Why a Low-Carb Diet Is the Only Answer for Diabetics

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Why a Low-Carb Diet Is the Only Answer for Diabetics

2005
Excerpted from The Diabetes Diet : Dr. Bernstein's Low-Carbohydrate Solution
By Richard K. Bernstein, M.D.

AND A VERY GOOD ANSWER FOR EVERYONE ELSE

In its March 30, 2001, edition, the respected journal Science published "The Soft Science of Dietary Fat," by Gary Taubes. The article was not in the strictest sense groundbreaking. It was almost more about the politics of diet than the science. For doctors like me who have been writing for decades about the dangers of a low-fat, highcarbohydrate diet and the benefits of a low-carbohydrate diet, Taubes's article was not so much news as a kind of vindication.

What Taubes did was show in clear and convincing detail that there was precious little evidence to support the prevailing hypothesis: that high cholesterol levels and other indicators of cardiac and other disease risk were a consequence of dietary fat, and that dramatically reducing fat and substituting large amounts of carbohydrate would reverse those risk factors. It's a hypothesis that many people still cling to fervently, despite mounting evidence to the contrary.

There never were, and still have never been, any studies supporting the notion that dietary fat is the killer it was for decades claimed to be. Taubes writes:

Despite decades of research, it is still a debatable proposition whether the consumption of saturated fats above recommended levels . . . will increase the likelihood of untimely death. . . . Nor have hundreds of millions of dollars in trials managed to generate compelling evidence that healthy individuals can extend their lives by more than a few weeks, if that, by eating less fat.

There are, however, many special-interest groups deeply vested in the high-carbohydrate, low-fat hypothesis.

Because "The Soft Science" was published in a magazine that is well known and respected for its rigorous and carefully researched reporting on science, and because the article was well researched, well reasoned, and well sourced, it was the catalyst for a tectonic cultural shift in attitudes on diet - on what is good for you and what is not.

Taubes won the National Association of Science Writers 2001 Science in Society Journalism Award for his work, but the real earthquake that set off the cultural shift was another article, also by him, that covered similar ground but reached a vastly larger audience.

On Sunday, July 7, 2002, millions of New Yorkers and other readers around the world woke up to the question, posed on the cover of the New York Times Magazine, "What If It's All Been a Big Fat Lie?" The cover showed a photograph of a succulent, nicely marbled steak with a pat of butter melting on top. The article inside convincingly explained that what most people have been told about carbohydrate, protein, and dietary fat is wrong.

In 1997, when my book Dr. Bernstein's Diabetes Solution was published, a low-carbohydrate diet was still a fairly radical concept. (When I published the first version of my diet and treatment plan, in 1981, low-carb diets were absolutely on the fringe.) According to nearly all major media, fat was poison. It was making us overweight, clogging our blood vessels with cholesterol, killing us with heart disease, diabetes, and so on. Quite a number of "experts" maintained that so-called complex carbohydrates, such as whole grain breads, oats, and pasta, were the answer to nearly every dietary need.

What was happening then - Americans getting fatter, the incidence of diabetes increasing dramatically - kept happening, and it is still happening today.

Over the last several years, with the wide success of low-carb weight-loss plans such as the Atkins Diet, Sugar Busters, the South Beach Diet, and Protein Power, the onceheretical concept of a low-carbohydrate diet has moved from the fringe to the mainstream - despite the continuing protestation of many diet "experts." Alfred Lubrano, in the Philadelphia Inquirer, wrote on December 7, 2003:

Avoiding bread, pasta and potatoes at what food experts say is an astonishing rate, many Americans are evangelically fixated on the low-carbohydrate dining espoused by diets such as Atkins and South Beach. Depending on the estimate, between nine million and 35 million people are following all or some of the tenets of a high-protein, low-carb eating regimen.

In the same article, Lubrano also writes: "Unlike lowfat and low-calorie, there are no government guidelines defining the term low-carbohydrate. The Grocery Manufacturers of America Inc. has petitioned the Food and Drug Administration to come up with a working definition, which food analysts say may happen early next year."

These diets have achieved widespread acceptance with readers and dieters if not with many old-school dietitians because they help people lose weight and lower several cardiac (and other disease) risk factors. We have now reached a flashpoint, and today low carb is a fad. A recent article by Candy Sagon in the Washington Post, "Low-Carb Crazed: Food Producers Scramble to Please a Nation Obsessed," included the following:

The supermarket is rapidly filling with new low-carb products. . . . I tried low-carb Sara Lee white bread spread with Skippy "Carb Options" peanut butter. I grilled a burger and squirted on Heinz's One Carb Ketchup (regular ketchup has more sugar). I sucked down a low-carb Michelob Ultra and wished that I could try the new low-carb Tostitos Edge or Doritos Edge that Frito-Lay is test-marketing in Phoenix and promising to introduce nationally in May. Pasta is a big no-no on the Atkins plan . . . but trust the food industry to develop low-carb pasta (five kinds under various brand names including Mueller's), and saucemakers like Rag? to introduce a new low-carb pasta sauce. Since steak is big on a high-protein diet, Lawry's has a low-carb version of its steak sauce. And although the Girl Scouts haven't come out with a low-carb Thin Mints cookie, candymaker Russell Stover has introduced low-carb mint patties. Snapple and Tropicana . . . now have new low-carb drinks made with the artificial sweetener sucralose.

The author also describes so-called low-carbohydrate offerings at many fast food restaurants, including Burger King, Subway, Baja Fresh, Hardees, and Blimpies. McDonald's and Wendy's have also joined the parade.

It is a blessing that low-carbohydrate diets have gained widespread acceptance, and that a lot of people now have at least some idea (but likely not a very good one) about the role of insulin in building body fat.

It's a bit of a curse, however, that the diets have taken hold so suddenly, because fads tend to promote false and misleading information. I suspect that the largest percentage - if not 100 percent - of the products mentioned in the Washington Post article are not in fact low carb by my standards. Among the "experts" there is little agreement on what low carb means, and when you throw marketing mavens into the mix (the same people who slapped no-fat! claims on candy), things become even more oversimplified as the ka-ching of supermarket cash registers rings throughout the land.

A decade or two ago, people clambered aboard the low-fat bullet train like the station was on fire. Fat was bad, low fat was good. No fat was even better. Where people had been calorie counters in the past, they threw that out the window as the train was pulling out, and started pigging out on low-fat foods. If the label said low fat, the thinking apparently went, it was okay to eat as much as you liked. As long as you avoided the "heart-attack foods" like steak and butter and sour cream, you could keep the no-fat potato. But in fact, the reverse was true.

Now there is the very real likelihood that we will start pigging out on so-called low-carb foods, thinking them virtuous while simultaneously having no idea why. (The grocery boutique Trader Joe's has begun a very significant low-carbohydrate campaign in its stores, providing a guide to the low-carbohydrate foods. They even have a significant stock of "no-carbohydrate" candies, which are sweetened with sugar alcohols rather than table sugar. In truth, because these contain alternate forms of sugar, they are not sugar free, despite the labeling laws.)

There is simply no question that a truly low carbohydrate diet - namely the one presented in these pages - is the solution for diabetics. Indeed, it's the solution to the obesity that plagues increasingly sedentary populations around the world.

How a Low-Carb Diet Works

A low-carb diet is superior for one simple reason: if done according to the guidelines (in this case I am referring to the guidelines in this book), people don't get fat, or don't stay fat, even as they reach the years of the supposedly inevitable "middle-age spread." In addition, all of the indicators for disease that are supposedly controlled by a low-fat diet, such as triglycerides and LDL (or "bad") cholesterol, descend to normal or low-normal ranges in most people. It's been shown over and over again that slim (not underweight) people live longer than fat people, or even people who are just heavy.

The reason that a low-carb diet can help you become or remain slim is tightly linked to the hormone insulin, which is the principal fat-building hormone. The process works like this: The lower the amount of fast-acting or concentrated carbohydrate you eat, the less significant is the increase of your blood sugar. The less significant the effect on your blood sugar, the less of the fat-building hormone insulin you will need (either injected or made by your body) to stabilize blood sugar. With less insulin at large in your bloodstream, fats you eat will not be stored but metabolized (you will literally pee them away as water or breathe them away as carbon dioxide). In addition, as blood sugars decrease, the efficiency of insulin increases, further minimizing insulin levels in your body, with the result that existing body fat will start to metabolize as well - it will, as they say, just melt away.

Besides playing a role in diseases that result from overweight and obesity, excessively high serum insulin levels are toxic to the body and carry a number of effects that reduce longevity. These include increased blood pressure and damage to the lining of the blood vessels, or endothelium. These effects increase the likelihood of heart attack, stroke, and atherosclerosis, in addition to other vascular difficulties.

In general, a low-carbohydrate diet provides the nutrients that people need without the excess carbohydrate that causes high blood sugars and requires high levels of insulin. In addition, protein, fat, and slow-acting carbohydrate, such as leafy and whole-plant vegetables and some kinds of root vegetables, tend to be broken down more slowly and continuously, so people who follow this diet tend to feel satisfied much longer after eating. It has also been shown that people on low-carbohydrate diets can consume more calories while losing the same amount of weight as those on simple restricted-calorie diets.

Although the diet I prescribe for my patients has been available to the public since the publication of my first book, Diabetes: The Glucograf Method for Normalizing Blood Sugar, in 1981, I never have published the diet separately until now. There are two reasons I have felt it necessary to do so.

First, as the number of diabetic, overweight, and obese people continues to increase, and as the popularity of lowcarbohydrate diets increases, many dieters, frustrated with the failure of the dietary recommendations of the American Diabetes Association and the American Heart Association (AHA), are looking for an alternative. Surfing diabetesrelated Web sites, discussion boards, and chat rooms, you'll see low carb everywhere - but you'll also see a lot of misconception as to what low carb means. As diabetics look for an alternative to the ADA and AHA recommendations, it's important that the advice be sound. Dr. Bernstein's Diabetes Solution is a comprehensive program for normalizing blood sugar and covers all the bases - medication, exercise, diet, blood sugar self-monitoring - but I hear over and over again about the diet portion: "Nobody ever told me that before." People who despaired of ever losing weight, ever having energy, ever being able to carry on a healthy sexual relationship, have said again and again that the diet was the main thing that helped them regain control of their lives. I've seen people shed 50 or more pounds in a few months and say they had never before felt in control of their appetites or their lives.

The second reason for this book is that because diabetes, obesity, and overweight are so closely intertwined, I have treated many nondiabetics - some who were in danger of becoming diabetic, others who just wanted to lose weight. I have seen them reverse their complications (which they had despite being "not diabetic"), shed enormous amounts of weight, and regain their health and energy. I recently saw a man who weighed more than 400 pounds. Clinically speaking, he wasn't a diabetic. In working him up, I found that his blood sugar levels were indeed slightly elevated, although not as much as I had suspected, and that he already had about fifteen diabetic complications. Most doctors would say to this man, "Lose weight and let's keep an eye on those blood sugars." This is effectively shifting the burden to the patient and not providing medical care.

I treated him as though he already was a diabetic. My definition of diabetic is anyone with elevated blood sugars, relative to the mean of normal (or the average for the healthy, young, adult nondiabetic population). In all likelihood, however, even the mean of normal is questionable as a safe standard because of the way the general population eats. A recent study published in Diabetes Care showed that in the United States the mean of normal was an average blood sugar level of 95 mg/dl (milligrams of glucose per deciliter of blood). For what I see in slim, young adults, a mean of about 83 mg/dl is really normal.

What this demonstrates is that there are a lot of Americans walking around with elevated blood sugar levels, and over time, even if they haven't been clinically diagnosed as diabetic, they are at serious risk for developing the complications associated with diabetes. The diet in this book is not just a diabetes diet, it's a longevity diet, a disease-prevention diet, and a fitness diet. It is the reason that although I have a "fatal illness," I am healthier than many considerably younger people.

It is also the reason that the cardiac and kidney risk factors of the gentleman described above dropped signifi- cantly over the next few months and his weight is coming under control.

Why the Diabetes Diet Is Superior

It's arguable whether any of the low-carbohydrate diets in the bookstores today is ideal for nondiabetics. But I can say that none of them is ideal for diabetics. Most of them depend heavily on the glycemic index, which is a subjective rather than objective evaluation of the speed of the action of carbohydrate on blood sugar. What does that mean? Sugars and starches are all carbohydrate. The body breaks them down at different rates; for example, 10 grams of glucose is going to affect your blood sugar considerably more rapidly than 10 grams of carbohydrate in spinach. The glycemic index (which we will discuss in greater detail in Chapter 3) attempts to rank most common foods by this speed - and thus the rapidity of the subsequent requirement for insulin (either made by the body or injected). The glycemic index, for reasons we'll get into later, is at best flawed and misleading. Many foods that I advise you to avoid are perfectly acceptable on mainstream low-carb diets that use it as a guide.

The Diabetes Diet works better than typical low-carb regimens for other reasons as well. The first is that, within the guidelines, you eat what you want and like to eat, but there are no "treat days." Many low-carbohydrate diet plans ignore the reality that much of overweight and obesity is directly related to carbohydrate addiction and constant snack ing. This may be because many dietitians and diet doctors really don't understand carbohydrate addiction, although the mechanism has been well documented (see page 135). Treat days are a little like having a smoker go all week without a cigarette and then saying, "Go ahead and have a cigarette on Saturday." My experience with my patients has demonstrated over and over that for people with a history of overeating "treats," it's much simpler just to give up the treats than to have the self-discipline to eat only one small portion of sweets or starches on a treat day. I have also found that when most people give up fast-acting carbohydrate, their desire to snack, indeed, their need to snack, goes away too. And, of course, treat days and the resultant high blood sugars make no sense for diabetics.

The second notable difference between the structure of this diet and others is that there are no "phases" here. The amounts of carbohydrate that you ought to eat will remain essentially constant for life. For purposes of weight loss, or if you significantly increase or decrease your physical activity, protein amounts can be adjusted, but that's about it. In that respect, this diet is much simpler to follow.

In most of the low-carb diets I know of, you begin on a highly restricted regimen and then, just as you start to lose weight nicely, you change your diet. You start to reintroduce into your meal plan foods that tend to be high in fastacting or concentrated carbohydrate. These diets often add the caveat that after phase one you will stop losing weight or slow your weight loss but you can stay on phase one for a longer period of time if you want to lose more.

There are a number of problems with this kind of phasing. A significant one is that if your weight loss is too fast - for instance, if you starve yourself - you're likely to get on the yo-yo diet roller coaster. Why? Your body can't make glucose from fat, so if you're starving yourself, your quickweight- loss diet may reduce your stores of protein (after your body converts some to glucose) in addition to fat. Your protein stores are principally your muscle mass. If you lose 10 pounds, you may lose 5 pounds of muscle in addition to 5 pounds of fat. If and when you gain back 10 pounds (or more) - which is likely because you're starving - what you gain back will be mostly fat. You'll end up worse off than when you started.

Another result is that you will have decreased your sensitivity to insulin, because our ratio of fat to muscle mass is one of the main factors affecting insulin sensitivity. Decreased sensitivity to insulin, also called insulin resistance, means there will be more of this fat-building hormone in your bloodstream.

From the perspective of a diabetic, phasing makes achieving normalized blood sugars considerably more diffi- cult, in part because you will likely need to make several adjustments to your medications. Medications for diabetes, in particular injectable insulin, must be carefully fine-tuned. We'll talk about this a little more in the next chapter. Just as important is the issue of carbohydrate addiction. Most low-carb diets might as well add the caveat that after phase one, you're going to quit the diet because suddenly you're back to the same old stuff that got you into trouble in the first place.

My college classmate became obese after years of poor diet, which included carbohydrate addiction and a lot of snacking. Then, several years ago, he went on a lowcarbohydrate diet and lost about 45 pounds over the course of a relatively short period. He looked great, felt great, had a whole new outlook and a whole new wardrobe. Then one evening he was at a party and "just had one" cracker. No problem, he thought. But it was the same as if he'd been a smoker who'd stopped and then just had one cigarette. It was impossible to stop at just one, and his diet never recovered.

He gained back the weight he lost in almost no time. The consequence? He's in much poorer health than he was, and his lipid profile is back in the unhealthy range. His new wardrobe, his newfound health and energy, his whole new outlook - all of that is out the window.

The restricted phase of these diets also plays into the not very healthy view of diet as a continuum between sin and virtue. The fast-food chain Subway ran an ad campaign that exemplified this, with an actor doing something "sinful" but excusing it by saying, "It's okay, I had Subway for lunch." (Subway sandwiches, by the way, have no place in this diet, not even their new "low-carb" sandwiches - unless you throw away the bread.)

Gluttony is one of the seven deadly sins, and from that frame of reference, the tendency is to look at abstinence as virtue and at indulgence as vice. The phasing of diets (and the treats) creates an unfortunate dynamic of deprivation and reward. Get through boot camp, so to speak, and then you can relax. Just lose that 20 pounds so you can fit into your wedding dress or tuxedo and look good for the pictures, then gorge yourself on the honeymoon, because you've got a mate and don't have to look your very best anymore. This is not healthy thinking and not healthy dieting. My aim is not to deprive you or starve you. The "reward" for the "virtue" of this diet is a healthy weight and overall health and longevity. In the end, you'll find it far more satisfying than the so-called yo-yo effect that phased diets regularly cause.

Finally, many people seem to equate low carbohydrate with high protein. That may be true of some diets, but not of this one. As noted previously, amounts of protein can be adjusted to suit individual needs, but I do not subscribe to the myth that as long as you aren't eating fast-acting carbohydrate there is no need to limit protein intake. A certain amount of protein does get converted to blood sugars by the body, and that will raise insulin levels and build fat. (Still, if you're going to overeat or binge, a 42-ounce steak is not as likely to lead to incessant snacking as a 42-ounce bag of corn chips.)

The idea here is to put yourself on a single regimen and then just stay with it. I provide guidelines, and the diet doesn't change much except in what you select to eat. Then depending on how rapidly you lose weight (or don't), and on any lifestyle changes (pregnancy, training for a marathon, or an injury that interrupts your regular exercise, for example), the amount of protein you consume may be changed. In that respect, there could hardly be a more reliable, simpler diet.

The wonderful recipes in this book have been created by a chef and restaurateur whose son is a type 1 diabetic. You could live off these innovative and creative dishes forever, but I encourage you to eat what you like and enjoy your eating within the guidelines. We have gourmet dishes that will have your friends or your mother-in-law asking for the recipe. We also have fast breakfasts for when you're on the go. So use the guidelines and the tools provided, and be healthy, feel great, and live long.

Copyright © 2005 by Richard K. Bernstein, M.D.

About the Author

Recognized as one of the world's foremost experts on diabetes, Richard K. Bernstein, M.D., F.A.C.E., is author of Diabetes Type II and Diabetes: The Glucograf Method for Normalizing Blood Sugar. His private practice in Mamaroneck, New York is solely devoted to diabetes and prediabetic conditions, including obesity.