Category Archives: Diabetic Diet

T1 Shelby Hughes Is Thriving on the Paleo Diet

Dietitian Kelly Schmidt posted an interview with Shelby at her blog. Shelby seems to tolerate a fair amount of carbohydrate (fruit and starchy vegetables) although I don’t know how much insulin she’s taking to process them. Her case of diabetes is a little unusual since she wasn’t diagnosed until age 39. I wonder if she has some residual beta cell insulin production.

Another thing I like about this story is that it illustrates that a paleo diet doesn’t have to be based on meat.

Read the rest.

My Critique of the Joslin Critique of the Paleo Diet

paleo diet, Paleolithic diet, hunter-gatherer diet

Huaorani hunter in Ecuador

The Joslin Diabetes Blog yesterday reviewed the paleo diet as applied to both diabetes and the general public.  They weren’t very favorably impressed with it.  But in view of Joslin’s great reputation, we need to give serious consideration to their ideas.  (I don’t know who wrote the review other than “Joslin Communications.”)

These are the main criticisms:

  • diets omitting grains and dairy are deficient in calcium and possibly B vitamins
  • you could eat too much total and saturated fat, leading to insulin resistance (whether type 1 or 2 diabetes) and heart disease
  • it’s not very practical, partly because it goes against the grain of modern Western cultures
  • it may be expensive (citing the cost of meat, and I’d mention fresh fruit and vegetables, too)

Their conclusion:

There are certainly better diets out there, but if you are going to follow this one, do yourself a favor, take a calcium supplement and meet with a registered dietitian who is also a certified diabetes educator  to make sure it is nutritionally complete, isn’t raising your lipids and doesn’t cause you any low blood glucose incidences.

Expense and Practicality

These take a back seat to the health issues in my view.  Diabetes itself is expensive and impractical.  Expense and practicality are highly variable, idiosyncratic matters to be pondered and decided by the individual.  If there are real health benefits to the paleo diet, many folks will find work-arounds for any expense and impracticality.  If the paleo diet  allows use of fewer drugs and helps avoid medical complications, you save money in health care costs that you can put into food.  Not to mention quality of life issues (but I just did).

Calcium and B Vitamin Deficiencies

This is the first I’ve heard of possible B vitamin deficiencies on the paleo diet.  Perhaps I’m not as well-read as I thought.  I’ll keep my eyes open for confirmation.

The potential calcium deficiency, I’ve heard of before.  I’m still open-minded on it.  I am starting to wonder if we need as much dietary calcium as the experts tell us.  The main question is whether inadequate calcium intake causes osteoporosis, the bone-thinning condition linked to broken hips and wrists in old ladies.  This is a major problem for Western societies.  Nature hasn’t exerted much selection pressure against osteoporosis because we don’t see most of the fractures until after age 70.  I wouldn’t be surprised if we eventually find that life-long exercise and adequate vitamin D levels are much more important that calcium consumption.

With regards to calcium supplementation, you’ll find several recent scientific references questioning it.  For example, see this, and this, and this, and this, and this.  If you bother to click through and read the articles, you may well conclude there’s no good evidence for calcium supplementation for the general population.  If you’re not going to supplement, would high intake from foods be even more important?  Maybe so, maybe not.  I’m don’t know.

If you check, most of the professional osteoporosis organizations are going to recommend calcium supplements for postmenopausal women, unless dietary calcium intake is fairly high.

If I were a women wanting to avoid osteoporosis, I’d do regular life-long exercise that stressed my bones (weight-bearing and resistance training) and be sure I had adequate vitamin D levels.  And men, you’re not immune to osteoporosis, just less likely to suffer from it.

Insulin Resistance

Insulin resistance from a relatively high-fat diet is theoretically possible.  In reality, it’s not common.  I’ve read plenty of low-carb high-fat diet research reports in people with type 2 diabetes.  Insulin levels and blood glucose levels go down, on average.  That’s not what you’d see with new insulin resistance.  One caveat, however, is that these are nearly all short-term studies, 6-12 weeks long.

If you have diabetes and develop insulin resistance on a high-fat diet, you will see higher blood sugar levels and the need for higher insulin drug doses.  Watch for that if you try the paleo diet.

Are High Total and Saturated Fat Bad?

Regarding relatively high consumption of total and saturated fat as a cause of heart or other vascular disease: I don’t believe that any more.  Click to see why.  If you worry about that issue, choose meats that are leaner (lower in fat) and eat smaller portions.  You could also look at your protein foods—beef, chicken, fish, eggs, offal, etc.—and choose items lower in total and saturated fat.  Consult a dietitian or online resource.  Protein deficiency is rarely, if ever, a problem on paleo diets.

In Conclusion

I think the paleo diet has more healthful potential than realized by the Joslin blogger(s).  I’m sure they’d agree we need more clinical studies of it, involving both type 1 and 2 diabetics.  I appreciate the “heads up” regarding potential vitamin B deficiencies.  My sense is that the Joslin folks are willing to reassess their position based on scientific studies.

I bet some of our paleo-friendly registered dietitians have addressed the potential adverse health issues of the paleo diet.  Try Amy KubalFranziska Spritzler (more low-carb than paleo) or Aglaée Jacob.  I assume the leading paleo diet book authors have done it also.

If you’re worried about adverse blood lipid changes on the paleo diet, get them tested before you start, then after two months of dieting.

Steve Parker, M.D.

PS: The paleo diet is also referred to as the Stone Age diet, caveman diet, Paleolithic diet, hunter-gatherer diet, and ancestral diet.

Do Tomatoes Have Too Many Carbohydrates?

Eat greens for vitamin K

Looks reasonable to me

Dr. Richard Bernstein wrote a great book advocating strict carbohydrate restriction for folks with diabetes.  I’m talking about a max of 30 grams a day, compared to 250–300 g in the standard American diet.

Dr. Bernstein cautions his diabetic patients and readers of Diabetes Solution to keep a tight lid on consumption of tomatoes.  An excerpt from page 149:

If you have them uncooked in salad, limit yourself to one slice or a single cherry tomato per cup of salad.

His concern is that tomatoes will raise your blood sugar too high.

That doesn’t make sense to me.  A 3-inch diameter tomato has 7 grams of carbohydrate, 2 of which are fiber.  So the digestible carb count is only 5 grams.  That’s not much.  So do tomatoes have a high glycemic index?  Unlikely, although it’s hard to be sure.  Good luck finding a reliable GI for tomatoes on the Internet.

I think Dr. Bernstein’s wrong about this one, which is rare.  I suppose it’s possible that tomatoes deliver some other substance to the bloodstream that interferes with carbohydrate metabolism, but Dr. Bernstein doesn’t mention that.

Do tomatoes play havoc with your blood sugars?

Steve Parker, M.D.

Ideas For A Paleo Diabetic Diet

Sirloin steak, salad, cantaloupe, 3 raspberries

Sirloin steak, salad, cantaloupe, 3 raspberries

I’ve been thinking about a paleo-style diabetic diet for over a year.  Here are some miscellaneous ideas for your consideration.

A paleo diabetic diet will have the following major food groups:

  • vegetables
  • fruits
  • nuts and seeds
  • proteins (e.g., meat, fish, eggs)
  • condiments

A paleo diabetic diet could (should?) emphasize salads and low-carb colorful vegetables and only (?) low-carb or low-glycemic-index fruits.


Total calories?  Probably in the range of 1,800 to 3,000 calories daily with an average of 2,000.  Remember that 85% of type 2 diabetics are overweight or obese. Calorie restriction—regardless of macronutrient ratios (% carb, protein, fat)—tends to improve or normalize blood sugar levels.  Weight loss will likely entail some caloric restriction, whether consciously or not.

Type 1 Versus Type 2 Diabetes

Type 1 and type 2 diabetics have many pathophysiologic differences.  Could a single paleo diabetic diet serve both populations equally well?  That’s the goal.


Diabetics have trouble metabolizing carbohydrates, so a paleo diabetic diet should probably be lower-than-average in digestible carbs.  100 g/day?  30 g/day?  I’m leaning toward 60 g ± 25%, so 45–75 g.  Smaller, less active folks could eat 45 g/day; larger, more active guys eat closer to 75 g.

Is there a role for very-low-carb or ketogenic eating patterns?  For most folks, that’s less than 50 g of digestible carbohydrate daily.  Under 30 g for some.  Use that only for those needing to lose weight?  Start everybody at  very low carb levels then increase carbs as tolerated?  On the other hand, there’s a lot to be said for simplicity.  It might be best to avoid very-low-carb (ketogenic) eating entirely.  Anyone not losing the desired amount of fat weight could cut portion sizes, especially carbohydrates.


I encourage fish consumption twice a week, diabetes or no.  Cold-water fatty fish have more of the healthy omega-3 fatty acids than other fish.


I’d encourage 1–2 ounces (28–56 g) of nuts or seeds daily.  Any more than that might crowd out other healthful nutrients.  Nuts are protective of the heart.


Protein-rich foods can definitely raise insulin requirements and blood sugar levels, but not in an entirely predictable way, and not to the extent we see with carbohydrates.  Should insulin users dose insulin based on a protein gram sliding scale?  I’m leaning towards simply recommending the same amount of protein at each meal, perhaps 4–8 ounces (113–229 g).

Fruit and Starchy Vegetables

Could a paleo diabetic diet even be “paleo” without fruit?  The problem with classic fruits is that they spike blood sugars too high for many diabetics.  To prevent that, Dr. Richard Bernstein outlaws all classic fruits (and other starchy carbs), even limiting tomatoes and onions to small amounts.  E.g., a wedge of tomato in a salad.  He doesn’t allow carrots either, unless raw (lower glycemic index than when cooked).  A paleo diabetic diet eater may be able to get away with eating lower-carb, lower-GI (glycemic index) fruits such as cantaloupe, honeydew, strawberries and other berries.  Some paleo diabetic dieters will tolerate half an apple twice a day.

Different diabetics will have different blood sugar effects when eating starchy vegetables and higher-carb fruits.  Type 1 diabetics will tend to be more predictable than type 2s.  Both may just need to “eat to the meter”: try a serving and see what happens to blood sugar over the next hour or two.

Starchy vegetables—potatoes and carrots, for example—may well have to be limited.  Again, eat to the meter.


This is looking to be gluten-free.  How trendy!  It’s a paleo celiac diet.

Use “natural” stevia as a sweetener?  If you read about how the product on your supermarket shelf  is made, it’s not at all natural.

Omega-6/Omega-3 Fatty Acids

A strict focus on omega-6/omega-3 fatty acid ratio will not appeal to many folks, even if it’s important from a health viewpoint.  Reserve this for advanced dieters who have mastered the basics?  Modern Western diets have an omega-6/omega-3 ratio around 10 or 15:1.  Paleolithic diets were closer to 2 or 3:1.  So we have an over-abundance of omega-6 fatty acid or deficiency of omega-3 that may be unhealthy.


To get dieters started, I’d design a week of meals based on 2,000 to 2,200 calories.  If still hungry, eat more protein, fat, and low-carb vegetables (and fruits?).

What do you think?

Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.  

PS: See Dr. Bernstein’s “no-no” foods on page 151 of his Diabetes Solution book.

PPS: The paleo diet is also known as the Paleolithic diet, Stone Age diet, caveman diet, hunter-gatherer diet, and ancestral diet.

The Case for Carbohydrate Restriction In Diabetes

MB900402413In 1797, Dr. John Rollo (a surgeon in the British Royal Artillery) published a book entitled An Account of Two Cases of the Diabetes Mellitus. He discussed his experience treating a diabetic Army officer, Captain Meredith, with a high-fat, high-meat, low-carbohydrate diet. Mind you, this was an era devoid of effective drug therapies for diabetes.

The soldier apparently had type 2 diabetes rather than type 1.

Rollo’s diet led to loss of excess weight (original weight 232 pounds or 105 kg), elimination of symptoms such as frequent urination, and reversal of elevated blood and urine sugars.

This makes Dr. Rollo the original low-carb diabetic diet doctor. Many of the leading proponents of low-carb eating over the last two centuries—whether for diabetes or weight loss—have been physicians.

But is carbohydrate restriction a reasonable approach to diabetes, whether type 1 or type 2?

What’s the Basic Problem in Diabetes?

Diabetes and prediabetes always involve impaired carbohydrate metabolism: ingested carbs are not handled by the body in a healthy fashion, leading to high blood sugars and, eventually, poisonous complications.  In type 1 diabetes, the cause is a lack of insulin from the pancreas.  In type 2, the problem is usually a combination of insulin resistance and ineffective insulin production.

Elevated blood pressure is one component of metabolic syndrome

Elevated blood pressure is one component of metabolic syndrome

A cousin of type 2 diabetes is “metabolic syndrome.”  It’s a constellation of clinical factors that are associated with increased future risk of type 2 diabetes and atherosclerotic complications such as heart attack and stroke. One in six Americans has metabolic syndrome. Diagnosis requires at least three of the following five conditions:

■  high blood pressure (130/85 or higher, or using a high blood pressure medication)

■  low HDL cholesterol:  under 40 mg/dl (1.03 mmol/l) in a man, under 50 mg/dl (1.28 mmol/l) in a women (or either sex taking a cholesterol-lowering drug)

■  triglycerides over 150 mg/dl (1.70 mmol/l) (or taking a cholesterol-lowering drug)

■  abdominal fat:  waist circumference 40 inches (102 cm) or greater in a man, 35 inches (89 cm) or greater in a woman

■  fasting blood glucose over 100 mg/dl (5.55 mmol/l)

Metabolic syndrome and simple obesity often involve impaired carbohydrate metabolism. Over time, excessive carbohydrate consumption can turn obesity and metabolic syndrome into prediabetes, then type 2 diabetes.

Carbohydrate restriction directly addresses impaired carbohydrate metabolism naturally.

Carbohydrate Intolerance

Diabetics and prediabetics—plus many folks with metabolic syndrome—must remember that their bodies do not, and cannot, handle dietary carbohydrates in a normal, healthy fashion. In a way, carbs are toxic to them. Toxicity may lead to amputations, blindness, kidney failure, nerve damage, poor circulation, frequent infections, premature heart attacks and death, among other things.

Diabetics and prediabetics simply don’t tolerate carbs in the diet like other people. If you don’t tolerate something, you have to give it up, or at least cut way back on it. Lactose-intolerant individuals give up milk and other lactose sources. Celiac disease patients don’t tolerate gluten, so they give up wheat and other sources of gluten. One of every five high blood pressure patients can’t handle normal levels of salt in the diet; they have to cut back or their pressure’s too high. Patients with phenylketonuria don’t tolerate phenylalanine and have to restrict foods that contain it. If you’re allergic to penicillin, you have to give it up. If you don’t tolerate carbs, you have to give them up or cut way back. I’m sorry.

Carbohydrate restriction directly addresses impaired carbohydrate metabolism naturally.

But Doc, …?

1.  Why not just take more drugs to keep my blood sugars under control while eating all the carbs I want?

We have 11 classes of drugs to treat diabetes.  For most of these classes, we have little or no idea of the long-term consequences.  It’s a crap shoot.  The exceptions are insulin and metformin.  Several big-selling drugs have been taken off the market due to unforeseen side effects.  Others are sure to follow, but I can’t tell you which ones.  Adjusting insulin dose based on meal-time carb counting is popular.  Unfortunately, carb counts are not nearly as accurate as you might think; and the larger the carb amount, the larger the carb-counting and drug-dosing errors.

2.  If I reduce my carb consumption, won’t I be missing out on healthful nutrients from fruits and vegetables?

No.  Choosing low-carb fruits and vegetables will get you all the plant-based nutrients you need.  You may well end up eating more veggies and fruits than before you switched to low-carb eating.  Low-carb and paleo-style diets are unjustifiably criticized across-the-board as being meat-centric and deficient in plants.  Some are, but that’s not necessarily the case.

3.  Aren’t vegetarian and vegan diets just as good?

Maybe.  There’s some evidence that they’re better than standard diabetic diets.  My personal patients are rarely interested in vegetarian or vegan diets, so I’ve not studied them in much detail.  They tend to be rich in carbohydrates, so you may run into the drug and carb-counting issues in Question No. 1.

Steve Parker, M.D.

PS:  The American Diabetes Association recommends weight loss for all overweight diabetics. Its 2011 guidelines suggest three possible diets: “For weight loss, either low-carbohydrate [under 130 g/day], low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to two years).”  The average American adult eats 250–300 grams of carbohydrate daily.

Found Another Paleo-Friendly Dietitian: Kelly O’Connell Schmidt, RD

And she has type 1 diabetes, too.  I look forward to some free time so I can peruse her site, Paleo Infused.  Kelly’s twitter handle is @kellyOC.


Dr. Frassetto Discusses Paleo Diet and Diabetes

Not Dr. Frassetto

Dr. Lynda Frassetto is a Professor of Medicine and Nephrology at the University of California San Francisco.  She and her colleagues have completed a study of the Paleolithic diet as a treatment for diabetes (type 2, I think).  As far as I know, details have not yet been published in the medical literature.

Dr. Frassetto spoke at the Ancestral Health Symposium-2012 earlier this year.  You can view the 35-minute video here.

She is convinced that a paleo diet, compared to a Mediterranean-style diet, is better at controlling blood sugars and “reducing insulin” in diabetics (presumably type 2s).  Insulin sensitivity is improved, particularly in those with insulin resistance to start with.  The paleo diet group saw an average drop of fasting glucose by 23 mg/dl (1.3 mmol/l).  One slide you’ll see in the video indicates the paleo diet reduced absolute hemoglobin A1c by 0.3%, compared to 0.2% with the “Mediterranean” diet.  (Let me know if I got the numbers wrong.)

Color me underwhelmed so far.

Questions raised by the video include:

  • what is the UCSF version of the paleo diet?
  • how many participants were in her study?
  • how long did her study last?
  • did she study only type 2 diabetics?
  • what exactly was the control diet?
  • how severe were the cases of diabetes studied?

For answers, we await publication of the formal report.

Steve Parker, M.D.

TV’s Biggest Loser Plan Improves Prediabetes and Diabetes in Small Study

TV’s “The Biggest Loser” weight-loss program works great for overweight diabetics and prediabetics, according to an article May 30, 2012, in MedPage Today.

This isn’t directly related to the paleo diet or lifestyle, but I thought you might be interested.

Some quotes:

For example, one man with a hemoglobin A1c (HbA1c) of 9.1, a body mass index (BMI) of 51, and who needed six insulin injections a day as well as other multiple prescriptions was off all medication by week 3, said Robert Huizenga, MD, the medical advisor for the TV show.

In addition, the mean percentage of weight loss of the 35 contestants in the study was 3.7% at week 1, 14.3% at week 5, and 31.9% at week 24…

The exercise regimen for those appearing on “The Biggest Loser” comprised about 4 hours of daily exercise: 1 hour of intense resistance training, 1 hour of intense aerobics, and 2 hours of moderate aerobics.

Caloric intake was at least 70% of the estimated resting daily energy expenditure, Huizenga said.

At the end of the program, participants are told to exercise for 90 minutes a day for the rest of their lives. Huizenga said he is often told by those listening to him that a daily 90-minute exercise regimen is impossible because everyone has such busy lives.

“I have a job and I work out from 90 to 100 minutes per day,” he said. “It’s about setting priorities. Time is not the issue; priorities are the issue.”

Of the 35 participants in this study, 12 had prediabetes and six had diabetes.  This is a small pilot study, then.  I bet the results would be reproducible on a larger scale IF all conditions of the TV program are in place.  Of course, that’s not very realistic.  A chance to win $250,000 (USD) is strong motivation for lifestyle change.

Steve Parker, M.D.

PS: Although not mentioned in the article, these must have been type 2 diabetics, not type 1.

Dr. Bernstein: Effect of Dietary Protein on Blood Sugar

The protein in this can raise your blood sugar

I’m considering whether I should advise my patients with diabetes to pay careful attention to the protein content of their diet.  It’s an important issue to Dr. Richard K. Bernstein, who definitely says it has to be taken into account.

Here are some of Dr. Bernstein’s ideas pulled from the current edition of Diabetes Solution:

  • The liver (and the kidneys and intestines to a lesser extent) can convert protein to glucose, although it’s a slow and inefficient process.
  • Since the conversion process—called gluconeogenesis—is slow and inefficient, diabetics don’t see the high blood sugar spikes they would see from many ingested carbohydrates.
  • For example, 3 ounces (85 g) of hamburger patty could be converted to 6.5 g of glucose under the right circumstances.
  • Protein foods from animals (e.g., meat, fish, chicken, eggs) are about 20% protein by weight.
  • Dr. B recommends keeping protein portions in a particular meal consistent day-to-day (for example 6 ounces with each lunch).
  • He recommends at least 1–1.2 g of protein per kilogram of ideal body weight for non-athletic adults.
  • The minimum protein he recommends for a 155-lb non-athletic adult is 11.7–14 ounces daily.
  • Growing children and athletes need more protein.
  • Each uncooked ounce of the foods on his “protein foods” list (page 181) provides about 6 g of protein.
  • On his eating plan, you choose the amount of protein in a meal that would satisfy you, which might be 3 ounces or 6–9 ounces.
  • If you have gastroparesis, however, you should limit your evening meal protein to 2 ounces of eggs, cheese, fish, or ground meat, while eating more protein at the two earlier meals in the day.

Dr. Bernstein wrote:

In many respects—and going against the grain of a number of the medical establishment’s accepted notions about diabetics and protein—protein will become the most important part of our diet if you are going to control blood sugars just as it was for our hunter-gatherer ancestors.


I haven’t changed my thinking on this issue yet, but will let you know if and when I do.  I don’t talk much about protein in Conquer Diabetes and Prediabetes in part because I wanted to keep the program simpler than Dr. Bernstein’s.

As with most aspects of diabetes, your mileage may vary.  The effect of dietary protein on blood sugars will depend on type 1 versus type 2 diabetes, and will vary from one person to another.  So it may be impossible to set rigid guidelines.

If interested, you can determine how much protein is in various foods at NutritionData.

Steve Parker, M.D.

Are Ketogenic Diets Crazy?

You get it?

Ketogenic diets don’t have anything to do with the paleo diet usually.  However, I think they may play a legitimate role in weight loss for overweight type 2 diabetics.  They could also be helpful in rapid control of blood sugars in out-of-control diabetics (excluding diabetic ketoacidosis).

Has anyone devised a ketogenic paleo diet yet?  I don’t recall one off the top of my head.

Registered Dietitian Franziska Spritzler recently reviewed the concept of low-carb ketogenic diets.  She thinks they are a valid approach to certain clinical situations.  Among dietitians, this puts her in a small but growing minority.

I hesitate to mention this, but I will anyway.  Many, if not most, dietitians too easily just go along with the standard party line on low-carb eating: it’s rarely necessary and quite possibly unhealthy.  Going along is much easier than doing independent literature review and analysis.  I see the same mindset among physicians.

Franziska breaks the mold.

Steve Parker, M.D.