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.