Tuesday, November 15, 2011

How to defend Low carb for diabetes with a doctor

Diabetes is the disease of the body's inability to bring down glucose levels post meal.

The hormone that is responsible for bringing the glucose level down is insulin.

There are two types of diabetes.

In Type1 diabetes the body has an impaired ability to create insulin in required quantities. This occurs normally due to an auto-immune condition where the body's immune system is somehow primed to act against beta cells (insulin producing cells) in the pancreas. In this case there may be a requirement to get insulin externally.

In Type2 diabetes the body is not responding to insulin. The condition is called insulin resistance. There are two versions of insulin resistance. One where the insulin receptors on each cell has a defect due to which it cannot respond to the insulin. Second where the cell is so replete with fuels that it modifies itself to become resistant to insulin.

The first condition is very complex and requires gene reprogramming (via epigenetics), which is possible but very slow, and takes a long time. An evolutionary diet based on food groups eaten around the time Homo Sapiens evolved is highly likely to help.

The second condition is simpler and requires calorie restriction. The condition may become complex if mitochondria (the power generators of the cells) are damaged due to excess fuels. The reduction in mitochondria is generally a genetic susceptibility and the damage is difficult to undo. Most fat people have this condition.

So if the condition is simply excess fuels then calorie restriction will help the problem. But this condition rarely reaches the diabetic stage without more complex problems occurring like insulin receptor damage or mitochondria damage.

When we have diabetes, the real and most obvious symptom is that glucose levels stay higher. The most obvious solution is to keep the glucose in the diet low (low carb), so that the body needs to deal with less glucose.

But this advice is never given by the doctors.

There are several reasons for this.
1) Low blood glucose level can be a fatal condition, while high blood glucose levels kills slowly. Advice to eat low carb invites law suits if the patient is not careful of his health, and dies due to negligence.

2) Maintaining glucose levels through diet is not a profitable business. The insulin manufacturers resist any publication of research papers, which show benefits for low carb diets. Almost all of the low carb friendly research is done outside the USA, restricted to a very few countries.

3) Until very recently, it was not possible to measure blood glucose very frequently. Which makes it difficult for the patient to be aware of the symptoms of low glucose and high glucose. This made low carb possibly a dangerous solution.

4) There has been a widespread campaign against saturated fat and cholesterol, this makes a prudent low carb diet also low in fat. The patient must eat something, proteins are not very good fuels, and they also provide fuel by converting to glucose, which again raises blood sugar. Since the doctor cannot recommend eating more fat, so they don't recommend low carb.

The first problem can be mitigated if the patient takes responsibility of his/her own health. Low carb is the healthier option in the long run. Dr. Bernstein has been living with it for the last 65 years.

The second is really an information restriction problem, and affects doctors providing care to the patients. They are not able to provide adequate information to the patient.

The third problem is mitigated by frequently measuring blood glucose using the cheaply available glucose meters. It is painful, but very effective for understanding how body responds to different foods, and how low or high blood sugar affects mood and feeling of general well being.

The final problem, is the real problem, when it comes to convincing a doctor or a patient to move to a low carb diet. Although there has been a lot of evidence that saturated fat and cholesterol are not a problem, but there has been no real conclusive evidence for them. The situation has changed since last year for saturated fat. The best known nutritionists have published a consensus paper in favor of saturated fats.

Even google has become very helpful in this regard. I found all of the research references in this article on the first hit when searching for "saturated fat research papers".

Before we get on with the articles and research papers I should explain what I mean by a prudent low carb diet for a diabetic person.

The diet should be tailored based on ones individual blood glucose level, and his/her individual response to different foods. Any food that raises blood glucose level an hour to two hour, or in some special food cases (so called low carb pasta) upto six hours later beyond 140mg/dl should be avoided or reduced so much that the blood glucose does not go beyond this level. It is known that all kinds of problems occur when blood sugar moves beyond this level.

A patient must count his/her carbs when eating so that they can maintain a tight control on the blood sugar levels. For a diabetic generally this means carb count below 100gms, and possibly below 50gms during the initial stage. Note only carbs and sugars are counted, not fibers. Fibers do not convert to glucose and have no contribution towards glucose. They are infact cause an increase in the requirement of glucose and may take a long time in digestion. This may cause persistence of high blood sugar levels for highly resistant people. This is called the chinese restaurant effect by Dr. Bernstein.

Being on medication poses certain problems with low carb diet. The diet itself is designed to lower blood glucose levels. When we factor in the glucose lowering medication, there is an obvious need to lower the medications. This must be done very carefully. It might be prudent to just let the blood glucose level go high, instead of risking too low glucose level. This is particularly important with insulin. Again it depends on the level of medication. One cannot just drop their medication, without considering very carefully what happens without the medication.

A patient is generally over loaded with glycogen (the storage form of glucose), before starting a low carb diet. The initial very low carb period helps in getting rid of this extra glucose, otherwise it gets difficult to get control of the glucose levels.

It is very difficult to reduce the carbs abruptly. There may be some sense in slowly reducing carbs, but this will delay recovery. So the transition should be as fast as possible, but don't over do it, and be extremely careful with medications.

A low carb diet is necessarily high in fats. Carbs and fats are both fuels for the body. For a diabetic Carbs are no longer acceptable fuels, so fat must take its place. Unfortunately constructing a low carb diet based on plants only is difficult, as they are all based on carbs. Coconut oil/ghee, fibrous vegetables, nuts, cheese and avocado help, but are not entirely sufficient. And the carbs do add up. It is very difficult to digest large quantities of fiber. Even milk is too high in carbs.

It does require eating a fair amount of eggs and fish/meat/chicken to supply the fuel the body needs. Effort should be made to keep the quantity of protein due to meat low, to keep glucose levels due to protein in check. A low carb paleo diet or the ketogenic version of the Perfect Health Diet is ideal.

Once good blood glucose level is achieved then efforts should be made to very slowly raise carb levels to check if the insulin sensitivity is returning. There is no point in staying at a very low carb level when the insulin sensitivity has returned. This is the recovery phase. Several supplements help, but they are not in the scope of this article.

I think the following article and the following lecture cover the issues very well for a layman.

Truth about Saturated Fats - It is jointly written by Dr. Mary Enig and Sally Fallon founder of Weston A Price Foundation. The Truth About Abs is a website were I first learnt the principles of dieting and exercise.

Episode 17: Saturated Fats, Cholesterol and Cardiovascular Disease - This audio clip is slightly higher level than the first article, but covers a lot more ground than the article. A list of bullet points are provide to guide through the material in the clip.

The following papers should be very convincing to a doctor. They are fairly recent, only one year old. These should be printed and important points highlighted, and then presented to the doctor. They will either convince the doctor, or you will know if the doctor is interested in your health. That last thing is very important to know before you trust your health in his/her hands.

A meta-analysis evaluating evidence for or against saturated fats. This paper was instrumental in shifting the opinion in favor of saturated fats. Ronald Krauss has been at the forefront of research on cardiovascular disease, when he says saturated fats are not to blame people listen.

The consensus paper already mentioned, does not go very far, but remember this is a consensus paper, and it takes a while to build consensus. It still is very neutral to saturated fats, and says that it is likely that other factors in the foods containing SFA may be to blame. This is a large change in stance. This paper at least exonerates coconut oil, if not ghee. As Coconut oil is free of cholesterol, and contains Vitamin E, it should become acceptable to doctors, based on this paper.

There are a couple of papers, which show that milk and its products are actually inversely related to cardiovascular diseases and diabetes.
Unfortunately the text of the first paper is not available for free. But the two papers exonerate ghee and other milk products from blame for heart diseases and diabetes both.

Unfortunately I don't have any such clear papers and as easy to find in favor of cholesterol. Suffice to say that the liver creates almost all of the cholesterol even for heavy meat eaters, so its not like the cholesterol in food impacts cholesterol levels. There is evidence that it is so, but not very clear to point out.

1 comment:

  1. infact a low carb approach has been tried by many Type II diabetics to achieve a normal healthy lifestyle: