Tag Archives: carbohydrate restriction

July 27, 2015 · 5:50 AM

Should Carbohydrate Restriction Be the Default Diet for Diabetes?

Yes….according to a manifesto to be published soon in Nutrition. It may be published already since this post has been sitting in my draft stack for a while. The abstract:

The inability of current recommendations to control the epidemic of diabetes, the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk or general health and the persistent reports of some serious side effects of commonly prescribed diabetic medications, in combination with the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects, point to the need for a reappraisal of dietary guidelines.

The benefits of carbohydrate restriction in diabetes are immediate and well-documented. Concerns about the efficacy and safety are long-term and conjectural rather than data-driven. Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss (although is still best for weight loss) and leads to the reduction or elimination of medication and has never shown side effects comparable to those seen in many drugs.

Low-Carb Spaghetti Squash With Meat Sauce

Low-Carb Spaghetti Squash With Meat Sauce

The lead author is Richard Feinman. Others include Lynda Frassetto, Eric Westman, Jeff Volek, Richard Bernstein, Annika Dahlqvist, Ann Childers, and Jay Wortman, to name a few. Some of them disclose that they have accepted money from the Veronica and Robert C. Atkins Foundation. That doesn’t bother me. I’m familiar with most of the supporting literature they cite, having read it over the last decade. I agree with these guys wholeheartedly.

Read the whole enchilada.

Steve Parker, M.D.

PS: The linked article is preliminary and may undergo minor revision over the coming months.

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November 11, 2014 · 2:02 AM

New Podcast Episode Features Professional Low-Carb Diet Proponents

Jimmy Moore posted an interview with Dr. Troy Stapleton and Franziska Spritzler, R.D. They both advocate carbohydrate-restricted diets for management of blood sugars in diabetes. Dr. Stapleton, by the way, has type 1 diabetes; I’ve written about him before. Franziska is available for consultation either by phone, Skype, or in person.

Steve Parker, M.D.

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February 2, 2014 · 5:20 AM

Consider Carbohydrate Restriction for Your GERD

Dr. Michael Eades has a post on gastroesophageal reflux disease (GERD) and it’s treatment with carbohydrate-restricted eating versus drugs. GERD is relatively severe and/or frequent heartburn caused by stomach acid backing up in to the esophagus. The lining of your stomach is designed to be resistant to a high-acid environment; your esophagus not so much. A quote from Dr. Eades:

Most people who have GERD, have it for the long term. It’s not something that comes and goes. So these folks go on GERD therapy for the long term, and the most prescribed medications for long-term GERD treatment are PPIs [proton pump inhibitors], which, you now know, keep stomach acid neutralized for the long term, and, as you might imagine, creates a host of problems.

The scientific literature has shown long-term PPI therapy to be related to the following conditions:

  • Anemia
  • Pneumonia
  • Vitamin B12 deficiency
  • Impaired calcium absorption
  • Impaired magnesium absorption
  • Increased rate fractures, especially hip, wrist and spine
  • Osteopenia [thin brittle bones]
  • Rebound effect of extra-heavy gastric acid secretion
  • Heart attacks

Read the rest if you or someone you love has GERD.

Here’s a scientific report supporting Dr. Eades’ clinical experience. Carbs were reduced to 20 grams a day.

Steve Parker, M.D.

PS: Some studies find no association between PPI use and pneumonia. It makes sense that we have stomach acid for good reasons, and that suppressing it may well have adverse effects.

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January 8, 2014 · 2:33 AM

Low-Carb Diet Improves Glucose Control in Japanese Type 2 Diabetics

Mt. Fuji in Japan

Mt. Fuji in Japan

I don’ know anything about Japanese T2 diabetes. I’ve never studied it. Their underlying physiology may or may not be the same as in North American white diabetics, with whom I am much more familiar.

For what it’s worth, a small study recently found improvement of blood sugar control and triglycerides in those on a carbohydrate restricted diet versus a standard calorie-restricted diet.

Only 24 patients were involved. Half were assigned to eat low-carb without calorie restriction; the other half ate the control diet. The carbohydrate-restricted group aimed for 70-130 grams of carb daily, while eating more fat and protein than the control group. The calorie-restricted guys were taught how to get 50-60% of calories from carbohydrate and keep fat under 25% of calories. At the end of the six-month study, the low-carbers were averaging 125 g of carb daily, compare to 200 g for the other group. By six months, both groups were eating about the same amount of calories.

Average age was 63. Body mass index was 24.5 in the low-carb group and 27 in the controls. (If you did the research, I bet you’d find Japanese T2 diabetics have lower BMIs than American diabetics.) All were taking one or more diabetes drugs.

The calorie-restricted group didn’t change their hemoglobin A1c (a standard measure of glucose control) from 7.7%. The low-carb group dropped their hemoglobin A1c from 7.6 to 7.0% (statistically significant). The low-carb group also cut their triglycerides by 40%. Average weights didn’t change in either group.

Bottom Line

This small study suggests that mild to moderate carbohydrate restriction helps control diabetes in Japanese with type 2 diabetes. The improvement in hemoglobin A1c is equivalent to that seen with initiation of many diabetes drugs. I think further improvements in multiple measures would have been seen if carbohydrates had been restricted even further.

Steve Parker, M.D.

Link to reference.

h/t Dr Michael Eades

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December 9, 2013 · 4:24 PM

What’s the Best Diet for Type 2 Diabetics?

DietDoctor has some ideas based on a recent scientific study:

A new exciting Swedish study provides us with strong clues on how a person with diabetes should eat (and how to eat to maximize fat burning). It’s the first study to examine in detail how various blood markers change throughout the day depending on what a diabetic person eats.

The study examined the effects of three different diets in 19 subjects with diabetes type 2. They consumed breakfast and lunch under supervision in a diabetes ward. The caloric intake in the three diets examined was the same, but the diets differed in the following manner:

  1. A conventional low-fat diet (45-56% carbs)
  2. A Mediterranean diet with coffee only for breakfast (= similar to 16:8 intermittent fasting) and a big lunch (32-35% carbs)
  3. A moderate low-carbohydrate diet (16-24% carbs)

All participants tested all three diets, one diet each day in randomized order.

Click through for results. Hint: Carbohydrate restriction works.

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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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May 22, 2013 · 2:05 AM

Carbohydrate Restriction Improve Polycystic Ovary Syndrome

MedPageToday reports that women cutting carbs from 55 to 41% of total calories see improved insulin sensitivity, lower testosterone levels, lower blood sugar levels, and improved lipid numbers.

Learn more about PCOS at UpToDate.com. It affects 5 to 10% of U.S. women.

From MedPageToday:

“A moderate reduction in dietary carbohydrate reduced both insulin and testosterone,” Gower told MedPage Today. “There is no reason not to recommend reduction in dietary carbohydrate, particularly processed carbohydrate, for women with PCOS. It may have tremendous benefit, and there is certainly no downside.”

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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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March 30, 2012 · 8:47 AM

Dr. Richard Feinman on Carbohydrate Restriction for Diabetes

Dr. Feinman is a professor of biochemistry at Downstate Medical Center (SUNY) in New York.  A few days ago he wrote about the rationale behind carb restriction as an approach to diabetes.  We’re singin’ from the same page of the hymnal.

-Steve

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November 6, 2011 · 8:32 PM

Severe Carb Restriction in Type 2 Diabetes

U.K. researchers found major metabolic improvements in obese type 2 diabetics following a very low-carbohydrate diet, compared to a low-fat portion-controlled diet.  The latter is a standard recommendation in the U.S. for overweight type 2 diabetics.
 
This study is an oldie (2005) but a goodie.
 
Methodology
 
The investigators randomly assigned 102 poorly controlled diabetics to follow one of the two diets for three months.  Participants had average weights of 224 pounds (102 kg),  body mass index 36, age 58, hemoglobin A1c’s of 9%.  Half of them were men.  About 40% of the diabetics in both groups were on unspecified oral diabetic drugs; 20% were on insulin and 40% were using a combination of the two.  Sulfonylurea was mentioned, but not metformin. 
 
Participants were randomly assigned to either a low-fat portion-controlled weight-loss diet or a low-carbohydrate diet.  The goal with the low-carb diet was “up to 70 g of carbohydrate per day,” including at least a half a pint of milk and one piece of fruit.  (Is a UK pint the same as in the US?).  Increased physical activity was recommended to both groups. 
 
Only 79 of the 102 participants made it through the three-month diet intervention.  Drop-out rate was the same for both groups.
 
What Did They Find?
 
(Differences are statistically significant unless otherwise noted.)
Weight loss for the low-carb group was 3.55 kg (7.8 lb) compared to only 0.92 kg (2 lb) for the low-fat cohort.
 
The total/HDL cholesterol ratio improved for the low-carb group (absolute decrease of 0.48 versus 0.10). 
 
Hemoglobin A1c and systolic blood pressure tended to decrease more for the low-carb group, but did not reach statistical significance.  For instance, HgbA1c dropped 0.55% (in absolute terms) for the low-carb group, and 0.23% for the low-fat group.  Lower HgbA1c indicates improved blood sugar control.
 
Caloric intake was not different between the groups (about 1350 cals/day by diet recall method).
 
The low-carb group reduced carbs to 109 g/day compared to 168 g in the  low-fat cohort.
 
The low-carb group consumed 33% of energy as carbs compared to 45% for the low-fat group.
 
The low-carb group consumed 40% of energy as fat compared to 33% in the low-fat cohort.
 
Protein intake was 26% of energy for the low-carbers compared to 21% for the low-fatters.
 
Absolute saturated fatty acid intake was higher for the low-carbers, but still considered moderate.
 
Insulin dose was reduced in about 85% of the insulin users in the low-carb group but in only 22% of the low-fat group.  Oral diabetic pill use was unchanged in both groups.
 
Comments
 
This is a classic research report that I cited in Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet.
 
The improved total/HDL cholesterol ratio in the low-carbers may reduce risk of heart and vascular disease.  These investigators didn’t look at LDL particle size.  Other studies have found that low-carb eating tends to shift LDL cholesterol (bad stuff) from small dense particles to light fluffy particles, which are thought to be less harmful to arteries.
 
The authors considered reduction of carbs to 109 grams a day to be “severe.”  That compares to 275 grams a day eating by the typical U.S. citizen.  I agree that a reduction of carbs by two-thirds is major restriction.  Dr. Richard Bernstein and I consider severe restriction to be 20–30 grams, or perhaps up to 50 g.
 
I suspect the improved metabolic numbers in the low-carbers would have been even more dramatic if they had reduced carbs well below 100 grams a day.  The Ketogenic Mediterranean Diet reduces digestible carbs to 20–30 grams daily.  Many diabetics start losing control of their blood sugars when daily carbs exceed 60–80 grams.
 
Low-carb diets often yield better weight loss than low-fat calorie-restricted diets, as was seen here.  This is often attributed to lower calorie consumption on the low-carb diets.  These investigators didn’t see that here.
 
Low-carb diets are often criticized as being hard to stick with.  The low-carbers here didn’t have any more drop-outs than the low-fat group.  Granted, it was only a three-month study.
 
Based on what we know today, the reduced need for insulin in these patients was entirely predictable. 
 
The authors had some concern about the higher relative saturated fatty acid consumption in the low-carbers.  In 2011, we know that’s not much, if any, cause for concern.
 
 
 
 
Reference: Daly, M.E., et al.  Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes—a randomized controlled trial.  Diabetic Medicine, 23 (2006): 15-20.  doi: 10.1111/j.1464-5491.2005.01760.x

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