U.S. News Health & Medicine
7/14/03
By Dara Mayers

The Bible says "make starches the star." That's the Diabetes Food and Nutrition Bible, published by the American Diabetes Association. "Grains, beans, and starchy vegetables form the foundation of the Diabetes Food Pyramid. The message is to eat more of these foods than of any of the other food groups." For 17 million Americans with diabetes, diet is a crucial part of treatment, And what the ADA bible preaches, many doctors, nutritionists, and patients believe.

But what if the ADA's high-starch diet--another way of saying high-carbohydrate--is not healthy for people with diabetes but harmful to them instead?

This possibility is now the source of heated debate in the diabetes community. It is "the most controversial aspect of diabetes treatment today," says Scott King, editor-in-chief of Diabetes Interview magazine. How controversial? "Malpractice!" is how physician and diabetes specialist Lois Jovanovic, chief scientific officer of the Sansum Medical Research Institute in Santa Barbara, Calif., describes conventional high-carb nutrition advice.

Carb consequences. These arguments are more intense than the nutrition wars over low-carb, Robert Atkins-like diets taking place in mainstream culture. For people with diabetes, the battle is about more than waistlines. As far as bodies are concerned, carbohydrates equal sugar. And complications from Type I and Type II diabetes, which are caused by high blood-sugar levels, include amputation, heart disease, blindness, and kidney failure. Often they are lethal. The illness is not necessarily a disaster, because people with diabetes who maintain close to normal blood sugar can effectively avoid these problems. A number of doctors and people with diabetes, however, believe the high-carb diet is a recipe for trouble.

"There are a number of myths surrounding diet and diabetes, and much of what is still considered sensible nutritional advice for diabetics can over the long run be fatal. I know, because it almost killed me," writes physician Richard Bernstein in his book Diabetes Solution. Bernstein, a Type I, or insulin-dependent, diabetic for the past 57 years, has been at war with the medical establishment since the 1970s. At that time, his failing health caused him to wonder why someone whose body couldn't process carbs--which are chains of sugar molecules--was repeatedly being told to eat a lot of them. Should people with diabetes be eating a diet that is, essentially, 50 percent to 60 percent sugar?

The reason, historically, has been fear of fat and the cardiovascular problems that plague diabetics. As the cholesterol-fat-heart-disease links moved doctors to recommend a low-fat diet, the amount of carbohydrates recommended for diabetics gradually increased to fill the void. In 1994, the ADA stated that people with diabetes could eat anything, including sugar itself. "There is no longer a diabetic diet. People with diabetes eat the exact same foods as anyone else," says Nathaniel Clark, national vice president for clinical affairs at the ADA. "We do not believe there is any harm in eating carbohydrates."
Bernstein does. He prescribes an extremely low carbohydrate diet--approximately 30 grams of carbs over three meals for diabetics to achieve normal blood-glucose readings round-the-clock. "In my experience," he says, "the ADA diet does not work for anyone."

He's not alone. "Diabetes is a disease of `carbohydrate intolerance.' Thus, meal plans should minimize carbohydrates because people with diabetes do not tolerate carbs," says Sansum's Jovanovic. She prescribes food considerably lower in carbohydrates than does the ADA.

Some patients are discovering low-carb benefits for themselves. Nancy Humeniuk, a 70-year-old retiree and Type II diabetic from Monterey, Tenn., was put on the ADA diet under the direction of a diabetes educator. "While I was following the diet, my blood-glucose levels were completely out of control," Humeniuk says. "They told me I was being noncompliant--but I was following the diet exactly. I was scared." After three months, Humeniuk switched to low carb. "Within three days of going low carb, my blood sugars were normal. And they have been for the past six years." Her cholesterol profile is also very good. "My doctor told me that whatever I was doing, I should keep it up," she says.

The ADA, however, remains firm in its stance. "A diet that is very low in carbohydrates is significantly higher in protein and in fat, and there are specific risks to people with diabetes from high-protein diets in regard to kidney disease and from high-fat diets in regard to cardiovascular disease," Clark says. The ADA is far from alone in its position. "We recommend that 45 to 60 percent of calories come from carbs," says Karen Chalmers, director of nutrition services at the Joslin Diabetes Center in Boston.

"Healthy fats." Scientific evidence supporting the low-carb approach has been thin. But some recent studies have refuted the idea that an Atkins-like diet increases cholesterol, or lipid, problems. "Our data would suggest that you don't get a negative lipid pattern with the Atkins diet," says James Hill, director of the Center for Human Nutrition at the University of Colorado, where a recent study compared the Atkins diet with a standard low-fat, high-carb diet. Cholesterol levels in the Atkins dieters were actually better after a year. Frank Hu, associate professor of nutrition and epidemiology at the Harvard School of Public Health, also believes that lower-carb diets are beneficial to some people with diabetes. He is careful to point out, however, that carbohydrates should be replaced with "healthy fats," such as the mono- and polyunsaturated fats found in olive oil, nuts, and avocados.

The kidney-disease claim is also disputed. "There is no evidence that in an otherwise healthy person with diabetes eating protein causes kidney disease," says Frank Vinicor, director of diabetes research at the Centers for Disease Control and Prevention.

Some people hope that the new data will have an impact. "The ADA is responsive to new scientific data and is likely to incorporate this information into new dietary guidelines with a lower proportion of carbohydrates," says ADA board member Barbara Kahn, a physician and diabetes expert at Harvard Medical School. Kahn has seen how difficult it is for people with diabetes to gain control while following current recommendations, so she is pushing for changes. Still, the ADA Web site and all of its literature continue to tell people with diabetes and the thousands of medical professionals who treat them to make starches "the centerpiece of the meal." Revising a bible is never easy, so it may be quite some time before this bit of medical gospel sees real change.

Meal plans
Dinner duel

Low-carb Diabetes Solution fare really differs from the standard advice for diabetics.

"DIABETES SOLUTION" DINNER
Steak 4-6 oz.
Cooked broccoli 2/3 cup
Salad w/dressing 1 cup

AMERICAN DIABETES ASSOCIATION DINNER
Pasta w/vinaigrette dressing 1 cup
Fish 3.5 oz.
Granola bar
Banana

Richard Bernstein, M.D., F.A.C.N., F.A.C.E.
New York Diabetes Center
Mamaroneck, New York