Long time Type 2 diabetic (almost 20 years), new to the forum, first post.
My doctor threatened to put me on insulin in March because my A1c was 8.4%
I’ve brought my average BG down from 194 to 136 with exercise and diet (6.36 on A1c calculator). I started out my diet by limiting carbs. In the past week I shifted to a Keto Diet.
I sent my BG numbers to my doctor and he was impressed then he urged me not to do a Keto diet. He said that fat promotes insulin production and increases insulin resistance. This completely contradicts all the Keto literature that claims that high fat diets reduce insulin secretion and insulin resistance. He went on to recommend a DASH diet which includes high fiber foods like whole grains, whole wheat, and oats.
Frankly, I’m flabbergasted. This is the same advice I got when I was first diagnosed with diabetes 20 years ago. I ate whole wheat bread, brown rice, whole wheat pasta, and oatmeal for over a decade and it wrecked my BG. I continued to increase my medication to adjust over the years. Now I’m maxed out on oral meds.
Does anyone else have experience with a doctor who is against a diet that is working to bring your BG levels down?
Any thoughts about Keto vs DASH? Has DASH actually worked for anyone out there?
I had a similar experience with a doctor, who strongly opposed eating keto (or even low-carb). He also strongly opposed strenuous exercise, weightlifting, and other such activities (on the premise that risk of injuries outweighed potential benefits). After doing some research, I realized that I wanted to use diet and exercise to help manage my BG, and that what I really needed was a new doctor. So I got one, and it’s been great to have a supportive physician who isn’t close-minded to such ideas (her take is generally “show me it works, and we’ll keep doing it!”).
A couple of further thoughts, based on what you’ve written:
Keto or low-carb and high-fiber diets aren’t mutually exclusive: you can use fiber supplements (just make sure to go with soluble fiber supplements when you can) in creative ways to achieve both low-digestible carbs and high-fiber goals. For a couple of years, I was eating less than 30g net carbs and more than 35g of fiber a day, and it was great for my cholesterol levels, if nothing else
Exercise really helps along with low-carb eating. Anything that can deplete glycogen (sprinting, biking at speed or up hills, weightlifting) can be very helpful in managing BG, although you have to be a bit careful if you’re taking certain kinds of orals or insulin.
Different diets work for different people: some people do just fine on high-fiber, moderate carb diets, and some do fine or better on low carb. There are even some unicorns out there that do well on high carb, low fat diets (although I’ve mostly heard about that from Type 1s who are very physically active and on pumps).
If you’ve maxed out on orals, you may be reaching a point after twenty years where diet, exercise, and orals just aren’t going to help maintain an A1c in a healthy range. We have several Type 2s in this forum who ended up (happily) on insulin therapy as the best treatment course to manage their BG and are healthy and doing well.
I’ve discussed DASH with my endo – and he was vehemently opposed to it! Yes, IF you eat grains, then whole grains are better and maybe even healthy, he said, but there are better ways to get fiber that don’t spike BG. He doesn’t generally ‘recommend’ keto - but only because he has found that more moderate approaches are easier for most of his patients; however, he said he will support someone that wants to go that route and can manage it effectively.
Absolutely – and a doctor that threatens a patient with insulin – as if it’s some sort of punishment for failure – is doing nobody any favors. If that’s his approach, I’d change doctors immediately.
Totally agree. Insulin should not be a weapon used to instill fear. It is in some cases the best tool that a T2 can have. Patients should not be taught to fear it.
DASH was horrible for me. Terrible numbers across the board. I’ve done Bernstein for well over a decade with A1cs that range from 4.9 to 5.5. Also decent BP, etc…I love it. I never feel deprived. It works and that’s all I need to know…Once you’ve been at it awhile, you’ll figure out safe variations or occasional treats that do no damage—we are all different, after all…And I agree with Gary totally. When my body says it needs insulin, I’ll give it insulin–not going to fool around with in-betweens. I learned here, early on, insulin is nothing to be feared. It is another tool for us all!..
When I was first diagnosed, I was given the standard ADA 1800-calorie diet SHEET and the doctor’s office’s 1000-mg Low Sodium diet sheet and told to figure out my way between the two “because if I followed both exactly I’d not find anything to eat”. Turns out, my best result was to follow something close to a clean-eating, more-restricted version of DASH-sodium (1000 mg instead of 1500 mg) along with restricting calories and paying attention to my fat intakes (less than 30% total calories, less than 7% total calories from saturated fats, less than 200 mg dietary cholesterol). That said, both my ability to adhere to that diet while working long hours in time-restricted environments (call centers) and lots of nearby temptations resulted in trashing the healthy eating, gaining back most of the weight I’d lost post-diagnosis, and ending up back on metformin.
Unlike Judith, I find Bernstein’s advice to the extreme side (much as I found Dr. Atkins’ advice); however, we know that excess carbs can raise triglyceride levels (which in women are better indicators of impending heart attacks than LDL levels). There are also mixed cues about fructose (a natural sugar found in fruits, but responsible for a lot of health issues when found in high-fructose corn syrup), hydrogenated and/or interesterified oils (issues with raising LDL and suppressing HDL), wheat (one of whose digestive products is related to opioids), and other specific foods and food groups.
FWIW, I’m a bit concerned about keto diets because of diabetes-related ketoacidosis. While DKA (diabetic ketoacidosis) strikes mostly people with T1D and can be either the cause for diagnosis or the cause of diabetes-related death, there is a subgroup of people with T2D who can develop ketoacidosis (not necessarily related to high BGs!), and I’d rather not test out the belief that I am NOT part of that group!
That said, in the end, you need to do what works for YOU.
Good for you Judith! Those are amazing A1c numbers. I hadn’t heard of Bernstein before. It sounds like it is similar to Keto but with moderate fat high protein (Keto is high fat moderate protein).
I hear you tmana. You need to find a diabetes management strategy that works for you. From what I’ve read keto acidosis is highly unlikely for T2s like myself. Also, it is pretty easy to monitor my BG and Ketones. Ultimately it’s a personal judgment call.
Quick update, my doctor backed down on his resistance to Keto after I consulted two CDEs in my HMO including a RD. The RD was very supportive of Keto and told me she’s seen a lot of success with her diabetic patients. She just cautioned me against consuming too much animal fat or being too strict on my carb intake especially with healthy green vegetables. I’m realizing that MDs don’t really have much training in nutrition.
I have two more weeks until my next A1c test but my BG average is down to 121mg/dL. I’ve been testing first thing in the morning, before dinner, and after dinner. It’s amazing how much my BG levels have stabilized. I see far less spiking than I used to and overall my BG is in a much healthier range. My doctor even took me off Glipizide because it was making my hypoglycemic.
I’m planning on incorporating intermittent fasting with my Keto next to see if it improves my BG even further.
Your doctor desperately needs a lesson in physiology. a keto diet needs very low insulin levels because insulin inhibits lipolysis. From my experience it is hard to say what increase insulin resistance one thing I think does is a prolonged period of high blood sugars. Sure going keto will make you less able to handle a lot of carbs but if you stay keto that is irrelevant.
The difference between nutritional ketosis and diabetic ketoacidosis (DKA) is similar to the difference between a light breeze and hurricane force winds.
The National Institute of Health sourced diagram below shows the relationship of the various factors to DKA.
You make a good point, however, that new medicines used with T2D, the SGLT2 inhibitor class (the so-called pee-drugs), put patients at increased risk of ketoacidosis at much lower blood glucose levels.
After I talked to Dr. Bernstein back in 1977, I immediately purchased a meter, but did consider his diet pretty extreme. He suggested some foods that I considered pretty unpalatable. I would characterize his diet plan as “protein to meet nutritional needs and enough fat to satisfy.” Any time you restrict carb foods, you automatically become high in something else.
While I’m not aiming for ketosis, I’ve found that many keto recipes can be incorporated. into Bernstein’s plan. That makes his plan seem far less extreme. It has worked for me in this past year, dropping my A1c numbers from high 7’s to 5.8
I completely agree with @Terry4 that nutritional ketosis is far different than ketoacidosis. It’s sustained high BS AND high ketones that’s the concern. I believe Dr. Bernstein discusses this both in his book and in his online lectures.
Just a thought on animal fats. Dr Robert Lustig has suggested that animal fats per se are not necessarily bad. He suggests that the SOURCE of the fat may be far more important. He notes that Argentinian beef takes 18 months to get to market compared to beef in the US that takes 6 weeks. His claim is that our cattle are sick and we just slaughter them before they die. He also discusses the differences between corn-fed and grass fed cattle. Don’t know if he is correct, but he makes an interesting case.
Also if you don’t have 150g of carb a day, your brain will shrivel up like a prune and die.
It probably does to a small extent overall, but mainly in muscles. it’s a switch to save glucose for the bits of you that need it. If the fats from keto badly increases insulin resistance, how come your BG has gone down?
I have eaten a low carb WOE for over 10 years, My starting A1c was 12.0, now MID 5’s with no meds. Diet and exercise only. I thought about doing the Keto program. I bought a meter and found out I was already in Nutritional Ketosis!
My doctor says I am doing a great job and to keep on doing what I am doing. I am very fortunate to be able to do this.
Just a note on this part… “Ketoacidosis-prone Type 2 diabetics,” that subgroup you talk about, are now usually considered to be suffering from a form of Type 1 LADA that doesn’t present with known antibodies. Like many other LADA cases, they often get misdiagnosed as Type 2, but unlike the more “normal” LADA (like myself), there are no antibody tests which can flag an autoimmune attack. They are now normally labeled as “Type 1b” or “Idiopathic Type 1” diabetics. The condition seems to be genetically linked, and is so rare that it really isn’t worth worrying about Unless you have it, of course…
I am no doctor, but a doctor did tell me once that they do not really get trained well in matters such as diet and exercise. I think you can try it for yourself, however the kietogic diet is very trick to maintain. It does sound to me like eating grains and whole bread already failed you once before. So try it out very carefully, or see a nutritionist for another opinion.
Quick update. I’ve been eating Keto for almost 5 months now. My A1c dropped from 8.4% to 6.3% and 6.6%. My doctor has since taken away one of my meds (Glipizide). I did talk to a nutritionist who worked with my doctor. She was very supportive of the Ketogenic diet as a way to manage blood glucose. My doctor backed off once I got her endorsement!
My doctor does not support low carb either, but does support my A1C and the good blood test results! He does not know I eat low carb as I don’t discuss it with him. Well done!
Also if you don’t have 150g of carb a day, your brain will shrivel up like a prune and die. 
Unless you have it, of course…