RON  RAAB  B.Ec. (Copyright – Ron Raab)

SUMMARY

This article outlines my before and after experience in adopting in 1998 a low carbohydrate/low glycemic index/low insulin/moderate protein/appropriate fat approach to the management of my Type 1, insulin dependent diabetes.

It outlines the rationale and many advantages of this approach, and the contradictions and some of the negative outcomes are inherent in the high carbohydrate/high insulin approach. It points out my experience an insulin pump is not necessary for excellent blood sugars. It also suggests, subject to further research, this approach may have an additional benefit in developing countries, where insulin is often prohibitively expensive, as it results in a reduction in insulin needed.

It should be understood this does not represent the position of any medical organisation with which I work or of which I am a member.

Expert advice should be sought before changes are made to a person treatment regime.

The logic and experience with the low carbohydrate/low insulin/moderate protein/appropriate fat approach to the management of diabetes.

I was diagnosed with Type 1 diabetes in 1957 at the age of 6, and started on one insulin injection daily increasing to two each day in 1959. In 1984 this increased to 3 each day and since 1994 to four each day.

I started self-blood glucose testing in 1980, and of course before I was testing urine. I now test 4 times each day (using a plasma calibrated meter) and I do moderate exercise 2-3 times per week, which I have been doing for many years.

I have had some background retinopathy and some neuropathy, including delayed stomach emptying. This was worsening before I adopted this new regime and it 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 educators and dieticians’ high carbohydrate, low glycemic advice.

But I could not achieve continuously near normal glucose levels, was having more and more severe hypos as a result, and my diabetes complications were worsening…..the current advice did not work for me.

In 1998, through the many contacts I had made, I became aware of another approach ­- the low carbohydrate, low glycemic index food plan together with much lower insulin dose and a moderate protein intake. I was also interested in this approach, as I had observed over many years when my carbohydrate intake was less, my blood sugars improved. This further encouraged me to try this very different food plan, while remaining sceptical and looking for results.

We want to achieve are normal blood glucose levels, and this came over to me as the best reason to examine the low carbohydrate approach. The generally advocated approach does not in my view produce normal or near normal glucose levels on a continuous, moment to moment basis.

The low carbohydrate diet continues to be discussed and there is increasing discussion in diabetes journals and at conferences.

I experimented a lot and, since July 1998, have reduced the total amount of daily carbohydrate from 200 grams then to 30-40 grams daily in 2000, which is all of a slowly absorbed type.

Here are some of the results…

My insulin dose has fallen by 50% to 20 units daily. My HbA1c has decreased from an average of 8.0% to 5.6%, an improvement of 30%. There is much less variation in daily blood glucose levels. Hypoglycemia is much less severe. Hypos now require less glucose – now generally only 5 grams to ease the level back up. There are no longer major swings, and “time–out” is no longer needed for recovery. What a relief!

Weight has dropped from 84 kg to 75 kg with body-mass index in the normal range; retinopathy has stabilised (my ophthalmologist made particular note of this). Blood pressure remains normal. Lipids are in the normal/acceptable range and have been for most of the period since I started this regime-with my focus being on eating the “right” type of unsaturated “healthy” fats, and avoiding saturated and trans fats.

Importantly, hunger has decreased (insulin is an appetite stimulant and this regime requires much less insulin). There is much more motivation, less frustration and my subjective quality of life and outlook has improved enormously. There is still some hunger in the evening; however, as I continue to experiment with the food plan and the type and range of meals, particularly in the evening, I am confident this will even out. I continue with regular mild exercise.

I do not regard this food plan as "radical" or a "fad". It should not be confused with the extreme food plans, which are often publicised.  It is not a high protein or a high saturated fat diet.

What is the rationale and why does this work so well?

Lowering daily carbohydrate intake makes sense on many levels. Why eat so much of a food type is at the root of blood glucose instability and which needs (much) more insulin to (try to) take care of, which in turn creates further problems. I do not think there is generally evidence comparing high compared to low carbohydrate intake, or the other way around, in terms of which results in better blood glucose control, other things being equal. Yet the high carbohydrate regime is generally being advocated as part of the dietary advice given to people with diabetes.

I have found the greater the intake of carbohydrate, the greater is the unpredictability of both the timing and size of the resultant increase in blood glucose.

We also know insulin absorption (i.e. the size and timing of the effect of insulin in lowering blood glucose) 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 a high carbohydrate (even of a slowly absorbed type) and concomitant high insulin regime must result in more erratic and unpredictable blood glucose profiles, compared to a low carbohydrate and appropriately matched low insulin regime.

This is the crux of the issue.  The importance and implications of this unavoidable reality are not factored into the advice being given.

On the other hand, the lower the carbohydrate/insulin mix, the less variability and more predicability there is in blood glucose levels. In my experience, the glucose curve flattens and approximates normal. Things just fall into place when adopting this approach and it has been a really marvellous event for me.

In fact this is actually implicit in the “Medical Nutrition Therapy’ advice of the American Diabetes Association (ADA), the nutritional advice of Diabetes Australia and many other organisations. Yet paradoxically they go on to recommend a high carbohydrate regime. For example, the ADA states starchy (carbohydrate) foods will raise the blood glucose concentration and the increase will depend on the rate and completeness of digestion of the starch in a food, which is influenced by many factors. This clearly implies the more starchy foods are eaten at a meal, the greater the potential variability in blood glucose as a result. Rather than logically recommending a lower carbohydrate intake, the advice is the opposite and recommends 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.

This simple advice would have been of immense value to me many years ago. It is a message with major implications:

we do not know what level of carbohydrate is most likely to produce the best blood glucose levels, other things being equal, as measured by HbA1c and some measure of post prandial or moment to moment levels. So therefore we suggest

you experiment with different levels of carbohydrate intake, with our professional assistance, to help ensure

your food intake is nutritionally adequate and takes into account other issues as well.

As an aside, the glucose tolerance test, which is sometimes used to help diagnosis diabetes, uses 100 grams of carbohydrate to pressure the body’s blood glucose regulating mechanism to see if it will rise above the normal level! So, if you follow this ADA advice, you may be forcing your body to digest/metabolise the equivalent of three glucose tolerance test loads each day! Of course it is in a different form of carbohydrate, but the volume is the same. It does not make sense to subject a body, which already has a major problem in metabolising carbohydrate, to such a huge carbohydrate load!

The historical reasons for advocating this approach seems to be in the USA in the early 1950s, it was becoming clear people with diabetes were suffering high rates of heart disease. This was attributed to the higher fat intake resulting from what was then a lower recommendation for total daily carbohydrate intake. The new reasoning went – “if we decrease fat intake to decrease the risk of heart disease, what will people then eat?” So they decided to start increasing the amount of carbohydrate to provide the aimed for calorie intake. This was done without examining the implications of higher carbohydrate intake in terms of blood glucose variation, the contribution of carbohydrate itself to heart disease and obesity, and any negative effects from the resulting higher levels of insulin needed to (attempt to) control blood sugar levels. This advice has continued to the present day, with the percentage of calories from carbohydrates increasing over time.

However, we know it is simply not true all fats contribute to heart disease – the saturated ones may, but unsaturated fats may indeed be protective against heart disease. It therefore follows it is easy and sensible to construct a diet is low in carbohydrate (and therefore requiring much less insulin), low in saturated fat and higher in unsaturated fat – thus providing the aimed for calories. A simple example of the calories can be obtained from healthy unsaturated fat is adding olive oil to a salad. Two tablespoons of olive oil yield 360 calories – a very significant amount in terms of daily needs and this can be quite easily augmented in other ways with other unsaturated fats.

Therefore, the proposition a high carbohydrate intake is essential to meet calorific needs of people with diabetes, because of the risk of heart disease, is clearly not the case.

Delayed and variable stomach emptying (gastroparesis).

Delayed and variable stomach emptying (gastroparesis), due to impaired vagus nerve function (another form of diabetic nerve disease), further adds to variable and unpredictable blood glucose levels. The greater the carbohydrate intake, the greater the size of the additional unpredictable glucose variability due to this cause as well.

Delayed stomach emptying can be very unpleasant, with symptoms ranging from mild to great discomfort and pain. The effect on blood sugar control also depends directly on the volume of carbohydrate consumed. Large amounts can remain in the stomach for variable periods of time, and then unpredictably, and possibly very suddenly, being ‘processed’ or ‘emptied’ with the resultant sugar entering the blood stream unpredictably.

In addition, the larger the amount of carbohydrate consumed then the larger amount of insulin needs to be injected, but the carbohydrate is remaining in the stomach undigested for unpredictable periods. However, of course the insulin is working, causing very variable blood sugars from this cause as well, and the possibility of major hypos.

Then an unpredictable amount of time later, the carbohydrate is digested and enters the blood stream sending the blood sugar straight up.The large carbohydrate content of the meal is a formula for further high blood glucose levels and hypos in this situation.

The medical literature states delayed stomach emptying in diabetes occur in 50% of patients with both Type 1 and Type 2 diabetes. It is not logical to advocate a high carb regime to such persons for this additional reason! Yet this is being done all the time to such people as part of the conventional dietary education. There is also continuing evidence of a relationship between high insulin doses and the development of vascular disease, including heart disease, independent of any other factor. This means a person on a high carbohydrate regime is potentially adding to the risk of heart disease because of this, whereas a person on a low carbohydrate, and therefore low insulin regime, is avoiding this possible risk factor.

There is also speculation the tragic so called “dead-in-bed’ phenomenon may also be caused by the very large amounts of insulin many are taking to try to match the very high carbohydrate intake, thereby resulting in a life-ending hypo, or through some other mechanism, when the mismatch is particularly bad. This seems plausible, don’t you think?

There is also increasing evidence of the damage brief increases in blood sugar, following meals, can do in terms of the development of diabetes complications. Therefore, even though the HbA1c level may be, for example 7.5%, which is considered by many as reasonably good, the high carbohydrate/high insulin regime inevitably produces greater swings in blood sugar than the alternative, and further contributes to diabetes complications on this additional basis. An HbA1c of 7.5% corresponds to an average finger blood sugar of 200mg/dl (11.1 mmol/L), which is more than double the normal blood sugar of 85 mg/dl (4.7 mmol/L).

Many people do not understand the relationship between HBbA1c levels and the in general corresponding average capillary blood sugar values. Another example- an HbA1c of 9.0% -many people understand this to mean this reflects an average capillary BG of 180 mg percent (10 mmol/l), when in fact it can reflect average capillary blood sugar value  of up to 260 mg/% (14.4 mmol/l)!

There is evidence “certain types of carbohydrates can adversely affect blood cholesterol levels”- the result of 5 large studies in Australia, Europe and the USA. In Diabetes Voice (International Diabetes Federation, 2002) it is stated in an article by Dr Swift, Secretary-General of ISPAD (International Society for Paediatric and Adolescent Diabetes):

nutritional management is commonly described as one of the cornerstones of diabetes care... unfortunately it is the cornerstone which may be least understood, most under-researched and to which there is the poorest adherence

The December 2001 edition of Diabetes Forecast (American Diabetes Association) states in an article entitled "Revolutionary Research - Part 2" in conclusion:

subjects with Type 2 diabetes experience clinically important improvements in triglyceride levels on a...high mono-unsaturated fatty acid diet……standard high-carbohydrate/low-fat diets in Type 2 diabetes need to be revisited.

Enormous resources and effort thankfully goes into developing new insulins and the diabetes press and medical literature has much information and discussion on the various profiles. Yet the other side of the coin, which insulin acts on, mainly carbohydrate, has no such precision applied to it! So one variable is highly tuned and the other one is allowed to vary within very wide parameters. The result must be greater variation in blood sugar. This is a lopsided approach, without logic. The same type of thinking thankfully after many years was corrected through the results of the Diabetes Control and Complications Trial unfortunately is being repeated with the carbohydrate/dietary component. Most people intuitively and logically understood we should aim at normal blood sugars, yet many considered without “evidence”, it was acceptable for to allow very mediocre blood sugar control. If the advice had been much tighter, then a lot of suffering and earlier deaths could have been prevented. In general, the same type of thinking is being applied to recommendations about carbohydrate with similar worse outcomes than could otherwise be the case.

We are overlooking a fundamental fact – blood glucose levels in diabetes will and must vary increasingly unpredictably as the amount of carbohydrate increases.

Economically Developing Countries

The logic of this approach has major implications for the treatment of diabetes in developing countries. The cost of insulin in such countries is very high – often $US30 and more per vial – around one month’s supply, often accounting for 50% and more of average family income. The high carbohydrate regime requires much more insulin in order to try to improve blood sugar levels. By adopting a low carbohydrate regime, the insulin dose will fall very significantly as it has in those of us who have adopted this regime. In my case, the insulin dose has fallen by 60%. This would mean a very significant financial saving for such people and this should never be underestimated. On a relative basis, this is the same as an average person in a developed country saving $US500 per month! Of course there may be other offsets, but nonetheless, this approach makes enormous sense in this situation as well. On top of this, blood glucose control would be greatly improved, not only because of the low carbohydrate/low insulin regime, but also because many people would be able to afford the volume of insulin needed!

Examples of Meals

Just one example of a satisfying meal which contains 12 grams carbohydrate and 120 grams protein gross is:

• soup made from stock
• garden salad
• medium size steak or fish or vegetable protein
• cooked vegetables (no potatoes or similar)
• coffee with small amount of milk

In summary – some healthy protein, low carb vegetables, salads, and/ or a small amount of other slowly absorbed carbohydrate and some healthy fats (such as olive oil, avocado).

There is a whole world of satisfying and indeed delicious, low carbohydrate foods and meals, which are readily available or can be easily prepared. This is a simple and practical regime which helps give you control of your life.

Problems with Estimating Carbohydrate in the Higher Carbohydrate Approach

Compare the above meal to the following high carbohydrate version meal of around 100 grams carbohydrate and 120 grams gross protein:

• soup containing carbohydrate (eg. canned soups are packed with carbohydrate).

• 2 slices bread or similar

• medium size steak or fish with pasta/potatoes/corn
• fruit /carbohydrate dessert
• coffee with milk

If you are wrong in estimating the 100 grams carbohydrate (say by 20%), then you will have 20 grams of carbohydrate either over- or under-accounted for. This can translate into a variation of easily 80 mg/dl (4.4 mmol/L) in the blood glucose level for a person of average weight. Even if your estimate of quantity is correct, the actual components of the pasta, for example may not be. It may be made of a particular version, which has egg in it, or a different type of flour). On top of , you will need much more insulin to (try to) cope with this large glucose load, with all the inherent variability and unpredictability of insulin absorption and action. Add to some gastroparesis (which most people with diabetes for more than 5-10 years are reported to have) and you have set yourself up for great variation in blood sugar, including the possibility of a major hypo at some stage during the next several hours after the meal. Isn’t this exactly what is happening with so many patients? Isn’t this likely result really self-evident? Their doctors and educators are telling them they should try to have normal blood sugars (because of the DCCT results), yet at the same time they are being instructed to have a high carbohydrate diet, which clearly makes this outcome impossible! What confusion! This is a formula for failure!

For many on such a regime, this also results in frustration, guilt, fear and depression, just as I was beginning to experience in trying to normalise my levels with such an approach. The low carb/insulin approach resolved the underlying causes of these completely for me.

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 regime underpins this approach. It is simple to design such a regime to be nutritionally complete.

Diabetic kidney disease is caused by high blood glucose rather than higher protein intake. Of course the role of protein in established kidney disease is a separate issue.

I have learned from such experts 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 carbohydrates slowly, making it the penultimate low-glycemic index form of carbohydrate, matching wonderfully 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 carbohydrate cannot be derived from other sources, for example vitamins and minerals which occur in some carbohydrate foods, such as fruit, also occur in foods such as salads and vegetables. In any case, the regime described in this article is a ‘low carbohydrate’, and not a ‘no-carbohydrate’ regime. So, again, the low carbohydrate regime passes all of these tests and I would invite readers to provide evidence to the contrary. As an aside, the current low fat advice when carried to the extreme is dangerous if it verges on being ‘no fat’ as fat, being a source of essential fatty acids, is essential for health.

The major pharmaceutical manufacturer, Bayer, now includes information about this approach with meters it sells in America and cites persons with diabetes who use this approach as "living proof of the success of this method". A major company like this does not make such comments lightly!

I have been invited to give my personal experience with this regime to a number of health care professional meetings and to Diabetes Associations in Australia, Japan , England  and Peru ( the presentation is available in Spanish). My experience and the rationale has been published in peer reviewed journals including BMJ Online and Practical Diabetes International (also available on this site).

I took part in a symposium titled “Carbohydrate- More or Less” at the Australian Diabetes Society/ Australian Diabetes Educators Association Scientific Meeting. My physician, Dr Richard Arnott, made a number of comments to the participants, including:

the improvement in Ron’s HbA1c has been dramatic….his previously severe hypoglycemia  has abated….lipids remain in the acceptable range…. call for further studies…. it is perhaps time to challenge the accepted dogmas.

Professor Paul Moffitt AM, a diabetes specialist honoured for his contribution to diabetes care by the Australian Government, wrote to me following my presentation:

I very definitely believe in a low carbohydrate diet and have done  so for many years.

By now you will have discerned logically my attitude to the use of the insulin pump. Firstly, those who use the pump come to realise it is not a substitute for accurately counting carbohydrate if essentially normal blood glucose levels on a continuous basis are to be maintained. In fact, those who are really serious about blood sugars, and use the pump while also having ‘higher’ carbohydrate end up back at square one - i.e. trying to match carbohydrate and insulin with precision, and this is not possible on higher carbohydrate intake. Of course there are many people who are happy with the pump and is fine. However I question whether they are actually able to achieve the same degree of blood glucose control as is possible with the low carbohydrate/low insulin regime, while taking higher carbohydrate. In my opinion and experience (I was a pump user many years ago in my struggle to find better blood sugars), the pump does not, and cannot result in the same degree of blood sugar control as can the low carbohydrate regime. So, the pump is unnecessary for good blood glucose control, and does not solve the basic problem – the unpredictability results from higher carbohydrate intake.

A common response to this approach is that it is too extreme or difficult for the “average” person to adopt, is what I thought when I first came across it, yet here I am having gone through the change and being marvellously happy with it and the results. Like any major change in life – the best approach is often to do it one step at a time and move on from there until one finds a level at which one is happy. Many may not want to reduce their total daily carbohydrate to 30 grams, which is the level which if done properly will result in effectively normal blood sugars.

The point is one should not throw ones hands up in despair and say “I know this will result in much better blood sugars, but it is all too much for me!” Take it one step at a time and move on from there…

Any major life change (such as commencing a new job, getting married or divorced, having children etc) requires psychological and other adjustments, and so it is with this regime. This has been easier than I anticipated. Once one understands it and reorientates oneself to this new approach, it becomes integrated into ones daily life and become the new “normal”.

I am trying to play a responsible role in discussion and debate about these issues. For me, and many others who now have these tools to achieve close to normal blood sugars 24 hours per day, there is no other way to achieve this than with a low carbohydrate regime.

In this article I have tried to show the veracity of this regime and its vast superiority in terms of blood sugar control, and for other important reasons, compared with the high carbohydrate regime. There will always be people who, even if they acknowledge this, choose not to adopt such a regime, or to adopt it partially, just as people who smoke may decide to continue for whatever reason. Just as we point out the dangers of smoking, I have tried to show the dangers of any regime is based on a high carbohydrate intake /high insulin dose for people with diabetes, because it must lead to higher and more unpredictable blood sugars.

There are health care professionals who actively discourage this approach, thinking it is not a superior approach – I would respectfully invite them to go through this article point by point and refute or indicate where they believe the reasoning is wrong, and for what reasons they reject each point. So far when requesting this, I have received only generalities, such as “low carbohydrate is unhealthy”, which avoid the central issues raised. I have not received any facts or evidence can reasonably be held to refute the main case made here.

In our opinion the current medical and nutritional establishment advice of high carbohydrate/high insulin is helping create very negative outcomes for many people. We consider there are very many people who would do much better on a low carbohydrate regime. The high carbohydrate recommendations as part of the treatment for diabetes are, we consider, a major mistake, resulting in enormous and unnecessary suffering and cost.    

Adopting a low carb regime is indeed a major change. It has to be done responsibly and with expert guidance, education and understanding, otherwise issues can arise, just as with any regime. People who are interested in this approach must be aware of this, for example around the issues of ketones. There are now excellent resources available…but one has to be fortunate to be able to access them.

In relation to ketones, my weight loss was accompanied by some urine ketones and there are issues relating to low carb and exercise. This is an issue about which I needed competent information and the most concerning. This is different to diabetic ketoacidosis due to lack of insulin, for example.

On the issue of ketones, more information is at http://www.diabetes-book.com and do a search for “ketoacidosis” and “ketones”. This site is an excellent recourse for this approach.

In summary, less carbohydrate requires less insulin, and the result is more predictability and less variation in blood glucose levels.

The Internet site www.insulinforlife.org relates to my professional work. Insulin For Life Incorporated was established in 1999 after I worked at the International Diabetes Institute in Melbourne, Australia for 20 years.

The individual now has the tools to maintain near normal blood sugars all the time - if one is lucky enough to be aware of them and chooses to use them.

This approach has changed my life.