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http://www.todaysdietitian.com/newarchives/0816p24.shtml

August 2016 Issue

Low-Carb Diets & Diabetes
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today's Dietitian
Vol. 18 No. 8 P. 24

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Historical Perspective

Before the discovery of insulin therapy in the early 1920s, diets for people with diabetes were low in carbohydrate and high in fat. However, after the discovery of insulin therapy and oral hypoglycemic medications, recommendations for carbohydrate intake gradually increased.1 Between 1921 and 1950, diets for people with diabetes generally limited carbohydrate to about 20% of calories.2 In the early 1950s, the American Diabetes Association (ADA), the Academy of Nutrition and Dietetics (the Academy, formerly the American Dietetic Association), and the US Public Health Service joined forces to make nationally applicable nutrition recommendations, and the carbohydrate percentages increased to up to 43% of calories per day.3 By 1971 through 1986, there continued to be an increase in the recommended percentage of carbohydrate, reaching a high of 60% of total calories per day in 1986.3 In 2004, the ADA issued a position statement in agreement with the National Academy of Sciences Food and Nutrition Board's recommendation that carbohydrate intake shouldn't exceed 65% of total calories per day. Moreover, the ADA stated that low-carbohydrate diets with less than 130 g/day were not recommended.4 This position was maintained in the ADA's 2008 Nutrition Recommendations and Interventions for Diabetes.5 It wasn't until 2013, after a review of the available evidence, that the ADA changed course regarding carbohydrate intake, noting that there was no conclusive evidence of an ideal amount of carbohydrate intake for people with diabetes.

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Safety and Efficacy

There's an emerging body of evidence showing the benefits and safety of carbohydrate restriction in people with diabetes. In addition to ADA's literature review resulting in the 2013 position statement on carbohydrate, nine randomized, controlled trials,7-15 one meta-analysis,16 and one retrospective study17 have shown efficacy and safety of low-carbohydrate and very low-carbohydrate ketogenic diets. Carbohydrate levels in these studies ranged from 20 g to 130 g per day.

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• Hyperglycemia is the most salient feature of diabetes. Dietary carbohydrate restriction has the greatest effect on decreasing blood glucose levels.
• During the epidemics of obesity and type 2 diabetes, caloric increases have been due almost entirely to increased carbohydrates.
• Benefits of dietary carbohydrate restriction don't require weight loss.
• Although weight loss isn't required for benefit [in glycemic control], no dietary intervention is better than carbohydrate restriction for weight loss.
• Adherence to low-carbohydrate diets in people with type 2 diabetes is at least as good as adherence to any other dietary interventions and is frequently significantly better.
• Replacement of carbohydrate with protein is generally beneficial [to glycemic control].
• Dietary total and saturated fat don't correlate with risk of cardiovascular disease.
• Plasma saturated fatty acids are controlled by dietary carbohydrate more than by dietary lipids.
• The best predictor of microvascular and, to a lesser extent, macrovascular complications in patients with type 2 diabetes is glycemic control (HbA1c).
• Dietary carbohydrate restriction is the most effective method (other than starvation) of reducing serum triglycerides and increasing high-density lipoprotein.
• Patients with type 2 diabetes on carbohydrate-restricted diets reduce and frequently eliminate medication. People with type 1 usually require lower insulin doses.
• Intensive glucose lowering by dietary carbohydrate restriction has no side effects comparable with the effects of intensive pharmacologic treatment.

Feinman and colleagues concluded that the evidence represents "the best-documented, least controversial results. The insistence on long-term randomized controlled trials as the only kind of data that will be accepted is without precedent in science. The seriousness of diabetes requires that we evaluate all of the evidence that is available. The 12 points are sufficiently compelling that we feel that the burden of proof rests with those who are opposed."