Tag Archives: Richard Bernstein

November 14, 2012 · 8:13 PM

Does Dietary Protein Affect Blood Sugars?

The protein in this can raise your blood sugar

I’m considering whether I should advise my patients with diabetes to pay careful attention to the protein content of their diet, assuming they’re not malnourished.  It’s an important issue to Dr. Richard K. Bernstein, who definitely says it has to be taken into account.

Protein can undoubtedly raise blood sugar levels.  But is the effect clinically significant?  Most  dietitians and physicians pay little attention to it as a source of hyperglycemia.  Here are some of Dr. Bernstein’s ideas pulled from the current edition of Diabetes Solution:

  • The liver (and the kidneys and intestines to a lesser extent) can convert protein to glucose, although it’s a slow and inefficient process.
  • Since the conversion process—called gluconeogenesis—is slow and inefficient, diabetics don’t see the high blood sugar spikes they would see from many ingested carbohydrates.
  • For example, 3 ounces (85 g) of hamburger patty could be converted to 6.5 g of glucose under the right circumstances.
  • Protein foods from animals (e.g., meat, fish, chicken, eggs) are about 20% protein by weight.
  • Dr. B recommends keeping protein portions in a particular meal consistent day-to-day (for example 6 ounces with each lunch).
  • He recommends at least 1–1.2 g of protein per kilogram of ideal body weight for non-athletic adults.  That’s more than the usual 0.8 g per kilogram.
  • The minimum protein he recommends for a 155-lb non-athletic adult is 11.7–14 ounces daily.
  • Growing children and athletes need more protein.
  • Each uncooked ounce of the foods on his “protein foods” list (page 181) provides about 6 g of protein.
  • On his eating plan, you choose the amount of protein in a meal that would satisfy you, which might be 3 ounces or 6–9 ounces.
  • If you have gastroparesis, however, you should limit your evening meal protein to 2 ounces of eggs, cheese, fish, or ground meat, while eating more protein at the two earlier meals in the day.

“In many respects—and going against the grain of a number of the medical establishment’s accepted notions about diabetics and protein—protein will become the most important part of our diet if you are going to control blood sugars just as it was for our hunter-getherer ancestors.”

Conclusions

I haven’t changed my thinking on this issue yet, but will let you know if and when I do.  I don’t talk much about protein in Conquer Diabetes and Prediabetes in part because I wanted to keep the program simpler than Dr. Bernstein’s.  Albert Einstein reportedly said, “Everything should be made as simple as possible, but not simpler.”

As with most aspects of diabetes, your mileage may vary.  The effect of dietary protein on blood sugars will depend on type 1 versus type 2 diabetes, and will vary from one person to another.  So it may be impossible to set rigid guidelines.

If interested, you can determine how much protein is in various foods at NutritionData.

Steve Parker, M.D.

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May 27, 2010 · 12:31 AM

Book Review: Diabetes Solution – The Complete Guide to Achieving Normal Blood Sugars

Here’s my review of Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars, published in 2007.  Per Amazon.com’s rating scale, I give it five stars (I love it).  

♦   ♦   ♦ 

Dr. Richard K. Bernstein gives away thousands of dollars’ worth of medical advice in this masterpiece, Diabetes Solution.  It’s a summation of his entire medical career and a gift to the diabetes community.  

The book starts off with some incredible testimonials: reversal of diabetic nerve damage, eye damage, and erectile dysfunction.  They’re a bit off-putting to a skeptic like me, like an infomercial.  Dr. Bernstein is either lying about these or he’s not; I believe him.  His strongest testimonial is his own.  He’s been a type 1 diabetic most of his life, having acquired the disease at a time when most type 1’s never saw 55 candles on a birthday cake.  He’s in his mid-70s now and still working vigorously.  

I only found one obvious error and assume it’s a misprint. He writes that 95% of people born today in the U.S. will eventually develop diabetes.  That’s preposterous.  The U.S. Centers for Disease Control predicts that one in three born in 2000 will be diagnosed.  

Dr. Bernstein delivers lots of facts that I can neither confirm nor refute.  He’s a full-time diabetologist; I am not.  

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

  

The central problem in type 1 diabetes is that, due to a lack of insulin,  ingested carbohydrates lead to spikes (elevations) in blood sugar.  The sugar elevations themselves are toxic.  The usual insulin injections are not good imitators of a healthy pancreas gland. So Dr. Bernstein is an advocate of low-carb eating (about 30 g daily compared to the usual American 250-300 g).  He says the available insulins CAN handle the glucose produced by a high-protein meal.  

Dr. B reminds us that insulin is the main fat-building hormone, which is one reason diabetics gain weight when they start insulin, and why type 2 diabetics with insulin resistance (and high blood insulin levels) are overweight and have trouble losing weight.  You can have resistance to insulin’s blood sugar lowering action yet no resistance to its fat-building (fat-storing) action.  Insulin also stimulates hunger, so insulin-resistant diabetics are often hungry.  

“Carbohydrate counting” is a popular method for determining a dose of injected insulin.  Dr. B says the gram counts on most foods are only a rough estimate—far too rough.  He minimizes the error by minimizing the input (ingested carbs).  From his days as an engineer, he notes “small inputs, small mistakes.”  

Dr. B also cites problems with the absorption of injected insulin.  Absorption is variable: the larger the dose, the greater the variability.  So don’t eat a lot of carbs that require a large insulin dose.  For adult type 1 diabetics, his recommended rapid-acting insulins doses are usually three to five units.  If a dose larger than seven units is needed, split it into different sites.  

He recommends diabetics aim for normal glucoses (90 mg/dl or less) almost all the time, and hemoglobin A1c of 5% or less.  This is extremely tight control, tighter than any expert panel recommends.  He says this is the best way to avoid the serious complications of diabetes.   

Here’s a smattering of “facts” in the book that made an impact on me, a physician practicing internal medicine for over two decades.  I want to remember them, incorporate into my practice, or research further to confirm:  

  • Hemoglobin A1c of 5% equals an average blood sugar of 100 mg/dl (5.56 mmol/l).  For each one % higher, average glucose is 40 mg/dl (2.22  mmol/l) higher.
  • He’s against any drugs that overstimulate (“burn out”) the remaining pancreas function in type 2 diabetics: sulfonylureas, meglitinides, “phenylalanine derivatives”.  Pancreas-provoking agents cause hypoglycemia and destroy beta cell function.
  • The insulin sensitizers are metformin and thiazolidinediones.  He likes these.
  • Blood sugar normalization in type 2 diabetes and early-stage type 1 can help restore beta cell function.
  • He often speaks of preserving beta cell function.
  • He believes in “insulin-mimetic agents” like alpha lipoic acid (especially R-ALA, and take biotin with either form) and evening primrose oil.  These  are no substitute for insulin injections but allow for lower insulin doses.  ALA and evening primrose oil don’t promote fat storage like insulin does.
  • He says many cardiologists take ALA for its antioxidant properties [news to me]
  • He says rosiglitazone works within two hours [news to me] but later admits it may take 12 weeks to see maximal benefit
  • One of his goals is to preserve beta cell function if at all possible
  • He prefers rosiglitazone over pioglitazone due to fewer drug interactions
  • “Americans are fat largely because of sugar, starches, and other high-carbohydrate foods.”
  • He’s convinced that people who crave carbohydrates have inherited the problem, which also predisposes to insulin resistance and type 2 diabetes.  Low-carb diets decrease the cravings for many, in his experience.
  • In small amounts, alcohol is relatively harmless: dry wine, beer, spirits.  Very few doctors have the courage to say this.
  • If you’re in a restaurant, you can use urine sugar test strips and saliva to test for presence of sugar or flour in food
  • A rule of thumb: one gram of carbohydrate will raise blood sugar about 5 mg/dl (0.28  mmol/l) or less for most diabetic adults weighing 140 lb (64  kg) and about 2.5 mg/dl (0.139 mmol/l) in a 280-pounder (127  kg).  This must refer to type 1 diabetics or a type 2 with little residual pancreas beta cell function; variable degrees of insulin resistance and beta cell reserve in many type 2s would make this formula unreliable.
  • Be wary of maltodextrin in Splenda: it does raise blood sugar.
  • Much new to me in his section on artificial sweeteners.  Be wary of them.
  • He avoids all grains, breads, crackers, barley, oats, rice, and pasta.
  • Most diet sodas are OK.
  • Coffees with 1-2 tsp milk is OK.  Cream is OK.
  • He eats NO fruit and recommends against it.
  • He avoids beets, corn, potatoes, and beans. A slice of tomato in one cup of salad is OK.  A small amount of onion is OK.
  • String beans and snow peas are OK.
  • Cooked vegetables tend to raise blood sugar more rapidly than raw.
  • Use “Equal” aspartame tabs as a sweetener.  Don’t use “powdered” Splenda.
  • Avoid nuts: too easy to overeat.
  • For desert: sugar-free Jell-O Brand Gelatin.
  • Yogurt?  Plain, whole milk, unsweetened.  Flavor with cinnamon, Da Vinci syrups, baking flavor extracts, stevia or Equal.
  • Avoid balsamic vinegar.
  • Need fiber?  Bran crackers or soybean products.
  • “Ideally, your blood sugar should be the same after eating as it was before.”  85 mg/dl (4.72  mmol/l) is his usual goal.  If blood sugar rises by more than 10 mg/dl (0.56 mmol/l) after a meal, either the meal has to be changed or medication changed.
  • Protein is a source of glucose: keep protein amounts at meals constant from day to day, especially if taking glucose-lowering drugs.
  • The lowest-carb meal of the day should be breakafast.  Why?  Dawn phenomenon.
  • He promotes strenuous, prolonged exercise, especially weight training (extensive discussion and instruction in book).
  • Many diabetics on insulin need dose adjustments in 1/2 and 1/4 unit increments [news to me: if I ordered 4 and 1/4 units of insulin at the hospital, the nurses would laugh].
  • Typical rapid-acting insulin doses for his adult type 1 patients are 3-5 units.  The “industrial doses” of insulin seen or recommended by many physicians reflect diets too high in carbohydrate.
  • He says Lantus only acts for nine hours (nighttime injection) or 18 hours (AM injection).
  • He doesn’t like mixed insulins (e.g., 70/30).
  • Humalog and Novolog are more potent than regular insulin, so the dose is about 2/3 of the regular insulin dose
  • “Only a few of the 20 available [home glucose monitoring] machines are suitably accurate for our purposes.”  “None are suitably accurate or precise above 200 mg/dl [11.11 mmol/l].”
  • Vitamin C in doses over 250 mg interferes with fingertip glucose monitors.  Later he says doses over 500 mg cause falsely low readings.
  • He prefers regular insulin (45 minutes before meal) over Novolog and Humalog, because of its five-hour duration of action.
  • Insulin users need to check glucose levels hourly while driving.
  • His personal basal insulin is 3 units Lantus twice daily.
  • He urges use of glucose (e.g., Dextrotabs) to correct hypoglycemia.
  • He says hypoglycemia is rare on his regimen.
  • He has an entire chapter on gastroparesis.

Dr. Bernstein’s recommended eating program in a nutshell:  

  • Some similarities to the Atkins diet, which he never mentions.
  • No simple sugars or “fast-acting” carbs like bread and potatoes, because even type 2s have impaired or nonexistent phase 1 insulin response.
  • Limit carbs to an amount that will work with your injected insulin or your remaining phase 2 insulin response, if any.
  • “Stop eating when you no longer feel hungry, not when you’re stuffed.”
  • Follow a predetermined meal plan (each meal: same grams of carb and ounces of protein)
  • Six g (or less) of carbs at breakfast, 12 g (or less) at lunch and evening meal.  So his patients count carb grams and protein ounces.
  • Supplements are not required IF glucoses are controlled and eating a variety of veggies.  Otherwise you may need B-complex or multivitamin/multimineral supplement.
  • Recipes are provided.

His has four basic drug treatment plans, tailored to the individual.  They are outlined in the book.  Dr. B provides detailed notes on what he does with his personal patients.  

Overall impressions:  

  • Too complicated for most, and they won’t give up higher carb consumption.  It requires a high degree of committment and discipline.  In fact, I’ve never had a patient tell me they were on the Bernstein program.
  • If I had type 1 diabetes, I might well follow his plan or the Low-Carb Mediterranean Diet, NOT the high-carb diet recommended by the ADA and many dietitians.
  • And if I had type 2 diabetes?  Low-Carb Mediterranean Diet first, Diabetes Solution as second choice.
  • If one can get his hemoglobins A1c down to 5% with other methods, would that be just as good?  Dr. B would argue that all other methods have blood sugar swings that are too wide.
  • Many new ideas and techniques here, at least to me.
  • He pretty much reveals his entire program here, which is priceless.
  • I’m not sure this plan will work unless the patient’s treating physician is on-board.
  • His personal testimony and breadth of knowledge are very persuasive. 

Steve Parker, M.D.  

Disclosure:  I was given nothing of value by Dr. Bernstein or his publisher in return for this review.

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March 6, 2010 · 2:00 AM

My Ketogenic Mediterranean Diet and Low-Carb Eating: Six-Month Summary

I started my Ketogenic Mediterranean Diet on September 1, 2009.  After two months, I stopped compulsive record-keeping and food measurement and made a few other intentional tweaks: fish five times a week instead of seven miminum, more nuts (often two ounces a day—I like nuts and they’re convenient), less salad, more dark chocolate.  Otherwise the last four months have been similar to the initial two months of strict KMD.  My daily digestible carbohydrate intake has probably crept up to 40 g compared to 20-25 g on the strict KMD—this is still considered very low-carb. 

Accomplishments

Starting weight was 170 pounds (77.3 kg) on September 1.   After two months—8.6 weeks—my weight clearly stabilized at 155 lb (70.5 kg).  I lost the 15 lb (6.8 kg) over the first six weeks then just hovered around 155 lb.  So average weekly weight loss over the six weeks was 2.5 pounds.  Also lost a couple inches (5 cm) off my waist.

For the last four months—November through February—I’ve been eating the aforementioned liberalized KMD.  Weight has stayed around 155-157 lb (71 kg).  No calorie counting.  I eat as much as I want, except for carbs.  The experience of the first two months taught me how to eat 20-25 g of carbs in a day; it’s the gauge by which I estimate I’m eating 40 g daily now.

Has It Been Easy?

Yeah, relatively easy.  Two other adults in my house are also eating low-carb, which definitely helps.  Blogging here also helps me maintain compliance.  I promised myself to report everything—the good, the bad, and the ugly—honestly.  Accountability is important. 

Staying with the program may be easier for me than for others because I am heavily invested in it, psychologically and time-wise. 

It’s also been helpful for me to participate at two low-carb online communities: LowCarbFriends and Active Low-Carber Forums.  We support each other.  Thanks, guys.

I took diet holidays twice, for three days at both Thanksgiving and Christmas.  Gained three to five pounds (1.8 kg) each time on high-carb eating, but lost it over the next week by returning to the strict KMD.

Any Surprises?

Induction flu.  I’d never heard of it before.  Occurs typically on days 2–5 of very low-carb dieting: achiness and fatigue.  Others also experience headaches and dizziness, and it may last 1–2 weeks.

Rapid weight gain during my diet holidays (aka cheat days).  I was not gorging.  I figure the weight was mostly new glycogen in liver and muscle.  And water.

Eating fish more than once a day is a lot of fish!  Quickly boring, even unappetizing.  But that’s just me.  I need to be a more creative.  Most of my fish lately has been canned tuna.

Assuming that the Daily Values of various nutrients recommended by the U.S. Food and Drug Administration are valid, the KMD foods come up short in many vitamins and minerals.  I bet this is an issue (a problem?) with many, if not most, very low-carb diets if supplements aren’t used.  Those Daily Values are debatable, of course.  For instance, Gary Taubes argues that you don’t need much vitamin C if eating few carbs.  My nocturnal leg cramps and constipation were proof enough for me that I needed at least some supplements.  The recommended KMD supplements remedy the DailyValue shortfall in vitamins and minerals.  Dr. Richard K. Bernstein has a 30-gram carbohydrate diet for his diabetic patients and himself, as outlined in his Diabetes Solution book: no supplements are required.  

As time passes, I worry less about getting enough of various micronutrients.   I feel fine.  I’m still taking the recommended KMD supplements (5 pills a day) plus sugar-free Metamucil.   

I never had hunger that I couldn’t satisfy within the guidelines of the diet. 

No major trouble with cravings or longing for carbs.  I’ve gone six months now without whole grain bread, oatmeal, pizza, and pasta—very unusual for me.  I’d be OK never eating them again.  What I do miss are sweet, often fat-laced, carbohydrates: pie, cookies, cinnamon rolls, candy bars, cake, ice cream.  I doubt that desire will ever disappear, although it does for some who eat very low-carb.   

I counted calories only during the first two months of this experiment.  Remember, fats and proteins are unlimited.  Nevertheless, I ate fewer calories than my baseline intake.   This calorie reduction is a well-documented effect of very low-carb diets.  Fats and proteins are more satiating than carbohydrates.  It’s possible I’ve limited total calories subconsciously. 

[An interesting experiment would be to try to gain weight by over-eating fats and proteins while keeping total digestible carbs under 30 g/day.  Has it been done already?]

What’s Next?

I’d like to answer some intriguing questions.

Why did my weight loss stop where it did, at 155 lb (70.5 kg)? 

If I’d started the KMD at 270 lb (123 kg) instead of 170 lb (77.3 kg), would my weight loss have stopped at 255 lb (116 kg), 210 lb (95.5 kg) or 155 lb (70.5 kg)? 

Will two people, 300 lb each (136 kg), end up at the same final weight when following the program religiously?  Probably not, but why not?    

Six months ago, I believed many scientific studies supported the idea that a higher intake of carbohydrates is healthier, long-term, than the very low-carb Ketogenic Mediterranean Diet and other very low-carb diets.  Studies seemed to support higher carbohydrate intake in the form of traditional fruits, vegetables, legumes, and whole grains.  After reviewing the scientific literature over the last few months, I’m not so sure that higher carb consumption is necessary or beneficial for long-term health and longevity.  The evidence is weak.  Nearly all the pertinent studies are observational or epidemiologic—not the most rigorous science. 

On the other hand, I still can’t help feeling that the recommended eating styles of people like Monica Reinagel, Darya Pino, and Holly Hickman may be healthier than the KMD over the long run, at least for people free of diabetes and prediabetes.  What features unify those three?  Food that is minimally processed, fresh, locally produced when able, including a variety of fruits, vegetables, nuts, whole grains, and legumes. 

It seems that the human body is marvelously designed to survive, even thrive, with multiple ways of eating—but not all ways.   

The strongest evidence for higher carb consumption supports whole grains as a preventative for heart disease (coronary artery disease).  But the effect is modest. 

The argument against higher carb consumption is simple for people with diabetes and prediabetes: carbs raise blood sugar levels, sometimes to an unhealthy degree.  

I don’t see much role for highly processed, refined carbohydrates except as a cheap source of energy (calories).

What’s next for me is to formalize an opinion on which carbs, if any, and in what amount, to add back into the diet of those who have lost weight with the Ketogenic Mediterranean Diet.  The answer will probably be different for two groups:

  1. those who have diabetes, prediabetes, or metabolic syndrome
  2. healthy people who just need to control weight

The goal is to maximize health and longevity without tipping over into excessive carb intake that leads to overweight and obesity with associated illnesses.  

The traditional Mediterranean diet—long associated with health and longevity—is rich in carbohydrates.  The Ketogenic Mediterranean Diet—much lower in carbs—has great potential to help with loss of excess weight and control of blood sugar levels.  Does the KMD incorporate enough of the healthy components of the Mediterranean diet?  We may never know for sure.

Steve Parker, M.D.

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