Category Archives: Dietary Carbohydrate

Why Can’t You Score a Great Hemoglobin A1c?

Is this device from 20 years ago?

The good folks over at Diabetes Daily conducted a survey of people with diabetes to find out what they were doing to get good HgbA1c levels. HgbA1c is a measure of average blood sugar levels over the prior three months. Lower HgbA1c levels, generally speaking, are linked to fewer diabetes complications. Prevention is always better than treatment. If you run across someone succeeding at anything, wouldn’t you want to know how they do it, assuming it’s a goal you share?  I recommend the entire report to you. An excerpt:

Type 2 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to:

  • Eat a very low-carbohydrate diet (<40 g per day): 32% vs. 13%
  • Eat a ketogenic diet (<20 g per day): 13% vs. 0%
  • Not vary their daily carbohydrate intake: 16% vs. 29%
  • Eat a low-carbohydrate lunch (<20 g) on a regular basis: 50% vs. 28%
  • Use an insulin pump: 10% vs. 3%
  • Vary the timing of their meal-time insulin: 53% vs. 40%
  • Exercise: Daily: 14% vs 8%. Exercise 4-6 times per week: 20% vs 8%.Exercise less than once per week: 51% vs 73%
  • Feel very confident about their diabetes management skills: 69% vs. 26%
  • Feel very optimistic about their long-term health: 58% vs. 30%
  • Feel that diabetes doesn’t greatly interfere with their daily life: 56% vs. 19%
  • Report a high degree of socioemotional support related to diabetes: 59% vs. 46%

Type 1 Diabetes

Those in the lower A1c bracket (<6.5%) are significantly more likely than those with a higher A1c (>8%) to:

  • Eat a very low-carbohydrate diet (<40 g per day): 22% vs. 7%
  • Not vary their daily carbohydrate intake: 9% vs. 28%
  • Use an insulin pump: 71% vs. 53%
  • Wear a continuous glucose monitor (CGM): 76% vs. 60%
  • Have lower “high glucose alert” setting on their CGM
  • Have lower “low glucose alert” settings on their CGM
  • Not vary the timing of their meal-time insulin: 43% vs. 59%
  • Incorporate the protein content of their meal in determining their bolus insulin dose: 44% vs. 23
  • Eat similar food every day, at similar times, AND limit eating out at restaurants: 20% vs. 7%
  • Exercise: Daily: 21% vs 11%. Exercise 4-6 times per week: 24% vs 8%. Exercise less than once per week: 40% vs 66%
  • Feel very confident about their diabetes management skills: 82% vs. 39
  • Feel very optimistic about their long-term health: 59% vs. 42el that diabetes doesn’t greatly interfere with their daily life: 35% vs. 21%
  • Report a high degree of socioemotional support related to diabetes: 68% vs. 56%

Source: Habits of a Great A1c Survey Data Report – Diabetes Daily

Lead researcher was Maria Muccioli, PhD.

Steve Parker, M.D.

PS: The Paleobetic Diet provides 40–80 g of digestible carbs daily. For 20–40 g/day, check out my Low-Carb Diabetic Mediterranean Diet.

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Low-Carb Eating for Diabetes Is Taking Off in the U.K.: Dr David Unwin Explains

 

diabetic diet, Paleobetic diet, diabetes,

Sunny’s Super Salad

The Diet Doctor website posted a video interview of Dr David Unwin (in the U.K.) discussing his experience with low-card diets in folks with diabetes (type 2, I assume). If  you’re short on time, just read the transcript. Thanks, Diet Doctor!

I took note of Dr Unwin’s transformation from a run-of-the mill follow-the-herd practitioner to a low-carb advocate. This happened around 2012 when Dr Unwin was 55 years old and on the threshold of retirement. Here it is:

Dr David Unwin speaking: ….There was one particular case I’ve talked about before where there was a patient who – so in 25 years I’d never seen a single person put their [type 2] diabetes into remission, I had not seen it once. I didn’t even really know it was possible.

Dr Bret Scher speaking:  We were not [taught] that it’s possible.

Dr Unwin:  No, my model was that the people with diabetes… It was a chronic deteriorating condition and I could expect that they would deteriorate and I would add drugs and that’s what would be normally going to happen. And then one particular patient wasn’t taking her drugs and she actually went on the low-carb diet and put her diabetes into remission.

But she confronted me with, you know, “Dr. Unwin, surely you know that actually sugar is not a good thing for diabetes.” “Yes, I do.” But then she said, “But you’ve never once in all the years mentioned that really bread was sugar, did you.” And, you know, I never did. I don’t know what my excuse was. So this this lady had done this wonderful thing and she’d also changed her husband’s life as well.

She’d sorted his diabetes out and she’d done it with a low-carb diet and that really made me think I didn’t know much about it. I didn’t know much about it. So I found out what she’d been on… on the low-carb forum of diabetes.co.uk and to my amazement there was 40,000 people on there, all doing this amazing thing. And I was blown away but then I was very sad because the stories of the people online were full of doctors who are critical of these people’s achievements.

***

Dr Unwin: And that original case that showed me you could put into remission; if you could repeat that, how wonderful for people… And when I now – because I think we’ve done 60 patients who put their type 2 diabetes into remission. So I’m able to say with confidence to people, you know, you stand a good chance. In fact I can say that of my patients who take up low-carb, about 45% of them will put their diabetes into remission which is amazing.

At no point does the transcript indicate they’re talking about type 2 diabetes rather than type 1, but that must be the case. Nor does it mention the amount of required carbohydrate restriction. I figure it’s between 20 and 100 grams/day of digestible carbohydrate, depending on one’s metabolic health and how many years of diabetes.

I’ve mentioned Dr Unwin before.

Source: Diet Doctor Podcast #33 – Dr. David Unwin – Diet Doctor

Steve Parker, M.D.

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2019 ADA Conference Recommendations on Medical Nutrition Therapy (Diet)

Shrimp Salad

I’m astounded by how many people with diabetes I meet who pretty much eat whatever they want. Others, when I ask if they’re on a particular diet, say, “I watch what I eat.” Which usually just means avoiding obvious sugar bombs.

The American Diabetes Association in 2019 hosted a conference on nutrition therapy for diabetes. I assume the ADA endorses the panel’s recommendations. The big news is continued movement toward carb-restricted eating. Some excerpts:

Today, there is strong evidence to support both the efficacy and cost-effectiveness of nutrition therapy as a key component of integrated management of individuals with diabetes. This is increasingly relevant as it is evident that “one-size-fits-all” eating plan is not suitable for prevention or management of diabetes, also considering diverse cultural backgrounds, personal preferences, comorbidities, and socioeconomic settings. The American Diabetes Association (ADA) is now emphasizing that medical nutrition therapy (MNT) is fundamental for optimal diabetes management, and the new report also includes information on prediabetes.

***

One of the key recommendations is to refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT [medical nutrition therapy] at diagnosis and as needed throughout the life span, particularly during times of changing health status to achieve treatment goals.

***

The new consensus recommendations consider that a variety of eating patterns are acceptable for the management of diabetes.

In the absence of additional strong evidence on the comparative benefits of different eating patterns in specific individuals, healthcare providers should focus on the key factors that are common among the patterns, including emphasizing non-starchy vegetables, minimizing added sugars and refined grains, and preferring whole foods over highly processed foods.

Reducing overall carbohydrate intake for individuals with diabetes is associated with the most evidence for improving glycemia and may be applied in a variety of eating patterns.

For selected adults with type 2 diabetes who are not meeting glycemic targets or where reducing anti-glycemic medications is a priority, reducing overall carbohydrate intake with low or very low carbohydrate eating plans is also a viable approach.

***

Regarding weight loss in overweight or obese folks with diabetes or prediabetes:

…a low carbohydrate diet is now recognized as a safe, viable, and important option for patients with diabetes, and the other is that greater emphasis is now placed on weight loss in patients who are overweight/obese for the prevention of diabetes and its treatment.

Indeed, in type 2 diabetes, 5% weight loss is recommended to achieve clinical benefits, with a goal of 15%, when feasible and safe, in order to achieve optimal outcomes.

In prediabetes, the goal is 7–10% for preventing progression to type 2 diabetes.

“Metabolic surgery,” better known as bariatric surgery, and medication-assisted weight loss (aka weight-loss drugs) should be considered in some cases.

***

Best approach for optimizing blood sugars:

For macronutrients, the available evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.

[Self-monitoring of carbohydrate consumption is important.]

People with diabetes and those at risk for diabetes are encouraged to consume at least the amount of dietary fiber recommended for the general population; increasing fiber intake, preferably through food (vegetables, pulses (beans, peas, and lentils), fruits, and whole intact grains) or through dietary supplement, may help in modestly lowering HbA1C.

***

What about sugar-sweetened beverages?

Firstly, sugar-sweetened beverages should be replaced with water as often as possible.

Secondly, if sugar substitutes are used to reduce overall calorie and carbohydrate intake, people should be counseled to avoid compensating with intake of additional calories from other food sources.

***

Is alcohol forbidden? No.

…educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended.

To reduce hypoglycemia risk, the importance of glucose monitoring after drinking alcohol beverages should be emphasized.

Steve Parker, M.D.

PS: I note that William Yancy, M.D., was on the expert panel.

PPS: Bold emphasis above is mine.

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The Low-Carb Diabetes Diet Revolution

Dr Maria Muccioli looks at low-carb diet approaches to type 1 diabetes in part 1 of a series at Diabetes Daily:

Not long ago, low-carbohydrate diets were considered to be on the fringes of medically-recommended strategies for diabetes control. Long regarded as a “fad diet” and with the health effects often called into question, many patients were routinely discouraged from attempting such an approach. However, in recent years, as more and more research demonstrated the potential benefits of a low-carbohydrate approach for people with diabetes and prediabetes, we have seen a rapid change in the nutritional guidelines and the professional recommendations for patients.

At the 79th American Diabetes Association (ADA) Scientific Sessions, we saw a symposium addressing the changes in the nutrition consensus report for adults with diabetes. Notably, a one-size-fits-all approach is no longer recommended, with experts suggesting now that various eating strategies and macronutrient distributions can work well for patients from a nutritional and glycemic control perspective. Moreover, low-carbohydrate diets were explicitly addressed as a relevant and effective strategy, that is “garnering more attention and support”, as per Dr. William S. Yancy, MD, MHS, who chaired the symposium titled “Providing Options – Using a Low-Carbohydrate or Very Low-Carbohydrate Diet with Adults with Type 1 Diabetes, Type 2 Diabetes or Prediabetes”. In this series, we explore the research and surrounding conversations regarding low-carbohydrate approaches for these distinct patient subgroups.

RTWT.

Source: The Low-Carb Diabetes Revolution (Part I): Type 1 Diabetes (ADA 2019) – Diabetes Daily

Steve Parker, M.D.

PS: Many paleo diets are lower-carb than the standard American diet, and nearly all are low-glycemic index. The Paleobetic Diet provides approximately 60 grams/day of digestible carbohydrate.

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Verner Compares Dr David Unwin’s and Diabetes UK’s Diet Advice for T2 Diabetes

Shrimp Salad

Low-carb vs standard “diabetic diet”:

The most significant fact to emerge is that those who follow the advice of Dr [David] Unwin are so often successful.

In a paper published in 2016, Dr Unwin presents the results for 68 out of 69 patients who had completed an average of 13 months, in which they had complied with the lifestyle advice:

(1) Patient satisfaction was high from reports of feeling better and having more energy. Mean body weight fell by 9.0 kg [20 lb], waist circumference fell by 15 cm [6 inches], blood glucose (BG) control measured as HbA1c, fell by 10 mmol/mol or 19%, liver function measured as serum glutamyl transferase (GGT) improved by 39% and total cholesterol (TC) fell by 5%. Systolic and diastolic BPs dropped significantly too. Plasma triglycerides were not measured, but in common with prior observations for low-carbohydrate diets a significant improvement would have been anticipated.From the perspective of the practice, there has been a huge saving in the expenditure on drugs used for the treatment of diabetes. The actual figure is about £38,000 [$51,000 US dollars] per year against the regional average, which represents the lowest spend per 1000 patients in any of the 19 surgeries in the surrounding Southport (UK) and Formby area for which information was available. This saving should be seen against the extra costs of the Norwood Surgery diabetes intervention at just under £9,000 per year.

(2) There has also been an improvement in the obesity prevalence as determined by BMI. This has dropped from 9.4% before the initiative commenced to 8.4%. The National Health Survey for England shows that for adults there has been a steady increase in the prevalence of obesity in England between 2010 and 2015.

Source: 305. A Comparison between the approaches to Type 2 Diabetes (T2D) by Dr David Unwin and Diabetes UK | Verners Views

RTWT for diet details.

PURE Study: High Carb Consumption Increases Risk of Death

How many innocent lives will be cut short by this tasty but silent killer?

Here’s the abstract of a new epidemiological study that investigated the relationships between diet, cardiovascular disease, and death rates. I don’t have the entire article. My sense is that the 18 countries studied are mostly non-Western:

Background

The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear.

Methods

The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35–70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3–9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering.

paleo diet, paleolithic diet, caveman diet

“Do you understand the words that are coming out of my mouth?”

Findings

During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12–1·46], ptrend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67–0·87], ptrend<0·0001; saturated fat, HR 0·86 [0·76–0·99], ptrend=0·0088; monounsaturated fat: HR 0·81 [0·71–0·92], ptrend<0·0001; and polyunsaturated fat: HR 0·80 [0·71–0·89], ptrend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64–0·98], ptrend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality.

Interpretation

High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings.

Source: Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study – The Lancet

Official Diabetic Diet Takes a Hit in the U.K.

DailyMail.com has a few of the details. A snippet:

More than 120,000 people signed up to a ‘low-carb’ diet plan launched by the forum diabetes.co.uk in a backlash against official advice.
More than 80,000 of those who ditched a low-fat high-carbohydrate diet found their blood glucose level drop after ten weeks.
By rejecting official guidelines and eating a diet high in protein and low in starchy food – along with ‘good saturated fats like olive and nuts – more than 80 per cent of the patients said they had lost weight.

An article at The Times says, “The results have led doctors to call for an overhaul of official dietary guidelines.”

Regular readers here won’t be surprised by these findings.

The road to this revolution is paved with scientific studies showing that dietary saturated fat has little or nothing to do with causing cardiovascular disease. I crossed that Rubicon in 2009.

If you want the benefits of low-carb eating, check out my free Paleobetic Diet. The book is even better.

Steve Parker, M.D.

PS: If you think carbs are bad, my books have zero digestible carbs. Unless you’re a termite.

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Increase in consumption of refined carbohydrates and sugar may have led to the health decline of the Greenland Eskimos 

Not much edible carbohydrate this time of year...

Not much edible carbohydrate this time of year…

From Dr. James Dr. DiNicolantonio:

“In conclusion, an increase in the intake of refined carbohydrate and sugar paralleled the rise in atherosclerotic disease in the Greenland Eskimos. While the total carbohydrate intake of the Greenland Eskimos was just 2–8% of total calories in 1855, this increased to around 40% of calories by 1955.5 The Greenland Eskimos studied by Bang and Dyerberg in the 1970s no longer consumed a traditional healthy Eskimo diet. Indeed, the intake of refined sugar in the Greenland Eskimos increased by almost 30-fold from 1855 (6 g/person/day or around 1½ teaspoonful of sugar) to the 1970s (164–175 g or around 40–44 teaspoonful of sugar). Moreover, the intake of refined carbohydrate increased 5–7-fold from 1855 (18 g/day from bread) to the 1970s (84–134 g/day from bread, biscuits and rye flour).

In summary, the intake of refined carbohydrate and sugar by the Greenland Eskimos increased in parallel to the rise in atherosclerotic disease. Considering that a similar event occurred in the USA and that the overconsumption of refined sugar is a principal driver of type 2 diabetes, hypertension, and coronary heart disease, this most likely explains the health decline of the Greenland Eskimos.”

Source: Increase in the intake of refined carbohydrates and sugar may have led to the health decline of the Greenland Eskimos — DiNicolantonio 3 (2) — Open Heart

Is Insulin Making You Hungry All the Time?

So easy to over-eat!

So easy to over-eat! Is it the insulin release?

No, insulin probably isn’t the cause of constant hunger, according to Dr. Stephan Guyenet. Dr. G gives 11 points of evidence in support of his conclusion. Read them for yourself. Here are a few:

  • multiple brain-based mechanisms (including non-insulin hormones and neurotransmitters) probably have more influence on hunger than do the pure effect of insulin
  • weight loss reduces insulin levels, yet it gets harder to lose excess weight the more you lose
  • at least one clinical study (in 1996) in young healthy people found that foods with higher insulin responses were linked to greater satiety, not greater hunger
  • billions of people around the world eat high-carb diets yet remain thin

An oft-cited explanation for the success of low-carbohydrate diets involves insulin, specifically the lower insulin levels and reduced insulin resistance seen in low-carb dieters. They often report less trouble with hunger than other dieters.

Here’s the theory. When we eat carbohydrates, the pancreas releases insulin into the bloodstream to keep blood sugar levels from rising too high as we digest the carbohydrates. Insulin drives the bloodstream sugar (glucose) into cells to be used as energy or stored as fat or glycogen. High doses of refined sugars and starches over-stimulate the production of insulin, so blood sugar falls too much, over-shootinging the mark, leading to hypoglycemia, an undeniably strong appetite stimulant. So you go back for more carbohydrate to relieve the hunger induced by low blood sugar. That leads to overeating and weight gain.

Read Dr. Guyenet’s post for reasons why he thinks this explanation of constant or recurring bothersome hunger is wrong or too simplistic. I agree with him.

The insulin-hypoglycemia-hunger theory may indeed be at play in a few folks. Twenty years ago, it was popular to call this “reactive hypoglycemia.” For unclear reasons, I don’t see it that often now. It was always hard to document that hypoglycemia unless it appeared on a glucose tolerance test.

Regardless of the underlying explanation, low-carb diets undoubtedly are very effective in many folks. And low-carbing is what I always recommend to my patients with carbohydrate intolerance: diabetics and prediabetics.

Steve Parker, M.D.

front cover

front cover

One Man’s N=1 Experiment Comparing Lower- Versus Moderate-Carb Diet For His Diabetes

Use the search box to find the recipe for this low-carb avocado chicken soup

Use the search box to find the recipe for this low-carb avocado chicken soup

Read his amazingly detailed post at Diatribe. Adam, who has type 1 diabetes, figured out during his college days that eating no more that 30 grams of carbs at a time was “a complete gamechanger” for improving his blood sugars. He experimented on himself to see if there was a difference between his usual lower-carb diet (146 grams/day) versus 313 grams/day.

A quote:

To my utter surprise, both diets resulted in the same average glucose and estimated A1c. But there were major tradeoffs:

The higher-carb, whole-grain diet caused four times as much hypoglycemia, an extra 72 minutes per day spent high, and required 34% more insulin. (A less healthy high-carb diet would have been far worse.)

Doubling my daily carbs also added much more effort and produced far more feelings of exhaustion and diabetes failure. It was not fun at all, and the added roller coaster, or glycemic variation, from all the extra carbs made it more dangerous.

See more at: http://diatribe.org/low-carb-vs-high-carb-my-surprising-24-day-diabetes-diet-battle#sthash.pZOgCWVl.dpuf

I think the lower-carb approach is healthier over the long run. Check with your own healthcare provider before making any drastic change in your diabetic diet.

Steve Parker, M.D.

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