Category Archives: Diabetic Diet

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.

I Found a Paleo-Friendly Physician

Dr. Ernie Garcia is an internist in Louisiana treating some of his patients—particularly those with high blood pressure and diabetes—with the paleolithic lifestyle.  (Mostly  paleo diet, or other aspects of paleo lifestyle, too?)

Read more at PaleolithicMD.

Steve Parker, M.D.

Nephrologist and Type 1 Diabetic Keith Runyan Tried the Paleo Diet

Jimmy posted a recent interview with type 1 diabetic Dr. Keith R. Runyan, who is a nephrologist and internist.

Dr. Runyan is training for the Great Floridian Triathlon this coming October so he naturally has a great interest in high level athleticism as it intersects with diabetes.  He fuels his workouts with dietary fats and proteins rather than the standard carbohydrates.

Dr. Runyan’s current carb consumption level didn’t come up specifically in the interview, but his website indicates he’s on a ketogenic diet heavily influenced by Dr. Richard Bernstein.  I figure he’s eating under 50 grams of digestible carbohydrate daily.  He also tried Loren Cordain’s paleo diet; my sense is that it didn’t help much with his diabetes, but perhaps some.  My sense is that he incorporates at least a few paleo features into his current eating plan.

People with type 2 diabetes can probably tolerate a higher level of carbohydrates, compared to type 1′s, generally speaking.  This didn’t come up in the podcast interview.

Overall, the interview strongly supports carbohydrate-restricted eating for folks with diabetes.  Definitely worth a listen for anyone with diabetes who’s not sold on a very-low-carb diet.  If you’re sitting on the fence, at least check out Dr. Runyan’s “About Me” page.

Steve Parker, M.D.

Triathlon: run, swim, bike

How Many Diabetic Diets Are There?

Elizabeth Woolley reviews most of them at her About.com column on type 2 diabetes. I don’t endorse everything there; just thought you might be interested.

I still see doctors at the hospital order “ADA diet” (American Diabetes Association) for their patients with diabetes.

There is no ADA diet.

-Steve

Random Thoughts On Paleo Eating For People With Diabetes

Not really pertinent, but I like buffalo

I was interviewed  yesterday by Amy Stockwell Mercer, author of Smart Woman’s Guide to Diabetes.  All I knew beforehand was that she was interested in my thoughts on the paleo diet as applied to diabetes.

In preparation, I collected some random thoughts and did a little research.

What’s the paleo diet?

Fresh, minimally processed food.  Meat (lean or not? supermarket vs yuppiefied?), poultry, eggs, fish, leafy greens and other vegetables, nuts, berries, fruit, and probably tubers.

Non-paleo: highly processed, grains, refined sugars, industrial plant/seed oils, legumes, milk, cheese, yogurt, salt, alcohol.

Is the paleo diet deficient in any nutrients?

A quick scan of Loren Cordain’s website found mention of possible calcium and vitamin D deficits.  Paleoistas will get vitamin D via sun exposure and fish (especially cold-water fatty fish).  Obtain calcium from broccoli, kale, sardines, almonds, collards.  (I wonder if the Recommended Dietary Allowance for calcium is set too high.)

What About Carbohydrates and Diabetes and the Paleo Diet?

Diabetes is a disorder of carbohydrate metabolism.  In a way, it’s an intolerance of carbohydrates.  In type 1 diabetes, there’s a total or near-total lack of insulin production on an autoimmune basis.  In type 2 diabetes, the body’s insulin just isn’t working adequately; insulin production can be high, normal or low.  In both cases, ingested carbohydrates can’t be processed in a normal healthy way, so they stack up in the bloodstream as high blood sugars.  If not addressed adequately, high blood glucose levels sooner or later will poison body tissues .  Sooner in type 1, later in type 2.  (Yes, this is a gross over-simplification.) 

Gluten-rich Neolithic food

If you’re intolerant of lactose or gluten, you avoid those.  If you’re intolerant of carbohydrates, you could avoid eating them, or take drugs to help you overcome your intolerance.  Type 1 diabetics must take insulin.  Insulin’s more optional for type 2′s.  We have 11 classes of drugs to treat type 2 diabetes; we don’t know the potential adverse effects of most of these drugs.  Already, three diabetes drugs have been taken off the U.S. market or severely restricted due to unacceptable toxicity: phenformin, troglitazone, and rosiglitazone. 

Humans need two “essential fatty acids” and nine “essential” amino acids derived from proteins.  “Essential” means we can’t be healthy and live long without them.   Our bodies can’t synthesize them.  On the other hand, there are no essential carbohydrates.  Our bodies can make all the carbohydrate (mainly glucose) we need.

Since there are no essential carbohydrates, and we know little about the long-term adverse side effects of many of the diabetes drugs, I favor carbohydrate restriction for people with carbohydrate intolerance.  (To be clear, insulin is safe, indeed life-saving, for those with type 1 diabetes.)

That being said, let’s think about the Standard American Diet (SAD) eaten by an adult.  It provides an average of 2673 calories a day (not accounting for wastage of calories in restaurants; 2250 cals/day is probably a more accurate figure for actual consumption).  Added sugars provide 459 of those calories, or 17% of the total.  Grains provide 625 calories, or 23% of the total.  Most of those sugars and grains are in processed, commercial foods.  So added sugars and grains provide 40% of the total calories in the SAD.  Remember, we need good insulin action to process these carbs, which is a problem for diabetics.  (Figures are from an April 5, 2011, infographic at Civil Eats.)

Anyone going from the SAD to pure Paleo eating will be drastically reducing intake of added sugars and grains, our current major sources of carbohydrate.  Question is, what will they replace those calories with? 

That’s why I gave a thumbnail sketch of the paleo diet above. Take a gander and you’ll see lots of low-carb and no-carb options, along with some carb options. For folks with carbohydrate intolerance, I’d favor lower-carb veggies and judicious amounts of fruits, berries, and higher-carb veggies and

Will these cause bladder cancer? Pancreatitis?

tubers.  “Judicious” depends on the individual, considering factors such as degree of residual insulin production, insulin sensitivity, the need to lose excess weight, and desire to avoid diabetes drugs.

Compared to the standard “diabetic diet” (what’s that?) and the Standard American Diet, switching to paleo should lower the glycemic index and glycemic load of the diet.  theoretically, that should help with blood sugar control.

A well-designed low-carb paleo diet would likely have at least twice as much fiber as the typical American diet, which would also tend to limit high blood sugar excursions.

In general, I favor a carbohydrate-restricted paleo diet for those with diabetes who have already decided to “go paleo.”  I’m not endorsing any paleo diet for anyone with diabetes at this point—I’m still doing my research.  But if you’re going to do it, I’d keep it lower-carb.  It has a lot of potential.

Are There Any Immediate Dangers for a Person With Diabetes Switching to the Paleo Diet?

It depends on three things: 1) current diet, and 2) current drug therapy, and 3) the particular version of paleo diet followed. 

Remember, the Standard American Diet provides 40% of total calories as added sugars and grains (nearly all highly refined).  Switching from SAD to a low-carb paleo diet will cut carb intake  and glycemic load substantially, raising the risk of hypoglycemia if the person is taking certain drugs.

Drugs with potential to cause hypoglycemia include insulin, sulfonylureas, meglitinides, pramlintide, and perhaps thiazolidinediones.

Who knows about carb content of the standard “diabetic diet”?  Contrary to popular belief, there is no monolithic “diabetic diet.”  There is no ADA diet (American Diabetes Association).  My impression, however, is that the ADA favors relatively high carbohydrate consumption, perhaps 45-60% of total calories.  Switching to low-carb paleo could definitely cause hypoglycemia in those taking the aforementioned drugs.

One way to avoid diet-induced hypoglycemia is to reduce the diabetic drug dose.

A type 2 overweight diabetic eating a Standard American Diet—and I know there are many out there—would tend to see lower glucose levels by switching to probably any of the popular paleo diets.  Be ready for hypoglycemia if you take those drugs.

Paleo diets are not necessarily low-carb.  Konner and Eaton estimate that ancestral hunter-gatherers obtained 35 to 40% of total calories from carbohydrates.  I’ve seen other estimates as low as 22%.  Reality likely falls between 22 and 65%.  When pressed for a brief answer as to how many carbohydrate calories are in the paleo diet, I say “about a third of the total.”  By comparison, the typical U.S. diet provides 50% of calories from carbohydrate.

Someone could end up with a high-carb paleo diet easily, by emphasizing tubers (e.g., potatoes), higher-carb vegetables, fruits, berries, and nuts (especially cashews). Compared with the SAD, this could cause higher or lower blood sugars, or no net change.

A diabetic on a Bernstein-style diet or Ketogenic Mediterranean Diet (both very-low-carb) but switching to paleo or low-carb paleo (50-150 g?) would see elevated blood sugars.  Perhaps very high glucoses.

Any person with diabetes making a change in diet should do it in consultation with a personal physician or other qualified healthcare professional familiar with their case.

Steve Parker, M.D.

Fun Facts!

  • A typical carbonated soda contain the equivalent of 10 tsp (50 ml) of sugar.
  • The typical U.S. adult eats 30 tsp  (150 ml) daily of added sweeteners and sugars.
  • U.S total grain product consumption was at record lows in the 1970s, at 138 pounds per person.  By 2000, grain consumption was up by 45%, to 200 pounds per person.
  • Total caloric sweetener consumption (by dry weight) was 110 pounds per person in the  1950s.  By 2000, it was up 39% to 150 pounds.
  • Between 1970 and 2003, consumption of added fats and oils rose by 63%, from 53 to 85 pounds.  [How tasty would that be without starches and sugars?  Not very.]
  • In 2008, “added fat” calories in the U.S. adult diet were 641 (24% of total calories).

Fun Facts provided by the U.S. Department of Agriculture. 

(The paleo diet is also referred to as the Paleolithic, Old Stone Age, Stone Age, Ancestral, Hunter-Gatherer, or Caveman diet.)

Dr. Andreas Eenfeldt Explains the LCHF Diet

LCHF Cheese

Dr. Eenfeldt of DietDoctor.com gave a talk at the inaugural Ancestral Health Symposium in California, on the rationale of the current low-carb, high-fat diet (LCHF) so popular in his home country of Sweden.  It’s very understandable to the general public and is a good introduction to low-carb eating.  The entire YouTube video is 55 minutes; if you’re pressed for time, skip the 10-minute Q&A at the end.

He also discusses the benefits of LCHF eating for his patients with diabetes.

If you reduce carbohydrate, you’re going to replace it with either protein, fat, or both.  Carbohydrate restriction, whether or not part of a Paleolithic eating pattern, generally improves blood sugar levels, especially in people with diabetes. 

Steve Parker, M.D.

Old Stone Age Diet Depended On Latitude

There isn’t any single Stone Age diet, according to J.A.J. Gowlett, who (whom?) I assume is an archeologist with the University of Liverpool.

(I was tempted to write “there isn’t a monolithic Stone Age diet.”  Get it?  “Lith” is Greek or Latin for “stone.”)

This is probably old new for you guys who have been interested in the paleo diet for much longer than I.

Here are a few more of Gowlett’s ideas:

  • The Stone Age is is more accurately referred to as the Old Stone Age.
  • Hominids (the family of human ancestors) branched off from ape ancestors around eight to 10 million years ago.
  • Roots and tubers have been a part of our ancestral diet for perhaps as long as three million years,  which “places starchy carbohydrate consumption as part of the deep ancestry of human beings.”
  • Meat eating assumed greater importance about two million years ago.
  • Migration to colder environments necessitated more meat consumption because plant foods were more limited.
  • Our ancestors migrated from tropical to temperate latitudes about by 1.7 million years ago.
  • Early humans began using fire for cooking between 500,000 to 1.5 million years ago.
  • Neanderthals were heavily carnivorous.
  • “Ancestors of modern humans are now believed to have evolved in the tropics, probably in Africa, from about 200,000 years ago.”  Their diet was perhaps 70% plant-based.
  • “In contrast, modern humans entering Europe 40,000 years ago would have adopted a meat-based diet by necessity, and maintained this over hundreds of generations.”
  • “Modern hunters and gatherers echo the variety of past diets, ranging from largely plant based in the tropics, to being also heavily meat based in the arctic.”
  • No ancient human population depended heavily on cereals or non-human milk.  “Fruit certainly came first of all….”

Potential Implications For a Paleo Diabetic Diet (highly speculative)

Diabetics with tropical lineage may do better with a plant-based diet.  Those with northern European ancestry may do better with meat-based.

Paleo diets likely had very high fiber contents, reflecting the degree to which they were plant-based.  We’re looking at 70+ grams of fiber daily.  That much fiber would tend to reduce the effect of carbohydrate on blood sugar levels.

Fruits and roots have a high concentration of carbohydrate, with potential adverse effects on blood sugar (raising it, of course).  Diabetics eating paleo-style may need to avoid or limit certain fruits and roots: the ones with lower fiber content and higher glycemic index.  Blood sugar responses will vary from one diabetic to another.  Monitor blood sugar levels one or two hours after carb consumption to learn your idiosyncratic response.

Steve Parker, M.D.

Reference: Gowlett, J.A.J.  What actually was the Stone Age diet?  Journal of Nutritional and Environmental Medicine, 13 (2003): 143-147.

Paleo Diet and Diabetes: Improved Cardiovascular Risk Factors

Sweden's Flag

Compared to a standard diabetic diet, a Paleolithic diet improves cardiovascular risk factors in type 2 diabetics, according to investigators at Lund University in Sweden.

Researchers compared the effects of a Paleo and a modern diabetic diet in 13 type 2 diabetic adults (10 men) with average hemoglobin A1c’s of 6.6% (under fairly good control, then).  Most were on diabetic pills; none were on insulin.  So this was a small, exploratory, pilot study.  Each of the diabetics followed both diets for three months.

How Did the Diets Differ?

Compared to the diabetic diet, the paleo diet was mainly lower in cereals and dairy products, higher in fruits and vegetables, meat, and eggs.  The paleo diet was lower in carbohydrates, glycemic load, and glycemic index.  Paleo vegetables were primarily leafy and cruciferous.  Cruciferous vegetables include broccoli, brussels sprouts, cauliflower, and cabbage.  Root vegetables were allowed; up to 1 medium potato daily.  The paleo diet also featured lean meats (why lean?), fish, eggs, and nuts, while forbidding refined fats, sugars, and beans.  Up to one glass of wine daily was allowed.

See the actual report for details of the diabetic diet, which seems to me to be similar to the diabetic diet recommended by most U.S. dietitians.

What Did the Researchers Find?

Compared to the diabetic diet, the paleo diet yielded lower hemoglobin A1c’s (0.4% lower—absolute difference), lower trigylcerides, lower diastolic blood pressure, lower weight, lower body mass index, lower waist circumference, lower total energy (caloric) intake, and higher HDL cholesterol (the good cholesterol).  Glucose tolerance was the same for both diets.  Fasting blood sugars tended to decrease more on the Paleo diet, but did not reach statistical significance (p=0.08, which is very close to significant).

So What?

The greater improvement in multiple cardiovascular risk factors seen here suggests that the paleo diet has potential to reduce the higher cardiovascular disease rates we see in diabetics.  This is just a pilot study.  Larger studies—more participants—are needed for confirmation.  Ultimately, we need data on hard clinical endpoints such as heart attacks, strokes, and death.

These diabetics had their blood sugars under fairly good control at baseline.  I wouldn’t be surprised if diabetics under poor control—hemoglobin A1c of 9%, for example—would see even greater improvements in risk factors as well as glucose levels while eating paleo.

There are so few women in this study as to be almost meaningless.

Results of this study may or may not apply to non-Swedes.

I see a fair amount of overlap between this version of the paleo diet and Dr. Bernstein’s Diabetes Solution diet and the Low-Carb Mediterranean Diet

Steve Parker, M.D.

Reference:  Jönsson, T., Granfeldt, Y., Ahrén, B., Branell, U., Pålsson, G., Hansson, A., Söderström, M., & Lindeberg, S.  Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study.  Cardiovascular Diabetology, 8 (2009)  doi: 10.1186/1475-2840-8-35