Diabetes

(written 10/11/2014, last update 2/28/2016)

Eighteen fantastic minutes here discussing insulin, carbs, and glucose.

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IT’S TIME RE-LEARN EVERYTHING YOU KNOW ABOUT TEACHING A “DIABETIC DIET”
What do the 2014 American Diabetes Association (ADA) Nutrition Guidelines really say
and what does the recent scientific evidence say?

A MODERN NUTRITION FAQ
real food pharmacist .com / diabetes

Ask yourself — biologically, why do we need to eat? It’s not just calories, but we eat to get nutrition — the essential building blocks our body needs for metabolism (run and repair). With that in mind, let’s consider the standard diabetic diet education taught for the past 20+ years. From the food pyramid to now, essentially, the “Plate Method” with a focus on vegetables, fruit, lean meat, low fat dairy, with 45-75 grams of “consistent carbs” (so called, healthy starch and whole grains) at each meal with 15-30 grams at snacks. This seems to be the consistent message delivered by everyone, but is that what the American Diabetes Association’s (ADA) own guidelines even say? What about published nutrition studies? Let’s see.

 

Question: Doesn’t the ADA recommend people (with type 2 diabetes) get at least 45-55% of one’s caloric needs from carbohydrates? Aren’t carbohydrates essential? As long as carbohydrates are “moderate and consistent” at each meal, do we really have to worry about them?

 

The 2014 American Diabetes Association (ADA) Nutrition Therapy Recommendations (download with MY annotations here: 2014 ADA Nutrition Therapy for Diabetes annotated) published in volume 37 of Diabetes Care, January 2014, DOES NOT actually recommend getting 45-55% of one’s caloric intake from carbohydrates. It states, “…macronutrient proportions should be individualized (page S126).”

With specific regards to carbohydrates it says “Evidence is inconclusive for an ideal amount of carbohydrate intake…(and)…collaborative goals should be developed….”
It goes on to say, “A variety of eating patterns are acceptable for the management of diabetes. Personal preferences and metabolic goals should be considered when recommending one eating pattern over another (page S122).”

At the same time, the following statement should raise red flags in regard to excess carbohydrate intake in a diabetic, “Carbohydrate intake has a direct effect postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management (page S123).” AND, “…total amount of carbohydrate eaten is the primary predictor of glycemic response (page S127).” (emphasis mine)

(note the 2015 ADA Standards of Care in January 2015.  Page S21 has the Goals of Nutrition Therapy for Adults with Diabetes.  It doesn’t have as much detail as the 2014 Recommendations but does repeat much of the same information including this on page S23: “A systematic review found consumption of whole grains was not associated with improvements in glycemic control…”.  The 2016 Standards from Jan 2016 are similar.)

Question: Shouldn’t we teach everyone the same and use the same educational materials?

As stated in the guideline, “A variety of eating patterns are acceptable for the management of diabetes. Personal preferences and metabolic goals should be considered when recommending one eating pattern over another (page S122).”

The guidelines specifically suggest any of the following may be healthful options when choosing a nutrition plan for a diabetic: “Mediterranean, DASH, plant-based, low fat, and low carb (page S126/133).”

 

Question: But what is the evidence for “low-carb” diets? Aren’t they unhealthy?

The evidence for LOW-CARB (or “Atkins”) in diabetics is actually strong. A nice, moderate, modern approach is a low carbohydrate diet that emphasizes a balance of nutrient dense real food. A well formulated low carb diet is NOT unlimited bacon and pork rinds, or processed “low carb” junk food….nor is it necessarily a high protein diet. A solid approach is with an emphasis on quality food choices from nutritious whole natural protein sources and natural fats along with a strong push for a wide variety of non-starchy vegetables at each meal.
It seems like a very reasonable approach to present this as an option for patients trying to achieve better glycemic control as well as improved metabolic markers and potentially weight loss.

Here’s a snapshot of some of the evidence directly from the aforementioned ADA guidelines:

• “Some published studies comparing lower levels of carbohydrate intake to higher carbohydrate intake indicated improved markers of glycemic control and insulin sensitivity with lower carbohydrate intakes (92, 100, 107, 108, 109, 110, 111) (page S127).”
• “Some studies comparing lower levels of carbohydrate intake to higher carbohydrate intake levels revealed improvements in serum lipid/lipoprotein measures, including triglycerides, VLDL triglyceride, and VLDL cholesterol, total cholesterol, and HDL levels (71, 92, 100, 107, 109, 111, 112, 115) (page S127).”
• “Two systemic reviews found little evidence that fiber significantly improves glycemic control (11, 88) (page S128).”
• “A systematic review (88) concluded that the consumption of whole grains was not associated with improvements in glycemic control in individuals with type 2 diabetes… (page S128).”

 

And a small snapshot of other evidence (also see bottom of this page):
A Low Carb diet reduced inflammation in T2DM, whereas a Low Fat diet did not.
A Paleolithic diet improved glycemic control and several other CV risk factors compared to a diabetic diet.
A low carb diet improved glycemic control and decreased medication burden more than an ADA low fat diet.
Low Carb diets reduce weight and improve Cardiometabolic risk factors.

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Question: My patients wouldn’t even consider giving up bread, cereal, rice, and pasta — don’t you understand?

Maybe, but do we even give them a choice? What if we gave them a legitimate plan that included real, whole nutrient dense foods including healthy fats cooked with large amounts of herbs and spices? What if cooking these meals could be taught easily? What if patients felt better and saw real results –significantly reduced blood sugars, lower medication burden, improved metabolic markers and, potentially, weight loss (as evidenced by the copious amounts of scientific studies referenced in this FAQ)?

What if they’d commit to it for 2 – 4 weeks? And then, what if they’d try 2 low-carb days per week?  What about 3, 4, or 5?  Would their health be better?  I’d imagine yes.

 

Question: Isn’t it good to teach everyone, “everything in moderation”?

One could argue that in a diabetic patient, introducing anything that raises the blood sugar puts a stress on the system and could potentially be viewed as damaging (aka. toxic). What level of blood glucose starts the damage and when is that ok?
Would we suggest half a pack of cigarettes is healthier than a whole pack, and thus, fine? How about a little dose of cyanide. How about one beer instead of six for the alcoholic?
A piece of birthday cake or holiday treat might be acceptable, but the notion of eating — half a cookie daily, small fries instead of large, two pieces of deep dish pizza instead of three, or a 100-calorie pack of processed sugar — is not.

 

Question: Ok, but whole grain products are good for these patients, we can have them switch to brown breads and whole grains – that’s Mediterranean, right?

The evidence sited in this FAQ shows countless examples of metabolic markers of disease improving when patients significantly reduce carbohydrates from all sources. I would challenge you to go to your local grocery store one afternoon. Stop first in the cereal aisle. Literally fill your cart with every cereal and oatmeal package that sells itself as a healthy whole grain or high fiber product. Do not (yet) look at the nutrition label. Next, go to the bread aisle and do the same thing. Now stop and look at what you have. Many “brown” products still contain enriched (white) flour…it’s hard to find “real” whole grains.  Even then, most whole grain products still have high carb loads and not that much fiber. Also be aware that 95% of the commonly available breads (white or brown) contain added sugars or high fructose corn syrup.
Some of the “healthiest” cereals have total carbohydrate counts well over 60 grams in a realistic serving. This, on top of brown toast and a glass of orange juice.
The biggest tragedy is patients who try to eat “healthy” but are tricked at the grocery store into buying heavily processed “health” foods.

Remember, straight from the ADA guidelines: “Two systemic reviews found little evidence that fiber significantly improves glycemic control…and….whole grains were NOT associated with improved glycemic control (11, 88) (page S128).”

It’s ok to say natural fiber foods are most likely healthy, BUT should not be saying it’s a magic bullet to fix or reduce hyperglycemia.

 

Question: Well, total carbohydrates may not matter that much — real whole grains are good because they have a low glycemic index, right?

As seen in the last question, finding “real” whole grains is not easy but what if you did? Notice how high cereal, brown breads, and brown rice still are.  True Low GI foods should be much, much lower than 40.

glycemic index

Also see the evidence below when “whole grain/low fat” diets are studied in real patients.

Yet again, let’s not forget — straight from the ADA guidelines: “A systematic review (88) concluded that the consumption of whole grains was not associated with improvements in glycemic control in individuals with type 2 diabetes… (page S128).”

Check out nutritiondata.self.com to research glycemic loads of different foods for yourself.

 

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Question: But if my patients don’t eat a “low-fat diet” won’t their blood cholesterol go through the roof?

Evidence points to the short answer being no (as seen by some of the scientific evidence above and below), so the bigger question is; what ultimately causes heart disease? Glycation and inflammation leading to damaged arterial walls which get infiltrated by large numbers of small dense LDL particles that are prone to oxidation. This is presumed to be the root cause of arterial plaques. Remember, LDL and cholesterol are essential for human life. The devil is in the inflammation and oxidation.

Here’s additional evidence from the current scientific literature regarding dietary saturated fat consumption:

2014 Association of Dietary Fatty Acids with Coronary Risk (An analysis of studies involving over 600,000 subjects published in 2014 in the Annals of Internal Medicine (Chowdhury et al). Conclusion: Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.)

2010 Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. (An analysis of studies involving over 300,000 subjects published in 2010 in the American Journal of Clinical Nutrition (Siri-Tarino, et al). Conclusion: There is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD.)

2015 Meta-Analysis: Evidence to Support Dietary Fat Restriction Recommendations (BMJ-Open Heart. Harcombe, et al).  (Analysis concludes the 1977 US Dietary Guidelines lacked evidence to recommend that Americans limit overall fat and saturated fat daily energy intake. Medscape.) 

2015 Dietary Intake of Saturated Fat Is Not Associated with Risk of Coronary Events or Mortality in Patients with Established Coronary Artery Disease (American Society for Nutrition. Pauschitz, et al.)  Study of 2412 patients over 4.8 years.

We should consider rethinking our fear of natural fats while placing an even stronger emphasis on avoiding “man-made” and industrial fats that are most prone to oxidation and subsequent inflammation.

Use of dietary linoleic acid for secondary prevention of coronary heart disease and death (A study published in 2013 in the British Medical Journal showed that replacing butter with vegetable oil increased mortality and CHD.)

The cardiometabolic consequences of replacing saturated fats with carbohydrates or omega-6 polyunsaturated fats.  (A 2014 BMJ editorial and review with 39 references.)

All of this is getting serious attention in the media: TIME magazine FAT 06 2014

Click here to ask “what about cholesterol and EGGS???” (note: 2015 US Dietary Guidelines are removing restrictions on dietary cholesterol).

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Question: Aren’t all diabetics supposed to eat 4-6 small meals per day?

This is not in the ADA guidelines.  Where is the scientific evidence to support this notion?  Is this how humans evolved and ate over the preceding thousands and thousands of years? This idea is based on thinking from 50 years ago when insulin was used without any means to monitor home blood sugars and the risk of serious hypoglycemia was a significant concern.  While still something to monitor, the idea of PREVENTING an effect or side effect from a medication by doing the exact opposite thing you’re trying to treat seems pretty backwards. Great care may be needed with medication selection and dose adjustments when patients begin significantly cutting carbs.  The goal is a lower medication burden with much better blood glucose control.

There is some conflicting data on fasting vs eating breakfast vs meal composition on insulin resistance.  The jury is out.

 

Question: How could I teach my patient something other than the low-fat plate method?

Consider a 2-4 week elimination diet. Give them a nutrient dense real food shopping list. Teach them tiny habits and how to set up their environment for success.  Teach them to “eat to their meter”.

What if they have just one low-carb day per week, what about two, three, or four?  Would their health be better?  I’d argue, yes.

Focus on adding nutrient dense foods (below) before eliminating the damaging foods (Refined Grains, Sugar and Hidden Sugars , Processed Oils).  Get good fiber, protein and fat at EACH meal.  Get too full on the good stuff to eat junk.

Foods to add everyday:

1) Fiber rich, lower carb foods (non-starchy veggies, berries, nuts)

2) Healthy Fats (olive oil, nuts, seeds, avocado, seafood/salmon/sardines, unsweetened almond milk, dark chocolate, eggs, butter, coconut),

3) Clean Protein (fresh meat, poultry, seafood, eggs, beans in small amounts??),

4) Helpful Beverages (water, unsweetened tea, coffee, protein/green smoothies, red wine?),

5) Herbs and Spices (garlic, ginger, turmeric, Italian spices, pepper, chile…)

More details on the “how” is a great topic for another day as the paradigm begins to shift…also see What to Eat here.

 

Conclusion:
This FAQ is not meant to be a complete review of all the literature and with everything there are counterpoints. BUT PLEASE take time to review what the actual ADA guidelines say and please review some of the evidence sited here. Evidence can be picked that shows many different things, but I hope the totality of all of this helps lay out some of the different options that we can use when caring for our patients.

At the very least, ask yourself: “if this patient sitting in front of me is intolerant to carbohydrates (diabetic or pre-diabetic), does it really make sense for me to still recommend they consume >50% of their calories from them?” Consider giving them a choice.

One size no longer fits all.

nmw 10/11/2014, edit 10/3/2015

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Other References:  I’ve attached two articles written by an RD/CDE. The first was accepted and published in one of the American Diabetes Association’s own journals (Diabetes Spectrum). And the second in a popular journal for patients (Self Management).

2012 American Diabetes Association Low Carb for Diabetes

2014 Diabetes Self Management-Carbohydrate Restriction

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reseach graphic

Research into Low Carbohydrate Nutrition (57)

2016

Comparison of DASH (Dietary Approaches to Stop Hypertension) diet and a Higher-Fat DASH diet on blood pressure and lipids and lipoproteins: a randomized controlled trial.  HF-DASH diet lowered BP as well as DASH but also reduced triglycerides and VLDL without significantly increasing LDL.  (Am J Clin Nutr. Chiu S, et al. Feb 2016)

Low carbohydrate diet over 2 years reduces medication burden by 40% & improves CV risk markers in diabetic patients. (CSIRO Australia Press Release. Feb 2016)

Effect of low-carbohydrate diets v low-fat diets on body weight and cardiovascular risk factors: a meta-analysis of randomized controlled trials. (British J Nutr. Mansoor, N, et al. Feb 2016)

2015

Dietary Carbohydrate Restriction as the first approach in diabetes management.  Critical review and evidence base.

Comparison of low and high carbohydrate diets for type 2 diabetes management: a randomized trial.  LC diet achieved substantial weight loss, greater improvements in A1c, fasting glucose, lipid profile, blood glucose stability, and reductions in diabetes medication requirements. (Am J Clin Nutr. Tay J, et al. Oct 2015)

Long-Term Effects of a Very Low Carbohydrate compared with a High Carbohydrate Diet on Renal Function in Type 2 diabetics.  Consumption of a LC high-protein diet does not adversely affect clinical markers of renal function in obese adults with T2DM and no preexisting kidney disease. (Medicine-Baltimore. Tay J, et al. Nov 2015)

Dietary Intervention for overweight and obese adults: Meta-analysis comparison of Low Carb and Low Fat Diets. Low carb diets associated with modest but significantly greater improvements in weight loss and predicted ASCVD risk in studies from 8-24 weeks. (Sackner-Bernstein, et al. PloS One. Oct 2015)

Paleolithic nutrition for metabolic syndrome: systematic review and meta-analysis Paleolithic diet resulted in greater short-term improvements in metabolic syndrome components than did guideline-based control diets. (Am J Clin Nutr. Manheimer EW, et al. Oct 2015)

Paleolithic nutrition improves plasma lipid concentrations to a greater extent than traditional heart healthy dietary recommendations.

A lower-carbohydrate, higher-fat diet reduces abdominal fat and increases insulin sensitivity in adults at risk of type 2 diabetes.

Do ketogenic diets suppress appetite? A systematic review and meta-analysis.

Comparison of a carbohydrate-free diet vs fasting on plasma glucose, insulin, and glucagon in type 2 diabetes.

2014

Retrospective study on the efficacy of a low-carbohydrate diet for impaired glucose tolerance.  “Low carb is effective for normalizing blood glucose and preventing progression to type 2 diabetes in patients with IGT.” (Diabetes Metab Syndr Obes. Maekawa, S, et al. June 2014)

Effects of low-carbohydrate and low-fat diets: a randomized trial (Ann Int Medicine). • Patient Summary  “Improved cholesterol, triglycerides, and weight loss.”

A Very Low Carbohydrate diet for type 2 diabetes management: a randomized trial (Diabetes Care).

Study: Eating High-Fat Dairy Lowers Type 2 Diabetes Risk

Randomization to a low-carbohydrate diet advice improves health related quality of life compared with a low-fat diet at similar weight-loss in Type 2 diabetes mellitus

Effects of a eucaloric reduced-carbohydrate diet on body composition and fat distribution in women with PCOS

Advice to follow a low-carbohydrate diet has a favourable impact on low-grade inflammation in type 2 diabetes compared with advice to follow a low-fat diet

Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice

A non-calorie-restricted low-carbohydrate diet is effective as an alternative therapy for patients with type 2 diabetes

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 prediabetes

Two diets with different hemoglobin A1c and antiglycemic medication effects despite similar weight loss in type 2 diabetes

Favorable effects of consuming a Paleo diet on metabolic syndrome

2013
Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets

Treatment of diabetes and diabetes complications with a ketogenic diet

Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials

Two diets with different hemoglobin A1c and antiglycemic medication effects despite similar weight loss in type 2 diabetes

2012
Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: a clinical audit

Effect of low-calorie vs. low-carbohydate ketogenic diet in type 2 diabetes

In type 2 diabetes, randomisation to advice to follow a low-carbohydrate diet transiently improves glycaemic control compared with advice to follow a low-fat diet producing a similar weight loss. Conclusion: “…insulin doses were reduced significantly more with the low carb diet at 6 months. Thus, aiming for 20% of energy intake from carbohydrates is safe with respect to cardiovascular risk compared with the traditional low fat diet approach. (Diabetologia. Gulbrankd, et al. Aug 2012)

2011
Reversal of nephropathy by a ketogenic diet

A pilot study of the Spanish Ketogenic Mediterranean Diet: an effective therapy for the metabolic syndrome

2010
Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet: A Randomized Trial

A low-carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with Type 2 diabetes mellitus: a one-year prospective randomized intervention study

Revealing the molecular relationship between type 2 diabetes and the metabolic changes induced by a very low carbohydrate ketogenic diet

Review: Macronutrients, Food Groups, and Eating Patterns in the Management of Diabetes

2009
Carbohydrate restriction has a more favorable impact on metabolic syndrome than a low fat diet

2008
The effect of a low carbohydrate, ketogenic diet vs. a low glycemic index diet on glycemic control in type 2 diabetes mellitus

Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal

Low-carbohydrate diet in type 2 diabetes: stable improvements of body weight and glycemic control during 44 months follow-up

Effects of weight loss from a very-low carbohydrate diet on endothelial function and markers of cardiovascular disease risk in subjects with abdominal obesity.

2007
Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women

Beneficial effects of ketogenic diet in obese diabetic subjects

2006

Low-carbohydrate diet score and the risk of coronary heart disease in women.  Data from 82,802 women in the large Nurses’ Heart Study (NHS). “Our findings suggest that diets lower in carbohydrate and higher in protein and fat are NOT associated with increased risk of coronary heart disease in women“. (New England Journal of Medicine. Halton, Willett, et al. Nov 2006)

Comparison of isocaloric very low carbohydrate/high saturated fat and high carbohydrate/low saturated fat diets on body composition and cardiovascular risk.

Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials.  Low carb diets have favorable changes in TG and HDL and induce weight loss.  (Arch Intern Med. Nordmann AJ, et al. Feb 2006)

2005
A low carbohydrate, ketogenic diet to treat type 2 diabetes

The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study

A low carbohydrate diet in Type 1 diabetes: clinical experience – a brief report

2004

Dietary fats, carbohydrate, and progression of coronary atherosclerosis in post menopausal women. Analysis in 235 women with established coronary heart disease. Conclusion: “In postmenopausal women with relatively low total fat intake, a greater saturated fat intake is associated with LESS progression of coronary atherosclerosis, whereas carbohydrate intake is associated with a GREATER progression.” (American Journal of Clinical Nutrition. Mozaffarian, et al. Nov 2004)

A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia: A Randomized, Controlled Trial | Annals of Internal Medicine

Comparison of energy -restricted very low carbohydrate and low fat diets on weight loss and body composition on overweight men and women

Article: Metabolic Effects of the Very Low Carbohydrate Diets

2003
A low carbohydrate as compared with a low fat diet in severe obesity

A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women

Summary: 25 Randomized Controlled Trials Between Low Carb & Low Fat — Full Table of Results

2012 download reference list low-carb studies (106 articles)

Also see these books for a comprehensive look at the scientific literature: The Art and Science of Low Carbohydrate Living and Principia Ketogenica.

 

diabetes food

 

 

Every person (diabetic or not) should learn to count carbohydrates….or at least learn “carbohydrate awareness”.  This is not as hard as it sounds.  Practice with the foods you eat most often and after a few weeks you’ll be an expert.  It’s a skill that will last your lifetime:

Some would suggest no one should likely be over 150 grams total per day and anyone with metabolic syndrome might consider targeting 75 grams per day.  The worse the metabolic syndrome (diabetes), one might consider less.

15 gram Carbohydrate Food List

Atkins Carb Count Book

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Dr. Jason Fung, a Toronto physician presenting 2 key topics in Diabetes:

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A visual guide to A1c% Results:

Excess sugar in the blood “glycates” or sticks to proteins.  The more sugar, the “thicker” the coating of sugar on the proteins…

No Glaze: Normal A1c                       Glazed: Diabetic A1c               Heavy frosting: Uncontrolled

          

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a1c chart

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