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CDE,MBA,RD
Type 2 Patients Avoiding ALL Carbs: Good or Bad?
Section:  Nutrition

Hi Everyone,

Many endocrinologists and my type 2 patients (non-insulin) have asked me through the years my opinion of these patients following a no carb/carb free diet in hopes of quickly lowering BG levels and reducing glucose toxicity.  This has been requested even if the patients are on oral agents, even sulfonylurea’s, which we all know can result in dangerously low BG levels. 

 

Some of my patients have tried this, despite my advice to the contrary, with and without reducing their oral agents……and to my surprise, have had good BG results, meaning BG levels in their target range.  I assume that those who did not experience low BG was due to the fact that their liver released its glucose via the counter-regulatory hormone glucagon.  But the hepatic glucose reserve is limited in the short term, right? Does the liver re-coup its glucose quickly enough to prevent low BG?  Or does the body then revert to gluconeogenesis (the synthesis of glucose from molecules that are not carbohydrates, such as amino and fatty acids) to keep the BG levels up and also re-fill the empty liver?

 

So my 3 questions to all of you (with hundreds of years of combined experience!) are:

 

1)     What is your experience with type 2 patients who are on a no carb/carb-free diet, with or without oral DM agents?

2)     Do you recommend, or agree with, these patients experimenting with this diet?

3)     Are your providers requesting this diet? 

 

Help!

 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

MEMBER COMMENTS
Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Interesting questions! I find that many of my clients tell me they're on a no-carb diet, but they're actually consuming more carbohydrate than they realize. Often they eliminate bread, potatoes, and any white foods. However, they still consume vegetables, both ones that are low in carbohdyrate and those with a higher carbohdyrate content. They often tell me they replaced white potatoes with sweet potatoes, not realizing that sweet potatoes contain carbohdyrate. Some still add sugar or sweetened creamers to their coffee, eat fruit, and snack on chips or pretzels.

Even those few folks who actually understand the breadth of foods that contain carbohdyrate, and have diligently decreased their intake of these foods, still consume some carbohdyrate, typically from lower carbohdyrate vegetables. I find the description 'no-carb' diet to be completely false in just about every instance.

I have three criteria I use when evaluating any diet:
1.  Does it contain a wide variety of nutrients to promote overall good health?
2.  Is it  helping this individual person reach their personal health goals?
3.  Does this person enjoy following this diet, and do they feel it's sustainable and realistic long-term?

I'm convinced there isn't one perfect diet that meets every individual person's needs. In my mind, that's a great thing, because it means I can help each client figure out the own eating plan, and teach them how to adapt this plan over time so it continues to fit their needs.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

I agree with Lynn's comment.  Most people simply don't realize they ARE eating carbs.  I also agree that if what they are doing is safe and meeting their individual needs then go for it.  
I find that many people are too restrictive on themselves.  I try to get across the idea that the individual should be able to consume a healthy, well balanced diet and if BGs are still out of control then medication is the answer.  I think it is a real problem when people have to restrict their intake to the point of malnutrition or starvation to achieve "good control".  I don't think that constitutes good control at all.  It is amazing what a small dose of insulin can do in those situations.
When my patients tell me they are on a 'no carb' diet I usually begin a discussion about foods, nutrients, and the body's need for them and they usually draw their own conclusions re: the need for carbs in the diet.
I think the general population thinks of carbs as bread, potatoes, rice, and potato chips.  They don't realize how many foods actually contain carbs.  

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Agree with all of your comments.  Have had a hypoglycemic pre-diabetic (Type 2) adult woman without medication.  Symptoms were relieved by going "no carb" by the endo, but very concerned she will be able to maintain this meal plan and what is she missing in nutrients. 

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?


This is a great topic, Maryann...and the responses so far are on target.

Having been a CDE  a very long time, I have seen the American Diabetes Association recommendations for carbohydrates change with some frequency. There is no doubt that the high carbohydrate amount recommended for so many years was extremely detrimental to people with type 2 diabetes. 

Here is a copy of one of the slides I used to use when teaching Medical Nutrition Therapy to health professionals:
American Diabetes Association dietary recommendations:
YEAR         CHO%     PROTEIN    FAT%

 pre 1921    ..................................................................starvation diets......

1921             20%          10%            70%

1950            40%           20%           40%

1971             45%           20%           35%

1986         50-60%       12-20%         30%

2007-2009*  Assess    15-20%      Assess*

The recommendation by the American Diabetes Association now is essentially assess what is realistic for the patient to actually follow.

 I try to urge patients to follow the South Beach Diet guidelines that encourage the use of low carbohydrate choices in foods.  I tell my patients the the pieces of the puzzle for what will achieve glycemic control are: exercise, diet, medications and stress management.  If they choose to continue a high percentage of carbohydrates, then the puzzle piece for medication will be larger.  In contrast, if less carbohydrates are consumed at one time, the medication piece of the puzzle will get smaller. If they use blood glucose monitoring before a meal and 2 hours after the start of a meal they will soon find out for themselves how much carbohydrate they can consume at one time to achieve glycemic control with their current regimen of exercise, medication, diet, etc. Individualization and ongoing support is the key to successful diabetes self-management as we all know for sure.

I do not encourage the no carbohydrate diet as I believe that some carbohydrates are needed to assure a healthy diet. If a patient insists on trying a no carbohydrate diet  to jump start weight loss , I encourage them to stay on it no more than 1 or 2 weeks...and drink lots of water.

 

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Thanks for sharing the slide you use to illustrate how carbohydate guidelines have changed over the years. I sometimes run into a situation where someone is exercising two or more hours per day in an attempt to control BG levels. That level of activity is of course fine for some people, but if they're turning into a gerbil on a wheel all in the name of BG control, it's time for an honest discussion about how exercise fits into an overall healthy, balanced life and the role of medication for BG control.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Pat and all,

Thank you for this discussion.  I had to laugh when I read Pat's commentary because having also been a diabetes educator for a LOOOOOOOOOOONG time, I've lived both personally and professionally, through the American Diabetes Association's dietary re-inventions many times over.  I do like the slide, though, Pat.

My concerns with people following a "no carb" diet, and I do by the way, realize it rarely is a truly no carb diet,  is that, then they are eating only protein and fat.  Obviously this poses some significant risks for people living with diabetes.  We know that the majority of people with diabetes will ultimately die from cardiovascular disease or stroke.  This increased protein and fat consumption will increase these cardiovascular risks, as well as increasing their risks for malnutrition without the nutrients from vegetables and fruits, and gastrointestinal issues with the fiber from fruits and vegetables.

We also know that as Americans, we already consume more protein than we need, and this is before anyone attempts a 'low carb' or 'no carb' diet.  These increased portions of protein are adding to the risks already imposed on the kidneys from long standing diabetes.

My recommendations to people living with diabetes are simply to eat sensibly.  Smaller portion sizes, and perhaps more frequent meals.  Consume more vegetables and fruits, and attempt to have their carbohydrates be more whole grains.  Eat brown, eat fruits with the peel, rather than those where the peel goes into the garbage.  Having a small amount of protein or fat whenever one is eating carbohydrate, does seem to slow the rise in blood glucose post meal, so this truly helps.  And unless they are lactose intolerant, we all need a minimum of two, or for women over 50, then three low fat dairy servings.

My final, and greatest, concern re the 'no carb' diet is that even people with Type 2 diabetes can, and do, go into ketoacidosis when they are otherwise compromised.  I just saw a 43 year old woman in the hospital this week, with Type 2 diabetes, and a new onset of a urinary track infection, who was on a "no carb" diet, who presented in DKA and was hospitalized in our medical intensive care unit for three days.  She was very acidotic and quite ill, and I can't help but feel that her "no carb-Atkins like" diet (she wanted to lose weight quickly for an upcoming wedding) contributed to the metabolic aberrations that set her up for DKA.  Certainly, her urinary track infection was the straw that broke the camel's back, BUT eating no carbs (she truly wasn't eating carbs at all) didn't help the situation.  I would never recommend this type of diet for a patient with Type 1 diabetes because of these inherent risks, and after this week, I'd be reluctant for giving any patient that this type of eating was safe for them.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

I too have had many patients tell me that they are on a no carb diet.  I encourage balance and work with clients to include whole grains, fresh fruits and vegetables in their diets though not all are receptive.  They are bombarded with messages that carbs are bad and have bought into this.  

Many of my patients however, who believe they are on a no carb diet do not realize that certain foods they eat do contain carbs.  What I also find, is that often what they are really doing is limiting carbohydrates at meals and not realizing that they are consuming carbs at snacks.  Unfortunately, the carbs that people generally select at snack times are not as healthy as ones that they would usually have at a meal.  

Carol


Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Hi Everyone,

I think we've opened a cans of worms here...meaning our frustrations with patients who have so many false ideas about the carbs they are truly eating...and all of our very different ways of approaching this self-care topic with our patients. Gee, I wonder if worms are low in carbs?? 

My own husband has T2 DM, and you'd think he'd know all about how to eat, right? Wrong! He just told me recently that he thought fruit contained NO carbs at all because it is so "light" and so low calorie (especially watermelon!).

I think that what is practical and do-able for patients with regard to carbs is telling them that they can find out themselves how many carbs they can eat and not exceed their 2 hr post meal BG goal by simply:  keeping a log of how many carbs eaten at meals (in handfuls, cups, exchanges, grams, choices, etc.) AND their 2 hr BG result on the same worksheet. 

After all, what they really want to know is "How many carbs can I eat and get away with it?"

Think about it...we do this in SO many areas of our lives:

1)  How much liquor can I drink at a party and still drive home sober?
2)  How late can I stay up and be coherent at work in the morning?
3)  How many calories can I eat and not gain weight?
4)  How fast can I drive and not get a ticket?
5)  How long can I sleep in and still be at work on time?


Pat,  I really like your "puzzle" analogy":  "I tell my patients the the pieces of the puzzle for what will achieve glycemic control are: exercise, diet, medications and stress management."

I came up with this:  BLOOD SUGAR CONTROL: THINK  "S.W.E.E.T.S":

S = Stress Control
W = Weight Control
E = Eating Control
E = Exercise
T = Taking Medication, If Needed
S = Self-Monitoring of Blood Sugar

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much



Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

I find this interesting as a patient.  I have followed a low carb diet for nearly six years, and for much of the time I have followed a very low carb diet.  I started this dietary approach after reading Richard Bernstein's book Diabetes Solution in 2005. Using this diet has enabled me to become lean and muscular, hardly a poster boy for malnutrition.  I have discussed low carb diets with many other diabetics, and there are large numbers who follow these diets in obvious conflict with the standard advice to eat a high carb diet.  And in my view, this conflict over low carb diets leads many diabetics to outright reject the advice of RDs and CDEs and that is a shame.

Personally, I know what carbs are in food and in general I would agree that while many people can tell you that there are carbs in bread and pasta, most are not as aware of the carb contents of other food.  And this extends to many diabetics and even those claiming to follow no carb diets. What is particularly strange to me is that dieticians and diabetes educators often are also quite naive about low carb diets, the response of human bodies to these diets and the basic research and science behind it.   I didn't learn the details about low carb diets from RDs and CDEs, I had to learn it on my own.  I was taught in my diabetes education classes that various foods were "free" and did not contain significant carbs, but in fact from a very low carb diet point of view, they are significant.

The most famous zero carb person was Owsley Stanley who only ate meat.  When I have done no carb, I have restricted to meat, seafood and pure fats and oils.  Even eggs contain carbs (0.5 g/egg).  It has been my experience (using metformin, actos, byetta, victoza and insulin) that low carb diets dramatically reduce post prandial blood sugar swings.  Those not using sulfonylureas or insulin will almost never have hypos as the normal countregulation will still function to maintain a normal fasting blood sugar by initiating gluconeogenesis.   It has also been my experience that with very low carb diets, dietary protein actually converts to blood sugar in significant enough quantities that it needs to be accounted for in bolus calculations.  I have not had a problem with low or very low carb diets using insulin as I adjust my dosing to account for the actual carb content of my meals.  Obviously, using a fixed sulfonylureas or fixed insulin dosing regime and making a change to a low carb diet is a problem. 

With a low carb diet, the body adapts to the use of ketone bodies for energy.  So much more of the energy comes from the burning of fat, this is what makes a diet ketogenic.  The body still regulates blood sugar, there is a store glycogen in the liver of about 150g and the liver can initiate conversion of lean body mass to generate blood sugar, but when you burn ketone bodies for energy, less energy is required from glucose and there is actually very little total glucose circulating in the blood.  People can go without food for 30 days and not die, and their blood sugar is fine.  Even when they do eventually die, it is not from a hypo.

I have met and interacted with many fellow diabetics who use low carb diets (both T1 and T2).  The application of a very low carb (steak and salad) diet to restore normal blood sugars is very common.   But increasing numbers are discovering that low carb diets enable dramatic improvements in post prandial excursions and for patients seeking tight blood sugar control limiting those excursions is the key to safely attaining aggressive goals.

Despite this, I continue to read advice suggesting that high carb diets lead to better outcomes and many diabetics feel that professional dietary advice is seriously wanting (read the comments).  And even in this forum, I still see claims that ketogenic diets cause DKA and that high protein diets cause kidney failure in people with normal kidneys.  These claims are just not true. 

Someday, I hope that low carb diets will be considered more objectively and appropriately as a dietary option for diabetics, but until then we will likely see ongoing conflict and "Carb Wars."

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Hi Brian,

You are very articulate and passionate in your blog....I found it a fascinating read, especially the pure science of ketogenic diets, protein conversion to BG, glucneogenesis, burning of ketone bodies for energy, etc. 

Can you share with me and the group alittle about your practice setting?  I'm a newbee, but started this particular blog topic.

Mary Ann Hodorowicz, RD, CDE, MBA, CEC

Re: Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?
Quote:

Hi Brian,

You are very articulate and passionate in your blog....I found it a fascinating read, especially the pure science of ketogenic diets, protein conversion to BG, glucneogenesis, burning of ketone bodies for energy, etc. 

Can you share with me and the group alittle about your practice setting?  I'm a newbee, but started this particular blog topic.

Mary Ann Hodorowicz, RD, CDE, MBA, CEC


Please understand.  I am a patient.  I am a well informed patient, but a patient nonetheless.

I found that a good resource with a description of the physiology and science behind low carb diets is in the new book "New Atkins for a New You" written by Drs. Westman, Phinney and Volek.  The best source for research on low carb diets (including very low carb diets) is the Nutrition and Metabolism Society (most journals have not been friendly towards low carb diets).  The leading researcher in this area is Dr Richard Feinman, Professor of Biochemistry at Downstate Med Center SUNY, he was the first scientist to conduct controlled trials of the Atkins diet.

I find you far from a newbie.  You are an RD and a CDE.  What alarms me is that I am a patient.  If I want professional medical advice concerning diabetes and nutrition, I should be coming to you with questions.

Re: Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?



I have met and interacted with many fellow diabetics who use low carb diets (both T1 and T2).  The application of a very low carb (steak and salad) diet to restore normal blood sugars is very common.   But increasing numbers are discovering that low carb diets enable dramatic improvements in post prandial excursions and for patients seeking tight blood sugar control limiting those excursions is the key to safely attaining aggressive goals.

Despite this, I continue to read advice suggesting that high carb diets lead to better outcomes and many diabetics feel that professional dietary advice is seriously wanting (read the comments).  And even in this forum, I still see claims that ketogenic diets cause DKA and that high protein diets cause kidney failure in people with normal kidneys.  These claims are just not true. 

Brian,
I understand your concerns.  This topic is about avoiding ALL carbs, not about low carb diets.  I understand diet, metabolism, and low carb diets and their possible benefits and I think all the other professionals on this blog do as well.  
We are not lacking basic knowledge of the topic nor disagreeing with you.  But we have a different view point.  Probably because we are coming at the topic from a different direction.  We are professionals and have been trained to look at diet and nutrition from a professional stand point.  I don't think there is a disagreement or misunderstanding here but different ways of looking at the same topic.  As professionals we have a responsibility to convey appropriate and safe diet information to the general population.  That is, to large groups of people with differing body types, conditions, problems, and concerns.  Low carb diets and especially no carb diets are not safe for everyone.  By the same token, I am not advocating a 'high carb diet' and I don't think anyone else here is either.  
Back in 2000 when Atkins was at its' most popular peak I had people in my diabetes education classes upset because I was telling them it was okay to eat fruits and vegetables.  I tried to explain to them that I am a professional and will not base my recommendations on what is popular.  Any 'diet' that recommends cutting out entire food groups is not safe for the general population.  
The instance above of the woman who was on a no carb diet and ended up in ICU for 3 days with ketoacidosis is a good case in point.  That is why we as professionals do not recommend these type of 'diets'-not only are they not safe for everyone but we have a responsibility to the people who look to us for advice to convey safe information.   
Again, no one is right or wrong here.  It is just two different ways of approaching the same topic.   

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

great summary, Brian. I agree with your findings.  Perhaps the recommendations for high carbohydrate percentages in the daily diet of people with type 2 diabetes is driven by drug companies.  If people ate less carbohydrates many would not need medication.....

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Donna
Thanks for your real life example.  

I find that the South Beach diet is the best recommendation for people who want to go low carb. It is a very good example of a diet that teaches good nutrition as well as steering people towards the low carbohydrate choices. What do you think

Regarding the range of diet recommendations from ADA over the years, it is rather humorous. I have often thought of putting together a comical booklet or slide presentation containing all of the ridiculous advice patients with diabetes have been given over the years.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

All -

Interesting discussion and dialogue. A couple of thoughts:

 

1) The current recommendations from American Diabetes Association (and remember the nutrition recommendations were updated last in 2008 yet I hear new ones are likely in 2012/13?) suggest individualizing the amount of carbohydrate within a range of carbohydrate within the Institute of Medicine 2002 Dietary Reference Intakes of 45 - 65% of calories - a moderate (in case there's any room for moderation!!). This range is reiterated in the more recently released Dietary Guidelines for Americans. Reality is people simply can't eat healthfully if they don't get at least 45% of calories as carbohydrate - that's fruits, veggies, starches, whole grains, low fat dairy.

 

2) We've GOT to encourage people with diabetes to balance both glycemic control and health (that is healthy eating). The two aren't mutually exclusive and one isn't a higher priority than the other. They are both important. I understand how and why healthy eating sometimes seem to fly in the face of logic when it comes to glycemic control. People become simplistic as well with this logic....if carbohydrate from food raises BG then restrict carbohydrate. Unfortunately that really doesn't mesh with what today we know about healthy eating, the pathophysiology of type 2 or the progressive disease process of type 2. In addition it doesn't mesh with current recommended medication treatment algorithms from ADbA or AACE.

 

Marion Franz and I just presented at AADE Battle Zone Carbohydrate: Applying Research Evidence  to Answer Complex Questions. In addition I've written a number of NutriZines on this topic. Most recently you can find Carbohydate and Diabetes: The Debate Continues

Let's make sure we let science drive our clinical advice vs. diet books like South Beach or self-proclaimed physicians like Richard Bernstein, MD who has never published a research study (that I know of) testing and documenting his low-carb hypotheses re: glycemic control.

 

Thanks for the terrific dialogue on this hot topic,

Hope

 

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

I was fortunate to be able to attend Hope and Marion's lecture at AADE and it was excellent and informative.  They presented a wealth of studies supporting the recommendations of including carbohydrate (and high fiber) in the diet.  There may be testimonials from people who believe they do well on "no carb" diet, but the scientific evidence supports including carbohydrate in the diet.

Carol

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

There is an active community of diabetics that outright rejects the USDA and ADtA recommendations on a high carb low fat (HCLF) diet.  And repeating and repeating the message does not go over very well.

Patients who follow a low carb diet not surprisingly tend to see less glucose excursions and some (actually many) of them have great success managing their blood sugars.  And "surprise" many also end up finding their cholesterol numbers magically turn up better.  This is contrary to the HCLF claims.  How exactly does repeating the HCLF mantra help?  Not at all.

If you want to serve these patients, then you should work to become well informed about low carb diets.  Read the "New Atkins for You."  Watch the video from Prof Gardner on his trial of diets. Read the literature in the Nutrition and Metabolish Journal.   The ADA now supposedly advocates an individualized diet (and the ADA also recognizes low carb as a weight loss diet for diabetics).  Learn about low carb diets and give your patients the informed advice that they need.  If they choose low carb, they need your help.

You may not agree with the choice of a low carb diet, but deliberately remaining uninformed about the choice is not doing your patients a service.

Re: Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?
Quote:

I was fortunate to be able to attend Hope and Marion's lecture at AADE and it was excellent and informative.  They presented a wealth of studies supporting the recommendations of including carbohydrate (and high fiber) in the diet.  There may be testimonials from people who believe they do well on "no carb" diet, but the scientific evidence supports including carbohydrate in the diet.

Carol


I agree Carol.  I loved the session.  I especially liked the review of the literature outlining all the research on the different approaches to healthy eating.  I think it is clear from the research that healthy eating including all the foods available to us from nature-vegs, fruits, grains, low fat dairy-as appropriate and supportive of healthy outcomes.  No flashy diet there!  Just good, sound advice that we have been advocating for years!  I think it is important to note that the research shows definitively that it is not so much the composition of our 'diet' as it is how much we eat that makes the difference.  Over and over the literature shows that total calories made the difference more than composition.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Brian -

I've just got to respond. As you know you are dialoging mainly with diabetes educators - some nurses and some registered dietitians. I think Micki Hall hit the nail on the head (thanks Micki!). As HCPs we continually search and read the ever evolving evidence to support our recommendations. We keep our ears to the news of new research and observe how it fits in to the existing database. Today there are excellent resources that help us seek and find answers.

 

I'm no exception. When it comes to this low carb discussion I continue to be amazed at the limited and simplistic view of the research about carbohydrate intake among people who believe in using a low carb intake and can't understand why USDA, ADbA and other leading health authorities don't promote "low carb" for weight management, glycemic control, lipid and blood pressure control, etc. I remember hearing the question: Why aren't low carb diets promoted?" asked at the HHS/USDA unveiling of the myplate.gov and the Dietary Guidelines 2010. Response from Dr. Robert Post (USDA staff person in charge, supporting Vilsack) - b/c there isn't research to support this (the DG advisory committee looked at weight loss and not glycemic control.)

 

When one practices good science and views the scientific database in total and factors in the way people generally eat and will eat b/c we are creatures of habit when it comes to food choices, the recommendation for moderate carbohydrate consumption is quite logical....and research based. I've again had the opportunity to look at this database in preparation for the AADE program I provided with my colleague Marion Franz. In addition I've been writing a chapter for a book for HCPs and have again reviewed this literature.

 

You mention Professor Gardner. Are you referring to a study he did which is captured in the American Diabetes Association's Nutrition Interventions and Recommendation (2008) as follows: Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months consuming low-carbohydrate vs. higher carbohydrate. At 1 year however, the differences were not significant and weight loss was modest with both diets (Gardner 2007). (I like to remind people that people with diabetes have it for a very long time and need to find a way of eating that works long term in their life.)

 

You also mention an Atkins diet book. Others mention Dr. Richard Bernstein and the South Beach Diet. These physicians have written consumer books but have not ANY published evidence-based research. If there is some, please share.

 

Reality is people with diabetes need to balance glycemic control and healthy eating. No doubt that's a challenge. It is logical, yet simplistic, to limit carbohydrate to achieve glycemic control in lieu of considering all we know about healthy eating (again thank you Micki for your post). This includes volumes of research promoting a moderate carbohydrate intake (45- 65% of calories) that contains quality sources of carbohydrate - whole grains, legumes, low fat dairy foods, fruits, and vegetables. And also helps prevent type 2.

 

I'd really like us to get off of this how much carbohydrate debate and focus squarely on helping people (who are, dietary surveys show) eating about 45 - 52% of their calories as carbohydrate to choose healthier sources of carbohydrate. That's what they're not doing.....with an average of 22 tsp of added sugars/day and not nearly enough of the aforementioned foods. Let's focus on quality vs. quantity!

 

Thanks, 

Hope Warshaw, MMSc, RD, CDE

Nutrition Section Editor, PRESENTdiabetes.com

 

 

 

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Thanks for the reminder about focusing on the quality of the carbohydrate intake, Hope. I routinely talk with folks with diabetes and tell them that I have two goals:  one is that they learn how food affects their blood sugar levels, and how to manipulate their food choices to help them achieve better bloog glucose control; and the second is that I want them to learn how to choose an overall healthy diet that is realistic and sustainable for them. People routinely tell me that their spouse 'can't' eat the same foods they do, because their spouse doesn't have diabetes. This is a great opportunity to let everyone know that healthy eating is for everyone - not just for someone with diabetes, or heart disease. etc. I get a similar response when one spouse is overweight and the other isn't; they believe that they should be eating vastly different types of foods. Another great opportunity to talk about appropriate portion sizes!

I bet this is something we all do, and it's simply gotten lost in the discussion about grams of CHO per day.

Re: Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?
Quote:

Brian -

I've just got to respond. As you know you are dialoging mainly with diabetes educators - some nurses and some registered dietitians. I think Micki Hall hit the nail on the head (thanks Micki!). As HCPs we continually search and read the ever evolving evidence to support our recommendations. We keep our ears to the news of new research and observe how it fits in to the existing database. Today there are excellent resources that help us seek and find answers.

 

I'm no exception. When it comes to this low carb discussion I continue to be amazed at the limited and simplistic view of the research about carbohydrate intake among people who believe in using a low carb intake and can't understand why USDA, ADbA and other leading health authorities don't promote "low carb" for weight management, glycemic control, lipid and blood pressure control, etc. I remember hearing the question: Why aren't low carb diets promoted?" asked at the HHS/USDA unveiling of the myplate.gov and the Dietary Guidelines 2010. Response from Dr. Robert Post (USDA staff person in charge, supporting Vilsack) - b/c there isn't research to support this (the DG advisory committee looked at weight loss and not glycemic control.)

 

When one practices good science and views the scientific database in total and factors in the way people generally eat and will eat b/c we are creatures of habit when it comes to food choices, the recommendation for moderate carbohydrate consumption is quite logical....and research based. I've again had the opportunity to look at this database in preparation for the AADE program I provided with my colleague Marion Franz. In addition I've been writing a chapter for a book for HCPs and have again reviewed this literature.

 

You mention Professor Gardner. Are you referring to a study he did which is captured in the American Diabetes Association's Nutrition Interventions and Recommendation (2008) as follows: Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months consuming low-carbohydrate vs. higher carbohydrate. At 1 year however, the differences were not significant and weight loss was modest with both diets (Gardner 2007). (I like to remind people that people with diabetes have it for a very long time and need to find a way of eating that works long term in their life.)

 

You also mention an Atkins diet book. Others mention Dr. Richard Bernstein and the South Beach Diet. These physicians have written consumer books but have not ANY published evidence-based research. If there is some, please share.

 

Reality is people with diabetes need to balance glycemic control and healthy eating. No doubt that's a challenge. It is logical, yet simplistic, to limit carbohydrate to achieve glycemic control in lieu of considering all we know about healthy eating (again thank you Micki for your post). This includes volumes of research promoting a moderate carbohydrate intake (45- 65% of calories) that contains quality sources of carbohydrate - whole grains, legumes, low fat dairy foods, fruits, and vegetables. And also helps prevent type 2.

 

I'd really like us to get off of this how much carbohydrate debate and focus squarely on helping people (who are, dietary surveys show) eating about 45 - 52% of their calories as carbohydrate to choose healthier sources of carbohydrate. That's what they're not doing.....with an average of 22 tsp of added sugars/day and not nearly enough of the aforementioned foods. Let's focus on quality vs. quantity!

 

Thanks, 

Hope Warshaw, MMSc, RD, CDE

Nutrition Section Editor, PRESENTdiabetes.com 

 


I have seen respected scientists and practioners discuss these matters with you over the years.  It is obvious to me that in your heart you believe that a high carb is the only appropriate diet for diabetics and that you believe everyone else is simply wrong.   I will leave it to others such as Dr. Richard Feinman to debate the evidence with you.  Your logic and statements tell me that you will never change your views.  And I really don't care to change your views.  What I would hope is that we might move beyond a fundamentalist view of the topic.  Good science is about being open and objective in examining alternatives.  It is time to stop denying that there have never been studies.  It is time to stop denying that there are numbers of scientists, medical practitioners and even dieticians who all beleive that low carb diets are a safe, effective diets and useful diets for managing diabetes. Patients deserve better.

In the meantime, I will continue to listen to my endocrinologist who strongly advocates a low carb diet and I will continue to sulk that no dietician can help me because of these attitudes.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Brian -

I've asked and remain ready and willing to read ANY research (that means randomized control trials in people with type 1 or type 2 diabetes of at least one year duration) that shows the effectiveness of consuming a low carb intake (which for the purposes of discussion we can call <40% of calories, though I know some low carbers profess lower is better).

 

By effectiveness I mean:

1) people can adhere long term to this type of intake,

2) people are able to lose more weight (and keep it off) and/or achieve glycemic control,

3) people can eat healthfully

 

I'm not aware of studies that meet the above criteria but I'd be delighted to read them if you have them.

 

Data from the NIH sponsored DCCT trial in the study referred to in this NutriZine shows a significantly lower A1c with more moderate carbohydrate intakes vs. lower carbohydrate intake. Additionally this NutriZine disucss the results of another 2 year weight loss study (in people who were overwt/obese and not necessarily with diabetes but some did have prediabetes/type 2) using a variety of carbohydrate levels from low of 35% to higher of 65% with commensurate changes in the other macronutrients. I capture the key results of the study in this ezine as well. Bottomline - no difference in weight loss and people graviated to eating b/w 43-53% of calories as carbohydrate: http://www.presentdiabetes.com/ezines/?pub_year=2009&section_id=13#ezine256

 

And just for the record, I support a carbohydrate intake that is healthy and that people can follow long term that also support glycemic, lipid and blood pressure control. To me this is a moderate carb intake 45 - 65%.

 

Hope Warshaw, MMSc, RD, CDE

Nutriiton Section Editor, PRESENTdiabetes.com

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

First, as a patient actively involved with the DOC (Diabetes Online Community), I know of NO ONE that advocates total avoidance of carbs. There is a huge difference between no-carb (which, if I remember correctly, killed several people in the 70's), and low-carb, which has so many different interpretations as to be a meaningless term. While Dr. Richard K. Bernstein advocates 30g of carbs a day, I'm getting fantastic results on 60 - 75g a day, and have an obese, non-diabetic friend who has had significant weight loss by limiting to under 100g per day.

 

I attended 2 fantastic presentations at AADE in Las Vegas: 1) Food, Fat and Satiety, by Christine Kessler, and 2) Fructose and CVD: A Not So Sweet Connection, by Cindy Brinn. Both of them concentrated on the fact that sugar (and by extension, in Kessler's talk, carbs) in excess are not good for anyone because they do not cause satiety, but rather a desire to eat more in a short time, and even when they are 100% glucose, they can be converted into fructose, which gets processed by the liver into fatty acids, triglycerides and VLDL.

 

So, as an insulin-user, I personally have decided to get my carbs from vegetables and milk, with occasional small servings of fruit, but to avoid the carb-heavy grains, potatoes, rice, pasta, cereal, corn and peas. The benefit I have found, after a year, is that I no longer crave carbs (except when I am depressed -- carbs stimulate dopamine production in the brain, which stimulates the pleasure center -- a "feel-good" response), I had the best lipid panel ever, including a normal VLDL for the first time, I have lost 30 lb., bringing me into normal weight range, I have eliminated the BG spikes caused by carb-heavy meals while having far fewer lows, and while losing weight, my fat has redistributed into subcutaneous fat, which means that the dangerous visceral fat must surely have decreased. And I am having no problem maintaining the eating plan.

 

I know one swallow does not make a summer (although there are hundreds and hundreds of anecdotes, if you look for them), but I am really hoping these kinds of stories spur research into truly low-carb diets, not 150g a day diets that look like low-carb to people who think 300g of carbs a day is OK, but are really NOT low-carb at all.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

I understand what you're saying, but if I ate 45-65% of my calories from carbs, EVEN whole grains and low-fat milk, I would gain weight, my lipid readings would get worse, I would need to use more insulin, and still would see BG spikes. 

 

I know that because I used to eat that way. I was never obese, but my weight settled at 150-155lb, which was BMI 27-27.5. I needed 35-45u on insulin a day, and if you poked my belly, it was hard as a rock, which means that all my fat was visceral. And I was happy if I could stay below 230 or so after meals.

 

I've been limiting carbs to vegetables and occasional small servings of fruit, whole milk and low-carb lavash bread, while increasing nuts, eggs, cheese and meat, including fish and poultry. The results after a year have been a 30 lb. weight loss, bringing me into normal BMI, the best lipid panel ever, including a first-time ever normal VLDL, much smoother BG results (usually between 70 - 140, in accord with AACE guidelines) with far fewer highs and lows, and my insulin dose is down to 25-30u a day. And I'm never hungry, except when it is time to eat. And I don't crave carbs or sweets, and I'm perfectly happy maintaining this style of eating.

 

I know that, as a professional, you need to rely on studies, not anecdotes (although there are many hundreds of them out there), but I have yet to become aware of a study which deals with truly low-carb diets -- when a study claims to be studying low-carb, but allows 150 or more grams of carb a day, it's not studying what it claims to. The word "low-carb" does not yet have a true definition, which further muddies the issue. 

 

So, I would like to see some studies on truly low-carb diets, which include vegetables for their phytonutrients, and which are sufficiently long-term to show the actual benefits. I think there is yet a lot to be learned about nutrition, and I trust that you are doing the best you know how, but all the results aren't in yet.

 

 

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

It was an eye-opener to read Gary Taubes' Good Calories, Bad Calories. Most of the studies that concluded that low-fat, high-carb diets were good, especially Ancel Keyes' studies were both cherry-picked, and politicized, and if viewed critically, could have gone either way. The reason is that you can't study just one nutrient at a time, and you have to consider ALL the evidence. As Christine Kessler said in her presentation at AADE, you can find directly conflicting information at every turn -- on traditional diets, the Inuit ate meat almost exclusively (their only source of carbs was when they could find berries in the summer, and berries are low-carb, too), and the French and Germans ate a lot of fat and alcohol, yet had a much lower or even almost non-existent incidence of heart disease, obesity, cancer and diabetes than we Americans who are trying so hard to eat low-fat. Is it just a coincidence that diabetes, obesity and heart disease started to show rises at the very same time as we started trying to go low-fat? Yes, the sugary sodas definitely contribute to obesity -- but people have to eat something, and if they're so drastically limiting fat, what else is there to eat but sugars and carbs, which change into glucose in the body anyway. Excess glucose is GOING to get converted to fat, because the body can only use so much energy. Even more disturbing is that excess glucose gets turned into fructose, which then converts into triglycerides and fatty acids.

 

As I said in another post, the field of nutrition science needs to open up to more studies about truly low-carb (but NOT NO-carb) diets.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Yes, there is a lot yet to be learned nutritionally.  But until it is learned, I will base my recommendations on what we do know.  That is, what has been scientifically proven.  
I am not convinced that the reason diabetes, obesity, and heart disease started to show a rise is due to Americans trying to eat low fat and therefore high carb.  The majority of the patients I see are not trying to eat low fat.  They are eating what is prevalent, cheap, and available and that is high fat, high calorie foods.  I don't see everyone running around trying to cut their fat intake.  I think that type of conclusion is convenient to nod our heads at and say yep, that must be it because it seems logical.  But it is not scientific, it is anecdotal.  I will not base what I recommend on anecdotal evidence.  No matter how logical it seems.  
Thanks for your input to the discussion.  I enjoy reading success stories.  I am planning to learn more about fructose and cardiovascular disease.  I missed that topic at AADE but have printed off the notes.  I sometimes have patients with a normal cholesterol level and elevated triglycerides.  I want to learn more about specific recommendations for them.  

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?


Hi Natalie!

In your August 19th'2011 post from 11:57 am you stated that "excess glucose is going to convert to fat....even more disturbing is that excess glucose gets converted into fructose, which then converts into tryglycerides and fatty acids" .
Well, American Heart Association supports your claim. Please read the following post of mine
 http://www.presentdiabetes.com/etalk/index.php?topicid=4351#-1 and pay close attention to the sources. A recommendation was made(for the first time ever!) to limit fructose from naturally occuring foods,-fruits in particular .

Fatty Liver Disease is an independent precursor for the development of Type 2DM.   .therefore there is a tremendous push to get Trigs to 100 or below. A lower-carb diet is the approved treatment of choice for FLD in the US..Source:
http://www.sciencedaily.com/releases/2011/02/110224091613.htm
Thank you. Isabella Wiznitzer, RN/CDE

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

OK, I'm going to add to the debate here. I started this blog originally and am awe-struck at ALL the posts and passions! 

Below is a copy and paste from the Standards of Medical Care in Diabetes, 2011, published by the American Diabetes Association (evidenced-based recommendations):

The optimal macronutrient distribution of weight loss diets has not been established. Although low-fat diets have traditionally been promoted for weight loss, several randomized controlled trials found that subjects on low-carbohydrate diets (<130 g/day of carbohydrate) lost more weight at 6 months than subjects on low-fat diets (
136,137); however, at 1 year, the difference in weight loss between the low-carbohydrate and low-fat diets was not significant, and weight loss was modest with both diets. A study comparing low-fat to low-carbohydrate diets, both combined with a comprehensive lifestyle program, showed the same amount of weight loss (7%) at 2 years in both groups (138). Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months with the Atkins low-carbohydrate diet than with higher-carbohydrate diets (139). Changes in serum triglyceride and HDL cholesterol were more favorable with the low-carbohydrate diets. In one study, those subjects with type 2 diabetes demonstrated a greater decrease in A1C with a low-carbohydrate diet than with a low-fat diet (137). A recent meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets (140). In a 2-year dietary intervention study, Mediterranean and low-carbohydrate diets were found to be effective and safe alternatives to a low-fat diet for weight reduction in moderately obese participants (141)

The RDA for digestible carbohydrate is 130 g/day and is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested protein or fat. Although brain fuel needs can be met on lower-carbohydrate diets, long term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability (
142).

Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile, renal function) and/or food preferences. Plant-based diets (vegan or vegetarian) that are well planned and nutritionally adequate have also been shown to improve metabolic control (143,144).

The primary goal with respect to dietary fat in individuals with diabetes is to limit saturated fatty acids, trans fatty acids, and cholesterol intake so as to reduce risk for CVD. Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. There is a lack of evidence on the effects of specific fatty acids on people with diabetes, so the recommended goals are consistent with those for individuals with CVD (125,145).

I’m sure this is also going to “stir the pot” a bit more, and I look forward to it!

 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much



Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

Thanks for the quote, Mary Ann! One thing I noticed: when it said that low-carb diets increased LDL, they didn't mention particle size, and from what I have been reading, that makes a difference. Another issue is that the body CAN convert as much as 58% of protein to glucose (I have read different figures in different places), and if so, then all the brain's glucose needs do NOT have to be met with carbohydrates. Dr. Richard K. Bernstein has been practicing extremely low-carb (30g a day) for over 40 years, is in his mid-70's and is still practicing -- obviously his brain is still receiving enough fuel.

 

The amount of carbs that you described as a low-carb diet may not be representative of a truly low-carb diet, and the results may therefore not truly represent what a low-carb diet can do. I guess the first priority would be to define the term.

 

Seems to me there's still a lot of research to be done before reaching a valid conclusion!

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

.....So, in the meantime, if our patients are preferring a "low carb" plan, are getting a balance of food groups albeit not in the percentages formally suggested, and are finding their A1C's and lipid panels are improving, their weight is dropping appropriately, and they are happy,  I suggest we consider accepting that as what works for them!  I'm all for being reasonable and I don't feel strongly that people have to follow a highly prescriptive "scientific" percentage to be healthy.  We have all types of body builds that are genetic and seem to respond differently to different diets.  Humans have had differing cultures and diets since the beginning of time.  I have respect for that fact and as long as we get healthy numbers in the end I think that tells us what is working!  Science is helpful but often doesn't have all the facts.  We need to use it judiciously.  

Re: Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?
Quote:

.....So, in the meantime, if our patients are preferring a "low carb" plan, are getting a balance of food groups albeit not in the percentages formally suggested, and are finding their A1C's and lipid panels are improving, their weight is dropping appropriately, and they are happy,  I suggest we consider accepting that as what works for them!  I'm all for being reasonable and I don't feel strongly that people have to follow a highly prescriptive "scientific" percentage to be healthy.  We have all types of body builds that are genetic and seem to respond differently to different diets.  Humans have had differing cultures and diets since the beginning of time.  I have respect for that fact and as long as we get healthy numbers in the end I think that tells us what is working!  Science is helpful but often doesn't have all the facts.  We need to use it judiciously.  


Hi Sonia
I agree completely with your philosophy as stated so eloquently in the above quote.

Re: Type 2 Patients Avoiding ALL Carbs: Good or Bad?

I also agree with Sonia and Pat 100%...

Every pt's BS's and A1c's will respond differently to the SAME meal plan, due to differences in body wt, medications, muscle vs. fat mass, stress, physical activity, etc. 

I had mentioned early on in this blog that I tell my patients very simply:  "Let's experiment with your carb intake....why not keep a log of how much you are eating, along with your pre and post-meal BS test results, and then you'll know how much is right for you."  Jokingly I may also say "Let's see how many carbs you can get away with...".....meaning how much can you eat at each meal routinely and still meet your post-meal goal. 

This is JUST like many other areas in real life: how much can I drink and drive home sober; how late can I stay up and be coherent the next morning for work...the list goes on and on.  This is the reality of life....scientific percentages are only a starting point for the HCP; when it comes to the pt's own life, the pt has to do the experiment and take ownership for the results!

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much