Carbohydrates and Type II Diabetes

 Carbohydrates and Type II Diabetes

(Image c/o olympichottub.com)

This week in one of my courses, we discussed a research study that examined the effects of exercise on type II diabetes.  During the discussion, we examined the dietary recommendations in the study.  The recommendations followed the standard diet prescription of high carb, low fat, low protein (60/20/20). During the discussion I posed the following question, “If type II diabetes is essentially a diseases of carbohydrate intolerance, or inability to control carbohydrate utilization, why are current recommendations for nutrition in diabetic patients so high in carbohydrates?”

The answers varied ranging from “good question” to “they take insulin to fix that” to “low-carb diets have no proven evidence”.  After the class I received an email from my professor asking me my own opinions on the issue and to send her some research on different dietary approaches to type II diabetes. For those of you not in academia, this is quite rare, I was extremely grateful to have my professor reach out and ask for my opinion.  If you ever have a professor who takes that approach listen up for they are truly a great resource to teach you not only the material but how to attack science with an open mind! So in honor of that email and the response I was able to send her way, today I want to tackle the issue of carbohydrate in the diet of diabetics.

Before I put forth my opinion and supporting facts, I would like to frame it in order to properly convey my “motive”. I have a completely open mind on the subject and approach it from my own personal experiences. The epidemic of obesity, type II diabetes, and metabolic syndrome is something I am passionate about and my view point stems solely from the basis that I would like to see a dramatic change in the current trend of these issues.  I do not adopt a specific stance on the issue (i.e. carbohydrates are bad or fat is bad), nor do I approach nutrition from a dogmatic point of view for I feel our knowledge in the field is in its infancy and we will continue to learn more over the next few decades. I hope from my following clarification and reasoning it is clear that I feel there are novel ideas in regards to dietary approaches for individuals with type II diabetes.

Without further ado, here is my stance on the “macronutrient” issue in specific regards to type II diabetes, obesity, and metabolic syndrome.

First off, I would like to state that I wish to address some common thoughts/beliefs including the following: 1) we need carbohydrates (glucose) to survive, 2) some type II diabetics require insulin, 3) high-protein diets may be harmful in some people with type II diabetes due to compromised renal function, 4) that current low-glycemic diets have proven to help with type II Diabetes.

1)    For the first statement, I completely agree with that point. Glucose is indeed an obligate substrate for some tissues, the brain and the blood cells, and while there is a lot of speculation and argument as to what is the minimum glucose requirement (studies have shown between 12-30g), the scientific community does agree that our minimum CHO intake required for proper/optimal function of those tissues is much lower than the recommended 200-300g of CHO/day (based on a 2,000 calorie diet). Also, it has been shown that certain tissues, including portions of brain, the cardiac muscle, and skeletal muscle run preferentially on other substrates (i.e. ketones or lactate)1,2.

2)    Since Type II diabetes, in essence, is a disease of carbohydrate intolerance/mismanagement it would make sense that control of dietary carbohydrate intake would help in treating the disease and in fact that has been shown in the research through low-glycemic based diets. In many cases type II diabetics require insulin to regulate blood glucose levels; however, wouldn’t it be ideal to be able to regulate blood glucose levels without medication or insulin? Although some individuals may not be able to (to use my words from class) “drive the metabolic bus” by diet and must require insulin, I think we as a society and individuals would benefit both in our health and monetarily if we could control these issues through non-pharmacological means. Currently, there are anecdotal case studies that describe individuals with type II diabetes who have been able to adequately control blood glucose levels through diet modification. Unfortunately, to my knowledge, no randomized clinical trials have been conducted regarding this issue (potential research project??!!!!).

3)    High-protein diets for individuals with normal renal function have shown to be safe, and efficacious for weight loss and improving glycemic control in individuals with type II diabetes3,4,5. In contrast, individuals with type II diabetes and impaired renal function should not be placed on a high-protein diet due to the dangers associated with high-protein intake and renal dysfunction3. These facts indicate a different macronutrient intake for type II diabetics with impaired renal function, these patients may benefit from the high-fat/ketogenic diet described below.

4)    I also agree that the low-fat diets and current recommendations do have a great deal of research behind them6,7,8. Furthermore, I think these dietary interventions and guidelines has done a good job of aiding glycemic control in patients with type II diabetes, although from my own reading, I have the view point that it is the low-glycemic nature of those diets that help with type II diabetes and that dietary fat is not the main culprit. My viewpoint/argument is not that these diets are not effective, but that there may be a more effective and more optimal dietary approach.

My skepticism on current dietary guidelines and viewpoint on the “Macronutrient ratio argument” stems from the fact that with the current trends in obesity and diabetes occurring despite those recommendations. In light of the notion that CHO induces hormonal/ endocrine responses in the body, there has been some interesting and compelling research regarding different macronutrient ratios in diets that elicit different hormonal/endocrine responses including low carbohydrate, very low carbohydrate ketogenic, and high protein diets in healthy individuals as well as in type I and type II diabetes treatment. Ultimately, I believe that although current dietary guidelines have shown to be efficacious, there may be an even more effective dietary approach to treating issues such as diabetes and metabolic syndrome.

Here are a few links to papers regarding those specific dietary interventions and their implications in type II diabetes (I apologize for not putting them in AMA citation format but I figured this would make them easier to access).

http://diabetes.diabetesjournals.org/content/53/9/2375.long

http://ida.lib.uidaho.edu:3304/ehost/detail?sid=cc535eb4-7f06-44c7-945e-b6c88a585d79%40sessionmgr113&vid=1&hid=123&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=aph&AN=16403424

http://www.nutritionandmetabolism.com/content/5/1/36

http://www.nejm.org/doi/pdf/10.1056/NEJM198809293191304

http://web.ebscohost.com/ehost/detail?sid=b3eb360c-02d6-4909-8942-422b586593df%40sessionmgr115&vid=1&hid=106&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=aph&AN=33402044

http://www.nutritionandmetabolism.com/content/5/1/9

http://www.nutritionandmetabolism.com/content/2/1/16

http://www.ncbi.nlm.nih.gov/pubmed/15801687?dopt=Abstract

 http://ncp.sagepub.com/content/26/3/300.full.pdf+html

To summarize the research, it appears that although Low-glycemic based diets are indeed effective in type II diabetes, there may be a more therapeutic benefit in low-carbohydrate, higher fat diets. I also agree that most of these studies are new and the long-term effects are not completely clear, however the mechanisms appear sound and the findings of such research are quite compelling and I believe warrant further research.

(As an interesting side note, these types of diets have been shown to improve epilepsy, alzheimers,  and various types of glucose-dependent cancers).

One usual remark on such diets is the danger of ketoacidosis, and although that is indeed a real danger, low-carb ketogenic diets have not been shown to lead to ketoacidosis in any of these studies and the two conditions appear to be quite different. In fact, as mentioned earlier, our bodies run more efficiently, and in some cases, preferentially on ketone bodies.  I must argue however, that in diabetic patients with compromised metabolic functions, clinicians ought to carefully monitor patients at the outset and at regular intervals to ensure that patients on low carbohydrate diets do not enter ketoacidosis (a highly unlikely situation with a proper diet but safety takes precedence over all other parameters).

In Summary

To summarize my point of view I will state that our society consumes entirely too many simple sugars, generally too many calories, and energy dense yet nutrient poor foods. We are currently experiencing a health crisis in the form of an obesity epidemic. Our current paradigm of a low-fat high complex carbohydrate diet has proven to be somewhat efficacious in managing and treating conditions such as type II diabetes; however, current research has begun to indicate that a lower carbohydrate, higher fat diet may indeed be more therapeutic in these types of individuals and warrants further research.  High protein diets have also shown to be more efficacious but due to the potential issues arising from renal dysfunction in type II diabetics the former (low-carb, high fat) approach appears to be the best choice.

I am of the opinion that our current knowledge and beliefs on what the optimal diet for these individuals may not be as correct as once assumed and as scientists we should have an open mind as the research continues forward.  I pose these questions and present this body of knowledge in the hopes of gaining a better understanding of the epidemic plaguing our country and developing a more effective way of preventing/treating the disease.

Prominent Researchers in the Field

  • Jeff Volek, Ph.D. University of Connecticut
  • Eugene J. Fine, M.D., Albert Einstein College of Medicine
  • Richard Feinman, SUNY Downstate Medical Center

  References

1)        Guzmán M, Blázquez C. Ketone body synthesis in the brain: possible neuroprotective effects. Prostaglandins, Leukotrienes and Essential Fatty Acids. 2004;70(3):287–292.

2)        Quistorff B, Secher NH, Van Lieshout JJ. Lactate fuels the human brain during exercise. The FASEB Journal. 2008;22(10):3443–3449.

3)        Knight EL, Stampfer MJ, Hankinson SE, Spiegelman D, Curhan GC. The Impact of Protein Intake on Renal Function Decline in Women with Normal Renal Function or Mild Renal Insufficiency. Annals of Internal Medicine. 2003;138(6):460.

4)        Friedman AN. High-protein diets: Potential effects on the kidney in renal health and disease. American Journal of Kidney Diseases. 2004;44(6):950–962.

5)        Gannon MC, Nuttall FQ. Effect of a High-Protein, Low-Carbohydrate Diet on Blood Glucose Control in People With Type 2 Diabetes. Diabetes. 2004;53(9):2375–2382.

6)        Wolever TMS, Jenkins DJA, Vuksan V, et al. Beneficial Effect of a Low Glycaemic Index Diet in Type 2 Diabetes. Diabetic Medicine. 1992;9(5):451–458.

7)        Rizkalla SW, Taghrid L, Laromiguiere M, et al. Improved Plasma Glucose Control, Whole-Body Glucose Utilization, and Lipid Profile on a Low-Glycemic Index Diet in Type 2 Diabetic Men: A randomized controlled trial. Diabetes Care. 2004;27(8):1866–1872.

8)        Moses RG, Barker M, Winter M, Petocz P, Brand-Miller JC. Can a Low–Glycemic Index Diet Reduce the Need for Insulin in Gestational Diabetes Mellitus?: A randomized trial. Diabetes Care. 2009;32(6):996–1000.

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