Balanced Op-Ed essay on value of low-carb diets for PWD. I especially liked the critique of the ADA’s “annual diabetes association convention in New Orleans this summer, there wasn’t a single prominent reference to low-carb treatment among the hundreds of lectures and posters publicizing cutting-edge research. Instead, we saw scores of presentations on expensive medications for blood sugar, obesity and liver problems, as well as new medical procedures. . .,” http://www.nytimes.com/2016/09/11/opinion/sunday/before-you-spend-26000-on-weight-loss-surgery-do-this.html?ref=opinion
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I read the NY Times piece. I’ve followed a carb limited way of eating for over four years now. It is the single most influential factor that helps me keep my blood glucose in range and much less variable. I also lost weight with little effort other than restricting carbs. My daily insulin needs were cut in half.
Unfortunately, this issue arouses contention whenever it’s raised here. And you can see from the article that the medical community is underwhelmed by the whole idea. I think the biggest reason for that is that nobody makes any money when a person with diabetes limits carbs.
The best thing I can say about limiting carbs for people with diabetes who take insulin is that fewer carbs = less insulin = smaller mistakes. This is known as Bernstein’s law of small numbers. Dr. Bernsteinhas lived with type ! diabetes for many decades, is in his 80’s now, and still practices medicine. He’s also active online and in videos. The diabetes status-quo would like to see this whole idea of low carbs disappear and go away forever.
In 32 years of living with type 1 diabetes, limiting carbs ranks up there with modern insulins and the CGM for value to me in controlling my blood glucose.
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Pros and cons.
Pros:
- Public, medical endorsement of the value of low carb
- Calling out the ADA for their absurd, ridiculous blindness (or is it what one community member refers to as their unofficial motto: “Keeping blood sugars high to support our corporate sponsors”? You decide.)
Cons:
- Continuing to prop up the shibboleth about obesity being the direct cause of diabetes in the first place. Given the evolving state of evidence, that hypothesis is more and more up in the air.
- Referring to low carb as a fad in a context that clearly indicates they mean “until recently”. Wrong. Low carb for weight loss has been widely known since the 1860s. A fad doesn’t last a century and a half.
- . . . and then contradicting their own characterization by saying, A low-carbohydrate diet was in fact standard treatment for diabetes throughout most of the 20th century.
On balance, a good step forward.
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On thing I do like in the article is that they do make sure to mention that the low-carb diet approach is effective only when patients continue to follow the way of eating. We know that it’s not a “cure.” It’s important that those reading don’t think they can spend a few weeks or months doing low-carb, then go back to habits that will again negatively impact their health.
I agree @David_dns, that the article seemed to link obesity to type 2 diabetes – which is unfair and even dangerous. I believe the intent was to say that low-carb is an effective approach to treat BOtH (or either) obesity and Type 2 diabetes, whether they occur together or separately. As you, though, I would have preferred that they clearly mention that the two issues are not necessarily causative of each other.
I was told by a CDE that low-carb was useless and that no one could maintain that diet for any length of time. That was six years ago. I am still doing low-carb and I will always be doing low-carb for the rest of my life. Truth be told, I will probably do low-carb even if I get an artificial pancreas next week. Even if there is a full on cure found. Why would I go back to eating crap?
I know that we are all different, but I think that every person with diabetes can improve their blood sugar control and make their life much easier by decreasing their carb intake. You just have to find that sweet spot (no pun intended) where you eat enough of the right type of carbohydrate to satisfy your personal taste and lifestyle while not causing spikes and overusage of insulin.
I would like to know if there is actually anyone out there, either type I or type II, who eats the recommended 45% carbohydrate FDA diet and has an A1c even close to six. And, if you do, how much insulin to you take on an average day? Most of the people I have ever heard talk about eating this way are unable to get there A1c anywhere close to an ideal range. I know that the A1c is not the end all of measurements. But, it is an average of your glucose levels for the last three months. It is the current benchmark.
What I do know is this; I have been eating low-carb for six years. Until I went low-carb I could not control my blood sugars. I had many many lows. Since I have been doing a low-carb diet (100 to 150 per day) my A1c has never been over 5.7. My last two A1c’s were 5.2. There is no way in hell I could have done this otherwise.
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That’s the first criticism of most dietitians. I’ve been limiting carbs in my diet (< 100 grams) for four and one half years. As long as I have diabetes, I will limit carbs. I enjoy much better BG control, 80%+ time in range, less weight, less insulin, greatly reduced variability, fewer hypos, and much less drama!
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Further analysis by the New York Times on the earlier opinion piece.
Actually I would term this an attempt to defend the status quo. Gina Kolata has been advocating the low fat calorie restricted diet for years. And organizations like the ADA I think are under pressure to defend themselves against being perceived as providing dietary advice that has seriously harmed the public. Just reading what is in this article it is clear that there is a huge distortion of the science and the studies that have been done.
Does the ADA fund any science on nutrition? There is a disturbing vacuum on nutrition science at the ADA scientific sessions. At this point I think it is pretty clear, enough studies have been done, low carb clear leads to better glycemic control and paranoia about fat is way, way overblown. If you can’t stay on a low carb diet, fine. But if you can follow a low carb diet (like I do) then dietary choice seems obvious.
I think it can be really hard for many of these people to admit they were wrong.
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I’ve lowered my carb intake more than I’d planned and gotten better results – but I’m still not willing to admit I was wrong! 
OK, that said, I think there will still always be a difference between people – some do well on extremely low carbs, others (like me?) need a bit more moderate amounts of carbs (been working with around 70g/day most of the time), and others need a bit more. And there are some for whom those ADA recommendations do work. I am definitely not one of them, though.
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The fat-is-bad-carbs-are-good “science” isn’t science, it’s politics and always has been. Read Gary Taubes, or Malcolm Kendrick, or Volek and Phinney, or Lyle McDonald, or . . . .
I wouldn’t even dignify the story as defending the status quo; that particular status quo is pretty conclusively discredited. It’s a misbegotten attempt at a holding action. [I didn’t use the word unethical, but I was thinking it. Notice I called it a “story”, not an article.]
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I get into such problems with low fat high carb diets, I don’t eat margarine, low fat cheese, low fat yogurt, etc. I am not over fond of bread, don’t eat much cake. And what is more it doesn’t help me with my blood sugars. I think the CDE I had when I was first diagnosed and eating how the dietitian told me, thought I was non compliant, I wasn’t. When I found TuD I discovered low carb and immediately my bgs and lipids improved enormously. I no longer eat very low carb, but keep an eye on my blood pressure and cholesterol to ensure I am not sliding too far down the slippery slope.
I have to say, though, it takes some courage to go against advice from health professionals to eat low carb, high fat. It is so engrained in my mind that fat is evil.
There’s such a herd mentality when it comes to much of the advice that health care practitioners give. Looking at it from their point of view, it’s much more comfortable to be wrong with the crowd than it is to be right alone.
I’ve been at odds with my doctor’s advice on statin use. I object to using a medication to lower a number that no study has shown to improve longevity.
Me too. Particularly when the number isn’t high to begin with!
I really don’t think there is some vast conspiracy to suppress the truth about low-carb diets in the medical community. The issue is that most of the trials where you look at really large numbers or even moderate numbers of people are observational or at least leave people to choose their own food, and most often these studies find those who eat a lot of vegetables, fruits and high-fiber, low GI foods tend to have the best glycemic control. There is rarely a strong association in those studies between the total number of grams of carbs consumed per day and the a1C, or if there i a weak correlation, it sometimes operates in the opposite direction – i.e. those eating more carbs have better A1Cs. (One exception: 46,000 teens, lower carb intake associated with lower A1C, but higher BMI and LDL cholesterol)
The cons of looking at observational data are many: There are probably very few people in the sample following a true low-carb diet, the people eating the “healthy” diet with the best A1C are in general probably a more health conscious lot and probably eating a lot fewer processed foods and restaurant foods, and possibly eating fewer calories, people are notoriously terrible at remembering what they ate, etc… And maybe for several decades there was a conspiracy to suppress evidence against the low-fat diet dogma, so that’s why there’s a paucity of research into low-carb diets now.
But if I were a doctor just looking at the available research, I would be wary of recommending low carb to my patients with such little scientific evidence to support it for T1Ds.
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Whether it is a conspiracy or a fracturing of the scientific community, what we have is a situation where the ADA and others have not funded nutrition research (let alone low carb
research) and refused to recognize studies that have been done on the subject. There is a good summary paper of the evidence for low carb diets that was done last year. And it is all to common to have arguments made that studies of “other questions” prove low carb diets don’t work. The study you cited that claimed low carb increased A1cs actually didn’t study low carb, it studied carb counting. And it showed that carb counting patients with a significant HbA1 reduction ended up eating more carbs than before the study started. I don’t see that having anything to do with low carb.
And while older doctors may be confused, most doctors who have been educated in the last 10 years have learned a very different view of the nutrition world. Significant numbers of new doctors support low carb nutrition diets for diabetes. My GP is a teaching practice and virtually all the new doctors are very supportive of low carb.
As a doctor I’m sure you are student of history. Low carb is like penicillin. Penicillin was not subjected to years of randomized controlled trials in order to prove is effectiveness and safety. Penicillin worked with a strong effect. It’s results could be observed in an experiment of N=1. That is the case with low carb. Patients that switch to low carb can see an immediate and significant improvement in glycemic control. And as a patient if you can drop your A1c by 1% you are reducing your risks of complications by a significant amount, probably far far more of a risk reduction than anything related to cholesterol or dietary fat. If low carb doesn’t work to improve glycemic control for a patient, fine. But if it does, as far as I can tell the patient will be far better off following low carb then eating a high carb low fat diet with poor glycemic control.
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"I was told by a CDE that low-carb was useless and that no one could
maintain that diet for any length of time. That was six years ago. I am
still doing low-carb and I will always be doing low-carb for the rest of
my life. "
I eat <60 g of carbs a day and plan to continue as well, because it’s been the only thing that has worked for me. My CDE told me I needed to eat 45g of carbs at each of the main meals, and 15 g of carbs with snacks, twice a day (total 165 g of carbs per day). I followed this advice until my A1c was 15.8 and insulin didn’t seem to do all that much (I can’t take oral meds). Then I followed “test, test, test,” and “eat to the meter,” and I found out starches spike up my BG. I was able to eat my vegan foods, with restrictions, and after 10 years of worsening numbers, they all came down in 10 weeks via the LC diet coupled with some insulin. Is this a restricted diet? Yes, it is for me, but it is something that works, and it’s very palatable. I wish I could eat bagels, but that’s no longer in the cards.
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FYI, I’m not a doctor. I said IF I was a doctor 
And as to your points, I’m not saying that low-carb diets don’t work for many…I’m just saying that if you are to do a pubmed search on diet and diabetes, most of the research you find will be equivocal or negative. Sure, the research is crummy – but the point is there is very little good research on most of these topics and doctors have to go based o that. (So, for instance, you pick at the protocol on that study I linked – but the point is that if you’re looking for evidence for low-carb, the protocols may be equally tangential/shoddy/etc and so likely doctors will have to include studies with tangential evidence if they want any insight).
I also think people who come to this site are a self-selecting bunch; they are people who have, for whatever reason, achieved really great control on a low-carb diet and vocally advocate for it. If there are people for whom low carb did not work, they probably don’t stick around too long, or stick to other topics because they don’t agree.
I personally agree that people in industrial society should, in general, be eating fewer carbs or at the least fewer net carbs (i.e. excluding fiber). My son typically eats between 75 and 110 grams of net carbs per day, which is about 25 to 50 percent less than the dietitians recommended. He actually NEVER ate the amount of carbs they suggested, so we were slightly horrified when the nutritionist said he should be eating 150 g of carbs a day.
But I’ve seen in my son that going really low carb backfires. If he eats eggs and cheddar cheese for breakfast a 300 is basically baked in. If he eats high fat foods with relatively little carb, especially dairy, he spikes high for hours and it’s worse because i’ve no idea how to bolus for it (I don’t believe it’s lipolysis that is causing the spike, but rather a huge increase in insulin resistance, which makes it tricky to bolus for). If his total carb intake for the day dips below, say 60 grams, all of a sudden he gets crazy insulin resistance, likely because his body interprets it as starvation and ramps up its defensive mechanisms to increase blood glucose. Sure, maybe if we went low enough for long enough, he would reach ketosis and then it would even out – but that could be at 12 g of carbs a day, meaning he would be eating a horribly restrictive diet.
I’ve also noticed, as I meet more D-families, that those whose children have the best control do NOT restrict carbs. They do meticulous logging, they are constantly tweaking basals and bolus ratios, their children are disciplined and willing to do things like waiting for the bend, they know how every minute ingredient in food affects their BG and they certainly avoid a few spiky carbs and certain times – but they do not restrict carbs.
So all I’m saying is that yes, many people have success with a low-carb diet, but that it doesn’t mean a doctor is “older” or “confused” if they’re not crazy about it. The evidence base – both in real life and in the literature – is not sufficient to make that the first-line recommendation for patients.
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It is true that you need to bolus differently for low carb and some (like your son) may not do well on the diet. But for years we have put up with being told that low carb is bad for everyone and that position has now crumbled. The science is there and even the Academy of Nutrition of Dietetics has reversed their position as demonstrated by their latest input to the USDA Dietary Guidelines which recommends restricting carbs for the entire US population.
I’m not suggesting that you need to change anything in your son’s diet, but it is not at all clear that you can extend your experience to a broader population. My experience with higher carb diets suggests that it would raise my blood sugars into the 300-400s after meals, cause me extensive serious hypos and probably raise my A1c by a couple of points. All very bad outcomes.
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The point here is that I am T2, not on insulin, and I am not able to do anything to affect spikes except exercise and drink lots of water. This study is about T2s, most of whom are not on insulin.
T2s get the short end of the stick, most do not have cgms nor even pumps. Here in Australia I am told I only need to test bgs once a year and should eat high carb low fat. What sort of advice is this to give a diabetic?!!!
And I do wish I could discuss diet properly with a health professional who understands more than one protocol.
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So, people shouldn’t try LCHF because it’s hard to follow? I’m so tired of hearing that. And, of course, most people who do LCHF say, “Well, if I can do it, so can you.” And that’s true. But that’s not the real problem with the " it’s hard to follow" argument. The problem with that argument is that the best response is actually, “So, what?”
So what if it’s hard to follow. Do you tell a salt-sensitive person with hypertension that it’s OK to eat a high salt diet, anyway, since it’s so hard to reduce salt if you’re a person who loves salty foods? Do you tell a person with a shellfish allergy to just carry their Epipen, since it’s so hard to not eat shellfish, if you love it so much? Or tell a patient with celiac that you know it’s hard to live without that bread, pasta, and other gluten-heavy foods, so we’ll give you a low gluten diet instead? No, you don’t do that. You tell patients that you’re sorry that it’s hard, but they have to follow that diet if they want their health to improve, and in some cases, if they want to stay alive. Diabetes is the only health condition I know of where the recommended diet is to eat more of what your body has trouble metabolizing properly.
The other thing about the “it’s to hard to follow” argument is that the people saying it are usually medical people and researchers without diabetes who are imagining themselves having to follow it and thinking no way. I thought that I could never do it, which is why I never tried the Atkins diet in all of my futile efforts to lose weight. But that was before. After I was diagnosed, I was taught by a CDE to do the carb-counting thing with a total daily carbs of around 120-130. I had lots of ups and downs. I felt awful. So I did a lot of research and discovered LCHF. I decided to try it for a few months. It did the trick, giving me a motivational boost to stick with it long-term. And now, there’s a good-sized community of people following LCHF and ketogenic diets, with lots of recipes and support out there. There was a lot less of that when I started LCHF. Having those resources make it a lot easier.
So, I think that instead of saying, "It’s too hard, so we’re not even going to try it, " they should tell their patients, “Let’s give this a reasonable shot. Here are resources to help you stick with this diet plan.” And set up a test period that people can follow in order to find out if it’s the best food plan for them. If it’s not LCHF, then try something else until you find what works best for you. The thing is, until you’ve tested any diet, you can’t know which foods will give you the best results. I think it’s a mistake to take a potentially helpful diet off the table “because it’s hard to follow”. Again-so what?
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