A recent study by Kaiser Permanente and Yale Medical Center found that severe hypoglycemia is quite common in people with Type 2 diabetes who take insulin-stimulating medications. This was true regardless of level of control, meaning those with elevated blood sugar and A1c levels experienced low blood sugar as well as those who were within or below their A1c goal. Severe hypoglycemia is defined as a blood glucose level less than 50 mg/dL and is associated with increased risk for heart attack, stroke, loss of consciousness, and death, particularly when it occurs during sleep. Its symptoms can be frightening and include sweating, shaking, dizziness, unsteadiness, and heart palpitations.

Although having tight control (A1c <6%)  is considered dangerous by many diabetes specialists because it suggests frequent low blood glucose levels, it's evident that anyone taking medications which cause the pancreas to secrete insulin is at risk for hypoglycemia as well.  (For the record, I think having a lower A1c is good, provided it's not due to  frequent lows). According to Dr. Kasia Lipska, an endocrinologist at Yale Medical Center, "It's important to note that it's not the HbA1c that directly causes hypoglycemia; it's the therapies we use to lower it."  Exactly.

Insulin-stimulating medications cause unpredictable blood glucose response in several ways. Typically prescribed to be taken twice a day at meals in fixed dosages, they are unable to make the pancreas produce the precise amount of insulin needed to cover the carbohydrate ingested at a meal, nor do they start working at exactly the right time to match the digestion of carbohydrate. In the poorly controlled overweight person with diabetes, taking this type of medication practically guarantees at least occasional episodes of low blood sugar leading to overtreating with juice, soda, or candy, resulting in hyperglycemia and weight gain. It also places a burden on the beta cells of the pancreas by causing them to secrete large amounts of insulin, thereby increasing progression of the disease. Precisely the problems diabetes management is supposed to avoid.

 I feel that carbohydrate restriction should be offered as an alternative to taking these types of medications, and I outline the basis for why this way of eating is ideal for diabetes management in my recent Answers.com article.  I have heard about or spoken with many people -- including  Type 2 bloggers Dan Brown, Steve Cooksey, and Eddie Mitchell,  as well as Dr. Jay Wortman -- who have been able to stop their insulin-stimulating diabetes meds and improve their blood glucose control by following a very-low-carbohydrate ketogenic diet (VLCKD). In most cases, those who adopt a VLCKD require only metformin, an insulin sensitizer that does not place a person at risk for hypoglycemic events.

The message given by many of my fellow dietitians and CDEs is, "You can eat the same foods everyone else does as long as you take your diabetes medication."  I don't feel comfortable naming names, but the vast majority of articles by RDs and CDEs that I've read advise individuals with diabetes to eat low-fat, high-carb meals and snacks and take whatever meds are needed to keep blood glucose in check. I realize many people may not want to change their eating habits, and that is of course their choice. But I think they should be told about the risks of these medications, including the strong likelihood that they will periodically experience low blood sugar when taking them. Some will want to assume the risk, but others may be interested in an alternative way of eating that involves less medication and no risk of low blood sugar.  Every patient I talk to who has ever experienced severe hypoglycemia would prefer to avoid it all costs. 

I'm not saying that there isn't a need for diabetes medication in some people. People with Type 1 diabetes obviously require long-acting and mealtime insulin, although considerably less of the latter when on a carbohydrate-restricted diet (Hypoglycemia is also minimized with this approach). Those with Type 2 who adopt a VLCKD may only need metformin and possibly a long-acting insulin, depending on how much beta cell function they have remaining. Dr. William Yancy and Dr. Eric Westman have demonstrated that insulin and oral diabetes medications can  be reduced and in some cases eliminated in people following a VLCKD, and that blood sugar control improves across the board with this method. Why not encourage and support those who are interested in trying it? 

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I also want to let you know that I'm going to be participating in a live video interview with TuDiabetes on Thursday, September 26, at 1:00 pm Pacific time. I'm sure many of you won't be able to listen live -- I'm taking the day off of work for it --- but it will be available on their archives.  Hope you can watch  :) 

References:
1. Kaiser Permanente. Severe low blood sugar occurs often in patients with Type 2 diabetes. Science Daily. July 30, 2013.
2.  Westman EC, et al.A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab 2:34, 2005
3. Yancy WS,  et al. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab 5:36, 2008. 

I wanted to share my most recent Answers.com articles with all of my readers. Please take a moment to click on them, and if you have time to read them and give feedback, that would be even better! 

Using Sugar Substitutes on a Low-Carb Diet: Pros and Cons

Thai Ginger Scallops with "Rice"

How Does Alcohol Fit Into a Low-Carb Diet?

Tips for Eating Low Carb on a Budget

As I mentioned previously, my contract with Answers.com states that I'm required to write 10 articles a month for the next year. So 15 articles down, 105 left to go :)   

This is what I'd love to get from any of you (via Facebook, Twitter, blog post comments, or using my website Contact page):

• Ideas for future articles  (Fact-based rather than opinion, easy-to-understand pieces for new as well as experienced low-carbers)
• Original low-carb recipes (Nutritional information not required -- I can do the analysis)
• Feedback on the articles 

If you're able to help me by providing any of the above, I'd greatly appreciate it!  Thank you all again so much for continuing to share my website and message with others. I'm not a natural at self-promotion but recognize that it's necessary to some extent. Since I'll be going into private practice at the end of the year, I'm doing my best to figure out how to do it in a way I'll be comfortable with. 

While doing research for one of my Answers.com articles, Defending Your Low-Carb Diet, I found an interesting article on WebMD. I know that much of the information found online is critical of carb restriction, but I was unprepared for the claims made on this website, which is extremely popular and considered a trusted source by many Americans. 

First of all, the article discusses "high-protein, low-carbohydrate diets" and defines "high protein" as 30-50% of caloric intake. Aside from the Stillman diet and perhaps the diets of a few bodybuilders, I don't know of any other popular low-carb plans that recommend more than 30% of calories from protein. On a 2000-calorie diet, 30%  is 150 grams of protein, and 50% is 250 grams. Most low-carb diets are moderate in protein, although some people may consume higher amounts. This article purports to talk about the risks vs. benefits of high-protein, low-carbohydrate diets, but the "benefits" are glossed over, and several of the statements seem to denigrate carb restriction in particular. 

According to Web MD,  high-protein, low-carb diets can cause many health problems:

• Kidney failure  This is untrue in the case of people with healthy kidneys. Although individuals with advanced kidney disease may need to restrict protein, there is no evidence that a high-protein, low-carb diet damages renal function (1).
• High cholesterol  The article states "It is well known that high-protein diets (consisting of red meat, whole dairy products, and other high fat foods) are linked to high cholesterol. Studies have linked high cholesterol levels to an increased risk of developing heart disease, stroke, and cancer."  First off, low-carb diets don't always result in elevated cholesterol levels. And in the vast majority of cases, lipid profiles become more favorable in terms of particle size and number, improved HDL to cholesterol ratio, and lower triglycerides, resulting in less risk of cardiovascular disease and stroke. The exception would be people with familial hypercholesterolemia, who may need to limit dietary fat and cholesterol and replace most foods high in saturated fat with items containing monounsaturated fat like olive oil. With respect to cancer, older and recent research has demonstrated that it is associated with lower rather than higher cholesterol levels (2,3). 
• Osteoporosis  Studies indicate this is not a concern with high protein consumption provided intake of   plants -- ie, nonstarchy vegetables -- is adequate (4).
• Cancer  It's irritating to repeatedly read the assertion that low-carb diets don't provide vitamins, minerals, fiber, and antioxidants. There are loads of micronutrients in animal products, and the vegetables, berries, nuts, and avocado consumed on carbohydrate-restricted diets supply plenty of fiber and antioxidants.
• Unhealthy metabolic state (ketosis)  The information on ketosis in this article was contradictory but predominantly negative. On the one hand, the benefits of ketosis (switching to fat burning, weight loss, reduced appetite) are discussed early in the article, but later:  "During ketosis, the body forms substances known as ketones, which can cause organs to fail and result in gout, kidney stones, or kidney failure." Where is the evidence for this statement?  Children with epilepsy following extremely low-carb ketogenic diets (about 10 grams of carb per day) were found to be at greater risk of developing kidney stones (5), but as far as I know, this hasn't been seen in adults following VLC diets that include nonstarchy vegetables and berries. As far as gout, people who already have the condition will need to continue to monitor their uric acid levels, and they would benefit from eating alkalizing plant foods like vegetables in addition to protein and fat. However, there is no evidence that ketogenic diets cause gout, and because this condition is  related to insulin resistance, outcomes may actually improve on a carb-restricted diet.  Finally, there is no evidence that ketogenic diets cause kidney failure; in fact, preliminary research suggests they may actually reverse kidney damage (6).

In the summary, "Is Low Carb Right for Me?" the writer states that carb restriction is dangerous, particularly for those with heart disease, and that low-carb diets don't allow a high intake of fruits and vegetables. I strongly disagree.  I believe this way of eating is beneficial for people with heart disease for the reasons listed above, as well  as improvements in hyperinsulinemia, hyperglycemia, and hypertension. And there are plenty of plant foods allowed on a low-carb diet. I eat vegetables at every meal, a few servings of nuts a day, berries once a day, and avocado just about every day on my VLC diet. I probably get more vegetables than most people do, along with more fiber and antioxidants. 

Although I guess I shouldn't be surprised, it concerns me that such a highly critical and inaccurate article was published on WebMD.  Perhaps there are even worse articles written on medical sites considered reputable? In my opinion, using scare tactics to discourage people from adopting a carbohydrate-restricted diet is troubling, particularly since this way of eating has had such a positive impact on a significant number of people and has the potential to improve the lives of so many others.

* Although low-carbohydrate diets are safe and healthy for most people, it's important to speak with your doctor prior to adopting a low-carb diet or making other dietary changes.

References:
1. Friedman AN, et al. Comparative effects of low-carbohydrate, high-protein vs. low-fat diets on the kidney. Clin J Am Soc Nephrol. 2012 Jul;7(7):1103-11
2. Kritchevsky SB, et al. Serum cholesterol and cancer risk: an epidemiologic perspective. Annu Rev Nutr. 1992; 12:391-416.
3. Strohmaier S, et al. Total serum cholesterol and caner incidence in the metabolic syndrome and cancer project (ME-CAN).J Epidemiol Community Health 2011; 65:A302 doi:10.1136/jech.2011 
4. Barzel US, et al. Excessive dietary protein can adversely affect bone. J Nutr 128:1051-1053, 1988
5. Sampath A, et al. Kidney stones and the ketogenic diet: risk factors and prevention. J Child Neurol. 2007 April:22(4):375-378
6. Poplawski MM, et al. Reversal of nephropathy by a ketogenic diet. PLoS One 6:1–9, 2011