One in four US teens are pre-diabetic or diabetic according to the CDC. To keep things in perspective, the rate was 9% in 1999 so things are increasing at a fast pace. So what kind of diabetic advice can some of these kids expect? Well here’s a little snippet from a review book TheFatNurse used for the RN license exam on lifestyle recommendation for diabetics:
Pretty much stuff you hear all the time right? Saturated fat is bad and make sure you eat complex carbs like whole grains not the white stuff. TheFatNurse also noticed that up to 70% of calories should be composed of carbs and monounsaturated fats. However, you may be surprised to know that such high carbohydrates weren’t always used to treat diabetics. From an ADA associated site article 5 years ago:
“Early on, it was recognized that carbohydrate had the largest impact on blood glucose levels. Between 1921 and 1950, diabetic diets generally limited carbohydrate to about 20 percent of calories (fat was about 60 percent). For a 1,500-calorie diet this would provide about 75 grams of carbohydrate and 100 grams of fat.”
TheFatNurse remembers going over diabetic recommendations back in Nursing school and thinking…if carbohydrate consumption can spike BG levels…why not just reduce the amount of carbohydrates in the diet? Apparently they thought this way too in the 1920s. This was partly due to insulin not being as widespread since it was still in its infancy:
“In the 1950s, experts recommended that the amount of carbohydrate be increased to about 40 percent.”
“In the 1980s the glycemic index was developed to compare how quickly carbohydrates in food are broken down in the body, converted to glucose, and released in the bloodstream. Surprisingly, it was found that sugar had less glycemic effect than white bread. The advice to avoid sugar was rethought, and the concept of counting carbohydrates became popular. Because experts were beginning to understand that fat may be linked to cardiovascular disease, the new recommendation for carbohydrate became about 50 to 60 percent of one’s diet, which in turn decreased the recommended percentage of fat to about 30 percent.”
So these developments lead to 60% of a person’s diet being composed of carbohydrates in which it should be mainly whole grains. Interestingly enough they mention white bread being worse than table sugar on the GI scale (70 vs 64)…but they didn’t mention whole grain wheat bread. Well, for those interested, Wheat bread is also worse than table sugar via the GI index (64 vs 68). This is primarily due to sucrose (table sugar) being composed of half glucose and half fructose. Therefore, the advice from TheFatNurse’s Textbook on promotiong fiber intake through whole grain consumption…if we are basing it on GI index…might need some reevaluation mayhaps?
Additionally, what about the fear of saturated fats on diabetics? It’s true that Diabetics are at high risk for heart disease, but if you’ve been following this blog or any of the dispatch authors then you will know the connection between saturated fat and heart disease can be murky. Of course, whenever reviewing articles, it’s important to make sure the study population reflects the population one is targeting. Therefore, research on saturated fat and heart disease in non-diabetic patient samples would be interesting but not always applicable to the diabetic population. So what are some recent research studies using diabetic samples?
Whoa hot off the presses! A two week old study involving 61 Type 2 diabetics randomized into a low carb or low fat diet:
“In the low-carbohydrate diet, 50% of the energy came from fat, 20% from carbohydrates, and 30% from protein. For the low-fat group the distribution was 30% from fat, 55-60% from carbohydrates, and 10-15% from protein, which corresponds to the diet recommended by the Swedish National Food Agency.”
From the study:
“The patients were randomised to either an LCD or a traditional LFD, both with an energy content of 6,694 kJ/day (1,600 kcal/day) for women or 7,531 kJ/day (1,800 kcal/day) for men. “
Limiting carbs to just 20% of diet? Hey that’s the 1921 diabetic diet in the US! However, TheFatNurse wishes they would have kept protein consistent between both groups to isolate the effect of carbs better.
“Despite the increased fat intake with a larger portion of saturated fatty acids, their lipoproteins did not get worse. Quite the contrary – the HDL, or ‘good’ cholesterol, content increased on the high fat diet.”
As covered before, how well HDL-C as a gauge for risk is controversial and many now feel looking at LDP particles as a much better indicator of risk. However, based on traditional measurements, this would be good.
“In both groups, the participants lost approximately 4 kg on average. In addition, a clear improvement in the glycaemic control was seen in the low-carbohydrate group after six months. Their average blood sugar level dropped from 58.5 to 53.7 mmol/mol (the unit for average blood glucose). This means that the intensity of the treatment for diabetes could also be reduced, and the amounts of insulin were lowered by 30%.”
“No statistically certain improvements, either of the glycaemic controls or the lipoproteins, were seen in the low-fat group, despite the weight loss.”
The studies ‘conclusion:
“…aiming for 20% of energy intake from carbohydrates is safe with respect to cardiovascular risk compared with the traditional LFD and this approach could constitute a treatment alternative. “
Interestingly enough, there are actually quite a bit of studies that have shown support for lower carb diets for diabetes. Here is another recent one using a low carb mediterrean style diet:
“compared the 2003 ADA diet (50 – 55% carbohydrates, 30% fats and 20% proteins) with a traditional Mediterranean (TM) diet (50 – 55% LGI carbohydrates, 30% fats – high in monounsaturated fat content, 15 – 20% proteins) and a low carbohydrate Mediterranean (LCM) diet (35% LGI carbohydrates, 45% fats – high in monounsaturated fat content, 15 – 20% proteins). “
While the higher fat content in mediterranean diets are normally composed of monounsaturated fats, it’s total fat content is still higher and carbohydrate content lower than ADA recommendations. Let’s compare the baseline results with the 12 month intervention respectively. As mentioned, the traditional markers may not actually mean as much but we can use the “poor man’s” insulin resistance of triglyerides/HDL instead. As Dr. Dayspring informs us, a ratio of 3 or above indicates likely insulin resistance.
ADA: 2.99 -> 2.26
TM: 2.79 -> 1.45
LCMD: 2.94 -> 1.36
“A low carbohydrate Mediterranean diet also increased HDL-C levels and was superior in reducing LDL, TG and HbA1c levels compared to ADA and standard Mediterranean diets. It would appear that the low carbohydrate Mediterranean diet should be recommended for overweight diabetic patients.”
So most patients were close to the 3 ratio cutoff and made vast improvements on all three diets. What’s a little disturbing is the ADA diet performing the worse out of the three. In contrast, the lower carb med diet won out. Even the regular med diet won out over the ADA diet. Of note, a 35% of total calories from carbs in the lower carb med diet wouldn’t be consider low enough in carbohydrates in some low carb communities. Would a 1920’s style med diet with 20% carbohydrates have performed even better? Regardless, the results from both studies definitely give pause to the ADA recommendations on carbohydrate consumption.
“In recent years, low carbohydrate diets have been shown to be effective in improving glycaemic control and body weight in type 2 diabetes [21 – 24] as well as weight loss in obese patients [25–27]. Based on this increasing evidence, in 2008 the ADA included a low carbohydrate diet as a possible intervention.”
What!? The ADA actually encourages some people to adopt a low carb diet!? Hard to tell from browsing their site which seems to be focused on fat reduction (particularly saturated fat) and eating whole grains. More importantly, TheFatNurse would have liked to have learned about low carb and diabetics back in nursing school. TheFatNurse wanted to find a current breakdown of nutrients like the 2003 ADA diet breakdown mentioned in the previous study but alas could not on their site. TheFatNurse did find this tho:
Looks kinda like this don’t it? If it works like my plate…then 75% of a diabetics diet is suppose to be carbohydrate(pasta, cereal, fruit in the picture)?
The Bottom Line: TheFatNurse was taught to memorize and recommend a specific low fat whole grain diet for diabetics. However, looking into the literature reveals there could be better options for some people. Shouldn’t these other options be taught in school or at least mentioned on the licensing exam? Of course It’s up to all healthcare practitioners to keep up to date with the literature but that may be difficult and worth a whole new future discussion.
***Please remember the information in this post is purely for academic thought and not clinical. Any interest in diet change should be consulted with your primary care provider first.