A person who is neither Pre-Diabetic
nor a clinically diagnosed Type 2 invariably asks me, “Isn’t eating Very Low
Carb…well, extreme?” In a word, my answer is, “yes.” I am highly Insulin
Resistant; therefore, I am highly Carbohydrate Intolerant. Carbs are “poison” for me. However, Insulin Resistance is a
relative term, measured on a continuum, a sliding scale; its inverse (1/IR) is
Insulin Sensitivity, a measure of how well your cells take up glucose. And
the degree to which you are Insulin Resistant
will determine how many carbohydrates you can eat. The determining factor for you will be your degree of Insulin Resistance/Carbohydrate Intolerance. For me,
it’s…well, extreme.
How does the “treatment-naïve”
(untreated) patient with a slightly elevated fasting glucose or hemoglobin A1c
determine the degree of Insulin Resistance/Carbohydrate Intolerance they have
developed? Well, there are laboratory tests, like the OGTT or Oral Glucose
Tolerance Test. Upon diagnosing me 33 years ago, my GP referred me to an Endocrinologist
who ordered this 2-hour test in a hospital outpatient setting. It confirmed the
GP’s diagnosis: I had T2DM. At the time (1986), the prevailing clinical
standard for an office diagnosis of frank Type 2 Diabetes was 2 consecutive
visits with a Fasting Blood Glucose (FBG) ≥ 140mg/dl. In 1996 the standard
changed to ≥ 126mg/dl.
Today, while the Fasting Blood
Glucose is still commonly used, the new diagnostic standard is the A1c test. It
measures the percentage of glucose on the surface of your red blood cells.
Since red blood cells have an average life of about 3 months, this test is a surrogate
measure of the rise and fall of your blood sugar 24/7 over a 2 to 3-month
period. The idea is that it captures the after-meal spikes, and therefore your Impaired
Glucose Tolerance (IGT), or Carbohydrate Intolerance, and is therefore more “convenient”
than the OGTT and much better than a fasting glucose measurement.
Be careful, though. You are at the
point I described in Retrospective #306. You are at a juncture. If you leave
the matter of “what's next?” entirely up to your “treatment team,” including your
clinician and RD or CDE, after you fail to lose weight following their
advice to “eat a restricted calorie,
balanced diet and exercise,”
your clinician will treat your symptom (high blood glucose) by
prescribing a pill (or pills) to lower your blood sugar. As such,
so long as you continue to eat a restricted calorie, balanced
diet, the CAUSE of your elevated blood sugars will NOT be addressed, and YOUR
DISEASE WILL PROGRESS. The CAUSE of your elevated blood glucose and
associated weight gain is the INSULIN RESISTANCE
that you developed from eating a balanced diet way
too high in processed carbs and sugars.
This errant course of treatment is in
part based on the erroneous belief that being overweight or obese caused your Type 2 Diabetes.
That’s the reason your doctor wants you to lose weight. But, in fact, the opposite
is true. Read Retrospective #308 for an explanation of “What Causes Type 2
Diabetes.” Insulin Resistance is the cause of both Type 2 Diabetes and obesity.
And Insulin Resistance, for us who are genetically predisposed, became
“expressed” from a diet that is composed of excessive
amounts (+/-60%) of processed carbs and sugars, i.e., all carbohydrates.
So, the only course of treatment
that treats
both the cause of Pre-Diabetes or Type 2 Diabetes, and obesity if you
have it, is one that reduces the carbohydrates in your
diet. The current government sanctioned dietary is 60%
(300g) carbs, 10% (50g) protein and 30% (65g) fat (% by calories), on a
2,000 kcal/day diet for a “woman of a certain age.”
The current draft of the 2020 Dietary
Guidelines for Americans (DGA) erroneously defines “Low Carb” as 45% (225g
or 900kcal) carbohydrate. That’s an improvement for a healthy eating
pattern for a person who has a normal glucose metabolism but
it is NOT low carb. It is only lower carb for people with a
normal glucose metabolism. IT IS WRONG.
Low Carb is usually defined as 10%
carbohydrate
(50g of carbs a day), 20-30% protein, 60-70%. Is this “extreme”?
You’d think so if you’re Pre-diabetic and you followed the recommendation of
the draft 2020 DGA, as your doctor will advise you to do, and your
condition will worsen and you will progress to more medication and risks of
complications.
Very
low carb is
usually defined as 5% carbohydrate (15 to 30g of
carbs a day), 20% protein and 75% fat. That is my extreme Way of Eating
(WOE), the way I have to eat to maintain good glucose control (even while still
taking 1 low-dose Metformin a day), fasting blood glucose below 100mg/dl (often
in the 70s and 80s) and A1c’s in the low 5s.
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