Tag Archives: type 1 diabetes

Another Paleo Diet Success Story For a Type 1 Diabetic

The Joslin Diabetes Blog has details. Lindsay Swanson was diagnosed with type 1 diabetes at age 25. Her initial interest was spurred by years of undiagnosed gastrointestinal issues. She eased into the Paleolithic diet by sequentially eliminating certain food classes, starting with grains, then soy, then legumes. As she did, she felt increasingly better. Lindsay eats few refined carbohydrates. My sense is she doesn’t require much insulin. A quote:

Much to my surprise, my blood sugars completely leveled out, so much so that I rarely need to treat a low blood sugar, and spikes are few and far between….Probably 75 percent of my diet consists of vegetables and plant based food, some with more carbohydrates depending on my activity level. I eat a lot of fat/protein regularly, examples: avocados, coconut oil (in tea and cooking), grassfed meats, bacon (and the reserved fat), oils, nuts, etc.

 

Effects of a Paleo-Style Diet on One Case of LADA

Dietitian Kelly Schmidt has a blog interview with Intrepid Pioneer, who has LADA—Latent Autoimmune Diabetes of Adulthood. LADA is much closer to type 1 than type 2 diabetes, so he’s on insulin. He was inspired initially by a “Whole 30 Challenge.” He makes room for cheese and home-brewed beer; so not pure paleo. Samples:

I was diagnosed May 2011 during my routine annual physical. At that time my blood sugars were up around 360 and my AC1’s ran around 12.3. At first I was treated as if I was a Type 2 with Metformin. The medicine only helped to control my blood sugars down to around 250 or so. At that time my endocrinologist informed me that I probably have LADA or Latent Autoimmune Diabetes, which basically has been coined type 1.5 Meaning I developed adult on-set Type 1. My father has had Type 1 all his life and was diagnosed as a child.

***

Since eating the Paleo lifestyle, and I hate it when one calls it a diet because then it feels temporary, I’ve pretty much stop taking my fast acting mealtime insulin. Meaning I only inject fast acting when I know I’m having Pizza for dinner as a treat, or for a thanksgiving meal, etc. My long acting insulin has reduced by over 10 units since starting this diet. All of that said, Paleo is great and it all tastes so good because it’s real food, but I have found that I also need to exercise, eating Paleo combined with exercise has yielded dynamic results. My endocrinologist was blown away by all that I had done, reduced my insulin injections and basically had my A1C’s in check — my last appointment I was 7.3. Still a bit more to go but the last time I was pushing 9 just six months before.

Read the whole thing (it’s brief).

Has Carbohydrate-Restricted Eating Been Studied in Type 1 Diabetes?

Sweden has lots of blondes

Sweden has lots of blondes

Yes, there are few published scientific reports. Let’s take a close look at one today. (See the references below for more.)

In the introduction to the study at hand, the authors note:

The estimation of the amount of carbohydrates in a meal has an error rate of 50%. The insulin absorption may vary by up to 30%. It is therefor virtually impossible to match carbohydrates and insulin which leads to unpredictable blood glucose levels after meals. By reducing the carbohydrates and insulin doses the size of the blood glucose fluctuations can be minimized. The risk of hypoglycemia is therefore minimized as well. Around-the-clock euglycemia [normal blood sugar] was seen with 40 g carbohydrates in a group of people with type 1 diabetes [reference #2 below].

The immediate resulting stable, near-normal blood glucose levels allow individuals to predict after-meal glucose levels with great accuracy.

For individuals with type 1 diabetes one year audit/evaluation of group education in this regimen has shown that the short-time lowering of mean hemoglobin A1c by 1 percentage unit and the reduction in mean rate of symptomatic hypoglycemia by 82% was maintained [reference #3].

***

There is no evidence for the use of the widely recommended high-carbohydrate, low-fat diet in type 1 diabetes.

Study Set-Up

Swedish investigators educated study participants on carbohydrate-restricted eating from 2004 to 2006 [reference #1]. They recently audited their medical records for results accumulated over four years. At the outset, participants were given 24 hours of instruction over four weeks. My sense is that they all attended the same diabetes clinic. The subjects’ mean age was 52 years and they had diabetes for an average of 24 years. Seven had gastroparesis. Fourteen used insulin pumps. Of the 48 study subjects, 31 were women, 17 were men. The diet regimen restricted carbohydrates to a maximum of 75 grams a day, mainly by reducing starchy food.

Results

As measured three months after starting the diet, HDL-cholesterol rose and triglycerides fell to a clinically significant degree (p<0.05). Average weight fell by 2.7 kg (5.9 lb); average baseline weight was 77.6 kg (171 lb). Hemoglobin A1c fell from 7.6 to 6.3% (Mono-S method).

As measured one year after start, meal-time insulin (rapid-acting, I assume) fell from 23 to 13 units per day. Long-acting insulin was little changed at around 19 units daily.

By two years into the study, half the participants had stopped adhering to the diet. The remainder were adherent (13 folks) or partly adherent (10). We don’t know what the non-adherents were eating.

Four years out, the adherent group had hemoglobin A1c of 6.0%, and the partly adherents were at 6.9% (p<0.001 for both). The non-adherent group had returned to their baseline HgbA1c (7.5%). Remember, at baseline the average HgbA1c for the group was 7.6%.

The authors don’t say how many participants were still adherent after four years. From Figure 2, adherence seems to have been assessed at 60 months: 8 of the 13 adherent folks were still adherent, and 5 of the 10 partly adherent were still in the game. So, of 48 initial subjects, only 13 were still low-carbing after five years later. By five years out, half of all subjects seem to have been lost to follow-up. So the drop-out rate for low-carbers isn’t as bad as it looks at first blush.

Conclusion

The authors write:

An educational program involving a low-carbohydrate diet and correspondingly reduced insulin doses for informed individuals with type 1 diabetes gives acceptable adherence after 4 years. One in two people attending the education achieves a long-term significant HbA1c reduction.

They estimate that this low-carb diet “may be an option for 10-20% of the patients with type 1 diabetes.” Only 17% of their current diabetes clinic population is interested in this low-carb diet. They didn’t discuss why patients abandon the diet or aren’t interested in the first place. Use your imagination.

Major carbohydrate restriction in type 1 diabetics significantly improves blood sugar control (decreases HgbA1c), lowers insulin requirements, and improves cardiovascular disease risk factors (increases HDL cholesterol and lowers triglycerides).

Paleo diets vary in total carbohydrate grams and percentage of calories derived from carbohydrate. Paleo diets tend to be lower in carb than usual Western diets, with 30% of total calories from carbohydrate probably a good rough estimate. The typical American eats 250 to 300 grams of carbohydrate daily, or about 50% of total calories. In the study at hand, the daily carb gram goal was 75, which would be 15% of calories for someone eating 2,000 cals/day.

Low-carb eating wasn’t very appealing to Swedes in the mid-2000s. I wonder if it’s more popular now with the popularity of LCHF dieting (low-carb, high-fat) in the general population there.

Steve Parker, M.D.

References:

1.  Nielson, J.V., Gando, C., Joensson, E., and Paulsson, C. Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: A clinical audit. Diabetology & Metabolic Syndrome, 2012, 4:23. http://www.dmsjournal.com/content/4/1/23

2.  O’Neill, D.F., Westman, E.C., and Bernstein, R.K. The effects of a low-carbohydrate regimen on glycemic control and serum lipids in diabetes mellitus. Metabolic Syndrome and Related Disorders, 2003, 1(4): 291-298.

3.  Nielsen, J.V., Jönsson, E. and Ivarsson, I. A low carbohydrate diet in type 1 diabetes: clinical experience – A brief report. Upsala Journal of Medical Sciences, 2005, 110(3): 267-273.

Life Expectancy for Type 1 Diabetics Much Improved

…but we’ve got a long way to go.

When I started my medical career three decades ago, it was rare to see a type 1 diabetic exceed 60 years of age. Thank God that has been changing for the better! A recent Scottish study found life expectancy in type 1 diabetics, compared to the general population, was 11 years shorter for men and 14 years shorter for women. In 1975, the gap was 27 years. One of the investigators was quoted by the article at MedPageToday:

“There is absolutely no doubt that glucose control is important for long-term outcomes in people with type 1 diabetes.”

From the Framingham Heart Study: Compared to those without diabetes, women and men with diabetes at age 50 died 7 or 8 years earlier, on average. This study population was a mix of type 2 and type 2 diabetes, with type 2 predominating, I’m sure.

Steve Parker, M.D.

“Rich the Diabetic” Is Sold On the Paleo Lifestyle

Click for his testimonial from 2012. Rich is a type 1 diabetic (he uses “diabetic” rather than “person with diabetes”). Rich was influenced by Tom Naughton, Robb Wolf, and Mark Sisson. He dropped his hemoglobin A1c by 2.5 over his first six months of paleo eating. This snippet explains some of his lifestyle changes:

The only thing I changed back in March, was starting to live paleo.  I’ve always worked out regularly, so I’m not really accounting my exercise in this improvement.  I’m probably about 70% paleo overall, but at home I’m 100% paleo.  My home no longer has any processed foods that come in a box, can, or sack.  I buy whole foods (fruits and lots of veggies), a little frozen veggies for convenience and storage time, lots of meat, no dairy, and lots of olive and coconut oil.  I cook a lot now, which means I do a lot more dishes than I want to, but it’s been worth it.

Read the rest.

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.

Type 1 Diabetic Notes Improvement On Paleo Diet

Type 1 PWD (person with diabetes) AllisonN wrote about her one-month paleo diet trial at DiabetesMine. The paleo diet version she followed was the Whole30 program, with which I’m not terribly familiar. Some quotes:

3. I have the best control in recent memory, but it’s not perfect. Like anything that involves tweaking and adjustments, the Paleo diet is hardly a cure. Now that I’m taking less insulin, there are fewer chances for me to go low, and more chances for me to go high. You can never expect anything — not a diet, not a medication, not an insulin pump — to run the show for you.

4. If you eat low-carb, you have to bolus for protein. This was the biggest shock for me. After querying my friends, I discovered that bolusing for approximately half the protein is what I need to do to prevent a post-meal spike. Gary Scheiner, author and CDE at Integrated Diabetes Services, explained, “Since your Central Nervous System needs glucose to function, if your diet is lacking in carbs, the liver will convert some dietary protein into glucose.  So it is usually necessary to bolus for some of your protein whenever you have a meal that is very low in carbs.” For me, a low-carb meal is anything under 30 grams of carbs.

***

One thing that I kept thinking about during my month-long Paleo experiment was how much of diabetes really is an experiment anyway. Think about how often we have to try out different things to see what works: Changing up bolus ratios and basal rates. Fiddling with different temp basals or snack choices before working out. Alternating what we eat for breakfast. While the Paleo diet may not be for everyone, I wholeheartedly believe that if what you’re doing currently isn’t giving you the results you want, maybe you should consider starting another experiment!

AllisonN wrote that the paleo diet hasn’t been studied scientifically in people. That’s not accurate. A handful of studies have been done, even involving people with diabetes. Search this site and you’ll find them. In addition, Lynda Frassetto’s study at University of California-San Francisco should be published later this year.

Read AllisonN’s post.

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.

Calories

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.

Carbohydrates

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.

Fish

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.

Nuts

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.

Proteins

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.

Gluten

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.

Implementation

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.

Aggressive Blood Sugar Control Prevents or Delays Neuropathy in Type 1 Diabetes

I couldn’t find a “neuropathy” picture so enjoy this

Aggressive efforts to control blood sugar either prevent or delay clinical neuropathy in patients with type 1 diabetes, according to the Cochrane Collaboraton as reported in MedPage Today.  Type 2 diabetics showed a strong trend in the same direction, but did not quite reach statistical significance (p=0.06, which is darn close to significant).  Be aware, however, that tight control of diabetes is often at the cost of more frequent episodes of hypoglycemia.

Intensive blood sugar control is also a treatment for established neuropathy.

One in ten diabetics has neuropathy at the time of diagnosis.  After 10 years, four or five of every 10 have it.  The pain of neuropathy is worse than the numbness.

The medical community is still debating how aggressively blood sugars should be managed.

Steve Parker, M.D.

PS: I don’t know what the Cochrane reviewers consider “tight control” because the article is behind a paywall, and the MedPage Today article didn’t address that either.

Reference: Callaghan BC, et al “Enhanced glucose control for preventing and treating diabetic neuropathy” Cochrane Database Syst Rev 2012; DOI:10.1002/14651858.CD007543.pub2.