Welcome all seeking refuge from low carb dogma!

~ Charles Darwin (it's evolutionary baybeee!)

Wednesday, January 22, 2014

Carbohydrate and Diabetes

Does carbohydrate intake cause diabetes?  How about hyperglycemia in the established diabetic, is that caused by carbs?  Is the only way to fix this without insulin to reduce carbohydrate, perhaps virtually eliminate it?

If you've come here from the low carb or paleo realms, you would answer yes, and yes, and an unequivocal yes.   I believe that when you cast aside the hyperbole about rotting scrambled brains, starving cells, toxic sugar and all the rest, the remaining misconception that using insulin causes your pancreas to break down is the most damaging of all.

image link
Dr. Eades is fond of hunting black swans.  By that I mean, the whole falsifiable hypothesis thing.  If I say all swans are white, then finding all the white swans in the world provides further support for my claim, but it can never be "proven".  However all I need is one black swan for the claim to be falsified.  Too bad those that are so fond of this are unable to distinguish black from white, or something like that.  Because unless they are, there can be no explanation for the Pima.  There are, of course, numerous other cultures that could be our proverbial black swan, but in diabetes research, the Pima are somewhat famous for having the highest rates, etc. in the US.   If one were to read Gary Taubes and listen to his lectures, they might get the impression that historically the Pima ate a low carbohydrate diet ... or at least lower than today.  Not true.

Traditional Diets:    

We estimated that the traditional Pima diet, although seasonably variable, was —70-80% carbohydrate, 8-12% fat, and 12-18% protein.
By the 1950s, Hesse reported a dietary composition of 61% carbohydrate, 24% fat, and 15% protein.  Reid reported in 1971 that Pima Indian women consumed a diet that was 44% carbohydrate, 44% fat and 12% protein.  Preliminary data from a dietary survey ... in 1989 shows that the current diet was ~47% carbohydrate, 35% fat, 15% protein and 3% alcohol.
[studied Mexican Pima vs. Arizona]
Mexican Pimas were lighter (64.2 ± 13.9 vs. 90.2 ± 21.1 kg, P < 0.0001; means ± SD) and shorter (160 ± 8vs. 164 ± 8 cm, P < 0.01) with lower body mass indexes (24.9 ± 4.0 vs. 33.4 ± 7.5 kg/m2, P < 0.0001) and lower plasma total cholesterol levels (146 ± 30 vs. 174 ± 31 mg/dl, P < 0.0001) than Arizona Pimas.  Only two women (11%) and one man (6%) had NIDDM, contrasting with the expected prevalences of 37 and 54% in female and male Arizona Pimas, respectively. 
The Pima diet ... appeared very monotonous and lacked several esssential nutrients because of the relative absence of fruits and vegetables.  The mane staples were beans (...), corn as tortillas, and potatoes.  Preliminary data by semiquantitative food frequency and 24-h recall suggest that ~23% of total energy intake is derived from fat.
The main sources of protein and carbohydrate in the diet were corn tortillas, wheat flour tortillas (which include ~30% vegetable fat in their formulation), and beans, which are typically fried with variable amounts of vegetable oil or shortening. 
What is it one should likely conclude is the likely cause of diabetes in this highly prone population?   There are many, so many, many more.

Dietary Interventions:

But how about once one gets diabetes?  Well, there's been considerable success in treating modern Pima with a traditional diet.  But I'd like to expand this just a bit to a new intervention I recently learned of.  Charles Grashow sent me the following two papers:  (1) Ma-Pi 2 Macrobiotic Diet Intervention in Adults with Type 2 Diabetes Mellitus, and (2) Medium- and Short-Term Interventions with Ma-Pi 2 Macrobiotic Diet in Type 2 Diabetic Adults of Bauta, Havana.    What is this Ma-Pi 2 Macrobiotic Diet?  I'll be honest, I never heard of this one, and I thought I'd heard of them all!   Interestingly:
Diet is a cornerstone of comprehensive treatment of diabetes mellitus. The macrobiotic diet is low in fat and rich in dietary fiber, vegetables and whole grains, and therefore may be a good therapeutic option. (1)
Total volume of the Ma-Pi 2 diet consisted of 40–50% whole grains (rice, millet, and barley), 40–50% vegetables (carrots, kale, cabbage, broccoli, chicory, onions, red and white radish, and parsley), and 8–10% legumes (adzuki beans, chickpeas, lentils, and black beans); all foods derived from organic cultivations with no chemical additives.  Gomasio (roasted ground sesame seeds with unreﬁned sea salt), fermented products (miso, tamari, and umeboshi), and seaweeds (kombu, wakame, and nori) were used as
complements of the diet’s nutritional value. Bancha tea (theine-free green tea) was the main source of liquid.   (2) 
Gee, I thought pharmaceuticals were our first line of treatment always and forevermore.   But I digress.

It's a vegan diet.  

Uh oh.  

About the macrobiotic part of this diet ... I have no comment.  Would this work without the seaweeds and fermented soy and special tea?  I don't know that there's been a controlled trial.  I would point this out however:
One of the main effects of the Ma-Pi 2 diet may be its potential to supply alkalis to metabolism. The amount of acid residue generated by the typical Western diet (mainly sulfuric amino acids contained in animal proteins) is currently under debate. It may be argued that such residue surpasses the capacity of homeostatic mechanisms, producing an increase in blood acidification, resulting in lowered plasma bicarbonate concentration.  One effect of this low level chronic acidosis may be increased insulin resistance.   Epidemiological studies reported in the literature also suggest that sustained high protein intake is associated with higher incidence of type 2 diabetes mellitus.
Sulfuric acid ... sulfuric acid ... where have I been warned about that before?  Oh that's right!  It's that stuff paleo oatmeal is made of!!   Remember Wheat Belly on Acid?

He merely adapted his take on oats to fit the anti-wheat agenda.   All hyperbole and such aside, this is the problem I have with the acid-alkaline balance crowd ... they can't even agree on which foods are supposedly causing the problem!!!  And yes, the paleos ARE on that wagon too (or were), see for example here (Cordain) and here (cites Cordain).

So let's ignore the woo woo and just look at this diet from a food compositional and macronutrient perspective.  Here you have here a whole grain based, vegan diet with some legumes that clocks in at almost 400g carb amounting to over 70% of calories in a 2200 calorie diet.  Both studies took diabetics and put them on roughly this same diet with some pretty impressive results.

Study 1 

This study included 16 type 2 diabetics that were all receiving insulin therapy at baseline.  There were 3 men and 13 women, average age of 60 with a range of diabetes duration from 9 to 31 years.  Their mean weight was 69kg with a BMI of 28.  Six months on Ma-Pi 2.  

Weight loss:  6.25 kg, ~14 lbs
Average HbA1c:  12.60 to 5.73

Medication Status at 6 Months:  NO INSULIN USE by any subject at the end of the intervention.   Dietary therapy ONLY for 12 of 16 or 75% of subjects. Four subjects were switched to glibenclamide.

Study 2

This study involved 61 subjects who were provided the Ma-Pi 2 diet at a center for 21 days, then provided instruction and some supplies to continue the diet at home for a total duration of 3 months.   Of interest, their baseline diet was assessed and was slightly lower in calories (1936 vs. 2174) and considerably lower in carbohydrate (242 g vs. 392 g), which worked out to be 50% carb, 30% fat and 20% protein.  Basically they did the opposite of what some of the low carb approaches do -- increased carb by 20% roughly split by decreasing fat and protein by 10% (a little less from protein, more from fat).

Unfortunately, this study does not give much individual detail about medications, but there are several inferences to reduction in insulin requirements in the results.  Direct quotes from the paper:
Daily diabetic medication consumption was high at onset: 53 patients used a total of 1341 insulin units (mean consumption: 25 u/person and 0.3 u/kgWt); 60 patients consumed 200 hypoglycemic pills (mean consumption 4 tabs/person).
Serum glucose, lipids, and other indicators reflected a non-optimal metabolic control at onset. The high glycemia value at onset (8.35 mmol/L) dropped fast during the first 3 days of intervention, parallel to the insulin consumption reduction.  After 21 days, the 2 mmol/L reduction (23%) was highly significant; 3 months later it was more evident (2.7 mmol/L, 32%), reaching values inside the metabolic control interval.
The high fiber, Mn, Mg, and Zn intake and the reduced fat and protein content of the diet have contributed to the observed decrease of the insulin demand. Only after 21 days, patients were able to control glycemia, serum lipids levels, and blood pressure.  The fact that patients diminished further the insulin doses at 3 months indicates that they continued carrying out well enough their diet at home in spite of slightly dietary transgressions.
 Excerpt of note:
The higher energy intake observed during this intervention, in comparison to previous values, would indicate that other dietary factors as energy alone should be related to the results. This Cuban study shows a diet low in fat (only 16–18% of the daily energy), low in proteins (12%), and high in whole grain cereals carbohydrates (70–72%) acting alone as powerful medication. 
What's that we're always hearing about letting food be thy medicine?

Protein and Lean Mass - Both Studies 

Lastly, of note, is that lean mass was assessed and various other measurements were made in both studies.  Those parameters are included in the table provided for Study 2, here is that information for Study 1 (I had to calculate the fat and lean masses from percents given, hence the adapted table).

In Study 1 there was virtually no change in lean mass despite the loss of about 6 lbs over 3 months' time.   In Study 2, only about 1 in 6 kg of weight lost was lean mass, which is a pretty good lean mass retention for any diet-only study.  Those numbers translate to 2.4 lbs out of 13.75 lbs of total weight.

I'm quite surprised by this as I'd expect greater lean mass losses with the cut in protein, and complete elimination of animal protein.   It even appears they took into account the reduced efficiency of digestion of plant protein.  Interesting stuff.  Is high carb somewhat protective of lean mass?  

Fess Up Time:  

I've got to admit, overall these results are quite compelling and not only "rival" but exceed many of those I've seen for low carb diets.   Could I eat this diet?  I do not think so.  If I were diabetic could I eat this diet?  I still do not think so.  I guess the idea of giving up all animal food and even avocados, nuts and olive oil doesn't really appeal to me.  I must be addicted to all of these things?  I must not care about my health?   This is the impression I get from those that advocate low carb as the one and only healthy way, who seem to view those that eat carbs as addicts lacking the resolve and/or even self-caring ....

Some Thoughts and Take Homes:

I look at these and I think that if I were diagnosed with diabetes, that might be motivation enough to try this approach for a few months!   In Study 2 the insulin was lowered in short order, and Study 1 seems almost too good to be true!  The levels they reported there are quite high for HbA1c and FBG -- were these w/o insulin for some period to get an idea of "uncontrolled" levels or were these with insulin?  I admit to skimming a bit so I might have missed this, but regardless, the results in that study rival those of the "crash diet".  Realize that in this study, we're talking older, primarily women (avg. 60) who had diabetes for 9 to 31 years, NOT newly diagnosed cases.
  • ALL took insulin at baseline
  • ALL were off insulin at 6 months
  • ALL were consuming almost 400 grams carbohydrate (mostly starch) per day
  • 75% were off all meds in 6 months

It seems possible that consuming this very low fat diet, even at somewhat higher calorie levels, might be yet another approach to "draining the swamp" -- reducing pancreatic and liver fat to restore insulin secretion and sensitivity.    It was noted in that study that c-peptide (a measure of insulin secretion) increased but not enough to reach statistical significance.  Postprandial c-peptide might have been a better measure.  In any case, in both Ma-Pi studies, insulin therapy was reduced or eliminated, again in ways that rival a VLC diet approach (see:  Diabetes "Crash" Cures: VLCal vs. VLCarb).   Perhaps, then, a Ma-Pi-2 "Crash" can be added to the tools in the med bag of the diabetes first responder.

Clearly if they are lowering insulin AND increasing carbohydrate intake concurrently, beta cell function is being restored to some considerable degree.  Something, I might add, that does not appear to be the case with VLCHF approaches.  

In any case, I think studies like these, taken together with those of traditional cultures like the Pima, ought to be given some consideration by the anti-grain, anti-carb, downright militant paleos and low carbers.  IF they are correct in all of their pronouncements, then this post could not be written.

In repetitious summary then:

  • Consuming large quantities of carbohydrates is not associated with high incidence of diabetes in innumerable traditional cultures, including one of the most obesity and diabetes prone modern cultures, the Arizona Pima.    Therefore:
Considerable evidence supports the claim that carbohydrate intake, and the postprandial insulin excursion it elicits, does not cause diabetes.

  • Eating a diet that increased carbohydrate intake by about 60% to almost 400 grams/day, in the context of a low protein, low fat diet, ameliorated or reversed the diabetes in the Ma Pi studies.  Therefore: 
This adds to the previous evidence supporting the claim that the hyperglycemia in diabetes is not caused by dietary carbohydrate.

  • Further, the aforementioned diet was based on whole grains (40-50%) and legumes (8-10%).  Therefore:
This provides evidence to refute the claim that starch in general, and grains or legumes in particular or the lectins etc. associated therewith cause or exacerbate diabetes.

Those that advocate low carbohydrate diets (paleo or otherwise) for the prevention and/or treatment of diabetes need to address these black swans.  As you can see, they are not even lone oddballs.  They don't even appear to be all that rare.


charles grashow said...

Therapeutic effect of the macrobiotic diet Ma-Pi 2 in 25 adults with type 2 diabetes mellitus

theraputic effect of macrobiotic ma-pi diet in type 1 diabetic children

Karen Norris said...

Oh my gersh!! I do know that as I attempt to up my carbs to 30 a meal my bg # are better except potatoes dont seem to make it happy. Lol I just realized I put butter on my cauliflower. Think it was that?! Vegan huh...shades of Leere Keith. How absolutely confusing this all is! Thanks Ev. Keep it coming

Glenn Dixon said...

I hate you. Every time I read your articles I can't resist telling my wife. It doesn't often go well...*sigh*

carbsane said...

Hmmm ... care to elaborate? ;-) I hate to be the source of marital discord!!

carbsane said...

Unless it was the only way, I do not see vegan in *my* future. Especially with my husband, unless he had some sort of epiphany. The man is not satisfied without some animal flesh every day. It doesn't need to be a thick steak or anything (he enjoys fish, other seafood and poultry and isn't into fat on beef or pork) but this diet? I might last a month or so, but him? I'd give him a week. OTOH he drops weight like crazy on LC in short order, so that would be my go-to crash for him (sans the stick of butter).

Glenn Dixon said...

She's still rather stuck on all of our low-carb reading from the past several years. I'm more persuaded by many of the things you've posted here. I may be blaming you unfairly :)

Screennamerequired said...

These types of diets have been used for a while. Even before Pritikin. You see many diabetics reversing their disease on Mcdougall forums.

carbsane said...


ExEffectsGuy said...

I feel so inadequate. I can't and absolutely won't be calculating my ratios of nutrients whether they be Macro, Micro, Globally Celestial or whatever. I am a type 2 diabetic and it ain't from eating fruit! Early on I had dietician that wanted me to track my food and drove me nuts with requests! For. one week I kept an agonizingly complete record of everything including breaking out every possible category of weight in grams, nutrient values and effects on blood sugar at 1, 2 and 3 hours. She was stunned and overwhelmed. She told me I didn't have to supply that much detail. I said well either it matters or it doesn't! She said I had a point. The subject was henceforth dropped.

carbsane said...

Peter is bitter.

Funny how the LCHF trajectories are FAR worse but it's the only answer. Also funny how he basically acknowledges that it works, just might be difficult to stick to outside the clinical setting.

charles grashow said...

He is very bitter

George Henderson

A raw food vegan diet might work better, because then you'd be starving,
and starvation probably does cure diabetes, if you didn't die or lose your mind first.

HbA1c is a red herring, because you need hemoglobin and reasonably long-lived red blood cells to have elevated HbA1c, so veganism will lower it even if glycation is increased. See the discussion here: imagine what happens to HbA1c in vegan anaemic states


George, I’ve been thinking a great deal about what an HbA1c really means. My own view about glucose is that resisting insulin is where maximum health comes from. The level of glucose in the blood stream is probably then actually irrelevant, if you are keeping that glucose out of cells. Neither glucose nor fructose is particularly reactive with biological
tissues unless they are phosphorlylated. There is a condition where
people have an inherited inability to uptake fructose in to their cells.
The fructose, considered to be the devil incarnate of glycoxidation,
doesn’t glycoxidise anything, despite permanent elevated plasma levels
with fructosuria. But the activated phosphate is another matter. The
papers are on my old hard drive, really must shift them over.

Of course the GK mutation points to insulin as the problem for vascular
damage, rather than glucose. Stan and I have batted this around a
little. Mostly the problems are inseparable but here insulin is looking unfriendly cf glucose.

Re raw food vegans, the loss of mind is intrinsic in the mental state of
veganism. Re fatality, perhaps the sooner the better would be a

carbsane said...

Yeah cuz all the LCHF folks are of sound mind.

carbsane said...

Furthermore, these were eating slightly more calories from baseline and I don't see how I wouldn't feel full on that diet. Satisfied from a palate and living life POV is another story, but sorry, LCHF is not much better in that regard.

carbsane said...

One more thought here. Insulin is the GOOD GUY. This is why diabetic complications are worse for T1's than T2's (if un or poorly controlled) despite similar hyperglycemia.

charles grashow said...

Your thoughts on Peter's statement


carbsane said...

Probably one of the most ridiculous things I've ever heard from a low carb advocate ... and that's saying a lot.

Insulin does so much more than transport glucose. That and the notion that cells are better off without it is absurd. It's a starvation state.

George said...

I would say the Ma Pi diet is a modified fast. Fasting is going to reverse diabetes, for sure. As a way of life, probably not optimal, in fact pretty much the diet you would get if you were being brainwashed by a cult, but a valid type of treatment in the short term.
The Pima intervention study that used improved food quality, which I would always expect to produce some improvement regardless of macronutrients, is susprisingly thin on results. Probably because improvements were more gradual than carb restriction results would have been. But a cure does not have to be the mirror image of the cause.

George said...

I got the HbA1c paper from you Ev, good paper that. Who knows why some people tolerate high FBG and others don't? That becomes an interesting question, that might have surprising answers.

carbsane said...

Did I say it was a modified fast? I don't think I did. I think the body might perceive it as a true fat fast ... negative flux of fat from the fat cells and small fat loads. What goes wrong first (most likely) in diabetes is adipocyte fatty acid uptake postprandially, coupled with lack of suppression of FA release. This is why I think Ma Pi works. Drain fat from organs, restore proper TAG/FA cycling and FA uptake/release in postprandial state.

There are other Pima interventions, I just didn't have time to list them. The one here was more to highlight the diet of the Mexican Pima that includes flour and such with low diabetes rates. But others, like the Odea Aboriginal study, all low fat, "high" carb by percentage calories.

carbsane said...

Glucose went down and HbA1c. I didn't see your comment. I am only responding to the limited query about Peter's response.

carbsane said...

Sorry, I misread your comment if you read my original response.



George said...

It's likely the energy is is poorly extracted from the Ma Pi food, at least at first. If the Pima fat % has increased that much, a lot of that new intake is likely to be from cheap oils. Setting the stage for an interplay between refined carbs, low protein, and omega 6 like the ones here:

Kade Storm A.K.A. Hedonist said...

I've been curious about the A1C red herring myself.

So does it matter or not?

Its good if low carbers use it, but it's bad if vegans use it? How much of an impact does a lower haemoglobin have on the final A1C result? What proof do they have aside from this kind of conjecture that the vegans have more 'glycation'? I would really like to know more about this issue because this debate has fallen so badly prey to circular reasoning that depending on how much of a bias one has, one can paradoxically explain away low and high fasting glucose. Low and high fasting insulin. Low and high A1C.

Kade Storm A.K.A. Hedonist said...

And even starvation can be good or bad, depending on diet, of course.

Wow. Just. Wow.

charles grashow said...

Study #1 - average daily intake on MA-PI diet was 2202 calories
Study #2 - average daiy intake was 2174 at clinic and 2144 at home

How is that a modified fast?

ExEffectsGuy said...

You summed up my epiphany moment! One day, thinking of my low carb life, and deciding whether to try the high fat life, I started thinking "well is insulin is so bad, why aren't type 1 diabetics dancing in joy?" I can make your insulin go to zero......just die. OK, that's the NEXT diet/Dr. Oz fat cure plan, but right or wrong, that was my cold slap in the face! Finding sane voices like this site and, yes, old nutrition films, seems to have straightened me out!

ExEffectsGuy said...

Another guy I've never heard of, but he must be right! He said he "thought about it" didn't he? Well...what more do you need?

charles grashow said...

t s said...

Sounds like great news. Looking forward to the Book.

George said...

I don't think that vegans with low HbA1c have more glycation. I think they have anaemia.

George said...

I figure that 2,000 calories of macrobiotic roughage supplies as much useable energy as 1,000 calories of Kentucky Fried Chicken with mashed potatoes and soda.
Remember Sam Feltham's nuts?

Kade Storm A.K.A. Hedonist said...

Sure. I should say that this isn't the first time I've heard this thought about anaemia.In the past, I've seen it used as a prerequisite for arguing further that one cannot gauge glycation level in vegans through A1C due to the likelihood of anaemia. This was also the impression I got between the lines from the commentary quotes that Charles had posted.

charles grashow said...

" 2,000 calories of macrobiotic roughage supplies as much useable energy as 1,000 calories of Kentucky Fried Chicken with mashed potatoes and soda. Maybe less."

Care to offer some proof for that statement. How valid is it to compare large amount of nuts (450 grams/day or almost 1 lb!) to veggies, brown rice and beans at much lower caloric amounts.

t s said...

What if a modified curry sauce was included? I can feast on curry anything without meat forever.

carbsane said...

I do believe with the right spices I could last a while, no way my husband could make it more than a week!

carbsane said...

Moving goal posts Georgie.

George said...

You might just have to do a blood count as well to eliminate anaemia. Rapid RBC turnover, as in a compensated version of hemolytic anemia, might be harder to spot but this is maybe not a vegan capability.

t s said...

compare the B12/protein/cholesterol from one oyster, one egg and braised beef brisket. One oyster kicks 'em all back to the farm.

Kade Storm A.K.A. Hedonist said...

They do regular checks for blood cell count, as well as the more basic anaemia testing under the medical system in UK. However, I couldn't be certain--any longer--of the story in other countries.


I don't know whether I can speak for their capability. Priority as well, I couldn't speak of because I'd rather not collectivise. Just as I don't see every low carber as a Jimmy Moore rationalising everything away. Anyway, vegans should pay particularly close attention to these factors with the kind of compromises they make, but then it's perfectly reasonable to assume that this should come as common sense for making dietary compromises.

carbsane said...

I guess you didn't read GCBC then. You clearly have no comprehension of what diabetes is (hint: beta cell dysfunction and relative insulin deficiency) .

Frassetto ....More sugar, equal carbs. Honey, pineapple, cantaloupe, lean protein (a lot) and low fat especially sat fat -- Go!

carbsane said...

PS. I'd rather advocate for reversal of T2, not "alleviating symptoms". A healthy metabolism processes carbs as we evolved to consume ;-)

khungus said...

A sign of the apocalypse:

The Primal Blueprint Podcast

charles grashow said...


You say "FACT: RCTs show conclusively that LCD work best to alleviate they symptoms of T2D."

SO - how do you explain the fact that ALL of the subjects on the MA-PI 2 macrobiotic diet were able to STOP their use of insulin.

Isn't that better than alleviating their symptoms?

You also say - "A vegan "high carb" diet will certainly help a T2D IF their current diet is a SAD. Why? LESS TOTAL carbohydrate and sugar."

Again - the macrobiotic diet in the study was appx 72% carb - that's MUCH higher than a typical SAD diet.

Glenn Dixon said...

NNOOOOoooooo! lol

abcdegh said...

I get the feeling, from all of the conflicting studies and information on the Internet, that either a low carb high fat diet or a low fat high carb diet seem to be healthy, but diets that are about equal in carbs and fat are very unhealthy (especially when you throw in processed foods and vegetable oils). This study seems to compare a LFHC to an Equal Carb and Fat diet (is there an acronym for that?). My feeling is that if you have a meal that will have lots of carbs, keep it low fat, and if you are going to have a big juicy steak, don't have pasta too. A lot of people can probably have a LCHF meal for lunch and then have a HCLF meal for dinner and be just fine. But for some people, one or the other all the time might work better depending on their genes and how their particular biology works. But I think over time, the equal carb/fat diet tends to be unhealthy.

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