Pioneering low-carb diet advocate Dr. Richard K. Bernstein has responded to the American Diabetes Association's recent support for low-carb diets with a critique of several of the ADA's most cherished notions.

In a recent "Ask Dr. Bernstein.com" tele-seminar presented to callers and listeners, he cited the ADA's 2008 guidelines for doctors, disputing the association's recommendations on several fronts:

• He said that the ADA's definition of a low-carb diet as one with 130 or fewer grams of carbohydrates per day "is four times higher than what I recommend and makes it impossible to maintain [blood glucose] control."
• He disputed the ADA's contention that an A1c of less than 6 for people with diabetes increases the risk of hypoglycemia. "The risk is only to people taking the industrial insulin doses that the ADA recommends for covering their high-carbohydrate diets.
• Regarding the ADA's recommendation that adults with diabetes shoot for blood sugar levels of 70 mg/dl to 130 mg/dl before meals and 180 mg/dl after meals - with even higher levels allowed for children - Dr. Bernstein said, "Children are not entitled to normal blood sugar levels? And neither are adults." Those guidelines, he said, "were created by non-diabetics to be imposed upon diabetics."
• Dr. Bernstein called the association's recommendation that people with diabetes regularly see podiatrists to have their foot calluses debrided with a scalpel "the most dangerous thing you can do to a diabetic." He said that 100 percent of the diabetic amputees he has ever interviewed in his university-based wound care clinic told him that their amputations arose from infections caused by an attempt to remove a callus - whether at the hands of a podiatrist, a family member or friend, or themselves. "I've seen too much of this. It's a nice income for podiatrists, but sooner or later, someone goes too deep," creating, he said, a wound that will not heal. Instead, he recommends using orthotics and shoe modifications to offload sites of high pressure or shear.
• He was perplexed by the ADA's positive appraisal that "gastric reduction surgery (GRS) can be effective." "We know about Symlin and Byetta, which when combined with a low-carb diet, are remarkably effective in curbing overeating and facilitating weight loss," said Dr. Bernstein, "but the ADA doesn't mention them at all in a 108-page set of guidelines. Yet it recommends the gastric surgery."
• Dr. Bernstein asserted that the ADA's recommendation of a diet rich in legumes, low-fat milk, whole grains, fruits and vegetables "creates sugar while fat does not." He recalled being interviewed with an ADA dietician and asking her how she could recommend whole grain foods when they created high levels of blood glucose. To illustrate, he chewed a slice of whole-grain bread and applied the resulting saliva to a urine glucose test strip. The strip turned black immediately, indicating the instant conversion of the bread to glucose by saliva.
• Regarding the ADA's recommendation that sucrose should be allowed in diabetic diets, Dr. Bernstein disputed it, saying that "insulin takes hours to catch up" to its effects.

Early Man Ate Few Carbs

In criticizing the ADA's calling 130 grams of carbohydrates per day "low carbohydrate", Dr. Bernstein cited early human history as an argument against it. "Until the creation of flour and bread, humans could not get anywhere near 130 grams a day." The difficulty in securing such a large amount of carbohydrates made obesity and atherosclerosis rare in early humans.

But in the 20th century, as immense quantities of carbohydrates became available to large populations, the incidences of diabetes, heart attacks and strokes increased significantly.