Are Carbs Really Necessary?

I wrote about the The Diabetes Diet Wars and the continuing controversy over low-fat versus low-carbohydrate late last year. Although I do not consider myself to be following a low carbohydrate way of eating I certainly eat less carbs than I did pre-diagnosis and a lot less than the average type 2 diabetic in a Western country.

I spend the first couple of hours each day reading and posting on several diabetes forums. Daily I see newly diagnosed type 2s reporting the advice they have received from dieticians, diabetes educators or doctors. Far too often that advice is to eat to a formula. The formula is usually 45 to 60 grams of carbohydrate at each of the three main daily meals and 15 grams for snacks. That gives 180 to 225 grams of carbohydrate daily as a minimum level. I have discussed the problems inherent in that advice in several previous posts. However, when I, or others, suggest to new people that they could benefit from eating less carbs we find they have been told horror stories of the dangers of inadequate carbohydrate input.

The most common warning is the need to eat a minimum of 130 grams of carbohydrate per day or the brain will lack sufficient energy to function, but there are others such as the dangers of fatigue from lack of energy or just the generalised warning "but your body NEEDS carbs!"

This is just one of many examples: What Should I Eat? New ADA Guidelines Can Help
"ADA does not recommend a specific mix of carbohydrates, fats, and protein. Rather, it refers people to the guidelines of the Institute of Medicine. These recommend that healthy adults get 45 to 65 percent of their calories from carbohydrates, 20 to 35 percent from fats, and 10 to 35 percent from protein.
[snip]
ADA discourages low-carb diets (diets that limit carbohydrate to fewer than 130 grams per day). Carbohydrates are major sources of fiber, vitamins, minerals, and phytochemicals (health-promoting chemicals in plants). People who overly restrict carbohydrates can miss out on these benefits as well as the good flavors of carbohydrate foods".

Despite statements like that, whether or not carbohydrates are essential is still a matter of differing opinions. Far too many health authorities accept that "carbohydrates are a necessary dietary component" is a given fact that needs no support. I can only offer my own opinion, supported by reading, personal experience and discussions with many people on the web and the net.

Carbohydrates are not essential to energy or cognition. Before I go on, I want to stress that although I eat carbohydrates myself my point is that I don't need carbohydrates for good health.

To meet our energy and cognition needs there is nothing that carbohydrates provide that can not be provided by protein or fat via gluconeogenesis, aided by glycogen storage in the liver and muscles. The oft-repeated need for a minimum intake of 130gms of carb per day for brain energy is nonsense. Ask a traditional Inuit. Or read Vilhjalmur Stefansson's story.

The issue is confused by the other factors mentioned in that ADA quote: fibre, vitamins, minerals, and phytochemicals. That is correct, the body needs all those and other micronutrients and flavonoids for good health. Some of those things, especially fibre, are available in most abundance in starchy foods like grains and root vegetables, so people tend to presume that is the best way to get them. Unfortunately it's not necessarily the best and certainly not the only way, it's just a convenient way. Adequate fibre is available in other, non-starchy vegetables; fibre is also readily available as a supplement in natural forms such as psyllium husk. The same logic applies to fruits; flavonoids, vitamins and other micronutrients are available from other vegetable sources with less effect on blood glucose levels. Again, note that I eat fruit, but with care and in small portions. Not because I have to but because I choose to.

There is no doubt that carbs provide quick energy. There is definitely a use for higher carbohydrate input before exercise or heavy activity for an athlete or a worker in a highly active job. But for the rest of us that does not usually apply. I have no energy problems in the mornings despite a simple breakfast that never exceeds 10gms carb; nor do I have energy problems after lunch despite rarely having eaten more than 25 gms total by that time.

Many people lead long, productive and healthy lives on ultra-low-carb diets. It may not be the way you would choose, but you only need to drop in on the Bernstein forum to meet a lot of people who do.

Personally I choose a middle ground. I used my meter to find, over time, how much I needed to reduce carbs at different meals to meet my blood glucose goals. But within those limits I include a significant level of carbs (by my standards) to add variety and flavour. My main focus is blood glucose control; for the micronutrients I consciously try for maximum variety in my vegetable input to try to cover the field.

To me carbohydrates are not essential, they are a luxury food that I treat similar to chocolate or scotch. Nice to eat and beneficial in moderation, but with specific limits which I should not exceed.

But, of course, if you believe the experts my brain will die before dinner from the lack of carbs. I had dire warnings from the dieticians seven years ago that one day I would hear a little voice in the back of my mind...

"I'm afraid. I'm afraid, Alan. Alan, my mind is going. I can feel it. I can feel it. My mind is going. There is no question about it. I can feel it. I can feel it. I can feel it. I'm a... fraid. Alan, please eat more carbs..."

I'm still waiting for that little voice (apologies to HAL 9000)

Cheers, Alan
Everything in Moderation - Except Laughter

Test, Test, Test

The best advice I received from any source, professional or otherwise, since I was diagnosed with type 2 diabetes was written by a lady named Jennifer. I first met her in cyber-space posting on the alt.support.diabetes usenet group where she regularly greeted newly diagnosed people with the advice I repeat below. It appeared as Jennifer's Information for the Newly Diagnosed on the a.s.d. home page and has now been repeated on many other web-sites. Some years ago she graciously gave me permission to spread it far and wide. I have been doing that ever since by providing a link to that a.s.d page.

The web-master made some improvements to the site which I just noticed today so I will be revising the link wherever it appears in earlier blog posts. It occurred to me that this may happen again, so I have decided to repeat Jennifer's original advice here in full so that it will always be available for me to reference.

Jennifer's Information for the Newly Diagnosed

"Sounds like you're planning a move to take control of your diabetes... good for you.

There is so much to absorb... you don't have to rush into anything. Begin by using your best weapon in this war, your meter. You won't keel over today, you have time to experiment, test, learn, test and figure out just how your body and this disease are getting along. The most important thing you can do to learn about yourself and diabetes is test test test.

The single biggest question a diabetic has to answer is: What do I eat?

Unfortunately, the answer is pretty confusing. What confounds us all is the fact that different diabetics can get great results on wildly different food plans. Some of us here achieve great blood glucose control eating a high complex carbohydrate diet. Others find that anything over 75 - 100g of carbs a day is too much. Still others are somewhere in between.

At the beginning all of us felt frustrated. We wanted to be handed THE way to eat, to ensure our continued health. But we all learned that there is no one way. Each of us had to find our own path, using the experience of those that went before, but still having to discover for ourselves how OUR bodies and this disease were coexisting. Ask questions, but remember each of us discovered on our own what works best for us. You can use our experiences as jumping off points, but eventually you'll work up a successful plan that is yours alone.

What you are looking to discover is how different foods affect you. As I'm sure you've read, carbohydrates (sugars, wheat, rice... the things our Grandmas called "starches") raise blood sugars the most rapidly. Protein and fat do raise them, but not as high and much more slowly... so if you're a T2, generally the insulin your body still makes may take care of the rise.

You might want to try some experiments.

First: Eat whatever you've been currently eating... but write it all down.

Test yourself at the following times:

Upon waking (fasting)
1 hour after each meal
2 hours after each meal
At bedtime

That means 8 x each day. What you will discover by this is how long after a meal your highest reading comes... and how fast you return to "normal". Also, you may see that a meal that included bread, fruit or other carbs gives you a higher reading.

Then for the next few days, try to curb your carbs. Eliminate breads, cereals, rice, beans, any wheat products, potato, corn, fruit... get all your carbs from veggies. Test at the same schedule above.

If you try this for a few days, you may find some pretty good readings. It's worth a few days to discover. Eventually you can slowly add back carbs until you see them affecting your meter. The thing about this disease... though we share much in common and we need to follow certain guidelines... in the end, each of our bodies dictate our treatment and our success.

The closer we get to non-diabetic numbers, the greater chance we have of avoiding horrible complications. The key here is AIM... I know that everyone is at a different point in their disease... and it is progressive. But, if we aim for the best numbers and do our best, we give ourselves the best shot at heath we've got. That's all we can do.

Here's my opinion on what numbers to aim for, they are non-diabetic numbers.

Fasting............................Under 110
One hour after meals.......under 140
Two hours after meals.....under 120

or for those in the mmol parts of the world:

Fasting............................Under 6
One hour after meals......Under 8
Two hours after meals....Under 6.5

Recent studies have indicated that the most important numbers are your "after meal" numbers. They may be the most indicative of future complications, especially heart problems.

Listen to your doctor, but you are the leader of your diabetic care team. While his /her advice is learned, it is not absolute. You will end up knowing much more about your body and how it's handling diabetes than your doctor will. Your meter is your best weapon.

Just remember, we're not in a race or a competition with anyone but ourselves... Play around with your food plan... TEST TEST TEST. Learn what foods cause spikes, what foods cause cravings... Use your body as a science experiment.

You'll read about a lot of different ways people use to control their diabetes... Many are diametrically opposed. After awhile you'll learn that there is no one size fits all around here. Take some time to experiment and you'll soon discover the plan that works for you.

Best of luck!
Jennifer"

As an engineer, when I read that, it made sense immediately. So simple, yet so powerful. And it has certainly worked for me. Thanks again Jennifer.

Post-script. I've been musing on Jenny's comment below and decided to add this.

I used Jennifer's wonderful advice to gain control of my numbers fairly quickly. Once I understood it I did not mess about and I used a lot of test strips in those early days. I fairly rapidly achieved the goals she set and I realised that I could do better. At the time, despite their poor advice on carbs and goals the ADA recommended something that stuck in my mind "Keeping your blood sugar (glucose) as close to normal as possible helps you feel better and reduces the risk of long-term complications of diabetes." That sounded logical to me so eventually I changed Jennifer's goals for myself to my present ones of:

Fasting............................Under 100
One hour after meals.......under 126
Two hours after meals.....under 100

or for those in the mmol parts of the world:
Fasting...........................Under 5.5
One hour after meals......Under 7.0
Two hours after meals....Under 5.5

Cheers, Alan
Everything in Moderation - Except Laughter.

I Ate Nothing! Why Are My BGs high?

Most of us discover fairly quickly after we start testing after meals that eating carbs leads to a rise in our blood glucose levels. That seems logical, and it is, so managing those carbs and the resulting spikes becomes a cornerstone of home treatment.

But pretty soon we also discover that logic has limitations. We go to bed at night with good numbers and wake with high numbers. But we didn't eat in our sleep. Or we make the mistake of thinking 'food = spike, fasting = no spike' and find that after eating nothing for six hours we might be normal or even high when we expected to be low.

It doesn't seem to make sense, does it? "I Ate Nothing! Why Are My BGs high?".

I am no expert on this, but I am pretty good at looking things up and then testing the things I read against my own results. My body, my science experiment. So I checked this out a long time back when I first came across the term "liver dump". Here is my rough version, based on the best explanation I've seen (or that I could understand at my level:-) . This is the medical-speak version:

"Stores of readily available glucose to supply the tissues with an oxidizable energy source are found principally in the liver, as glycogen. Glycogen is a polymer of glucose residues linked by a-(1,4)- and a-(1,6)-glycosidic bonds. A second major source of stored glucose is the glycogen of skeletal muscle. However, muscle glycogen is not generally available to other tissues, because muscle lacks the enzyme glucose-6-phosphatase.
*snip*
The major site of daily glucose consumption (75%) is the brain via aerobic pathways. Most of the remainder of is utilized by erythrocytes, skeletal muscle, and heart muscle. The body obtains glucose either directly from the diet or from amino acids and lactate via gluconeogenesis. Glucose obtained from these two primary sources either remains soluble in the body fluids or is stored in a polymeric form, glycogen. Glycogen is considered the principal storage form of glucose and is found mainly in liver and muscle, with kidney and intestines adding minor storage sites. With up to 10% of its weight as glycogen, the liver has the highest specific content of any body tissue. Muscle has a much lower amount of glycogen per unit mass of tissue, but since the total mass of muscle is so much greater than that of liver, total glycogen stored in muscle is about twice that of liver. Stores of glycogen in the liver are considered the main buffer of blood glucose levels."

For the really detailed version click on the links.

Below I put that in words that I understand. I am no biochemist, so if any experts are reading this please correct any errors I make or omissions from over-simplification.

Liver Dumps.

We need glucose for energy. When we eat a meal it is usually a mix of carbohydrates, protein and fats. Carbohydrates are an easily converted source which quickly appear as glucose in our blood. We also, more slowly, obtain glucose by gluconeogenesis from protein or even fats and also from the stored energy in our liver and other organs.

When we create more glucose than our immediate needs some is stored. Some is stored as fat, especially if we have excess insulin floating around, and some is converted to glycogen. Glycogen is stored mainly in the liver and the muscles. The muscles are selfish because the glycogen stored in the muscles can usually only be used for the muscles, but the glycogen stored in the liver is our supply for any glucose needed by the rest of the body. When the body needs it the right amount is automatically released to the right places. As a result there is always a steady flow of energy to meet a person's needs, regulated to demand, regardless of when or what they eat.

At least, that is how it works in non-diabetics. It is the body's version of a fuel tank. Unfortunately, for type 2s, the system can be flawed. Type 2s on the internet use the term "liver dump" for the release of excessive glycogen fr0m the liver to become blood glucose at times when it wasn't really needed or wanted.

For example, one cause of the Dawn Phenomenon is thought to be the body sensing our need for energy when we are about to wake, leading to excessive glycogen release until we eat and send the signal to stop the release. That's why a breakfast soon after we wake is an essential meal for many of us. Similarly, fasting, exercise or heavy physical activity can lead to a liver dump if the body senses the reduction in blood glucose levels and over-compensates with excessive glycogen release.

Preventing liver dumps is complex and I know no general solution. For dawn phenomenon the most common treatment is to eat a late night snack; but the reports of successful snacks vary widely so it's best to perform your own experiments until, hopefully, you find the one that works for you. A minority never does, and others find that the only solution for them is basal insulin.

For those who experience liver dumps after fasting the solution is easy. Don't fast for long periods. Eat something every few hours, even if it is only a small snack.

For those who get them during or after exercise, I have seen reports of success from people who spread small carby snacks across the period of exercise, including a snack before starting.

Sorry I can't be more specific with answers on this one, just suggestions. Once again it's your body, your science experiment

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter

Postscript: Another good comment on the "Dawn Phenomenon can be found in the Misc.Health.Diabetes FAQs. Click on the link and scroll down to "Why is my morning bg high? What are dawn phenomenon, rebound, and Somogyi effect?".