Tag Archives: diabetic diet

December 3, 2013 · 2:00 AM

Meal Plans To “Conquer Diabetes and Prediabetes”

For both types 1 and type 2 diabetes, carbohydrate restriction is a great way to help control blood sugars and minimize the toxicity and expense of drug therapy. Here are some low-carb recipes from my book, Conquer Diabetes and Prediabetes.

Breakfast:  Mexican Scrambled Eggs

4 large eggs (50 g each)

1.5 tbsp (22 ml) olive oil

4 tbsp (60 ml) Pico de Gallo a la Rose (see my post of Jan. 5, 2013) or commercial picante sauce (having 2 g or fewer carbs per 2 tbsp)

salt and pepper

Whisk the eggs until smooth, add salt and pepper to taste; set aside. Heat the olive oil in a medium-sized frying pan then add the eggs and cook until done, scrambling now and then. Transfer to plate and top with 4 tbsp (60 ml) Pico de Gallo a al Rosa. Digestible carb grams: 6.

Lunch:  Low-Carb Chili

1 cup (240 ml) Low-Carb Chili (see below)

1 oz (28 g) almonds

Enjoy 1 oz of almonds around mealtime or later as a snack. Digestible carb grams: 13.

LOW-CARB CHILI

It’s spicy, but not hot spicy. Peeled and sliced cold cucumbers make a nice side dish. If your children or housemates aren’t eating low-carb, they may enjoy the chili mixed 50:50 with cheese macaroni, and buttered cornbread on the side.

Ingredients

20 oz (567 g) raw ground beef, 80% lean meat/20% fat

20 oz (567 g) raw pork Italian sausage

1 large onion

14.5 oz (411 g) canned diced tomatoes

4 oz (113 g) tomato paste

1 tbsp (15 ml) dry unsweetened cocoa powder

5  garlic cloves

½ tsp (2.5 ml) salt

¼ tsp (1.2 ml) ground allspice

2 tbsp (30 ml) chili powder

¼ tsp (1.2 ml) ground cinnamon

½ tbsp (7.5 ml) ground cumin

¼ tsp (1.2 ml) ground cayenne pepper

2 packets (1 g per packet) Splenda tabletop sweetener

1 cup (240 ml) water

Preparation

Cut the Italian sausage into small pieces. Sauté the sausage, ground beef, onions, and garlic in a large pot. Don’t just brown the meat, cook it thoroughly. When done, drain off the fat if desired. Add the remainder of ingredients, bring to a boil, then simmer for about an hour. Add additional water if the chili looks too thick. Makes eight cups. Serving size is one cup (240 ml).

Nutrient Analysis:

Recipe makes 8 servings of 1 cup (240 ml). Each serving has 492 calories, 14 g carbohydrate, 3 g fiber, 11 g digestible carbohydrate, 24 g protein, 38 g fat. 10% of calories are from carbohydrate, 21% from protein, 69% from fat.

Notes: Analysis is based on fat not being drained from the cooked meat. Calorie count and calories from fat would be a bit lower if you drained off fat.

Dinner:  Shark and Broccoli

4 oz (110 g) shark, raw

2 cloves (3 g) garlic, peeled and diced

3 tbsp (45 ml) olive oil

1.5 cups (150 g) chopped raw broccoli

salt and pepper

6 oz (180 ml) dry white wine

Lightly salt and pepper the shark, then set aside. Sauté the garlic in 2 tbsp (30 cc) of the olive oil a few minutes over medium heat. Then add the broccoli and sauté to your preference, adding salt and pepper to taste. Remove to a dish. Add another 1 tbsp (15 ml) olive oil to the pan and sauté the shark at medium heat until done, careful not to overcook. Enjoy with dry white wine. Digestible carb grams: 11.

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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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September 26, 2013 · 3:49 PM

Carbohydrate Restriction Versus Drugs for T2 Diabetes

“The only person definitely known to have died as a consequence of an association with a low-carbohydrate diet is Dr. Herman Tarnower, author of the Scarsdale diet, although, as they say used to say on the old TV detective shows, the immediate cause of death was lead poisoning. His girlfriend shot him.”

That’s how Richard David Feinman starts a post on management of blood sugars in type 2 diabetics with risky drugs instead of carbohydrate restriction. Of course, you can use both strategies if you have to, and many do.

Read the rest.

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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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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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April 13, 2013 · 2:00 AM

Periodic Tests, Treatments, and Goals for PWDs (Persons With Diabetes)

If you don't like your physician, find a new one

If you don’t like your physician, find a new one

So, you’ve got diabetes. You’re trying to deal with it or you wouldn’t be here. You’ve got a heck of a lot of medical information to master.

Unless you have a good diabetes specialist physician on your team, you may not be getting optimal care. Below are some guidelines you may find helpful. The goal is to prevent diabetes complications. Many primary care physicians will not be up-to-date on the guidelines. Don’t hesitate to discuss them with your doctor. Nobody cares as much about your health as you do.

Annual Tests

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.) The complete ADA guidelines are available on the Internet.

  • Lipid profile (every two years if results are fine and stable)
  • Comprehensive foot exam
  • Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense
  • Serum creatinine and estimate of glomerular filtration rate (MDRD equation)
  • Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
  • Comprehensive eye exam by an ophthalmologist or optometrist (if exam is normal, every two or three years is acceptable)
  • Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
  • Flu shots

Other Vaccinations, Weight Loss, Diabetic Diet, Prediabetes, Alcohol, Exercise, Etc.

Additionally, the 2013 ADA guidelines recommend:

  • Pneumococcal vaccination. “A one time re-vaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
  • Hepatitis B vaccination to unvaccinated adults who are 19 through 59 years of age.
  • Weight loss for all overweight diabetics. “For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).” For those on low-carb diets, monitor lipids, kidney function, and protein consumption, and adjust diabetic drugs as needed. The optimal macronutrient composition of weight loss diets has not been established. (Macronutrients are carbohydrates, proteins, and fats.)
  • “The mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes.” “It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal.”
  • “A variety of dietary meal patterns are likely effective in managing diabetes including Mediterranean-style, plant-based (vegan or vegetarian), low-fat and lower-carbohydrate eating patterns.”
  • “Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control.”
  • Limit alcohol to one (women) or two (men) drinks a day.
  • Limit saturated fat to less than seven percent of calories.
  • During the initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
  • Those at risk for diabetes, including prediabetics, should aim for moderate weight loss (about seven percent of body weight) if overweight. Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years). Also important is exercise: at least 150 minutes per week of moderate-intensity aerobic activity. “Individuals at risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake).” Limit intake of sugar-sweetened beverages.
  • “Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate), spread over at least 3 days/week with no more than two consecutive days without exercise. In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week.”
  • Screening for coronary artery disease before an exercise program is depends on the physician judgment on a case-by-case basis. Routine screening is not recommended.
Steve Parker MD, low-carb diet, diabetic diet

Olive, olive oil, and vinegar: classic Mediterranean foods

Obviously, some of my dietary recommendations conflict with ADA guidelines. The experts assembled by the ADA to compose guidelines were well-intentioned, intelligent, and hard-working. The guidelines are supported by 528 scientific journal references. I greatly appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

General Blood Glucose Treatment Goals

The ADA in 2013 suggests these therapeutic goals for non-pregnant adults:

  • Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
  • Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
  • Hemoglobin A1C: under 7%
  • Blood pressure: under 140/80 mmHg
  • LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular disease: <70 mg/dl or 1.8 mmol/l may be a better goal.)
  • HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
  • Triglycerides: under 150 mg/dl (1.7 mmol/l)

The American Association of Clinical Endocrinologists (AACE) in 2011 proposed somewhat “tighter” blood sugar goals for non-pregnant adults:

  • Fasting blood glucoses: under 110 mg/dl (6.11 mmol/l)
  • Peak glucoses 2 hours after start of meals: under 140 mg/dl (7.78 mmol/l)
  • Hemoglobin A1C: 6.5% or less

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely.

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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February 12, 2013 · 7:32 AM

Once Again, Low-Carbohydrate Ketogenic Diet Beats Low-Calorie For Overweight Diabetes

Kuwait City and Towers

Kuwait City and Towers

A low-carbohydrate ketogenic diet is safe, effective, and superior to a low-calorie diet in type 2 diabetics, according to a report last year in Nutrition.

Kuwaiti researchers gave 102 adult overweight diabetic men and women their choice of diet: 78 chose ketogenic, 24 went low-calorie.  Average age was 37, average weight 211 lb (96 kg).  The study lasted six months.  The ketogenic diet was very much Atkins-style, starting out at 20 grams of carbohydrate daily.  Once good weight-loss progress was made, and if carb cravings were an issue, dieters could increase their carbs in small increments weekly.

This is all they said about the low-calorie diet: “Participants in the low-calorie diet group were given appropriate guidelines and a sample low-calorie diet menu of 2200 calories is presented in Table 1” (it’s typical and reasonable).

What Did They Find?

The low-carb ketogenic dieters lost 12% of body weight, compared to 7% lost by the low-calorie dieters.  Furthermore, the ketogenic dieters showed significant lowering of total cholesterol, LDL cholesterol (bad cholesterol), and triglycerides.  HDL cholesterol (good cholesterol) rose.  The low-calorie dieters seem to have had a significant drop in LDL cholesterol, but no changes in the other lipids.

Fasting blood sugar levels dropped significantly in both groups, but more in the ketogenic dieters.  Both groups started with fasting blood sugars around 162 mg/dl (9 mmol/l) and fell to 108 mg/dl (6 mmol/l) in the ketogenic group and to 126 mg/dl (7 mmol/l) in the low-calorie group.

Glycosylated hemoglobin (hemoglobin A1c) levels fell in both groups, more so in the ketogenic dieters.  The drop was statistically significant in the ketogenic group, but the authors were unclear about that in the low-calorie dieters.  It appears hemoglobin A1c fell from 7.8% to 6.3% with the ketogenic diet (the units given for glycosylated hemoglobin were stated as mg/dl).  In the low-calorie dieters, hemoglobin A1c fell from 8.2 to 7.7%.

What’s Odd About This Study?

The title of the research report indicates a study of diabetics, but only about 25% of study participants had diabetes (total subjects = 363).  (The figures I share above are for the diabetics only.)

Glycosylated hemoglobin, a test of overall diabetes control, is reported in Fig. 1 in terms of mg/dl.  That’s nearly always reported as a percentage, not mg/dl.  Misprint?

None of the participants dropped out of the study.  That’s incredible, almost unbelievable.

The low-calorie diet was poorly described.  Were 140-lb women and 250-lb men all put on the same calorie count?

Food diaries were kept, but the authors report nothing about compliance and actual food intake.

Clearly, some of these diabetics were on insulin and other diabetic drugs.  The authors note necessary reductions in drug dosages for the ketogenic group but don’t say much about the other dieters.  They imply that the drug reductions in the low-calorie group were minimal or nonexistent.

Grand Mosque of Kuwait

Grand Mosque of Kuwait

So What?

Calorie-restricted diets are effective in overweight type 2 diabetics, but ketogenic diets are even better.

The effectiveness and safety of ketogenic diets for overweight type 2 diabetics has been demonstrated in multiple other populations, so this study is not surprising.  We’ve seen these lipid improvements before, too.

The favorable lipid changes on low-carb ketogenic diets would tend to reduce future heart and vascular disease.

I know little about Kuwaiti culture and genetics.  Their contributions to the results here, as compared with other populations, is unclear to me.  Type 2 diabetes is spreading quickly through the Persian Gulf, so this research may have wide applicability there.

Steve Parker, M.D.

Reference:  Hussain, Talib, et al.  Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes.  Nutrition, 2012; 28(10): 1016-21. doi: 10.1016/j.nut.2012.01.016

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January 24, 2013 · 7:16 AM

How About the Paleo Diet for Diabetes?

Not Dr. Frassetto

Dr. Lynda Frassetto is a Professor of Medicine and Nephrology at the University of California San Francisco.  She and her colleagues have completed a study of the Paleolithic diet as a treatment for diabetes (type 2, I think).  As far as I know, details have not yet been published in the medical literature.

Dr. Frassetto spoke at the Ancestral Health Symposium-2012 earlier this year.  You can view the 35-minute video here.

She is convinced that a paleo diet, compared to a Mediterranean-style diet, is better at controlling blood sugars and “reducing insulin” in diabetics (presumably type 2s).  Insulin sensitivity is improved, particularly in those with insulin resistance to start with.  The paleo diet group saw an average drop of fasting glucose by 23 mg/dl (1.3 mmol/l).  One slide you’ll see in the video indicates the paleo diet reduced absolute hemoglobin A1c by 0.3%, compared to 0.2% with the “Mediterranean” diet.  (Let me know if I got the numbers wrong.)

Color me underwhelmed so far.

Questions raised by the video include:

  • what is the UCSF version of the paleo diet?
  • how many participants were in her study?
  • how long did her study last?
  • did she study only type 2 diabetics?
  • what exactly was the control diet?
  • how severe were the cases of diabetes studied?

For answers, we await publication of the formal report.

Steve Parker, M.D.

PS: I’m quite interested in the paleo diet as a treatment for diabetes.  I explore the concept at the Paleo Diabetic blog.

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December 3, 2012 · 1:04 PM

Dietitians’ Views on Mediterranean Diet for Diabetes

An eating pattern similar to the traditional Mediterranean diet can be integrated with existing national guidelines for the management of diabetes, blood pressure, and cholesterol. Existing data suggest that the Mediterranean diet has health benefits, including improved glycemic control and reduced cardiovascular risk, and may offer benefits to diabetes patients and clinicians alike in terms of palatability, ease of explanation and use, and promotion of improved health.

Olive oil and vinegar

Olive oil and vinegar

This excerpt is from an article by three dietitians writing in Diabetes Spectrum in 2009.  Click through for details if interested.

—Steve

Reference:  doi: 10.2337/diaspect.24.1.36  Diabetes Spectrum January 1, 2011 vol. 24, no. 1, p.36-40

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