Tag Archives: low-carb

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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Meal Plans For “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:  Brats and Tomatoes

6 oz (170 g) tomato, sliced

2 tbsp (30 ml) AMD vinaigrette (see below) or commercial Italian dressing (regular, not low-fat, with 3 g or fewer carbs per 2 tbsp or 30 ml)

salt and pepper

2 pre-cooked bratwursts (about 2.3 oz or 65 g each)

6 tsp (30 ml) mustard (optional)

Dress the tomato slices with the vinaigrette, plus salt and pepper to taste. Heat 2 pre-cooked bratwursts as instructed on package. Use mustard on the brats if desired. Digestible carb grams: 8.

AMD VINAIGRETTE

Try this on salads, fresh vegetables, or as a marinade for chicken, fish, or beef. If using as a marinade, keep the entree/marinade combo in the refrigerator for 4–24 hours. Seasoned vinaigrettes taste even better if you let them sit for several hours after preparation. This recipe was in my first book, The Advanced Mediterranean Diet; hence, “AMD vinaigrette.”

Ingredients

1 clove (3 g) garlic

juice from ½ lemon (23 g or ml)

a third of a cup (78 ml) oil olive

2 tbsp (8 g) fresh parsley

½ tsp (2.5 ml)) salt

½ tsp (2.5 ml) yellow mustard

½ tsp (1.2 ml) paprika

2 tbsp (30 ml) red wine vinegar

Preparation

In a bowl, combine all ingredients and whisk together. Alternatively, you can put all ingredients in a jar with a lid and shake vigorously. Let sit at room temperature for an hour, for flavors to meld. Then refrigerate. It should “keep” for at least 5 days in refrigerator. Shake before using. Servings per batch: 3.

Nutrient Analysis:

Recipe makes 3 servings (2 tbsp or 30 ml per serving). Each serving has 220 calories, 2 g digestible carb, almost no fiber, negligible protein, 24 g fat. 3% of calories are from carbohydrate, 97% from fat.

Lunch:  Easy Tuna Plus Pecans

5-oz can (140 g) of albacore tuna

2 tbsp (30 ml) Miracle Whip Salad Dressing (or real, high-fat mayonnaise)

1 tsp (5 ml) lemon or lime juice

1 oz (28 g) pecan halves

Drain the liquid off the can of tuna then place tuna in a bowl. Add Miracle Whip Salad Dressing and lemon or lime juice. Mix thoroughly and enjoy. Eat 1 oz of pecan halves around mealtime or later as a snack. If you want to simplify this, forget the Miracle Whip and lemon; just use 1 oz (28 g) of commercial tartar sauce that derives at least 80% of calories from fat and has less than 3 g of carb per 2 tbsp or 30 ml. Digestible carb grams: 5.

Dinner:  Ham Salad

2 oz (60 g) cooked ham, cut in to small cubes

1 oz (28 g) celery, sliced and diced

1 oz (28 g) seedless grapes (about 4 grapes), cut into small chunks

1 oz (28 g) walnuts, coarsely crumbled

4 oz (110 g) romaine lettuce

3 tbsp AMD vinaigrette or commercial Italian, French, or ranch dressing having 2 or fewer grams of carb per 2 tbsp or 30 ml)

Lay out a bed of lettuce then sprinkle these on top: ham, celery, grapes, walnuts. Finish construction with AMD vinaigrette or commercial dressing. You’re done. Alternatively, substitute cooked chicken or steak for ham. With chicken, apple may work better than grapes. If having a glass of wine (6 fl oz or 180 ml) with meal, delete the grapes or the carb count will be too high. Digestible carb grams: 10.

(When commercial dressing is used, the digestible carb count is closer to 13 than 10 g.)

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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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Franziska Spritzler Explains Why So Many Dietitians Are Against Low-Carb Diets

Click for details. Briefly:

1. They think it’s dangerous. 
2.They believe the diet-heart hypothesis. 
3. They think the diet is unbalanced.  
4. They think no one will follow it long term.

Franziska debunks these ideas one by one.

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Dr. Jay Wortman Cured His Type 2 Diabetes With Low-Carb Eating

First Nation people traditionally ate salmon, a great source of marine omega-3 fatty acids

First Nation people traditionally ate salmon, a great source of marine omega-3 fatty acids

DietDoctor Andreas Eenfeldt recently interviewed Jay Wortman, M.D., and posted it at his blog. Dr. Wortman apparently cured his type 2 diabetes with a low carb diet. The interview doesn’t reveal how many carbohydrate grams Dr. Wortman eats daily, but I’m guessing under 60 g, perhaps as low as 30. He avoids sugars and starches.

Dr. Wortman also did research on application of the ancestral diet (low-carb) among aborigines on the west coast of Canada. I think they call them First Nation people. The low-carb diet helped them get off diabetes and high blood pressure drugs while losing excess weight. Dr. Wortman mentioned the diet improved heartburn, too. Folks who go low-carb frequently report an improvement in heartburn. That’s even been studied scientifically.

Steve Parker, M.D.

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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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“ItsTheWooo” Explains Reluctance to Try Very-Low-Carb Eating For Weight Management

Click for details. ITW, BTW, is a nurse. A snippet:

At work, a few days ago, I was sitting at the station alongside a new nurse; she’s very young (about my age when I first started using a ketogenic diet for my obesity) and she is also very very overweight. In addition to being a young female (thus common sense that she prefers to be thin), observing her eating behavior made it patently obvious this poor girl has been trying for years to correct her obesity.  She always refuses food if offered to her, and when she does bring food, she rarely eats it, and it’s always healthy food like salads.

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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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Is Low-Carb Killing Swedish Women?

MPj04384870000[1]A recent Swedish study suggests that low-carbohydrate/high protein diets increase the risk of cardiovascular disease in women.  I’m not convinced, but will keep an eye on future developments.  This is a critical issue since many women eat low-carb/high protein for weight loss and management.

Researchers followed 43,000 women, 30-49 years of age at enrollment, over the course of 16 years.  In that span, they had 1270 cardiovascular events: ischemic heart disease (heart attacks and blocked heart arteries), strokes, subarachnoid hemorrhages,  and peripheral arterial disease.  Food consumption was estimated from a questionnaire filled out by study participants at the time of enrollment (and never repeated).

In practical terms, … a 20 gram decrease in daily carbohydrate intake and a 5 gram increase in daily protein intake would correspond to a 5% increase in the overall risk of cardiovascular disease.

So What?

To their credit, the researchers note that a similar analysis of the Women’s Health Study in the U.S. found no such linkage between cardiovascular disease and low-carb/high protein eating.

The results are questionably reliable since diet was only assessed once during the entire 16-year span.

I’m certain the investigators had access to overall death rates.  Why didn’t they bother to report those?  Your guess is as good as mine.  Even if low-carb/high protein eating increases the rate of cardiovascular events, it’s entirely possible that overall deaths could be lower, the same, or higher than average.  That’s important information.

I don’t want to get too far into the weeds here, but must point out that the type of carbohydrate consumed is probably important.  For instance, easily digested carbs that raise blood sugar higher than other carbs are associated with increased heart disease in women.  “Bad carbs” in this respect would be simple sugars and refined grains.

In a 2004 study, higher carbohydrate consumption was linked to progression of blocked heart arteries in postmenopausal women.

It’s complicated.

Steve Parker, M.D.

PS: I figure Swedish diet doctor Andreas Eenfeldt would have some great comments on this study, but can’t find them at his blog.

Reference: Lagiou, Pagona, et al.  Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study.  British Medical Journal, June 26, 2012.  doi: 10.1136/bmj.e4026

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A Dietitian’s View of Ketogenic Diets

You get it?

Registered Dietitian Franziska Spritzler recently reviewed the concept of low-carb ketogenic diets.  She thinks they are a valid approach to certain clinical situations.  Among dietitians, this puts her in a small but growing minority.

I hesitate to mention this, but I will anyway.  Many, if not most, dietitians too easily just go along with the standard party line on low-carb eating: it’s rarely necessary and quite possibly unhealthy.  Going along is much easier than doing independent literature review and analysis.  I see the same mindset among physicians.

Franziska breaks the mold.

Steve Parker, M.D.

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