-Calorie Diets” and “T2 Diabetes and Low-Carb Diets.”  By the way, I use “blood sugar” and “glucose level” interchangeably. 

Overview of the Low-Carb Mediterranean Diet (LCMD)

You’ve been eating 20–30 grams of carbohydrate daily on the KMD.  Now you’re going to increase to 40-100 grams daily, gradually adding carbs that may have beneficial effects on health and longevity.  Adding excessive carbs will lead inevitably to elevated blood sugars in diabetics and prediabetics, to regain of excessive body weight, or a stall in weight-loss progress.

Most people reading this have type 2 diabetes, prediabetes, or metabolic syndrome and have had trouble controlling their weight or blood sugar levels with their former ways of eating.  A few readers are entirely new to the world of diabetes.  In all these cases, we want to avoid adding carbohydrates that sabotage control of blood sugars and metabolic syndrome.  That sabotage may take two forms:

  1. eating particular carbs that will spike your blood sugars too high and for too long
  2. excessive amounts of carbs, which will do the same

For non-diabetics and those with normal carbohydrate metabolism, carbs that potentially raise blood sugar too much are not an immediate issue.  But even for non-diabetics, these glucose-producing foods are associated—at least in women—with excessive body weight, future diabetes, heart disease, and gallbladder disease.  So we may as well avoid them.  For more information, read about high-glycemic-index eating.

If you are not at your goal weight already, adding too many carb grams now will impair your ability to convert your body fat into energy.  Eat too many carbs, and your body will use them for the energy it needs rather than your body’s fat.  You may well continue to lose weight eating 40, 60, or 100 grams a day, but maybe not.  Everybody is different.  Many diabetics will not be able to handle over 70 grams of carb daily.  Some, not even that much.  Continue to weigh yourself daily.  Diabetics must monitor their blood sugar levels as discussed elsewhere.    

Implementation of the LCMD

So, what healthy carbs are we going to add to the Ketogenic Mediterranean Diet?  Fruits, more vegetables (including starchy ones), legumes, yogurt and other dairy products, and whole grains.

To avoid carb overdose and loss of glucose control, we’re adding back carbs incrementally.

I’ve divided the new carbs into groups and specified a serving size for each source of carbs.  Each serving has about 7.5 grams of digestible carbohydrate.

What you do next is add one daily carb serving from the list of Carb Groups and Serving Sizes (PDF) and see what happens with your weight—and glucose levels if you’re diabetic or prediabetic—over the next week.  This is not one carb serving on Monday, two on Tuesday, three on Wednesday, etc.  It’s seven carb servings during a week, one on each day.

Essentially, you still eat the Ketogenic Mediterranean Diet but are adding a daily carb serving.  If your weight loss stalls, you gain weight, or glucose levels rise significantly, you’ve added too many carbs and must cut back, or try different carb sources.  I’ve written elsewhere about acceptable blood sugar levels.   

On the other hand, if you handled the extra carb serving without trouble for a week, you may add one more daily carb serving.  Monitor your progress for another week. 

A Daily Log will help you keep track of your eating and blood sugars.

If you’re handling those carbs, you may increase by one additional carb serving every week.  You’ve added too much carb if your weight loss stalls, you gain excessive weight, or your glucose levels rise too much.  Then you must cut back or try different carbs—especially different carb groups.      

Many people who have diabetes or weight management problems will not be able to increase carbs to more than six additional daily servings.  Either weight or glucose levels will rise.  But that’s OK because you don’t necessarily need more carbs for a long and healthy life.  For many folks, additional carbs are unhealthy. 

Diabetics and prediabetics should probably distribute, eventually, their additional carbs evenly among two or three daily meals.  Eating two or three new additional carb servings all at once as a bedtime snack, for example, is likely to cause high blood sugars through the night and into the next morning.  On the other hand, those same carbs eaten at breakfast and followed by an exercise session an hour later might be handled just fine.  Your home glucose monitor will be indispensable in this respect. 

By the way, if you wish to cut back on your animal protein consumption at this point, feel free.  It’s your choice. I’d continue to eat cold-water fatty fish at least two or three times weekly, along with the usual olive oil and nuts.

Are you with me so far?

OK, so you’re going to add some carbs to your diet, but which ones?  I’ll assume at this point you have diabetes, prediabetes, or metabolic syndrome.  For the potential health benefits, I’d add carbs in this order:

  • fruits
  • more vegetables
  • legumes
  • yogurt and other dairy products
  • whole grains

This is just a loose guideline, not a commandment.  I suggest everyone eventually add one or two servings of fruit daily, classic fruits rather than technical fruits like tomato and avocado already on the KMD.  Berries, in particular, have much to recommend them.  Legumes, yogurt and other dairy products are listed after fruits and veggies because the evidence in favor of their long-term health benefits is not as strong. 

For people with normal carbohydrate metabolism, I’d list whole grains second or third rather than last, but in diabetics…

grains are problematic.  Diabetics are prone to developing blockages in their heart and brain arteries that can cause heart attacks, strokes, and premature death.  Consumption of whole grains on a regular basis is associated with significantly lower risk of developing these problems.  But there’s a fly in the ointment.  Grains, even whole grain products, have a relatively high glycemic index, meaning they cause spikes in blood glucose which could have adverse long-term impact.  Nearly all the studies linking whole grain consumption with less heart disease were done in the general population, not the diabetic population.  Whole grains could be even healthier for diabetics than the general population—we just don’t know.

Diabetics who see a significant spike in blood sugar after grain consumption could address that with higher dosages of diabetic medications.  Would that be healthier than avoiding grains?  In 2010, we just don’t know. 

Eating grains in a meal containing fat and protein also tends to smooth out or eliminate blood sugar spikes.  That goes for other high-glycemic-index carbs, too, like white potatoes. 

Yogurt deserves special mention because it’s a component of the traditional doctor-recommended Mediterranean diet.  It’s a great source of calcium.  Does it have anything special you couldn’t get elsewhere?  Probably not.    

Now you’re ready to enhance the KMD with an extra carb serving daily.  Why not start with a fruit?  Choose a variety of items within any given carb group, and try eventually to eat from multiple carb groups.  Variety ensures you get adequate vitamins, minerals, and phytonutrients. 

Nevertheless, just to be sure, continue your supplements as on the KMD.   

Things are getting a little complicated now.  If you lose your way and regain weight or glucoses get out of control, you can always return to home base: the Ketogenic Mediterranean Diet.

Welcome to the Low-Carb Mediterranean Diet!

Steve Parker, M.D.

Summary of Documents for the Diabetic Mediterranean Diet:

Updated December 20, 2010

36 responses to “Low-Carb Mediterranean Diet

  1. Doc, I’m Type I and I cannot add carbs beyond the minimum contained in 5% vegetables! I do the 30g Bernstein advocates, my HbA1c stays at 5.5%. I add any more to that, I’m back on the rollercoaster.

    I can enjoy carbs when my blood sugar’s low – I’ve calibrated berries etc so I know exactly how much I need to eat to bring my bg up to normal – these little treats delight me.

    Antother thing – I’m an MFT, a psychotherapist – every carb-craver and hypoglycemic I’ve seen has stabilized on the Bersnstein Diet and then lost control of their carb intake when they began to add them back. I don’t know if low-dose naltrexone would help, but these people are carboholics.

    I think it may be true that all Type II diabetics and MetS are carboholics

  2. Steve Parker, M.D.

    Thanks for your comments, Jonathan. Dr. Bernstein’s ideas should have wider currency.

    -Steve

  3. Hi Dr. Parker.

    Nice article. However, you said:

    “Whole grains could be even healthier for diabetics than the general population—we just don’t know.”

    I am unaware of any health benefits that grains bestow upon anyone. In fact it appears that grains either who or refined contain many anti-nutrients that are best avoided by everyone.

    Dr. Loren Cordain writes about this extensively. His paper Cereal Grains: Humanities Double Edged Sword goes into great detail about the dangers of grain to human beings.

    That said, it’s great to read another doctor that is promoting a low carb approach to eating for the gen pop as well as for diabetics.

    You might be interested in the Nutrition and Metabolism Society’s work. http://www.NMSociety.org.

    Cheers,
    Fred

    • I’m not sure how whole grains – essentially sugar – would reduce the risk of stroke and heart attacks. The paper you use in your blog post is a meta not a study so while it suggests an association, there is not proof of cause and effect.

      I think it’s a bit dangerous to use meta’s when trying to determine anything of value. They are only useful for sparking the funding of a good study.

      • Very good points, Fred. I can’t disagree.

        Compared to pure sugar, whole grains would provide some vitamins, protein, minerals, fiber, and phytonutrients that might confer some health benefit. But, yes, the starch in grain is readily converted to simple sugars.

        -Steve

  4. Hi, Fred. Thanks for your input. I really should join the Nutrition and Metabolism Society.

    There’s some observational evidence that whole grains may reduce the risk of stroke and heart attacks in the general population. I wrote about it here:

    http://diabeticmediterraneandiet.com/2010/04/24/whole-grains-reduce-heart-attacks-and%c2%a0strokes/

    -Steve

  5. Teresa

    Hi Dr. Parker,
    I’m researching the Mediterranean diet for my cousin’s husband. He went to the doctor 2 days ago and the doctor told him to do a mediterranean diet. His sugar was in the 300’s, he’s overweight, and has high blood pressure.

    My comment is more about where you say people taking medications should not do the diabetic mediterannean diet. Is that “any” medications or specific ones? The doctor did give him medicines to take but she also said to do a mediterranean diet so we aren’t sure if he can do this diet or not.

  6. Hi, Teresea.

    I can see where my Disclaimer would be confusing and misleading regarding drugs.

    The point I was trying to make (not very well) pertains mostly to people who are on medications that have the potential to cause dangerously low blood sugars. Sulfonylureas and insulin immediately come to mind. Folks on those drugs and eating the typical 250 grams of carbs daily may well get in to trouble with low blood sugar when they cut back to 20 grams of carb daily.

    So a personal physician should be involved, reducing drug dosages as needed.

    Very low-carb eating also tends to lower blood pressure. People taking drugs to control high blood pressure may find that their blood pressures are too low when they cut way back on carbs. Blood pressure pill dosages may need to be reduced, or even stopped in some cases.

    My page on “Low Carb Diets and Diabetes” has more information on this:

    http://diabeticmediterraneandiet.com/t2-diabetes-and-low-carb-diets/

    For some reason, unusually low blood pressures don’t seem to be a problem in people not already being treated for high blood pressure.

    Thanks for your interest.

    -Steve

  7. Tom

    Steve,

    Any word on the pdf for LCMD and the shopping list?

    I was recently diagnosed T2 and I am very interested in your work.

    Thanks,

    Tom

  8. Good question, Tom. I may have time to do them in a couple weeks.

  9. david wilson

    It’s great to see that there are doctors who don’t feel bound to parrot the doctrine that a low fat, high carb regime is right for diabetics, despite its forty-year record of abject failure. Type 2 low carbers like me know that it’s possible to get blood sugars down almost to non-diabetic levels, and to keep them at those levels without any apparent progression for many years, simply by diet alone (or diet + metformin). Of course we are warned that we run a big risk of heart disease – despite the great improvements we make in all the important CVD risk factors! How’s that for cognitive dissonance?

  10. I like your diet very much and it is basically the way I eat these days. I used to do very low-carb, but rarely these days. I find I do better with some good carbs. I have Hashimoto’s thyroiditis and I’m on thyroid hormones. I take my oral temperature several times a day (think I should do it in the ear – lol) to monitor how much I need. This is the most scientific way I have found to montior my metabolism and need for hormones based on how I feel.

  11. Jennifer, it seems logical to monitor body temperature when being treated with thyroid hormones. Most physicians don’t have much experience with it, depending more on lab tests.

    -Steve

  12. Jim E. Garrett

    Thank you Dr. Parker, I have been looking for a way to help control my newly diagnosed Type 2 (diagnosed just after New Year’s Day) and this seems to be a great way as I LOVE food. I am overweight and have hypertension, too. Also being physically disabled which makes exercise difficult doesn’t help me much. My drugs seem to keep me on the hypo side of the blood sugar problem – I know that can be very dangerous too. Thanks for being part of my learning experience, and I will discuss this with my doctor who is very supportive of patients gaining knowledge and taking an active hand in treatment.

  13. vickie ferrell

    i love what you recommend, tell us more.

  14. Andy Narain

    Hi Doc, I’m a per-diabetic who started to regularly exercise (doing strength, resistance, aerobic, anaerobic, and yoga) for at least an hour EVERY DAY since I became serious about taking care of my per-diabetes. I’m a male, 5′ 10”, and weight 151, so I think I’m in the BMI range. I don’t need to lose weight, in fact I’m trying to keep my weight, since I lost ten pounds in a month. I also have high cholesterol and high blood pressure, so I got three things to take care off.

    I’m taking supplements, but it’s only temporary until I can get my blood sugar to where I want it to be. I’m starting to see signs of blood sugar decrease, and my blood pressure starting to go down near the per-hypertension stage, better than when it was near stage 2.

    I can do the low carb diet. I’m not attached to sodas, grains, sweets, or anything. The problem I’m having is that I’m still hungry after eating a low carb diet. I have high metabolism, so foods leave my stomach rather quickly. I try to eat food full of fiber, but stuff like legumes and eggplants have good amount of carbs. And I can’t eat brown rice, because that shoots my blood sugar up, no matter what GI it suppose to be.

    I feel frustrated because the only things that stick to my stomach are foods full of carbs or foods that will spike my blood sugar.

    • Hi, Andy.
      Some of my patients report that they have less trouble with hunger if they consume lots of water around mealtime or add a tsp of sugar-free Metamucil to 8 oz water and drink that. Other get relief be eating a couple hard-boiled eggs, a chicken breast, or a 4-oz can of tuna.

      -Steve

    • Hey, Andy. Thanks for stopping by. I wonder if you’d still feel hungry after eating, in addition to your regular meals, a couple hard-boiled eggs or 4-6 ounces of chicken.

      -Steve

  15. Kay Hawkins

    What do you think about protein shakes with low (3g) carbs and high protein (20g)? And what about almond milk? Thanks for all!

  16. I myself is following a mediterranean diet and have been very happy with the results. I was diagnosed to have type 2 diabetes about 5 years ago and was advised to lose weight. It was really a struggle for me but thankfully because of this diet that I am trying to follow for several years now I achieved the weight my doctor has required me. I hope many would be able to read this article so they will have an idea how essential it is to follow a healthy diet. I also found an article which may also be helpful for people like me who wants to become well again. You can find it here http://www.mediterraneandietrecipebook.com/.

  17. I’ve combined the Mediterranean Nutrition Plan with my Blood Type O Nutrition Plan. Being Blood Type O, my body has a harder time digesting grains, even if they are whole wheat. I eat rye bread / crackers instead. I’ve almost completely let go of white flour and sugar – they have no nutritional value. Fresh fruit and dried fruit combined with nuts make a great dessert.

    • When I look for rye bread or rye crackers in my local supermarkets, I find them. But the first ingredient listed on the back is usually refined wheat flour. They mix in some rye flour so they can call it “rye bread.”

  18. Hi Dr. Steve,
    I’m a 20 year old Type 1 diabetic. I was diagnosed at 5 years old, so I’ve had it for 15 years. Now, my problem is this, I want to lose weight, but I can’t seem to do it. All the info on weight loss is for Type 2s! I’m not overweight, it’s just that I’ve gained some extra pounds over the years though I was very slim for most of my life. Please help me out. If possible could I consult you via email. Please. My Dr. is great, but all he’s concerned about is my HbA1C and doesn’t get how important my weight is to me. He says ‘it’s my body type’, yet I’ve been slim most of my life. Heck Halle Berry is diabetic, and look at her.

    Evelyn (Kenya).

    • Yes….Halle Berry…..look at her!
      Evelyn, I don’t think email consultations are legal where I live (Arizona, USA) – The licensing board here seems to require a physical exam.
      Here’s a trend I’ve notice among overweight type 1 diabetics: They seem to eat high-carbohydrate diets and take all the necessary insulin to keep the associated blood sugars in check. The insulin/carb combo promotes body fat accumulation. If you think cutting back on dietary carbs and insulin is a solution, you’re probably right. Of course, that could raise the risk of hypoglycemia if not done right.
      -Steve

  19. I have to have to be gluten free! I the Med. Diet ok for me? Thanks so much for your help!! Carol
    mcdoncj@frontier.com

  20. mary romano

    Hello Dr. Parker,
    I am a type 2 and of cause always having problems with my weight, I read your KMD and I thought that’s what I was looking for. My Endo just dropped me and I was shocked. I am no saint my a1 goes up and down just like a lot of folks and I try but some days it’s harder then others. I guess I am not healthy enough for her. But she never really gave me any direction just more drugs, so now I must find another doctor. But before i do i am going to try this diet, I have enough medication for two months. It looks easy enough even for me.

    • Hi, mary. That’s disconcerting when your doctor drops you. When I have to do that, I always give the patient an explanation. You deserve one, too. Maybe it’ll be for the best. I certainly hope so. Best wishes.
      -Steve

  21. mary romano

    I started doing your kmd and in seven days I have dropped my BS 100 points and have lost 8 pounds. I have only walked a few times but will now start every day for 15 mins. So being dropped made me mad and she always wanted me to drop the meat and eggs and use egg beaters. they are not good and use more grain. but that made me want to eat something i don’t seem to be able to do. I bought the book and am waiting for it to come in. Thanks.

  22. Hamzah Mustak

    Hi Dr. Parker,

    I have familial hypercholesterolemia. I recently had great weight loss success with a low carb/high fat diet but found that my cholesterol (both LDL and total) were elevated. I was advised to try a Mediterranean diet but want to avoid the grains. Do you have any thoughts / experience with the KMD and LCMD and its effects on cholesterol?

    • It varies from person to person, Hamzah. HDL (the “good cholesterol”) tends to go up; LDL usually stays the same or rises a bit but not to the degree that HDL does. Total cholesterol up, down, or no change.

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