Tag Archives: very low-carb diet

Very Low-Carb Diet Beats ADA Diet in Type 2 Diabetes According to New Study

Compared to a mildly carbohydrate-restricted American Diabetes Association diet, a very-low-carbohydrate ketogenic diet was more effective at controlling type 2 diabetes and prediabetes, according to University of California San Francisco researchers.

Some non-starchy low-carb vegetables

Some non-starchy low-carb vegetables

Details, please!

Thirty-four overweight and obese type 2 diabetics (30) and pre diabetics (4) were randomly assigned to one of the two diets:

  1. MCCR: American Diabetes Association-compliant medium-carbohydrate, low-fat, calorie-resticted carb-counting diet. The goals were about 165 grams of net carbs daily, counting carbohydrates, an effort to lose weight by eating 500 calories/day less than needed for maintenance, and 45–50% of total calories from carbohydrate. Protein gram intake was to remain same as baseline. (Note that most Americans eat 250–300 grams of carb daily.)
  2. LCK: A very-low-carbohydrate, high-fat, non-calorie-restricted diet aiming for nutritional ketosis. It was Atkins-style, under 50 grams of net carbs daily (suggested range of 20–50 g). Carbs were mostly from non-starchy low-glycemic-index vegetables. Protein gram intake was to remain same as baseline.

Baseline participant characteristics:

  • average weight 100 kg (220 lb)
  • 25 of 34 were women
  • average age 60
  • none were on insulin; a quarter were on no diabetes drugs at all
  • most were obese and had high blood pressure
  • average hemoglobin A1c was about 6.8%
  • seven out of 10 were white

Participants followed their diets for three months and attended 13 two-hour weekly classes. Very few dropped out of the study.

Results

Average hemoglobin dropped 0.6% in the LCK group compared to no change in the MCCR cohort.

A hemoglobin A1c drop of 0.5% or greater is considered clinically significant. Nine in the LCK group achieved this, compared to four in the MCCR.

The LCK group lost an average of 5.5 kg (12 lb) compared to 2.6 kg (6 lb) in the MCCR. The difference was not statistically significant, but close (p = 0.09)

44% in the LCK group were able to stop one or more diabetes drugs, compared to only 11 % in the other group

31% in the LCK cohort were able to drop their sulfonylurea, compared to only 5% in the MCCR group.

By food recall surveys, both groups reported lower total daily caloric intake compared to baseline. The low-carbers ended up with 58% of total calories being from fat, a number achieved by reducing carbohydrates and total calories and keeping protein the same. They didn’t seem to increase their total fat gram intake;

The low-carbers apparently reduced daily carbs to an average of 58 grams (the goal was 20-50 grams).

There were no differences between both groups in terms of C-reactive protein (CRP), lipids, insulin levels, or insulin resistance (HOMA2-IR). Both groups reduced their CRP, a measure of inflammation.

LCK dieters apparently didn’t suffer at all from the “induction flu” seen with many ketogenic diets. They reported less heartburn, less aches and pains, but more constipation.

Hypoglycemia was not a problem.

If I recall correctly, the MCCR group’s baseline carb grams were around 225 g.

Bottom Line

Very-low-carb diets help control type 2 diabetes, help with weight loss, and reduce the need for diabetes drugs. An absolute drop of 0.6% in hemoglobin A1c doesn’t sound like much, translating to blood sugars lower by only 15–20 mg/dl (0.8–1 mmol/l). But remember the comparator diet in this study was already mildy to moderately carbohydrate-restricted. At least half of the type 2 diabetics I meet still tell my they don’t watch their carb intake, which usually means they’re eating around 250–300 grams a day. If they cut down to 58 grams, they most likely will see more than a 0.6% drop in hemoglobin A1c after switching to a very-low-carb diet.

This is a small study, so it may not be reproducible in larger clinical trials and other patient populations. Results are consistent with several other similar studies I’ve seen, however.

Steve Parker, M.D.

Reference: Saslow, Laura, et al (including Stephen Phinney). A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or PrediabetesPLoS One. 2014; 9(4): e91027. Published online Apr 9, 2014. doi: 10.1371/journal.pone.0091027     PMCID: PMC3981696

PS: When I use “average” above, “mean” is often a more accurate word, but I don’t want to have to explain the differences at this time.

PPS: Carbsane Evelyn analyzed this study in greater detail that I did and came to different conclusions. Worth a read if you have an extra 15 minutes.

 

 

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Filed under Carbohydrate, Glycemic Index and Load, ketogenic diet, Prediabetes

Radiologist With Type 1 Diabetes Thrives on Very Low Carb Diet

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

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

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

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

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

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

Here’s what the diabetes educators told him:

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

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

Norman Swan: The lining.

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

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

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

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

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

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

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

He notes that…

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

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

Steve Parker, M.D.

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Potential Problems With Major Carbohydrate Restriction

Caprese salad, naturally low-carb

Caprese salad, naturally low-carb

Ketogenic Diets

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

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

What Could Go Wrong?

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

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

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

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

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

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

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

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

What About Adherence to the Diet?

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

Or not.

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

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

Steve Parker, M.D.

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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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Book Review: Atkins Diabetes Revolution

I must give credit to Dr. Robert C. Atkins for popularizing an approach – carbohydrate restriction – that helps people with diabetes control their disease, and likely helps prevent type 2 diabetes in others.  Mary C. Vernon and Jacqueline Eberstein do a great job explaining his program in their 2004 book, Atkins Diabetes Revolution: The Groundbreaking Approach to Preventing and Controlling Type 2 Diabetes

On the Amazon.com five-star rating scale, I give this book four stars.

I can best summarize this book by noting that it is the standard Atkins diet with a few modifications: 1) special supplements  2) you add additional carbs to your diet more slowly  3) the warning that diabetics may well end up with a lower acceptable lifetime carbohydrate intake level.

By way of review, the Atkins diet is a very low-carb diet, particularly in the two-week induction phase.  “Very low-carb” means lots of meat, chicken, fish, eggs, limited cheese, and 2-3 cups daily of salad greens and low-carb veggies like onions, tomatoes, broccoli, and snow peas.  After induction phase, you slowly add back carbs on a weekly basis until weight loss stalls, then you cut back on carbs.

As an adult medicine specialist, I have no expertise in pediatrics.  I didn’t read the two chapters related to children.

The authors present “complimentary medicine”in a favorable light.  Unsuspecting readers need to know that much of complementary medicine is based on hearsay and anecdote, not science-based evidence.  In that same vein, the two chapters on supplements for diabetes and heart disease recommend a cocktail of supplements that I’m not convinced are needed.  I don’t know a single endocrinologist or cardiologist prescribing these concoctions.  Then again, I could be wrong.   

Vernon and Eberstein provide two excellent chapters on exercise.

A month of meal plans and recipes are provided for 20, 40, and 60-gram carbohydrate levels.  [The average American is eating 250-300 g of carbs daily.]  The recipes look quick and easy, but I didn’t prepare or taste any of them.

The 5-hour glucose and insulin tolerance test (GTT, paged 61) that Dr. Atkins reportedly ran on all patients who came to him is rarely done in other medical clinics.  This doesn’t mean it’s wrong, but certainly out of the mainstream.  The authors admit that at least a few people will have to count calories – specifically, limit total calories – if the basic program doesn’t control diabetes, prediabetes, and the metabolic syndrome.  Limiting portion size will speed weight loss, they write.

What we don’t know with certainty is, will long-term Atkins aficionados miss out on the health benefits of higher consumption of fruits, vegetables, legumes, and whole grains?  Much of the scientific literature suggests, “Yes.”

What if we compare the long-term outlooks of a diabetic Atkins follower with a poorly controlled diabetic who’s 80 pounds overweight and eating a standard American diet?  The Atkins follower is quite likely to be healthier  and live longer.

Steve Parker, M.D.

 

 

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My Ketogenic Mediterranean Diet: Day 26

Weight: 161 lb

Transgressions:

Exercise:

Comments

Pending

-Steve

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My Ketogenic Mediterranean Diet: Day 9

CB044404Weight: 164 lb

Transgressions: none

Exercise: 30 minute brisk walk in 90° heat

Comments

I just discovered that fried pork skins (aka pork rinds) are low- or no-carb, making them a possible substitute for dieters who miss the crunch, taste, and convenience of potatoe or corn chips.  I like home-made quacamole salad—will have to try it with pork rinds or celery sticks.

-Steve

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