Category Archives: Diabetic Diet

Free Online Paleo Recipes

Sirloin steak, salad, cantaloupe, 3 raspberries

Sirloin steak, salad, cantaloupe, raspberries (on the Paleobetic Diet)

Or paleo-ish anyway.

Most diabetics eating paleo-style need to know how may grams of digestible carbohydrate they’re eating. Their blood sugars will go too high if they eat too many carbs. “Too many” varies from one person to another. Additional nutrient numbers are just icing on the cake. (Oops! Not a good metaphor for a Stone Age diet website.) Other than this site, I’ve only found three other sites that divulge basic nutritional analysis of their free recipes. Several sites listed are primarily low-carb, so you have to see if the recipe you’re interested in fits your definition of paleo.

Before you go, I just want you to consider financially supporting the owners and writers at the following sites. Many of them have books or services for sale. Some have a Donate button. If they can’t bring home the bacon, the websites go down and the recipes go bye-bye.

Recipes With Nutritional Analysis

Catalyst Athletics

Linda’s Low-Carb Recipes

Hold the Toast (I bet Dana Carpender’s “500 Paleo Recipes” book provides basic nutrient analysis.)

Paleo Diabetic

More Recipes (You can do your own nutritional analysis at places like Fitday.)

The Clothes Make the Girl

NomNom Paleo

The Paleo Diet

Julianne’s Paleo & Zone Nutrition (see drop-down menu under Paleo Links, Recipes, and Meals tab)

Everyday Paleo (see drop-down menu under Food tab)

Paleo Food

Paleo Plan

Stalkerville

Perfect Health Diet

Diabetes Warrior

Whole Life Eating

Nell Stephenson

Paleo Diet Lifestyle

Happy hunting!

Steve Parker, M.D.

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.

Large Breakfast High in Protein and Fat Wins Versus Small Breakfast Approach in Type 2 Diabetes

…according to research reported at MedPageToday.  This was a relatively small study with about 30 participants in each treatment arm. A snippet:

Patients in the big-breakfast group were instructed to consume 33% of their daily calories in their morning meal — that included up to 30% protein, up to 37% fat, and the rest in carbohydrates. Patients in the small-breakfast group were instructed to consume 12.5% of their daily calories at breakfast — with up to 70% in the form of carbohydrates.

Average fasting glucose decreased 14.51 mg/dL in the big breakfast group and decreased 4.91 mg/dL in the small breakfast group (P=0.011), she said at the annual meeting of the European Association for the Study of Diabetes.

The big breakfast group also saw a significant drop in systolic blood pressure (almost 10 mmHg), although probably not to the point it created a problem. That fall could help you reduce or avoid high blood pressure drugs.

Read the whole enchilada.

What’s Gestational Diabetes?

You can't tell if she has it just by looking

You can’t tell if she has GD just by looking

In a recent article Amy Campbell over at Diabetes Self-Management defines gestational diabetes and goes over risk factors, diagnosis, and why it’s important. Subsequent posts cover management principles.

Here’s my review from 2010.

In terms of the best diet, a recent study found no significant outcome differences on a 40% carb diet compared to a standard 55% carb diet. I would have guessed the lower-carb diet would be better.

To my knowledge, the paleo diet has never been studied systematically as an approach to gestational diabetes.

European Guidelines Reject Very Low Carbohydrate Diets for Diabetes

Conquer Diabetes and Prediabetes

“Really?”

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.

Enjoy!

♦  ♦  ♦

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.

Physician With Type 1 Diabetes Thriving on Low-Carb Paleo-Style Diet

"Put down the bread and no one will get hurt!"

Could you give up bread for life?

ABC Radio provides the audio and transcript of an interview with Dr. Troy Stapleton, who was diagnosed with type 1 diabetes at age 41. He lives in Queensland, Australia. At the time of his diagnosis, he says…

I was advised to eat seven serves of bread and cereals, two to three serves dairy, fruit, starchy vegetables, and to balance that intake with insulin. If you add up all those serves, they were recommending a diet of up to about 240 grams of carbohydrates a day, and to balance it with insulin. I was going to be the best patient, and there has been some important trials that show that if you do control your blood glucose well then you can reduce your incidence of the complications.

Dr. Stapleton believes we evolved on a very low carbohydrate diet; the Agricultural Revolution led to our current high carb consumption. He was concerned about the risk of hypoglycemia with standard diabetic diets.

There was a different approach where essentially you went on a very low carbohydrate diet, this made a little bit of sense to me. Why would I eat carbohydrates and then have to balance it with insulin?

Here’s what the diabetes educators told him:

What they say is you need to estimate the amount of carbohydrate you’re going to eat, and then you need to match that carbohydrate dose essentially with an insulin dose. So you sort of look at your food and you go, okay, I’m having 30 grams of carbohydrate and I need one unit of insulin per 15 grams of carbohydrate, so two units. It sounds really quite straightforward, except that it’s very, very difficult to estimate accurately the amount of carbohydrate you’re eating. The information on the packets can be out by 20%. Most people say that your error rate can be around 50%.

And then of course it changes with what you’ve eaten. So if you eat carbohydrates with fat and then you get delayed absorption, then that glucose load will come in, and then the type of carbohydrates will alter how quickly it comes in to your bloodstream. And then of course your insulin dose will vary, your absorption rate will vary by about 30%. Once you think through all the variables, it’s just not possible. You will be able to bring your blood glucose under control, but a lot of the time what happens is you get a spike in your glucose level immediately after a meal, and that does damage to the endothelium of your blood vessels…

Norman Swan: The lining.

Troy Stapleton: That’s correct, it causes an oxidative stress to your endothelium, and that is the damage that diabetes does, that’s why you get accelerated atherosclerosis.

Here’s what happened after he started eating very low carb:

It’s been amazing, it’s been the most remarkable turnaround for me and I just cut out carbohydrates essentially completely, although I do get some in green leafy vegetables and those sorts of things. My blood sugar average on the meter has gone from 8.4 [151 mg/dl] down to 5.3 [95 mg/dl]. My HbA1c is now 5.3, which is in the normal range. My blood pressure has always been good but it dropped down to 115 over 75. My triglycerides improved, my HDL improved, so my blood lipid profile improved. And I would now have a hypoglycaemic episode probably about once a month after exercise. [He was having hypoglycemia weekly on his prior high carb diet with carb counting insulin adjustments.]

He was able to reduce his insulin from about 27 units a day down to 6 units at night only (long-acting insulin)! He admits his low insulin dose may just reflect the “honeymoon period” some type 1s get early on after diagnosis.

Norman Swan: So when you talk to your diabetes educator now, what does he or she say?

Troy Stapleton: Look, they’re interested, but they’ll tell me things and I’ll say, well, that’s actually not true. I’m quite a difficult patient, Norman.

He says he’s eating an Atkins-style diet. Combining the transcript and his notes in the comments section:  1) he doesn’t eat potatoes or other starchy vegetables or bread, 2) he eats meat, eggs, lots of non-starchy vegetables, some berries and tree nuts, olives, and cheese, 3) an occasional wine or low-carb beer, 4) coffee, and 5) he eats under 50 g/day of carbohydrate, probably  under 30 g. This is a low-carb paleo diet except for the cheese, alcohol, and coffee.  Cheese, alcohol and coffee are (or can be) low-carb, but they’re not pure paleo.

He notes that…

There is an adaption period to a very low carbohydrate diet which takes 4–6 weeks (ketoadaption). During this time symptoms include mild headaches, lethargy, cramps, carb cravings and occasional light headedness. These symptoms all pass.

Read or listen to the whole thing. Don’t forget the comments section. All the blood sugars you see there are in mmol/l; convert them to mg/dl (American!) by multiplying by 18.

Steve Parker, M.D.

No Great Benefit to Carb Counting Compared to Other Insulin-Dosing Methods

…according to an article at MedPageToday. Briefly, carb counting involves estimating the digestible carbohydrate grams in a meal (often called net carbs), then dosing rapid-acting insulin based on those grams and the individual’s prior responses to insulin. It turns out there’s not a lot of hard clinical evidence to back up the practice. A quote from the article:

Carbohydrate counting is the best known method for matching insulin dosing to meals, and is the recommended dietary strategy for achieving glycemic control in type 1 diabetes, though that recommendation has been largely based on expert consensus, Bell said.

One commentator said it doesn’t work very well because most folks aren’t very good at it, they’re not vigilant enough. Why do we so often want to blame the patient?

A review panel “compared carbohydrate counting with usual care, which consisted of either general nutrition advice or low dietary glycemic index (GI) advice.” They found no significant differences in hemoglobin a1c between the approaches.

Read the rest.

Dr. Richard Bernstein on the Paleo Diet for Diabetes

DiabetesHealth has a brief article on Dr. Bernstein’s view of the Paleolithic diet. They quote him thusly:

There’s no way the ADA [American Diabetes Association] diet or any high-carbohydrate and low-fat diet will enable you to control blood sugars. It turns out that the kind of diet I recommend is essentially a Paleolithic diet, which is what humanity evolved on. Our ancestors did not have bread, wheat, sweet fruits, and all of the delicious things that we have today. These have been specially manufactured for us nowadays. For food, our ancestors had a paucity of roots, some leaves, and principally meat to eat. If they lived near the shore, they had fish.

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.

My Critique of the Joslin Critique of the Paleo Diet

paleo diet, Paleolithic diet, hunter-gatherer 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 KubalFranziska 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.