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From Ottawa, Ontario, Canada:

I was originally diagnosed as Type 2 and on medication (2 years ago, age 31). Now they say I'm Type 1 (still producing insulin) and on 3 injections per day of Humalog and Ultralente. Are there any positive effects on starting a low carb diet?


Regarding the effects of a low carbohydrate diet: I do not personally have wide experience with it in patient use. Since I don't recommend it, for the reasons explained below, I cannot speak about details. However, I do have some thoughts that people may find helpful as they consider this diet for their own use. There is a review of the approach in the latest "Diabetic Reader" (from June Bierman and Barbara Toohey). Since Barbara and June had been using it themselves and felt it was helping both weight loss and glucose control in their personal "two rat study," this bias may be reflected in what was reported. However, it's probably worth reading, since I know they had been looking for some authoritative answers on this very same question.

Here are my thoughts, based more on theoretical concerns than on hard data. The low carbohydrate diet is higher in both fat and protein than what is currently recommended. This creates at least the need for users of this approach to be very mindful of the kind of fat in the diet, to avoid sending cholesterol and triglycerides through the roof. On a related issue, I have concerns that the very low carbohydrate diet has real potential for putting extra stress on kidney function (both via high protein intake and relative to disposal of the ketones that are an inevitable by-product of really sticking to it -- at the carbohydrate levels advocated by Atkins and others). Also note that much of the dramatic weight loss which low carb intake produces is water loss (you get dehydrated): as soon as adequate carbohydrate is added back in to the diet, water balance is quickly restored. The quick jump in weight convinces people that carbs are "fattening," if they don't understand the dehydrating effect of minimal carb intake and how heavy water is. Quick weight loss also suggests that muscle is being broken down. The body does that to try to get enough carb in the blood stream to fuel the brain, by converting certain amino acids from protein into glucose. It can't do this with fat.

There is no one right level of carb intake for everyone. I suggest to my clients that they keep track of carb intake, glucose, and weight and that we review these values relative to lipids and kidney function periodically. In this way, we can identify those people (mostly Type 2's who also have weight and blood pressure problems, in my experience) who will do better with a somewhat lower carb intake. I do not, however, find that these folks benefit from chowing down on sour cream and cheese, as the Atkins approach might suggest. If they do, they seem to have greater problems with sustained weight loss and with maintaining a beneficial lipid (blood fat) profile. I worry about the effect of all this on cardiac risk, kidney health and total nutrient intake.

As I said, the very low carbohydrate diet is not an approach that I personally recommend. However, if people are going to try it at a level of carbohydrate intake that produces mild ketonuria, I suggest working with a knowledgeable dietitian to make sure that the resulting diet is otherwise nutritionally adequate and following up closely with their physician to monitor kidney function (microalbuminuria at the very least).


Original posting 9 Sep 97


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