Wednesday, December 25, 2019

Retrospective #312: Isn’t eating Very Low Carb…well, extreme?

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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