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Low Carbohydrate Diets: Why You Don't Want the "Experts" to Tell You What to Eat
22 August 2007
Richard D. Feinman, PhD, is Professor of Biochemistry at State University of New York Downstate Medical Center, co-editor-in-chief of the journal Nutrition & Metabolism, and Director of the Nutrition and Metabolism Society (www.nmsociety.org).
Diabetes may be described as a disease of glucose intolerance: high blood glucose is both the characteristic indicator and the cause of complications.
The loss of control of glucose metabolism is what makes a low carbohydrate diet a good therapeutic approach, and it's why I'm astonished that experts encourage people with diabetes to eat carbohydrates and then "cover" them with insulin [1].
I am also surprised to hear negative reactions to carbohydrate restriction from people who have actually seen the deleterious effects of high dietary carbohydrate on people with diabetes. On that note, I offer my personal rebuttal to Hope Warshaw's recent article, "Why You Don't Want to Go Low Carb or Vegan," April/May 2007.
Ms. Warshaw's argument is that "avoiding carbohydrate, as some low carb diets suggest, does not entirely return blood glucose levels to the normal range after meals." Well, depending on the patient, sometimes blood glucose does return to normal. In any case, ingesting carbohydrate raises blood glucose.
Ms. Warshaw goes on to say, "Second, an adequate amount of carbohydrate is an important component of a healthy eating plan, providing essential fuel, vitamins, minerals, and fiber." I thought fuel is just what we are trying to reduce. And does anybody think that having to take a vitamin supplement is in the same ballpark as injecting insulin? And how healthy is an eating plan that requires medication?
At the 2004 Brooklyn conference on the Nutritional and Metabolic Effects of Low Carbohydrate Diets, William Yancy, Jr., of Duke University described his research with type 2 patients. After sixteen weeks on a low carbohydrate diet, seven of the 21 patients discontinued their medication and ten of the 21 reduced their medication. During the post-lecture discussion, two physicians "warned" that doctors should not put diabetic patients on a low carbohydrate diet without first reducing their medication.
Of course, if you are taking medication, you should reduce carbohydrates only with medical supervision. In most diseases, however, a reduction in medication is considered a sign of improvement. Why would Ms. Warshaw recommend a diet that requires more medication?
It strikes me as odd that what most experts know about metabolism - diabetes is, after all, a metabolic disease - they learned in medical school from somebody like me [2]. The first thing we teach medical students at Downstate Medical Center is that there is no biological requirement for carbohydrate.
It is true that your brain needs glucose, but glucose can be supplied by the process of gluconeogenesis; that is, glucose can be made from other things, notably protein. This is a normal process: when you wake up in the morning, between thirty and seventy percent of your blood glucose comes from gluconeogenesis. There is no requirement for dietary glucose.
The second thing we teach medical students is that almost all the increased caloric intake during the ongoing epidemic of obesity and diabetes has been due to an increase in consumption of carbohydrate and a decrease in the consumption of fat (Figures 1A and B). When you look at the foods whose consumption increased during the diabetes epidemic, you see that cereals and grains are among the major ones. (Of course, almost everything increased except red meat and eggs.)
So what is Ms Warshaw's complaint? Well, she points out that "studies that compare low carb diets to conventional diets demonstrate early initial weight loss and improvement in other health parameters, such as blood glucose control ([3]). But studies of low carb diets that last longer than six months do not show significantly more weight loss."
Something's wrong here. Because low carb diets do the same as traditional diets after one year, then you don't want to be on a low carb diet? If they are equal, why doesn't that mean that you don't want to be on a traditional diet? In any case, what is rarely mentioned is that in the study in reference [3], the diets were quite different at six months; as the study proceeded, however, the low carb group added back more carbohydrate. The lesson is clear: the more carbohydrate, the worse the weight control. And the long-term outcomes were not the same. Triglycerides and HDL (healthy cholesterol) were much better on the low carb diet than the low fat diet (Figure 2).
Reference [3] is important for showing the general health benefits of low carb diets even when a difference in weight was not maintained, but that study did not include people with diabetes. What happens in those people? Figure 3 shows the results from a controlled ward study of ten diabetic patients before and after three weeks on a strict low-carbohydrate diet [4]. The figure shows the dramatic reduction in insulin fluctuation and, on average, the "return of blood glucose levels to the normal range after meals." Patients were content with the diet, lost weight, had improved lipid profiles, and increased insulin sensitivity by 75 percent.
I don't know of any study on any other diet that shows such good effects on controlling glucose and insulin without increasing drugs. And it's not just the glycemic control. We recently summarized data in the literature showing that all of the features of the so-called metabolic syndrome-high triglycerides, low HDL, hypertension and obesity-are exactly the features that are improved by low carbohydrate diets [5]. If we had been describing a drug, everybody would have rushed out to buy stock in our pharmaceutical company.
Ms. Warshaw's complaint is that these studies "show that many study subjects drop out of the study and are unable to stick with the diet." She does not mention that the drop-out rate from the low fat diet was the same as from the low carb diet; that's generally true of the many low carbohydrate studies. In any case, wouldn't it be good for diabetes counselors to encourage compliance rather than to dissuade people from a strategy that actually works for the many people who follow it?
You might want to think twice before you let Ms Warshaw tell you what you don't want to do. "You'll have type 2 diabetes for the rest of your life, and you'll likely struggle with weight management throughout your life as well." She seems to be saying that you may as well go ahead and eat candy because it's all hopeless. There are, however, several sites on the Internet that provide a more hopeful look at managing diabetes with carbohydrate restriction; for example, D-solutions (www.dsolve.com) and Dr. Richard Bernstein's forum (http://www.diabetes-book.com).
I am most concerned that if Ms. Warshaw really had something positive to offer, she wouldn't need to dissuade people from making their personal choice. Candy followed by insulin is not good enough.
- American Diabetes Association: Nutrition Recommendations and Interventions for Diabetes-2006. Diabetes Care 2006, 29:2141-2157.
- RD Feinman, M Makowske: Metabolic Syndrome and Low-Carbohydrate Ketogenic Diets in the Medical School Biochemistry Curriculum. Metabolic Syndrome and Related Disorders 2003, 1:189-198.
- GD Foster, HR Wyatt, JO Hill, BG McGuckin, C Brill, BS Mohammed, PO Szapary, DJ Rader, JS Edman, S Klein: A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 2003, 348:2082-90.
- G Boden, K Sargrad, C Homko, M Mozzoli, TP Stein: Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Ann Intern Med 2005, 142:403-11.
- JS Volek, RD Feinman: Carbohydrate restriction improves the features of Metabolic Syndrome. Metabolic Syndrome may be defined by the response to carbohydrate restriction. Nutr Metab (Lond) 2005, 2:31/ Available without subscription at (www.nutritionandmetabolism.com/content/pdf/1743-7075-2-31.pdf)
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I walked into a medclinic 3 weeks ago because I had been experiencing pain (comes and goes)up and down both arms. The doctor said I looked fine and was confused, but suggested blood tests. The next day, he called to tell me I had a bg reading of 366 and that I'd probably had diabetes for a while and didn't know it...the pain may be neuropathy. He prescribed metformin. I bought a monitor and tested myself. But, even with the meds, I couldn't control the bg and the readings which ranged from 296 to an alarming 393! (The doctor had said at 400, we put you in the hospital).
So, I was determined to go on the Atkins Induction. One day later, the bg reading was 179 (with metformin 2/day). The second week of induction, the average was 150 with some as low as 143. The pains in my arms are gone! I am so happy to have stumbled across this blog, because I was starting to crave cake and I was doubting the intelligence of this low carb lifestyle.
Thank you Doctor for this article. I am now confident that this is the way to continue. I am praying that soon, I can eliminate taking the metformin. I have also noticed that I have no acid reflux or gas.
I'm eating many more vegetables than I have ever eatin in my life! And I substitute my cravings for cake with sugar-free jello and whipped cream or sugar-free candy. I also have nuts like almonds & macadamia, seeds like sunflower and pumpkin, and many different cheeses to help with snacks. Low carb does not mean ONLY meat! My motivation and prize are my lower bg readings!
(anonymous on 19 November 2007,)
Watch out for those sugar free candies, some of the sugar alcohols they contain do raise your BG almost as much as sugar. There are other sweets you can make yourself that are extremely low carb.
To Imy, I'm also puzzled by the co-relation of my A1c numbers and average bld glucose. This time my A1c of 6.3 came to 129, higher than most of the figures on my meter, last time my A1c of 6.6 came to average of 139, I can't remember ever being that high. My A1c in May was 5.9 and my average was 117. The number I see is to divide the average by about 20 in all my A1c's, yours is almost 24, I do feel your average should be closer to 130, although, that may be higher than your actual numbers.
I often feel the numbers on our meters are much lower than than what is obtained in the labs. I'm like you, a type 2 not on meds and hope never to be, on a low carb lifestyle, I refuse to call it a "diet", this is for the rest of my life, not temporary, on veggies, whole grains but not much and low fat, but putting olive oil on everything I eat. I eat no red meat and chicken once in a while only, but do eat fish and nuts and cheese like another poster. My trigs are very low!!
I exercise religiously, I feel it's the most important thing to do for all of us, luckily, I can do so will continue to do so. I do feel using our common sense in choosing what we choose to eat. Extreme "diets" don't work in the long run, unless, that's what you really want to do. But let's not insist on having that cake also and then wondering what went wrong!
I was just recenlty diagnosed with type 1 diabetes and am becoming very frustrated. Can you tell me what the normal blood sugar level should be before and after meals? It seems that no matter what I eat, example, salad with no dressing and dry chicken breast, for dinner, my sugar levels are always in the upper 200's....Help
Is oat bran an ground flax seed harmful or benefical for diabetics?
Is oat bran and gorund flax seed benefical or harmful to blood sugar levels. Also is olive oil benefical or harmful? Thank you!
" Posted by anonymous8888 on 5 January 2008
I was just recenlty diagnosed with type 1 diabetes and am becoming very frustrated. Can you tell me what the normal blood sugar level should be before and after meals? It seems that no matter what I eat, example, salad with no dressing and dry chicken breast, for dinner, my sugar levels are always in the upper 200's....Help"
If you are on a low carb diet, you need fat. Dry chicken breast? Where's the skin? Salad with no dressing, Have your choice of low carb dressing.
Check out proteinpower.com or any other low carb website. There's tons of advice for diabetics and none of it includes leaving fat out of your diet.
Read Good Calories, Bad Calories by Gary Taubes.
Too much protein and not enough fat can cause higher BG levels.
Good Luck.
perfect. brilliant!
to lmy and ladybird. Take a blood sugar reading every 15 minutes from the time you eat a meal until 2 hours afterward. By only measuring at 1 and 2 hours you are missing the peak reading, which is probably going way over 200.
To anonymous8888, if you are a Type I then you are on Insulin. In the short term you need to be taking larger doses of insulin. In the longer term you need to buy Dr. Bernstein's Diabets Solution book and see how to save your life.
I am a low-carb advocate. I am a diabetic who keeps my HgbA1c = 4.5 - 4.8 through low-carb eating and exercise.
There are many misconceptions in people's comments.
1) Yes, you do require a certain amount of carbs per day. However, you body can make all of them from other foods that you eat. It's called gluconeogenesis.
2) It's true that not everyone would stick with a low-carb diet. People who give advice to diabetics should at least offer them the option. Right now it's suppressed information.
3) Your body will only break down its own muscle tissue to make glucose if you don't eat enough protein.
4) Eating a lot of protein is not harmful to you unless you have very very bad kidneys. Only a very small percentage of diabetics are so far gone kidney-wise that they should not eat a lot of protein.
5) You shouldn't argue with your glucometer. If you have any food and you want to see its effect on blood sugar then just take a baseline reading, then eat the food, then test every 20 minutes for two hours. See how the food affects your blood sugar.
6) Let's cut the RDs some slack. They are only technicians. They aren't paid, and aren't allowed to think. They have to do as they were taught or they could be guilty of malpractice. When the textbooks and their classes change then they will change. You really wouldn't want it any other way.
7) Doctors, on the other hand, are allowed and even encouraged to think. If you have a doctor who is stronly against low-carb then that doctor is not working in your best interest. Time to move on.
8) If you haven't tried low-carb for your diabetes, you really should. Ask yourself would you rather keep on eating flour, sugar, etc and eventually end up having your body parts cut off a little bit at a time, or would you rather just give up the bread, cake, and potatos, and keep your body intact. It's your choice.
Bravo Dr. Feinman! I noticed many of the same bizarre contradictions in the conventional, text-book thinking on diabetes and diet that you have skewered here.
I couldn't believe it when I found out that my cousin was told by his doctor to feed his diabetic child a high carb diet and then offset that with high doses of insulin. Some day medical historians will look back on that thinking as one of the stranger dogmas in medical history, akin to bleeding patients and other odd treatments of the past that were not based on scientific evidence.
I have been researching alot since being diagnosed 3 months ago and this is one of the best articles I have seen to date.
Great.
My father was diagnosed a diabetic in the early '70s. He started out on tablets (sorry, don't know which ones) and controlled his carbohydrate intake. Once the initial scare wore off, he started increasing his intake. He rollercoasted over the next few years, having to go into hospital every so often to be "stabilised". The diabetes got worse until he had to start injecting insulin. He then started "contolling" his disease by eating and drinking what he liked and just injecting the appropriate amount of insulin to sort out the blood sugar levels. Maybe this was OK, all I know is that he died early as a result, about 10 years later. Diabetes runs in my family, and having looked at the "low-carb" arguments, I try and keep to a low level myself, certainly not the vast amounts of pasta/potatoes etc recommended at the moment. It strikes me that if you don't allow the blood sugars to leap around all over the place, less damage will be done. So far I am not diabetic, and I am hoping to stay that way.
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