European Guidelines on Diabetes and Prediabetes vs. My Viewpoint on Video

10/3/2013

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.

14 Comments

Judi

10/3/2013 07:39:44 am

Just when you think progress is being made there is this nonsense. Newly diagnosed people just have no hope! Your work in this area is so valuable and very much appreciated. Thanks!

Franziska Spritzler link

10/3/2013 07:48:11 am

Thanks so much for your comments and support, Judi!

Ann

10/3/2013 08:10:06 am

I wish that someone would do a careful analysis of the connections between the EASD, the American Diabetes Association, the Canadian Diabetes Association and the manufacturers of drugs and processed foods. The levels of dietary carbohydrate and fat recommended by the diabetes organizations guarantee that the overwhelming majority of people with diabetes will struggle with increased blood glucose levels and a significantly higher risk of serious complications than those who follow a low-carbohydrate diet and manage to keep their blood glucose levels in the 5% range or lower. Many diabetics who follow these organizations' dietary guidelines will be blamed for their high blood glucose levels because they will be presumed not to be complying with dietary recommendations. Everyone who eats as much carbohydrate and as little fat as these guidelines recommend will also need to take medications with well-documented serious side-effects to lower their blood glucose and, even then, will be unlikely to achieve "normal" blood glucose levels. Their risk of serious complications will remain dangerously high. This is all great for the pharmaceutical industry and for any company that sells cereals, breads, legumes and other supposedly "healthy" carbohydrate products. It's not good for diabetics, however. Also, notice that there are no people with any type of diabetes on these organizations' Boards of Directors!

10/3/2013 08:24:20 am

Thank you very much for your insightful comments, Ann. I'm in 100% agreement with all of them, of course.

Gerri

10/3/2013 02:03:50 pm

Arrrgh, here we go again. Can't believe transfats are included. What decade are these organizations living in? I'd like to see their references for transfats. So very discouraging that guidelines continue to put health at risk. Any info on who funded this project? Hoping we'll be freed one day from low fat, grain based, high carb authoritative recommendations.

Enjoyed your interview.

10/3/2013 09:43:59 pm

Thanks so much for your comments, Gerri. These recommendations don't make any sense to me either. And as Ann pointed out, people with diabetes aren't on the board of directors of the organizations that publish these guidelines, nor are successful PWDs consulted about what type of diet they follow.

PhilT

10/3/2013 05:56:39 pm

Cardiologists should not be allowed within a country mile of dietary advice to the public. They should stick to their discipline and work with dietitians etc to formulate appropriate dietary recommendations which should then be owned and promoted by the latter.

We've had 40 years of lipophobic cardiology messing with our food, and look where that got us.

The diabetes world is over-focussed on heart disease and glosses over people that go blind and lose limbs by following their nutritional guidance.

10/3/2013 09:46:30 pm

I'm not religious, but I have to say "Amen" to that, Phil! Thanks for your comments and support.

Anna

10/3/2013 11:21:05 pm

Hi Franziska, I really enjoyed your online Q&A session and just wanted to remark on how uncannily similar our experiences seem to be. I am also mid-40s, normal FBS, problem with post-prandial BS into the 200s, now eating LC, Paleo-like + dairy (~50g carb) and rarely a BS over 120. I owe it all to resources like yours, Jenny Ruhl and Dr. Bernstein. Thanks for sharing all of your helpful information.

10/4/2013 12:09:16 am

Hi Anna,

Yes, we're definitely very similar in terms of blood glucose and using VLC to successfully manage high postprandials! And I suspect there are many others with the same issue who aren't aware of this because their doctors rely solely on fasting BG values. Jenny Ruhl once told me that if more dietitians checked their blood sugar after a meal, most of them would start making different recommendations to their patients with diabetes.

Thanks so much for your feedback and support.

Eddie Mitchell link

10/4/2013 02:51:20 am

Hi Franziska

Your video is fantastic, as you would expect I agree with every word. If every newly diagnosed diabetic received a copy or link to your video and a copy of Dr. Richard Bernstein’s Diabetes Solution, they would have a fantastic start and be on their way to good Blood glucose control and a happier healthier life. Sadly so few people are receiving the correct dietary information, and end up paying a terrible price. The saddest part in all this, diabetics do not have to progress to amputations, blindness and kidney failure.

You quoted a piece from a paper published by the European Society of Cardiology (ESC) in collaboration with the European Association for the Study of Diabetes (EASD)

"Carbohydrates may range from 45-60% of total energy. Metabolic characteristics suggest that the most appropriate intakes for individuals with DM are within this range. There is no justification for the recommendation of very-low-carbohydrate diets in DM."

I would suggest the number of diabetics consuming 45-60% of total energy from carbohydrates and holding long term safe, i.e. non diabetic HbA1c is one of the shortest lists in the world. In the UK 93% of type one diabetics are >6.5. The stats for type two’s also prove very poor control by the majority. The stats I refer to are those published by the NHS and are rock solid.

We hear so often as advocates of lowcarb, our experience is only anecdotal, and that science says otherwise. Well, true science backs us up. For five years I have seen what the establishment has achieved, and the failure rate is pitiful. What company or organisation other than the healthcare industry would tolerate a failure rate of 93% ?

The day must come, when all diabetics will be informed that a severe carb restriction is a healthy and viable option, and a sound alternative to chasing highly elevated BG numbers with ever increasing medication.

Kind regards Eddie

10/4/2013 04:47:44 am

Hi Eddie,

Thanks so much for your feedback and continued support, as well as your excellent comments. The number of people with uncontrolled diabetes is abysmal, and they often believe they are doing the right thing by following a high-carb, low-fat diet. Thanks for adding your voice. Keep up the great work at Low Carb Diabetic.

Steve Parker, M.D. link

10/9/2013 02:55:53 pm

I saw that European document and immediately objected to the allegation that no studies support carbohydrate restriction in diabetes. A couple years ago, I put together this list of supportive scientific articles:

Accurso, A., et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutrition & Metabolism, 9 (2008). PMID: 18397522. One of the watershed reports that summarize the major features and benefits, based on 68 scientific references.

Boden, G., et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Annals of Internal Medicine, 142 (2005): 403-411. In these 10 obese diabetics, a low-carb diet spontaneously reduced calorie consumption from 3100 daily to 2200, accounting for the weight loss—1.65 kg (3.63 pounds) in 14 days. Blood sugar levels improved dramatically and insulin sensitivity improved by 75%.

Daly, M.E., et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes—a randomized controlled trial. Diabetes Medicine, 23 (2006): 15-20. Compared with a low-fat/reduced-calorie diet, weight loss was much better in the low-carb group over three months, and HDL ratio improved.

Davis, Nichola, et al. Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes. Diabetes Care, 32 (2009): 1,147-1,152. The Atkins diet was superior—for weight loss and glycemic control—when measured at three months, when compliance by both groups was still probably fairly good. After one year, the only major difference they found was lower HDL cholesterol in the low-carb eaters.

Elhayany, A., et al. A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Diabetes, Obesity and Metabolism, 12 (2010): 204-209. In overweight type 2 diabetics, a low-carbohydrate Mediterranean diet improved HDL cholesterol levels and glucose control better than either the standard Mediterranean diet or American Diabetes Association diet, according to Israeli researchers.

Haimoto, Hajime, et al. Effects of a low-carbohydrate diet on glycemic control in outpatients with severe type 2 diabetes. Nutrition & Metabolism, 6:21 (2009). DOI: 10.1186/1743-7075-6-21. A low-carbohydrate diet is just as effective as insulin shots for people with severe type 2 diabetes, according to Japanese investigators. Five of the seven patients on sulfonylurea were able to stop the drug.

Nielsen, Jörgen and Joensson, Eva. Low-carbohydrate diet in type 2 diabetes: stable improvement of body weight and glycemic control during 44 months follow-up. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-14. Obese people with type 2 diabetes following a 20% carbohydrate diet demonstrated sustained improvement in weight and blood glucose control, according to Swedish physicians. Proportions of carbohydrates, fat, and protein were 20%, 50%, and 30% respectively. Total daily carbs were 80-90 g. Hemoglobin A1c, a measure of diabetes control, fell from 8% to 6.8%. These doctors had previously demonstrated that a 20% carbohydrate diet was superior to a low-fat/55-60% carb diet in obese diabetes patients over six months.

Vernon, M., et al. Clinical experience of a carbohydrate-restricted diet: Effect on diabetes mellitus. Metabolic Syndrome and Related Disorders, 1 (2003): 233-238. This groundbreaking study demonstrated that diabetics could use an Atkins-style diet safely and effectively in a primary care setting.

Westman, Eric, et al. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-36. Duke University (U.S.) researchers demonstrated better improvement and reversal of type 2 diabetes with an Atkins-style diet, compared to a low-glycemic index reduced-calorie diet.

Yancy, William, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes [in men]. Nutrition & Metabolism, 2:34 (2005). DOI: 10.1186/1743-7075-2-34. A low-carb ketogenic diet in patients with type 2 diabetes was so effective that diabetes medications were reduced or discontinued in most patients. The authors recommend that similar dieters be under close medical supervision or capable of adjusting their own medication, because the diet lowers blood sugar dramatically.

Yancy, W., et al. A pilot trial of a low-carbohydrate ketogenic diet in patients with type 2 diabetes. Metabolic Syndrome and Related Disorders, 1 (2003): 239-244. This pioneering study used an Atkins Induction-style diet with less than 20 grams of carbohydrate daily.

Most if not all of these refer to type 2 diabetes.

-Steve

10/9/2013 10:24:22 pm

Thanks so much, Steve! I remember this impressive list from one of your blog posts. I believe there are several more now, including a few looking at Type 1 diabetes.

Hope you get a chance to listen to my Tu Diabetes interview, because I'd love to get your feedback. I enjoyed your interview several months ago and, as I've said before, feel that your Diabetic Mediterranean Diet and ketogenic version are fantastic for anyone interested in low carb, whether or not they have diabetes.

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European Guidelines on Diabetes and Prediabetes vs. My Viewpoint on Video

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