I recently picked up a copy of Diabetic Living magazine at the grocery store checkout to see what advice they’re offering to diabetics today. In addition to offering nutrition and exercise advice, Diabetic Living features articles on diabetes-related illnesses and complications.
While I found a great deal to like in this attractive, lavishly illustrated magazine, I was also alarmed at much of the advice offered.
The first thing I read was a special report entitled Cutting Through the Carb Confusion, which promised to “sort through the clutter, sift through the research, and try to resolve the debate…”
Reading this article, Diabetic Living magazine seems to be in denial about the increasing levels of carbohydrates in the American diet. According to their expert, it’s a fallacy that the average American eats an enormous and increasing amount of carbohydrates. “Americans consume about 50 percent of their calories from carbohydrate, and the needle has not moved for years,” says Joanne Slavin, PhD, who was an advisor to the 2010 U.S. Dietary Guidlines Advisory Committee.
Hmm. That doesn’t quite ring true to me. Especially after reading a study in the American Journal of Clinical Nutrition entitled “Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes in the United States: an ecologic assessment.” (Am J Clin Nutr 2004;79:774 –9).
After analyzing decades of data from the NIH, CDC, and the USDA, the authors of this study make the following statements:
- “Since 1963, the consumption of carbohydrates steadily increased [from an average of 374 g/day] back to 500 g/day”
- “The percentages of energy from protein (P 0.083) and fat (P0.79) were not associated with the prevalence of type 2 diabetes”
- “Between 1980 and 1997, however, total energy intake increased by 500 kcal/d. This increase was due primarily to increases in dietary carbohydrate.” Specifically, 428 kcal (nearly 80% of the increase in total energy) came from carbohydrates, 64 kcal (12% of the increase in total energy) came from protein, and only 45 kcal (8% of the increase in total energy) came from fat. This represents a relative increase in consumption of dietary carbohydrates from 48% to 54% of total energy intake over a 20-y period and a relative decrease in dietary fat from 41% to 37% of total energy intake. During the same period, the prevalence of type 2 diabetes increased by 47% and the prevalence of obesity increased by 80%, indicating a significant positive correlation between the percentage of energy from refined carbohydrates and the prevalence of type 2 diabetes and obesity.
To ensure that this study wasn’t anomalous, I took a quick peek at the CDC’s own data, via their “Morbidity and Mortality Weekly Report” (MMWR). (February 6, 2004 / 53(04);80-82). According to the CDC:
- “During 1971–2000, mean energy intake in kcals increased, mean percentage of kcals from carbohydrate increased, and mean percentage of kcals from total fat and saturated fat decreased,”
- The latest national dietary data available indicate that the previously reported increase in energy intake has continued, reflecting primarily increased carbohydrate intake.
Next, the article makes another unbelievable claim, still with no research or data. According to Slavin, “studies have found that people who get half or more of their calories from carbohydrate are at healthier body weights.”
Really? Healthier body weights than what? Are they really saying that people whose diets are composed of more than 50% carbohydrates have healthier body weights than those whose intake is less than 50% carbohydrates?
I would have loved to see some citations for the claims that this article makes. It seems that Professor Slavin’s “research sifter” must have been set to catch studies like these that show lower carbohydrate intake improves obesity, risk factors for heart disease, and/or diabetes indicators:
- Volek JS, Sharman MJ, Love DM et al. Body composition and hormonal responses to a carbohydrate-restricted diet. Metabolism 2002;51:864-870
- Acheson KJ. Carbohydrate and weight control: where do we stand? Curr Opin Clin Nutr Metab Care. 2004 Jul;7(4):485-92
- Hite AH, Berkowitz VG, Berkowitz K. Low-carbohydrate diet review: shifting the paradigm. Nutr Clin Pract. 2011 Jun;26(3):300-8
- Dyson PA, Beatty S, Matthews DR. A low-carbohydrate diet is more effective in reducing body weight than healthy eating in both diabetic and non-diabetic subjects. Diabet Med. 2007 Dec;24(12):1430-5.
- Feinman RD, Volek JS. Carbohydrate restriction as the default treatment for type 2 diabetes and metabolic syndrome. Scand Cardiovasc J. 2008 Aug;42(4):256-63.
- Frisch S, Zittermann A, Berthold HK, Götting C, Kuhn J, Kleesiek K, Stehle P, Körtke H. A randomized controlled trial on the efficacy of carbohydrate-reduced or fat-reduced diets in patients attending a telemedically guided weight loss program. Cardiovasc Diabetol. 2009 Jul 18;8:36.
There are plenty of other studies out there showing the effectiveness of low-carb diets on reducing obesity and cardiovascular disease indicators, but if we’re reading this magazine then we’re probably interested in diabetes after all, so let’s take a look at a few studies that asses a low-carb diet’s usefulness in combating diabetes:
- Nielsen JV, Jönsson E, Ivarsson A. A low carbohydrate diet in type 1 diabetes: clinical experience–a brief report. Ups J Med Sci. 2005;110(3):267-73.
After changing the diets of 22 patients with poorly controlled Type 1 diabetes to a low-carb diet with an increased intake of protein and fat to produce a caloric equivalent diet, these researchers report that the incidence of hypoglycemia was reduced, A1Cs dropped, meal insulin requirements dropped, and triglyceride levels were also reduced. They concluded that the low-carb diet “is a feasible alternative in the treatment of Type 1 diabetes and leads to improved glycemic control.”
- Klupa T., et al. The influence of dietary carbohydrate content on glycaemia in patients with glucokinase maturity-onset diabetes of the young. J Int Med Res. 2011;39(6):2296-301.
The authors of this study studied low-carbohydrate diets on patients with maturity-onset diabetes of the young (MODY) and found that the high-carb patients had significantly higher glucose levels and an increased number of glucose spikes. They conclude that “…diets with a modestly limited carbohydrate content may improve glycaemic control in patients with GCK MODY.”
- Halton TL, Liu S, Manson JE, Hu FB. Low-carbohydrate-diet score and risk of type 2 diabetes in women. Am J Clin Nutr. 2008 Feb;87(2):339-46
These Harvard researchers studied 85,000 women for a 20-year period and found that those with the greatest carbohydrate intake had the highest rate of diabetes and those who ate the most fat had 9% less incidence of diabetes than those who ate the least fat. The authors conclude not only do diets lower in carbohydrates and higher in fat and protein not increase the risk of Type 2 diabetes, they may reduce the risk.
AGEs: A Useful Caution
The article entitled is there an A.G.E. limit sounds a useful cautionary tale about Advanced Glycated End Products. (It’s interesting to note that when you check your A1C, you’re actually measuring an Advanced Glycated End Product: the glycation of a red blood cell.) AGEs are believed to be heart disease promoters and are a solid justification for not consuming heavily oxidized fats. Note that AGEs are not a justification for avoiding fats, just for preparing them in a more gentle manner than harsh grilling or extremely high temperatures. Braising, basting, or sous vide will produce far fewer AGEs than more harsh cooking methods.
In examining the AGEs produced by various cooking methods, the article overlooks another source of AGEs: formation within the body. I think the readers of Diabetic Living would have benefitted from knowing that excess glucose levels in the body are also a source of AGEs, as the increased glucose concentration makes glycation more likely. Optimizing glucose levels is therefore crucial to minimizing AGEs. While I did find a reference to controlling glucose levels in this issue of Diabetes Living, I was surprised at how they define “tight control.” Read on…
“Keep Your Blood Glucose Under Tight Control”
A subsequent article on peripheral neuropathy observes that having high blood glucose levels for a very long time seems to be a major factor in developing peripheral neuropathy. After making the logical recommendation to “keep your blood glucose under tight control,” Diabetes Living defines “tight control” as below 130 mg/dL fasting and below 180 mg/dL postprandially. I hate to break to you, but 130 mg/dL fasting and 180 mg/dL postprandially is not “tight control.” It boggles my mind that many experts think that diabetics don’t deserve the same glucose levels that non-diabetics achieve. Spend some time on Richard Bernstein’s diabetes forum and you’ll find an impressive number of diabetics who are achieving glucose levels equal to non-diabetics, through careful monitoring and, more importantly, by eating foods that minimize glucose response, thus reducing the neuropathy-inducing glucose spikes.
I wonder if the “professionals” out there are so afraid of people going hypo or being too inattentive to achieve non-diabetic-like glucose levels that they’ve resigned themselves to defining 130 mg/dL fasting and 180 mg/dL post-prandial as “tight control.” (If that’s tight control, I shudder to think what “acceptable” glucose control is.)
I can understand why the fear of hypoglycemia trumps the clinical goal of achieving non-diabetic glucose levels. Human nature makes it easy to view degeneration from damagingly high glucose levels as the inescapable result of diabetes. Yet a physician who tries to prevent diabetes-induced complications by advocating extremely rigorous glucose control would likely be condemned when a patient inadvertently goes hypo.
It’s sad that the information gatekeepers can’t acknowledge that just because controlling glucose to within non-diabetic ranges is beyond the desire or capability of some diabetics, it’s still the recommended clinical goal. One of the principal conclusions of the famed Diabetes Control and Complications Trial (DCCT) is to “…support early intensive treatment…with the goal of maintaining HbA1c levels as close to normal as is safely possible, to achieve long-term beneficial effects on the risk of complications.”
The benefits of normalizing glucose levels permeates scientific research. Why is the same advice so sadly lacking in today’s clinical guidelines and mainstream publications?
Skip the Dessert and the Diabetes Living
While likely well intentioned, I find Diabetes Living too firmly entrenched in the mindset that has helped diabetes become the epidemic that it is today. With its bias against the benefits of low-carb eating, its endorsement of damaging glucose levels, its promotion of grains that skew LDL into atherosclerotic particle sizes, and its outdated fear of dietary fats, Diabetes Living is best left on the rack in the grocery store checkout line, along with the candy bars that most diabetics do know to avoid.