![]() 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.
60 Comments
8/3/2013 12:00:50 am
Hi Brenna,
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Linda
8/2/2013 11:25:36 pm
Is there a way to subscribe to your blog so that we receive all new entries?
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8/3/2013 12:06:49 am
Hi Linda,
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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.
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8/3/2013 04:24:05 am
Thanks so much for your comments, Steve! Agree with them, particularly your last line.
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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.
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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.
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8/3/2013 01:38:38 am
Hi Franziska thanks for another great post.
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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.
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8/3/2013 03:26:29 am
Franziska
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8/3/2013 04:42:11 am
Thank you so much for your comments,Dr.Briffa. I agree.
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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.
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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.
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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.
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Victoria P
8/3/2013 11:51:04 am
Franziska, Diane Kress RD CDE is also another low carb dietitian.
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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!
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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! :)
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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) 8/3/2013 10:45:50 pm
From Dr.Jay Wortman's blog.
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8/3/2013 11:16:53 pm
Hi Eddie,
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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.
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8/4/2013 11:33:48 am
Hi Terry,
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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.
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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.
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8/4/2013 09:36:58 pm
Thanks for your comments and support, Sheila. Very encouraging to hear from other dietitians who understand this.
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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...
Gerri
8/4/2013 02:35:59 pm
Grateful for the trail blazers like you. Takes moxie to risk professional backlash.
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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.
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Lisa
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.
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8/4/2013 09:47:00 pm
Hi Lisa,
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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.
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8/4/2013 11:11:16 pm
Agreed, Tim. I'm feeling more encouraged than ever that the tide is turning.
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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?
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8/5/2013 01:48:28 pm
Hi Cahide,
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Cahide
8/9/2013 01:55:06 pm
Hi Franziska,
Lisa
8/8/2013 07:37:45 pm
I agree wholeheartedly with everything you say.
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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/
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.
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8/13/2013 04:23:05 pm
Hi John,
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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
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8/15/2013 05:17:42 pm
Hi John,
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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.
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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.
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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.
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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.
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R. Smith
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). 9/16/2013 08:45:41 pm
Hi, nice to see another dietitian from Australia on this great site!
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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 :)
To answer your question is simple.
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9/8/2013 09:21:11 pm
Hi Alan,
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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.
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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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marianne
11/23/2018 09:35:07 pm
Bonjour à tous ! Sorry for my very bad english ...
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