I received an email from a registered dietitian (FS) in May, 2013. She had some reasonable questions for me and I thought you might be interested in my answers. Here’s her email first:
So funny that you happened to comment on my blog post today because I’d already planned to email you. I’m writing an article on low-carbohydrate diets for Diabetes Self Management magazine and was hoping to ask you a few questions about your experience treating your patients with the Diabetic Mediterranean and Ketogenic diets. We could do it via e-mail if you like. What I’d really like to know is how many of your patients were/are successful in sticking to the diet long term and what type of feedback you’ve received from them, along with any other information you feel is pertinent. Also, what carb range to you recommend for your diabetic patients?
First, let me explain a little about my medical practice. I’m a full-time hospitalist, meaning I treat adult patients only in the hospital setting. Nearly all of my patients come in through the emergency department. I treat a great variety of problems, like pneumonia, heart failure, cellulitis, pancreatitis, urinary tract infections, headaches, strokes, GI tract bleeding, cholecystitis, altered mental status, out of control diabetes, etc. My training is in Internal Medicine.
By the way, I work in Scottsdale, Arizona, which is a fairly sophisticated and affluent community. My two hospitals employ some dietitians who receptive to very-low-carb eating.
As it turns out, 30% of my hospitalized patients happen to have diabetes, at least 95% of which is type 2. This is typical for non-pediatric hospitalists. Nearly all of these diabetics have an established diagnosis of diabetes and a relationship with an outpatient doctor who is treating it. I usually ask them, “Are you on any special diet, or do you pretty much eat whatever you want?” Half of them say “nothing special; I eat what I want”! Three out of 10 respond that they “avoid sweets and desserts” or something similar. One or two of every 10 report they make a strong effort to reduce carb consumption below the usual American level (250-300 g/day). No more than five of every 100 has ever heard of Dr. Richard Bernstein’s Diabetes Solution. (I consider Dr. B the founder and leader of the modern carbohydrate-restricted diabetes diet movement.) No more than one of every 100 follows Dr. Bernstein’s or a similar very-low-carb or ketogenic diet.
Once these patients leave the hospital, I cannot follow them in a clinic setting. I wish I could. I see many of them in the hospital only once, which is not much time to develop a trusting relationship. Perhaps surprisingly, I don’t often do a “hard sell” for a low-carb diet, even though that’s what I’d follow if I had diabetes of either type. People have to be ready to make a change in hard-wired eating behavior, like an alcoholic is ready to quit drinking only when he’s hit “rock bottom.” For someone with diabetes, that rock bottom point is typically at the time of initial diagnosis or when a major complication hits (such as neuropathy, kidney impairment, or retinopathy). They’re more receptive to change then. All of my hospitalized diabetics get a business card referring them to my Low-Carb Mediterranean Diet website (Diabetic Mediterranean Diet).
Since I have no outpatient clinic, I have no way of knowing how many of them adopt a low-carb way of eating. I do get unsolicited emails from diabetics who have adopted the Low-Carb Mediterranean Diet or Ketogenic Mediterranean Diet, and they report satisfying results with weight management and glucose control. Problem is, as mentioned, I don’t know the denominator. Not once in two years has anyone ever contacted me to report they were harmed by the diets or that they didn’t help at all with glucose control.
I’m convinced you can get good nutrition eating low-carb and very-low-carb. By “low-carb,” I mean under 130 g/day, and “very-low-carb” is under 50 or so. An added benefit for diabetics is that they may be able to avoid the cost and toxicity of some diabetes drugs. We have no long-term toxicity data on most of our diabetes drugs. (Insulin and metform are safe long-term.)
Whether a diabetic goes with Dr. Bernstein’s, my Low-Carb Mediterranean Diet, or Dr. Atkins’ Diabetes Revolution, I think they’re going to be better off over the long run compared to eating a typical “diabetic” diet that has 200+ grams of net carbs. Of course, I have no hard proof. We may never have it. Of those who choose LCMD, I have no data on how many of them actually follow it long-term. Hey, I finally answered one of your questions!
If one of my diabetics prefers to eat Bernstein or Atkins-style over my program, I have no problem with that at all. (The Atkins program recommends some nutritional supplements that I’m not convinced are necessary or even minimally helpful.)
How many diabetics stick with a carb-restricted diet (e.g., under 130 g/day) long-term, more than 2-3 months? My guesstimate is only two or three out of ten. The problem is that we live in a highly carb-centric culture: temptation abounds, we form firm dietary habits in childhood, carbs are cheap, and, frankly, many taste very good.
Incidentally, I don’t have diabetes but I strive to keep my digestible (or net) carbs in the range of 60 to 80 grams/day. The carb restriction helps me control my weight, and I’m seeing some preliminary evidence that it may help with prevention of dementia and mild cognitive impairment.
The long-term carbohydrate intake range I recommend for diabetics is 60-80 g of net or digestible carb daily. Twenty or 30 g/day (a la Bernstein or my Ketogenic Mediterranean Diet) can help overweight diabetics lose the excess fat a little quicker and easier. But 30 d/day over the long run is extremely difficult for all but the most highly motivated. If I had type 1 diabetes, I’d give 30 g/day a serious try, like Dr. Bernstein. Competitive endurance athletes may need more than 100 g/day. Some mild type 2’s may be able to adequately handle over 80 g/day depending on degree of residual pancreas beta cell function. It bothers me to see a type 2 diabetic taking 4-5 diabetes drugs just so they can control diabetes while eating a high-carb diet (e.g., over 200 g/day). Again, we don’t know the long-term effects of most of these drugs.
I’m sorry for being so long-winded! I hope this helps. Email me soon if you have more questions and I’ll respond w/in 24h. Or call me at xxx-xxx-xxxx. Please keep up the good work. In turn, I’ll keep doing my little part to turn around this carb-centric culture. At least until the science dictates otherwise.
9 responses to “E-mail Interview With a Low-Carb Friendly Dietitian”
I so appreciate your work Dr. Steve and also Franziska Spritzler’s work who I met through your e-mails. I must be one of the very few who try to stick to the VLCD lose weight (-30 so far) and get my A1c down to the 5% range (last A1c was 6%) which I have read as ideal. Thank you both so very much for All your hard work. Unfortunately none of my T2 friends don’t seem interested at all in controlling their BG or their eating. One friend recently almost died from complications of a BG well over 300. Even my own internist does not seem educated in a low carb diet to control BG and suggested I go on the Forks over Knives diet and Not Worry so much about my BG. Thanks Again.
Marsh, I’m so glad it’s working for you. Thanks for commenting.
Dr. Parker…im shocked by the percentages you quoted. No wonder T2 is out of control. I assumed people were at least aware of the role carbs play although I’ve also seen little interest by my GP in low carbing or really emphasizing diet and lifestyle changes. He seems uninterested. I do find it a challenge to stick with low carbing for the long haul especially if you eat out or on vacations. And harder for men since you really need to learn some cooking and baking skills to make it work. I also appreciate your books and blogs and all your educational efforts. I wish i lived closer to you so I could have an apptment with you.
Very interesting article. The exchange of thoughts / comments should make us all sit up and begin to question how a much improved outlook to lifestyle i,e, eating, exercise, sleep patterns etc can so greatly improve all our health. Franziska is one who questions the ‘normal’. If we all wish to improve lifestyle we can inquire and learn but we must be prepared to action and keep to it. Some find this easier than others. I have been following a low or reduced carbohydrate and high fat lifestyle for five years now and it certainly has had very good health rewards.
All the best Jan
Jan, I hope you’re sharing your experience, when appropriate, with those in your social circle affected by diabetes and prediabetes. Great job on your part!
I am on a VLC diet (2 years now) for insulin resistance/PCOS. My biggest fear is ever being hospitalized, because I know what they would serve me–a “1200 cal/day ADA diet” full of carbs (yes, I know that there really is no such thing as an “ADA diet” but the hospitals don’t seem to know this!).
If you have patients who want to be lower carb in the hospital, are you able to get appropriate food for them? You mentioned some low carb friendly dietitians, but do you get push back from others?
My health is so good on the VLC diet that the chances of being hospitalized are remote, but I literally have nightmares about arguing with a dietitian that I need real, whole eggs instead of bowls of wheat bran cereal, toast and orange juice.
Hi, Janknitz. Thanks for commenting.
The two hospitals I work at now do a good job of providing carb-restricted diets. They are in a minority among U.S. hospitals. I haven’t gotten any resistance from the dietitians here.
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