Posts Tagged ‘diabetes’



I was walking on a very dark street and I assumed the guy was talking on a cell phone, apparently about a dinner party. The voice was saying “Remember, I don’t eat red meat.” Just a few years ago, such a statement would have sounded strange. Of course, a few years ago a man talking to himself on the street would have been strange. He would have been assumed to be insane. Even more insane if he told you that he was actually talking on the telephone. But yesterday’s oddity pops up everywhere today. Neo-vegetarianism affects us all. Described well by Jane Kramer’s excellent review of veggie cookbooks in the April 14 New Yorker,

“…from one chili party to the next, everything changed. Seven formerly enthusiastic carnivores called to say they had stopped eating meat entirely, and would like to join my vegetarians for the pesto. Worse, on the night of that final party, four of the remaining carnivores carried their plates to the kitchen table, ignoring the cubes of beef and pancetta, smoky and fragrant in their big red bean pot, and headed for my dwindling supply of pasta. “Stop!” I cried. “That’s for the vegetarians!”

The New Yorker review describes well the different forms of vegetarianism and the various arguments for them, some better than others. The treatment of animals, more than their slaughter, is probably most upsetting. Just the review, in this week’s London Review of Books, of “Farmageddon. The True Cost of Cheap Meat” and “Planet Carnivore” is sufficiently scary as to be unreadable. Most of us just live with it. Personally, I think of it by analogy with the announcements on airplanes that, under conditions of low pressure, you should put your own oxygen mask on before helping others. When we start treating people better we can help the animals. Maybe a rationalization. In any case, one cause that doesn’t sit well is “…the health argument (doctors and nutritionists, alarmed by the rise in illness and obesity in a high-fat Big Mac world)…”

It’s not a high fat world any more than it’s a vegetarian country. A better description might be: Doctors and nutritionists, alarmed by the reduction in funding for anything but the party line, and imbued with a missionary zeal, try hard to find something wrong with meat, especially red meat. A lifeline for bloggers, there is a “meat kills” article every couple of months, usually an epidemiologic study with an odds ratio of 1.4. Odds ratio is what it sounds like: Your odds of getting a disease with the intervention vs your odds under control conditions. (Similar to a hazard ratio (HR) which is  the ratio of probabilities).  The ORs or HRs are commonly around 1.5 for the usual “is associated with” paper. For comparison, the odds ratio for getting lung cancer if you smoke is about 20 compared to not smoking. If you are a heavy smoker, they’re about 30.

Since we don’t really know what causes cancer or even heart disease or especially all-cause mortality, most of us let the “meat will kill you stories” go by, like other “breaking” news stories. But when the dictum is “meat causes diabetes” it is hard to ignore. Far-fetched and dangerous for it’s obscuring the elephant in the room: carbohydrate.

One of the worst of the meat scares was Pan, et al (JAMA Intern Med. 2013;173(14):1328-1335.) from the Harvard School of Public Health, a major supplier of these studies. This stuff has been deconstructed by several bloggers but a new technique is to look at the changes in consumption over time, rather than at a single time-point for ingestion.  Most of these studies are based on food questionnaires and measuring differences increases the error.  Error in a parameter that already has some uncertainty. (When you take the derivative of a function, you make the signal-to-noise ratio worse). It is like weighing the captain by weighing the ship before and after they are on board. The data are likely to have great scatter and you have more room to lump them into quintiles or otherwise find a way to come up with some kind of positive correlation. (This irony is a cover for my emotional reaction to a very serious collapse in scientific standards in the medical literature.) Pan’s paper concludes:

“Increasing red meat consumption over time is associated with an elevated subsequent risk of T2DM [type 2 diabetes mellitus]….”

You have to read the original to evaluate papers like this. First off, as in much of the medical literature, there is only one figure but several mind-numbing tables. This is a sufficiently serious problem that a whole book, “Medical Illuminations”  (recommended), has been written about it. The tables give you the raw data (at least as averaged into big groups) and the outcome from “corrected models.” However, when you plot the raw data you see that the reduction in red meat intake, the ultimate recommendation of the paper, leads to an increase in diabetes. What? That’s the opposite of the authors’ conclusion.


The table does not list this conclusion. You have to calculate it yourself. The table shows “models” that have been “corrected” for confounders. Most of us think that when you get a positive result, you have to make sure that there weren’t underlying factors (other than the one you are interested in) that account for the outcome. So, for example, if you say that increase in a particular food is associated with a disease, you are expected to subtract out the effect of any increased calories. If your primary data don’t show an effect then you are, more or less, out of luck. You can, however, “correct” with something known to cause the disease, something expected to make things worse. If this makes things better, you may have shown a benefit in your outcome but it becomes far-fetched unless there is  a very small number of variables. Generally though, if your “confounders” improve the correlation, they are the controlling variables.

I wrote a letter to the editor saying “The authors measured the effect of reducing meat consumption, which increased the frequency of diabetes in all the cohorts studied, opposite to the expectation of a consistent dose-response curve.” The journal published the letter along with the authors’ answers (they get the last word). The journal has a strict policy on brevity and you are not allowed to use any figures so I couldn’t send the picture of what things are really like.  The authors answer to the dose-response question:

 “Figure 1 in our article1 showed that increasing red meat intake within a 4-year period was positively associated with T2DM in the subsequent 4 years in a dose responsive manner, not “the effect of reducing meat consumption, which increased the frequency of diabetes in all the cohorts studied,” as claimed by Dr Feinman.

Astounding. The first highlighted sentence does not contradict the second. My figure shows that increasing red meat or decreasing red meat increased diabetes. How is this possible? It is possible if the data have too much randomness to be reliable.

So how do they justify their conclusion? Simple, they correct the data for confounders. They correct for initial red meat intake which makes the effect of an increase in meat stronger as you would expect. They then correct for age but they don’t show you what that effect is. In fact, they correct for race, marital status, family history of T2DM, history of hypertension, history of hypercholesterolemia, smoking status, initial and changes in alcohol intake,…” — I’m not making this up — “physical activity, total energy intake, and diet quality, postmenopausal status and menopausal hormone use plus initial body mass index and weight change.” Mirabile dictu, they are able to get the answer to come out the way they want.

It would probably be hard to explain to the authors why this doesn’t make any sense. If you have to do so much work to get the answer, it can’t mean anything. It’s all like the old joke about the woman who calls the police because the guy next door is exposing himself. When the cops come, she shows them the window.  The cop says “Lady, that window is too high to see anything.” She says “Sure. Where you are, but stand on this chair and you will see.”

So, does all this mean anything at all? Well, it means that diabetes is not correlated with red meat unless you include many other factors. Maybe those factors are what we should be warned about. But it is simple. This is not done in a vacuum. There are big epidemiologic studies. The real point is, as in my Letter to the Editor, “Red meat consumption decreased as T2DM increased during the past 30 years.” The data are compelling:


Their answer was “ this ecological relationship cannot be used to argue against the causal relationship between red meat intake and T2DM because many other factors have changed over time.”

This statement stands as the embodiment of the total lack of common sense and the irrational perspective of the epidemiologist. (Okay. Just these epidemiologists). There are always more factors. If your data don’t come out the way you want, drag in as many factors as you need (age, initial red meat intake, race, marital status, shirt size, etc.) until it does. If somebody else’s data shows you that you are wrong, point out all the things that they have left out. The end of common sense. The end of science.

But why do they do this? I am not sure why you would think that red meat had much to do with diabetes but the study showed that you were wrong. Research gives you a lot of failures. You just go on to something else. Nobody knows about motivation, nobody knows what was on their mind. Seven possible reasons are NIH grants P01CA087969, R01CA050385, U19CA055075, R01DK058845, P30DK046200, U54CA155626 and K99HL098459. Nonetheless, one has the sense that the authors really believe their conclusion and that there is a general emotional and puritanical reaction to red meat and its agents.

“Components in red meat that may contribute to T2DM…”

“…The time has been

That, when the brains were out, the man would die,

And there an end…”

— William Shakespeare, Macbeth.

A big problem: the underlying mechanism. What might actually be the agent that confers such danger on red meat? Pan, et al say “Components in red meat that may contribute to T2DM risk include heme iron, high saturated fat and cholesterol, added sodium and nitrites and nitrates in processed meat, etc.”

This list is notable for the presence of saturated fat and cholesterol. Isn’t that dead? The latest report about evidence that saturated fat does not pose a risk has a certain degree of squabbling but it is only one in a long line of individual studies and meta-analyses that drive a stake through the heart of cholesterol and saturated fat as a risk. Walter Willett, an author on Pan, et al just couldn’t face the result and wanted the paper withdrawn, but the history of risk of saturated fat and cholesterol is demonstration of one failure after another, some from his own lab. The idea never dies. One interesting part of the squabbling was the statement, “A 2009 review concluded that replacing saturated fats with carbohydrates had no benefit, while replacing them with polyunsaturated fats reduced the risk of heart disease. Several scientists say that should have been mentioned in the new paper.” Presumably it is the second part, rather than the first that they want mentioned.

But underneath it all is the moralistic, puritanical mindset. In trying to face the evidence in the original report, Alice Lichtenstein said, “It would be unfortunate if these results were interpreted to suggest that people can go back to eating butter and cheese with abandon.”  Abandon? I guess we are supposed to think of the gutted pig scene in Fellini’s Satyricon.



All such moralistic proscriptions have the risk of what pyschologists call counter-control.  I personally rarely eat meat before 6 PM, but when I found out that Mark Bittman says that that is what we all must do, it made me get out left-over spareribs for lunch. Along these lines, it is heartening to see that in her review of Deborah Madison’s Vegetable Literacy, Kramer points out that, in the preparation of cardoon risotto “there is permission to simmer it in a ‘light chicken stock,’ and even an acknowledgement that vegetable stock might ‘overwhelm’ the flavor of that delicately bitter member of the sunflower family.…” And, in the end, “The book is sly. Think of it as a pro-choice cookbook decorously wrapped in carrots and beans and lettuce leaves. Apart from the chicken broth, you won’t find anything ‘animal’ listed but read what she has to say about some of those recipes, and you will detect the beginning of a stealth operation — a call to sit down at the dinner table together and put an end to the testy herbivore-carnivore divide.” This suggests that they might both be in tune with my own philosophy which I call antidiscarnivorianism.

Illustration by Robin Feinman. Reference:


The  SBU (Swedish Council on Health Technology Assessment) is charged by the Swedish government with assessing health care treatments. Their recent acceptance of low-carbohydrate diets as best for weight loss is one of the signs of big changes in nutrition policy.  I am happy to reveal the next bombshell, this time from the American Diabetes Association (ADA) which will finally recognize the importance of reducing carbohydrate as the primary therapy in type 2 diabetes and as an adjunct in type 1.  Long holding to a very reactionary policy — while there were many disclaimers, the ADA has previously held 45 – 60 % carbohydrate as some kind of standard — the agency has been making slow progress. A member of the writing committee who wishes to remain anonymous has given me a copy of the 2014 nutritional guidelines due to be released next year, an excerpt from which, I reproduce below.

Nutrition Therapy Recommendations for the Management of Adults With Diabetes 

This position statement on nutrition therapy for individuals living with diabetes replaces previous position statements, the last of which was published in 2013 [1] and incorporated into the Standards of Medical Care of 2014 [2]. In particular, evidence suggests that the starting point for therapy for type 2 diabetes and adjunct treatment of type 1, should be some form of very low-carbohydrate diet. The amount of carbohydrates is the most important factor influencing glycemic response after eating and should be considered when developing the eating plan. Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management. While it is still recognized that there is not an ideal percentage of calories from carbohydrate for all people with diabetes, carbohydrate intake should be as low as possible for most people. 

There are several good references for implementation [3, 4] although the degree of reduction of dietary carbohydrate should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. Collaborative goals should be developed with the individual with diabetes. For good health, any carbohydrate intake should come from vegetables, fruits, legumes, and dairy products rather than intake from other carbohydrate sources, especially those that contain high starch and sugar.  In recognizing the importance of removing carbohydrates, the current guidelines deviate from, and consider inappropriate, previous recommendations from 2008 [5] that “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 glucose lowering medications.” While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, it is now recommended that consumption should be minimized to avoid displacing nutrient-dense food choices.

Recommendations for low-carbohydrate diets.

The new recommendations emphasizing low-carbohydrate diets follow from the observations noted previously [5] that improvements in serum lipid/lipoprotein measures including improved triglycerides, VLDL triglyceride, and VLDL cholesterol, total cholesterol, and HDL cholesterol levels are now recognized as a reliable feature of lower-carbohydrate diet compared with higher carbohydrate intake levels. Through the collaborative development of individualized nutrition interventions and ongoing support of behavior changes, patients should understand the rationale of carbohydrate restriction and be made aware of its potential value.

Most important for clinicians is understanding results of two independent comparative studies from the laboratories of David Jenkins [6] and of Eric Westman [7] shown in Figure 1.

Fad_Westman_Jenkins_FigFigure 1. Comparison of High Cereal and Low Glycemic Index Diets and of Low Glycemic Index Diets and Low Carbohydrate Diets

The role of body mass in diabetes.  

More than three out of every four adults with diabetes are at least overweight, and nearly half of individuals with diabetes are obese. Because of the relationship between body weight (i.e., adiposity) and insulin resistance, weight loss has long been a recommended strategy for overweight or obese adults with diabetes. Two important experimental results bear on the new recommendations. First, in numerous trials, low-carbohydrate diets of one type or another out-perform other diets to which they are compared. No diet is better than carbohydrate restriction for weight loss. However, it has been shown that the features of both type 1 and type 2 diabetes are improved by low-carbohydrate diets even in the absence of weight loss.

Previous recommendations on nutritional therapy have failed to take account important work of Nuttall and Gannon who have clearly shown that the symptoms of type 2 diabetes can be improved without the requirement for weight loss [8-10].  Even under weight-maintenance conditions, dietary carbohydrate restriction dramatically improves glycemic control as well as HbA1c and lipid markers. This fact is important given the resistance that many individuals show to weight loss.  A series of papers from Nuttal and Gannon [8-10] measured many hormones and parameters in response to various carbohydrate-reduced diets. Although the percentage of carbohydrate differed in many of these studies, the most effective level of carbohydrate in improving the markers was the lowest level of carbohydrate used.  Results from one study from Nuttall and Gannon’s lab [10] are shown in Figure 2.  A low-carbohydrate (20% energy) diet was instituted for five weeks under conditions where weight was maintained. It is clear from the figure 24-hr integrated and postprandial glucose as well as hemoglobin A1c was improved after the five-week diet period (●) compared to performance before (▲).   These results contrast with outcomes from low-fat and calorie-restricted diets, which generally require weight loss for diabetes symptoms to improve. While the results have recently been extended to longer periods [8], it is important to recognize that nothing in the results contradicts the idea that benefit will continue to accrue as long as the diet is adhered to.

EDUC_AHRQ_Gannon_May4 Figure 2. Comparison of blood glucose, endogenous insulin and glycosylated hemoglobin in sixmales with mild untreated type 2 diabetes fed a low-carbohydrate/ high-protein diet (non-ketogenic;20% carbohydrate, 30% protein). Results are shown before (▲) and after (●) the five-week regimen.

It is now recognized that the amount of dietary saturated fat and cholesterol recommended for people with diabetes is the same as that recommended for the general population. Recent studies have confirmed that there is no relation between dietary saturated fat and cholesterol and cardiovascular disease [11-13]. Previous statements that “patients on low-carbohydrate diets, monitor lipid profiles” is no longer considered appropriate although all patients with diabetes should monitor their lipids.

Is this real? Can you believe it? 

Is this real? No. It’s not real. It could be real if the American Diabetes Association adopts it. You believed that it was real because it is reasonable and it follows from both common sense and scientific principles. You believed it because it provided you with the data rather than giving you the opinion of a committee that chose whatever studies it wanted to, and took the conclusions at face value. Most of all, you believed it because we all want to believe it. Previous guidelines from the ADA have been incomprehensible and ultimately embarrassing. Since the principles of low-carbohydrate diets are so reasonable, bloggers and others have continually tried to find signs of their acceptance in each new position statement from the ADA, signs that could be described as “encouraging first steps.” Invariably, the ADA guidelines have been, instead, the camel-like creations of a committee characterized by stultifying clichés — one reason that you might have believed that the version above was real is that I included trivial phrases — the text that is in blue  — from the 2013 guidelines. I wrote this because several bloggers tried to put a positive spin on the 2013 guidelines and I was going to comment on how little it would have taken for them to get it right. So I decided to write it for them.

Imperial Dishabilement. Critique of the 2013 Guidelines

Diabetes Care is the house organ of the ADA. The 2013 guidelines are subject only to internal review. No real peer review is possible and it shows. We are not supposed to be too critical, however. Standards of propriety are expected of the reader. We are supposed to refrain from blunt criticism of style and content, like Robert French’s critique of A companion to Woody Allen in the Times Literary Supplement (October 4, 2013):

“The book is 90% of obfuscation, 10% illumination. Statements of the obvious abound (‘Like many Christians, Jews, Muslims and others, Allen can practice a faith without always believing in it’).”

 We are expected to ignore fatuous remarks stating that one of the goals of nutrition therapy is:

 “To maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence.”

I admit that I had to ask an English professor for an explanation as to why this particular line is so annoying. “It implies that there is some agency out there who wants to deny you pleasure or unjustly limit your food choices.” But statements of the obvious do abound. Some examples:

“For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss.” (twice)

“Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another.”

“A healthful eating pattern, regular physical activity, and often pharmacotherapy are key components of diabetes management.”

“Effective nutrition therapy interventions may be a component of a comprehensive group diabetes education program or an individualized session achieved.”

“Health professionals should collaborate with individuals with diabetes to integrate lifestyle strategies that prevent weight gain or promote modest, realistic weight loss.”

All such documents have a certain degree of boiler plate but here it is relentless and overpowering and it takes the place of the science. And it protests too much. “Individualized” appears 21 times in the guidelines. But it is disingenuous. Individualized is just what the previous guidelines were not and those recommendations are specifically not retracted. It is not sufficient to say that your paper “replaces previous position statements.” You have to explain what the previous ones were and why they are no longer applicable.

If therapy is individualized, what principles is individualization based on? “Individuals who have diabetes should receive individualized Medical Nutrition Therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian (RD) familiar with the components of diabetes MNT.” In other words, you’re on your own, or worse, turn it over to the RD’s.  Where do the RD’s get their understanding of diabetes MNT?  Well, probably from the last implementation of the ADA guidelines which were unabashed in what they opposed:

“Low-carbohydrate diets might seem to be a logical approach to lowering postprandial glucose. However, foods that contain carbohydrate are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability” [5] and…

“For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to1 year).”


“For patients on low-carbohydrate diets, monitor lipid profiles, renal function,and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed.”

In other words, low-carb diets are okay if you don’t mind having a heart attack or kidney failure (oh, of course only if you have nephropathy; it’s not a failure to understand of English usage that puts the disclaimer in the wrong place in the sentence ) and the low-carb diet will lead to hypoglycemic episodes.

Most of all, you have to provide new guidance. But guidance is not available in the 2013 position statement. :

“The optimal macronutrient intake to support reduction in excess body weight has not been established.”

“Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.”

“The evidence suggests that several different macronutrient distributions/eating patterns may lead to improvements in glycemic and/or CVD risk factors (88). There is no “ideal” conclusive eating pattern that is expected to benefit all individuals with diabetes (88). ” (Reference 88 is to the same group’s review of low carbohydrate diets).

Evidence does not generally suggest what is not ideal.  This is especially true if you don’t look at all the evidence and this is the ADA guideline’s greatest failing. The two figures above, by themselves, constitute a strong case for low carbohydrate diets. These papers are not cited by the 2013 guidelines although I have personally pointed them out to members of the committee.  Non-scientists ask me: “Can you do that? Can you just leave out relevant papers?”

And “ideal” may not be possible anywhere in medicine. What you want is best practice or, as we describe it, the “default diet,” what you try first, your best bet.

The bottom line is that the 2013 guidelines are weak on science and dreadful in style. The two are closely linked. Obfuscation rather than clarification. The emperor is naked. The document would never survive real peer review. In the end, we have to ask why this is tolerated. The answer is usually that the ADA is a private organization and they may do as they choose. Or are they? They are tax exempt and their officers and editors have federal grants. On publication, Diabetes Care is their journal and the editors can publish whatever they like. Or can they? Is any paper in such a publication to be believed if there is this level of bias among the editors? Are they accountable at all?

The writing committee. 

There are no real credentials in science. We all accept that a major part of our understanding of the physical world comes from a clerk in a patent office. But that’s only true if the science is correct. So who did the ADA get to present their position? The list is below. You can Google them to see their qualifications. There are two PhD’s and, oddly, only one representative of the M in MNT (Medical Nutrition Therapy), Will Yancy, who, in fact, has provided strong evidence supporting low-carbohydrate diets. Yancy is a co-author on the un-cited study in Figure 1 (ref. 4). The first author of the 2013 Guidelines, Allison Evert has two publications: those Guidelines and the review paper on low-carbohydrate diets, a subject with which she appears to have no experience.  Most of the other authors also appear to have no experience with research on the effects of macronutrients. Most have little research experience at all.  As for Yancy, who has made a major contribution to dietary carbohydrate restriction, it is generally assumed that they threatened his life.

Allison B. Evert, MS, RD, CDE

Jackie L. Boucher, MS, RD, LD, CDE

Marjorie Cypress, PhD, C-ANP, CDE

Stephanie A. Dunbar, MPH, RD

Marion J. Franz, MS, RD, CDE

Elizabeth J. Mayer-Davis, PHD, RD

Joshua J. Neumiller, PharmD, CDE, CGP, FASCP

Robin Nwankwo, MPH, RD, CDE

Cassandra L Verdi, MPH, RD

Patti Urbanski, MED, RD, LD, CDE

William S. Yancy, Jr., MD, MHSC


1. American Diabetes Association: Nutrition Recommendations and Interventions for Diabetes–2013. Diabetes Care 2013, 36(Suppl 1):S12-S32.

2. Association AD: Standards of Medical Care in Diabetes — 2014. Diabetes Care 2014, 37, Supplement 1:S15-S80.

3. Bernstein RK: Dr. Bernstein’s diabetes solution : the complete guide to achieving normal blood sugars, 4th edn. New York: Little, Brown and Co.; 2011.

4. Vernon MC, Eberstein JA: Atkins Diabetes Revolution.  The Groundbreaking Approach to Preventing and Controlling Type 2 Diabetes. New York: William Morrow; 2004.

5. American Diabetes Association: Nutrition Recommendations and Interventions for Diabetes–2008. Diabetes Care 2008, 31(Suppl 1):S61-S78.

6. Jenkins DJ, Kendall CW, McKeown-Eyssen G, Josse RG, Silverberg J, Booth GL, Vidgen E, Josse AR, Nguyen TH, Corrigan S et al: Effect of a low-glycemic index or a high-cereal fiber diet on type 2 diabetes: a randomized trial. JAMA 2008, 300(23):2742-2753.

7. Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR: The Effect of a Low-Carbohydrate, Ketogenic Diet Versus a Low-Glycemic Index Diet on Glycemic Control in Type 2 Diabetes Mellitus. Nutr Metab (Lond) 2008, 5(36).

8. Gannon MC, Hoover H, Nuttall FQ: Further decrease in glycated hemoglobin following ingestion of a LoBAG30 diet for 10 weeks compared to 5 weeks in people with untreated type 2 diabetes. Nutr Metab (Lond) 2010, 7:64.

9. Gannon MC, Nuttall FQ: Control of blood glucose in type 2 diabetes without weight loss by modification of diet composition. Nutr Metab (Lond) 2006, 3:16.

10. 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(9):2375-2382.

11. Forsythe CE, Phinney SD, Feinman RD, Volk BM, Freidenreich D, Quann E, Ballard K, Puglisi MJ, Maresh CM, Kraemer WJ et al: Limited effect of dietary saturated fat on plasma saturated fat in the context of a low carbohydrate diet. Lipids 2010, 45(10):947-962.

12. Jakobsen MU, Overvad K, Dyerberg J, Schroll M, Heitmann BL: Dietary fat and risk of coronary heart disease: possible effect modification by gender and age. Am J Epidemiol 2004, 160(2):141-149.

13. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM: Saturated fat, carbohydrate, and cardiovascular disease. Am J Clin Nutr 2010, 91(3):502-509.

The reporter from Men’s Health asked me: “You finish dinner, even a satisfying low-carb dinner,” — he is a low-carb person himself — “you are sure you ate enough but you are still hungry. What do you do?”  I gave him good advice. “Think of a perfectly broiled steak or steamed lobster with butter, some high protein, relatively high fat meal that you usually like.  If that doesn’t sound good, you are not hungry.  You may want to keep eating. You may want something sweet.  You may want to feel something rolling around in your mouth, but you are not hungry.  Find something else to do — push-ups are good.  If the steak does sound good, you may want to eat. Practically speaking, it’s a good idea to keep hard-boiled eggs, cans of tuna fish around (and, of course, not keep cookies in the house).” I think this is good practical advice. It comes from the satiating effects of protein food sources, or perhaps the non-satiating, or reinforcing effect of carbohydrate. But the more general question is: What is hunger? (more…)

The joke in academic circles is that there are three responses to a new idea. First, “This is wrong,” second, “There’s nothing new in this,” and third, the sub-title of this post. Priority in a scientific discovery is fundamental in science, however, and “we thought of this first” is not always that funny.  Getting “scooped” can have serous practical consequences like jeopardizing your grant renewal and, if nothing else, most of us are motivated by a desire to solve the problem and don’t like the feeling that, by analogy, somebody came along and filled in our crossword puzzle.  In dietary carbohydrate, all three of the responses co-exist.  While an army of dietitians is still claiming that people with diabetes need ever more carbohydrate, in the background the low-fat paradigm crumbles and, somewhat along the lines of the predictions in A Future History of Diabetes , the old guard are coming forward to tell us that they have been recommending low-carb all along.

The latest discoverer of the need to reduce dietary carbohydrate is David Jenkins whose recent paper is entitled “Nuts as a Replacement for Carbohydrates in the Diabetic Diet.” [1] The title is crazy enough, following the tradition of getting away from nutrients, that is, well-defined variables, and replacing it with “food,” that is, mixtures of everything. It is, in fact, not really a low carbohydrate study but the experimental design is not the problem.  It is the background and rationale for the study which recognizes the disintegration of the low-fat diet paradigm but, at the same time, fails to cite any of the low-carbohydrate studies that have been instrumental in showing the need to replace carbohydrates in the diabetic diet. Given forty years of studies showing the benefits of low carbohydrate diets and forty years of unrestrained attacks on the method, it will be interesting to see how Jenkins shows that it is actually the nutritional establishment that invented carbohydrate restriction.

Disputes over priority are well known in the history of science. Newton’s frequently quoted statement that he had seen farther than others because he had “stood on the shoulders of giants” has been interpreted by some historians as a sarcastic comment aimed at Robert Hooke  with whom he had, among other things, a dispute over the priority for the inverse square law (force of gravity varies as the inverse of the square of the distance: F = GmM/g2). Hooke was short and suffered from kyphosis and is assumed not to have shoulders you would profitably stand on.

Even Einstein had trouble.  His dispute with the mathematician David Hilbert about priority for the field equations of general relativity (also about gravity) is still going on, a dispute that I prefer to stay out of. Cited by his biographer, Abraham Pais, Einstein had apparently made up the  verb to nostracize (nostrazieren) which he accused Hilbert of doing. (He meant that Hilbert had made Einstein’s idea community knowledge.  Googling the word gives you only “ostracize” and “Cosa Nostra.”)

It is not the priority dispute, per se — the original low carbohydrate diet is usually attributed to William Banting who published the Letter on Corpulence in 1863, although Brillat-Savarin’s 1825 Physiologie du goût  understood the principle. He said that some people were carbophores and admitted to being one himself.  It is not just priority but that the people who are now embracing carbohydrate restriction were previously unrestrained in their attacks on the dietary approach and were adamant in denying the strategy to their patients.

David Jenkins: “Nuts.”

In trying to find an appropriate answer to the recent bit of balderdash by the redoubtable Hope Warshaw, Tom Naughton recounted the story of the Battle of the Bulge of WWII.  Towards the end of the war, Hitler launched a massive winter attack around the city of Bastogne where, at one point, American Forces were surrounded. When the Germans demanded surrender, the American General, Anthony McAuliffe, sent the one-word reply: “Nuts!”  I always thought it was a euphemism and that he actually went “Vice-presidential” as it was called in the last administration, but it turns to have been a common expression with him and he really did write “nuts” which, of course, had to be explained to the German couriers. (There is a “Nuts” Museum in Bastogne commemorating the battle which the Americans won somewhat as described in the movie Patton).

For installation in the Nutritional Nuts Museum and as an example of the current attempts to co-opt carbohydrate restriction, one can hardly beat Jenkins’s recent paper [1].

Richard:…Who knows not that the gentle duke is dead? ….

King Edward: Who knows not he is dead! Who knows he is?

Queen Elizabeth: All-seeing heaven, what a world is this!

– William Shakespeare, Richard III

The trick is to act as if the point you are making is already established. The Abstract of Jenkins study: “Fat intake, especially monounsaturated fatty acid (MUFA), has been liberalized in diabetic diets to preserve HDL cholesterol and improve glycemic control….” It has? Liberalized by whom?  Although the American Diabetes Association guidelines are traditionally all over the place, few would consider that there is any sense of substantial liberalization on replacing carbohydrate with fat from them or any health agency.

“Replacement of carbohydrate by healthy fat … has been increasingly recognized as a possible therapeutic strategy in the treatment of diabetes [2] as concerns emerge over the impact of refined carbohydrate foods in increasing postprandial glycemia and reducing HDL cholesterol.”  Reference [2] ((1) in the original) actually “emerged” in 2002 and is ambiguous at best: “Carbohydrate and monounsaturated fat together should provide 60–70% of energy intake.” (It is not my style of humor, but the behavioral therapists call this “shoulding on people.”) The paper admits that the evidence “is based on expert consensus”  and contains what might be called the theme song of the American Diabetes Association:

 “Sucrose and sucrose-containing food do not need to be restricted by people with diabetes based on a concern about aggravating hyperglycemia. However, if sucrose is included in the food/meal plan, it should be substituted for other carbohydrate sources or, if added, be adequately covered with insulin or other glucose-lowering medication.” (my italics)

In fact, one emerging piece of evidence is Jenkins 2008 study comparing a diet high in cereal with a low glycemic index diet [3].  The glycemic index is a measure of the actual effect of dietary glucose on blood glucose.  Pioneered by Jenkins and coworkers, a low-GI diet is based on the same rationale as a low-carbohydrate diet, that glycemic and insulin fluctuations pose a metabolic risk but it emphasizes “the type of carbohydrate,” that is, it is a politically correct form of low-carbohydrate diet and as stated in the 2008 study: “We selected a high–cereal fiber diet treatment for its suggested health benefits for the comparison so that the potential value of carbohydrate foods could be emphasized equally for both high–cereal fiber and low–glycemic index interventions.” (my emphasis) The Conclusion of the 24-week study was: “In patients with type 2 diabetes, 6-month treatment with a low–glycemic index diet resulted in moderately lower HbA1c levels compared with a high–cereal fiber diet.”  The figure below shows the results for HbA1c and weight loss and just looking at the figures, the results are certainly modest enough.

By coincidence, on almost the same day, Eric Westman’s group published a study that compared a low glycemic index diet with a true low carbohydrate diet [4].  The studies were comparable in duration and number of subjects and a direct comparison shows the potential of low carbohydrate diets (NOTE: in the figure, the units for the change are those of the individual parameters; an earlier version showed this as % which was an error):


Fad_Westman_Jenkins_FigWe thought of this first.

Oddly, neither of these papers are cited in the current study by Jenkins, et al.  In fact, according to the paper, the precedents go way back:

“Recently, there has been renewed interest in reducing carbohydrate content in the diet of diabetic patients. In 1994, on the basis of emerging evidence, the American Diabetes Association first suggested the possibility of exchanging dietary carbohydrate for MUFA in dietary recommendations for type 2 diabetes). Although not all studies have shown beneficial effects of MUFAs in diabetes, general interest has persisted, especially in the context of the Mediterranean diet.”

The ADA discovered low carbohydrate diets ? Did my blogpost see it coming, or what? But wait…

 “low carbohydrate intakes have also been achieved on the Atkins diet by increasing animal fats and proteins. This influential dietary pattern is reflectedin the relatively lower pre-study carbohydrate intakes of ~ 45% in the current study rather than the 50–60% once recommended.

The researchers in this area might not feel that 45 % carbohydrate has much to do with the Atkins diet but, in any case, it appears not to have been “influential” enough to actually get the studies supporting it cited.

Again: “Fat intake, especially monounsaturated fatty acid (MUFA), has been liberalized…” but “… the exact sources have not been clearly defined. Therefore, we assessed the effect of mixed nut consumption as a source of vegetable fat on serum lipids and HbA1c in type 2 diabetes.”  Therefore? Nuts?  That’s going to clearly define the type of MUFA?  Nuts have all kinds of nutrients.  How do we know that it is the MUFA in the nuts?  In fact, the real question is whether any benefit would not be due to the reduction in carbohydrate regardless of what it were replaced with. So what was the benefit? The figure above shows the effect on hemoglobin A1C. As described by the authors:

 “The full-nut dose reduced HbA1c by two-thirds of the reduction recognized as clinically meaningful by the U.S. Food and Drug Administration (.0.3% absolute HbA1c units) in the development of antihyperglycemic drugs…”

 In other words, almost meaningful, and

 “the number of participants who achieved an HbA1c concentration of <7% (19 pre-study participants, down to 13 post-study participants) was significantly greater on the nut treatment than on the muffin treatment (20 pre-study participants, remaining at 20 post-study participants…).”

This is some kind of accomplishment but the figure above shows that, in fact, the results were pretty poor.  The statistics do show that the “full nut dose” was significantly different from the half-nut dose or the muffin.  But is this what you want to know?  After all, nobody has an average change in HbA1c.  What most of us want to know is the betting odds. If I down all those nuts, what’s the chance that I’ll get better.  How many of the people in the full-nut study did better than those in the half-nut study (did the authors not know that this would sound funny?).  You can’t tell for sure because this information is buried in the statistics but the overlap of the error bars, highlighted in pink, suggests that not everybody gained anything — in fact, some may have gotten worse.

What kind of benefit is possible in a dietary intervention for people with diabetes?  Well, the studies discussed above from Jenkins himself and from Westman show that, with a low-GI diet, it is possible to obtain an average reduction of about 4 %, more than ten times greater than with nuts and with a real low-carbohydrate diet much greater.  I have added an inset to the Figure from Jenkins with data from a 2005 study by Yancy, et al. [5].  The red line shows the progress of the mean in Yancy’s studied.  If you had diabetes, would you opt for this approach or go for the full-nut dose?


1. Jenkins DJ, Kendall CW, Banach MS, Srichaikul K, Vidgen E, Mitchell S, Parker T, Nishi S, Bashyam B, de Souza R et al: Nuts as a replacement for carbohydrates in the diabetic diet. Diabetes Care 2011, 34(8):1706-1711.

2. Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian AD et al: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002, 25(1):148-198.

3. Jenkins DJ, Kendall CW, McKeown-Eyssen G, Josse RG, Silverberg J, Booth GL, Vidgen E, Josse AR, Nguyen TH, Corrigan S et al: Effect of a low-glycemic index or a high-cereal fiber diet on type 2 diabetes: a randomized trial. JAMA 2008, 300(23):2742-2753.

4. Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR: The Effect of a Low-Carbohydrate, Ketogenic Diet Versus a Low-Glycemic Index Diet on Glycemic Control in Type 2 Diabetes Mellitus. Nutr Metab (Lond) 2008, 5(36).

5. Yancy WS, Jr., Foy M, Chalecki AM, Vernon MC, Westman EC: A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab (Lond) 2005, 2:34.

Doctor:  Therein the patient must minister to himself.

Macbeth: Throw physic [medicine] to the dogs; I’ll none of it.

— William Shakespeare, Macbeth

The epidemic of diabetes, if it can be contained at all, will probably fall to the efforts of the collective voice of patients and individual dedicated physicians. The complete abdication of responsibility by the American Diabetes Association (sugar is okay if you “cover it with insulin”) and by other agencies and individual experts, and the media’s need to keep market share with each day’s meaningless new epidemiologic breakthrough leaves the problem of explanation of the disease and its treatment in the hands of  individuals.

Jeff O’Connell’s recently published Sugar Nation  provides the most compelling introduction to what diabetes really means to a patient, and the latest edition of Dr. Bernstein’s encyclopedic Diabetes Solution  is the state-of-the art treatment from the patient-turned-physician.  Although the nutritional establishment has been able to resist these individual efforts — the ADA wouldn’t even accept ads for Dr. Bernstein’s book in the early editions — practicing physicians are primarily interested in their patients and may not know or care what the expert nutritional panels say.  You can send your diabetes story to Michael Turchiano (  and Jimmy Moore ( at The Patient’s Voice Project.

The Patient’s Voice Project

The Patient’s Voice Project, which began soliciting input on Friday, is a research study whose results will be presented at the Office of Research Integrity (ORI) conference on Quest for Research Excellence, March 15-16 in Washington, D.C. The conference was originally scheduled for the end of August but there was a conflict with Hurricane Irene.

The Patients Voice Project is an outgrowth of the scheduled talk “Vox Populi,” the text for which is at the end of this post.  A major stimulus was also our previous study on the Active Low-Carber Forums, an online support group. The March conference will present a session on “Crisis in Nutrition” that will include the results of the Patient’s Voice Project.

Official Notice from the Scientific Coordinator, Michael Turchiano

The Patient’s Voice Project is an effort to collect first hand accounts of the experience of people with diabetes (type 1 and type 2) with different diets.  If you are a person with diabetes and would be willing to share your experiences with diet as a therapy for diabetes, please send information to Michael Turchiano ( and a copy to Jimmy Moore ( Please include details of your diets and duration and whether you are willing to be cited by name in any publication.

It is important to point out that, whereas we think that the benefits of carbohydrate restriction have been greatly under-appreciated and under-recommended, the goal is to find out about people’s experiences:both benefits and limitations of different diets. If you have not had good success with low-carbohydrate diets, it is equally important to share these experiences.

  • Indicate if you saw a physician or other health provider, what their attitudes were and whether you would be willing to share medical records.
  • We are particularly interested in people who have switched diets and had different outcomes.
  • Include any relevant laboratory or medical results that you think are relevant but we are primarily interested in your personal reactions to different diets and interaction with physicians and other health providers.
  • Finally, please indicate what factors influenced your choices (physician or nutritionist recommendations, information on popular diets(?) or scientific publications).

Thanks for your help.  The Patient’s Voice Project will analyze and publish conclusions in popular and scientific journals.

The Survey of the Active Low-Carber Forums

The Active Low-Carber Forums (ALCF) is an on-line support group that was started in 2000.  At the time of our survey (2006), it had 86,000 members and currently has more than 130,000.  Our original survey asked members of the forum to complete a 27-item questionnaire and to provide a narrative on any other health issues.  Some of the narrative answers included in the published paper were as follows:

“I no longer have diabetes, high blood pressure, sleep apnea, joint pain, back pain and loss of energy.”

“I started low carbing for diabetes. My 3 month blood sugar was 8.9 when diagnosed. It is now 5.4. My doctor is thrilled with my diabetes control and as a side benefit, I lost all that weight!”

 “I’m controlling my diabetes without meds or injecting insulin (with an a1c below 5), my lipid profile has improved, I’ve lost weight, I’ve gained both strength and endurance, and I’ve been able to discontinue one of my blood pressure meds.”

 “I have much more energy, fewer colds or other health problems. I was able to go completely off oral diabetes medication.”

The survey covered a number of topics.  We found that most respondents had the perception that they ate less food than before their low-carb diet, and most felt that the major change in their diet was a large increase in the consumption of green vegetables and a corresponding large decrease in fruit intake.

Physicians Attitudes in the ALCF survey

The Patient’s Voice Project is likely to tell us as much about physicians, or at least their interaction with patients, as about the patients themselves. We found in the ACLF survey that slightly more than half of the people who responded said that they had consulted a physician. We were surprised that about 55 % said that the physician or other health professional was supportive of their diet. Another 30 % or so fit the category of “did not have an opinion but was encouraging after seeing results.” Only 6 % of responders indicated that “they were discouraging even after I showed good results,” which may be a surprising result depending on your feeling about the rationality of doctors vs hostility to the Atkins diet.  Perusal of patients’ opinions on diabetes websites, however, suggests that the story on people with diabetes will not be as encouraging. 

The Survey on Sources of Information

Given the contentious nature of the debate on diet in diabetes therapy, it is not surprising that a  group following a low-carb strategy would  not put much stock in official sources. The table below shows the breakdown on sources of information from the ALCF survey.  Of the half of respondents who said that they relied on original scientific publications, 20 % felt they had generally inadequate access (important articles were not accessible) whereas 61 % felt that access was adequate and were able to see most articles that they wanted.

Voices of Dissatisfaction.

Posts on the ALCLF itself reinforced the idea that official recommendations were not only a limited source of information but that many were perceived as misleading. Typical posts cited in the paper:

“The ‘health experts’ are telling kids and parents the wrong foods to eat. Until we start beating the ‘health experts’ the kids won’t get any better. If health care costs are soaring and type 2 diabetes and its complications, as are most of these expenses why are we not putting a ‘sin’ tax on high glycemic foods to cut consumption and help pay for these cost? Beat the ‘health experts’ – not the kids!”

 While I am not a fan of sin taxes, the dissatisfaction is clear, and…

 “Until I researched it three years ago – I thought the most important thing was low fat. So I was eating the hell out of low fat products and my health continued to get worse.”

Similarly, the recent article in Diabetes Health by Hope Warshaw with its bizarre recommendation for people with diabetes to increase their carbohydrate intake elicited a number of statements of dissatisfaction:

“Respectfully, this column is not helpful to diabetics and probably dangerous. I am going on 6 years of eating 30-35 carbs/day. My A1c has been in the “non-diabetic” range ever since I went this route and I feel better than I have in years. I am not an exception among the many folks I know who live a good life on restricted carb diets.”

“…carbohydrates are a very dangerous and should be consumed with caution and knowledge. i had awful lipids and blood sugar control on a low fat/high carb diet. now that i have switched to a lower carb diet – all my numbers are superb. and the diet is easy to follow and very satisfying!”


The Project is intended to bring out the patient’s perspective on diet as therapy in diabetes.  The goals are to document people’s experience in finding the right diet. In particular, we are interested in whether switching to a low-carbohydrate diet provided improvement over the recommended diet typical of the ADA. Or not.  We are looking for a narrative that can bring out how people make decisions on choosing a diet and sticking with it: the influences of physicians, the media and personal experimentation. Your diabetes story.

Text of Abstract for the Original ORI Conference

 Crisis in Nutrition: IV. Vox Populi

 Authors: Tom Naughton, Jimmy Moore, Laura Dolson

Objective: Blogs and other social media provide insights into how a growing share of the population views the current state of nutrition science and the official dietary recommendations. We ask what can be learned from online discussions among people who dispute and distrust the official recommendations.

Main points: A growing share of the population no longer trusts the dietary advice offered by private and government health agencies. They believe the supposed benefits of the low-fat, grain-based diets promoted by those agencies are not based on solid science and that benefits of low-carbohydrate diets have been deliberately squelched. The following is typical of comments the authors (whose websites draw a combined 1.5 million visitors monthly) receive daily:

 “The medical and pharmaceutical companies have no interest in us becoming healthy through nutrition. It is in their financial interest to keep us where we are so they can sell us medications.”

 Similar distrust of the government’s dietary recommendations has been expressed by doctors and academics. The following comments, left by a physician on one of the authors’ blogs, are not unusual:

 “You and Denise Minger should collaborate on a book about the shoddy analysis put out by hacks like the Dietary Guidelines Advisory Committee.”

“Sometimes I wonder if people making these statements even took a basic course in biochemistry and physiology.”

 Many patients have given up on their health care professionals and turn to Internet sites for advice they trust. This is particularly true of diabetics who find that a low-fat, high-carbohydrate diet is not helping them control their blood glucose. As one woman wrote about her experience with a diabetes center:

 “I was so frustrated, I quit going to the center for check ups.”

The data suggest a serious problem in science-community interactions which needs to be explored.

Conclusions & recommendations: Our findings document a large number of such cases pointing to the need for public hearings and or conference. The community is not well served by an establishment that refuses to address its critics from within the general population as well as health professionals.

“Headlines” is one of Jay Leno’s routines on The Tonight Show. While low on production values, it provides amusing typos, odd juxtapositions of text and inappropriate couplings from real notices and newspapers. The headlines are frequently very funny since, like fiction in general, authored comedy has to be plausible. There have been many other versions of the same idea including items in the New Yorker but Jay Leno’s audience rapport adds to the impact. Expert as he is, though, Jay seemed a little off guard when nobody laughed at the headline: “The Diabetes Discussion Group will meet at 10 AM right after the pancake breakfast.” It’s probably generational. After 30 or so years having the American Diabetes Association tell you that sugar is Ok as long as you “cover it with insulin” and that diabetes, a disease of carbohydrate intolerance, is best treated by adding carbohydrate and reducing fat, who knows what anybody believes.

One of the headlines on a previous show that did get a laugh said: “To increase gas mileage, drive less.”  (If Jay only knew how much we spent to get the USDA committee to come up with the advice that if you want to lose weight, you should eat less).

“.. Have we eaten on the insane root,
That takes the reason prisoner?”
— William Shakespeare, Macbeth.

For tragic humor in the bizarre field of diabetes information, it is really hard to compete. About the same time as the headlines sequence on the Tonight Show, DiabetesHealth  an organization and website that is intended to “investigate, inform, inspire” produced an inspiring investigation from the literature. The story is entitled “Maple Syrup – A Sweet Surprise.”  You gotta’ read this:

 “Meet the latest superfood: maple syrup.  Wait a minute…maple syrup? The super-sugary stuff poured on pancakes and waffles and used to glaze hams? That maple syrup? That’s right. Researchers from the University of Rhode Island have discovered that the syrup-produced in the northeastern United States and Canada–contains numerous compounds with real health benefits.”

So how did people with diabetes fare on the maple syrup? Well, there were no people. Or animals. The researchers did not test the effect of consumed maple syrup but only chemically analyzed samples of the stuff.

“‘In our laboratory research, we found that several of these compounds possess anti-oxidant and anti-inflammatory properties, which have been shown to fight cancer, diabetes, and bacterial illnesses,’ said Navindra Seeram, an assistant professor of pharmacognosy (the study of medicines derived from natural sources) at the university and the study’s lead author”

“Pharmacognosy,” incidentally, is the only English word correctly pronounced through the nose.  The article indicates that “a paper describing their results will appear in the Journal of Functional Foods. Scientists hope that these discoveries could lead to innovative treatments as the beneficial substances are synthesized to create new kinds of medicine.”  The article, however, is nothing if not circumspect:

“You might want to pause for a moment before rushing out and buying jug after jug of Canada’s finest maple syrup, though. It still contains plenty of sugar,…” In fact, by far the major ingredient in maple syrup is sucrose which, again, only has to be “covered” with insulin. So, with all those beneficial compounds, we will need less insulin per gram of sucrose with maple syrup, right?    Would Jay Leno have gotten a laugh if the diabetes meeting followed the pancakes and maple syrup breakfast?  How about if they were whole grain pancakes?

“If you can look into the seeds of time,
And say which grain will grow, and which will not…”
— William Shakespeare, Macbeth.

Not to be outdone, the American Diabetes Association website offers the lowdown on just how good grain is. Fiber, in general, is so good for you that you should be careful not to snarf it up too fast. As they point out, it is “important that you increase your fiber intake gradually, to prevent stomach irritation, and that you increase your intake of water and other liquids, to prevent constipation.” Doesn’t really sound all that healthy but foods with fiber “have a wealth of nutrition, containing many important vitamins and minerals.” Now, vitamin deficiency has always seemed to me to be the least of our nutritional problems but there’s more: “In fact,” using fact in its non-traditional meaning, fiber “may contain nutrients that haven’t even been discovered yet!” (their exclamation point). Not to belabor all the metaphors here, the ADA, long telling us that people with diabetes deserve to have their carbs, are surely offering pie in the sky.

I don’t believe in time travel, of course, so when somebody sent me the following article that was supposed to be a chapter from a Study of the History of Diabetes from 2016, I didn’t think about it much.  Then I read an article about a woman who had been charged with neglect in the death of her son from complications due to diabetes.  It seems she “was trying to live by faith and felt like God would heal him.”

For some reason, that made me think of the Future History, so here it is.

Chapter IV.  ACCORD to The Court

We have seen how, early in the history of medicine, diabetes was recognized as a disease of carbohydrate intolerance and how, until the discovery of insulin, removing carbohydrate from the diet became the major treatment (Chapters I and II).  We chronicled the shift away from this medical practice under the influence of low fat recommendations and the ascendancy of pharmacology that followed the discovery of insulin.  Nonetheless, it persisted in the popular mind that you don’t give candy to people with diabetes, even as health agencies seemed to encourage sucrose (sugar) consumption.

The rather sudden reappearance of carbohydrate restriction, the so-called modern era in diabetes treatment, is usually dated to 2008, the precipitating event, publication of the ACCORD study in which a group undergoing  “intensive treatment” to lower blood glucose showed unexpected deaths [1].  ACCORD concluded that “These findings identify a previously unrecognized harm of intensive glucose lowering in high-risk patients with type 2 diabetes.” The intensive treatment turned out to be intensive pharmacologic therapy and this flawed logic lead to a popular uprising of sorts, a growing number of patients claiming that they had been hurt by intensive drug treatment and typically that they had only been able to get control of their diabetes by adherence to low carbohydrate diets. Blogs compared the ACCORD conclusion to an idea that alleviating headaches with intensive aspirin led to bleeding and we should therefore not treat headaches.

The conflict culminated in the large judgment for the plaintiff in Banting v. American Diabetes Association (ADA) in 2014, affirmed by the Supreme Court in 2015.  Dalton Banting, coincidentally a distant relative of the discoverer of insulin, was an adolescent with diabetes who took prescribed medications and followed a diet consistent with ADA recommendations.  He experienced worsening of his symptoms and ultimately had a foot amputated. At this point his parents found a physician who recommended a low carbohydrate diet which led to rapid and sustained improvement.  The parents claimed their son should have been offered carbohydrate-restriction as an option.  The case was unusual in that Banting had a mild obsessive-compulsive condition, expressed as a tendency to follow exactly any instructions from his parents or other authority figures.  Banting’s lawyers insisted that, as a consequence, one could rely on his having complied with the ADA’s recommendations.  Disputed by the defense, this was one of several issues that made Banting famous for vituperative courtroom interactions between academics.

Banting was a person with type 2 diabetes.  Unlike people with type 1 diabetes, he was able to produce insulin in response to dietary (or systemic) glucose but his pancreas was progressively dysfunctional and his body did not respond normally, that is, he was insulin-resistant.  Although most people with type 2 diabetes are at least slightly overweight, Banting was not, although he began gaining weight when treated with insulin.

The phrase “covered with insulin…” rocked the court: the president of the ADA, H. Himsworth, Jr., was asked to  read from the 2008 guidelines [2]: “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 glucose lowering medications.”

Jaggers (attorney for Banting): “Are there other diseases where patients are counseled to make things worse so that they can take more drugs.”

Himsworth: “We only say ‘can be.’  We don’t necessarily recommend it.  We do say that ‘Care should be taken to avoid excess energy intake.’”

It soon became apparent that Himsworth was in trouble.  He was asked to read from the passage explaining the ADA’s opposition to low carbohydrate diets:

“Low-carbohydrate diets might seem to be a logical approach to lowering postprandial glucose. However, foods that contain carbohydrate are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability.”

Jaggers: “Important sources of energy?  I thought we wanted to avoid excess energy,” and “would you say that taking a vitamin pill is in the same category as injecting insulin?”


Jaggers: “Dr. Himsworth, as an expert on palatability, could you explain the difference between Bordelaise sauce and Béarnaise sauce?” [laughter]

Damaging as this testimony was, the tipping point in the trial is generally considered to have been the glucometer demonstration.  Banting consumed a meal typical of that recommended by the ADA  and glucometer readings were projected on a screen for the jury, showing, on this day, so-called “spikes” in blood glucose.  The following day, Banting consumed a low carbohydrate meal and the improved glucometer readings were again projected for the jury.  Defense argued that one meal did not prove anything and that one had to look at the whole history of the lifestyle intervention but was unable to show any evidence of harm from continued maintenance of low blood sugar despite testimony of several expert witnesses.  In the end, the jury agreed that common sense overrides expert testimony and that Banting should have been offered the choice of a carbohydrate-restricted diet.

Banting was held in New York State which adheres to the Frye standard: in essence, the idea that scientific evidence is determined by “general acceptance.” The explicit inclusion of common sense was, in fact, a legal precedent [3].   The Supreme Court ultimately concurred and held that the more comprehensive standards derived from Daubert v. Merrill-Dow, could sensibly be seen to encompass common sense.

The final decision in Banting lead to numerous law suits.  The ADA and other agencies changed their tactics claiming that they never were opposed to low carbohydrate diets and, in fact, had been recommending them all along [4].  This is discussed in the next chapter.


1. Gerstein, H. C. et al., Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 358 (24), 2545 (2008).

2. American Diabetes Association, Nutrition Recommendations and Interventions for Diabetes–2008. Diabetes Care 31 (Suppl 1), S61 (2008).

3. Berger, M, Expert Testimony: The Supreme Court’s Rules Issues in Science and Technology (2000).

4. American Diabetes Association, Nutrition Recommendations and Interventions for Diabetes–2016. Diabetes Care 36 (Suppl 1), S12 (2013).