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.
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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 et.al. 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 have 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 ascomplements 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?
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?
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.
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:
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.
Comments
Therapeutic effect of the macrobiotic diet Ma-Pi 2 in 25 adults with type 2 diabetes mellitus
http://arab-board.org/sites/default/files/Vol.11%20No.4.pdf#page=8
theraputic effect of macrobiotic ma-pi diet in type 1 diabetic children
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.
http://high-fat-nutrition.blogspot.com/2014/01/macrobiosis.html
George Henderson
said...
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 http://circoutcomes.ahajournals.org/content/3/6/661.long
Peter
said...
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
kindness.
"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."
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.
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.
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.
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.
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.
Wow. Just. Wow.
Study #2 - average daiy intake was 2174 at clinic and 2144 at home
How is that a modified fast?
Remember Sam Feltham's nuts?
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.
"Rapid RBC turnover, as in a compensated version of hemolytic anemia, might be harder to spot but this is maybe not a vegan capability."
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.
Frassetto ....More sugar, equal carbs. Honey, pineapple, cantaloupe, lean protein (a lot) and low fat especially sat fat -- Go!
The Primal Blueprint Podcast
https://itunes.apple.com/us/podcast/the-primal-blueprint-podcast/id789935889
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.
Thank you for putting out this information, Evelyn.
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