More on low carb and diabetes

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Last week I wrote a short piece on low carb and diabetes, specifically Type 1 diabetes. That’s the diabetes where the body can’t produce insulin (aka Diabetes Mellitus or T1DM).

Conventional wisdom has it that people with T1DM should eat a decent amount of carbs (200+ grams a day), which is a fair bit, and you match the insulin you inject to cope with that carb load.  The trouble is that:

  1. It’s really hard to exactly match the insulin to the glucose load
  2. Operating like this means that you will be constantly hyperinsulinemic (high insulin) which causes long term damage to the diabetic.  This is the same problem that Type 2 diabetics have.  They are insulin resistant in the first instance, so they simply produce their own high insulin and that’s the health risk of Type 2 diabetes.

I also commented on a series on ABC’s Radio National Health Report. The item in the first week was an interview with Gary Taubes (well known author and low carb expert) and an interview with a Type 1 diabetic getting excellent outcomes on low carb.

The second week was a response form Dr Maartan Kamp a diabetes expert. He was completely condescending and paternalistic to the point of being embarrassing.  He said that he would never promote low carb diets for diabetics because people wanted to eat normally.

I am writing this blog because I have been surprised by  the voracity of the comments and emails I have received about the medical profession and diabetes. Common medical profession – do your reading and get your act together.  Snap out of it!

Here’s a note from a Type 1 diabetic

I’ve been type 1 since 1970 and my initial diabetic diet was relatively low-carb — at least compared with what in the Eighties was conventional wisdom. I spent decades eating cereal with skimmed milk and pasta with marinara sauce and being told by board-certified endocrinologists that I just needed more exercise and more insulin to get my hemoglobin A1c under 10.5 or so. The culmination was Symlin, an expensive synthetic relative of amylin that left me nauseated every waking moment but helped a little, partly by slowing digestion and partly by making me too nauseated to eat much. About five years ago I went low-carb and when I belatedly saw my endocrinologist he was pleased that my A1c was around 8 but insisted that the human brain cannot function on under 100g of dietary carbs a day. Now my A1c runs around 6.5 and I’m still overweight but my complications are getting no worse. My hatred for the American Diabetes Association is boundless.

Here’s one from a doctor practicing low carb with diabetes

Speaking from the coal face of General Practice, using a lower carb “real food” approach is incredibly successful in controlling type I DM. Done right, most end up on a smallish dose of long-acting insulin at night, with very little or no need for any short-acting boluses during the day. Great Hba1c, low triglycerides, high HDL. The only problem is the patient having to nod along to their endocrinologist and specialist nurse, and casually omit informing them of what they’re really doing. Sad state of affairs

Here a note from Catherine Crofts – a doctoral student and pharmacist who really got mad at the medical profession’s attitude.

Following up Maartan Kamp’s response to the people with diabetes not being advised to follow a low carbohydrate diet because it essentially limit their food choices raises some really interesting inconsistencies within the health field but also some important questions around informed choice.  With respect to dietary advice for people with diabetes, what he said was  “So what we attempt to do is actually allow people to continue to live their life the way they wish, eat the way they wish.”

People who suffer from gout (painful swelling in the joints, also known as gouty arthritis) are routinely recommended to avoid purine rich foods.  The alternative is to continually suffer from gout attacks that may lead to one or more joints being crippled.   Will this dietary change have significant social implications?  Almost undoubtedly – many men really grumble if you ask them to limit their bread, red meat and beer intake.  While medication can treat or prevent gout, the important point is these people are always given the information that changing their diet can reduce the frequency of gout attacks.   Whether they choose to follow the advice is up to them.

As a pharmacist, I have counselled many patients with this dietary advice and provided printed  information for them to take home – sometimes with graphic pictures with the consequences of untreated gout.   The threat of amputations, or not being able to run around with the children/grandchildren in the future can be a good motivator for change.

People with coeliac disease must avoid all foods containing gluten to avoid severe gastro-intestinal upset.  Again, these people are given strict counselling as to what foods they need to avoid and again, the consequences of what will happen if they don’t follow this advice.  People with coeliac disease usually become very good at avoiding all trace of gluten, (bread or anything with flour, wheat or some other grains, many processed foods).  I also get quizzed from some patients as to the presence of gluten in medications and other health products.

Children with severe epilepsy are often recommended to follow a very strict ketogenic diet as it is proven to reduce the risk of seizures.  Many of these children become seizure free and their parents go to some pretty extreme lengths to maintain this diet…now a lifestyle for them.

There are other examples, but these people cannot “continue to live their life the way they wish, eat the way they wish” if they want to stay healthy and disease free. 

Ironically, adults who develop late-onset seizures are not offered the same dietary treatment as children as for some reason adults are deemed by the medical profession to be unable to adhere to the dietary advice.   Sure, many won’t be able to as it is not easy, but surely they should be given the chance?

This brings in then the interesting question of informed consent.  People have to consent to having any medical treatment based on a clear understanding of the facts, implications and consequences both on for the immediate and future concerns.  Sufficient information needs to be provided to allow someone to make that informed consent.  If insufficient information is provided, it can raise some serious ethical questions.

What Dr Kamp said smacks of “let’s not tell the people of a possible non-drug option because they can’t stick to it, so we won’t even given them the chance to try”.  That attitude is simply condescending and paternalistic.  The bigger question is whether it is ethical?

I have to agree Catherine and so does someone on the ABC site:

Listening to Dr Kemp, one wonders how many patients with either type I or type II diabetes get the benefit of ‘informed consent’, so that before they rely on insulin, exercise and calorie reduction they are informed that a low carb diet is an optional pathway.

7 comments

  1. The more I listen and read, the more I sense that diabetics and pre-diabetics in Australia and elsewhere are being dudded by the unhelpful advice they are getting from state and national diabetes organisations.

    In this case, the advisor is more concerned that diabetics be free to keep eating junk refined carbs as a “lifestyle choice” than for sufferers to be informed that their condition and insulin-needs could be downsized dramatically simply by eating mainly meat, fish, eggs, cheese, nuts and green vegetables, avocados, tomatoes, etc.

    Of course, there is no great hardship involved in such a “lifestyle change”. It’s essentially a shift to eating wholefoods rather than the processed junkfoods that are making the world fat and sick. It’s something most of the world will need to do, if global obesity and type 2 diabetes is ever going to be reversed.

    Awkwardly, the benefits from embracing such a low-carb, wholefood diet will bring a growing realisation that much of the standard nutrition advice on offer from diabetes organisations globally is lightweight and unhelpful, in my opinion.

    Yes. I have a big bee in my bonnet about what I consider to be the poor dietary advice given to Australian diabetics and pre-diabetics. Typically, that standard advice is to eat heaps of refined carbs.

    For example, check out pages 2 to 7 of the Australian Diabetes Council’s (ADC’s) high-carb, so-called “healthy food choices” advice: http://www.australiandiabetescouncil.com/ADCCorporateSite/files/0f/0f5f0ab9-55da-45b5-9481-89f082333b6f.pdf

    That advice is that dissimilar to the University of Sydney’s high-carb, low-GI (Glycemic Index) products promoted as “Healthy Choices” : pp. 10-11 at http://www.gisymbol.com.au/cmsAdmin/uploads/Glycemic-Index-Foundation-Healthy-Choices-Brochure.pdf

    What is little-known is that GENUINELY low-GI diets actually ARE low-carb diets: fresh meats, fish, eggs, cheese, green leafy vegetables, avocados, tomatoes, etc.

    Minimal GI, minimal GL. And no low-GI Healthy stamps required.

    Do Australia’s diabetics and pre-diabetics really benefit from the Head of Research at the ADC – also a spokesman for pro-sugar Dietitians Association of Australia and the Chief Scientist of the University of Sydney’s pro-sugar Glycemic Index business – selling Healthy stamps for processed carbohydrates – including particular brands of sugar and sugary products – to food companies for up to $6,000 a pop? (p.5) http://www.foodhealthdialogue.gov.au/internet/foodandhealth/publishing.nsf/Content/D59B2C8391006638CA2578E600834BBD/$File/Resources%20and%20support%20for%20reformulation%20activities.pdf

    2. ACTIVITIES BASED ON FALSE VIEW THAT SUGAR IS NOT A HEALTH HAZARD

    Readers, notice that the view “added sugar is not a problem” is embedded in low-GI crew’s “strict nutrition criteria” on page 5 of that reformulation link above.

    Unfortunately, it is clear that modern rates of sugar consumption (100% carbs) – including via sugary drinks – ARE a major problem, being a key driver of both obesity and type 2 diabetes: http://care.diabetesjournals.org/content/33/11/2477.full.pdf

    And yet the ADC’s Head of Research – with the help of his boss at the University of Sydney’s low-GI enterprise – has published and defended a spectacularly faulty paper recklessly (falsely) seeking to exonerate modern sugar consumption as a key driver of obesity: http://www.australianparadox.com

    Similarly, the ADC’s Head of Research and his boss at the University of Sydney’s low-GI business have falsely exonerated added sugar as a cause of type 2 diabetes in their pop-sci diet books: http://www.australianparadox.com/pdf/diabetes.pdf

    Now, let’s see if I have this right:

    x Refined sugar clearly is a menace to public health, a key driver of obesity and type 2 diabetes: http://care.diabetesjournals.org/content/33/11/2477.full.pdf and http://www.nytimes.com/2011/04/17/magazine/mag-17Sugar-t.html?pagewanted=all&_r=0

    x And yet the ADC’s Head of Research operates a business around the assumption that sugar is NOT a health hazard, and has published nonsense-based exonerations of sugar as a menace to public health: see downward sloping lines (!) in Figures 1 and 2 of http://www.australianparadox.com

    x Notably, the University of Sydney’s low-GI business is a commercial partner of the Australian sugar industry, helping it in 2008 to produce a new brand of sugar: http://www.csrsugar.com.au/Better-For-You-Products/CSR-LoGiCane-LowGI-Sugar.aspx ; http://www.logicane.com/Partners

    x Traditionally, links between universities and the sugar industry globally may not have boosted either scientific integrity or public health. Indeed, in the US, “Big Sugar” set out in the 1950s to scramble and mislead science on the links between modern sugar consumption and chronic diseases. On the way, Harvard University in the 1960s and 1970s became America’s “most public defender” of “modern sugar consumption” as harmless, its “science” reportedly corrupted by heavy funding from the sugar and sugary food industries: http://www.motherjones.com/environment/2012/10/sugar-industry-lies-campaign

    x In Australia, the University of Sydney is home to our highest-profile academic defenders of added sugar in food as harmless: http://www.theaustralian.com.au/news/health-science/a-spoonful-of-sugar-is-not-so-bad/story-e6frg8y6-1226090126776

    3. POOR SCHOLARSHIP AND A MAJOR CONFLICT OF INTEREST

    Is anyone else disturbed by:

    x this extraordinarily poor scholarship;
    x this poor understanding of the link between high-carb diets, sugar (100% carbs), obesity and type 2 diabetes; and so
    x what seems to be poor dietary advice given to Australia’s pre-diabetics and suffering diabetics by the ADC?

    Is anyone else unsettled by the extraordinary conflict of interest involving the activities of the ADC’s Head of Research as a service provider to commercial producers of processed carbohydrates, including the sugar and sugary food industries (see various links above)?

    Of course, the ADC’s and the University of Sydney’s efforts to falsely exonerate added sugar as a key driver of obesity and type 2 diabetes would be harmless academic time-wasting if it were not for the fact that modern rates of sugar consumption – including via sugary drinks – clearly ARE a key driver of both obesity and type 2 diabetes: http://care.diabetesjournals.org/content/33/11/2477.full.pdf

    4. INDIGENOUS HEALTH AND THE CHARLES PERKINS CENTRE

    Tragically, outsized rates of sugar consumption – alongside alcohol and tobacco – are a major driver of the unacceptable gap in life expectancy between Indigenous and non-Indigenous Australians: bottom row of Box/Table 2 at https://www.mja.com.au/journal/2013/198/7/characteristics-community-level-diet-aboriginal-people-remote-northern-australia

    Unfortunately, the University of Sydney’s new $500 million Charles Perkins Centre for the study of obesity, diabetes and cardiovascular disease begins its life with a serious cloud over the University’s commitment to competence and integrity in scientific research.

    “A 50,000-square-metre building housing lecture halls and close to 1000 researchers will be the hub of the project, named in honour of Charles Perkins, the first Aboriginal man to graduate from university”: http://www.smh.com.au/national/university-sets-up-500m-centre-for-obesity-research-20130724-2qjq8.html

    Is it ironic – or just notable – that the University of Sydney’s highest-profile paper on obesity and its highest-profile obesity researchers – set soon to move into the Charles Perkins Centre – happen to be those who have recklessly (falsely) sought to exonerate as harmless a major contributor to the premature deaths of Charles Perkins’s First Australians? http://www.australianparadox.com

    5. ENDPIECE

    Readers, I have spent a great deal of time getting my facts correct on these serious matters. Please be very critical of me if I am wrong on any matters of fact, here or elsewhere. Certainly, if I have anything important wrong, I encourage representatives from the ADC and the University of Sydney to come online, correct me and tell their side of the story.

    Finally, to be upfront about my conflicts of interest, apart from arguing for the introduction of genuine quality control, competence and integrity in science at Group of Eight universities, I am campaigning for a ban on all sugary drinks in all schools in all nations. That proposal is contained in the following link, as is an outline of my qualifications to pursue these matters.

    Please join the push to give all kids a fairer start in life: http://www.australianparadox.com/pdf/Sugary-Drinks-Ban.pdf

    Readers, if after assessing the facts you think this proposal has merit, please forward it to parents, students, teachers, principals and heads of schools, nurses, doctors, dentists and others involved in public health and education.

    1. From march last year: http://aussieexotics.com/forum/off-topic/meat-is-bad-good-for-you-3472.msg186012.html#msg186012

      “Yesterday a friend was asking me about diabetes because she knows I research the shit out of this stuff, well I ended up on the American Diabetes Association (ADA) website, checked their dietary guidelines for diabetes management and saw they recommend apple juice/margarine/bagels/pineapple/etc for brekky, vanilla wafers/rolls/apples with lunch, and rice/angel cakes/crackers with dinner – and then I stumbled on their 2010 Annual Report (6mb PDF) and checked the financials… every one of the top contributors to research funding is a pharmaceutical company.

      I’m not even joking.

      Not just contributors to research like “oh we’d like to help cure this strange malady”, but the over-arching fund sources of all research for *some* reason happen to be the companies which sell the drugs to control it.”

  2. roryrobertsonformerfattie · · Reply

    Grant,

    if it turns up, please delete my second (repeat) comment. Sorry, I thought the first one disappeared into the ether.

    Happy Friday and thanks very much.

    rgds,
    rory

  3. A BRILLIANT PAGE Doc, thanks so very much. I also have taken the opportunity to copy the above comment and post it on FB

  4. Terri Bidwell · · Reply

    I am a member of the medical profession and sadly would have to agree. I have been dismayed at many colleagues not even bothering to give patients powerful dietary and lifestyle options and just giving more insulin or in other cases more lipid lowering drugs because ” patients won’t want to modify ther diet” this includes gastric stapling being bandied around as ” the only thing that works” for obese adults. It’s true SOME or even many people won’t change their behaviour but I think we have a duty to give adequate information about all the options. The effect of giving up sugar for obese adults can actually result in very significant sustained weightloss especially if they stop eating all processed foods. Another example is that moderate exercise up to 7-10 hours a week will halve a persons morbidity and mortality from the top 5 diseases ( cardiac, cancer, stroke, diabetes etc) and the dose response relationship kicks in at just 10 mins a day for those who previously did nothing. This is more powerful than any drug we give. Yet many sedentary people are not given an exercise prescription ” because they won’t want to do it”.
    I have to admit it takes longer to explain all this information than it does to write another script but that is no excuse.

  5. MargaretRC · · Reply

    I am really thankful that my T1 son has a doctor who said to keep his carbs as low as possible. He eats low carb and is doing great.

    1. Lucky kid. I hope that more newly-diagnosed type 1 diabetics get low-carb diets from the start. Interesting that after insulin became available way back when, the standard diabetic diet was high-fat and low-carb: diabetics were thought, even with insulin, to be unable to tolerate much carbohydrate. I recall reading in the late 70s or early 80s an almost derisive article in the American Diabetes Association’s magazine about the old diets and envying people on them. Eggs fried in the undrained fat from a few slices of bacon? Coffee with heavy cream? Well, that’s what I’m having for breakfast now.

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