Very low-carbohydrate diets in the management of diabetes revisited

Screen Shot 2016-04-01 at 1.15.06 PM.pngJust out –  our latest paper in the New Zealand Medical Journal – a review and viewpoint on low carb for diabetes.

We’re just continuing to make the point that low carb eating is a very sensible way to go for people with diabetes. The outcomes are better. Here’s the abstract.

Full text here

ABSTRACT 

Humans can derive energy from carbohydrate, fat, or protein. The metabolism of carbohydrate requires by far the highest secretion of insulin. The central pathology of diabetes is the inability to maintain euglycaemia because of a deficiency in either the action or secretion of insulin. That is, because of either insulin resistance often accompanied by hyperinsulinaemia, or insulin deficiency caused by pancreatic beta cell failure. In individuals dependent on insulin and other hypoglycaemic medication, the difficulty of matching higher intakes of carbohydrates with the higher doses of medication required to maintain euglycaemia increases the risk of adverse events, including potentially fatal hypoglycaemic episodes. Thus, mechanistically it has always made sense to restrict carbohydrate (defined as sugar and starch, but not soluble and insoluble fibre) in the diets of people with diabetes. Randomised clinical trials have confirmed that this action based on first principles is effective. The continued recommendation of higher-carbohydrate, fat-restricted diets has been criticised by some scientists, practitioners and patients. Such protocols when compared with very low-carbohydrate diets provide inferior glycaemic control, and their introduction and subsequent increase in carbohydrate allowances has never been based on strong evidence. The trend towards higher-carbohydrate diets for people with diabetes may have played a part in the modern characterisation of type 2 diabetes as a chronic condition with a progressive requirement for multiple medications. Here we will introduce some of the evidence for very low-carbohydrate diets in diabetes management and discuss some of the common objections to their use.

Henderson-1998-NZMJ-1432-FINAL

15 comments

  1. Some nice work there. Out of interest, what is the likelihood, that anyone from the NZ Ministry of Health will take notice and think about re-evaluating their food / nutrition guidelines?

  2. Charles Grashow · · Reply

    Then how do you explain people reversing their T2D with a low fat high carb macrobiotic diet??

    1. Insulin resistance is caused by several factors from sugar to high iron to poor guy microbiome to stress. Low carb doesn’t fixthese, nor does high carb on their own. Insulin resistanc eis the root cause and it has loads of lifestlye factors. But low carbis a safe option when you are insulin resistant and haven’t fixed the other things.

    2. Our article doesn’t rule out other diets improving diabetes if they result in weight loss.
      However, I wonder why the 4 macrobiotic trials aren’t included in any meta-analysis. They’re not even in the vegan and vegetarian diet and diabetes meta-analysis http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4221319/
      This oversight implies that they don’t meet quality standards.
      The question is, what dietary approach is most suitable for most people? The choice needs to have experimental and mechanistic support of types recognised by the medical community, be nutritionally adequate, and be culturally acceptable (i.e. use foods people recognise and like).
      Macrobiotics is based on non-scientific, magical principles. This might reduce its recognition in some quarters.
      http://rationalwiki.org/wiki/Macrobiotics

  3. Jill Mitchell · · Reply

    How exciting! Could you please post this to the Diabetes Queensland Facebook page. I can’t. They blocked me. Thank you Grant.

    1. Hi Jill – just did it but the sire is moderated – I doubt they’ll “allow it”!!

  4. Greetings !
    If we reduced the amount of carbs in the diet , that means we either should increase the amounts of fat or protein , many people with diabetes type 2 prefer high protein diet . Can high protein diet be very risky to diabetics same as high carbs diet ?

    1. Hi Lamis,
      High protein in the context of low carb with adequate fat is not problematic for most people; the Bernstein diet has quite a high protein % for diabetes treatment. As long as the protein is a natural food and still has its fat attached, it’s okay, although extremes of liver or kidney disease can affect the metabolism of protein.

  5. helen thompson · · Reply

    Do twice cooked rice/potatoes etc which then becomes starch resistant become 50 percent less carbs. (50% less available to the body as the rest becomes fibre according to BBC website). Or is this a too simplistic approach?

    1. Hi Helen,
      Delaying the appearance of glucose in this way (and by using naturally resistant starches such as beans, lentils, and peas) has some benefit if these foods are exchanged for grains and sugar, especially in the early stages of pre-diabetes, but overall the evidence for restricting carbohydrate is stronger than for manipulating GI.

  6. thompsonhelen · · Reply

    Do twice cooked potatoes/rice/pasta which becomes starch resistant (and then becomes 50 percent fibre and not absorbed according to BBC website) then become 50 % percent less carbohydrate? Or is this too simplistic? And does this apply to bread that has been toasted?

    1. Hi Helen,
      while there are strategies that lower the GI of carbohydrate-dense foods somewhat, and that may be useful for healthy people, I’ve not seen evidence that this is as effective as lowering carbohydrate density and total carbohydrate intake for people with diabetes.
      If you cool a potato you reduce carb a bit and increase fibre a bit, but if you replace potato with (say) caulifower you reduce carb a lot while increasing fibre.
      It’s also the case that low-GI foods don’t affect people equally, and the GI index is an average, and not as reliable a guide for individuals as the carb density (carb g per 100g on nutrition label) and total carb amount.

  7. Pieter · · Reply

    I’m type 2 Diabetic, Been doing everything the doctor told me for the last few years and taking metformin every day (1000mg), managed to keep my hba1c down to about 41 using medication.

    Stats were as follows
    Weight 94
    HBA1c 41 or higher
    Cholesterol/Tri/HDL/LDL 6.2/1.4/1.22/4.3

    3 months ago, the day after my last visit to my doctor, I stopped metformin and started on a LCHF diet (also calorie restricted) using intermittent fasting during the week and only eating lunch and dinner 800-1200 cals per day. Weekends I eat breakfast and dinner with a light snack at lunch time.

    Exercise everyday doing 2x 15 minute walks in the morning and evening plus a 30 minute walk at lunch twice or three times per week.

    Had my doctor visit today (3 months later).

    Stats now
    Weight 82 (Lost 12kg)
    HBA1c 35 (no metformin taken during the last 3 months)
    Cholesterol/Tri/HDL/LDL 8.2/1.6/1.4/6.1
    When I wake in the morning my ketones are anywhere between 0.8 and 2 depending on what I ate the night before.

    So my weight is down
    I have excellent sugar control
    Cholesterol not looking that great but then its been high for the last 30 years.

    Here are some of the things my doctor said.

    “you must eat a carb based breakfast because your brain needs the sugar” “you are starving your brain”
    “I can smell ketones in your breath, which means you are in ketosis you are putting your health at risk” (My ketones were 0.9 this morning)
    “Have weatbix and low fat milk for breakfast”
    “Be careful to not eat a lot of bacon and eggs”
    Dont fast, its dangerous to go without food for more than 12 hours

    I wish Doctors would read articles such as these so that they could help us better.

    Thanks for the hard work and please don’t give up, we need people like yourself to keep fighting this fight for the rest of us.

    Any idea on how I can go about finding a Pro LCHF Doctor in the Papakura Area.

    Thanks

    1. Keep up the good work, Dr Lily Fraser is the closest and she’s in Mangere sorry don;t know anyone LCHF docs in Papakura..anone else?
      Triglycerides could be a little lower – I’d prefer to see these < 1.0, but hopefully as weight los plateaus they will drop…

  8. […] the author of a recent review of low-carbohydrate diets for diabetes in the New Zealand Medical Journal, we appreciate that Professor Sof Andrikopoulos’s article on Paleolithic (“Paleo”) diets for […]

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