Wednesday, August 20, 2008

Low Carb Diets Also Work for People with Type 1 Diabetes

It's no secret that type 1 diabetes and type 2 diabetes are very different diseases. The etiology is completely different, and often, the treatment protocols differ as well. Some of this is based on simple realities, but there is also a notion that what applies to one type is not necessarily applicable to the other. However, this is largely unsubstantiated by clinical evidence. In fact, many changes and/or innovations in diabetes care are based on learning from a group with a different type of diabetes.

One element I frequently hear pertains to carbohydrate consumption. There is an attitude among many people with type 1 that because they will require insulin regardless of what they eat, so there is no real reason to "avoid" or minimize the consumption of certain food groups (notably, carbohydrates). I understand the logic, but the notion of "I can eat anything I want as long as I 'cover' it with insulin" is pretty flawed.

This month's edition of the journal Diabetes Care features a submission from researchers in Australia. Their goal was to try and quantify the effects of glycemic index on postprandial glucose excursion (PPGE) in children with type 1 diabetes. "Excursion" is kind of a euphemism for just how high blood glucose levels go after eating before returning to a more normal level. In their study, the researchers conclude that low–glycemic index meals produce a lower PPGE than high–glycemic index meals -- should we really be surprised?! In other words, they found that if people with type 1 diabetes wish to stabilize blood glucose levels and avoid large peaks and valleys, then going low-carb is far more effective than simply the eat what you want and cover it methodology which seems so prevalent these days.

To be sure, some argue that a diet such as that prescribed by Dr. Richard Bernstein might very well be effective, but is also too extreme for most people, and you can count me among them. Indeed, in James S. Hirsch's book "Cheating Destiny: Living With Diabetes, America's Biggest Epidemic", the author has an entire chapter (Chapter 8) dedicated to Dr. Bernstein's Solution, and he describes Dr. Bernstein (who has type 1 diabetes) as a man who eats a diet that is too fat-laden, and Dr. Bernstein himself is probably too often hypoglycemic for many people with diabetes. However, Dr. Bernstein himself has never proclaimed that his "solution" is meant for everyone. Instead, he uses it to demonstrate that reliance on insulin also has health consequences, and that patients really need to strike an acceptable balance (which will be different for each person) between insulin and carb consumption.

The summary, however, is that low-carb diets do work, and they work for everyone (with type 1 or type 2 diabetes, as well as for those who do not have diabetes). The core argument is that the medical establishment, and especially the American Diabetes Association, has prescribed a diet that is more harmful than it is healthy for people with diabetes, and that sound judgment is in order for anyone with diabetes. However, in the interest of stabilizing blood glucose levels, people with type 1 diabetes would benefit greatly by limiting consumption of refined carbohydrates. Not only will they not require as much insulin, but that provides benefits demonstrated by his law of small numbers, namely that the smaller the dosage of insulin, the smaller any mistakes are likely to be.

There is nothing "extreme" about that conclusion!


Lee Ann Thill said...

I'm curious about what regimen the study subjects were on, and if they had controlled for insulin delivery method and timing of the boluses. I'm not in the 'eat whatever you want and just cover' camp, but I am of the belief that type 1's can eat anything as long as they do so in moderation with a keen eye on portion control. Because I eat the things I like, including ice cream, candy bars, and other things that were a non-no when I was a kid, I've spent considerable effort trying to manage my post-prandial numbers by tinkering with both when I take my bolus in relation to when I eat, and using the combo bolus feature which offers the variables of how much insulin up-front vs. extended, and how long to extend it. I've found that I can maintain excellent numbers even after eating carb-rich treats as long as I keep it to a single serving (I measure my Ben & Jerry's on a nutritional scale in grams, not a gram over or under the serving size - volumetric measurements are useless for anything but pure liquid IMO), and use the combo bolus that works best for me. Everyone has to find a plan with a balance that works for them, but I think it's erroneous to assume one only maintain excellent BG's by severely restricting what they eat, and I think so many of these scientists and nutritionists never seem to honor the social and emotional components of eating that affect us all.

P.S. I eat *a lot* of produce and whole grains - I don't just eat ice cream and candy bars! Moderation, Variety and Balance :)

mollyjade said...

It frustrates me when either side talks as if their diet is the only one that works. The best diabetes diet is whatever one you can sustain while getting the best blood glucose levels you can. I'm with you and lee ann thill about the moderation. I have problems matching my insulin and carbs if I eat too many carbs, but also if I eat too few. I really wish there were a term for this mid-range carb diet. I'm not low-carb, but I'm not anything goes either.

Jenny said...


How can Dr. Bernstein's diet be "Too fat laden" in view of the mass of research Gary Taubes has presented that fat is not what causes heart disease? Just what exactly is supposed to be wrong with fat. Dietary carbs ==> Triglycerides & high LDL. Not fat.

Cheating Destiny's chapter on Bernstein was very mean spirited. The author insinuated some very venal things about Dr. Bernstein that are simply not true.

The author clearly was in denial about how out of control his own blood sugars were. I would trust that chapter as much as I would a chapter about AA written by an alcoholic who was still drinking.

The way he was treating his son based on his own denial verged, in my mind, on child abuse and I was disturbed by his seeming pride in how he drove with blood sugars out of control enough to cause several accidents. If anyone needed to take another look at lower carb eating that was the guy.

Dr. Bernstein's diet is more extreme than many of us need to adopt to achieve normal blood sugars, but that is because he came up with his system 25 years ago. He is still using slower insulins and has never tested Apidra or Novolog or newer pump systems. He is at an age where people are set in his ways. But those ways have helped a lot of people achieve control and avoid complications.

But Bernstein's basic premise: small inputs make for small mistakes, should be the first lesson taught everyone who goes onto insulin.

Anonymous said...

Dr. Berstein's diet is extreme, but it works. He is his own test subject and living proof that his extreme way of managing his diabetes results in reversing complications and living to a ripe old age. I am on this plan and people criticize my extreme diet often, but I just respond, "You know what is really extreme? loosing your feet at 35 or going blind at 40, thats a little more extreme than I prefer"

Anonymous said...


Anonymous said...

Most parents are aware of the glycemic index of foods (there are numerous books on the subject). Both of our pedi-endos encouraged us to modify the glycemic index of her food in order to prevent postprandial spikes. And glycemic load plays a part as well, not giving too large a portion. But your title is misleading when it comes to children with diabetes. NO WHERE in the article did I read that they advise lowering the amount of carbohydrate a child is to eat per day. In fact, the amount of carbohydrate to be eaten, as well as the amount per meal (meal plan) is calculated at diagnosis by a nutritionist. If a parent were to alter the amount of carbohydrate their child consumes and put their child on a low-carb diet, I believe this would be addressed at one of the three month visits. Our endo carefully goes over the amount of carbs, insulin given, growth and weight charts. Your title leads one to conclude that a low carb diet is safe for children and that is not the case. Low glycemic and low carb are two different things.

Scott S said...

To Anonymous:

While I appreciate all comments, there is nothing misleading about the title. By its very definition, a low-carb diet is also very low on the glycemic index, including minimization of highly-refined carbohydrates (such as while rice, flour, etc.). While the study did note that carbohydrate AMOUNT is considered to be the most important dietary determinant of postprandial glucose control (citing the American Diabetes Association: Nutrition recommendations and interventions for diabetes–2006: a position statement of the American Diabetes Association. Diabetes Care 29:2140–2157, 2006), I believe you are presuming that anyone recommending low-carb is must therefore be recommending no-carb. I don't believe such dietary restrictions are desirable or even sustainable over a lifetime, but I do believe that managing carbohydrate consumption can be an important element in sustained glycemic management. You state that my "title leads one to conclude that a low carb diet is safe for children and that is not the case". Where in this title do I state anything about children with type 1 diabetes? Your flawed presumption is that the vast majority of individuals who have type 1 diabetes are children is just wrong. The reality is that most people with autoimmune-mediated type 1 diabetes mellitus are not children, but fully-grown adults who have lived with type 1 diabetes mellitus for many years. It is these presumptions that also explain why JDRF has only recently begun to acknowledge that a largely un-tapped fundraising audience for the organization is adults with type 1 diabetes -- nearly 40 years after being founded! The good news is that the JDRF has recently started working to make itself more representative of the broader patient community of all individuals, including adults, with type 1 diabetes.