Category Archives: Low-Carb

Long-Term T2 Diabetes Diet Trial: Low-Carb Edges Out High-Carb Eating

Paleo-compliant low-carb meal. I almost used this for my Paleobetic Diet book cover.

Paleo-compliant low-carb meal. I almost used this for my Paleobetic Diet book cover.

This is an important report because most diet studies last much less than one year. Details are in the American Journal of Clinical Nutrition.

Study participants were 115 obese (BMI 35) type 2 diabetics with hemoglobin A1c averaging 7.3%. Average age was 58. So pretty typical patients, although perhaps better controlled than average.

They were randomized to follow for 52 weeks either a very low-carbohydrate or a high-carbohydrate “low-fat” diet. Both diets were designed to by hypocaloric, meaning that they provided fewer calories than the patients were eating at baseline, presumably with a goal of weight loss. The article abstract implies the diets overall each provided the same number of calories. They probably adjusted the calories for each patient individually. (I haven’t seen the full text of the article.) Participants were also enrolled in a serious exercise program: 60 minutes of aerobic and resistance training thrice weekly.

Kayaking is an aerobic exercise if done seriously

Kayaking is an aerobic exercise if done seriously

The very low-carb diet (LC diet) provided 14% of total calories as carbohydrate (under 50 grams/day). The high-carb diet (HC diet) provided 53% of total calories as carbohydrate and 30% of calories as fat. The typical Western diet has about 35% of calories from fat.

Both groups lost weight, about 10 kg (22 lb) on average. Hemoglobin A1c, a reflection of glucose control over the previous three months, dropped about 1% (absolute reduction) in both groups.

Compared to the HC diet group, the LC dieters were able to reduce more diabetes medications, lower their triglycerides more, and increase their HDL cholesterol (“good cholesterol”). These triglyceride and HDL changes would tend to protect against heart disease.


You can lose weight and improve blood sugar control with reduced-calorie diets—whether very low-carb or high-carb—combined with an exercise program. No surprise there.

I’m surprised that the low-carb group didn’t lose more weight. I suspect after two months of dieting, the low-carbers started drifting back to their usual diet which likely was similar to the high-carb diet. Numerous studies show superior weight loss with low-carb eating, but those studies are usually 12 weeks or less in duration.

diabetic diet, low-carb diet, paleobetic diet

Low-Carb Brian Burger and Bacon Brussels Sprouts (in the Paleobetic Diet)

The low-carb diet improved improved lipid levels that might reduce risk of future heart disease, and allowed reduction of diabetes drug use. Given that we don’t know the long-term side effects of many of our drugs, that’s good.

If I have a chance to review the full text of the paper, I’ll report back here.

Steve Parker, M.D.

Reference: Jeannie Tay, et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. First published July 29, 2015, doi: 10.3945/​ajcn.115.112581    Am J Clin Nutr

Book Review: “Stop the Clock: The Optimal Anti-Aging Strategy”

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“I wish we could have read PD Mangan’s book thirty years ago!”

I read P.D. Mangan’s 2015 book, Stop the Clock: The Optimal Anti-Aging Strategy. I give it five stars in Amazon’s rating system. High recommended.

♦   ♦   ♦

I approached this book with trepidation. I like PD Mangan even though I’ve never met him. We’ve interacted on Twitter and at our blogs. You can tell from his blogging that he’s very intelligent. I don’t know his educational background but wouldn’t be surprised if he has a doctorate degree. My apprehension about the book is that I was concerned it would be brimming with malarkey and scams. Fortunately, that’s not the case at all.

Twin studies have established that 25% of longevity is genetic. That leaves a lot of lifestyle factors for us to manipulate.

I’m not familiar with the anti-aging scientific literature and don’t expect it will ever be something I’ll spend much time on. But it’s an important topic. I’ll listen to what other smart analysts—like Mr. Mangan—have to say about it.

It’s quite difficult to do rigorous testing of anti-aging strategies on free-living humans. So the best studies we have were done with worms, rodents, and monkeys; the findings may or may not apply to us. For example, long-term calorie restriction—about 30% below expected energy needs—is known to prolong life span in certain worms and rodents, with mixed results in rhesus monkeys. It’s the rare person who would follow such a low-calorie diet for years as an experiment. I doubt I would do it even if proven to give me an extra five years of life. I like to eat.

There are several prominent theories of how and why animals age. The author thinks the major factors are:

  1. oxidative stress
  2. inflammation
  3. a decline in autophagy (perhaps most important)

An effective anti-aging program should address these issues.

In the anti-aging chapter of his book, The South Asian Health Solution, internist Ronesh Sinha says that “Lifestyle practices that reduce excess inflammation in the body will help delay the aging process.” Dr. Sinha is a huge exercise advocate and low-carb diet proponent.

Mr. Mangan makes a convincing argument that a good way to forestall aging is to apply hormetic stress. Hormesis is a phenomenon whereby a beneficial effect (e.g., improved health, stress tolerance, growth, or longevity) results from exposure to low doses of an agent or activity that is otherwise toxic or lethal when given at higher doses.

Needs a bit more hormetic stress

Needs a bit more hormetic stress

In case you’re not familiar with hormesis, here’s a major example. Lack of regular exercise leads is linked to premature death from heart disease and cancer. Starting and maintaining an exercise program leads to greater resistance to injury and disease and longer life span. On the other hand, too much exercise is harmful to health and longevity. We see that in professional athletes and excessive marathon runners. Something about exercise—in the right amount—enhances the body’s intrinsic repair mechanisms. That’s the hormetic effect of exercise; one mechanism is by turning on autophagy.

Autophagy is the body’s natural process for breaking down and removing or recycling worn-out cellular structures. This wearing-out occurs daily and at all ages.

If you’re thinking Mr. Mangan recommends exercise as an anti-aging strategy, you’re exactly right. Especially resistance training and high intensity training. His specific recommendations are perfectly in line with what I tell my patients.

Calorie restriction is another form of hormesis; the body reacts by up-regulating stress defense mechanisms. As a substitute for calorie restriction, the author recommends intermittent fasting. Intermittent fasting increases insulin sensitivity, which leads to enhanced autophagy. Fasting seems perfectly reasonable if you think about it, which very few do. Many of us eat every three or four hours while awake, whether a meal or a snack. If you think about it, that’s not a pattern that would be supported by evolution. In the Paleolithic era, we often must have gone 12–16 hours or even several days without food. Hominins without the resiliency to do that would have died off and not passed their genes down to us.

Steve Parker MD, Advanced Mediterranean DIet

Naturally low-carb Caprese salad: mozzarella cheese, tomatoes, basil, extra virgin olive oil

Another anti-aging trick is a low-carb diet, defined as under 130 grams/day, or under 20% of total calories. It may work via insulin signaling and weight control.

Glutathione within our cells is a tripeptide antioxidant critical for clearing harmful reactive oxygen species (free radicals). We need adequate glutathione to prevent or slow aging. Cysteine is the peptide that tends to limit our body’s production of glutathione. We increase our cysteine supply either through autophagy (which recycles protein peptides) or diet. Dietary sources of cysteine are proteins, especially from animal sources. Whey protein supplements and over-the-counter n-acetyl cysteine are other sources. Fasting is another trick that increases cysteine availability via autophagic recyling.

I don’t recall the author ever mentioning it, but if you hope to maximize longevity, don’t smoke. Even if it has hormetic effects. Maybe that goes without saying in 2015.

When I read a book like this, I always run across tidbits of information that I want to remember. Here are some:

  • those of us in the top third of muscular strength have a 40% lower risk of cancer (NB: you increase your strength through resistance training not aerobics)
  • exercise helps prevent cognitive decline and dementia, at least partially via enhanced autophagy
  • exercise increases brain volume (in preparing to do this review I learned that our brains after age 65 lose 7 cubic centimeters of volume yearly)
  • optimal BMI may be 20 or 21, not the 18.5-25 you’ll see elsewhere (higher BMI due to muscle mass rather than fat should not be a problem)
  • Scientist Cynthia Kenyon: “Sugar is the new tobacco.” (in terms of aging)
  • phytochemicals (from plants, by definition) activate AMPK, a cellular energy sensor that improves stress defense mechanisms and increases metabolic efficiency
  • curcumin (from the spice turmeric) activates AMPK
  • coffee promotes autophagy
  • he does not favor HGH supplementation
  • in the author’s style of intermittent fasting, you’re not reducing overall calorie intake, just bunching your calories together over a shorter time frame (e.g., all 2,500 calories over 6-8 hours instead of spread over 24)
  • mouse studies suggest that intermittent fasting could reduce risk of Alzheimer’s disease and Parkinsons disease
  • consider phytochemical supplements: curcumin, resveratrol, green tea extract
  • calorie-restriction mimetics include resveratrol, curcumin, nicotinamide, EGCG, and hydroxycitrate
  • supplemental resveratrol at 150 mg/day improved memory and cognition in humans

The author provides very specific anti-aging recommendations that could be followed by just about anyone. Read the book for details. Scientists are working feverishly to develop more effective anti-aging techniques. I look forward to a second edition of this book in three to five years.

Steve Parker, M.D.

PS: People with certain medical conditions, such as diabetics taking drugs that can cause hypoglycemia, should not do intermittent fasting without the blessing of their personal physician. If you have any question about your ability to fast safely, check with your doctor.

PPS: If you have diabetes or prediabetes and want to reduce your carbohydrate consumption, consider my Low-Carb Mediterranean Diet or Paleobetic Diet.

Low-Carb Diet Beats Low-Fat for Weight Loss While Improving Cardiovascular Risk Factors

…according to an article at MedPageToday.

Many physicians have been reluctant to recommend low-carb diets out of fear that they increase cardiovascular risk. How could that happen? By replacing carbohydrates with fats, especially saturated fats, leading to atherosclerosis. I don’t buy that theory (here’s why).

medical clearance, treadmill stress test

This treadmill stress test is looking for atherosclerotic heart disease, aka coronary artery disease and coronary heart disease

A recent study compared low-carb to low-fat dieting over 12 months and actually found better improvements in cardiovascular disease risk factors on the low-carb diet (max of 40 grams a day).

After 12 months, folks on a low-carbohydrate diet had lost 5.3 kg (11.7 lb), while those on a low-fat diet with similar caloric value had lost 1.8 kg (3.9 lb). Both groups showed lowering of LDL cholesterol, while the low-carbers had better improvements in HDL cholesterol and triglycerides.

DietDoctor Andreas Eenfeldt can add this study to his list of others that show better weight loss with low-carb diets compared to low-fat.

Steve Parker, M.D.

Listen to Low-Carb Diet Proponents Franziska Spritzler and Dr. Troy Stapleton

Who says low-carb paleo diets are mostly meat?

Who says low-carb paleo diets are mostly meat?

Jimmy Moore posted an interview with Dr. Troy Stapleton and Franziska Spritzler, R.D. These two wouldn’t consider themselves paleo diet gurus by any means. They advocate carbohydrate-restricted diets for management of blood sugars in diabetes, consistent with my approach in the Paleobetic Diet. Dr. Stapleton might argue I allow too many carbohydrates. By the way, he has type 1 diabetes; I’ve written about him before. Franziska is available for consultation either by phone, Skype, or in person.

Steve Parker, M.D.

Very-Low-Carb Diet Beats Medium-Carb ADA Diet in Type 2 Diabetes

Compared to a traditional American Diabetes Association diet, a very-low-carbohydrate ketogenic diet was more effective at controlling type 2 diabetes and prediabetes, according to University of California San Francisco researchers.

The debate about the best diet for people with diabetes will continue to rage, however. You’ll even find some studies supporting vegetarian diets. I’m still waiting for published results of the Frassetto group’s paleo diet trial.

Some non-starchy low-carb vegetables

Some non-starchy low-carb vegetables


Thirty-four overweight and obese type 2 diabetics (30) and prediabetics (4) were randomly assigned to one of the two diets:

  1. MCCR: American Diabetes Association-compliant medium-carbohydrate, low-fat, calorie-resticted carb-counting diet. The goals were about 165 grams of net carbs daily, counting
    carbohydrates, an effort to lose weight by eating 500 calories/day less than needed for maintenance, and 45–50% of total calories from carbohydrate. Protein gram intake was to remain same as baseline. (Note that most Americans eat 250–300 grams of carb daily.)
  2. LCK: A very-low-carbohydrate, high-fat, non-calorie-restricted diet aiming for nutritional ketosis. It was Atkins-style, under 50 grams of net carbs daily (suggested range of 20–50 g). Carbs were mostly from non-starchy low-glycemic-index vegetables. Protein gram intake was to remain same as baseline.

Baseline participant characteristics:

  • average weight 100 kg (220 lb)
  • 25 of 34 were women
  • average age 60
  • none were on insulin; a quarter were on no diabetes drugs at all
  • most were obese and had high blood pressure
  • average hemoglobin A1c was about 6.8%
  • seven out of 10 were white

Participants followed their diets for three months and attended 13 two-hour weekly classes. Very few dropped out of the study.


Average hemoglobin dropped 0.6% in the LCK group compared to no change in the MCCR cohort.

A hemoglobin A1c drop of 0.5% or greater is considered clinically significant. Nine in the LCK group achieved this, compared to four in the MCCR.

The LCK group lost an average of 5.5 kg (12 lb) compared to 2.6 kg (6 lb) in the MCCR. The difference was not statistically significant, but close (p = 0.09)

44% in the LCK group were able to stop one or more diabetes drugs, compared to only 11 % in the other group

31% in the LCK cohort were able to drop their sulfonylurea, compared to only 5% in the MCCR group.

By food recall surveys, both groups reported lower total daily caloric intake compared to baseline. The low-carbers ended up with 58% of total calories being from fat, a number achieved by reducing carbohydrates and total calories and keeping protein the same. They didn’t seem to increase their total fat gram intake;

The low-carbers apparently reduced daily carbs to an average of 58 grams (the goal was 20-50 grams).

There were no differences between both groups in terms of C-reactive protein (CRP), lipids, insulin levels, or insulin resistance (HOMA2-IR). Both groups reduced their CRP, a measure of inflammation.

LCK dieters apparently didn’t suffer at all from the “induction flu” seen with many ketogenic diets. They reported less heartburn, less aches and pains, but more constipation.

Hypoglycemia was not a problem.

If I recall correctly, the MCCR group’s baseline carb grams were around 225 g.

Bottom Line

Very-low-carb diets help control type 2 diabetes, help with weight loss, and reduce the need for diabetes drugs. An absolute drop of 0.6% in hemoglobin A1c doesn’t sound like much, translating to blood sugars lower by only 15–20 mg/dl (0.8–1 mmol/l). But remember the comparator diet in this study was already mildy to moderately carbohydrate-restricted. At least half of the type 2 diabetics I meet still tell my they don’t watch their carb intake, which usually means they’re eating around 250–300 grams a day. If they cut down to 58 grams, they most likely will see more than a 0.6% drop in hemoglobin A1c after switching to a very-low-carb diet.

If you’re developing a new diabetes drug that drops hemoglobin A1c by 0.6%, you’ll get FDA approval for effectiveness.

This is a small study, so it may not be reproducible in larger clinical trials and other patient populations. Results are consistent with several other similar studies I’ve seen, however.

Steve Parker, M.D.

Reference: Saslow, Laura, et al (including Stephen Phinney). A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or PrediabetesPLoS One. 2014; 9(4): e91027. Published online Apr 9, 2014. doi: 10.1371/journal.pone.0091027     PMCID: PMC3981696

PS: When I use “average” above, “mean” is often a more accurate word, but I don’t want to have to explain the differences at this time.

PPS: Carbsane Evelyn analyzed this study in greater detail that I did and came to different conclusions. Worth a read if you have an extra 15 minutes.

The Mellberg Study: Paleo Diet and Obese Postmenopausal Women

Sweden's Flag. Most of the researchers involved with this study are in Sweden

Sweden’s Flag

Swedish researchers compared a Paleolithic-type diet against a lower-fat, higher-carb diet so often recommend in Nordic countries and in the U.S. Test subjects were obese but otherwise healthy older women. The study lasted two years. Dieters could eat as much as they wanted.

They found that the paleo-style dieters lost more weight, lost more abdominal fat, and lowered their trigyceride levels. When measured six months into the study, the paleo dieters had lost 6.5 kg (14 lb) of body fat compared to 2.6 (6 lb) kg in the other group.

Measured at two years out, the paleo dieters had lost 4.6 kg (10 lb) of body fat compared to 2.9 kg (6 lb) in the other group, but this difference wasn’t statistically significant.

The greatest weight loss was clocked at 12 months: Paleo dieters were down 8.7 (19 lb) kg compared to 4.4 kg (10 lb)  in the other group.

But this study was about more than weight loss. The investigators were also interested in cardiometabolic risk factors and overall body composition.

The Set-Up

I don’t know what the researchers told the women to get them interested. Weight loss versus healthier diet versus ?  This could have influenced the type of women who signed up, and their degree of commitment.

A newspaper ad got the attention of 210 women in Sweden; 70 met the inclusion criteria, which included a body mass index 27 or higher and generally good health. Average age was 60. Average BMI was 33. Average weight was 87 kg (192 lb). Average waist circumference was 105 cm (41 inches). The women were randomized into one of two diet groups (N=35 in each): paleolithic-type diet (PD) or Nordic Nutrition Recommendations diet (NNR). There were no limits on total caloric consumption. (Were the women told to “work on weight loss”? I have no idea.)

We don’t know the ethnicity of these women.

Here’s their version of the paleo diet:

  • 30% of energy (calories) from protein
  • 40% of energy from fat
  • 30% of energy from carbohydrate
  • high intake of mono- and polyunsaturated fatty acids
  • based on lean meat, fish, eggs, vegetables, fruits, berries, and nuts
  • additional fat sources were avocado and oils (rapeseed [canola] and olive) used in dressings and food preparation
  • cereals (grains), dairy products, added salt and refined fats and sugar were excluded
  • no mention of legumes, potatoes, or tubers

The NNR diet:

  • 15% of energy from protein
  • 25-30% of energy from fat
  • 55-60% of energy from carbohydrate
  • emphasis on high-fiber products and low-fat dairy products

Over the 24 months of the study, each cohort had 12 group meetings with a dietitian for education and support, including “dietary effects on health, behavioral changes and group discussion.”

Various blood tests and body measurements were made at baseline and periodically. Body measurements were made every six months. Body composition was measured by dual energy x-ray absorptiometry. Diet intake was measured by self-reported periodic four-day food records.

Stockholm Palace

Stockholm Palace


30% of participants (21) eventually dropped out by the end of the study and were lost to follow-up, leaving 27 in the PD group and 22 in the NNR cohort.

Food record analysis indicated the PD group indeed reduced their carb intake while increasing protein and fat over baseline. Baseline macronutrient energy percentages were about the same for both groups: 17% protein, 45% carb, 34% (I guess the percentages don’t add to 100 because of alcohol, which wads not mentioned at all in the article.) Two years out, the PD group’s energy sources were 22% protein, 34% carb, 40% fat. For the NNR group, the energy sources at two years were 17% protein, 43% carb, and 34% fat. As usual, dietary compliance was better at six months compared to 24 months. The PD group failed to reach target amounts of protein energy (30%) at six and 24 months; the NNR group didn’t reach their goal of carbohydrate energy (55-60%). The PD group ate more mono- and poly unsaturated fatty acids than the NNRs.

In contrast to the food record estimates of protein intake, the urine tests for protein indicated poor adherence to the recommended protein consumption in the PD group (30% of energy). Both groups ate the same amount of protein by this metric. (This is an issue mostly ignored by authors, who don’t say which method is usually more accurate.)

“Both groups had statistically significant weight loss during the whole study, with significantly greater weight loos in the PD group at all follow up time points except at 24 months.” Largest weight loss was measured at 12 month: 8.7 kg (19 lb) in the PD group versus 4.4 kg (10 lb) in the NNRs.

The PD group lost 6.5 kg (14 lb) of body fat by six months but the loss was only 4.6 kg (10 lb) measured at 24 months. Corresponding numbers for the NNR group were 2.6 and 2.9 kg (about 6 lb). So both groups decreased their total fat mass to a significant degree. The difference between the groups was significant (P<0.001) only at six months. The greatest weight loss was clocked at 12 months: PD dieters were down 8.7 kg (19 lb) compared to 4.4 kg (10 lb) in the NNRs. Both groups saw a significant decrease in waist circumference during the whole study, with a more pronounce decrease in the PD group at six months: 11 versus 6 cm (4.3 versus 2.4 inches).

Fasting blood sugars, fasting insulin levels, and tissue plasminogen activator activity didn’t change.

Both groups had improvements in blood pressure, heart rate, c-reactive protein, LDL cholesterol, PAI-1 activity, and total cholesterol. The PD group saw a greater drop in triglycerides (by 19% at two years, but levels were normal to start with at 108 mg/dl or 1.22 mmol/l).

Reported daily energy intake fell over time for both groups, without statistically significant differences between them.

paleo diet, Steve Parker MD, diabetic diet

Sweet potato chunks brushed with olive oil, salt, pepper, and rosemary. Ready for the oven.


As measured at six months, the paleo dieters lost 10% of their initial body weight, compared to 5% in the NNR group. That’s worth something to many folks. However, the researchers didn’t find much, if any, difference in the groups in terms of cardiometabolic risk factors. They wonder if that reflects the baseline healthiness of these women. Would a sicker study population show more improvement on one of the diets?

I’m surprised the NNR group lost any weight at all. In my experience it’s hard for most folks to lose weight and keep it off while eating as much as they want, unless they’re eating very-low-carb. We’ve seen short-term weight loss with ad libitum paleo diets before (here for example, and here, and here). I bet the women signing up for this study were highly motivated to change. 

Legumes and potatoes are a debatable part of the paleo diet. Most versions exclude legumes. We don’t know if these women ate legumes and potatoes. Other than this oversight, the study paleo diet is reasonable.

The authors noted that the paleo diet group failed to reach their protein intake goal (30% of total calories), and suggested reasons “such as protein-rich foods being more expensive, social influences on women’s food choices or a lower food preference for protein-rich food among women.”

The results of this study may or may not apply to other population subgroups and non-Swedes.

The authors write:

In conclusion, a Palaeolithic-type diet during two years with ad libitum intake of macronutrients, including an increased intake of polyunsaturated fatty acids and monounsaturated fatty acids reduces fat mass and abdominal obesity with significantly better long-term effect on triglyceride levels vs an NNR diet. Adherence to the prescribed protein intake was poor in the PD group suggesting that other component of the PD diet are of greater importance.

Does this study have anything to do with diabetes? Not directly. But it suggests that if an overweight diabetic needs to lose excess body fat without strict calorie control, a lower-carb paleo-style diet may be more effective than a low-fat, higher-carb diet. I would have liked to have seen lower fasting blood sugar and insulin levels in the paleo dieters, but wishing doesn’t make it so.

Steve Parker, M.D.

PS: Carbsane Evelyn has taken a look at this study and blogged about it here and here. I’ve not read those yet, but will now.

Reference: Mellberg, C., et al (including M. Ryberg and T Olsson). Long-term effects of a Palaeolithic-type diet in obese postmenopausal women: a 2-year randomized trial. European Journal of Clinical Nutrition, advance online publication January 29, 2014. doi: 10.1038/ejcn.2013.290

Low-Carb Diet Works in Japanese With Type 2 Diabetes

Mt. Fuji in Japan

Mt. Fuji in Japan

I don’t know much about Japanese T2 diabetes. I’ve never studied it. Their underlying physiology may or may not be the same as in North American white diabetics, with whom I am much more familiar. Physiologic differences are suggested by the fact that Japanese develop type 2 diabetes at lower BMIs (body mass index) than do Western caucasians.

For what it’s worth, a small study recently found improvement of blood sugar control and triglycerides in those on a carbohydrate restricted diet versus a standard calorie-restricted diet.

Only 24 patients were involved. Half were assigned to eat low-carb without calorie restriction; the other half ate the control diet. The carbohydrate-restricted group aimed for 70-130 grams of carb daily, while eating more fat and protein than the control group. The calorie-restricted guys were taught how to get 50-60% of calories from carbohydrate and keep fat under 25% of calories. At the end of the six-month study, the low-carbers were averaging 125 g of carb daily, compare to 200 g for the other group. By six months, both groups were eating about the same amount of calories.

Average age was 63. Body mass index was 24.5 in the low-carb group and 27 in the controls. All were taking one or more diabetes drugs.

The calorie-restricted group didn’t change their hemoglobin A1c (a standard measure of glucose control) from 7.7%. The low-carb group dropped their hemoglobin A1c from 7.6 to 7.0% (statistically significant). The low-carb group also cut their triglycerides by 40%. Average weights didn’t change in either group.

Bottom Line

This small study suggests that mild to moderate carbohydrate restriction helps control diabetes in Japanese with type 2 diabetes. The improvement in hemoglobin A1c is equivalent to that seen with initiation of many diabetes drugs. I think further improvements in multiple measures would have been seen if carbohydrates had been restricted even further.

Steve Parker, M.D.

Link to reference.

h/t Dr Michael Eades

Recipe: Sunny’s Super Salad

diabetic diet, Paleobetic diet, diabetes,

You won’t be able to eat this in one sitting if you’re small or sedentary

This huge salad is a full meal. It fills a 10-inch plate (25 cm). Since it contains five vegetables, you should feel virtuous eating it. Who says the paleo diet’s all about meat?


8 oz (230 g) raw chicken breast tenderloin (it cooks down to 5 oz)

1/4 cup (60 ml) canned mandarin orange wedges (6-7 wedges) (if you can only find these packed in syrup or light syrup, add 3 g to the digestible carb count below)

1/4 tsp (1.2 ml) lemon pepper seasoning

4 oz (110 g) hearts of romaine lettuce

1 oz (30 g) baby spinach

2.5 oz (1/4 cucumber or 70 g) cucumber, peeled and sliced into discs

2 oz (60 g) California avocado, peeled and seeded, cut into wedges (1/2 of standard-sized avocado)

3 oz (85 g) fresh tomato (a typical roma or small tomato)

1 oz (30 g) walnuts

6 tbsp (90 ml) extra virgin olive oil

2 tbsp (30 ml) vinegar (we used balsamic)

1/4 tsp (1.2 ml) salt

1/4 tsp (1.2 ml) fresh ground black pepper

1/4 tsp (1.2 ml) crushed dried rosemary

diabetic diet, Paleobetic diet, low-carb, seasoning

Like Deborah on “Everybody Loves Raymond,” my wife often makes lemon chicken


First cook the chicken breast over medium heat in a skillet. If you think the meat will stick to the pan, add a smidgen (1/2 tsp or 2.5 ml) of olive oil to the pan. Don’t overcook or the meat will get tough. It’ll take five or 10 minutes.

While that’s cooking, prepare your vinaigrette. In a jar with a lid, place the olive oil, vinegar, salt, pepper, and rosemary, then shake vigorously for 20 seconds. Not 21 or you’ll ruin it. You’re done.

If you use a commercial vinaigrette instead, use one that has no more than 2 g of carbohydrate per 2 tbsp. You may have trouble finding that since so many of the commercial guys add sugar.

Place the lettuce and spinach on a plate then add the cucumber, avocado, tomato, cooked chicken, walnuts, and mandarin orange wedges on top. Drizzle two or three tbsp of the vinaigrette over it (nutritional analysis assumes three). Enjoy.

Servings: 1

(Actually, you’ll have enough vinaigrette left over for one or two more salads or vegetable servings. Save it in the refrigerator.)

Nutritional Analysis:

57 % fat

12 % carbohydrate

31 % protein

710 calories

25 g carbohydrate

10 g fiber

15 g digestible carb

990 mg sodium

1,570 mg potassium

Prominent features: Rich in protein, vitamin A, B6, C, copper, iron, manganese, magnesium, pantothenic acid, selenium, and phosphorus.

low-carb diet, diabetic diet, Paleobetic diet, balsamic vinaigrette,

I like this and use it. The lower left corner says “with EXTRA VIRGIN OLIVE OIL.” In order, the listed ingredients are water, balsamic vinegar, soybean oil and extra virgin olive oil, sugar….  2 tbsp has 3 grams of carb. Which oil would you guess predominates? BTW, balsamic has the most carbs of all the vinegars.

Consider Low-Carb Eating Instead of Drugs for Your GERD

How about this one?

It’s easier to pop a pill than change your diet, especially if someone else is paying for the pills

Dr. Michael Eades has a recent post on gastroesophageal reflux disease (GERD) and it’s treatment with carbohydrate-restricted eating versus drugs. A quote:

Most people who have GERD, have it for the long term. It’s not something that comes and goes. So these folks go on GERD therapy for the long term, and the most prescribed medications for long-term GERD treatment are PPIs [proton pump inhibitors], which, you now know, keep stomach acid neutralized for the long term, and, as you might imagine, creates a host of problems.

The scientific literature has shown long-term PPI therapy to be related to the following conditions:

  • Anemia
  • Pneumonia
  • Vitamin B12 deficiency
  • Impaired calcium absorption
  • Impaired magnesium absorption
  • Increased rate fractures, especially hip, wrist and spine
  • Osteopenia [thin brittle bones]
  • Rebound effect of extra-heavy gastric acid secretion
  • Heart attacks

Read the rest if you or someone you love has GERD. Acid-reducing Nexium is the second most-prescribed drug (by sales) in the U.S. We have stomach acid for a reason. It’s not nice to fool Mother Nature eliminating it.

Here’s a scientific report supporting Dr. Eades’ clinical experience that carbohydrate restriction helps with GERD. Carbs were reduced to 20 grams a day.

Steve Parker, M.D.

European Guidelines Reject Very Low Carbohydrate Diets for Diabetes

Conquer Diabetes and Prediabetes


A recent diabetes treatment guide from European doctors states “there is no justification for the recommendation of very low carbohydrate diets in diabetes mellitus.”

I disagree.

The 2013 guidelines are from the European Society of Cardiology and the European Association for the Study of Diabetes. I compiled the following articles in favor of carbohydrate restriction a couple years ago. You won’t find anything newer listed. Admittedly, all or nearly all of the patients involved had type 2 diabetes, not type 1. We do have a handful involving type 1s.


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Accurso, A., et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutrition & Metabolism, 9 (2008). PMID: 18397522. One of the watershed reports that summarize the major features and benefits, based on 68 scientific references.

Boden, G., et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Annals of Internal Medicine, 142 (2005): 403-411. In these 10 obese diabetics, a low-carb diet spontaneously reduced calorie consumption from 3100 daily to 2200, accounting for the weight loss—1.65 kg (3.63 pounds) in 14 days. Blood sugar levels improved dramatically and insulin sensitivity improved by 75%.

Daly, M.E., et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes—a randomized controlled trial. Diabetes Medicine, 23 (2006): 15-20. Compared with a low-fat/reduced-calorie diet, weight loss was much better in the low-carb group over three months, and HDL ratio improved.

Davis, Nichola, et al. Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes. Diabetes Care, 32 (2009): 1,147-1,152. The Atkins diet was superior—for weight loss and glycemic control—when measured at three months, when compliance by both groups was still probably fairly good. After one year, the only major difference they found was lower HDL cholesterol in the low-carb eaters. 

Elhayany, A., et al. A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Diabetes, Obesity and Metabolism, 12 (2010): 204-209. In overweight type 2 diabetics, a low-carbohydrate Mediterranean diet improved HDL cholesterol levels and glucose control better than either the standard Mediterranean diet or American Diabetes Association diet, according to Israeli researchers.

Haimoto, Hajime, et al. Effects of a low-carbohydrate diet on glycemic control in outpatients with severe type 2 diabetes. Nutrition & Metabolism, 6:21 (2009). DOI: 10.1186/1743-7075-6-21. A low-carbohydrate diet is just as effective as insulin shots for people with severe type 2 diabetes, according to Japanese investigators. Five of the seven patients on sulfonylurea were able to stop the drug. 

Nielsen, Jörgen and Joensson, Eva.  Low-carbohydrate diet in type 2 diabetes: stable improvement of body weight and glycemic control during 44 months follow-up. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-14. Obese people with type 2 diabetes following a 20% carbohydrate diet demonstrated sustained improvement in weight and blood glucose control, according to Swedish physicians. Proportions of carbohydrates, fat, and protein were 20%, 50%, and 30% respectively. Total daily carbs were 80-90 g. Hemoglobin A1c, a measure of diabetes control, fell from 8% to 6.8%. These doctors had previously demonstrated that a 20% carbohydrate diet was superior to a low-fat/55-60% carb diet in obese diabetes patients over six months.

Vernon, M., et al. Clinical experience of a carbohydrate-restricted diet: Effect on diabetes mellitus. Metabolic Syndrome and Related Disorders, 1 (2003): 233-238. This groundbreaking study demonstrated that diabetics could use an Atkins-style diet safely and effectively in a primary care setting.

Westman, Eric, et al. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & Metabolism, 5 (2008). DOI: 10.1186/1743-7075-5-36. Duke University (U.S.) researchers demonstrated better improvement and reversal of type 2 diabetes with an Atkins-style diet, compared to a low-glycemic index reduced-calorie diet.

Yancy, William, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes [in men]. Nutrition & Metabolism, 2:34 (2005). DOI: 10.1186/1743-7075-2-34. A low-carb ketogenic diet in patients with type 2 diabetes was so effective that diabetes medications were reduced or discontinued in most patients. The authors recommend that similar dieters be under close medical supervision or capable of adjusting their own medication, because the diet lowers blood sugar  dramatically.

Yancy, W., et al. A pilot trial of a low-carbohydrate ketogenic diet in patients with type 2 diabetes.  Metabolic Syndrome and Related Disorders, 1 (2003): 239-244. This pioneering study used an Atkins Induction-style diet with less than 20 grams of carbohydrate daily.

So there!

Steve Parker, M.D.

h/t to Reijo Laatikainen for tweeting the European article.