My Critique of the Joslin Critique of the Paleo 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 Kubal, Franziska 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.