Archive for July, 2011

In my last post, I commented on a reply from Hope Warshaw  — the diabetes educator (ahem, ahem) — to a reader of this blog in which she pooh-poohed his “experience of one” with using a low-carb diet to manage diabetes.

The same reader emailed me that he conducted an “experiment of one” in recent days to compare his blood sugar after drinking a 12-ounce Pepsi versus eating some of the foods Hope Warshaw recommends for diabetics.  Take a look:

Food Carbs BG before BG at 60 mins
12-ounce Pepsi 42 g 89 156
Oatmeal, milk 40 g 113 163
Whole wheat bread 48 g 93 141
Whole wheat toast, milk 36 g 103 173

Perhaps those numbers don’t look scary to you, but they do to me.  Here’s what Chris Kresser of The Healthy Skeptic wrote about post-meal glucose levels awhile back:

Even the American Association of Clinical Endocrinologists is now recommending that post-meal blood sugars never be allowed to rise above 140 mg/dL. Unfortunately, less informed groups like the ADA haven’t caught up with the science.

The consequences of this are severe. Nerve damage occurs as blood sugar rises above 140 mg/dL. Prolonged exposure to blood sugars above 140 mg/dL causes irreversible beta cell loss (the beta cells produce insulin). 1 in 2 “pre-diabetics” get retinopathy, a serious diabetic complication. Cancer rates increase as post-meal blood sugars rise above 160 mg/dL.

Every one of the high-carb meals produced a glucose level above 140 in my reader’s one-man experiment.  The biggest spike (173 mg/dL) was produced by two pieces of whole wheat toast and a glass of milk – a normal breakfast for a lot of people.

With those results in mind, let’s look at the advice Hope Warshaw doled out to diabetics in a Q & A article for Health.com:

Q: Do I need to pay attention to the sugars on the nutrition facts label?

A: No. Pay attention to the total carbohydrates. The sugars content includes the amount of added and natural sugar in a serving. The amount of sugars are included within the total carbohydrate count, which is the key piece of information you need for planning meals and snacks.

Well, so far so good.  She’s telling diabetics to watch their carbs.  Perhaps I misjudged the woman.  Let’s skip ahead.

Q: Are nutrition recommendations different for people who have just been diagnosed with type 2 diabetes than they are for those who’ve had diabetes for years and take insulin injections?

A: No, the Dietary Guidelines for Americans, which are supported by the American Diabetes Association, are appropriate for pretty much everyone, including most people with type 1 and type 2 diabetes: Eat more whole grains, low-fat and fat-free dairy foods, fruits, and vegetables; limit consumption of high sodium processed foods and saturated and trans fats; get more of your protein from seafood and poultry and nonmeat sources, like beans (legumes); and eat all sources of protein in portions no larger than three ounces cooked. The Dietary Guidelines for Americans also recommend getting 45% to 65% of your calories from carbohydrates (with less than 25% of your total carbohydrates from added sugar); 20% to 35% from fat; and 10% to 35% from protein.

Nope, turns out I judged her correctly after all.  We need to eat lots of carbohydrates because the USDA says so.  Never mind what happens to blood-sugar levels in living, breathing (for now) diabetics who consume the high-carb meals the USDA recommends.   Brilliant.  And can someone please explain to me why beans — which are full of carbohydrates — are better for diabetics than meats?

Q: I’ve heard there are healthy and unhealthy carbohydrates. What should I eat more of, and what do I need to limit?

A: Foods that contain carbohydrates are starches, grains, fruit, vegetables, and dairy foods. The healthiest sources of carbohydrates provide plenty of vitamins and minerals per calorie—they are nutrient-dense. Everyone should eat more fiber-rich carbohydrates, such as whole grains, fruits, vegetables, and beans (legumes). You should try to eat at least three servings or half your servings of starches as whole grains each day. Less healthy carbohydrates like candy, sweetened beverages, and ice cream pack little nutritional punch but contain plenty of calories; keep them to a minimum.

Yes, grains are more nutrient dense than a Pepsi.  But as my reader discovered in his one-man experiment, they can jack up your blood sugar just as high or higher.

Q: Is it OK for people with prediabetes and diabetes to eat some sugar and sweets?

A: Yes. People with diabetes can enjoy sugary foods and sweets in moderation.

And then take a moderate shot of insulin.

However, the amount of sweets you eat should be balanced with your diabetes nutrition goals, such as weight loss, blood glucose, and blood lipid control.

Yes, balance your diet with your goals for blood glucose.  Then eat your grains.  Then watch your blood sugar shoot up.  Then take your drugs so you can meet your blood glucose goals.

Be aware that some desserts and sweets, for example ice cream and cheesecake, are also high in fat and the fat may be the unhealthy saturated type.

You know, for a woman who told the reader not to bother her anymore unless he could quote some controlled clinical studies, Ms. Warshaw doesn’t seem to apply the same intellectual rigor to her own advice.  Can she point to any long-term clinical studies that prove saturated fat is bad for us?  Has she simply ignored all the recent studies showing that low-carb/high-fat diets produce better lipid profiles than high-carb diets?

Q: How many carbohydrates should an adult man or woman who is trying to lose weight eat each day?

A: Aim to get roughly half of your calories from carbohydrates.

Yes, be sure to do that.  Then take insulin to bring your blood sugar back down.

Head.  Bang.  On.  Desk.

For example, a sedentary woman who wants to lose weight should limit her calories to 1,400 to 1,600 a day, so she should consume 700 to 800 calories from carbohydrates daily.

Bang.  On.  Desk.  Again.

Following is a sample meal plan that would meet this guideline, along with examples of serving sizes.

  • Seven starch servings (one serving is a slice of whole wheat bread, or half a medium baked potato)
  • Two servings of milk and yogurt (one serving is eight ounces of fat-free milk, 2/3 cup of fat-free yogurt)
  • Four servings of vegetables (one serving is one cup of salad or a half-cup of cauliflower or carrots)
  • Five ounces of meat (cooked)
  • Three servings of fruit (one serving is a cup of cantaloupe, 2 small tangerines, a small banana, or a small apple)
  • Six servings of fat (one serving is a teaspoon of olive oil, two tablespoons of avocado, four pecan halves, or a tablespoon of reduced-fat mayonnaise)

Seven servings of starch per day, eh?  Two servings of whole-grain starch plus a cup of milk pushed my reader’s blood sugar to over 170 mg/dL.  (Thank goodness he didn’t add a banana to that meal, as Ms. Warshaw would recommend.)  So for many diabetics out there, Ms. Warshaw’s diet is an invitation to walk around with jacked-up blood sugar all day.  But of course she’s a big fan of Metformin and other drugs that lower blood sugar, so it all balances out.

Q: Since I have diabetes, do I need to prepare my food separately from my family?

A: No. The foods that are healthy choices for you will also be healthy choices for your family members who don’t have diabetes.

That’s true.  Too bad Ms. Warshaw and the ADA have no flippin’ idea which choices are actually the healthy ones.

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A reader of this blog wrote to Hope Warshaw, author of the “eat your carbs and take your drugs” article in Diabetes Health that was the subject of my last post.  I didn’t see his original email to her, but he did forward me her response.  Here’s the opening:

Rather than throwing stones and continually citing Richard Bernstein, MD, who as far as I know has only written consumer books and not published one research paper on his recommendations, or discussing your own experience of one, how about providing/discussing citations of well conducted long term research studies in people with type 1 and type 2 diabetes (or even prevention trials) who more successfully manage glycemia, lipids and blood pressure and eat healthfully on an intake of carbohydrate below 40% of total calories.

I see … the reader has successfully managed his diabetes with diet, but we can simply dismiss that evidence because it’s an “experience of one.”  Ms. Warshaw apparently is convinced the reader is the only diabetic in the world who found a low-carb diet beneficial.  Therefore her advice to eat a high-carb diet is still correct.

Riiiight … except we already know it’s not an “experience of one.”  I quoted some comments diabetics posted on the Diabetes Health site regarding Ms. Warshaw’s article in my previous post.  Here are a few more:

I set out on a low carbohydrate diet and within 6 months had normal blood sugar, normal blood pressure and lost over 100 pounds. People don’t need more drugs and bad dietary advice. I think we have all see the rising rates of obesity and diabetes and you are not helping the situation. If you really want to stop the rise, tell people the truth. Low Carbohydrate diets normalize blood sugar.

As a physician with pre-diabetes I am appalled that a high carbohydrate diet continues to be promoted. I am 56 years old. For the past 5 years I have maintained normal fasting blood sugars on a low carb diet.

I have been eating low carb for almost 1 year now and my diet includes lots of non stachy vegetables, fruits(strawberries, blueberries, raspberries), lean meats, eggs, nuts and some low carb desserts occasionally. My A1C is 5.6 and I have accomplished this by diet/exercise alone.

I am a type I diabetic and I know for a fact what 45-65% of calories as carbs can do to my BG… This is absurd and border-line dangerous statement from some “best-selling author.”

On Facebook and in other corners of the blogosphere, a lot of people are complaining that they also left comments on the article, but those comments never showed up.  Perhaps Diabetes Health isn’t interested in letting the world see how many diabetics disagree with their house expert.  Whatever the explanation for the blocked comments, it’s clear that many, many people have successfully managed their diabetes by doing the opposite of what Ms. Warshaw recommends.  It’s not an “experience of one.”

Ms. Warshaw continued in her reply:

And instead of reading top line messages in resources like myplate.gov, dig into the research based information in the Dietary Guidelines Advisory Committee Report, 2010. Here’s the link: http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm

A couple of quotes from the Carbohydrate Chapter:

The Institute of Medicine (IOM) (2002) set an acceptable macronutrient distribution range (AMDR) for carbohydrates of 45 to 65 percent of total calories. Thus, current dietary guidance recommends consumption of carbohydrate-containing foods, including vegetables, fruits, grains, nuts and seeds, and milk products. Carbohydrate foods are an important source of fiber and other nutrients.

Well, there you have it:  Ms. Warshaw’s dietary recommendations for diabetics must be correct because the USDA and other experts say so.  No other proof needed  — which is a rather odd position for her to take, considering how she ended her reply:

No need to write back unless you’ve got well conducted published research studies to share.

So we’ve got someone who is supposedly interested in helping diabetics, but arrogantly dismisses comments from actual diabetics who’ve achieved normal blood sugar through a low-carb diet.  You’d think she would find all those “experience of one” stories intriguing and look into the matter a little more.

Banging my head on my desk didn’t diminish my annoyance with Ms. Warshaw’s reply to the reader, so this morning I wrote to her myself:

———————————————————

Dear Ms. Warshaw –

I’ve been following your responses to people who questioned your advice to diabetics to consume a high-carbohydrate diet.  Those responses boil down to two arguments:

1.  I’m right because the USDA Dietary Guidelines say I’m right.
2.  Show me the long-term clinical studies proving carbohydrate restriction is effective for diabetics, or shut up and leave me alone.

Appealing to the authority of the USDA — whose mission is to sell the grains our government subsidizes — isn’t proof of anything.  As you may already know, one member of the committee that wrote those guidelines has already stated publicly that the guidelines aren’t based on good science.  I read the entire, mind-numbingly dense, stupefying, often-contradictory report myself, and I agree:  the guidelines aren’t based on anything resembling solid science.  So let’s set those aside and deal with actual science.

Here are links to just a few of the clinical studies that demonstrated the effectiveness of low-carbohydrate diets for managing diabetes:

The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus

Forty-nine (58.3%) participants completed the study. Both interventions led to improvements in hemoglobin A1c, fasting glucose, fasting insulin, and weight loss. The Low-Carbohydrate Ketogenic Diet group had greater improvements in hemoglobin A1c (-1.5% vs. -0.5%, p = 0.03), body weight (-11.1 kg vs. -6.9 kg, p = 0.008), and high density lipoprotein cholesterol (+5.6 mg/dL vs. 0 mg/dL, p < 0.001) compared to the LGID group.  Diabetes medications were reduced or eliminated in 95.2% of LCKD vs. 62% of LGID participants (p < 0.01).

A low-carbohydrate, ketogenic diet to treat type 2 diabetes

The Low-Carbohydrate Ketogenic Diet improved glycemic control in patients with type 2 diabetes such that diabetes medications were discontinued or reduced in most participants. Because the LCKD can be very effective at lowering blood glucose, patients on diabetes medication who use this diet should be under close medical supervision or capable of adjusting their medication.

Utility of a short-term 25% carbohydrate diet on improving glycemic control in type 2 diabetes mellitus

Compared to baseline diet, after 8 weeks of a 25% carbohydrate diet, subjects showed significantly improved glycemia as evidenced by fasting blood glucose values (p<0.005) and hemoglobin A1c levels (p<0.05). Those previously treated with oral hypoglycemic agents showed, in addition, a significant decrease in weight and diastolic blood pressure despite the discontinuation of the oral agent. When then placed on a 55% carbohydrate diet, the hemoglobin A1c rose significantly over the ensuing next 12 weeks (p<0.05).

Yes, I know:  you asked for long-term studies.  As far as I can tell from my online research, there are few if any controlled clinical studies of dietary interventions that have lasted more than a year or perhaps two at most.  So you appear to be asking your critics to quote the results of studies that have never been conducted.

But I’m clearly mistaken about that.  You obviously have access to a long list of multi-year clinical studies on carbohydrate-restricted diets.  I know this because of what you wrote in your article in Diabetes Health:

“Countless research studies do not show long term (greater than six months to a year) benefit of low carb diets on blood glucose, weight control, or blood fats.”

Since you’ve examined countless such studies, could you please provide me a list of, say, a dozen references to clinical studies in which subjects adhered to a carbohydrate-restricted diet for more than a year, but failed to achieve improved glucose control compared to a control group?  If you could point me to studies matching that description that lasted five or ten years, that would be super.  I’d like to share them with my readers.  Then we’ll all understand exactly how countless studies failed to show any long-term superiority of carbohydrate restriction for glucose control.

Also, given that you don’t like anyone to promote dietary advice that isn’t backed up by long-term clinical studies, could you please provide a list of multi-year clinical studies in which a diet of 45-65% carbohydrates produced superior glucose control and lower A1c when compared to a control group, or – better yet – when compared to a group in which carbohydrate was restricted to less than 40%?  The diabetics among my readership especially would love to see the scientific basis for your advice — after all, their lives depend on it.

Best regards,
Tom Naughton
Writer/Director “Fat Head: you’ve been fed a load of bologna”

———————————————————

I haven’t received a reply.

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As the Allies were advancing in December of 1944, the Germans launched a massive counter-attack in what became known as the Battle of the Bulge.  The 101st Airborne Division was sent to hold the town of Bastogne, a vital transportation hub the Germans desperately wanted.  The “Screaming Eagles” were surrounded, out-numbered, short on ammunition, and freezing in their summer uniforms.  But when the German commander demanded their surrender, U.S. general Anthony McAuliffe sent a one-word reply:  “Nuts!” The Screaming Eagles dug in and held the town.

The Grains-and-Drugs Axis is in full counter-attack mode.  The USDA Dietary Guidelines call for greater restrictions on fat and more whole grains in our diets.  The new My Plate tells us to fill 25% of our plates with grains.  And now the dimwits at Diabetes Health magazine -– which reaches hundreds of thousands of diabetics -– are telling people with  blood-sugar issues to eat even more carbohydrates.

That advice comes in the form of an article titled Type 2 Diabetes: From Old Dogmas to New Realities.  There’s no subtitle, but there should be, and it should read:  Just give up and take your drugs, dangit!

In the last decade, dramatic changes have occurred in our understanding of the onset and progression of prediabetes. Lightning speed changes have also occurred regarding the therapies available to achieve optimal blood glucose control. Even with all of this change, however, many old dogmas hang on. It’s time to be aware of the new realities. In this article,  I focus on two common old dogmas and the new realities.

Old Dogma: Losing weight will make blood glucose levels plummet no matter how long you have had type 2 diabetes.

New Reality: Research shows that the greatest impact of weight loss on blood glucose is in the first few months and years after diagnosis… Once insulin production is on a dwindling course (particularly after 10 years with type 2), weight loss has less impact on glucose control.

The reality is that if blood glucose is out of control, it’s time to progress to blood glucose-lowering medication(s), because it’s doubtful that weight loss alone will get and keep blood glucose under control. Today, most experts, including the American Diabetes Association and American Association of Clinical Endocrinologists, agree that people with type 2 should start on a blood glucose-lowering medication that decreases insulin resistance–the core problem in type 2–at diagnosis.

Got that?  The people whose livelihood depends on writing prescriptions for drugs agree that you need drugs, so take your drugs.  I agree that weight loss alone won’t lower high blood sugar -– I’ve known some skinny type 2 diabetics –- but that doesn’t mean a change in diet can’t do the trick.  It just has to be the right kind of diet, one that won’t jack up your blood sugar in the first place.

Speaking of diet …

Old Dogma: People with type 2 diabetes should follow a low carbohydrate diet.

New Reality: Nutrition recommendations for people with type 2 diabetes from the American Diabetes Association and other health authorities echo the recently unveiled U.S. 2010 Dietary Guidelines for carbohydrate: about 45 to 65 percent of calories. (Americans currently eat about 45 to 50 percent of calories as carbohydrate–not a “high carb” intake.)

Countless research studies do not show long term (greater than six months to a year) benefit of low carb diets on blood glucose, weight control, or blood fats. People with type 2 diabetes, like the general public, should lighten up on added sugars and sweets (yes, they’re carbohydrate). They should eat sufficient amounts of fruits, vegetables, whole grains, and low fat dairy foods–all healthy sources of carbohydrate.

Well, there you have it:  the USDA and other (ahem, ahem) health authorities recommend we get 45 to 65 percent of our calories from carbohydrates, so it must be true.  We consume a higher proportion of carbohydrates now than we did 30 years ago, the rate of type 2 diabetes has skyrocketed during that same period, so what this proves is that we should eat even more carbohydrates.

As for those “countless studies” that didn’t show low-carb diets improving glucose control beyond six months to a year, there’s a reason for that:  most dietary studies last six months to a year.  So we can interpret that statement as “countless studies failed to show any benefit after the study ended and we stopped tracking the benefits.”  Over and over, we see medical authorities warning that we don’t know the long-term effects of low-carbohydrate diets.  Right … because the long-term clinical studies haven’t been conducted.

But there are plenty of doctors out there — Dr. Richard Bernstein, Dr. Mary Vernon, Dr. Steve Parker, Dr. James Carlson, to name just a few — who do know the long-term effects of a low-carbohydrate diet for their diabetic patients.  Those effects include weight loss, lower fasting glucose, reduced reliance on drugs, and even a complete reversal of diabetic symptoms in some cases.

A few people commenting on the Diabetes Health article have had the same experience:

Respectfully, this column is not helpful to diabetics and probably dangerous. I am going on 6 years of eating 30-35 carbs/day. My A1c has been in the “non-diabetic” range ever since I went this route and I feel better than I have in years.

It was not until I started a low carbohydrate diet that my blood glucose numbers fell. They fell rapidly and have been easy to maintain under such a diet.

I had awful lipids and blood sugar control on a low fat/high carb diet. Now that I have switched to a lower carb diet – all my numbers are superb.

Ordinary people get it, even if the supposed experts don’t.  As for the  experts at the American Diabetes Association, here are a few points from their own literature:

  • Your digestive system turns carbohydrates into sugar quickly and easily
  • Carbohydrate is the food that most influences blood glucose levels
  • The more carbs you eat, the higher your blood glucose goes
  • The higher your blood glucose, the more insulin you need to move the sugar into your cells
  • The Food Pyramid is an easy way to remember the healthiest way to eat.
  • At the bottom of the pyramid are bread, cereal, rice and pasta.  These foods contain mostly carbohydrates.
  • You need six to eight servings of these foods per day

Head.  Bang.  On.  Desk.

You’d think someone writing up those guidelines might spot the contradiction.  But the contradiction is less surprising when you look at a short list of who provides the ADA with its funding:

  • Abbott Pharmaceuticals
  • Amylin Pharmaceuticals
  • AstraZeneca
  • Eli Lilly and Company
  • GlaxoSmithKline
  • Merck & Co.
  • Pfizer Inc.
  • Cadbury Schweppes (candy/soda maker)
  • Kraft Foods
  • J.D. Smucker Company
  • General Mills

From what I read online, the publisher of Diabetes Health also sells medical devices and started the magazine to promote its products.  Like I always say, follow the money.

It’s time for those of us who don’t want more diabetics to be killed by bad advice to stand up and say “Nuts!” to the commanders of the Grains-and-Drugs Axis.  If you know a diabetic, give him or her a copy of Dr. Bernstein’s Diabetes Solution or Dr. Steve Parker’s Conquer Diabetes and Prediabetes.  Point your family and friends to books and blogs that educate people about what causes type 2 diabetes and how to avoid it.

Then join the Nutrition and Metabolism Society, one of the few organizations dedicated to fighting bad nutrition science with good nutrition science.  By joining NMS at any membership level –  from $10 on up — you will be supporting the kind of research that’s necessary to overcome years of misinformation promoted by the USDA and ADA.

Think of it as providing badly-needed weapons for the Screaming Eagles of nutrition research.  They’re surrounded, but they won’t give up.  And they will win the battle.

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