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.

8 responses to “The Case for Carbohydrate Restriction In Diabetes

  1. It is not just carbs that are a problem but the type of carbs – complex carbs that are metabolised slowly as from root vegetables have a beneficial metabolic outcome. Refined carbs (novel foods in terms of our physiology) cause glycaemic spikes and over production of insulin – hyperglycaemia and ultimately hypoglycaemia. Complex carbs do not give the hyper/hypo swings which upset glucose tolerance and are pro inflammatory.

    The other aspect of this is that most carbs that are a problem come from grains which are high in lectins not designed to be used by humans. Lectins bind to leptins, upset glucose tolerance and satiety mechanisms are pro inflammatory and incite platelet aggregation – they totally disrupt cell and body metabolism. We tolerate them to a greater or lesser degree depending on our overall health.
    So the best answer for most Western Diseases including type 2 diabetes is the Paleolithic Diet – free from grain lectins, dairy and all the foods that were not available when our physiology evolved in hunter gatherer times.

    Give the body what it needs for health and you will be surprised – many seemingly intractable problems will just disappear!

    • Hi, Amanda.
      I wonder if you find glycemic index helpful. I tend to think it is, with diabetics better off avoiding the higher GI foods. I vaguely recall at least one study, however, finding that low-GI eating was no better than regular-GI.
      A baked potato would be considered a complex carb yet its GI is a high 85 ( Quite a few of my patients have told my their sugars go too high if they eat potatoes. It depends, of course, on how much is eaten and what else is in the meal, along with numerous other factors.


  2. Reblogged this on What Do You Mean I Can't Eat Red Vines? and commented:
    Great and insightful post.

  3. Thank you for crediting Dr John Rollo; the earliest case i knew of before this was when adventurer Josiah Harlan treated diabetes on the north-west-frontier of india by the method of “abstaining from vegetable food” in the late 1820s. Harlan was self-educated by study of medical encyclopedias, so Rollo’s work must have been quite well known by then.
    I found it interesting that diabetes was known in this part of the world, among men rich enough to afford fruit gardens and sugar, despite a pre-western diet.

  4. Another wonderful post, Steve. Adding to your response to Amanda above, from my own experience, even small amounts of root vegetables like potatoes, yams, etc. spike my blood sugar. I tried eating these foods for a few months and my postprandial numbers did not improve. However, I’ve observed far less of a glycemic impact from Greek yogurt, provided I keep the serving size reasonable (1/2 to 1 cup). I think we’re all so unique in terms of how our bodies respond to various foods, and we should experiment to find a way of eating that works best, tweaking it as needed as things change over time.

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