First off, I hope all of you and your families had a wonderful Thanksgiving. Mine was really nice: delicious food and great conversation with family and dear friends.
I've been wanting to write a post like this for some time now. My intention is not to criticize other people's beliefs but rather to explain my own and why I hold them. Looking over a number of "Paleo Thanksgiving" menus prompted me to finally address my ambivalence about Paleo, Primal, Weston A. Price Foundation, and other "real food" ways of eating. I know that several people who read this blog identify with one or more of these ways of eating. Please keep in mind that I strongly favor a whole foods approach over a diet containing processed foods. I'm a proud member of Real Food Dietitians, and I recently became a Primal Docs featured member. However, I think carbohydrate restriction is ultimately more important for people trying to manage diabetes, prediabetes, obesity, metabolic syndrome, and PCOS.
Diabetes, Hyperinsulinemia, and Insulin Resistance
There's a lot of convincing research supporting very-low-carbohydrate diets for people with Type 2 diabetes, metabolic syndrome, and polycystic ovarian syndrome. I'm planning a blog post on insulin resistance and hyperinsulinemia in the near future, but suffice it to say that many, if not most, overweight people have impaired insulin sensitivity, resulting in elevated blood sugar and insulin levels that cause hunger, damage blood vessels and nerves throughout the body, and promote fat storage. Keeping carb intake very low (less than 50 grams per day) will have a beneficial effect on insulin resistance and hyperinsulinemia in virtually everyone, whereas a diet containing twice or three times as much carbohydrate may work for a portion of this population, but most will need to restrict carbohydrates further to lose weight and achieve healthy blood sugar and insulin ranges. In general, the works of Drs. Steve Phinney, Jeff Volek, Eric Westman, Richard Feinman, Michael Eades, Richard K. Bernstein, and other low-carbohydrate researchers are more exciting and convincing to me than authors who classify themselves as Paleo or Primal.
People with Type 1 diabetes or normal weight individuals with blood sugar issues (I'd place myself in the latter category) will also benefit from keeping carbohydrate levels very low. I followed a Primal, moderately low-carb (100 grams or so per day) diet for a while but continued to have postprandial blood sugars over 160 and sometimes as high as 200. Only when I began restricting carbohydrates to 15 or fewer grams per meal did my blood sugar response normalize, and it's remained this way for the past year and a half.
I realize dairy is controversial in the Paleo and Primal community due to its lactose content, insulin-stimulating properties, and potential for allergies, but I personally consume quite a bit of it without any problems. In fact, I have Greek yogurt, cheese, sour cream, and/or cream every day and maintain a healthy weight. While there are certainly people with legitimate reasons to avoid dairy (such as true allergies or hypercalcemia), I think many others will do okay with it. If you have other symptoms that clear up when you eliminate dairy, then obviously you shouldn't eat it.
I understand the WAPF's position on the benefits of raw milk, but I disagree that pasteurized, homogenized dairy products are inherently bad. My parents are from Switzerland and grew up on pasteurized milk products, as did their parents, and continued consuming them throughout their lives. They're now in their 70s, active, and in excellent health, and I know there are many others like them. While raw milk may contain more nutrients and allow for better absorption of fat-soluble vitamins, I think pasteurized milk provides benefits as well.
Here's where I may lose some of my readers (if I haven't lost you already). There was recently a very successful Gluten Summit, and two intelligent MDs, Drs. Davis and Perlmutter, have written books detailing the devastating effects gluten can have on susceptible individuals. But not everyone is gluten sensitive! I avoid grains because of their carb content and I don't really mind not eating them, but there are other low-carbers who consume low-carb bread, wraps, etc., without any problems. Dr. Steve Parker's Low Carbohydrate Mediterranean Diet allows grains for those who tolerate them. The Paleo Thanksgiving yam and sweet potato recipes I saw online contain a lot of carbohydrates. Eating a small amount would be fine, but many people tend to eat larger portions of foods they're told are healthy. I'm not saying that grains are good for you, but to be honest, I'd rather someone with diabetes eat a forkful of stuffing (about 3 grams of carb) than a cup of sweet potatoes (37 grams of carb if plain).
Another controversial area among Paleo/Primal/WAPF devotees is sweeteners. Honey or pure maple syrup is often recommended as an alternative to table sugar. However, these items contain more carbohydrate per serving than sugar does, so they're not a good choice for people with diabetes or insulin resistance. Green leaf stevia is recommended as an option for those who need to limit carbohydrates. But have you tasted stevia? It's got an interesting flavor (reminiscent of anise, in my opinion), but it really doesn't work well as a sweetener for all types of food. I rarely use any sweetener at all, but when I do bake occasionally, I use erythritol, a sugar alcohol that isn't absorbed by the body and tastes very similar to sugar. Some have argued that erythritol is a processed product made from corn, but I think people with issues related to glucose intolerance would be better off consuming it -- or even saccharin -- instead of "natural" sweeteners, including fruit juice. Again, it's best to avoid all types of sweeteners except in limited amounts. I do eat a square of 85-90% cacao dark chocolate a few times a week. It's sweetened with sugar but only has about 2 grams of net carb.
Pastured and/or Organic
As a former vegetarian for ethical reasons, I strongly support raising animals as naturally and humanely as possible. I would prefer to always eat pastured, organic, or naturally raised meat, dairy, and eggs, and most of the time I do, at least at home. But there are many people who can't afford to eat this way on a daily basis. I've written about this before, but I feel even more strongly now that people on limited budgets shouldn't be made to feel that they're jeopardizing their health if they can't buy organic food. I've seen individuals on low-carb forums say that they have to quit eating low carb because it's too expensive. But there are lots of ways to eat low carb without spending a lot of money (also Google "low carb on a budget"). Replacing higher-carb items with conventionally raised animals, eggs, and cheese can have a profound positive effect on blood glucose and insulin levels, as well as weight. And at the end of the day, that's the most important thing.
I hope I didn't offend any of the people I respect yet differ with on this issue, but I wanted to make clear where I stand. If folks with diabetes or weight issues can combine "real food" and low carbohydrate intake, this is ideal. But I'll always place carb restriction as the top priority for them because I truly believe it's the key to improving their health.
1. Volek JS, Feinman RD.Carbohydrate restriction improves features of the Metabolic Syndrome. Metabolic Syndrome may be defined by the response to carbohydrate restriction. Nutr Metab (Lond) 2005 ;2:31
2. Accurso A, et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutr Metab (Lond) 2008; 5: 9
3. Westman EC, et al. Low Carbohydrate Nutrition and Metabolism. Am J Clin Nutr 2007; 86(2):276-284
4. Mavropolous JC, et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutr Metab (Lond) 2005: 2:35
The latest guidelines on treatment of diabetes, prediabetes, and cardiovascular disease published by the European Society of Cardiology (ESC) in collaboration with the European Association for the Study of Diabetes (EASD) are extremely comprehensive (48 pages) and contain over 500 references. Much of the discussion focuses on cardiovaascular risk factors and treatment, although a fair amount of time is spent on diabetes management itself. I'll confess that I didn't have time to read the entire document and certainly don't expect you to, but I did read the short section entitled "Prevention of cardiovasclar disease in patients with diabetes," paying particular attention to the "Diet" section. To say that I was disappointed with the recommendations would be an understatement.
A few quotes from the paper:
"Carbohydrates may range from 45-60% of total energy. Metabolic characteristics suggest thta the most appropriate intakes for individuals with DM are within this range. There is no justfication for the recommendation of very-low-carbohydrate diets in DM."
On the contrary, there are many studies (cited in previous blog posts, most recently this one), along with anecdotal evidence from thousands of people with diabetes, demonstrating that VLCKDs can dramatically improve glycemic control to the point that diabetes medication can be significantly reduced or even eliminated in the case of T2 diabetes.
"Total fat intake should not exceed 35% of energy. For those who are overweight, <30% may facilitate weight loss."
Restricting fat to these levels guarantees that the diet will be high in carbohydrate, which does not benefit people with diabetes regardless of their weight.
"Saturated and trans-fatty acids combined should be <10% of total daily energy intake. A lower intake of <8% may be beneficial if LDL-C is elevated."
Grouping saturated and trans fats together is extremely misguided. One is highly processed and has been shown to cause a number of health problems, while the other is a healthy, natural fat that people have been consuming for thousands of years.
"Vegetables, legumes, fruits, and whole-grain cereals should be part of the diet."
I agree with vegetables and certain fruits being appropriate for people with diabetes, but there is no reason to consume legumes or whole-grain cereals, as they don't contain any nutrients that can't be found in other foods.
Last week I did an interview on TuDiabetes about carbohydrate restriction for people with diabetes where I discussed these issues in more detail, among others, in response to questions from the audience. Feel free to give me any feedback, positive or negative, if you're able to watch. I apologize for sitting so close to the camera that my face pretty much takes up the whole screen and really looks pretty strange, but I'm new to this videotaped live interview thing.
Also, here's a link to my most recent Answers.com articles on a few low-carb breakfast ideas I discussed in the interview.
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 :)
1. Kaiser Permanente. Severe low blood sugar occurs often in patients with Type 2 diabetes. Science Daily. July 30, 2013.
Franziska Spritzler, RD, CDE