Reprinted with permission, The Fitness Insider, Adam Campbell, November 29, 2006. I have added "ADA" in red to clarify what was from the ADA letter since my formatting is different from Adam's.
The ADA Responds... And So Do I
As expected, the American Diabetes Association responded to my diabetes story.
I've posted it here, along with a few responses of my own. (Click the link for a PDF of the letter: Download ADA_Response.pdf)
ADA: Dear Editor,
In fairness to Men’s Health readers, we would like to clarify some of the issues presented in your December 2006 article, “The Cure for Diabetes.” This article was an opportunity to educate your readers about the greatest health crisis of the next quarter century – the alarming growth of diabetes. Unfortunately, your writer presented an unbalanced story on a disease that affects 10.5 percent (10.9 million) of all men aged 20 or older - with nearly one-third of them not knowing they have it.
AC: In fairness to people with diabetes, we wanted to clarify some of the issues presented in your 2006 Nutrition Recommendations, published in the September issue of Diabetes Care. You had an opportunity to provide diabetes and healthcare providers with unbiased, scientific recommendations, yet you presented an unbalanced report on the efficacy of low-carbohydrate diets in the prevention and treatment of diabetes. Our story intended to raise awareness on this relevant and important topic, and encourage physicians, scientists, and major health organizations to enter into a serious and objective discussion on the use of low-carbohydrate diets as a potential medical nutrition therapy for diabetes.
For instance, in your 2006 report, you stated, "Although there are no data specifically in patients with diabetes, diets restricting total carbohydrate to <130 href="http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16318637">Duke University study in our story, which concludes, "The [low-carbohydrate diet] improved glycemic control in patients with type 2 diabetes such that diabetes medications were discontinued or reduced in most participants." Does this not qualify as "data?" If your answer, is "No," then that begs the question, "Why not?" It's one thing to acknowledge that data exists, but doesn't meet your qualifications; it's another to simply deny its existence.
Perhaps you should have said, "There's no data over 22 months on people with diabetes." Otherwise, you've also denied the existence of this study from Jorgen Vestin Nielsen and Eva Joensson, which found that advising patients to consume a low-carbohdrate diet resulted in improved measures of long-term blood sugar, and that there was no occurrence of heart disease in these patients (23 patients in all). Unfortunately, heart disease did occur in 3 out of 5 patients who didn't adopt the diet.
In addition, this study, from Guenther Boden and colleagues at Temple University, found that “In a small group of obese patients with type 2 diabetes, a low-carbohydrate diet followed for 2 weeks resulted in...much improved 24-hour blood glucose profiles, insulin sensitivity, and hemoglobin A1c; and decreased plasma triglyceride and cholesterol levels. The long-term effects of this diet, however, remain uncertain.” As you would no doubt point out, the authors stress that this was short-term, but there’s another way to think about this: If you can achieve these benefits in just 2 weeks on a low-carbohdyrate diet, what are the potential long-term benefits? While we whole-heartedly agree that more research is needed in are of medical nutrition therapy for diabetes, we can't understand why there isn't a movement by the ADA to better understand low-carbohdyrate diets.
ADA: The article glosses over the difference between type 1 and type 2 diabetes. Between 5-10 percent of Americans have type 1 diabetes, which occurs when the body does not produce insulin. Patients with type 1 must take insulin for the rest of their lives in order to survive. Because it is an autoimmune disorder, type 1 diabetes is not preventable – an important distinction from type 2 diabetes.
AC: We certainly understand this, and by no means intended to trivialize the seriousness of type 1 diabetes. However, this story was about type 2 diabetes. That said, many physicians have effectively used low-carbohydrate diets along with adequate insulin as a therapy for type 1 diabetes. Just ask Richard Bernstein, M.D., who has had type 1 diabetes for 55 years, and has not only successfully treated himself, but also thousands of patients. But again, like Mary Vernon, M.D., the doctor featured in my story, the ADA has chosen to disregard this observational evidence from practicing physicians.
Here are a few additional studies, including a couple that are based on patient data from Dr. Bernstein and Dr. Vernon. Again, according to the ADA, these data don't count.
Gannon MC, Nuttall FQ: Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes.Diabetes 2004, 53:2375-2382.
The Effects of a Low-Carbohydrate Regimen on Glycemic Control and Serum Lipids in Diabetes MellitusDaniel F. O'Neill, Eric C. Westman, Richard K. BernsteinMetabolic Syndrome and Related Disorders Dec 2003, Vol. 1, No. 4: 291-298.
A Pilot Trial of a Low-Carbohydrate, Ketogenic Diet in Patients with Type 2 DiabetesWilliam S. Yancy Jr., Mary C. Vernon, Eric C. Westman.Metabolic Syndrome and Related Disorders Sep 2003, Vol. 1, No. 3: 239-243
Clinical Experience of a Carbohydrate-Restricted Diet: Effect on Diabetes MellitusMary C. Vernon, John Mavropoulos, Melissa Transue, William S. Yancy Jr., Eric C. WestmanMetabolic Syndrome and Related Disorders Sep 2003, Vol. 1, No. 3: 233-237
ADA: For the past five years, the cornerstone of ADA’s message has been that lifestyle modifications are the first line of defense against the development of type 2 diabetes and diabetes complications. The landmark Diabetes Prevention Program study (DPP) in 2001, funded in part by the ADA, showed a 58 percent reduction in progression to type 2 diabetes among people who had maintained a healthy lifestyle, compared to the control group. This healthy lifestyle includes physical activity and weight loss.
AC: It's interesting that you bring up the Diabetes Prevention Program. It's a great example of how lifestyle intervention (diet and exercise) can be more effective than even medication for the prevention of diabetes. In fact, the conclusions from the DPP state: "The lifestyle intervention reduced the incidence [of diabetes] by 58 percent, and metformin [reduced it] by 31 percent... [so] the lifestlye intervention was signifcantly more effective than metformin."
Now, there are a couple of points to make in regard to this.
1. The first is that the DPP doesn't support the ADA's recommendations for a low-fat diet, particularly for people with diabetes. That's because although all participants were at high risk for diabetes when the study started, they were still all non-diabetic. And 4.8 percent of the people on the ADA's lifestyle intervention developed diabetes while on the program, compared to 7.8 percent of those taking metformin, and 11 percent who did nothing.
2. The DPP study states that participants were encouraged to lose 7 percent of their body weight through a low-fat diet and by engaging in exercise for 150 minutes a week. The results: Overall, the dieters ate, on average, 249 fewer calories a day, while 58 percent (does this number look familiar? See above) adhered to the 150-minute/week exercise quota, and 50 percent lost 7 percent of their body weight. So what can we conclude? That exercising and dieting for weight loss reduces your risk of diabetes. Wow! Fascinating stuff. I guess I'm not sure why this is being brought up in response to my story. I clearly pointed out in the story that the ADA recommends to "cut calories and add exercise to reduce insulin resistance." I can't say that anyone in the world debates this advice. Which is why it wasn't the point of the story. My story centered on the specific nutrition recommendations which encourage people with diabetes to eat a diet that features carbohydrates, the only nutrient that signficantly raises blood sugar, the defining marker of the disease. In fact, if you're diagnosed with diabetes, one of the first things they do is teach you to count carbohydrates. Why? So that you can adjust your medication. More carbohydrates equals more medication. And as I wrote in the story, the need for more medication usually indicates that a disease is worsening.
3. It seems to me that the DPP is an informative academic study, but not really relevant in practical terms because it's what the ADA has been recommending for years, and yet we still have an "epidemic" of diabetes. Shouldn't the ADA take some responsibility for what's happened? The ADA's Dr. Buse told me that ultimately, exercise and dieting won't work long-term, so it's best to go ahead and get them on medication right away. (You can read about it in this position statement.) This is well meaning, as the idea is to help people lower their blood sugar even if they won't help themselves (through diet and exercise). But overall, it's a bit like they're blaming the patients for the fact that their therapy isn't working. True, not everyone who develops diabetes is going to change their diet or start exercising, but shouldn't they be given all of their options first? I would have thought that because of the seriousness of this disease, the ADA would be looking for alternatives to the current recommendations, since clearly they aren't working. Especially an alternative as logical as reducing carbohydrates, which automatically reduces the need for some, if not all, medication in many cases.
ADA: It is important for a person with diabetes to consult with a dietitian to develop a food plan that will reflect the needs, tastes, preferences, and lifestyle of the individual. Proper consultation can result in the achievement of desired goals for weight loss or maintenance, blood pressure, blood cholesterol and blood glucose.
AC: You're preaching to the choir on this one. However, just because a person with diabetes might have a "taste" for sugar, doesn't mean they should be encouraged to go ahead and eat it. That seems to be the gist of the ADA's recommendations when they state, "Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucoselowering medications."
ADA: The scientifically-based meal plan recommended by the ADA includes a variety of foods containing carbohydrates from whole grains, legumes, fruits, vegetables, and low-fat milk. These foods are important sources of fiber, vitamins, and minerals.
AC: Sure, but it's based on high-starch foods like grains. And as I pointed out in the story, and you in your 2006 position statement (although worded differently), starch is no better than sugar when it comes to controlling blood glucose. It's also hard to accept the vitamin and mineral argument when compared to medication. For instance, perhaps a person would rather take a multi-vitamin instead of metformin or an insulin shot.
ADA: While low-carbohydrate diets have been a popular and controversial topic, current research does not support the long-term effectiveness and safety of low-carbohydrate diets for the treatment and management of diabetes. Diabetes is a progressive, life-long disease that must be managed long-term. It is not wise to rely on short-term study results for a disease that will always remain a part of that person’s life. The effects of such diets on kidney and cardiovascular disease risks are especially concerning, considering these are two of the biggest diabetes-related complications.
AC: Please show me the research that raises the concern. I understand that the ADA practices evidence-based medicine, so please produce the evidence that shows low-carbohydrate diets increase kidney and cardiovascular disease risk in patients with type 2 diabetes. In fact, it would be enlightening to see the evidence that shows the increase in kidney and cardiovascular risk in non-diabetics. For instance, Ron Krauss' work (1, 2, 3, 4, 5) shows that eating more carbohydrate and less fat increases the risk of cardiovascular disease. And as I showed in the story, more than a dozen studies over the last 5 years have shown that low-carbohydrate, high-fat diets are as effective or, in most cases, more effective at lowering overall heart disease risk than low-fat diets (which are high-carb by nature)--particularly because they raise HDL (good) cholesterol while simultaneously lowering triglycerides. Not to mention that lead to greater weight loss.
Here are several of those studies (many of the links include full text of the study):
Brehm, B. J., Seeley, R. J., Daniels, S. R. & D’Alessio, D. A. (2003) A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women.
J. Clin. Endocrinol. Metab. 88:1617-1623. Sondike, S. B., Copperman, N. & Jacobson, M. S. (2003) Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents.
J. Pediatr. 142:253-258. Samaha, F. F., Iqbal, N., Seshadri, P., Chicano, K. L., Daily, D. A., McGrory, J., Williams, T., Williams, M., Gracely, E. J. & Stern, L. (2003) A low-carbohydrate as compared with a low-fat diet in severe obesity.
N. Engl. J. Med. 348:2074-2081 Foster, G. D., Wyatt, H. R., Hill, J. O., McGuckin, B. G., Brill, C., Mohammed, B. S., Szapary, P. O., Rader, D. J., Edman, J. S. & Klein, S. (2003) A randomized trial of a low-carbohydrate diet for obesity.
N. Engl. J. Med. 348:2082-2090 Volek, J. S., Sharman, M. J., Gomez, A. L., Scheett, T. P. & Kraemer, W. J. (2003) An isoenergetic very low carbohydrate diet improves serum HDL cholesterol and triacylglycerol concentrations, the total cholesterol to HDL cholesterol ratio and postprandial pipemic responses compared with a low fat diet in normal weight, normolipidemic women.
J. Nutr. 133:2756-2761 Volek, J. S., Sharman, M. J., Gomez, A. L., DiPasquale, C., Roti, M., Pumerantz, A. & Kraemer, W. J. (2004) Comparison of a very low-carbohydrate and low-fat diet on fasting lipids, LDL subclasses, insulin resistance, and postprandial lipemic responses in overweight women.
J. Am. Coll. Nutr. 23:177-184 Sharman, M. J., Gomez, A. L., Kraemer, W. J. & Volek, J. S. (2004) Very low-carbohydrate and low-fat diets affect fasting lipids and postprandial lipemia differently in overweight men.
J. Nutr. 134:880-885 Brehm, B. J., Spang, S. E., Lattin, B. L., Seeley, R. J., Daniels, S. R. & D’Alessio, D. A. (2005) The role of energy expenditure in the differential weight loss in obese women on low-fat and low-carbohydrate diets.
J. Clin. Endocrinol. Metab. 90:1475-1482 Meckling, K. A., O’Sullivan, C. & Saari, D. (2004) Comparison of a low-fat diet to a low-carbohydrate diet on weight loss, body composition, and risk factors for diabetes and cardiovascular disease in free-living, overweight men and women.
J. Clin. Endocrinol. Metab. 89:2717-2723 Stern, L., Iqbal, N., Seshadri, P., Chicano, K. L., Daily, D. A., McGrory, J., Williams, M., Gracely, E. J. & Samaha, F. F. (2004) The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial.
Ann. Intern. Med. 140:778-785 Yancy, W. S., Jr, Olsen, M. K., Guyton, J. R., Bakst, R. P. & Westman, E. C. (2004) A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial.
Ann. Intern. Med. 140:769-777 Aude, Y. W., Agatston, A. S., Lopez-Jimenez, F., Lieberman, E. H., Marie, A., Hansen, M., Rojas, G., Lamas, G. A. & Hennekens, C. H. (2004) The national cholesterol education program diet vs a diet lower in carbohydrates and higher in protein and monounsaturated fat: a randomized trial.
Arch. Intern. Med. 164:2141-2146Seshadri, P., Iqbal, N., Stern, L., Williams, M., Chicano, K. L., Daily, D. A., McGrory, J., Gracely, E. J., Rader, D. J. & Samaha, F. F. (2004) A randomized study comparing the effects of a low-carbohydrate diet and a conventional diet on lipoprotein subfractions and C-reactive protein levels in patients with severe obesity.
Am. J. Med. 117:398-405 McAuley, K. A., Hopkins, C. M., Smith, K. J., McLay, R. T., Williams, S. M., Taylor, R. W. & Mann, J. I. (2005) Comparison of high-fat and high-protein diets with a high-carbohydrate diet in insulin-resistant obese women.
Diabetologia 48:8-16 Dansinger, M. L., Gleason, J. A., Griffith, J. L., Selker, H. P. & Schaefer, E. J. (2005) Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial.
J. Am. Med. Assoc. 293:43-53 Daly, M.E., Paisey, R. Paisey, R. Millward, B.A., Eccles, C., Williams, K., Hammersley, S., MacLeod, K.M., Gale, T.J. (2006) Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes--a randomized controlled trial.
As for kidney disease, the concern you voice has never been shown, and it's inappropriate for the ADA to state this, especially since carbohydrate restriction leads to an improvement in blood glucose levels, which REDUCES the risk for kidney disease.
ADA: As a result of improperly addressing these crucial components of diabetes management, not only did your publication provide a disservice to your readers by suggesting that a low-carbohydrate diet is the only safe solution to the prevention and treatment of type 2 diabetes, your publication printed dangerous information that could potentially jeopardize the lives of millions of Americans with diabetes or at risk for diabetes.
AC: We didn't suggest that a low-carbohydrate diet is the only safe solution. But we did present another side to the story--that many people with diabetes have had and are having great success in controlling their blood sugar with a low-carbohydrate diet, despite the fact that the ADA doesn't recommend this as a therapy. The truth is, we think patients who can be successful with ADA recommendations should follow them, but we don't see any great success. In fact, we see a worsening of the problem.
ADA: Larry C. Deeb, MDPresident, Medicine & Science, American Diabetes Association
Richard R. Rubin, PhD, CDEPresident, Health Care & Education, American Diabetes Association
John B. Buse, MD, PhD, CDE, FACEPresident-Elect, Medicine & Science, American Diabetes Association
AC: So that's one letter. I've gotten a bunch of other letters, too. Here are a few:
Your article accurately reflects the rapidly changing scientific understanding of diet and diabetes, as well as the "oral tradition" of diet therapy before medications were available. Congratulations on a job well-done.
Eric C. Westman, MD MHS
Associate Professor of Medicine Duke University Medical Center
I am living proof of Mr. Campbell's conclusion about carbs and diabetes. I feel very fortunate that I was able to discover this relationship and not rely on the information provided by the ADA. If his article saves one person it would, in my opinion, accomplish more than the $51,000,000.00 spent last yr. by the ADA. Keep up the great work!
That was a great article about diabetes. I identified with it completely. At 32 extremely overweight 220#, 5'9'' and lazy as hell I developed insulin dependant diabetes. The starches have to go, but that's OK there's a world of great alternatives out there to eat, which will actually make you look and feel like new again. Stop poisoning yourself one mouthful at a time. Now at 48 a 27 year civil servant at @165# and an 8 pack, I run 15 or so 5K?s and 2, 1/2 marathons a year, additionally I routinely place in weight lifting competitions at the local YMCA and the MWR gyms on the Navy Base where I work. That?s' 1st - 4th place in pull-ups, dips, pushups, sit-ups and bench. By the way that's against college students, mid twenties sailors and marines. There are worse hobbies!
I just finished reading the article on diabeties and agree wholeheartedly with the doctor 3yrs ago I was told I was diabetic my glucose count was 320, my acia blood test was 9 and i tipped the scale at 364 I went on a low carb diet and got immediate results Today my glucose is always between 80 and 100 my acia test is between 5 and6 which is normal and i have lost 120pounds i also include a daily exercise routine in my program and do not take any meds at all This diet plan definetly works!!
You are right on! We work with Dr. Bernstein and produced the Secrets to Normal Blood Sugars by Dr. Bernstein. As a pharmacist and diabetes educator, I have seen time and time again, that by reducing carbs, blood sugars go down and people get off of meds. And if you add a little phyical activity to the mix, the results are even greater. It will probably take another 5-10 years for the medical community to accept the obvious. But it will happen!Your Friend in Diabetes Care,