Thoughts on Dr Berstein's book?

Type 1 and LADA
21

Do no other Type 1s take issue with his emphasis on carbs? One of my major issues with him as a Type 1 (particularly a female) is that he acts as if carbs are the be all and end all of diabetes control. Limit carbs and BAM - normal control, easy as that! Oh, sure, he touches on DP and such, but 99% of his emphasis is on diet. Maybe this comes mostly from working with older patients, who knows.

I'm in my early 30s now and was in my early 20s when I first read his book, and this is part of the reason I did not agree with his methodology right from the start. I don't know about others, but carbs are not the only thing that has a huge impact on my BG. I can go to work all week and then have an increase in activity level on Saturday and be lowering pump settings and dealing with lows for days. And monthly hormones have an enormous impact that require me to re-adjust all my pump settings up or down by a fair bit at least two or three times a month (with no warning other than suddenly running extremely high or low).

His book may be comprehensive with dietary advice, but it pretty much ignores the impact of exercise and hormones other than spending perhaps one paragraph mentioning them, at least from what I remember from reading an older edition. So his book, in my opinion, is not a complete methodology for diabetes control. Other books cover exercise and hormones in far more detail and provide strategies for dealing with them. I also really can't agree with his dislike of the pump and of modern insulin analogues (and probably CGMs, too).

I also do not understand why he has never (to my knowledge) published a peer-reviewed paper. I understand in the beginning he did not have a medical degree and was rejected and so on, but that's no longer the case today, and it seems to me he'd be a lot more accepted (and therefore possibly benefit a lot more people) if he made the effort to validate his diet through empirical research. He wouldn't even need to do anything different - just do a case study on a few of his new patients.

I actually don't disagree with his low-carb approach at all. I used to be one of those people who said I would never limit carbs, but I've changed over the past few years, although I do think his limits are a little extreme.

22

Absolutely.

23

I don't consider it a complete system, and actually think it is pretty limited in scope, because he is unfortunately stuck with only one bit of advice to lower BG: namely to eat only from his limited diet list and only 6g carb in the morning, 12g carb at noon, and 12g carb at night. If you can't take that advice, or don't want to, or if you do take that advice and find that it doesn't work for you, then you are done, because he has no other advice for what to do.

The best part of his book is in my opinion the detailed information about all the potential complications of diabetes and how to test for them. But in terms of actual usable day-to-day advice on managing and adjusting your insulin techniques, I find the Pumping Insulin, Type 1 Diabetes (Hanas), and Think Like a Pancreas books much better. The Type 1 Diabetes (Hanas) book isn't talked about much, but is in my opinion the closest thing to a complete book for Type 1 diabetes, because it covers everything (though it is of limited value for Type 2's).

24

He actually has collaborated on a couple peer-reviewed articles which you can find on PubMed. But as you say he has never set up a scientifically valid test with a control group to look at the effects of his diet approach. To be fair, he is not a researcher, he is a clinical physician in private practice who writes diet books. So it isn't surprising that he hasn't done such a study. But it would certainly make his recommendations a lot easier to believe if he HAD done such a study.

The closest he has come is to select a subset of his patients and show their results: HERE Unfortunately this is pretty irrelevant, because it is not only a hand-chosen set of patients (presumably the "best result" T1s and T2s he could select from all his patients and not an average and certainly not a randomly selected group with a control group), but the T1's he picked are all adult onset of fairly recent onset.

25

My main issue with his diet is that it's all carb oriented but doesn't (I don't recall which edition I have...) address balancing your diet more precisely with macronutrient ratios of Protein/ Carbs/ Fat which I think is a more effective way to approach total nutrition and dietary needs. I'm as guilty as anyone as counting the carbs and damning the torpedoes and everything else but I think that it's very possible to study your diet more effectively and eat and maintain decent glycemic control while consuming a few more carbs.

I also wonder what Dr. Bernstein's "batting average" would be, i.e. how many of his "adherents" or "followers" or "people who have made an informed decision to try his approach" actually abide by the 30G/ day approach. I see a lot of "I like Dr. Bernstein and low carb...but not that low..." posts which makes me wonder about a great market opportunity, like come out with a 50-75G plan, or a 120G plan (mine, ha ha!!) that gets great results and allows a bit more freedom, debauchery, rock and roll and celebration. Everything you put in your mouth doesn't have to be a party but well, there's sometimes when a party can be fun and controlled. I beat the numbers he reports in the study Jag cited. Perhaps I "cheat" by exercising a lot but well, if you look at it as a chance to "play", it can be fun too! I saw earlier a Bernsteiner mentioned that he does aerobic and anaerobic but, at least in my edition of the book, Dr. B rx's anaerobic only because he's not a fan of shoveling in carbs nor of pumps to "cover" gonzo aerobic exercise. I am a fan of both but like a run. It's a great feeling. I've done that for, geez a bit longer than I've been on Tu and can get high for a week off of a great run.

26

I don't mind when topics like this recirculate from time to time. We have some members that weren't here for the last go-round. I prefer when commenters stick to reporting their experiences and leave out the emotional triggers. We can talk without shouting and remain respectful.

I think when I started paying attention to the last round of "low carb controversy," it provided me with a lot of info that influenced my successful foray into carb limits. I am grateful for the "pitched battles" that I was able to watch from the sidelines. It was not a wasted discussion to me.

Suggesting, even tangentially, that someone change his/her way of eating is akin to starting a conversation about religion, politics, or sex in polite company!

BadMoonT2 - Your response was thorough, on point, and needed! Thank-you.

27

Gee thanks! My main point was that a T1 who does olympic weight lifting (which I consider to be competitive exercise) and is not in the 50 plus age group may find the recommendation restrictive. I am a T1 who is in the 50 plus age range who does daily vigorous exercise and chooses not to follow the B way simply because I need the nutrients and don't struggle with bg management or weight issues. Like others have said I also find other things impact my control besides carbs.

28

Thanks Terry. It's true this argument will never be won and the positions of the repeat participants are unlikely to shift.

But there are, as you say, new folks coming by all the time. Many are newly diagnosed or have decided to tighten up their control. Level of carb consumption is a decision we all have to make. These discussions provide a short course about the pro's and cons of different approaches.

29

The argument can't be really won since science is not actively seeking to answer the question "scientifically". There are billions of people eating every day but food studies are hard, as you either have to lock people up and feed them carefully controlled portions or rely on self-reporting, both of which have shortcomings. I think that science could answer the question with a cleverly designed study, maybe hiring some sort of observer, maybe even an R2D2 like creature to follow you around and watch what you eat and do or something, but they aren't looking now.

In this regard, I think the biggest question surrounding Dr. Bernstein's magnificent book and practice is "can people with diabetes safely aim for normal blood sugar?" I have found that I can and I know there's other folks running their own experiements who have also been very successful. It's time for mainstream medicine to study those people (ok, US!!), find out how we do it and figure out how to help other people take control of diabetes the old-fashioned way, by beating the hell out of it...

30
It's true this argument will never be won and the positions of the repeat participants are unlikely to shift.

I like it when debate illuminates a topic well. If I want "vanilla," I can go see my endo!

31

His mantra of fewer carbs = less insulin = smaller mistakes is wisdom that will stand the test of time.

Aiming lower is something you've endorsed before. When I correct for a high BG, I aim for 85. Why not? I almost always miss a little high, a great outcome.

32

AR, although the 30 g/d of carbs is the thing that provokes the most heated discussion, perhaps the part about aiming for normal blood sugars is the most revolutionary part of the book.

Study the most successful and teach others their secrets, what a concept:)

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:)

34

Bernstein certainly is a polarizing author. His hardcore stance turns off a lot of folks.

I find his low carb approach to be beneficial but I just cannot go to his extremes. I am T2 and have never met a carb that I didn't like, so making a conscious effort to control them is a huge help.

I may be wrong but I believe his reason for recommending low carb to his T1 patients is to help stabilizing blood glucose levels, trying to take the extreme highs and lows out of the equation. I believe he calls it the law of small numbers, Less carbs equals smaller bolus' with a smaller chance for error.

I have seen it debated in this discussion whether Bernstein's is a complete system. I say yes it just may not be the system for you. Many people thrive on his system but it is by no means the only system. I prefer Gary's system which is a little bit of Bernstein, a little Walsh and a lot of advice taken from the pages of TuDiabetes. It's what works for me. YDMV so Gary's system may not work for you.

35

I believe that everyone with diabetes should read Dr. Bernstein’s book. The strongest message that comes out of his writing is that you can control your diabetes. Very few of us can or are willing to live with only 30g of carb per day. At the same time, many of us know that the current thinking of “Type 1’s can eat anything” isn’t right either. Everyone of us has to find the balance that works for us most of the time and then do our best. I couldn’t be a patient of Dr. Bernstein, but at the same time I have learned from him and respect his convictions and advice.

36

Hi KiwiK: Woohoo! I am not 55+ yet, so I get to be a youngin'! Lots of debate here about Bernstein, but unlike some who have commented, I will say that you are new to TuD so you probably haven't seen the past debates and you are asking a legitimate question.

I read Bernstein's first edition shortly after I was diagnosed. I just find him too extreme and too full of himself, and IMO it is just weird to not use the best technology available (pumps, etc.) and to do things like use glucose tabs to fuel workouts. But his book is a worthwhile read and as many have pointed out, take what works for you and leave what doesn't work for you. What I think is unfortunate is that someone hasn't written a "middle way" guidebook.

Have you seen Ginger Vieira's book Your Diabetes Science Experiment? Ginger is a youngin' and a power lifter.

37

The mental damage is more directly targeted about the running low constantly. For example our cognitive abilities at 80mg/dl is on a par with having two pints (of a normal ale that is not the good stuff) on board, and while like hypo awareness (and with drinkers) it can be dispelled away by becoming a persons norm. This is also why in some countries a diabetic can't drive if their BG is below 99 and it's an immediate removal of license if they do.

But also look at HbA1c and the push the low carb brigade have to lower it to very low levels. There is a reason a T1's optimum is defined as 6.0-6.4, with a rock bottom at 5.2 and any lower is back in the danger zone. Yes we all know fine well higher gives you long term side effects, but so does lower which as other discussions on here have brought up the various long term studies including those at Joslin and various universities which link mental conditions to hypo's and running low. On top of that you have the brain needing 130g per day itself, ok fine it can source a lot of that fuel from fat also, or neat glucose which it supposedly prefers, but still that's a fair amount!

So you bring in Attia and a study on normal athletes. Great, but the issue there is they have a pancreas! I have a ride coming up shortly and it's been calculated out I'm going to burn about 9800 calories on it. I am oddly open minded (even if it doesn't always look it) as being low carb on such a thing would be tactically advantageous as I wouldn't need to carry so much fuel. Or would I? And what was the solution in the low carb thing for this? walnuts. High calorie content ok, but that's 1.5Kg of walnuts! Let alone trying to eat them at speed...and I hate walnuts anyhow but that's another matter :P

Not even going to bother discussing the issues involved with dealing with proteins and amino acid issues with them on certain types of food. But fat is bulk I can do without trying to get my optimum performance weight back down to 53Kg again. I go light as the lighter I am with increased muscle mass means the faster I am (even more so on the climbs).

I've been fortunate enough to have access to a team of dietitians who were able to calculate my NEEDED carbs for exercise, and yes they had to really nail the text books for the calculations for it. As an interesting fact that's a fraction under 1g/min depending on temporary basal amounts (still needed to metabolise things), temperature, wind, weather, and other external factors.

There does seem to be a rather large group of loud, usually in the T2 camp, who push low carb which is fine for them. But also seem to ram it down the throat of everyone else and particularly the kids who we've seen on here getting subjected to 10-15g a day diets by over zealous parents. It's bad enough as a kid to have this getting lumbered on them making there lives utterly none normal. I'm a T1, it doesn't stop me doing anything. I want that burger, I'll have it. I want that chocolate cake I'll have it. I want to ride in the Tour de France, I will! It doesn't stop me doing anything, and dietary boundaries are something which are utterly not necessary if a T1 knows the variables around them. And that unlocks our freedom, not pressures to avoid carbs or other factors locking us down from the likes of Bernstein.

38

I was maybe a tad harsh. I was kind of aiming more at everything being dependent more on what each of us does really and everything has to be open to everyone's lifestyle. Berstein is too lay down the law and do things my way, and find his numbers (like the 4.8% A1c) dangerous as it contradicts everyone else. He does seem to fit T2 better than T1, and he is boundary to enabling T1's do anything and everything they so wish to and stripping them of their freedom.

39

I understand your concern about hypos and I do think our efforts to tighten blood sugar control should always carefully manage the risks of hypos. But a core principle that Bernstein uses is the "law of small numbers" and my experience is that this dramatically reduces the rate and severity of hypos by greatly reducing blood sugar swings. And our brains don't stop working at 80 mg/dl and they run fine on ketones. Carbohydrates are not an essential macronutrient.

But I do agree with you and other posters like Jen that Bernstein doesn't say much about sports or exercise with low carb diets, a better resource for that is "The Art and Science of Low Carb Performance" by Phinney and Volek. I think athletes on low carb diets such as Tim Olson who won the Western States 100 ultramarathon in record time really do suggest that there are different paths. We each have to find our own way. For me, Bernstein has enabled tight control, my standard deviation is less than 30 and I've had A1c in the 5s for three years running and I haven't had a true hypo (< 70 mg/dl) in three months. As I've said before, "What works, works," and the same applies to whatever you are doing.

40

Yes, but lets not fail to point out that you are a T2.