The low carbohydrate/low insulin regimen
– personal experience in type 1 diabetes
Copyright © 2003 Ron Raab
In this article, I describe my before and
after experience in adopting a low carbohydrate/low insulin/moderate
protein/appropriate fat approach to the management of my
type 1 diabetes. The Diabetes Centre in New York
specialises in this approach and this article is based on
what I learnt there and have applied since June 1998. I
outline the rationale for and advantages of this approach
and the contradictions inherent in the high
carbohydrate/high insulin approach. These are my personal
views and do not represent the position of
organisations with which I work.
I was diagnosed with type 1 diabetes in 1957
at the age of six years, and started on one insulin injection
daily increasing to two each day in 1959. In 1984 this increased
to three injections daily and since 1994 to four each day.
I started self-blood glucose testing in 1980, and of course
before that I was testing urine. I now test four times each
day (using a plasma calibrated meter) and I also do moderate
exercise two to three times per week.
I have had some background retinopathy and some neuropathy,
including some delayed stomach emptying. This was worsening
before I adopted this new regimen and was concerning me
greatly. I tried my best to get really good blood glucose
levels and applied the current Diabetes Association and
professional medical, diabetes ducators and dietitians high
carbohydrate, low glycaemic advice. But I could not achieve
continuously near normal glucose levels and was having more
and more severe hypos as a result as well. The current advice
did not work.
Low carbohydrate food plan In 1998, through the many contacts
I had made, I became aware of another approach – the low
carbohydrate, low glycaemic index food plan together with
much lower insulin doses and a choice of protein intake.
I also visited a diabetes center in New York that specialises
in this. Its Director Dr Richard Bernstein has had type
1 diabetes for over 50 years. He adopted this food plan
many years ago after a lot of experimentation and reported
that his diabetes control dramatically improved. I was also
interested in this approach, as I had observed over many
years that when my carbohydrate intake was lower, my blood
sugar improved. This further encouraged me to try this very
different food plan, while remaining sceptical and looking
for results. I was intrigued by reports of normal HbA1cs
in Dr Bernstein’s book1 and internet site http://www.diabetes-normalsugars.com,
news reports and from personal accounts. The low carbohydrate
diet was and continues to be discussed a lot in the USA
and elsewhere and there is increasing discussion in diabetes
journals and at conferences.
I experimented a lot and, since July 1998, have reduced
my total daily carbohydrate intake from 200 grams then to
30–50 grams daily in 2000, all of a slowly absorbed type.
I do not regard this food plan as ‘radical’ or a ‘fad’,
and should not be confused with more extreme food plans
such as high protein or high saturated fat diets.
My insulin dose has fallen by 55% to 16 units daily. My
HbA1c has fallen by 33% to 5.6% and continues to
improve. There is much less variation in my daily blood
glucose levels. Hypoglycemia is much less severe, and require
only 3–5 grams of glucose tablets to ease the level back
up. There are no more dramatic swings and ‘time-out’ is
no longer needed for recovery, unlike with the high carbohydrate/high
insulin regimen.
My weight has dropped from 84kg to 72kg with body mass index
in the normal range; retinopathy has stabilised; blood pressure
remains normal and lipids are in the normal/acceptable range
and have remained so for most of the period of four years
since I started this regimen, with the focus being on not
over-consuming the ‘wrong’ type of fats. The weight loss
was accompanied by some urine ketones but this has not been
an issue since and is
different to ketoacidosis due to lack of insulin, for example.
Importantly, my hunger has decreased (insulin is an appetite
stimulant and this regimen has resulted in lower levels
of insulin). I have more motivation, less frustration and
my subjective quality of life and outlook have improved
enormously. I also continue with regular mild exercise.
Lowering daily carbohydrate intake makes sense on many levels.
Why eat so much of a food type that is at the
root of blood glucose instability and which requires more
insulin in response, which in turn creates further problems.
There is no evidence supporting high carbohydrate intake
over lower intake in terms of blood glucose control, yet
this is what is being generally advocated and promoted.
Also kidney disease seems to occur subsequent to high blood
glucose rather than higher protein intake, according to
professionals such as Dr Bernstein and his expert colleagues.
The general principles also apply to type 2 diabetes.
The greater the intake of carbohydrate, the greater the
potential for unpredictability in the timing and size of
the resultant increase in blood glucose. This is like adding
more petrol to a fire that you cannot control! We also know
that insulin absorption is variable, both between different
injection sites and at different times. This variability
also increases as the quantity of insulin injected increases.
It therefore follows that a high carbohydrate
and concomitant high insulin regimen must result in more
erratic and unpredictable blood glucose profiles, compared
to a low carbohydrate and appropriately matched low insulin
regimen.
Surprisingly, this is implicit in the Medical
Nutrition Therapy advice of the American Diabetes Association
(ADA), the nutritional advice of Diabetes Australia and
many other organisations. The ADA states that starchy (carbohydrate)
foods will raise the blood glucose concentration and the
increase will depend on the rate and ompleteness of digestion
of the starch in a food, which is influenced by many factors.
This clearly implies that the more starchy foods that are
eaten at a meal, the greater the potential variability in
blood glucose as a result. However, rather than logically
recommending a lower carbohydrate intake, the advice is
the opposite and ecommends a high intake – up to 60% of
calories from carbohydrate, which can mean up to 300 grams
of carbohydrate per day in some individuals.
Diabetes Australia provides similar recommendations. Additionally,
significant errors result from a ‘high’ arbohydrate meal.
For example, a 20% variation (say 20 grams carbohydrate)
in a meal is greater in absolute carbohdyrate than is recommended
to treat a hypo. This does not occur in the case of a low
carbohydrate meal
because a 20% variation equals only a few grams of carbohydrate.
Delayed or variable stomach emptying (gastroparesis),
which occurs as a result of impaired vagus nerve function
(another form of diabetic nerve disease), further adds to
variable and unpredictable blood glucose levels. The medical
literature indicates that it occurs in 50% of patients with
both type 1 and type 2 diabetes. This also contributes to
greater blood glucose variability with higher carbohydrate
intake.
Large amounts of carbohydrate can remain in the stomach
for variable periods of time, and then unpredictably,
and possibly very suddenly, are ‘processed’ or ‘emptied’
resulting in a rapid increase in blood glucose. Gastroparesis
can also increase the risk of hypos if a large amount of
insulin is injected in response to a
high carbohydrate meal and the carbohydrate remains in the
stomach.
There is also continuing evidence of a relationship between
‘high’ insulin doses (which are implicit in the high carbohydrate
regimen) and the development of vascular disease, including
heart disease, independent of any other factor. There is
also increasing evidence of the damage that brief increases
in blood sugar following meals can do in terms of the development
of diabetes complications.
Therefore, even if a patient’s HbA1c level is considered
to be reasonably good, a high carbohydrate/high insulin
regimen inevitably produces greater swings in blood sugar
than a low carbohydrate/low insulin regimen, and further
contributes to diabetes complications.
Just one example of a satisfying meal that contains 12 grams
of carbohydrate and 120 grams of protein is:
• Soup made from stock
• Garden salad
• Medium-sized portion of steak,
fish or vegetable protein
• Cooked vegetables (no potatoes
or pasta)
• Coffee with a small amount of milk.
I have consulted with the chief of the Metabolic and Obesity
Research Laboratory and Professor of Medicine and Biochemistry
at Boston Medical Centre, USA. She saw no basis for concern
with the proportions and nature of the low carbohydrate,
moderate protein, moderate fat regimen that underpins this
approach. It is simple to design such a regimen to be nutritionally
complete.
I have learned from such experts that protein and fat are
essential nutrients, while carbohydrate is not. The body
makes some carbohydrate from protein, particularly when
carbohydrate from external food sources is low or non-existent.
The body manufactures such carbohydrate slowly, making it
a low-glycaemic index form of arbohydrate, matching the
profile of regular insulin. About 10% of the ‘real’ or net
protein of a food is converted in
this way. There are no nutrients in high-carbohydrate foods
that cannot be derived from other sources, for example vitamins
and minerals that occur in fruit also occur in foods such
as salads and vegetables. In any case, the regimen described
in this article is a ‘low carbohydrate’, and not a ‘no-carbohydrate’,
regimen.
I have been invited to give my personal experience with
this regimen at a number of professional health care meetings
and diabetes associations in Australia, England and Japan.
I made a presentation at the Australian
Diabetes Society/Australian Diabetes Educators Association
Annual Scientific Meeting in August 2000 at
the symposium ‘Carbohydrate – More or Less?’. Following
this presentation, my local physician, Dr Richard Arnott,
made a number of comments to the participants, including
that ‘the improvement in Ron’s HbA1c has
been dramatic… his previously severe hypoglycemia has abated…
lipids remain in the acceptable range… there is a call for
further studies... it is perhaps time to challenge the accepted
dogmas…’ Professor Paul Moffitt, a diabetes specialist honoured
for his contribution to diabetes care by the Australian
government, wrote to me following my presentation that:
‘I very definitely believe in a low carbohydrate diet and
have done so for many years.’
A common response to this approach is that it is too extreme
or difficult for the ‘average’ person to adopt. That is
what I thought when I first came across it, yet having gone
through the lifestyle change I am now marvellously happy
with it and the results. Many may not want to reduce their
total daily carbohydrate to 30 grams, which is the level
needed to result in effectively normal blood sugars, but
any significant move in this directon, say to 20
grams per meal (even if taking four meals daily) will result
in major improvements if the insulin regimen is also tailored
to it properly.
I am grateful to Dr Bernstein and colleagues who brought
this approach to my attention.
Ron Raab
BEc
President, Insulin For Life Incorporated, Australia
Insulin For Life Incorporated (http://go.to/insulinforlife)
was established in 1999, following my
work at the International Diabetes Institute in Melbourne,
Australia for 20 years.
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