Carbohydrates and Diabetes ~ Part II

I really struggle sometimes wondering what goes on in the minds of the staunch low carb advocates.  Something comes along that's just their sort of "red meat" revelation -- you know a "what if everything you thought you knew was wrong" sort of bombshell -- and they just seem incapable of wrapping their head around it because it goes against what they've been told by their LC heroes.  Instead of even trying to reconcile the cognitive dissonance, it seems they'd rather just move the goal posts .... just one more time?   I suppose it is easier to believe in fairy tales, to convince yourself that the rebel path you chose on the word of so-called experts is the right one to optimal health and immortality.  The alternative does tend to get rather uncomfortable.  

When I wrote Carbohydrates and Diabetes, my intent was to dispel one of the more common remaining myths about carbohydrates.  This is one that, sadly, is embraced by the mainstream as well.  I believe this is because there is enough of an intuitive connection between blood sugar and food sugar, and it is technically correct that all starchy carbohydrate is effectively "sugar" as it is broken down into glucose.  

Commemorative Low Carb Guru Teaspoons

And then you have your teaspoon crowd, the ones that fixate on the capacity of your circulatory system to carry glucose as if this is in any way meaningful with regards to how much dietary carbohydrate you can consume.  Simply put, the fact that normally the glucose in your bloodstream amounts to about 1-to-2 teaspoons (closer to 1 fasted, perhaps approaching 2 after a large carb load), really tells us nothing about the role of carbs in diabetes.  Put another way, this is no more relevant than the amount of fat in your bloodstream, or amino acids for that matter.

Statistically every human eats more than 5-10 grams of carbs at a time, and it's not like we have to eat a few grams every half hour to keep blood glucose levels steady.  The same goes for fat.  Statistically every human eats more than a half to 1 gram of fat at a time.  And yet most humans don't have "damaged metabolisms" as a result.  This is because of insulin.  Insulin doing its job -- or one of its various jobs to be more accurate -- of clearing excesses of all three macros from circulation so as to maintain a relatively steady supply regardless of the state of nutrition at any given time.   

Insulin does more than facilitate nutrient uptake, however, its most important roles appear to be its action in the liver to suppress the liver's glucose production (glycogen breakdown and/or gluconeogenesis).   This is real reason why the hyperglycemia of diabetes has very little to do with dietary carbohydrate.   A pancreas that produces insufficient insulin, and as a result too much glucagon is the likely primary problem.  I am convinced by the various review articles that I've discussed this past year or so, that insulin deficiency is the primary defect in the etiology of diabetes.  Hepatic (liver) insulin resistance (or the adaptation/dysfunction we call IR) is perhaps a secondary cause, while peripheral IR is almost assuredly a symptom, if it even exists (again, as it has been described and defined to date).  

All that said, the fact that hyperglycemia isn't due to eating carbs does not absolve the macronutrient entirely.  Carbs could still be implicated if it were shown that they cause the insulin deficiency.  Indeed, this is still the major charge of those like Wiezen Wampe (hehe ... that's Wheat Belly, ever since I found it in German I just kinda like that name better!)  when he implores us to baby our pancreata.  The purpose of Carbohydrates and Diabetes was to discuss a smattering of the wealth of evidence against this "exhausted pancreas" model vis a vis carbohydrate intake.  Using your insulin is not like driving a car that will eventually wear out.  Insulin in your body is not like odorous fumes in a room that you cease to smell if you're in the room for a while.  

If carbohydrate consumption caused diabetes, then the traditional Pima would have become diabetic ... they clearly appear to be genetically predisposed ... but they did not.  Nor do their Mexican "cousins" that still consume a more traditional diet including not just carbs, but grains.  If decreasing carbohydrates was required to treat, put in remission or reverse diabetes, then we would not see improvements on a high carb diet.  Yet we do, with Ma Pi 2 as discussed in the blog post, and others like DASH, Pritikin, etc.  

    

Why am I writing this follow-up?  Well, because of some of the feedback and responses to that post.  First and foremost, Fred Hahn commented.  That's the full screenshot that you can click to enlarge, but I'll post it chopped up to break up my wall of text and keep you from having to scroll up and down.

Really?  Not a single one?  It would be far closer to the truth to state that every single one does, compared with the truth in this statement!  To then call ME disingenuous?   I tweeted this out with a link to the most obvious statement I could find:

Screenshot of this post

Or how about with a more modern paleo bent?  Diane is Diane Sanfilippo of Practical Paleo fame.  She's tickled pink that Amazon searchers seeking paleo information land on her stuff rather than that outdated low fat Cordain/Wolf stuff.

Screenshot of this post

Nahhh ... no implication that carbs give you diabetes.  It seems to be stated pretty clearly here by Hahn's friend and "expert", Gary Taubes:

Over the years, prominent diabetologists and endocrinologists— from Yalow and Berson in the 1960s through Dennis McGarry in the 1990s— have speculated on this train of causation from hyperinsulinemia to Type 2 diabetes and obesity. Anything that increases insulin, induces insulin resistance, and induces the pancreas to compensate by secreting still more insulin, will also lead to an excess accumulation of body fat.   (GCBC, Kindle Location 8027)

I could go on, but I won't bother.  It seems silly that one should even have to refute such nonsense, but I felt the need to call out the utter stupidity of Fred's comment.    What's even funnier, is that in the next lines he appears to be making the case for how carbs cause diabetes.

OK so let me get this straight.  On the Ma Pi 2, 70+% carbohydrate diet, in one study, all of the subjects who were taking insulin at baseline were no longer taking it after 6 months, because ... what?   Eating carbs forced their pancreata  to produce insulin??  Gee if only it were that easy, eh?    Here is the link to the study he then cites:  Mechanisms of β-Cell Death in Type 2 Diabetes.  So what Fred is saying is that eating carbs will eventually kill of your beta cells ... so it's only a matter of time for those no-longer diabetic Ma Pi dieters until they need their insulin again.   You'd think that only glucose is implicated there, but ...

Whereas some free fatty acids and lipoproteins have been shown to be pro-apoptotic for the β-cell, others are protective. Thus, long-term exposure to saturated fatty acids such as palmitate appear highly toxic ...

Oh and ...

Lipoproteins may affect β-cell survival in a similar way, whereby VLDL and LDL are pro-apoptotic ...

But I digress because that paper discussed possible mechanisms by which diabetic hyperglycemia -- as in uncontrolled frank diabetes, not transient glucose spikes from a carby meal -- can contribute to cell death.  Since the Ma Pi dieters had restored their insulin function, I don't think they need to fear this.   Still, if all you need to do to cure diabetes is to *force* your pancreas to secrete more insulin, why wouldn't you just do that?    

In his last ditch effort to alleviate whatever cognitive dissonance he might have had, Fred claims:

Fred has emphatically stated many times that carb restriction is the only and best way to treat diabetes.  He is not alone.  It matters not that the Ma Pi 2 studies suggest otherwise.   If you can't eat a small potato without your blood sugar spiking through the roof then you have not cured your diabetes.  The subjects in the Ma Pi 2 studies were consuming almost 400 grams of carbs per day.  So the purple highlighted comment is also wrong.  Since the carbs were starch, they likely were eating less sugar, but not less total carbs.  Contrary to LC propaganda, the SAD is not particularly high carb by percentage.  In most dietary studies where weight maintaining "usual intake" is verified, carb intake tends to be 45-50% of calories, in a diet of equal caloric value to the Ma Pi 2, this only amounts to only 250-275 grams of carbs.    These dieters likely increased their carb intake during this study.  

So Fred, if you're reading this, you really need to read the studies, etc., so that you can avoid such gross errors in the future.  

Next up, Peter D/Hyperlipid.  In a blog post on the 3 month study, making fun of it's "macrobiotic" thing.   (Hat tip to Charles Grashow as I don't read that blog) .  To refresh, in that study the subjects had all meals prepared for them and served at a clinic for the three weeks, followed by instruction to follow the diet for two more months at home.  Peter first focuses on the fact that the blood glucose levels rebound slightly during the months at home using this diagram from the paper.

So ... the diet is not sustainable?  Perhaps.  Is this ANY different than what we see for many other diets?  I mean it's not like LC has any better track record in this regard.  Remember Shai?  

Nah, no rebound in that fasting glucose in the diabetics there (blue is LC, gold is Mediterranean).  But this is interesting:

Everything improved when you have a real macrobiotic cook serving you. Do it yourself and by twelve weeks things are already starting to fall to pieces

I'm not sure "fall to pieces" is fair, but Peter has just acquiesced that a 70% carb diet to the tune of over 350 grams of carbs improved everything.  So it is a matter of adherence, not the evilness of the carbohydrates.   However Peter would prefer to distract than address this inconsistency with his advocated diet.   No, it is best to claim they are metabolically broken and then speculate that by a year or more, they'll be worse off because ...

There is no answer for diabetics other than LCHF    ~PeterD/Hyperlipid

OK ... because he says so I guess.  My other reason for linking to that post is that George Henderson commented on my initial post, and there, regarding HbA1c.    Now in the 3 month study, HbA1c's were not supplied, but they were in the 6 month study.  However blood glucose levels were reported.  So in comments, in response to George, Peter expands on his thoughts:

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.

Uhhh, OK.  In my opinion, anyone who believes that cells are healthier if they can resist insulin, really needs a reality check.  I mean a T1 diabetic is apparently Peter's desired metabolic state.  The brain still gets its glucose and there's no insulin around to bother the other tissues or make you fat.  It's a low carber's ideal.  (shakes head)    By resisting insulin, Peter is actually referring to the mistaken notion that without insulin cells cannot take up glucose.  I again refer you to  this post as to why I call that notion mistaken.  If you have elevated blood glucose, it is getting into your cells, and where it probably causes problems in diabetics is that it isn't effectively stored (and comes with a hefty dose of fatty acids).    But, the Ma Pi dieters had lowered blood sugar so I don't really get what he's trying to say.  Enough of the chocolate picker anyway, but I'll leave you with an excerpt from George on his blog:

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.

George posted these two "rebuttals" on this blog as well, and I'd like to addess those in this post because they demonstrate, yet again, how low carbers are constantly moving goal posts and/or ignoring inconvenient facts.    We'll do the blood sugar thing first, I've cobbled together two replies in one image:

I had blogged about unusually low HbA1c's and apparently he got this idea from the paper discussed.  It is true that hemoglobin glycation is an imperfect measure of glycemia in some disease/dysfunctional states.  George seems to have taken that and ran with it by presuming that all of the subjects on this vegan diet, what, perhaps didn't really improve glycemic control?  Rather, he surmises sans facts, that they all became anemic with blood cells turning over faster than Fred Hahn can talk himself through his first circle.  He is implying that they had low HbA1c despite high glycemia.  Well, in the study that provided both parameters, both HbA1c and fasting blood glucose declined considerably.  I'd say that there's no reason to question that the decline in HbA1c was indeed due to the decline in glucose levels.  Still, this rebuttal is not so much moving goal posts as it is a display of the mental gymnastics required to reconcile one's dogmatic stances.  I have again cobbled together the two relevant comments into one image.

As you can see, George repeated the notion that this diet was some sort of "fast".  I responded in my comments that it might, indeed, be like a fat fast (one where fat other than that accompanying whole foods is abstained from, not the Atkins kind) and could help "drain the swamp" of  fat buildup despite the caloric intake.  However, there really is no way to look at this diet as any sort of modified fast.  While it was obviously somewhat hypocaloric (effectively) as weight was lost, in general the calorie intakes were quite a bit higher than normally prescribed, at roughly 2150-2200 calories/day.    Some sort of cult diet??  Really??  Yeah and this so-called "nutritional ketosis" is perfectly normal ;-)  C'mon George!!   In between these comments, Charles had pointed out the calorie levels of this supposed "modified fast" which elicited that second comment.

Whoa?!  Macrobiotic roughage??  I have been hearing since the 80's from both sides of the white rice/brown rice fence, cereal fibers arguments, glycemic index, and all that jazz.  Pretty much, glycemic index is a bust and has little if any meaning to anyone except diabetics looking to better manage glycemic excursions with insulin, etc. 

Roughage?   Is it really too much to ask that people think a bit critically before commenting such as above?   It's not like I didn't screen cap and include the make-up of the diet involved in addition to describe it.  You know, 40-50% whole grains, which was itemized as being mostly brown rice ... 350 grams of brown rice to be exact.  Here's nutritiondata.com's take on the nutritional content of that roughly half of the diet.

By my calculations, that fiber clocks in at less than 5% of the carb content, making the rest of it, minus less than a teaspoon's worth of sugar, easy to assimilate starch.   We are so waaaaaaaaaaay past that 151st insidiously fattening gram of carbohydrate already with the rice here.  But George's take is interesting ... that our Ma Pi dieters were actually on a severely calorie restricted diet, though I must say, I've NEVER seen the roughly 50% assimilated figure before!   Scam Feltham and his nuts notwithstanding.  (See here for that reference!)

Carbohydrates do not cause diabetes.   Using your pancreas does not wear it out.  Of these things I am sure, and I have a boatload of peer reviewed scientific research, billions of human people-years worth of long term free living observation, and at least as many unverifiable anecdotes as any other advocate out there to back that up.  It's just that the first two carry a lot more weight.

Ahh ... I feel better after that mini rant.  I'm sorry dear readers, but I get so sick of this dysfunctional mix of unsubstantiated claims, denials, exaggerations and flat out fraud.  This idea that carbs cause insulin resistance is erroneous.  I have tracked down the other source of Taubes' quote above and what I have found out there is that Berson (and Yalow) said no such thing about the etiology of diabetes (or its link to obesity for that matter).  I await one one other citation from Berson & Yalow, just to confirm that Taubes did not simply mis-attribute to the citation itself while getting it correct about the researchers.  If history is any guide, I'm thinking this won't be the case, especially since we are talking about more than just the single quote in GCBC.    Indeed it is interesting how much the view of diabetes in the 60's reflects my own and that of most diabetes researchers.   Stay tuned....