Diabetic Diet: Is Determining Glycemic Load Better Than Counting Carbs?

 

 

 

 

 

 

 

To count carbs or discount them ‒ the debate continues. Being type 2 insulin dependent, I’m trying to make sense of the differing conclusions of two studies that have been published recently. It’s hard to say what these studies really show ‒ it can get confusing with all the information out there ‒ especially when pilaf (pilao) is on Sunday’s lunch menu!

Dr. Andrea Laurenzi of San Raffaele Vita-Salute University in Milan suggests that diabetes patients may benefit from counting the number of carbohydrates in their diet. In a small study ‒ published online in the America Diabetes Association journal Diabetes Care ‒ the Milan researchers looked at 61 adults on insulin pump therapy and found that those who learned to count carbs had a small reduction in weight and waist size after 6 months. Additionally, they reported gains in quality of life and an improvement in blood sugar levels.

On the other hand, Jiansong Bao at the University of Sydney in Australia, says the number of carbs alone might not be the best way to go. Writing in the American Journal of Clinical Nutrition, he feels that how many carbs you eat might be less important for your blood sugar than your food’s glycemic load, a measure that also takes into account how quickly you absorb those carbs.

Dr. Sanjeev Mehta, of the Joslin Diabetes Center and Harvard Medical School in Boston says while Laurenzi’s findings do not prove that carb counting is the answer for people with type 1 diabetes, it is widely recommended that people on insulin try to estimate the carbohydrate content of their meals to help calculate their insulin doses. Indeed, a few other studies too have suggested that carbohydrate counting can help people with type 1 diabetes control their blood sugar levels.

There are books and online resources available for people who are interested in learning how to count carbs. However, some people have difficulty learning or sticking with the method, Mehta noted, and benefit from help from a professional, such as a dietitian or certified diabetes educator.

Mayo Clinic nutritionist Katherine Zeratsky, R.D., L.D. explains counting carbohydrates is a method for controlling the amount of carbohydrates you eat at meals and snacks. This is because they have the greatest impact on your blood sugar. Eating consistent amounts of carbohydrates every day helps you control your blood glucose level.

But carbohydrates aren’t the only dietary consideration when you have diabetes. You need to also limit fat and cholesterol and control the number of calories you consume. The best way to do this is to control portion sizes, she says.

“Eating a healthy diet helps you control your diabetes and reduces your risk of diabetes-related conditions, such as heart disease and stroke. So, just because a food contains no carbohydrates doesn’t mean that you can eat it in unlimited amounts,” she cautions.

However, Bao claims the so-called glycemic load of a food, which also takes into account how quickly it makes the blood sugar rise, might work better. Foods with soluble fiber, such as apples and rolled oats, typically have a low glycemic index, one of the contributors to glycemic load. Foods with a low glycemic index cause the blood sugar to rise slowly, and so put little pressure on the pancreas to produce insulin.

The glycemic load is calculated by multiplying the amount of carbs in grams per serving by the food’s glycemic index divided by 100. (The glycemic index for a variety of foods can be found here.)

The Sydney researchers say their findings also suggest that eating foods with high glycemic loads could be linked to chronic disease like type 2 diabetes ‒ which does not require insulin injections ‒ and heart disease by raising blood sugar and insulin levels.

The researchers took finger-prick blood samples from 10 healthy young people who ate a total of 120 different types of food ‒ all with the same calorie content. They also had two groups of volunteers eat meals with various staples from the Western diet, such as cereal, bread, eggs and steak. And the glycemic load repeatedly trumped the carb count in predicting the blood sugar and insulin rise after a meal.

A Reuters report quotes Dr. Edward J. Boyko ‒ a diabetes expert at the University of Washington in Seattle who wasn’t involved in the Sydney study ‒ saying it wasn’t certain the findings would hold up in people who aren’t completely healthy, adding, long-term effects and other nutrients in the food might also be important for disease risk.

“It would just be speculation whether a dietary change like this would help people with type 2 diabetes.” The most important problem, Boyko points out, remains pure and simple overeating. “The excess weight is the main thing we ought to focus on…The simplest message would be, eat less.”

Diabetes: Is the ADA Shifting its Stance About Carbs?

Carbohydrates are a very touchy subject with diabetics. And for me at least, understanding carbs in a diabetic diet is more difficult than quantum mechanics (or double-entry accounting if you’re not a science type). Diabetologists and dieticians, too, have differing views. I found this article by LAURA DOLSON very instructive and am reproducing it here for those who may have missed it. You can find the lively discussion that followed the article’s publication here.

You may be surprised to know that for the past couple of decades, the American Diabetes Association has been sort of a cheerleader for carbs. Yes, I’m talking about the organization who’s mission it is to promote education and research in ways aimed at preventing diabetes and alleviating the suffering of diabetics.

What is diabetes? It is essentially a disorder of the body’s ability to process carbohydrates. This includes Type 1 and Type 2 diabetes, pre-diabetes, metabolic syndrome, insulin resistance, and all the other points on the diabetes spectrum. (The Endocrine Society suggests that anyone with a fasting blood glucose of 89 or above is at risk for damage to their health.)

In light of this, you’d think that limiting carbohydrate intake would be a priority in educating people about handling these disorders. And yet, the ADA jumped right onto the Food Pyramid bandwagon and began to advise people to get at least 55% of their calories from carbohydrate, such as in the Food Pyramid for Diabetes (see illustration above).

In 2008, they made one exception: diabetics trying to lose weight could follow a low-carb diet for up to one year; this was later loosened further to two years. But still they did not recommend a low-carb diet for health, blood sugar control, or preventing progression of the diabetes.

Now, in the March 2011 edition of the ADA magazine “Diabetes Forecast” are three rather remarkable articles. The first is called The “ADA Diet” Myth, which claims that there is no such thing as the ADA Diet! (Who else was having this hallucination?) Instead, Stephanie Duncare, director of nutrition and medical affairs for the ADA says, “For more than 15 years now, ADA has recognized that people with diabetes should eat in a way that helps them reach their blood glucose, cholesterol, blood pressure, and weight goals. For some, this means a relatively higher-carbohydrate diet, and for others, the diet may be lower in carbohydrate”. Well, hallelujah to that, especially if the goal is “normal blood glucose” (normal meaning “a blood glucose level that will not cause further damage in the pancreas”).

Even more bold is an article called, “Are Carbs the Enemy?” which attempts to cover the debate. They first present a sort of wimpy pro-carb stance. This section of the article has a notable absence of anything to do with science, instead relying on statements such as “Gone are the days of ‘diabetic diets’ that were meager and confining” and “as long as people eat less or cover their carb intake with medications, they can keep blood glucose levels in check with a healthy diet” (“healthy” in this case meaning “high-carb”).

The article then goes on to describe a low-carb approach, citing Dr. Richard Bernstein. This section cites actual evidence, and makes what I think is a much stronger case for controlling blood glucose by limiting carbohydrates. The article goes on to a section on saturated fats which is much more balanced than usual, and then the normal “we don’t have the long-term studies”. The article concludes with the statement: “In the end, the best diet is the healthy one you’re able to follow.”

The only thing I would add is that people need support in making those changes, and as far as I can tell they are still leaving an awful lot up to the individual to figure it out for themselves. There has been quite a defeatist attitude coming from the organization that is supposed to be helpful – along the lines that it is asking just too much of people to cut carbs in any significant way. Are dietitians now actually going to support people in finding a diet that achieves as close to a normal blood glucose as possible? It would be a very big change if this happened any time soon.

But wait, there’s more! A follow-on short piece called “Eating With Diabetes: 3 Approaches” lists the low-carb approach first, and then follows with “Moderate-Carb” and “Vegan/High-Carb”. The weird thing is that the three approaches are described as “less than 10% carb”, “40-50% carb” and “75% carb”. What about people who normalize their blood glucose with 20% carb or 30% carb? Why not just say, “it’s a spectrum disease, with a spectrum of carb that will treat it effectively”? In any case, I don’t want to complain too loudly, because this is SO great to see in an ADA publication!

Now, to be sure, the ADA is not yet changing their basic stance. Nowhere on the latest update of the diabetes.org Web site is it stated that diabetics should follow a low-carb diet. On the other hand, there is no longer anything I can find that says to eat over half of calories from carbohydrate, either. The former food pyramid, as far as I can tell, has vanished, and there are several hints that low-carb eating is becoming a bona-fide option.

There are statements such as, “Understanding the effect of carbohydrate on blood glucose levels is key to managing diabetes. The carbohydrate in food makes blood glucose levels go up.” Although diabetics are still advised that “a place to start is at about 45-60 grams of carbohydrate at a meal.”, (yikes) it goes on to say to adjust from there. Even though this is not what most of us would call a low-carb diet, for most people it is a reduction from their previous advice.

[Side note: I also notice it doesn’t actually say 45-60 g/meal is a good place to start. If that actually controls someone’s blood glucose, that’s great, but I would think that in the cases where it doesn’t, it would be more disheartening to subsequently take more carb away. Why not start lower, and then add? Also, most likely, the person for whom this works is losing weight – a phase which doesn’t last forever.]

To me this looks like the beginnings of a real change in approach from the ADA. The Titantic may actually be turning around! This could make a difference to the health of millions of people, and nothing could make me smile more than that.

By Laura Dolson/about.com

Image courtesy about.com