Why I'm More Low Carb than Paleo/Primal/WAPF, etc.

Wurst und Käse Salat. Bring on the cheese!

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.

Dairy
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. 

Grains
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).

Sweeteners
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.


References
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 

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