Why Are Many Dietitians So Critical of Low-Carbohydrate Diets?

8/3/2013

As someone who tries to read a wide variety of blogs devoted to carb restriction, I often see negative statements about dietitians not understanding the science behind energy balance, hormonal regulation, and blood glucose control. I frequently get e-mail from people saying something to the effect of, "I didn't know there was such a thing as a low-carb dietitian!" There are actually several registered dietitians I know of personally who believe in at least moderate carbohydrate restriction and higher fat intake than currently recommended by government health organizations. However, the majority of RDs favor low-fat diets that are inherently higher carb given the relatively narrow protein range of 15-30% that is almost universally agreed upon.

Why are so many dietitians against low-carb? It's usually one or more of the following beliefs -- some of which I used to share, by the way:

1. They think it's dangerous. Ketosis. Just hearing the word makes most dietitians uneasy. The thought of someone eating fewer than 130 grams of carbohydrates per day is generally considered unhealthy and insufficient to support brain health. Never mind that our ancestors were often in ketosis for long periods of time and many scientists, physicians, athletes, people with diabetes, and others eating low-carb diets use ketones as an alternative energy source with excellent results. There are studies demonstrating that ketone bodies are the preferred fuel for the heart, adrenal cortex, and other tissues in addition to the brain. Aside from people with Type 1 diabetes who can develop the very dangerous condition of diabetic ketoacidosis from illness coupled with inadequate levels of insulin, levels of ketones do not rise to dangerously high levels in the blood because they are efficiently used for energy by the body.

2.They believe the diet-heart hypothesis. Despite much evidence to the contrary, many dietitians think that fat, particularly saturated fat, raises LDL ("bad") cholesterol and increases heart attack risk.

3. They think the diet is unbalanced. I've heard the following comments many times: "How do you get enough vitamins and minerals if you don't eat whole grains? And what about the fiber?" A low-carb diet can provide high amounts of all vitamins and minerals (animal products are the best sources, despite what's promoted in the media), as well as adequate fiber from nonstarchy vegetables, berries, nuts, and seeds.

4. They think no one will follow it long term. Some of my colleagues say that while low-carb diets may help people lose weight, they don't really stick with it and just end up regaining all the weight plus more. Well, for some folks this may be true, but I tend to believe they'd behave the same way after losing weight on any other diet. There are many people who follow a carbohydrate-restricted diet for life and stay healthy doing so, and their experiences shouldn't be discounted just because others end up abandoning it.

Again, these are beliefs held by many, but not all, dietitians. I'm obviously very much in favor of LCHF diets, and there are at least five other RDs I know of who more or less share my view:

Valerie Berkowitz,MS,RD,CDE, and her husband, Dr Keith Berkowitz, worked with Dr. Atkins at the Atkins Center for several years. She offers carbohydrate restriction as an option for her patients and has also written low-carb articles for various magazines.

Algaee Jacob, MS, RD, CDE, is a Paleo dietitian with expertise in digestive health and diabetes management using a low-carb approach. She recently wrote an article on the benefits of low-carb diets for diabetes published by Today's Dietitian -- very encouraging!

Adele Hite, RD, MPH, educated patients about carb restriction while working at the Duke Lifestyle Medical Clinic with Dr. Eric Westman and is currently working on low-carb research and pushing for policy change in the area of nutrition.

Cassie Bjork, RD, LD, is the co-host of the Low Carb Conversations with Jimmy Moore podcast and a proponent of eating lower-carb, higher-fat real foods.

Lily Nichols, RD, CLT, is a whole foods dietitian and Pilates instructor who specializes in digestive health, follows a moderately low-carb diet, and understands the benefits of carb restriction for weight and diabetes.

There are many others out there as well, along with more conventional RDs who don't advise their patients to follow a low-carb diet but don't discourage them if they're achieving good results. I understand the frustration with dietitians not "getting it," but we need to remember that the women I just listed, myself included, weren't always so favorable toward carb restriction either. There is always hope that more will come over to our side, and I think that's likely to happen if we continue speaking out about the research supporting LCHF and the benefits so many have experienced from adopting this way of eating.

58 Comments

Brenna link

8/2/2013 11:08:26 pm

There are a whole bunch of RDs and LNs at Nutritional Weight and Wellness who fully support you and low carb eating!

We also have a podcast called Dishing Up Nutrition. Enjoy!

Franziska Spritzler link

8/3/2013 12:00:50 am

Hi Brenna,

Nice to meet you, and thanks so much for your support! I wasn't aware of Nutrition Weight and Wellness -- looks like a great group of dietitians and nutritionists! I'll definitely check out your podcast, as well as your blog. Thanks also for listing me on your blogroll. Much appreciated :)

Linda

8/2/2013 11:25:36 pm

Is there a way to subscribe to your blog so that we receive all new entries?

8/3/2013 12:06:49 am

Hi Linda,

If you follow me on Facebook or Twitter, I always post or tweet every new blog entry, but I realize you may not see them all. If you have an RSS reader, you can also subscribe to the RSS feed feed. Aside from that, just checking back once a week or so is probably the best I can offer. I rarely post once a week --- this week was unusual with 2 posts within 3 days. I really appreciate your support and interest in my blog. Thank you :)

Steve Parker, M.D. link

8/3/2013 12:46:27 am

I always thought the dietitians who "go against the grain" of traditional dietary advice have a strong independent streak and are perhaps smarter than average. On the other hand, the "traditional" dietitians may not have the time to do independent research into the nutrition literature and form their own opinions. I didn't abandon the time-honored diet-heart hypothesis myself until 2009, when I spent 80 hours reviewing the literature. Few doctors will do that; it's easier (and safer?) to just go along with the crowd.

-Steve

8/3/2013 04:24:05 am

Thanks so much for your comments, Steve! Agree with them, particularly your last line.

Kelly Booth link

8/3/2013 12:48:15 am

I do hope more dieticians come around to your way of thinking! I was in the hospital in December and when a dietician came in to talk to me, I was told low carb was dangerous. I told her, “I don’t buy that crap. I follow the studies and I know that isn’t true.” Then she said that it wouldn’t sustain me. I have been doing low carb for several years and I am not underweight. As for the their claim that people won’t stay on them long-term (I heard a CDE say that last fall), I think there is a difference between people wanting to do low carb to lose weight and those wanting to control blood sugar. For me, low carb is a way to achieve good blood sugar control and since Type 1 is not going to go away, doing low carb for life is the only option available that I can live a long, healthy life with.

8/3/2013 04:27:36 am

Thank you very much for posting about your experience, Kelly. Good for you for speaking up while hospitalized. I definitely believe people with T1D are better off following some level of carb restriction and that it can be easily sustained for life. Sorry the CDE sees it differently. Best of luck to you always.

Eddie Mitchell link

8/3/2013 01:38:38 am

Hi Franziska thanks for another great post.

I have been asking Doctors, and medical professionals, including Dietitians, this question for five years, how do I hold non diabetic BG numbers with two Metformin pills, other than a low carb high fat diet regime ? the silence has been deafening. Maybe I should follow a multi drug regime as outlined in the ACCORD study, no, that ended early because too many people were dying.

We know many type two diabetes drugs have been banned such as Actos and Avandia. Other type two medications carry black box cancer warnings and are under the FDA spotlight, because of victims reporting very serious side effects. At best, all type two drugs (some very expensive) reduce HbA1c by two full points, very often they reduce HbA1c to a much lesser degree. A lowcarber can reduce HbA1c by 3, 4, even 5 full points with the correct diet, and modest exercise regime, often a little help from a very well proven, low cost, and safe drug such as Metformin, is all that is required.

The first line of defence, for most newly diagnosed type two diabetics, should be dietary changes and exercise. According to the US Dietitian Hope Warshaw "Old Dogma: People with type 2 diabetes should follow a low carb diet. New Reality: Nutrition recommendations for people with type 2 diabetes from the American Diabetes Association and other health authorities echo the recently unveiled U.S. 2010 Dietary Guidelines (1/31/11) for carbohydrate : about 45 to 65 percent of calories. (Americans currently eat about 45 to 50 percent of calories as carbohydrate--not a "high carb" intake.)" Complete lunacy in my opinion. Last word to Doctor Malcolm Kendrick.

“The reality is that over the years, and around the world we have killed literally millions of diabetics by advising them to eat a high-carb diet and avoid fats. Only now is it being recognised that previous advice was and remains useless, dangerous and scientifically illiterate"

Kind regards Eddie

http://diabeteshealth.com/read/2011/06/28/7199/type-2-diabetes-from-old-dogmas-to-new-realities---part-2/#commentpost

8/3/2013 04:35:05 am

Fantastic comments as usual, Eddie. I've seen that article from Hope several times, and it still irritates me. Thanks for the rebuttal from Dr. Kendrick and for your continued support.

John Briffa link

8/3/2013 03:26:29 am

Franziska

My experience tells me that other common explanations for why dieticians are critical of low-carbohdrate eating are:

1. they don't read or don't understand or don't believe the published research

2. they struggle with independent thinking and prefer to stick with the herd

These issues are not, of course, exclusive to dieticians.

8/3/2013 04:42:11 am

Thank you so much for your comments,Dr.Briffa. I agree.

js290

8/4/2013 02:42:24 pm

They seem to be willfully ignorant of metabolism in general and Nature's ability to optimize on the better fuel that is fat. Religious zealots, the lot of 'em.

Axel F link

8/3/2013 10:23:43 am

I think that among cardiologist´s and many other doctors, the fear of fats is the main reason for them being critical of the low carb approach. The data on the role of LDL-C (LDL-cholesterol) as a risk factor is fairly strong. Clinical guidelines on cardiovascular prevention emphasize that LDL-C should be a target for risk modification.
However, more and more doctors now see carbohydrate restriction as an effective tool to treat conditions such as the metabolic syndrome and type-2 diabetes. So I believe the tides may be slowly turning. Thus, a slight elevation of LDL-cholesterol may not matter that much when you see all the other positive effects, such as weight reduction, lowering of TG, lowering of LDL-P and elevation of HDL-C and so on. Besides, you can always use statins to lower LDL-C, but thats another delicate issue.
Thanks for a great article Franziska. kepp up the good work.

8/3/2013 10:35:02 pm

Thanks so much for your comments, Axel! Appreciate getting a cardiologist's perspective on carb restriction as it relates to heart health. I agree that the many benefits of LC outweigh the risks of potentially higher LDL-C.

Please keep up your good work as well!

Victoria P

8/3/2013 11:51:04 am

Franziska, Diane Kress RD CDE is also another low carb dietitian.

8/3/2013 10:38:22 pm

Thanks, Victoria! I knew there were others :)

Jennifer Elliott link

8/3/2013 06:50:48 pm

Hi Franziska. Great post and I totally agree with what you've said. I would add that even if a dietitian does the research, has personal and clinical experience of the benefits of lower carb, there are other deterrents to openly practicing and advocating this approach. I have been recommending lower carb for IR/ Met Syn for about 10 years. Despite the results speaking for themselves and the support of GPs who refer clients to me, I am aware how tenuous my position within the health system can be. A few years ago another dietitian complained to the Dietitians Association that I was recommending a diet that could lead to CHD because of the sat fat content. The Assoc then wrote to my employers implying that my practice was unprofessional because it didn't follow usual dietary guidelines. The result of an extensive interview process, where I was asked to provide a detailed rationale and evidence for the approach I use, found in my favour. So I've been practicing for a long time now but can still get a little nervous when my contract comes up for renewal!

8/3/2013 10:53:05 pm

Hello Jennifer, and thank you so much for your feedback and sharing your own experience as a low-carb dietitian. I completely agree that any RD who supports and recommends LC is putting herself/himself at risk for retaliation by other RDs. I'm so sorry that this happened to you but very encouraged that you were exonerated of the charges of unprofessional conduct. I know you're not in the US, but something very similar happened to a dietitian named Annette Presley several years ago in her home state of Texas. A couple of local dietitians decided to report her to the state dietetic association because she was recommending people eat butter instead of margarine. Can you imagine?! She was also investigated and vindicated after providing evidence supporting her position. I know I'll be able to do the same if this happens to me, but I completely understand and share your concern. Thank you so much for continuing to educate and speak out for what you know is right despite the risks involved! :)

Sharon

12/29/2013 07:33:19 am

I'm just a normal Baby Boomer with many of the signs of metabolic syndrome. I found Jennifer's book 'Baby Boomers, Bellies & Blood Sugars' - and this is enormously helpful. And now I found your blog, Franziska - and have posted this to my FB page too because a number of friends have seen my earlier success with the original Atkins diet, which I regret now that I let go (after nearly 3 years success) after becoming confused with all the 'expert' criticism. However I know that I felt a completely different (better) person on that eating plan, and with Jennifer's guidelines now making it feel much easier to fit into my lifestyle), I see no reason why this should not succeed. I appreciate all these comments above!

12/29/2013 12:39:43 pm

Hi Sharon, (Have to reply here because this site doesn't allow me to reply to responses)

Thanks so much for your kind words of support. Jennifer's book is indeed a treasure, and I'm so glad you're having good results following her recommendations. Thanks also for sharing on your Facebook page as well. I wish you the very best of luck and good health in 2014!

8/3/2013 10:45:50 pm

From Dr.Jay Wortman's blog.

"My friend, the Swedish low-carb physician, Dr Andreas Eenfeldt, who blogs at www.dietdoctor.com has been quite active lately and has contributed to recent events in Sweden. As you may know, the Swedish government investigated another low-carb physician, Dr Anna Dahlquist, who was publicly advocating ketogenic diet for the treatment of diabetes. A couple of nutritionists made a formal complaint of malpractice against her which compelled the Swedish Ministry of Health to investigate. When the report was published, it exhonorated the doctor and found that the low-carb diet approach she was using was a valid treatment option. This appears to have galvanized a resurgence of low-carb dieting in Sweden"

http://www.drjaywortman.com/blog/wordpress/2011/11/

Kind regards Eddie

8/3/2013 11:16:53 pm

Hi Eddie,

Thanks for providing the information from Dr. Wortman's blog about Dr. Dahlquist. I do remember reading about that investigation. It always seems to start with dietitians at the local level, doesn't it? Very relieved that she was cleared of malpractice and that this episode was a big contributor to LCHF's rising popularity in Sweden.

Terry O'Rourke

8/4/2013 10:29:57 am

Dear Franziska - Thank you for your outspoken advocacy for low carb, high fat diets (LCHF). As a type 1 diabetic, I discovered the potent and positive effects of the LCHF diet I started 15 months ago. I lost and kept off 23 pounds (15% of my weight), cut my insulin total daily dose in half, dropped my A1c from 6.8% to 5.9%, and eliminated my blood pressure meds. I have fewer hypoglycemia incidents and overall just feel better. I so appreciate your vocal support for this way of eating. I know it is right for me and seeing your professional support encourages me.

I think the LCHF movement is pickup up steam and more of your professional brethran will continue to join you.

8/4/2013 11:33:48 am

Hi Terry,

Thank you so much for your very kind words and continued support. I'm very glad to hear that you continue to have such fantastic results on LCHF. Your experience is similar to many other T1s I have either heard from personally or learned about through others. I just can't back down from something I believe in so strongly. Thanks so much for the appreciation. I appreciate you too! And I hope your prediction comes true.

Lisa

8/4/2013 04:37:16 pm

Terry, it is great to know that another type 1 diabetic has discovered the magic secret to diabetes control. The Diabetes Australia association advises diabetics to snack on "low" glycemic foods (even though they are HIGH glycemic, such as bread) and to base all meals on carbohydrates. It sickens me to think of all the suffering these naïve diabetics will face simply because of their high carb diet. I work in healthcare, and every week we see patients with hideous ulcers and feet and toes missing from diabetes. My son is type 1 and I vow that he will never go through that pain, which is why we as a family now eat low carb. I have yet to meet another diabetic who has modified their diet as we have. Most people think we are weirdos because we don't eat wheat! My son's last HbA1c was 5.5, by the way.

Sheila Leard, RD,CSSD link

8/4/2013 02:09:05 pm

Just as traditionally trained MD's are taught to treat elevated cholesterol with Statins, traditionally trained RD's will still rely on carbohydrate counting to control diabetes. It takes confidence and experience to go against the norm.

8/4/2013 09:36:58 pm

Thanks for your comments and support, Sheila. Very encouraging to hear from other dietitians who understand this.

Theresa Link, RD, LMNT

8/7/2013 10:49:56 am

I'm a dietitian and I'm with you!!! I first heard Gary Taubes speak at FNCE in 2009 and it changed me forever. However, here in Nebraska, I think I may be the only one...

Please don't ever stop blogging - it gives me faith for the future of our profession!

In ketosis since 2011 and never felt better :)

Gerri

8/4/2013 02:35:59 pm

Grateful for the trail blazers like you. Takes moxie to risk professional backlash.

The only CDE I went to was unsupportive. She was also a NP. I received the standard warning of brain starvation, quoted the ACCORD study headline & told LC was impossible to maintain. I never went back.

Change is always a painfully slow process.

Thanks for another great post.

8/4/2013 09:39:32 pm

Thanks so much for your continued support, Gerri. Always appreciate hearing about your experience as a person with T1D.

8/4/2013 04:26:57 pm

Are dieticians actually taught low fat and high carbs are healthy at university? I can't understand why most dieticians push the healthy wholegrain/base your diet on carbs propaganda, if it is the complete opposite of the truth. My son's "diabetic dietician" told him it's ok to eat McDonalds! My son eats low carb due to my own research and not following the " carbs are essential for energy" rubbish found in every single diabetic book and publication I was given.

8/4/2013 09:47:00 pm

Hi Lisa,

Thanks for your comments. Yes, dietitians are typically taught that the US Dietary Guidelines, which push LFHC, provide the healthiest nutrition recommendations for the public. We are advised to teach label reading using the Daily Values (DV), which specifies 300 grams of carbohydrates per day for a person consuming 2000 calories and less than 60 grams of fat.

Tim

8/4/2013 10:24:44 pm

It's heartening to note the number of medical professionals who responded to this blog post positively. Change is coming for the simple reason that we have the facts on our side.

8/4/2013 11:11:16 pm

Agreed, Tim. I'm feeling more encouraged than ever that the tide is turning.

Cahide

8/5/2013 11:20:12 am

Science says carbohydrate (whether starches or sugar, complex or simple, whole grain or refined--whatever) raises blood glucose levels, which increases insulin, which causes fat storage. So why would anyone in the health field tell anyone who falls within the parameters of metabolic syndrome to eat more of the toxin that is causing this problem? Why would anyone in the health field tell any variety of diabetic to eat more of the toxin that is killing them?

Science says fat does not raise blood glucose levels, so why would anyone in the health field tell these same people not to eat one of the nutrients that can help to keep blood glucose under control?

It's as if the dogmas of "heart healthy whole grains" and that Old Demon Fat are matters of faith where science has no business butting in.

I am lucky that my NP, who is my primary care person, when she asked me if I knew I was pre-diabetic, agreed to let me try to get the problem under control through diet, by cutting out the starches and sugars. Of course, she had a copy of Wheat Belly prominently displayed on a bookshelf in her office. And in her recent email to us, her patients, she encouraged us to practice medicine without a license. In other words, she encourages us to read, to educate ourselves, to question our health care providers, and to take an active role in our own care. My NP gets it.

Maybe Drs. Phinney and Volek's book, The Art and Science of Low-Carbohydrate Living, should be required reading for every dietitian.

8/5/2013 01:48:28 pm

Hi Cahide,

Thanks so much for your comments. Wonderful that you've got a nurse practitioner who is open-minded, advises you to do your own research and take control of your own health, and is anti-wheat. You're very fortunate to have her.

I'd love if that book was required reading for RDs. It's one of my favorites.

8/9/2013 01:55:06 pm

Hi Franziska,

Actually, the best thing about my NP is that she takes NP students into her office to do their clinicals. So they must be exposed to her attitudes toward her patients and her support of LCHF as a tool to manage the diseases that the low fat high carb diet advice has caused.

If it's taking so long for many of the national health organizations to change their attitude about a LCHF diet, maybe change will come through this type of grass roots support by those health care professionals who are working with patients in their own practices.

Maybe things really are looking up.

8/8/2013 07:37:45 pm

I agree wholeheartedly with everything you say.

In Australia, the Dietician's Association is sponsored by: Nestle, Kellogs and the Australian Wheat and Legume Board, so I guess money talks.

Wheat Belly is my bible. It just made everything about controlling my child's diabetes make so much sense.

8/8/2013 09:21:03 pm

Thanks very much for your comments and support, Lisa! Yes, the US Academy of Nutrition and Dietetics is also sponsored by Kelloggs, along with Coca Cola, PepsiCo, and SoyJoy: http://www.eatright.org/corporatesponsors/
It's just plain wrong and one of the many reasons I am no longer a member of that organization.
Happy to hear that your child's diabetes is well controlled on a wheat-free diet :)

Nan link

8/9/2013 08:28:21 am

Swedish doctor, Andreas Eenfeldt MD, has a current posting on this topic, with article from Today's Dietician: http://www.dietdoctor.com/todays-dietitian-very-positive-to-low-carb

8/9/2013 10:00:39 am

Thanks, Nan!

John link

8/12/2013 10:33:17 pm

I'm seeing more and more low carb sympathizing dietitians all the time, especially here in Canada. The tide hasn't turned, but we're getting there. Still quite a few staunch holdouts. My new endo supports my ketosis. I never thought I'd see the day an endocrinologist supporting it, especially for a type 1 diabetic. There is hope.

Now if we could only convince a diabetes educator, even one. Go Pepsi.

8/13/2013 04:23:05 pm

Hi John,

Thanks so much for your comments. I'm glad to hear that you're seeing increased acceptance of and support for carb restriction among dietitians. And of course having an endo on your side is fantastic.

I'm sure there are diabetes educators besides myself, Aglaee Jacob (who's in Canada), and Valerie Berkowitz who believe in a low-carb approach, but we're definitely outnumbered and our voices drowned out by the leading CDE proponents of the low-fat, high-carb method.

Dr John Faulks

8/15/2013 10:11:32 am

Very interesting read, great contributions all. I'd just like to make a couple of comments in response. Current Dietetic guidelines are based on the review process of thousands of RCT studies and assessed for scientific rigour and level of evidence weighted. Governments usually have a vested fiscal interest in keeping their populations healthy (though I accept can be strongly influenced by food industry), whereas books such as those listed above, are usually written for profit and should always be scrutinised with a critical eye. In my experience most dieticians advocate for a 'balanced approach' to eating, despite sterotypes to the contrary listed above. That is, one should not exclude food groups, or severely restrict any of macronutrient groups; it's about quality. I think more discussions should be based on the type of carbohydrate and glycaemic load, which we know has a huge impact on insulin response and other health parameters. My caveat is be wary of any overly restrictive approach, which can promote a range of problems around disordered eating. Moderation, variety and balance is always the key. Cheers, John

8/15/2013 05:17:42 pm

Hi John,

Thanks so much for sharing your comments. Unfortunately, there is not a lot of funding for studies on carbohydrate restriction, but in the RCTs that have been conducted, low-carb diets have proved to be at least as effective and often more effective than low-fat diets for weight loss and BG control. I think a lot of dietitians do not realize this or do not accept these findings.

I would argue that in many people, myself included, a balanced diet containing all of the food groups has not been as effective as carbohydrate restriction in terms of achieving adequate blood sugar control. I don't have diabetes (my fasting BG is consistently in the 80s), but after a mixed meal containing 50 grams of whole, low-GI carbs (oatmeal, fruit, brown rice, etc.), my blood sugar frequently increased to >200, a level universally regarded as unhealthy. In people with diabetes, this effect is more pronounced unless taking antihyperglycemic meds that often have adverse effects, including weight gain.

When I limit my carbs to less than 15 grams per meal, my blood sugars do not go over 130. I assure you that my diet is balanced and healthy. I obtain sufficient amounts of all micronutrients, feel terrific (and some say look much younger than my 46 years), and do not in any way feel deprived or overly restricted with this way of eating. In fact, I say with 100% honesty that I feel more satisfied on VLC than I ever have in the past.

I feel that people should be able to decide for themselves whether carb restriction is the approach they'd like to take for managing blood glucose and weight. Those that wish to follow the "Healthy Plate" or similar eating plan and take oral diabetes medications and/or insulin can continue to do so regardless of whether others choose a different path.

I thank you again for sharing your point of view here.

8/15/2013 06:30:12 pm

The first Australian Dietary Guidelines were published in 1980 and revised this year. The committee said they had reviewed 1000s of scientific articles before making their recommendations. This may give the impression that the science behind the guidelines is strong but it's not the case. The reason is that the notion that there is one way of eating or set of guidelines that will suit an entire population has never been established. Recommended nutrient intakes are quite well established but how to achieve these by suggesting we all follow a similar eating pattern is a different proposition. The recommendation for grain foods is a good example. For the last 10 years the Guidelines recommended 19 to 60 year old women have the equivalent of 8 to 18 slices of bread per day! This year it's recommended they have 4 to 6 serves instead. I know many women who cannot tolerate even this lower amount, yet achieve good health outcomes and nutritionally adequate diets on a much lower carb intake. Science already shows us that people metabolise foods differently. The one-size-fits-all mentality inherent in Dietary Guidelines is out-of-date, not supported by science and harmful to many.

8/15/2013 09:34:54 pm

Thanks so much for your excellent comments, Jennifer. Very much appreciate your experience and insight. Your last line sums it up very nicely.

R. Smith

8/28/2013 07:42:42 pm

Hi, Diabetes Dietitian from australia here. I notice no one has yet brought up the concern over long term high protein in terms of renal risk in diabetes. Any comments? If someone really is getting beautiful bgs, then maybe any renal risk is worth it. But I've seen people on low carb who are still having brittle control. I'm not anti-low carb though. I think the more tools in our toolkit the better when it comes to individualised care. Realistically though, I am still not convinced that it is a solution for the majority of people with diabetes. Simply because I know the majority of my patients would laugh at me if I asked them to follow strict low carb (I work in a low ses and highly multicultural population, where carb foods are often very important socially, culturally etc) But might be great for a minority. We should at least be giving people info so they can make an informed choice for themselves in these matters.

8/28/2013 09:02:53 pm

Hello, and thanks so much for your comments.In reality, low-carb diets shouldn't contain much more protein than a low-fat diet; a well-formulated LC diet is high in fat and moderate in protein. For people with diabetes who don't have renal disease, I don't feel it's necessary to limit protein. Obviously, someone with advanced nephropathy is another story.

I completely agree that many people may not want to restrict carbohydrates -- and this includes the majority of my own patients at the Veterans hospital -- but feel, as you do, that it should be presented as an option and encouraged given the large amount of research backing up its effectiveness for BG control.

Alan D link

9/8/2013 04:32:58 pm

It is interesting that doctors who themselves are diabetic endorse and promote low carb for blood glucose control. Dr Richard K Bernstein a Type 1 diabetic and inventor of some of the first self monitoring BG monitors has a fantastic book "the diabetes solution", teaching suffers how to normalise blood sugars.
Another, Dr J Wortman Type 2 sufferer cured his condition and has normal BG avoiding carbohydrates. Look for the YouTube video curing type 2 diabetes
Your concern about high protein is valid however this is avoided by replacing much of the carbs with good sources of fully saturated fatty acids. Namely full cream, real butter, ghee. It is great to see a dietitian participating in a low carb conversation. No doubt you may still be under the misconception that saturated fats are detrimental, rather than the fact they are an essential dietary requirement that has been unfairly deamonised and that cholesterol causes coronary heart disease.
Australia is a great country but many years behind Europe in many ways.
Whatever you think about diabetes and low carb i urge you to look up the Diabetic Doctors linked above.

Interestingly the Swedish Government medical review has officially endorsed Low Carb High Fat as a valid diet.

9/9/2013 08:16:02 pm

Not sure what you mean re Australia being "many years behind Europe"? I actually worked as a Diabetes Dietitian in the UK for a year and came back with precisely the opposite impression! But perhaps that was just the UK . . and admittedly it was 10 years ago. At the time, it was all "simple sugars are bad", "complex carbs are fine", which in Australia, we had dumped years before based on glycaemic index research (Australia definitely still the leader in GI research; USA and UK slowly coming around it appears, after years of skepticism).
Speaking of which . . I couldn't find anything much on this website about glycaemic index, but surely it is another piece of the metabolic control puzzle to consider? I've seen hundreds of BGs in my time, and the GI of the carbs eaten prior, definitely has an impact; with lower GI usually giving much better BGs than higher GI, especially in GDM and Type 2 DM. We do have an advantage in Australia in that a lot more of our foods - specific brands etc - have been tested for GI compared with other countries.
As I stated previously, I believe dietitians need multiple tools in our' 'toolkit'. Low carb may be one tool; but if people just can't/won't consider that level of restriction, low GI or some other tool might be better.
One thing I would be nervous about with low carb and Type 1 DM especially, are those who like the idea but end up applying it erratcially. Low carb some days, then 'breaking out' with lots of carbs other days. BG management nightmare! Perhaps that's why some of us are hesitant to promote it willy-nilly. We know human nature! Some personality types can be super-disciplined and follow a radical diets long-term, but most can't. Much better to find a plan that can be maintained consistently, day after day, even if it is somewhat higher in carb, than to trigger or excalate a restrain-binge-restrain-binge lifestyle.

9/16/2013 08:45:41 pm

Hi, nice to see another dietitian from Australia on this great site!

I'm interested in your comment about high protein and renal risk. This concern is often expressed but so far I haven't been able to find good refs supporting this connection. In fact, there was an extremely interesting case study reporting the reversal of kidney damage in a man with type 2 diabetes following a minimal carb diet

A low-carbohydrate diet may prevent end-stage renal failure in type 2 diabetes. A case report
Jørgen Vesti Nielsen1*, Per Westerlund1 and Per Bygren2

I read this a couple of years ago and was so excited by the results and implications that I wrote to one of the authors, who said that in his 40 years as a renal specialist he had never seen kidney damage of this extent reversed. It really challenges what we think eg that handling the excess load of waste products from protein metabolism will further stress damaged kidneys. But one theory of the cause of kidney impairment in type 2 diabetes is that high insulin levels have an inflammatory effect on the lining of blood vessels and as a result of this damage, protein leaks through into the urine. Perhaps the improvement in this man's insulin resistance on a lower carb diet was the key to his recovery.

I totally agree that the more tools in a dietitian's kit the better. And it's not just understanding the benefits of lower-carb diets for various conditions, but also the range of lower carb eating plans that can be tailored to an individual. A strict low-carb plan is only one option and not for everyone. I give every client with met syn/ IR information about how carbs are metabolised, features of IR etc and help them find an eating plan, generally lower carb, that suits their situation.

Nutrition & Metabolism 2006, 3:23 doi:10.1186/1743-7075-3-23

9/16/2013 10:03:18 pm

Always great to hear from you, Jennifer! Thanks so much for sharing that study supporting carb restriction in established renal disease, as well as your own experience working with T2 DM clients. Very much appreciate your contributions to this discussion :)

9/8/2013 03:30:11 pm

To answer your question is simple.
The American Dietetic Association who register Dietitians is funded by the worst of the Carb Dealers and manufacturers of fake food. Coke Cola, Kelloggs, General Mills, Unilver etc. They control what can be taught. Link here http://www.eatright.org/corporatesponsors/

9/8/2013 09:21:11 pm

Hi Alan,

Yes, you are absolutely right! Thanks so much for your comments, insights, and recommendations.

GrannyM

9/29/2013 12:30:16 am

It's very sad that so many hospitals rely on their RDs to provide meals for patients. I recently lost my BFF. We were both in the same boat, health wise, until 10-12 yrs ago. I started reading the science and changed the way I eat. My friend didn't want to give up the foods she loved and didn't read the evidence. My health improved, hers got worse.

During her last few months I had many opportunities to see what she was eating during her hospitalizations. One day I even called her order in to the dietician. I was informed that the carb number was too low and given some options all of which were sugar or starch. Her order was already all sugar & starch with a tiny amount of protein coming from a couple of cheese slices (Am. processed) and some cottage cheese. I asked the dietician why they were insisting on these and she said they followed the guidelines. Pudding was added to the order. I saw many of my friends food trays over the last few months and they were all mostly sugar & starch...so basically all sugar! I hope I never have to go to a hospital. I think they contributed to her death.

9/29/2013 02:42:58 am

Thanks very much for your sharing your experience and that of your best friend. I agree that the meals served in the hospital likely worsened her health. I'm very sorry for your loss.

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Why Are Many Dietitians So Critical of Low-Carbohydrate Diets?

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