Category Archives: Carbohydrate

September 27, 2013 · 5:06 AM

Do Clinical Studies Support Carbohydrate-Restricted Eating in Type 1 Diabetes?

Sweden has lots of blondes

Sweden has lots of blondes

Yes, there are a few. We’ll take a close look at one today. (See the references below for more.)

In the introduction to the study at hand, the authors note:

The estimation of the amount of carbohydrates in a meal has an error rate of 50%. The insulin absorption may vary by up to 30%. It is therefor virtually impossible to match carbohydrates and insulin which leads to unpredictable blood glucose levels after meals. By reducing the carbohydrates and insulin doses the size of the blood glucose fluctuations can be minimized. The risk of hypoglycemia is therefore minimized as well. Around-the-clock euglycemia [normal blood sugar] was seen with 40 g carbohydrates in a group of people with type 1 diabetes [reference #2 below].

The immediate resulting stable, near-normal blood glucose levels allow individuals to predict after-meal glucose levels with great accuracy.

For individuals with type 1 diabetes one year audit/evaluation of group education in this regimen has shown that the short-time lowering of mean hemoglobin A1c by 1 percentage unit and the reduction in mean rate of symptomatic hypoglycemia by 82% was maintained [reference #3].

***

There is no evidence for the use of the widely recommended high-carbohydrate, low-fat diet in type 1 diabetes.

Study Set-Up

Swedish investigators educated study participants on carbohydrate-restricted eating from 2004 to 2006 [reference #1]. They recently audited their medical records for results accumulated over four years. At the outset, participants were given 24 hours of instruction over four weeks. My sense is that they all attended the same diabetes clinic. The subjects’ mean age was 52 years and they had diabetes for an average of 24 years. Seven had gastroparesis. Fourteen used insulin pumps. Of the 48 study subjects, 31 were women, 17 were men. The diet regimen restricted carbohydrates to a maximum of 75 grams a day, mainly by reducing starchy food.

Results

As measured three months after starting the diet, HDL-cholesterol rose and triglycerides fell to a clinically significant degree (p<0.05). Average weight fell by 2.7 kg (a little over a pound); average baseline weight was 77.6 kg (171 lb). Hemoglobin A1c fell from 7.6 to 6.3% (Mono-S method).

As measured one year after start, meal-time insulin (rapid-acting, I assume) fell from 23 to 13 units per day. Long-acting insulin was little changed at around 19 units daily.

By two years into the study, half the participants had stopped adhering to the diet. The remainder were adherent (13 folks) or partly adherent (10). We don’t know what the non-adherents were eating.

Four years out, the adherent group had hemoglobin A1c of 6.0%, and the partly adherents were at 6.9% (p<0.001 for both). The non-adherent group had returned to their baseline HgbA1c (7.5%). Remember, at baseline the average HgbA1c for the group was 7.6%.

The authors don’t say how many participants were still adherent after four years. From Figure 2, adherence seems to have been assessed at 60 months: 8 of the 13 adherent folks were still adherent, and 5 of the 10 partly adherent were still in the game. So, of 48 initial subjects, only 13 were still low-carbing after five years later. By five years out, half of all subjects seem to have been lost to follow-up. So the drop-out rate for low-carbers isn’t as bad as it looks at first blush.

Conclusion

The authors write:

An educational program involving a low-carbohydrate diet and correspondingly reduced insulin doses for informed individuals with type 1 diabetes gives acceptable adherence after 4 years. One in two people attending the education achieves a long-term significant HbA1c reduction.

They estimate that this low-carb diet “may be an option for 10-20% of the patients with type 1 diabetes.” Only 17% of their current diabetes clinic population is interested in this low-carb diet. They didn’t discuss why patients abandon the diet or aren’t interested in the first place. Use your imagination.

Major carbohydrate restriction in type 1 diabetics significantly improves blood sugar control (decreases HgbA1c), lowers insulin requirements, and improves cardiovascular disease risk factors (increases HDL cholesterol and lowers triglycerides).

Low-carb eating wasn’t very appealing to Swedes in the mid-2000s. I wonder if it’s more popular now with the popularity of LCHF dieting (low-carb, high-fat) in the general population there.

Steve Parker, M.D.

References:

1.  Nielson, J.V., Gando, C., Joensson, E., and Paulsson, C. Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: A clinical audit. Diabetology & Metabolic Syndrome, 2012, 4:23. http://www.dmsjournal.com/content/4/1/23

2.  O’Neill, D.F., Westman, E.C., and Bernstein, R.K. The effects of a low-carbohydrate regimen on glycemic control and serum lipids in diabetes mellitus. Metabolic Syndrome and Related Disorders, 2003, 1(4): 291-298.

3.  Nielsen, J.V., Jönsson, E. and Ivarsson, I. A low carbohydrate diet in type 1 diabetes: clinical experience – A brief report. Upsala Journal of Medical Sciences, 2005, 110(3): 267-273.

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September 5, 2013 · 5:31 AM

European Guidelines Not In Favor of Low Carbohydrate Diets for Diabetes

Conquer Diabetes and Prediabetes

“Really?”

A recent diabetes treatment guide from European doctors states “there is no justification for the recommendation of very low carbohydrate diets in diabetes mellitus.”

I disagree.

The 2013 guidelines are from the European Society of Cardiology and the European Association for the Study of Diabetes. I compiled the following articles in favor of carbohydrate restriction a couple years ago. You won’t find anything newer listed. Admittedly, all or nearly all of the patients involved had type 2 diabetes, not type 1.

Enjoy!

♦  ♦  ♦

Accurso, A., et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutrition & Metabolism, 9 (2008). PMID: 18397522. One of the watershed reports that summarize the major features and benefits, based on 68 scientific references.

Boden, G., et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Annals of Internal Medicine, 142 (2005): 403-411. In these 10 obese diabetics, a low-carb diet spontaneously reduced calorie consumption from 3100 daily to 2200, accounting for the weight loss—1.65 kg (3.63 pounds) in 14 days. Blood sugar levels improved dramatically and insulin sensitivity improved by 75%.

Daly, M.E., et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes—a randomized controlled trial. Diabetes Medicine, 23 (2006): 15-20. Compared with a low-fat/reduced-calorie diet, weight loss was much better in the low-carb group over three months, and HDL ratio improved.

Davis, Nichola, et al. Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes. Diabetes Care, 32 (2009): 1,147-1,152. The Atkins diet was superior—for weight loss and glycemic control—when measured at three months, when compliance by both groups was still probably fairly good. After one year, the only major difference they found was lower HDL cholesterol in the low-carb eaters. 

Elhayany, A., et al. A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Diabetes, Obesity and Metabolism, 12 (2010): 204-209. In overweight type 2 diabetics, a low-carbohydrate Mediterranean diet improved HDL cholesterol levels and glucose control better than either the standard Mediterranean diet or American Diabetes Association diet, according to Israeli researchers.

Haimoto, Hajime, et al. Effects of a low-carbohydrate diet on glycemic control in outpatients with severe type 2 diabetes. Nutrition & Metabolism, 6:21 (2009). DOI: 10.1186/1743-7075-6-21. A low-carbohydrate diet is just as effective as insulin shots for people with severe type 2 diabetes, according to Japanese investigators. Five of the seven patients on sulfonylurea were able to stop the drug. 

Nielsen, Jörgen and Joensson, Eva.  Low-carbohydrate diet in type 2 diabetes: stable improvement of body weight and glycemic control during 44 months follow-up. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-14. Obese people with type 2 diabetes following a 20% carbohydrate diet demonstrated sustained improvement in weight and blood glucose control, according to Swedish physicians. Proportions of carbohydrates, fat, and protein were 20%, 50%, and 30% respectively. Total daily carbs were 80-90 g. Hemoglobin A1c, a measure of diabetes control, fell from 8% to 6.8%. These doctors had previously demonstrated that a 20% carbohydrate diet was superior to a low-fat/55-60% carb diet in obese diabetes patients over six months.

Vernon, M., et al. Clinical experience of a carbohydrate-restricted diet: Effect on diabetes mellitus. Metabolic Syndrome and Related Disorders, 1 (2003): 233-238. This groundbreaking study demonstrated that diabetics could use an Atkins-style diet safely and effectively in a primary care setting.

Westman, Eric, et al. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-36. Duke University (U.S.) researchers demonstrated better improvement and reversal of type 2 diabetes with an Atkins-style diet, compared to a low-glycemic index reduced-calorie diet.

Yancy, William, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes [in men]. Nutrition & Metabolism, 2:34 (2005). DOI: 10.1186/1743-7075-2-34. A low-carb ketogenic diet in patients with type 2 diabetes was so effective that diabetes medications were reduced or discontinued in most patients. The authors recommend that similar dieters be under close medical supervision or capable of adjusting their own medication, because the diet lowers blood sugar  dramatically.

Yancy, W., et al. A pilot trial of a low-carbohydrate ketogenic diet in patients with type 2 diabetes.  Metabolic Syndrome and Related Disorders, 1 (2003): 239-244. This pioneering study used an Atkins Induction-style diet with less than 20 grams of carbohydrate daily.

So there!

Steve Parker, M.D.

h/t to Reijo Laatikainen for tweeting the European article.

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September 3, 2013 · 2:00 AM

Radiologist With Type 1 Diabetes Thrives on Very Low Carb Diet

"Put down the bread and no one will get hurt!"

“Put down the bread and no one will get hurt!”

ABC Radio provides the audio and transcript of an interview with Dr. Troy Stapleton, who was diagnosed with type 1 diabetes at age 41. Dr. Stapleton lives in Queensland, Australia. At the time of his diagnosis…

I was advised to eat seven serves of bread and cereals, two to three serves dairy, fruit, starchy vegetables, and to balance that intake with insulin. If you add up all those serves, they were recommending a diet of up to about 240 grams of carbohydrates a day, and to balance it with insulin. I was going to be the best patient, and there has been some important trials that show that if you do control your blood glucose well then you can reduce your incidence of the complications.

Dr. Stapleton believes we evolved on a very low carbohydrate diet; the Agricultural Revolution led to our current high carb consumption. He was concerned about the risk of hypoglycemia with standard diabetic diets.

There was a different approach where essentially you went on a very low carbohydrate diet, this made a little bit of sense to me. Why would I eat carbohydrates and then have to balance it with insulin?

Here’s what the diabetes educators told him:

What they say is you need to estimate the amount of carbohydrate you’re going to eat, and then you need to match that carbohydrate dose essentially with an insulin dose. So you sort of look at your food and you go, okay, I’m having 30 grams of carbohydrate and I need one unit of insulin per 15 grams of carbohydrate, so two units. It sounds really quite straightforward, except that it’s very, very difficult to estimate accurately the amount of carbohydrate you’re eating. The information on the packets can be out by 20%. Most people say that your error rate can be around 50%.

And then of course it changes with what you’ve eaten. So if you eat carbohydrates with fat and then you get delayed absorption, then that glucose load will come in, and then the type of carbohydrates will alter how quickly it comes in to your bloodstream. And then of course your insulin dose will vary, your absorption rate will vary by about 30%. Once you think through all the variables, it’s just not possible. You will be able to bring your blood glucose under control, but a lot of the time what happens is you get a spike in your glucose level immediately after a meal, and that does damage to the endothelium of your blood vessels…

Norman Swan: The lining.

Troy Stapleton: That’s correct, it causes an oxidative stress to your endothelium, and that is the damage that diabetes does, that’s why you get accelerated atherosclerosis.

Here’s what happened after he started eating very low carb:

It’s been amazing, it’s been the most remarkable turnaround for me and I just cut out carbohydrates essentially completely, although I do get some in green leafy vegetables and those sorts of things. My blood sugar average on the meter has gone from 8.4 [151 mg/dl] down to 5.3 [95 mg/dl]. My HbA1c is now 5.3, which is in the normal range. My blood pressure has always been good but it dropped down to 115 over 75. My triglycerides improved, my HDL improved, so my blood lipid profile improved. And I would now have a hypoglycaemic episode probably about once a month after exercise. [He was having hypoglycemia weekly on his prior high carb diet with carb counting insulin adjustments.]

He was able to reduce his insulin from about 27 units a day down to 6 units at night only (long-acting insulin)! He admits his low insulin dose may just reflect the “honeymoon period” some type 1s get early on after diagnosis.

Norman Swan: So when you talk to your diabetes educator now, what does he or she say?

Troy Stapleton: Look, they’re interested, but they’ll tell me things and I’ll say, well, that’s actually not true. I’m quite a difficult patient, Norman.

He says he’s eating an Atkins-style diet. Combining the transcript and his notes in the comments section:  1) he doesn’t eat potatoes or other starchy vegetables or bread, 2) he eats meat, eggs, lots of starchy vegetable, some berries and tree nuts, olives, and cheese, 3) an occasional wine or low-carb beer, 4) coffee, and 5) he eats under 50 g/day of carbohydrate, probably  under 30 g. This is a low-carb paleo diet except for the cheese, alcohol, and coffee.  Cheese, alcohol and coffee are (or can be) low-carb, but they’re not pure paleo.

He notes that…

There is an adaption period to a very low carbohydrate diet which takes 4-6 weeks (ketoadaption). During this time symptoms include mild headaches, lethargy, cramps, carb cravings and occasional light headedness. These symptoms all pass.

Read or listen to the whole thing. Don’t forget the comments section. All the blood sugars you see there are in mmol/l; convert them to mg/dl (American!) by multiplying by 18.

Steve Parker, M.D.

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August 17, 2013 · 1:33 AM

E-mail Interview With a Low-Carb Friendly Dietitian

Conquer Diabetes and Prediabetes, Steve Parker MD

Brain food that won’t spike blood sugars

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?

My response:

Dear F,

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.

Sincerely,

-Steve

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August 12, 2013 · 8:17 AM

Deteriorating Brain Function Linked to High Insulin Levels and Insulin Resistance: Here’s How You Fight Back

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

Don’t wait to take action until it’s too late

Insulin resistance and high blood insulin levels promote age-related degeneration of the brain, leading to memory loss and dementia according to Robert Krikorian, Ph.D.  He’s a professor in the Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati Academic Health Center.  He has an article in a recent issue of Current Psychiatry – Online.

Proper insulin signaling in the brain is important for healthy functioning of our brains’ memory centers.  This signaling breaks down in the setting of insulin resistance and the associated high insulin levels.  Dr. K makes much of the fact that high insulin levels and insulin resistance are closely tied to obesity.  He writes that:

“Waist circumference of ≥100 cm (39 inches) is a sensitive, specific, and independent predictor of hyperinsulinemia for men and women and a stronger predictor than body mass index, waist-to-hip ratio, and other measures of body fat.”

Take-Home Points

Dr. Krikorian thinks that dietary approaches to the prevention of dementia are effective yet underutilized.  He mentions reduction of insulin levels by restricting calories or a ketogenic diet: they’ve been linked with improved memory in middle-aged and older adults.

Dr. Krikorian suggests the following measures to prevent dementia and memory loss:

  • eliminate high-glycemic foods like processed carbohydrates and sweets
  • replace high-glycemic foods with fruits and vegetables (the higher polyphenol intake may help by itself)
  • certain polyphenols, such as those found in berries, may be particularly helpful in improving brain metabolic function
  • keep your waist size under 39 inches, or aim for that if you’re overweight

I must mention that many, perhaps most, dementia experts are not as confident  as Dr. Krikorian that these dietary changes are effective.  I think they probably are, to a degree.

The Mediterranean diet is high in fruits and vegetables and relatively low-glycemic.  It’s usually mentioned by experts as the diet that may prevent dementia and slow its progression.

Read the full article.

I’ve written before about how blood sugars in the upper normal range are linked to brain degeneration.  Dr. Krikorian’s recommendations would tend to keep blood sugar levels in the lower end of the normal range.

Steve Parker, M.D.

PS: Speaking of dementia and ketogenic, have you ever heard of the Ketogenic Mediterranean Diet?  (Free condensed version here.)

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June 23, 2013 · 4:08 PM

Carbohydrate Counting Not All It’s Cracked Up to Be

…according to an article at MedPageToday. In brief, carb counting involves estimating the digestible carbohydrate grams in a meal, then dosing rapid-acting insulin based on those grams and the individual’s prior responses to insulin. Turns out there’s not a lot of hard clinical evidence to back up the practice.

Carbohydrate counting is the best known method for matching insulin dosing to meals, and is the recommended dietary strategy for achieving glycemic control in type 1 diabetes, though that recommendation has been largely based on expert consensus, Bell said.

One commentator said it doesn’t work very well because most folks aren’t very good at it, they’re not vigilant enough.

A review panel “compared carbohydrate counting with usual care, which consisted of either general nutrition advice or low dietary glycemic index (GI) advice.” They found no significant differences in hemoglobin a1c between the approaches.

Read the rest.

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June 16, 2013 · 12:22 AM

Should People With Diabetes Restrict Carbohydrates?

MB900402413Dr. John Rollo (a surgeon in the British Royal Artillery) in 1797 published a book, An Account of Two Cases of the Diabetes Mellitus. He discussed his experience treating a diabetic Army officer, Captain Meredith, with a high-fat, high-meat, low-carbohydrate diet. Mind you, this was an era devoid of effective drug therapies for diabetes.

The soldier apparently had type 2 diabetes rather than type 1.

Rollo’s diet led to loss of excess weight (original weight 232 pounds or 105 kg), elimination of symptoms such as frequent urination, and reversal of elevated blood and urine sugars.

This makes Dr. Rollo the original low-carb diabetic diet doctor. Many of the leading proponents of low-carb eating over the last two centuries—whether for diabetes or weight loss—have been physicians.

But is carbohydrate restriction a reasonable approach to diabetes, whether type 1 or type 2?

What’s the Basic Problem in Diabetes?

Diabetes and prediabetes always involve impaired carbohydrate metabolism: ingested carbs are not handled by the body in a healthy fashion, leading to high blood sugars and, eventually, poisonous complications.  In type 1 diabetes, the cause is a lack of insulin from the pancreas.  In type 2, the problem is usually a combination of insulin resistance and ineffective insulin production.

Elevated blood pressure is one component of metabolic syndrome

Elevated blood pressure is one component of metabolic syndrome

A cousin of type 2 diabetes is “metabolic syndrome.”  It’s a constellation of clinical factors that are associated with increased future risk of type 2 diabetes and atherosclerotic complications such as heart attack and stroke. One in six Americans has metabolic syndrome. Diagnosis requires at least three of the following five conditions:

■  high blood pressure (130/85 or higher, or using a high blood pressure medication)

■  low HDL cholesterol:  under 40 mg/dl (1.03 mmol/l) in a man, under 50 mg/dl (1.28 mmol/l) in a women (or either sex taking a cholesterol-lowering drug)

■  triglycerides over 150 mg/dl (1.70 mmol/l) (or taking a cholesterol-lowering drug)

■  abdominal fat:  waist circumference 40 inches (102 cm) or greater in a man, 35 inches (89 cm) or greater in a woman

■  fasting blood glucose over 100 mg/dl (5.55 mmol/l)

Metabolic syndrome and simple obesity often involve impaired carbohydrate metabolism. Over time, excessive carbohydrate consumption can turn obesity and metabolic syndrome into prediabetes, then type 2 diabetes.

Carbohydrate restriction directly addresses impaired carbohydrate metabolism naturally.

Carbohydrate Intolerance

Diabetics and prediabetics—plus many folks with metabolic syndrome—must remember that their bodies do not, and cannot, handle dietary carbohydrates in a normal, healthy fashion. In a way, carbs are toxic to them. Toxicity may lead to amputations, blindness, kidney failure, nerve damage, poor circulation, frequent infections, premature heart attacks and death, among other things.

Diabetics and prediabetics simply don’t tolerate carbs in the diet like other people. If you don’t tolerate something, you have to give it up, or at least cut way back on it. Lactose-intolerant individuals give up milk and other lactose sources. Celiac disease patients don’t tolerate gluten, so they give up wheat and other sources of gluten. One of every five high blood pressure patients can’t handle normal levels of salt in the diet; they have to cut back or their pressure’s too high. Patients with phenylketonuria don’t tolerate phenylalanine and have to restrict foods that contain it. If you’re allergic to penicillin, you have to give it up. If you don’t tolerate carbs, you have to give them up or cut way back. I’m sorry.

Carbohydrate restriction directly addresses impaired carbohydrate metabolism naturally.

But Doc, …?

1.  Why not just take more drugs to keep my blood sugars under control while eating all the carbs I want?

We have 12 classes of drugs to treat diabetes.  For most of these classes, we have little or no idea of the long-term consequences.  It’s a crap shoot.  The exceptions are insulin and metformin.  Several big-selling drugs have been taken off the market due to unforeseen side effects.  Others are sure to follow, but I can’t tell you which ones.  Adjusting insulin dose based on meal-time carb counting is popular.  Unfortunately, carb counts are not nearly as accurate as you might think; and the larger the carb amount, the larger the carb-counting and drug-dosing errors.

2.  If I reduce my carb consumption, won’t I be missing out on healthful nutrients from fruits and vegetables?

No.  Choosing low-carb fruits and vegetables will get you all the plant-based nutrients you need.  You may well end up eating more veggies and fruits than before you switched to low-carb eating.  Low-carb and paleo-style diets are unjustifiably criticized across-the-board as being meat-centric and deficient in plants.  Some are, but that’s not necessarily the case.

3.  Aren’t vegetarian and vegan diets just as good?

Maybe.  There’s some evidence that they’re better than standard diabetic diets.  My personal patients are rarely interested in vegetarian or vegan diets, so I’ve not studied them in much detail.  They tend to be rich in carbohydrates, so you may run into the drug and carb-counting issues in Question No. 1.

Steve Parker, M.D.

PS:  The American Diabetes Association recommends weight loss for all overweight diabetics. Its 2011 guidelines suggest three possible diets: “For weight loss, either low-carbohydrate [under 130 g/day], low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).”  The average American adult eats 250–300 grams of carbohydrate daily.

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March 12, 2013 · 8:12 AM

Potential Problems With Major Carbohydrate Restriction

Caprese salad, naturally low-carb

Caprese salad, naturally low-carb

Ketogenic Diets

First, let’s define ketogenic diets.  For most folks, that means eating under 50 grams of digestible carbohydrate daily.

Your body gets nearly all its energy either from fats, or from carbohydrates like glucose and glycogen. In people eating “normally,” 60% of their energy at rest comes from fats. In a ketogenic diet, the carbohydrate content of the diet is so low that the body has to break down even more of its fat to supply energy needed by most tissues. Fat breakdown generates ketone bodies in the bloodstream. Hence, “ketogenic diet.” Also called “very-low-carb diets,” ketogenic diets have been around for over a hundred years.

What Could Go Wrong?

Long-term effects of a very-low-carb or ketogenic diet in most people are unclear—they may have better or worse overall health—we just don’t know for sure yet. Perhaps some people gain a clear benefit, while others—with different metabolisms and genetic make-up—are worse off.

If the diet results in major weight loss that lasts, we may see longer lifespan, less type 2 diabetes, less cancer, less heart disease, less high blood pressure, and fewer of the other obesity-related medical conditions.

Ketogenic diets are generally higher in protein, total fat, saturated fat, and cholesterol than some other diets. Some authorities are concerned this may increase the risk of coronary heart disease and stroke; the latest evidence indicates otherwise.

Some authorities worry that ketogenic diets have the potential to cause kidney stones, osteoporosis (thin, brittle bones), gout, and may worsen existing kidney disease. Others disagree.

Soon after adoption of very-low-carb eating, dieters may have headaches, bad breath, easy bruising, nausea, fatigue, aching, muscle cramps, constipation, and dizziness, among other symptoms. “Induction flu” may occur around days two through five, consisting of achiness, easy fatigue, and low energy. It clears up after a few days.

Very-low-carb ketogenic diets may have the potential to cause  low blood pressure, high uric acid in the blood, excessive loss of sodium and potassium in the urine, worsening of kidney disease, deficiency of calcium and vitamins A, B, C, and D, among other adverse effects.

Athletic individuals who perform vigorous exercise should expect a deterioration in performance levels during the first three to four weeks of any ketogenic very-low-carb diet. The body needs that time to adjust to burning mostly fat for fuel rather than carbohydrate.

Competitive weight-lifters or other anaerobic athletes (e.g., sprinters) will be hampered by the low muscle glycogen stores that accompany ketogenic diets. They need more carbohydrates.

What About Adherence to the Diet?

It’s clear that for many folks, compliance with very-low-carb diets is difficult to maintain for six to 12 months.  Some can’t do it for more than a couple weeks. Potential long-term effects, therefore, haven’t come into play for most users. When used for weight loss, regain of lost weight is a problem—but regain is a major issue with all weight-loss programs. I anticipate that the majority of non-diabetics who try a ketogenic diet will stay on it for only one to six months. After that, more carbohydrates can be added to gain the potential long-term benefits of additional fruits and vegetables, legumes, and whole grains.

Or not.

People with type 2 diabetes or prediabetes may be so pleased with the metabolic effects of the ketogenic diet that they’ll stay on it long-term.

The most famous ketogenic diet is Dr. Atkins New Diet Revolution.  I’ve put together one call the Ketogenic Mediterranean Diet.

Steve Parker, M.D.

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March 9, 2013 · 2:00 AM

Dr. Sigurdsson’s Thoughts on the Best Diet for Diabetes

"Vegan? Vegetarian? Mediterranean? Low-Carb? ADA? Low GI? SAD?

“Vegan? Vegetarian? Mediterranean? Low-Carb? ADA? Low GI? SAD?

Remember that recent report on the best diet for diabetes from American Journal of Clinical Nutrition?  I didn’t think so.  Here’s Dr. Axel Sugurdsson’s summary:

Ajala and coworkers conclude that their review provides evidence that modifying the amount of macronutrients can improve glycemic control, weight and lipids in type 2 diabetes. In their analysis, low carbohydrate diets appeared to provide superior weight loss, better control of blood glucose, and better lipid profile, compared with low fat diets. The authors also conclude that vegan and vegetarian diet may improve glucose control and promote weight loss in type 2 diabetes.

Here’s the verbatim conclusion of the researchers from the article abstract:

Low-carbohydrate, low-GI, Mediterranean, and high-protein diets are effective in improving various markers of cardiovascular risk in people with diabetes and should be considered in the overall strategy of diabetes management.

No mention of vegan and vegetarian diets per se.

And now Dr. Sigurdsson’s concluding opinion:

What is the best diet for diabetes?  Although, there is probably not a simple answer,  the question reflects one of the main challenges of modern medicine. It is likely that our dietary recommendations will have to be tailored to the needs of the individual. A one-size-fits-all approach is unrealistic. Although not providing any definitive answers, the study by Ajala and coworkers is an important contribution to our understanding of this highly important issue.

Read the rest.

I’ve reviewed some of the literature supporting vegetarian diets for diabetes.  I’ve seen some evidence that the paleo diet may be beneficial.  Regular readers here know that I currently favor a carbohydrate-restricted Mediterranean-style diet for control of diabetes.

Steve Parker, M.D.

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March 6, 2013 · 2:00 AM

The Case For Carbohydrate Restriction in Diabetes

Dr. Rollo would recognize this

Dr. Rollo would recognize this

In 1797, Dr. John Rollo  published a book called An Account of Two Cases of the Diabetes Mellitus. Dr. Rollo was a surgeon in the British Royal Artillery. He discussed his experience treating a diabetic Army officer, Captain Meredith, with a high-fat, high-meat, low-carbohydrate diet. In case you don’t know, this was an era devoid of effective drug therapies for diabetes.

The soldier apparently had type 2 diabetes rather than type 1.

Rollo’s diet led to loss of excess weight (original weight 232 pounds or 105 kg), elimination of symptoms such as frequent urination, and reversal of elevated blood and urine sugars.  (Don’t ask me how they measured blood and urine sugar back then.)

This makes Dr. Rollo the original low-carb diabetic diet doctor. Many of the leading proponents of low-carb eating over the last two centuries—whether for diabetes or weight loss—have been physicians.

Carbohydrate Intolerance

Diabetes and prediabetes always involve impaired carbohydrate metabolism: ingested carbs are not handled by the body in a healthy fashion, leading to high blood sugars and, eventually, poisonous complications.

Diabetics and prediabetics—plus many folks with metabolic syndrome—must remember that their bodies do not, and cannot, handle dietary carbs in a normal, healthy fashion. In a way, carbs are toxic to them. Toxicity may lead to amputations, blindness, kidney failure, nerve damage, poor circulation, frequent infections, premature heart attacks and death, among other things.

What To Do About It

Diabetics and prediabetics simply don’t tolerate carbs in the diet like other people. If you don’t tolerate something, you have to give it up, or at least cut way back on it. Lactose-intolerant individuals give up milk and other lactose sources. Celiac disease patients don’t tolerate gluten, so they give up wheat and other sources of gluten. One of every five high blood pressure patients can’t handle normal levels of salt in the diet; they have to cut back or their pressure’s too high. Patients with phenylketonuria don’t tolerate phenylalanine and have to restrict foods that contain it. If you’re allergic to penicillin, you have to give it up.

Stretching actually doesn't do any good for the average person

Stretching actually doesn’t do any good for the average person

If you don’t tolerate carbs, you have to give them up or cut way back. I’m sorry. Alternatively, you could eat lots of carbs and take drugs to prevent the dangerous elevations in blood sugar they cause. We have 11 classes of drugs to treat diabetes. Unfortunately, the long-term side effects of most of them are not well-established. And they can get very expensive.

The American Diabetes Association recommends weight loss for all overweight diabetics. That tends to improve carbohydrate metabolism. The ADA’s 2011 guidelines suggest three possible diets: “For weight loss, either low-carbohydrate [under 130 g/day], low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).”

If I were a diabetic eating over 200 grams of carb daily, I’d cut my carbs way below 130 grams initially, to 20–30 grams of digestible carb.  Then gradually increase carbs as tolerated, based on blood sugar readings. Ask your doctor what he thinks.

Steve Parker, M.D.

 

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