Diabetes Treatment: New Dogma, Old Dogma or Just Carbophobic Myopia?

One of the points of contention raised in my brief exchange with Dr. Ron Rosedale over on the PaleoHacks forum is the notion that insulin is a harmful drug, and that diabetes should not be treated with insulin to "cover" dietary glucose.  This will only make the diabetic sicker and move them down the path of progression of their disease.   This reminded me of the flurry of blog hit pieces on the ADA's Hope Warshaw a while back.  One of the things these bloggers took special exception to was Warshaw's use of the term dogma and calling LC "old" dogma.  For starters:
Old Dogma: Losing weight will make blood glucose levels plummet no matter how long you have had type 2 diabetes. The message that people continually hear from their providers is "If you'd only lose weight, your blood glucose would go down." And the common reply from people with type 2 is "I'll try harder with my 'diet' over the next few months, but please don't put me on a diabetes medication."
New Reality: Research shows that the greatest impact of weight loss on blood glucose is in the first few months and years after diagnosis. (Read the Look AHEAD trial results, a study about the effect of weight loss on heart disease in type 2 diabetes.) In fact, the biggest bang for the effort per pound is likely in the prediabetes phase. (The sad fact is that most people don't know that they have prediabetes.)Large studies have shown that with loss of five to seven percent of body weight (approximately 10 to 20 pounds) and 150 minutes of physical activity (30 minutes five times a week), people can prevent or delay the progression to type 2. Once insulin production is on a dwindling course (particularly after 10 years with type 2), weight loss has less impact on glucose control.
There's absolutely nothing wrong with this part of her writings.  It is true, that the earlier the intervention, the more likely the disease can be reversed.  I do find her "reality" unduly defeatist, because one would imagine that the morbidly obese tend to have fairly long-standing diabetes, and yet gastric bypass surgery restores proper glucose metabolism in a surprisingly high percentage of patients.   Still, that bolded part (my emphasis) of her comments is a sentiment you hear all too often in low carb circles.  Why just this disease?  If one reads about low carb forums like Jimmy's, Active Low Carbers or Low Carb Friends, it doesn't take long to get the impression that a surprisingly high percentage of the participants are on some medication or other for something that may or may not be related to their weight and diet:  thyroid meds, blood pressure meds, antidepressants, etc. etc.  And yet many of these same folks will resist going on any diabetes medications even if they are unable to do what they think is the right thing -- avoid all carbs in all perpetuity -- for this condition.      No insulin or insulin secretagogues for these folks!  This is the sad legacy of the Taubesian demonization of insulin.  I'm going to address this issue in a future post.  For now, Warshaw continues:  
Old Dogma: People with type 2 diabetes should follow a low carbohydrate diet.
New Reality: Nutrition recommendations for people with type 2 diabetes from the American Diabetes Association and other health authorities echo the recently unveiled U.S. 2010 Dietary Guidelines (1/31/11) for carbohydrate: about 45 to 65 percent of calories. (Americans currently eat about 45 to 50 percent of calories as carbohydrate--not a "high carb" intake.)
Countless research studies do not show long term (greater than six months to a year) benefit of low carb diets on blood glucose, weight control, or blood fats. People with type 2 diabetes, like the general public, should lighten up on added sugars and sweets (yes, they're carbohydrate). They should eat sufficient amounts of fruits, vegetables, whole grains, and low fat dairy foods--all healthy sources of carbohydrate.
If one substitutes "safe starches" for whole grains, and perhaps drops the obligatory "low fat" from the dairy recommendation, this is not so far off what many, many who consider themselves paleo-inspired or ancestral-styled in their diets.  But calling low carb old dogma??  How dare she!!  Low carbers are  the avant garde thinkers of nutrition world!  They're too smart to fall for conventional wisdom!!    Diabetes is a disease of glucose intolerance, how stupid is Hope to suggest we give diabetics more of what they are intolerant of!  That's downright criminal ... it would be like giving gluten to a celiac, peanuts to a kid with a severe allergy.  Heck, to a diabetic all carbs are poison!   You see Hope, her minions at the ADA and all of those doctors and researchers in Big Pharma really just want to keep you sick.  That way they can sell you their books and medications.  This is different from, say Mark Sisson with his Contest Giveaways, hawking of supplements and all manner of (pricey, some might say overpriced) PB stuff, and engaging the likes of Jimmy Moore to help push PB to #1 on Amazon, exactly how?  But I digress ...

One of the more amusing ironies in all of this is the oft-heard canard:  "Before the discovery of insulin, they treated diabetics with a low carb diet".   If that's not OLD, I don't know what is.  And ummm ... How many analogies can we make here for replacement of "treatments of necessity" -- from when we didn't know the cause or have full knowledge of the mechanisms -- with modern life-saving treatments?  Before the discovery of insulin, diabetics didn't live very long either, but ...  Point being, as McGarry discusses in his (GCBC cited) masterpiece What if Minkowski Had Been Ageusic -- An Alternative Angle on Diabetes, diabetes is really not a disease of glycemic disorder, glycemic disorder is the manifestation of an underlying dysregulation in fat metabolism.  In that article, as I've discussed previously,  McGarry "wonders" over what different paths diabetes research and treatment might have taken were glucosuria, the spilling of glucose into urine that accompanies severe hyperglycemia, not the discovery of Minkowski.  Ageusics lack a sense of taste, so as legend had it, Minkowski tasted the urine of his pancreatized dogs and diabetes became synonymous with hyperglycemia.

I have presented abundant evidence on this blog, backed by the research of Edwin Bierman, J. Denis McGarry, Keith Frayn, and Guenther Boden, that "diabetes" as we know it, begins with a defect in the fat tissue metabolism ... the hyperglycemia we associate with diabetes is a symptom, not the cause.  I've blogged previously, Diabetes ~ A Disease by any other Name?, that perhaps we need to shelve the term "diabetes" and come up with more specific diagnoses/names for the various causes of hyperglycemia.   Early detection screenings might then target metabolic markers of dysfunction present far earlier in the progression of the disease.

One simply cannot read the research of that quartet of giants in the field and come away with the conclusion that carbohydrate consumption causes diabetes.  There is simply no evidence to support the notion that diabetics have exhausted their genetically susceptible pancreata.  Using insulin does not cause dysfunctional insulin secretion.  Using insulin does not cause resistance to it.   Now as I discussed in Glucose and NEFA: From Dysfunctional Metabolism to Toxicity, in agreement with the aforementioned researchers, it is the inability of fat tissue to contain free fatty acids that appears to be the initiating factor in the cascade.  Indeed there's some evidence now emerging that the defect is first evident on the uptake side of the equation, even before the fat cells lose their ability to constrain the fatty acids appropriately in their stores.  

In this regard, rather than promote insulin resistance, carbohydrate consumption should promote sensitivity.  Indeed it does ... and most of TWICHOO even supports this ... all except the part where anything that increases insulin causes insulin resistance. Think about it, it's rather ironic, but insulin serves to trap your fat in fat cells. This is what the diabetic wants!!  Here is where someone will jump on me and ask if I wish to suggest that a diabetic should eat even more carbs.  Here's the problem with that strawman ... define "more" ... more specifically, define the context.  For sure eating a ton of carbs in the context of a surplus energy SAD is detrimental, and adding more carbs on top of that without reducing something else (e.g. fat) is not prudent and will most certainly turn a bad situation worse.  But we could just as easily say the same for adding more butter or even coconut oil to a SAD.  

But there's quite a bit of evidence that dramatically increasing carbs, commensurate with decreasing fat, actually improves the situation for diabetics and sometimes even reduces their need for medications.  Yes, I did just write that. How can that be?  More carbs would require more insulin for a diabetic to "cover".  This is going to drive their blood sugars through the roof CarbSane!   Some responders to Jimmy Moore's query about safe starches were willing to concede that starch may be safe for us metabolically normal to consume, but remain steadfast that starch is unsafe for those with deranged metabolisms.   

To evaluate the effect of increased dietary carbohydrate in diabetes mellitus, glucose and immunoreactive insulin levels were measured in normal persons and subjects with mild diabetes maintained on basal (45 per cent carbohydrate) and high carbohydrate (85 per cent carbohydrate) diets. Fasting plasma glucose levels fell in all subjects and oral glucose tolerance (0 to 120-minute area) significantly improved after 10 days of high carbohydrate feeding. Fasting insulin levels also were lower on the high carbohydrate diet; however, insulin responses to oral glucose did not significantly change. These data suggest that the high carbohydrate diet increased the sensitivity of peripheral tissues to insulin.

The metabolic effects of high-carbohydrate (70%), high-fiber (70 g) (HCHF) and low-carbohydrate (39%), low-fiber (10 g) (LCLF) diets were examined for 10 subjects with insulin-dependent diabetes mellitus (IDDM). After a l-wk control period subjects on a metabolic ward were randomly allocated to HCHF or LCLF diets for 4 wk. After a 6-wk washout period subjects re-entered the metabolic ward for 4 wk on the alternate diet. Artificial-pancreas studies were performed on each diet for measurement of insulin requirements. Compared with the LCLF diet, the HCHF diet reduced basal insulin requirements (P < 0.025), increased carbohydrate disposed of per unit insulin (P < 0.0008), and lowered total (P < 0.0004) and high-density-lipoprotein cholesterol (P < 0.00 1 3). Glycemic control and other lipid fractions did not differ significantly. These results suggest that in IDDM patients, HCHF diets enhance peripheral glucose disposal, decrease basal insulin requirements, and lower total cholesterol without altering glycemic control or triglycerides. 

The influence of low and high fibre diets upon carbohydrate tolerance was examined in five maturity-onset, non-insulin dependent diabetics. After 14 days on a diet rich in natural fibre (30g/ day), the subjects consumed a high fibre (13 g) test meal. They then ate a low fibre diet (10 g/day) followed by a low fibre (1 g) test meal. Mean basal plasma glucose concentrations were similar after both fibre diets; however, both mean basal plasma. insulin and gastric inhibitory polypeptide (GIP) were significantly lower after the high fibre diet. Affer the high fibre test meal, significantly lower mean plasma glucose, insulin and GIP concentrations were measured. This study is the first study to demonstrate the ability of an institutionally supervised diet of natural foodstuffs rich in fibre to improve carbohydrate tolerance in maturity-onset, non-insulin dependent diabetics. This finding is relevant to the dietary management of diabetics.

 High-carbohydrate, high-fiber diets for insulin-treated men with diabetes mellitus
The effects of high-carbohydrate, high plant fiber (HCF) diets on glucose and lipid metabolism of 20 lean men receiving insulin therapy for diabetes mellitus were evaluated on a metabolic ward. All men received control diets for an average of 7 days followed by HCF diets for an average of 16 days. Diets were designed to be weight-maintaining and there were no significant alterations in body weight. The daily dose of insulin was lower for each patient on the HCF diet than on the control diet. The average insulin dose was reduced from 26 ± 3 units/day (mean ± SEM) on the control diets to 11 ± 3 (P < 0.001) on the HCF diets. On the HCF diets, insulin therapy could be discontinued in nine patients receiving 15 to 20 units/day and in two patients receiving 32 units/day. Fasting and 3-hr postprandial plasma glucose values were lower in most patients on the HCF diets than on the control diets despite lower insulin doses. Serum cholesterol values dropped from 206 ± 10 mg/dl on the control diets to 147 ± 5 (P < 0.001) on the HCF diet; average fasting serum triglyceride values were not significantly altered on the HCF diets. These studies suggest that HCF diets may be the dietary therapy ofchoice for certain patients with the maturity-onset type of diabetes. 

In a randomised cross-over study 18 noninsulin-dependent (NIDDM) and 9 insulindependent (IDDM) diabetics were put on to a high carbohydrate diet containing leguminous fibre (HL) for 6 weeks, and also a standard low carbohydrate diet (LC) for 6 weeks. During two identical 24 h metabolic profiles mean preprandial and mean 2 hour postprandial blood glucoses were significantly lower on HL in both groups, as were also several overall measures of diabetic control, including the degree of glycosuria. Total cholesterol was reduced significantly on HL in both groups, and the HDL/LDL cholesterol ratio increased significantly on HL in the NIDDM group. A diet high in complex carbohydrate and leguminous fibre improves all aspects of diabetic control, and continued use of a low carbohydrate diet no longer appears justified.

The above is just a sampling.  Low carbers often smugly refer to comparisons of LC to LF diets and say that the researchers or those making dietary recs are stupid to suggest that the diets are simply not low enough in fat.  Perhaps this is not so stupid after all.  Because the percentage of carbs in these diets is often higher than the 65% target Warshaw advocated, and in the range of 70-85%.  We're talking traditional Pima and Kitivan  terroir here.  Yes, those Pima, despite what Taubes would have you believe, their traditional diet was ~70–80% carbohydrate, 8–12% fat, and 12–18% protein.  What we see going on, when culture after traditional culture is exposed to the "Western Diet" is an increase in fat consumption and a decrease in carbohydrate consumption (at least as a percentage of energy calories), and an increase in obesity and diabetes.  Does this mean fat is fattening and sickening?  No.  Nor, in my book does it absolve carbohydrates of all nature.    Still ... if we're looking to ancestral solutions to a modern problem, starch may well be the answer.

It seems that if the standard "diabetes diet" advocated by the ADA is failing, this may be because ultimately it does not go far enough in terms of cutting fat.  Consider that many consider a diet to be low fat with as high a threshold as 30% of energy, and a protein sufficient diet around the 75% carb level is necessarily only 10-15%  fat.   

To sum up as regards the title of this post, as it turns out LC is the old dogma.  It's an old dogma that so-called revolutionaries would have you believe is now cutting-edge science bucking the mainstream.  The cited studies are but a smattering of what one will find as regards the causes of insulin resistance and diabetes and diet.  I think that viewing diabetes merely as hyperglycemia is the true "old dogma".   Focus on hyperglycemia is myopic and leads to erroneous oversimplifications that fasting and postprandial glucose and insulin levels are solely related to the quantity of dietary glucose.  That is simply not true.

Of course glycemic control is paramount for the diabetic, but as paradoxical as it sounds, a strong case can be made for eating more carbohydrates to that end.  This is clouded by those who "try" to follow an ADA diet that is nothing more than an attempt to lose weight on SAD-lite.  One thing that is clear, the reversal of T2 seems to necessitate extreme measures.  Be it the crash diet, or VLC, or VLF or gastric bypass, verifiable dramatic turnarounds have been reported.  

It may not be that the Perfect Health Diet is best for reversing diabetes in diobeseticsbut this diet should be excellent in maintenance of a transforming intervention.  Still, I can see no way that a SAD to PHD conversion would not usher in some health improvements.   That there should be any concern that it would be unsafe for someone to try is ludicrous in my opinion.

There can be no denying that VLC diets perform very well for reversing diabetes, but they don't really work in the long run.  Oh sure, for most, if they remain very low to zero carb, their hyperglycemia will remain largely controlled.  Yet many of these people (see, for example Tom Naughton's reply to Jimmy's initial query) who were never diabetic, have essentially succeeded at turning themselves so.  The common retort to that seems to be a lot of rationalizing about the "good" kind of  "physiological insulin resistance" and how if you never eat carbs who needs proper GSIS anyway?  Well, for one, insulin is instrumental in amino acid transport.  Is the "up the fat" movement in LC circles making matters even worse for those who would otherwise retain some signalling if not consciously limiting protein?  (I believe Paul and I have some differences over protein content in the diet where he seems to favor more limits.)

In any case, I don't believe there is any such thing as "good" insulin resistance.  The glucose-sparing sort in fasting and starvation is a defense mechanism.  Of course it is ultimately beneficial to the human in that context, but that doesn't make starvation a beneficial state.  If you had a choice between no food and Happy Meals for several weeks, the meal would be more beneficial, but that doesn't make Happy Meals good for you.  So in this regard, a person with impaired insulin signaling -- even if they don't "need" it -- is at least rolling the dice that it is not impacting them otherwise given the myriad roles insulin plays in our bodies.

I remain a huge fan of VLC diets for weight loss.  The more I delve into the science, however, the less convinced I become that it is even advised in maintenance, let alone optimal.  


ejazz1 said…
One of the reasons I chose the dash diet, when I was diagnosed with type 2 in 2004 was because of several articles I read concerning the importance of fiber in controlling blood sugar levels particularly after eating a meal. I have been able to maintain my weight loss for 6 years, yearly a1c test has been 4.2, fasting blood sugar levels 70-85 and 85-105 levels 2hrs after meals. I never counted carbs only calories while I was losing weight. I don't count calories now but I occasionally go to a website I found several years ago where I can input my food intake for a day to give me an idea of how many calories I eat and a breakdown of percentage of fat, carbs and protein. I'm usually around 2400-2500 calories a day, 20% protein 60%carbs 20% fat +/- 2 to 3% and usually 60 to 70 grams of fiber a day. This is the complete opposite of what I've read on different diabetes forums. I have been criticized on those forums for suggesting that each person should find a eating plan that best fits their needs. I also feel it is important for blogs such as yours to be out here providing more objective analysis of lc and vlc especially for newly diagnosed diabetics who go to those forums seeking advice on how to manage their diabetes and only getting one viewpoint.
P2ZR said…
1) "Consider that many consider a diet to be low fat with as high a threshold as 30% of energy." So that would make pop diets like "Zone" low fat (and at 40% CHO, high carb), huh. I think there could be a major food reward thing going on here: unless a former SAD'er is paying close attention to calories on a 40/30/30-type diet, it is just way too easy to overeat carb+protein combos - unless you decide to venture into low-reward terroir and segregate your butter from your rice and what have you.

2) You've pinpointed my beef with Sisson. I actually love some of his writing, but he's the canniest paleo marketer out there, and whatever moderation he espouses is utterly udone by his cultivating his bacon-headed grok mob (err, army). Love how you've so graciously linked his stuff, btw; I'm hoping he'll reciprocate at some point ;)

3) Okay, I know that this is your CARB-sane, not hydrocarbons-and-their-manufacturing-additives-sane asylum, but I'd like to get your chemist's take on the newly-resurrected plastics debate: http://chriskresser.com/how-plastic-food-containers-could-be-making-you-fat-infertile-and-sick. A commenter on the PHD blog took issue with it, calling it alarmist (http://perfecthealthdiet.com/?p=4982#comment-35979), but he also works in the plastics industry, so I'm wary of embracing his reassurances. My understanding is that PP, HDPE, LDPE are all relatively inert, and it's not like I'm going to ferment some pH 4 kombucha (or whatever it is that WAPF'ers fancy these days) in it. But with some lingering hormonal weirdness after AN recovery, I'd like to play things safe/r....

Wow, epic tripartite comment. Loving the leptinacious debunkeriffic posts lately :)
Sue said…
"I remain a huge fan of VLC diets for weight loss. The more I delve into the science, however, the less convinced I become that it is even advised in maintenance, let alone optimal."

I agree. Only problem with VLC - its good while sticking with it but a few slips and its hard to stop with the carbs. Perhaps better dieting with a few more carbs - eating what you will be eating at maintenance but just lower calories to encourage fat loss.
Wolfstriked said…
Wow Carbsane,that collection of Ward studies is amazing though I am a bit confused as to your stance about fat intake on a 70percent diet.Dr.Kwasnieski said that you should choose a fuel supply and lower the other one accordingly(keeping protein constant)mentioning the Japanese diet as being healthy.I will say that the PHD does not work for me and I get bad glucose control YET I can drink a sugary drink and a bagel and be very stable.I do wonder though if my alcohol damaged liver is the cause of the PHD not working for me also.See I feel that maybe its just not enough carbs since my liver has a hard time making up the rest.

But you do have to question the bad results with the SAD diet though....:( Great post Ms.Carb Sane;)
OnePointFive said…
In the 1950s the accepted 'diabetes diet' was about 33% carb. Advising this type of diet didn't work in rural India where people were vegetarian or near vegetarian and traditionally ate a very high carb diet.
Vijay Viswanathan, successfully adapted the local diet for his patients prescribing a high carb (67%)/ very high fibre diet.fat was less than 14% Calorie restriction depended on weight.

"Acceptability of diet was good and the dose of drugs needed small. 500 patients of high carbohydrate diets were available for follow up from10 to 15 years.Periodic estimations of blood sugar and lipids were done.There was a definite improvement in carbohydrate tolerance (P<0.001). Cholesterol and triglycerides,if elevated,showed a significant reduction (P<0.001 ). Plasma immunoreactive insulin assays showed increased peripheral sensitivity to insulin. Thus the high carbohydrate diet is (1) acceptable to patients, (2) achieves good control of diabetes and (3) lowers serum lipids."

This gives a bit more detailof the development of the diet over the years. A high proportion of the carbs were from pulses that we now know to be very low on the GI index, (Bengal gram has a GI of 11 )http://onlinelibrary.wiley.com/doi/10.1002/0470862092.d0602/full
( I tried to find out more but annoyingly references are behind the pay wall and the link on google to his paper High Carbohydrate, High Fibre diet in Diabetes (1981)is dead)
CarbSane said…
Thanks OPF! The term "pulses" is foreign to me. I never heard it until I heard Zoe Harcombe use it. The dreaded legume!
MM said…
Well, I don't know how most diabetics are, but I know my dad, who has not very well controlled blood sugar, basically refuses to go on insulin because he's afraid of needles. So, he takes several different drugs which keep his avg blood glucose at around 200. He's also convinced himself that if he goes on insulin it will shorten his life, but I think the real underlying problem, at least with him, is the needle phobia.
CarbSane said…
@ejazz: I am so grateful for your "contrarian" input here regarding your DASH success. I believe VLC still offers a great initial approach, but I also see it as a trap for many who could probably enjoy a less stressful life with the same or even better glycemic control. And trust me folks, I'm not wont to give up my fat intake (lower than most low/lower carbers but still north of most SAD's) anytime soon. I think this is an issue for many who find LC and fall in love with eating all those formerly forbidden fatty foods. And so many of us have nightmares of low fat diets. But if the quest is for best health for each individual -- for the long run -- I would at least try all options were I a diabetic.

@Sarah -- Glad you're enjoying the leptinacious debunkerifficness. Love that!!

1. Funny, I was thinking the same thing about Zone and PHD for weight loss. They suffer the same problems to different degrees. Anyone who thinks that monotony and/or elimination of many fattening foods (be it reward, caloric density, emotional triggers, whatever ...) on a VLC diet has nothing to do with weight loss is kidding themselves. So long as one can stick to it, and avoid substitutes/LC "junk", it goes a good long way to cutting caloric intake. This is evident in just about every plan comparing ad libitum LC to any other "restrictive" plan. Zone requires a bit too much complex food combining IMO, and enough fat where carbs + fat = not enough food (bulk) for many to feel satisfied. I never tried PHD for weight loss. I believe going from SAD to PHD most would lose, but it would not be the same as those going hard-core Paleo, low carb or even ad libitum very low fat. As you say those mixed foods do get you in trouble in ad libitum land. PHD is higher fat and lower carb but 100-150g starch is a LOT -- especially for someone transitioning from VLC.

2. Agree :-) I am a bit befuddled by his loyal following of critical-thinking skeptics of mainstream diet info when he is SO open about his business model and such. At least he walks the walk and looks the part ... but how hard can it be to maintain a former pro-triathlete ectomorph physique in his line of work?

3. Plastics ... Hmmm... haven't gotten to look much into that. I still have several non-stick pots I cook in too. ;-) I liked Paul's response.
CarbSane said…
@Wolfstriked: Long time no see ... nice to see you! Do you have poor postprandial BG control on PHD or fasting levels. If it's a damaged liver, this is associated with hypoglycemia (see the original paper on the Whitehall study from my Keep the leptinade flowing post) they discuss this, not hyperglycemia. OTOH, you could have fatty liver that might interfere with NEFA clearance and triglyceride formation.

Seems in this regard, however, if PHD is not perfect for diabetics or those with Metabolic Syndrome, it may well be that it's not high enough in safe starch foods, or that safe starches don't contain as much of the beneficial soluble fiber (IMO that's the winner winner chicken dinner -> butyrate in gut) and too much fat and saturated fat vs. MUFA.

The more I look into this stuff the more I come away thinking long term VHF diets merely mask rampant hyperglycemia but do not reverse, and may even exacerbate the underlying pathology.

@Sue: I agree wholeheartedly. This was why I fashioned my "cheating" plan this go round (not for BG issues but for sustainability issues). And really this was why I started looking into all of this in 2009 when I was no longer losing weight. For all the rah rah "livin la vida" stuff, most have a heck of a time adhering to this diet. Volek & Phinney apparently addressed this in their latest book much to the chagrin of many. I don't see how more moderate isn't better than VLC - binge cycles.
CarbSane said…
@MM: Yeah I hadn't thought of that. I also think for T2's, they are first classed as NIDDM - non-insulin dependent. Thus using insulin psychologically equates to a downward slide past the point of no return. But intense early insulin treatment can put T2 into remission ... In low carb circles, however, I think the reticence is more due to fears of weight gain as well as stigma of using anything but metformin.
Galina L. said…
What about benefits of LC for other conditions? For some reasons I don't need my asthma inhaler any more and stoppered having urinary tract infections and that annoying ones-a-year flue at the beginning of the year (there are more things in that list)? It is not the weight loss itself, because I had such conditions before I gained 26 lb between 45 and 46. Well, of course, my diet is not for everyone, it produced physiological IR, but if somebody's diet improves the situation with general health and allergies, is not it the mark of the right diet for that particular individual? I wouldn't lose to my modest goal without IF, for example. While IF contributed to IR even more than VLC (in my case), especially exercising in a fasted state. It is the main reason I watch very closely the discussion about safe starches - I want to decide for myself how important not to be IR. Looks s like I have to choose between IR which is never the perfect state and a weight loss or even not regaining. I am not telling you that you are wrong. I see the situation as a complicated one. Probably, the Nature intended me to be around BMI 30 at middle age, and fighting it is almost the same as teenager girl would be fighting female curves.
Tsimblist said…
My late father resisted insulin and managed his T2 with diet & meds for 30 years. When he finally understood that his body was requiring way more insulin than normal and that his meds were prodding his tired pancreas to secrete even more, then he asked to be put on insulin. His reasoning was that he needed to give his pancreas a break before he totally wrecked it. Unfortunately, in his case, it was "too little, too late".

I think that part of his resistance was his perception that using insulin was "the beginning of the end". He had let his blood sugar get quite high before he finally asked for the insulin.

He had tried a low fat, vegetarian diet as a last ditch effort just before resorting to the insulin. The initial results were encouraging. His blood sugar dropped. But then he fell from a step ladder onto a concrete floor and his blood sugar went wild. He retreated to low carb and insulin.
Wolfstriked said…
Thanks for the welcome Carbsane and I do frequent this site alot but have become a lurker mostly.My hypo is postprandial and I feel pretty level headed upon awakening.If I eat a PHD meal I feel like crapola early morning and once my hypoglycemia rears its ugly head its a day long affair.If I drink a bit too much I get hypo the next day and if I do two days in a row I get scary hypo where it drops all day long,after meals or not.It sucks because I love beer.I guess the hypo is actually forcing me to no be an alcoholic so its got its good points. :)

Today I had a VLC breakfast and then at noon I ate a bagel,apple and a banana.I felt great and still do.Just now I had a boil in bag rice pack(80gms carbs) and some veggies with some Parmesan cheese.Feel pretty good right now also.But this could be the calm before the storm and will see what happens by friday.
Lerner said…
Happy Halloween to Evil-lyn and all the other inmates! I implore everyone to please be very careful about what gets put into your trick-or-treat bags. Most dangerous of all might be the dreaded candy from a tree. Look at what happened to poor Snow White: just one bite of that apple and she immediately went into a coma. The danger from carbs is no joke.
Tonus said…
Heck, Eve bit into an apple and now we're all IR!
Sanjeev said…
> bacon-headed grok mob (err, army)

mobs and armies are neolithic inventions.

IMHO the word you seek is either "tribe" or "pack"
Muata said…
Tonus said "Heck, Eve bit into an apple and now we're all IR!"

Sue said…
Galina, I think the asthma and other things improved not from low carb per se but by what you removed from the diet.
I like to think that nature doesn't want us all to be fat in middle age!
Galina L. said…
It is very possible, Sue. Now I regret I didn't remove products in stages. One of disappearing symptoms on LC was leg edema. I noticed it returns promptly after rare re-eating of the wheat. Doesn't looks like potatoes or fruits do the same, but I so rarely eat something starchy in significant amounts, I don't have enough data.I will experiment more in a future, after menopause, when I will not need to be in ketosis in order to manage migraines. What is causing the leg edema - I don't know. My doctor doesn't know either and he said it was quite common in females after 40 and he gives such patients some diuretic.Yo see, there is something going on after that certain age. Never had edema before 45, and than some switch turned it on. It was one of couple symptoms to disappear first on LC, together with abnormal appetite, for eczema and asthma it took maybe 6 months to notice the change, asthma gone, but eczema still exist on smaller scale and not requires a treatment, flue disappeared in two years.
It is more common to discuss diets for a weight loss, that other health benefits stay in a shadow. My mom normalized her blood pressure and gastric reflex on LC. For that the wheat is a clear suspect. I also have some evidence, that in mom's case the elimination of morning oatmeal was quite beneficial. So, it could be grains .
I am almost 51, my mom is 75, before we were sort of fine(appetite was always a problem for both of us) - things may get worse with age.
KitavanEater said…

Hans just posted a new paper by Frayn. I was wondering if you could comment on it in regards to your understanding of the issue?
Will Hui said…
Nice post, I had been wondering about the "avoid carbs if you are insulin resistant" line of thinking for a month or so now. It seems the vegan doctors (McDougall, Barnard) are having great success reversing type 2 diabetes on a HCLF approach. I think Paleo/LC folks tend to counter this with "whole foods is better than SAD", implying that LC is still optimal for metabolic derangement. But results on HC happen quickly -- within a week or two according to McDougall. So I'm not even sure if LC is optimal in that sense either.

OTOH, it seems like the diabetic improvements could be explained by fiber (+ butyrate) alone. Is there any good comparison of starch vs fat on insulin sensitivity while controlling for fiber intake? This could have implications for both LC (eat more green vegetables) and HC (white rice won't do you much good).

Also, when we say that HF diets cause physiological insulin resistance, is that only the case in the context of VLC where the body really does lack the glucose it wants? What of a diet that includes some carbs but still gets the bulk of its calories from fat? To put it in a different way, is it the "HF" portion or the "VLC" portion that is causing the physiological IR?
Sue said…
Galina said:
"It is more common to discuss diets for a weight loss, that other health benefits stay in a shadow."
True. Had a guy lose about 37 pounds - and his blood pressure and cholesterol is now normal.

Will said:
"McDougall, Barnard) are having great success reversing type 2 diabetes on a HCLF approach."
It must be actually losing weight that reverses it. Like the study where folks were on a very low calorie diet and reversed type 2. Evelyn talked about it in a post.
CarbSane said…
Oh wow ... I do believe I have the greatest group of regular commenters here at the Asylum! Laughed my booty off!

On the more serious notes --

@Galina & Sue: I think Sue is getting at what I was going to suggest, which is that I believe in the overwhelming number of cases, it's some food ingredient you're probably sensitive to that is in a food with carbs than the carbs themselves. One of the premises of "safe starches" is that the starch itself is not the problematic component of these foods.

I also am reticent to name names because folks think this is somehow mean and rude, but two promoters of how healthful LC are are Jimmy Moore and Dana Carpender. In the past year Jimmy has had a lengthy illness, he's now suspended n=1 for metabolic/IR reasons, had injuries, boils, and overall doesn't exude healthy to me. Dana likes to say how LC is so wonderful for her health but in this past year she's been diagnosed with ADHD, PCOS and she's taking at least 3, likely more prescription meds. I'm not saying that their diets are causing this (though a progression to pathological IR on a very high fat diet comes as no surprise), but the myriad things LC supposedly cures seems to come at some expense over the long run. I hope this doesn't happen for you Galina.

@Kitivaneater: Welcome to the Asylum! There's a lot to chew on in that post. I've already put some of those citations in my library for future reference. I'm efforting getting my hands on the full text of that Frayn paper. I commented over on Hans' blog. That we always see elevated NEFA with metabolic disorders but elevated NEFA don't always precipitate the metabolic disorders may be where the genetic susceptibility comes in.

@Will: I'm not sure if you've commented here before or not b/c of your common name. If you're new, then Welcome! And thanks for the positive feedback. Lots of the HC diets are also high fiber so we cannot separate that out. Our guts are clearly involved in insulin signaling -- most prominently with GLP-1 -- I haven't looked much into this and fiber though. I have a blog post in the works on the reversibility of the physiological IR and what causes it. High fat definitely seems to contribute. I think Sue is possibly right that going from SAD to McDougall-style diet likely leeds to energy deficit/weight loss. But it also could be lowering the fat leads to more rapid depletion of ectopic fat in muscle and pancreas, etc.

@Tsimblist: Thanks for sharing your Dad's experiences as well. It seems that there are many reasons folks tend to put off insulin. The newer pen injectors and delivery forms (e.g. basal pumps, longer lasting) may hopefully change some of this. I'm not saying everyone should go on insulin, but reasons for not doing so should not be out of misplaced fears and/or stigma that requiring insulin therapy signals the end.
Galina L. said…
To Will,

It is being adapted to function well in ketosis or in a fasted state causing physiological IR. In order to get into ketosis, you have to eat less than 50 gram of carbohydrates a day. If you eat that amount of carbs but not too much fat, or no food at all (fasted state), you will be in ketosis. Body make ketones out of your body fat in that situation. So, it is the VLC part, especially when combined with regular fasting.
I want to add, it feels pretty good - stable BS level causing very stable mood and energy levels regardless of fluctuations in hormones. As a female, I know too well how variation in mood feels like, especially at pre-menopausal age.
Tsimblist said…
@Will: I am a big fan of fiber in my diet. I believe that is one reason why whole foods are so beneficial. My hero is Denis Burkitt (Fibre Man).

I understand that Taubes disses Burkitt in GCBC. Taubes blames Burkitt for distracting us with the fiber thing when he knew that insulin was the real problem. At least that is what I have gleaned from some Google research. I don't own a copy GCBC, so I can't verify that.
Quarrel said…

re Frayn paper, this isn't it?


It's not the pdf, but seems to be there?

Quarrel said…
Ah- scratch that, you're talking about this one:


which, yes, isn't there..

CarbSane said…
All but one page of his discussion on fiber is available on Google books here.
Tsimblist said…
Evelyn, thank you for the link. There were a few pages missing in the "Fiber" chapter, but it basically confirms my understanding.

This quote from page 128 of Taubes GCBC sums it up:

"In the process, Cleave's refined-carbohydrate hypothesis of saccharine diseases was transformed into Burkitt's fiber hypothesis of Western dieseases. This transformation of the causal agent of disease from the presence of carbohydrates to the absence of fiber may have been influenced by factors other than science..."

This quote from pages 131-132 is why Burkitt is my hero: "Burkitt then spent the next decade lecturing on the dangers of fiber-poor diets. He would condemn modern diets equally for their "catastrophic drop in starch," for their high fat content---"We eat three times more fat than communities with a minimum prevalence of [Western] diseases," he would say; "We must reduce our fat!"---and for their lack of fiber, which he considered "the biggest nutritional catastrophe in [the United Kingdom] in the past 100 years."
Tsimblist said…
Why am I a big fan of fiber?

(climbs on soapbox) Because it feeds the friendlies living in our gut. (steps off soapbox)

Programming of Host Metabolism by the Gut Microbiota
Will Hui said…
@Sue: Yeah, it could be mostly the weight loss. Since fiber is also satiating, it's probably hard to disentangle the independent effect of fiber from calorie deficit as well.

@Evelyn: Actually I've been reading your blog since May. But this is my first time commenting so thanks for the welcome :)
Lerner said…
I went looking for a talk online by McGarry, but he died in 2002 (from brain cancer). I did instead come across one by McDougall (Sept 2011), which he describes as a preview of his new presentation that he'll be using.


He does mention studies from circa 1930 on HC being good for diabetes. There's also even a mention (at 1:01) for high fat and meat pushing people into full blown diabetes (Rabinowitch 1930).

Earlier, he does mention harm from using insulin as opposed to diet alone, as shown in the TRACE and ACCORD studies.

Things go round and round.
CarbSane said…
Probably one of the problems with fiber is that the difference between soluble and insoluble has not been stressed. The fiber in All-Bran is not the good stuff, but the stuff in oats is. Soluble fiber yields SCFA that feed your gut cells and no-doubt are involved in metabolic signalling in some way.
"Think about it, it's rather ironic, but insulin serves to trap your fat in fat cells. This is what the diabetic wants!"

ah, the proverbial lightbulb for me - when I was originally listening to a podcast interview with Datis Kharrazian, the thyroid guy, and he talked about putting his patients on a liquid fast where they drink only a sugary liquid to "unwind" their insulin resistance, I couldn't honestly make sense of that I that time; I must have still been a TWICHOOB. Now after reading this post, however, I get it. Thanks!
KitavanEater said…
Thanks for responding! Hans wrote a post on the paper, http://hanswuhealth.blogspot.com/2011/11/preliminary-review-of-adipose-tissue.html,

But he also cited Dr Davis? Did he lose some credibility?
Frank said…

C'mon... he simply said that he encounter the idea there first, linking to a 2009 blog post. Davis blog was quite popular at that time, and his ideas where not as quacky as right now.

Hans is a very bright guy and seriously I don't know how he find the time to read that much and do so much research while doing an MD degree. Big kudos to him. Beside, he's very much influence from imminst and the calorie restriction list, which are both incredible ressources when it comes to nutrition (not so much these days anymore tho', in case of imminst) and supplements sciences. Look for post from Michael over there or another guy named Kismet. You'll have your mind blown away by their understanding of science, especially in the case of Michael Rae, which I've yet to see someone proving him wrong when he brings evidences to the table.

So please, be respectful to Hans ;-) His blog is wonderful.
CarbSane said…
To this day many bloggers I respect still link to or give deference to others whom I do not. I form my opinions based on what each says in their own right on any topic. I'm just a little more vocal {grin} of calling it like I see it, and part of that is because I have a little more freedom to do it.

Thanks so much for bringing that post to my attention KE. Hans was kind enough to send me the full text on the Frayn paper. It's a semi-game changer, but not nearly what the abstract/intro might lead one to believe. I will be blogging on it for sure!
CarbSane said…
Oh ... and I also think both Davis and Eades of years past are different men from the Davis and Eades that emerged in 2010 and 2009 respectively. To name two.
Lerner said…
Quote Evelyn: "Hi Lerner: Just FYI, I blogged on McGarry's last lecture here.."

Thanks, I read it. There is also a sponsored annual "The J Denis McGarry Lecture" with 6 done so far, but the people in charge don't seem to have thought of actually recording and uploading them. What a waste.

wrt vegan-advocate McDougall, he does have quite a marketing operation of his own. I tend to think of weight loss (as opposed to macro-nutrient changes) as being primarily responsible for most improvements. But in discussing a study like "High Carb and Low Calories results in..." McDougall mostly concentrates on the carbs.

But wrt weight, in the video at http://vimeo.com/30473854 at ~ 1:04:14 McDougall presents a case-study Benjamin, who does very well on his BG, Chol and TAG despite his weight changing only from 313 to 310 lbs. Still, I'd first of all wonder if the weight figures are true. Screen shot of stats is at:


Btw, McDougall also has quite a good stage presence.
Lerner said…
I happened across a free journal (the authors pay) with probably a low impact rating but nevertheless some articles might be interesting to some. (Besides, since they are mostly reviews then the real impact rating to consider might be of the reviewed articles themselves.)
Editorial Diet and Exercise in the Treatment of Fatty Liver July 2011

"Intrahepatic fat, possibly more than visceral or intramyocellular fat, may thus be a prominent factor modifying the metabolic risk associated with increasing whole-body adiposity..."

one example:
Review Article Putative Factors That May Modulate the Effect of Exercise on Liver Fat: Insights from Animal Studies

"...exercise training appears to be more potent in reducing IHTG in subjects with increased baseline IHTG, for example, subjects with NAFLD, type II diabetes, or the elderly."

And somewhere was the claim that intrahepatic fat from fructose is harder to get rid of.
Anonymous said…
COMIA- METTETAL...it's all in the bag now - AEGEAN with MARS.
And they got the SAIIL and the SALED with BAUTERS.
So don't plan on anymore trips soon.
Passports " confiscated".
I think you call it PHOCKST?
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