Diabetes UK is the UK’s largest and most prominent diabetes charity. Have a look here and you will se the charity proudly proclaiming that: We stand up for the interests of people with diabetes by campaigning for better standards of care. However, I’m doubtful that Diabetes UK is fulfilling its brief in this respect, seeing as it continues to suggest that diabetics should include starchy carbohydrates which every meal (see herefor more on this). You’ll see that Diabetes UK’s advice on this matter starts like this: At each meal include starchy carbohydrate foods such as bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals.
Yet, these starchy staples break down into sugar, and some of them can release their sugar quite quickly into the bloodstream too. And if we eat them in quantity, like we often do, that only adds to their disruptive effects. Now, what rationale is there for diabetics to include at each meal foods that are disruptive to blood sugar? Here’s at least some of Diabetes UK’s ‘logic’ on this: The amount of carbohydrate you eat is important to control your blood glucose levels.
This is perhaps the vaguest and woolliest sentences I have ever read. What does it mean? I suppose what Diabetes UK would like people to take it to mean is Diabetics need to eat starchy carbohydrates with every meal.
However, I reckon there’s another, far more relevant way of interpreting this sentence which goes something like: The more starchy carbohydrate you eat, the more out-of-control your blood sugar level will be, the more ‘diabetic’ you will be, and the more likely you are to start to take medication for this or to need to increase your medication regime. Remember the advice to eat generally sugar-disruptive starchy carbs with each meal comes from the UK’s largest diabetes charity which, it says, campaigns for better standards of care for diabetics.
What sort of care is it referring to, do you think? Because on the face of it, it doesn’t look like nutritional care is part of its remit. And if that’s the case, maybe what’s being referred to here is medical care including medication.
Now, that would help to explain why Diabetes UK recently had a bit of a PR push on the idea that many diabetics are not taking their medication as prescribed. See this story from the Guardian in the UK for a typical instance of how this story was reported. The story, details the hundreds of thousands that are not taking their prescribed diabetes medication, and warns of the ills that may befall them as a result.
If Diabetes UK were so very concerned with the health of diabetics perhaps they could start by giving some decent nutritional advice for a change. How about starting by telling diabetics that the more starchy carbohydrate they eat, the more likely they are to require medication, and the more of the medication they are likely to need over time.
Elsewhere, I read that Douglas Smallwood, chief executive of Diabetes UK, has said it is a “tragedy” that many diabetics do not take their prescribed medication. My opinion is that the real tragedy here is the fact that Diabetes UK gives advice which makes it more likely to need that medication in the first place.
Those of you who clicked on the link to the Guardian newspaper and read it may have noticed that the Diabetes UK research was, in fact, partnered by the Association of the British Pharmaceutical Industry. Now, looking on the Diabetes UK website I can find no mention of where the charity derives its funding. Under ‘Corporate Partners’ Diabetes UK states this (and only this):
UK funds research for a future without diabetes while teaching children and adults to live with diabetes today. Our corporate partners provide vital and valued support to our work.
In the UK, 2.3 million people have been diagnosed with diabetes and more than half a million people have the condition but don’t know it yet. These figures are set to double by 2010.
Diabetes can develop at any age and those with friends or relatives with diabetes will understand how difficult it can be to learn to live with the condition.
People are being diagnosed with diabetes at an alarming rate; each year 100,000 people are diagnosed with Type 2. One in 20 of your employees, colleagues, friends and family will develop diabetes in their lifetime.
Lots of scary stuff about diabetes there, but no detail at all about who the corporate sponsors are and to what extent they fund Diabetes UK.
I was, however, able to find a letter in BMJ from 2003 that draws our attention to the need for charities and patient advocacy groups to declare their funding [1]. In this letter, the author states: Diabetes UK received around £1m from 11 pharmaceutical companies manufacturing diabetes drugs but this is not mentioned in the annual report.
I don’t want to come across unduly cynical, but is it right that a diabetes charity should have a less-than-transparent financial relationship with the drug industry. And is it right that this charity should be giving nutritional advice that, at the end of the day, looks likely to benefit the pharmaceutical industry. And after all of this, should it then go on to partner with that pharmaceutical industry in ‘research’ highlighting the need for people to take their diabetes medication. Or did I miss something?
References:
1. Hirst J. Charities and patient groups should declare interests. Letter BMJ 2003;326:1211
John Briffa said,
“I don’t want to come across unduly cynical, but is it right that a diabetes charity should have a less-than-transparent financial relationship with the drug industry. And is it right that this charity should be giving nutritional advice that, at the end of the day, looks likely to benefit the pharmaceutical industry.”
I think this is one for Ben Goldacre, bad scientist and the tragi-cynical Witchfinder General for all England … and beyond.
http://www.badscience.net/
John
An interesting point. Acording the ABPI/PMCPA code pharmaceutical companies must disclose funding of patients’ groups:
http://www.bmj.com/cgi/content/full/332/7533/69-a
though I have not located the precise place in the document where it states this.
http://www.abpi.org.uk/links/assoc/PMCPA/pmpca_code2006.pdf
It is evident that the only meaningful way that this could be achieved is if said groups advertise this information in their literature or on their websites.
http://www.bmj.com/cgi/eletters/332/7533/69-a#126085
One possibility is that you might try applying to Heather Simmonds, Director of the PMCPA for her views on the matter, although you may have to wait till doomsday or beyond for an answer.
http://www.bmj.com/cgi/eletters/336/7634/0#187763
http://www.bmj.com/cgi/eletters/335/7618/480#188132
“Or did I miss something?”
By my count, 3 question marks in the paragraph.
Reading this article made me recall an old joke.
Q: What do you call a med student that graduates last in his class?
A: Dr.
It’s definitely not right. I think all the Diabetes associations are the same – giving out the wrong advice that benefits the pharmaceutical companies not the patient.
Ross. Do you go around blog sites correcting grammar all day?
@Barry Sharp
I think you’ll find that ‘ross’ is a tiresomely underemployed pharmaceuticals operative whose own blogsite scores precious few meaningful hits.
Food is divided into five main food groups and we need to eat from these groups, in the right proportions every day in order to enjoy a healthy balanced diet. The five food groups are below. Each of these food groups contains different nutrients that our bodies need to function and be healthy.
• fruit and vegetables
• starchy carbohydrates such as bread, cereals, pasta, rice and potatoes
• milk and dairy foods
• meat, fish and alternatives
• fatty and sugary foods
The comment that Dr Briffa refers to is that Diabetes UK suggests having something from the starchy carbohydrate food group at each meal. Diabetes UK recommends this to help aim towards stable blood glucose levels. If people choose varieties from the starchy carbohydrate group that are low GI , these do not affect blood glucose levels as much as they are more slowly absorbed helping to avoid peaks and troughs in blood glucose levels.
All carbohydrates break down to glucose during digestion which enters the blood and converted into a universal unit of energy in the cells.
Carbohydrates are needed in the diet because:
• The brain uses glucose to function (it does not need insulin to cross the blood brain barrier)
• Starchy carbohydrate foods, pulses and fruits contain fibre (both soluble and insoluble). Soluble fibre is important for heart health and insoluble is important for bowel health, preventing constipation.
• Fruit and pulses contain numerous essential vitamins and minerals.
• By removing whole food groups, for example carbohydrates, are likely to increase the consumption of other food groups resulting in an inbalance of the whole diet. Research has shown that by reducing carbohydrate consumption, the amount of fat they eat tends to increase drastically, particularly saturated fat. People with Type 2 diabetes are at an increased risk of heart disease compared to the general population, therefore they should be even more vigilant about their fat intake.
• Fat has nearly twice as many calories per gram as both carbohydrate and protein. Even if someone was not increasing saturated fat levels and concentrating on consuming better types of fat (mono and poly), the risk for gaining weight are real. As we know increased weight can result in increased insulin resistance and therefore could translate into increased medications or insulin requirements.
The diet recommended for people for diabetes is the same diet as recommended for everybody else a healthy well balanced diet including all of the food groups above in the correct quantities.
With regard to Diabetes UK and the pharmaceutical industry, we do indeed work in partnership with pharmaceutical companies to achieve our mission and vision.
Our relationship with pharmaceutical companies is governed by very strict guidelines and total monies from pharmaceutical companies accounted for less than 4.5 per cent of our total income in 2007.
Diabetes UK abides to the stringent policies of the Charity Commission regarding our duty to be transparent and accountable and our legal and financial information can be found on our website (www.diabetes.org.uk)
Interestingly, the ‘The Influence of the Pharmaceutical Industry’ report published by the House of Commons Health Committee in 2005, cites Diabetes UK (point 268 on page 76) as only one of two charities who “explained their funding policy.”
Amen. Looks very much like Diabetes UK uses the same play book as the American Diabetes Association.
If I followed ADA/Diabetes UK guidelines, I would be well on my way to frank T2 diabetes with chronically very high post-prandial BG levels after eating the recommended high starch meals, as well as very overweight. I have no doubt about this. My glucose meter doesn’t lie.
Instead, I ignore just about everything both groups advise and follow a very carb restricted diet of whole, minimally processed foods prepared at home (much of my food comes direct from the farms), take no diabetic medications, and achieve normal or nearly normal blood glucose readings throughout the day. Any food that gives me a high post meal reading is off my diet. It’s very simple. There is also something else that can provide the same nutrients without raising blood sugar levels. Additionally, I lost the weight gained from my former bread and pizza baking efforts and now maintain a normal BMI of about 21-22 or so.
The only interest these “charity” groups have in “helping” people with diabetes is “helping” them stay diabetic, on medications, and in need of diabetic support products and services. Diabetes has grown into a huge cash cow for all sorts of ancillary businesses. Follow the money … the ADA/DUK won’t kill the cow, not while they can milk it so profitably.
I guess I sound cynical … well, let’s just say I had a rude awakening about health “care” a few years ago and cynicism seems like an essential life skill now.
Sara Spiers, Care Manager, Diabetes UK
“Food is divided into five main food groups and we need to eat from these groups, in the right proportions every day in order to enjoy a healthy balanced diet.
…• starchy carbohydrates such as bread, cereals, pasta, rice and potatoes…”
Tell me what it is in these foods that we can’t get elsewhere and in a form that is not generally disruptive to blood sugar levels?
“The comment that Dr Briffa refers to is that Diabetes UK suggests having something from the starchy carbohydrate food group at each meal.”
How does eating foods that are generally destabilising for blood sugar help individuals to stabilise blood sugar levels? Can you explain the logic in this (I’m not seeing it).
“If people choose varieties from the starchy carbohydrate group that are low GI, these do not affect blood glucose levels as much as they are more slowly absorbed helping to avoid peaks and troughs in blood glucose levels.”
Even low GI foods when eaten in quantity can be very disruptive to blood sugar levels. Why are you not advising diabetics of this fact, and why in the light of this are you not advising diabetics to be wary regarding these foods and their effect on blood sugar balance?
“By removing whole food groups, for example carbohydrates, are likely to increase the consumption of other food groups resulting in an inbalance [sic] of the whole diet.”
Who said anything about removing carbohydrates from the diet?
“Research has shown that by reducing carbohydrate consumption, the amount of fat they eat tends to increase drastically, particularly saturated fat. People with Type 2 diabetes are at an increased risk of heart disease compared to the general population, therefore they should be even more vigilant about their fat intake.”
Can you cite the evidence which shows that saturated fat causes heart disease? Can you cite the evidence which shows that eating less saturated fat reduces the risk of heart disease? (it’s actual studies I want, not ‘official’ recommendations).
“Fat has nearly twice as many calories per gram as both carbohydrate and protein. Even if someone was not increasing saturated fat levels and concentrating on consuming better types of fat (mono and poly), the risk for gaining weight are real. As we know increased weight can result in increased insulin resistance and therefore could translate into increased medications or insulin requirements.”
Please answer the following question: is the fundamental problem diabetics have one of controlling:
a. carbohydrate (sugar)?
b. fat?
Also, do you believe that eating carbohydrate could contribute to insulin resistance?
“Diabetes UK abides to the stringent policies of the Charity Commission regarding our duty to be transparent and accountable and our legal and financial information can be found on our website (www.diabetes.org.uk)”
Can you please direct us to the page on the site where you list your corporate sponsors (the names of the companies, please) and the level of funding received by them?
Would Dr. Briffa like to suggest foods containing carbohydrates that are not disruptive to blood sugar levels?
Adam
Would you like to have a go at answering your own question before I do?
Starchy carbohydrates are not required in the diet. Have low carbohydrate vegies instead:
leafy green salad veg, celery, cucumber, zucchini, cabbage, mushrooms, broccolli, asparagus, aubergine, cauliflower, gren beans, peppers, tomatoes, spinach etc.
Diabetics have a problem with controlling blood sugar – those foods that contribute to this should be removed.
what question? that was the first time i typed something!
Hi, Doctor Briffa, once again, you are spot on. I am so, so, disappointed, fed up, even angry, with people like Sara Spiers and medical docs who never spend a minute doing their own research and actually reading all the true evidence, but instead follow the party line. This whole type 2 diabetes information structure nearly destroyed me completely, over 10 years of total compliance with “THEIR so called balanced diet recommendations and medications, I nevertheless came within a hairs breath of kidney disease and dialysis until I decided to do some research, discovered the real facts about the notorious “Balanced Diet” (and the utterly false positive messages about fibre, invented because they couldn’t seem to make the false cholesterol hypothesis work the way they wanted it to work) and its effects on diabetics, and reversed my own kidney disease within 18 months. It is absolutely criminal the way the establishment is literally killing diabetics (slowly and painfully) by giving them incorrect information and then blaming them for non-compliance when things go wrong. People go to your local hospital’s Renal department and see 50 and 60 year olds already on dialysis because of their type 2 and become as enraged with the system and the current guidelines as I am.
Sorry about the rant Dr Briffa, but as you can guess I am somewhat angry with the likes of Spiers and all the diabetes associations around the world who blindly follow what the American diabetes Association does, easy isn’t it, to follow blindly and never do your own research!
Glenice
Adam
If you can’t or won’t answer the question, just say. Which is it?
i can’t answer my question – that i why i asked you.
I’m glad someone from Diabetes UK is reading your website Dr Briffa. I am astounded at their dietary recommendations. If I followed what they said my diabetes (type 2) would be out of control….I know because I’ve tested my blood glucose after eating starchy vegetables, fruits, rice and wholemeal bread, and even in small quantities of those my blood glucose levels rise too high and stay that way 2 hours post prandial.
As for carbohydrate, nowhere did you say to cut out carbohydrate as Sara Speirs suggests you have ! I eat lots of low carbohydrate vegetables, lots of kale, cabbage, chicory, asparagus, salads, broccoli, okra, cauliflower, and more. For fruit I can eat avocados and a small quantity of berries sometimes. I check my blood glucose levels often so I know what effects various foods have on it. The rest of my diet consists of fresh fish, meat, nuts, seeds and eggs…..my diet is well balanced and my diabetes is well controlled. I am slim too 🙂
Anne
“SANOFI-AVENTIS continues to support the NHS to develop tailor-made solutions to help meet local circumstance and priorities, such as an initiative among the south Asian population in Warwickshire to improve awareness of diabetes and heart disease. In 2006, sanofiaventis supported more than 70 patient groups and charities, including Diabetes UK, the Stroke Association, the British Heart Foundation, Cancerbackup, the Prostate Cancer Charity and Bowel Cancer UK. The company supported Diabetes UK’s Measure Up awareness campaign, which helps the charity achieve its objective of reducing the number of people with undiagnosed diabetes.”
http://www.abpi.org.uk/publications/publication_details/annualReview2006/ar2006_community.asp
“Lilly funding to Diabetes UK in 2007 was £65,000 which represents 0.25% of the organisation’s income in 2006.”
http://www.lilly.co.uk/Nitro/newTemplates/general/Content_IT_LBCT.jsp?page=1471
Bristol Myers Squibb
http://www.b-ms.co.uk/info-for-patients2.htm
I hope more and more people begin to listen to you Dr Briffa. I have previously written to you directly regarding the diabetic diet and I am the proof in the pudding. I have stopped following dietician’s advice for a few years now and follow a very low carbohydrate diet, avoiding starchy carbohydrate. My HBAc1 results are fantastic, on average 5.5%, I feel great and I have more enery. On the odd occasion I do eat starchy carbohydrate I regret it. I eat lots of fruit (carbohydrate) vegetables fish eggs and meat. Together with small portions of pulses. I now have a very low dose of insulin. I have been insulin dependant for 30 years, since the age of ten, and I have always been in control of my diabetes and not scared of it. Unfortunately too many people are afraid to cut out starchy carbohydrate as they believe and trust what their doctor says as being gospel…It disgusts me that diabetes is a big money making business…Good Luck Doctor Briffa, don’t give up
To Sara , Dietician, You have 5 food groups. Two of these are carbohydrates and fruit and vegetables, but fruit and veg are also carbohydrates. Your food pie chart (not a pun) includes a large section for breads etc and another section for fruit and veg so the daily diet is supposed to be mainly carbs according to that. No wonder there is so much diabetes. Also where is the evidence that ‘we need to eat from these 5 groups every day’? You and your colleagues seem to have learned this parrot fashion. I do not mean to be insulting but do you sometimes wonder why there is so much against this. This is just an arbitrary classification and out-of-date. Where did the Stone Age people get these ‘carbs’ from?
Grains and carbs in that form were grown in order to feed a population who had nearly run out of meat but that does not mean that they are a necessary food.
Anne, I wrote mine without seeing your contribution. I’m glad we agree and that the diet is working for you.
When I was told I had Type II, an appointment was arranged with a dietician. She just trotted out the high-carb line – bread, pasta, potatoes, etc., etc.,
When I told her what I eat (bacon & egg for breakfast, etc) her response was “are you on the Atkins diet?”. An interesting response.
Doctors don’t heal, they manage symptoms and prescibe drugs.
“Doctors don’t heal, they manage symptoms and prescribe drugs.” Thank you, Robin, I’ll have to remember that. Sadly it is so true for almost all of them.
The main problem with the dietary advice issued by Diabetes UK is that it doesn’t work. Eat the high carb low fat diet advocated and your diabetes will progressively worsen and your need for medication will increase. Even with increased medication Blood Glucose levels will fluctuate, increasing the risk of both hypreglycemia and hypoglycemia.
Diabetics have trouble utilising glucose as a fuel. In type 2 diabetes this is appears to be caused by a combination of insulin resistance and an absolute or relative insulin deficiency. Why on earth would you choose to use the very fuel that your body has trouble utilising as your preferred source of energy? This will inevitably result in dangerously high blood glucose levels, chronically high insulin levels, weight gain, difficulty utilising fat as a fuel and a host of long term complications.
Better to follow a low carb, higher fat diet which humans have been happily consuming in many parts of the world for thousands of years. Base your diet around natural foods: eggs, cheese, meat, fish, nuts and seeds (in moderation), and non starchy vegetables. These foods are satiating, nutrient dense and a good source of complete amino acids.
In my opinion, by advocating the othodox low fat high carb diet Diabetes UK have damaged the health of the very people they claim to be seeking to help. I have seen very little evidence that saturated fat is unhealthy and leads to weight gain. Indeed, as fat consumption has decreased the population of the UK has gained weight. The chief culprit seems to be the very food advocated for weight loss: starchy carbohydrates (complex carbs). How can the very same food that farmers feed cattle to promote rapid weight gain, ie corn, lead to weight loss in humans? The answer, of course, is that they don’t.
These foods are nutrient poor and often need to have nutrients adding to them as part of the maufacturing process.
Diabetes UK should uregently readdress the dietary advice it gives. I am not aware of any long term studies that show the current dietary advice works – specifically for diabetics, but just as importantly for the wider population as a whole. The resistance to advocating a low carb diet would have more credability if there was was scientific evidence to support the current approach. In fact the low fat high crab dodietary approach ahs been a hopeless failure, as evidenced by the increasing lelves of obesity, metabolic syndrome and diabetes.
Sara Spiers has trotted out the same old nonsense:
The brain does not run exclusively on sugar – it can also run perfectly well on ketones. Additionally carbs are not the sole source of blood glucose – the liver can manufacture glucose from amino acids if need be.
Type 2 diabetics don’t normally have a problem with low blood glucose. This only tends to occur if they are following the dietary advice advocated by Diabtes UK when over medication in conjunction with a high carb diet leads to roller coster blood glucose levels.
The 5 categories of foods are somewhat arbitary. Why on earth link fatty and sugary foods. It shows a bias against fats. In nature these foods are hardly ever combined, as they might be in processed and manufactured foods: cakes, biscuits, etc.
Diabetes UK is doing a great disservice by recommending the same “healthy well balanced” diet for diabetics as for everybody else. Show me the research that proves that following this advice leads to a reduction in medication and normal bllod glucose levels for diabetics. I very much doubt it eexists. Whereas there have been a large number of recent studies that show the superiority of the low carb, higher fat approach.
Paul Anderson
Well said, Glenice, and sorry to hear you’ve had to suffer at the hands of these people.
What the ‘mainstream’ medical establishment is too stupid/self-complacent/insert your own adjective to realise is that they no longer control the medical information that their patients get, now that the internet makes it so much easier for ‘alternative’ theories and treatments to be publicised, and for patients to access them.
More and more people are accessing their own (very likely more up to date) information, make up their own minds about how their condition should be treated, and where they can’t get what they want from mainstream medicine, they’re going to ‘alternative’ practitioners or simply self-treating with medications or nutritional supplements bought online. (If anyone thinks self-treatment isn’t already happening, just look at some of the thyroid and adrenal forums).
Jackie
It’s quite staggering isn’t it how the Diabetes organisations toe the party line? Ms Spears is unlikely to have a medical background (or surely she would have said so) but has merely repeated the mantra “low fat, high carb good”, “high fat, low carb baaahd” like the good little sheep that she is.
I guess they don’t want to risk their funding being cut off by an irate industry ” in which case they should be asking themselves what, exactly, is their raison d’etre? Are they there to serve the patients, or to pander to the whims of industry ” “there’s this new PPAR-gamma agonist… there’s this new HDL-raising drug… there’s this new angiotensin II antagonist…” and so on, ad nauseam. As far as I can see, they are merely self-serving “do-gooders” that actually do more harm than good, and yet get to go home at night in the delusion that somehow, they made someone’s existence more meaningful. If it wasn’t so damaging for so many people it would be pathetic. As it stands it is a hugely harmful endeavour ” Ms Spears I would suggest you have blood on your hands, and until you do the prerequisite research on the vomitus you posted here I suggest applying Superglue to your fingers while typing ” your scribblings would undoubtedly be all the more coherent for it.
I found this comprehensive review article a big help in understanding the science behind low-carb diets.
JOEL M. KAUFFMAN ‘Low-Carbohydrate Diets’. Journal of Scientific Exploration, Vol. 18, No. 1, pp. 83”134, 2004
http://www.scientificexploration.org/jse/articles/pdf/18.1_kauffman.pdf
Sarah Spiers and Adam
Welcome to the ‘Curious World of Dr Briffa and friends’!
Sarah – I hope you weren’t hoping to join some meaningful debate on the relative merits of one dietary approach versus another. If so, I hate to disillusion you – but this really isn’t the website on which to do it.
Dr B doesn’t do meaningful debate. He does mocking comments (based on his own unique interpretation of the medical research) and deliberate misinterpretation of your comments readily supported by his band of merry supporters (you have already met ‘Cathy’, ‘Hilda’ and ‘John’).
All in the hope that by your 4th patient, evidence based reply to his facetious/ insulting/ incorrect comments you will admit defeat, and kindly go away so Dr B and friends can post unpleasant comments about yourself, your organisation, and any collateral bodies.
Adam – i guess you’ve worked out what degree of ‘futile cycling’ goes on here!
So feel free to add another post as I and many dietitians do when we feel like we have a moment to spare for entertainment. But please don’t expect meaningful debate. Your time may be better spent finding out whether Dr Briffa has a case to answer with his comments that debase the excellent job that your organisation does in representing the diabetic population in the UK.
Catherine Collins RD
Once again you focus not on the issue at hand, but on me.
And again you fail to engage with the science and the woefully inadequate dietary advice diabetics are usually given (and then accuse me of shying away from meaningful debate ” how ironic).
Do you not see how standard dietetic advice given to diabetics is likely to worsen their condition and increasing their risk of complications and death? And then you say the comments here are a source of entertainment to you and other dietitians.
While you and others are entertained by this issue Catherine, real people are likely to be harmed as a result of standard diabetic dietary advice. Just think about that for a moment: you might imagine that diabetics might feel seriously let down by you and those like you that derive entertainment from this issue.
Ecce homo
🙂
Catherine Collins RD – if you have anything meaningful to add then go ahead otherwise scram!
Sara Spiers – look closely at what you are recommending for diabetics – when you do you will realise that its wrong. Do the right thing and get those diet recommendations changed.
Sara Spiers – here is some homework for you:
http://nmsociety.org/index.php?option=com_content&task=view&id=31&Itemid=50
You will learn a lot.
Catherine Collins’ comment epitomises the arrogance of the medical industry and its “business with disease”. Her stance is that the mainstream medical establishment is always “right”, and anyone with the temerity to disagree is by definition a crank.
I am not a “merry supporter” Catherine and your ad hominem BS fools nobody. You just can’t stomach the fact that people have minds of their own and have discovered through their own endeavours that the dietetic emperor is completely naked. Your twisted take is to suggest that the agreement among individuals commenting here is akin to some form of cult (a la Dr Briffa), but the truth is, Catherine Collins, it is you that inhabits the cult in which saturated fat and (eek) vitamins represent the very devil himself.
Read the above comments Catherine; they are from genuine people that have themselves experienced the gross failure of the system ” the system you so doggedly defend, and yet you post here with the expectation that your “expertness” will convince those here that the fat emperor’s arse is in fact opulently clothed. You don’t come here to debate, you come here to debase; a fact that is all too obvious to those whose intelligence you insult.
We should probably feel pity for Catherine and her cult ” they have seen the writing on the wall. They do not enjoy the unquestioning acceptance of their victims as they did in days of yore. Nutrigenomics will render this dangerous cult even more redundant than it is already. I’d get those P45’s in order Catherine.
To Sara Spiers and Catherine Collins, just in case you visit again to read more comments: if your dietary advice is correct, where are all the diabetics who are getting better, reducing or eliminating their diabetes medications by following your eating advice? The only time I hear diabetics claim their blood glucose is under control and they don’t need as much medication or they can eliminate it altogether is when they reject your advice and follow a low-carbohydrate nutrition plan. Show us all the diabetics who listen to you and get better! And as far as the nutritional advice you give, I don’t care how much you’ve studied, all you do is parrot the same assimilated nutrition commonplaces anyone could rattle off just by repeating what can be gleaned from reading the newspaper and popular women’s magazines.
You only have to read the evidence to see that it makes entirely logical sense. It’s not an ‘idea’ or a ‘cult’ – the evidence is there. I think we should do a large study and perhaps the dieticians could lead this and change the working practice! I used to believe the low fat advice, but since reading all the evidence I have had to admit that low carbs is the way to go, to control diabetes and lose weight! Think how we could could change things if the ‘establishment’ would go with us.
I do not wish to be charged with Briffaphilia but have to agree with his stance on both diabetes and weight loss/nutritional dietary advice. I have been following a paleo style diet for nearly two years with excellent results in terms of body composition and general health (I have not had a day off work since going paleo – prior to that colds would really hit me and I would take about two sick-days a year). Before Paleo (BP), I was a classic ‘whole grain, low-fat’ eater. But after looking at the results of traditional dietary advice on my own body, I knew that it was not working as dieticians and nutrionists suggested it should or would. A state of voluntary chronic hunger cannot be sustained by ANYONE.
What I find staggering about the exchange above is that there is good evidence (annecdotally, if not otherwise), that diabetes can be managed and cured with an appropriate change in diet to ‘low-carbing’. If I was involved with ANY organisation “devoted to the care and treatment of people with diabetes in order to improve the quality of life for people with the condition”, I would investigate these claims. A single case of a person curing themselves of diabetes should be worthy of investigation as it might ‘open the door’ for a cure, but there appear to be hundreds of people curing themselves by REJECTING the official dietary advice. To maintain their credibility the diabetes organisations must grasp this nettle and undertake controlled clinical trials – I mean what have they got to lose? Either their current advice will be proven to be good advice (which will ‘silence Dr Briffa and his cult’), or it will be proven wrong (in which case they can change their advice and still fulfill their objective of providing care and treatment to people with diabetes and improve the quality of life for people with the condition).
Simple really! 😉
In fact the risk of losing drug company funding is the ONLY reason I can think of that would cause Diabetes UK would not to conduct such an experiment.
Diabetes UK may have been frank with the Commons Health Committee about their funding but they haven’t been here. Any hope that Sara Spiers might return to clear the matter up has been in vain.
Sue
There’s a lot of reading on that website! Are there any articles in particular that you think are most useful?
sokpuppet,
Have a read of the presentation by Ron Raab and Dr Katharine Morrison.
They are short presentations. There is much more info on the site under different sections.
Dr B – I don’t think you answered Andy’s question – “Would Dr. Briffa like to suggest foods containing carbohydrates that are not disruptive to blood sugar levels?”
Seriously though. what next. Will charities that help people with drug problems be suggesting the go and have lots of the very thing that is making them ill in the first place “drugs”. (oh but it will help you loose weight though)
Drug problem – solution – take more drugs
Peanut allergy – solution – eat more peanuts
Torn Muscle – solution – run more
Alcohol problem – solution – drink more alcohol
sugar problem (diabetes) – UK diabetic solution – eat more high sugar carbohydrate foods
weird…..
Hi Sue
Thanks! Seems like common sense really – low GI foods reduce glucose spikes and will lessen the burden on the pancreas. Have I got that right?
All those who are seriously interested in knowing the facts behind the diabetes & obesity debate, must please read ‘The Diet Delusion’ by Gary Taubes. The answers to everyone’s questions are in there.
It is a long read but certainly anyone who calls themselves a dietician, nutritionist or doctor would be wise to ensure they fully digest this book.
Sally, thanks:
“It is a long read but certainly anyone who calls themselves a dietician, nutritionist or doctor would be wise to ensure they fully digest this book.”
Mind you, uncomfortable.
ross
“my triglyceride levels have plummeted from a pretty scary level to a point where I’ve been able to reduce my medication.”
Thanks for this ross, but can I point out to you that diabetes is a problem characterised by raised blood sugar levels (not raised triglyceride levels).
Another thought crossed my mind – we have had several people on this site who have posted to the effect that once they eschewed the regular/traditional/diabetes UK advice and went paleo/low carb, their condition improved markedly.
What I would like to know from the defenders of the regular/traditional/diabetes UK advice is, can anyone of them encourage a post from a diabetic for whom they have improved the quality of life?
What would be particularly interesting is if the diabetic concerned had actually tried a ‘paleo’ approach, but found that the nutritional guidelines of Diabetes UK produced better results.
You’d think that a big (and growing), organisation like Diabetes UK would have numerous success stories. Statistically, several of their diabetics must surely have tried the paleo route – so, IF DUKs GUIDELINES ARE EFFECTIVE, some of them must have tried paleo/low-carbing and found it inferior to complex/starchy carbing.
Just a thought!
Come out! Come out! Wherever you are!
Dr Briffa
Thanks for eventually answering the question Dr Briffa, and I hope you gain a modicum of satisfaction in the way you address your commentators.
But I have some concerns, Dr B, about your – dare I suggest – rather passé clinical references? The research world has moved on for diabetics and non-diabetics alike since these citations were published (Heavens! Using bona fide medical references to justify your alternative/ complementary/whatever stance! How very daring!).
Indeed, at risk of alienating your key audience, the ‘UCP-2′ model/ oxidative stress/ manganese etc popularly assumed to contribute to the pathogenesis of diabetes (especially Type 2) has – unfortunately ” been disproven. A couple of years ago. Sorry. http://lib.bioinfo.pl/pmid:17916951.
Never mind. I agree that manganese-deficient rats should eat manganese-rich cake. But ‘Dr Briffa’s Sucroguard’ ™ is, well, superfluous to manganese requirements – especially as the above reference again quotes the common finding that human diabetics have twice the blood manganese levels of non-diabetics.
Pay Biocare-Not-Dr-Briffa £6.30 pcm for a futile pill-for-diabetic-ills? No thank you, Cathy. I’d rather boost my blood levels with a nice cup of tea.
http://hera.ugr.es/doi/1507920x.pdf
http://lib.bioinfo.pl/pmid:16118651
SkepTicTacToe, there’s a link here:
http://www.badscience.net/forum/viewtopic.php?f=3&t=5487
Curiously enough, since moving to a more low GI oriented diet and starting going to the gym earlier this year my triglyceride levels have plummeted from a pretty scary level to a point where I’ve been able to reduce my medication. And you know what? A low GI diet and exercise are recommended by Diabetes UK. Their paymasters must be sorely displeased.
Just to repeat for the benefit of any Briffas reading who may be hard of thinking …. by following Diabetes UK’s advice I have been able to reduce my medication. And that’s even without taking Briffa’s patented snake-oil, amazing. OK,so that’s just me but I don’t imagine that I’m unique here.
Disclaimer: I have never received a penny from Big Pharma… although I admit I have played a small part as a conduit for taxpayers money to flow their way in recent years. I refer to this relationship as “keeping myself alive.”
Ross,
Just a few observations. THe GI of several of the foods you refer to are: Instant Rice (91), brown rice (55), Mashed Potatoes (73), New Potatoes 56, Wholemeal Bread (69), All Bran (42) Porridge Oats (49).
By way of comparison the GI of table sugar is 65 and a mars bar 68 and chocolate 49. I am sure diabetes woudn’t advocate eating these foods. Or do they?…… And they don’t receive funding from Cadbury’s …… or do they?
And then of course there’s the glycemic loads of these starchy carbohydrates which, unless you eat ridiculously small and unsatisfying portions tends to be very high.
A low GI is something in the teens, or lower eg brocolli (15), cauliflower (15), cucumber (15).
even better still eat fats and protein. You will find that this lowers both your tryglicerides and blood sugar, is more statiating, and quite possibly imporves you quality of life.
If you are managing your diabetes without drugs and achieveing a hba1c below 5 I would be pleasantly surprised – good luck to you.
One further point – the more inuslina diabetic uses, the more difficult or not impossible it is to avoid both highs and lows. A type 1 diabetic needs to use as little insulin as possible whilst maintaining tight control. This can only be done by eating a low carb diet. The greater the insulin use, the greater the margin of error.
Starchy carbohydrates are of no help to a diabetic, if indeed they are good for anyone at all, in my opinion.
Paul.
John Stone said,
“Mind you, uncomfortable.”
Yes, and I can feel my ‘irritable bowel’ coming on at the thought …
Frank: “sugar problem (diabetes) – UK diabetic solution – eat more high sugar carbohydrate foods”
That’s misrepresenting the advice. As Diabetes UK’s advice is only partially quoted in this blog post you might find the following gives a better context:
http://jkn.com/View?j=912225.421546931238
Insulin is a multi-billion dollar industry worldwide. What business would put this at jeopardy with usage reduction strategies? (or heaven forbid ….. a cure.)
You’ll note the bulk of the research dollars are devoted to delivery systems (nasal, tablet) so as to move away from needles. This will allow them to keep selling insulin in some form or another.
Message to the pharma cartels – we do not want new delivery systems – we want a cure. (for type 1 that is: type 2 people should be changing their lifestyles and curing themselves.)
Catherine Collins RD
My, you do seem so very pleased with yourself! Why is that?
Could it be because you believe you have managed to deflect the issue from the woefully inadequate dietically-driven dietary advice many diabetics are given?
Or could it be that you think you have got away without having to really engage with the science (never mind the common sense) which shows how flawed such advice is?
Notice, Catherine, how Sara Spiers (Care Advisor at Diabetes UK) has stayed away from here after posting her, I think, ridiculous assertions. Seems she is unable or unwilling to answer the simplest of questions I posed to her above. Maybe you’d like to have a go at answering these questions for her?
Oh, and do please to remember to focus on the issue and not on me. Remember, Catherine, people’s lives are at stake here…
except, of course, dr briffa the title you give the blog post , the reference you give, and the content of the actual blog post is largely to do with the vague notion that Diabetes UK’s advice is flawed due to their relationship with drug companies. Yet, you have a cosy relationship with a pill company.
The reference you give suggest that patient groups should declare interests – yet you have studiously failed to declare your interest in SucroGuard!
Anyway, thinking about the science. Would you like to describe the diet you would like to see diabetics following, and back it up with some evidence, then point out the substantial differences between your ideas, and diabetes UK’s advice?
Dr B – I don’t think you answered Andy’s question – “Would Dr. Briffa like to suggest foods containing carbohydrates that are not disruptive to blood sugar levels?”
“Or could it be that you think you have got away without having to really engage with the science (never mind the common sense) which shows how flawed such advice is?”
Dr B, I think Catherine Collins did engage with the science. You stated that:
“Justification for the inclusion of manganese in Sucroguard comes from studies which show that manganese levels are generally low in diabetics (Biol Trace Elem Res. 2001;79(3):205-19) and that manganese deficiency appears to contribute to glucose intolerance in animals and may be reversed by supplementation (J Nutr 1990;120:1075”9).”
Catherine Collins said:
“Indeed, at risk of alienating your key audience, the ‘UCP-2′ model/ oxidative stress/ manganese etc popularly assumed to contribute to the pathogenesis of diabetes (especially Type 2) has – unfortunately ” been disproven. A couple of years ago. Sorry. http://lib.bioinfo.pl/pmid:17916951. Never mind. I agree that manganese-deficient rats should eat manganese-rich cake. But ‘Dr Briffa’s Sucroguard’ ™ is, well, superfluous to manganese requirements – especially as the above reference again quotes the common finding that human diabetics have twice the blood manganese levels of non-diabetics.”
Aer you going to engage with the science?
Hi Ross, thanks for the link. You would hope that at least someone would achieve the results that this guy did, by following Diabetes UK advice. It would be interesting to know if the guy involved would see even greater benefits if he went ‘paleo’.
I must point out that by going ‘paleo’, Anna (#9) seems to have removed her need for medication completely, Glenice (#15) has reduced her medication significantly – and has achieved results she was otherwise unable to, following the advice of Diabetes UK. The same goes for Anne (#18), who found that following the dietary recommendation of Diabetes UK her ” blood glucose levels rise too high and stay that way 2 hours post prandial.” Christine’s position (#20) on Diabetes UK dietary advice is similar also. None of them seem to have taken “Briffa’s patented snake-oil” 🙂
Short of sock-puppetry, I find these posts rather convincing (albeit anecdotal). So, while it seems that there are cases of diabetics achieving good results by following Diabetes UK advice, this advice does not appear to work across the board. Paleo eating DOES seem to have greater success – and unlike the Diabetes UK nutritional advice, we have yet to hear from a diabetic who says that paleo eating did NOT work for them.
Given their objective and the anecdotal evidence, I still think that Diabetes UK should conduct trials based upon the paleo diet. That way we could sort this issue out once and for all, and avoid some of the more unpleasant exchanges we have seen here!
Dr B, I cant see my original post re. this so I wondered what your thoughts are in relation to NHS Blog Doctor’s article stating that you think Diabetes UK is “deliberately and maliciously encouraging diabetics to eat an inappropriate diet, knowing that such a diet will make their diabetes deteriorate, thus increasing their need for medication.”
http://nhsblogdoc.blogspot.com/search/label/Dr%20John%20Briffa
Admittedly they will find it hard to swallow (!) but Catherine Collins RD and Sara Spiers really do need to digest ‘The Diet Delusion’ by Gary Taubes!
In my personal experience, once people receive a diagnosis of diabetes (both types) and start following the advice of their GPs, endocrinologists, diabetes nurses, and dieticians, their condition always worsens. They are locked into a downward spiral of ill-health, driven by high blood glucose & high insulin levels (endogenous or not) and compounded by pharmaceuticals.
As far as their impact on blood glucose is concerned, there is no difference between the so-called good, complex carbs and simple sugars. As Paul Anderson demonstrates by quoting the GI of some examples, we might as well be eating chocolate, jelly babies and spoonfuls of table sugar, as bread, potatoes, rice and breakfast cereals. In simple terms, the more processed (including by cooking) a carbohydrate-based food is, the worse it is for us.
For anyone battling with diabetes or weight issues the only way out is to ignore the ‘experts’ and drastically cut the carbs. Find a doctor and / or a nutritionist that doesn’t spout dogma (much easier said than done…) and does understand the science of metabolism.
Clearly, the received wisdom on the subject of diet is not right. If it was correct the incidence of obesity & diabetes (not to mention all our other epidemic ills) would be decreasing, as patients followed doctors’ orders. There is a wealth of evidence (from research, clinical experience & anecdotal) that indicts processed carbohydrates as the scourge of the 21st century. Whilst we argue the toss on this site there are millions of people suffering, in this country alone, because the truth is not reaching the masses. Much more could be achieved if our dissenting voices were united. If there are any clinicians and biochemists out there who feel the time is right to move this forward, please contact me.
I don’t know if I’m allowed to post my e-mail address here but I guess it’ll soon be removed if not! sally@diet-therapy.co.uk.
SkepTicTacToe,
I’m not defending DUK’s advice, so please don’t jump down my throat, but I can give you one ” admittedly very small and totally unrepresentative ” example of people who can’t go totally low-carb: elite athletes with Type I.
They will typically eat a carb-laden breakfast to give them slow release energy throughout morning training, and again at lunch if they have more training or a match in the afternoon.
However, most of them don’t eat carbs in the evening (after about 7pm) because the body doesn’t metabolise carbs well when asleep and carbs suppress the action of cortisol, which is the hormone that helps us wake up in the morning.
John ” hope I’ve got the science right here. I work with elite athletes but not from a nutritional point of view.
Hi Rob – interesting point.
I was reading Lauren Cordain’s Paleo Diet for Athletes the other day and he actually recommends athletes broadly follow the paleo diet but ingest refined carbs at key points through the day to restore glycogen levels
This approach was only proposed for athletes following a program of heavy training and on consecutive days (regardless of whether they had diabetes).
Cheers,
I wondered what John Briffa thought of ‘The Diet Delusion’ by Gary Taubes that Sally Taylor recommended. Do you think it a book worth buying?
Catherine Collins you are doing it again; ascribing something to me that I didn’t in fact do. I didn’t advise you to take Sucroguard or any other vitamins, why on earth would I do that?
Nice try BUT…Catherine said “especially as the above reference again quotes the common finding that human diabetics have twice the blood manganese levels of non-diabetics.” ” you have quoted from one Nigerian study that is not exactly representative of type 2 diabetes patients in the UK or US eating a SAD-type diet. Could it be that Nigeria has higher levels of manganese in their water? Could it be that diabetics in Nigeria are less well controlled and have a higher water intake (and therefore higher manganese intake) due to hyperglycaemia-driven thirst?
“The median manganese concentrations were similar in Sweden, Hungary, and Guatemala at 3”4 μg/L. In Zaire and Nigeria, the median manganese concentrations were slightly higher”11 and 16 μg/L”.
Rather an elephant-like confounding factor in your “evidence” that the UCP-2/oxidative stress model is “disproven”. Oxidative stress as a factor in type 2 diabetes has demonstrated so frequently I am amazed someone that claims to read the literature can possibly dismiss it.
Here’s a more recent study from Pakistan (1): “The results of this study showed that the mean values of Zn, Mn, and Cr were significantly reduced in blood and scalp-hair samples of diabetic patients as compared to control subjects of both genders (p < 0.001).” But I guess you missed that one huh Catherine? But that is not really representative either. All this demonstrates is that geographical differences may play a role and that you can’t cherry pick one study and generalise the findings (shame on you). Turkey ” higher manganese in diabetics, Austria ” lower, so really …
(1) http://tinyurl.com/6ct2yg
SkepTicTacToe wrote (message 58):
“I must point out that by going ‘paleo’, Anna (#9) seems to have removed her need for medication completely, Glenice (#15) has reduced her medication significantly – and has achieved results she was otherwise unable to, following the advice of Diabetes UK. The same goes for Anne (#18), who found that following the dietary recommendation of Diabetes UK her ” blood glucose levels rise too high and stay that way 2 hours post prandial.” Christine’s position (#20) on Diabetes UK dietary advice is similar also. None of them seem to have taken “Briffa’s patented snake-oil” ”
I’m Anne from message number 18, and that’s correct that following the dietary recommendations of Diabetes UK did make my blood glucose levels rise too high. I discovered Dr Briffa’s website well after my diagnosis of diabetes and well after I discovered what foods helped my diabetes and what didn’t. I enjoy a Paleo diet but without much fruit as fruit raises my blood glucose.
Shortly after my diagnosis of diabetes (type 2) I had a consultation with the dietician attached to my GP’s practice and the advice she gave was to show me Diabetes UK’s little booklet and recommended that I follow it, plus she recommended that I eat dried apricots to give me extra calcium…dried fruit for a diabetic ! The mind boggles. In my naivety I wrote a letter of complaint to my GP about the dietician and her dreadful advice, the first and only time I have ever written a letter of complaint about a medical professional. Later, my endocrinologist revealed to me the current thinking – he said I should eat more carbohydrates, and, to cover the blood sugar rises I would get from those carbohydrates, he prescribed me a diabetes medication. I really don’t get this kind of logic at all.
I am not overweight, I have never been. I do exercise, in particular weight lifting exercise, and I have no problems getting energy when I go to the gym. I eat some high protein food which is just what my muscles need, both before and afterwards. One’s body makes any glucose it needs from proteins (gluconeogenesis) and from the store that is in the liver which is replenished from what little carbohydrates I do eat (veggies) plus protein metabolism…that’s my understanding of the chemistry of it, but I always have tons of energy and my blood glucose levels are stable with this way of eating.
The doctor who has most influenced me is Dr Richard Bernstein of http://www.diabetes-book.com/ BUT I must stress that I had discovered which foods did and which foods didn’t affect my blood glucose adversely before I discovered Dr Bernstein’s book and website, I discovered this all by taking my blood glucose measurements after eating various foods with my little meter. Anyone can do that and see what’s going on. If only more diabetics would do this I’m sure they would learn lots and help themselves….I’ve met diabetics who just parrot what Diabetes UK says about a ‘healthy diet’, yet their HbA1c’s are high and they never test their blood. Btw, my HbA1c is 5.3.
Anne
sally (and dr briffa)
would you like to suggest an approximate diet for diabetics and explain the substantial difference between your proposal, and ‘standard’ advice to diabetics?
superburger,
Dr Bernstein recommends the following amount of carbs – 6g for Breakfast and 12g for lunch and dinner = total 30g for the day.
You can read some of the chapters of his book online here:
http://www.diabetes-book.com/readit.shtml
Also, an article from Bernstein re the ACCORD Study and ADA:
http://www.diabeteshealth.com/read/2008/03/26/5701.html
dr bernstein is free to advise what he likes.
It would be nice if you could provide some sort of peer reviewed reference for some diet that you would advise diabetics. Then highlight the differences between this advice and D-UK adivce.
To address the question posed by Superburger, I believe a ‘paleo’ diet, as has been suggested already by various posts (see http://paleodiet.com/ for info), or the best approximation we can get to it in this day & age, is what’s required to maintain or re-establish good health in anyone.
Man is not designed to eat any other way. It is common sense that the more we deviate from that path, the more our health will suffer. And the evidence is all around us. If conventional beliefs regarding diet were correct, the incidence of chronic disease in Westernised societies would be falling, not increasing.
The clear difference between this view and the standard advice to diabetics is both the quantity and the quality of carbohydrate, fat and protein that is recommended – and the precise ratios of these macronutrients should be tailored to an individual’s needs.
There is an awful lot uttered about diet but I believe the subject is overcomplicated by the ‘experts’. And therein lies the problem. People are confused by conflicting advice from doctors, dieticians, nutritionists, diet gurus, et al. Surely the right basic diet for mankind can be distilled into simple principles – we need to eat REAL food, not manufactured substitutes, and preferably that which is not inherently toxic if it were to be consumed raw. Perhaps a useful rule of thumb might be the closer a food resembles its natural state, the better it is for us, and the longer it can remain in a cupboard without spoiling, the worse it is for us.
Now, I’m sure there are those who will come up with exceptions to these rules, and some may even be valid, but the point I’m making is that we have to simplify it so every man, woman & child can grasp the facts of what constitutes a healthy diet.
Our lifestyles are so far removed from nature that we’ve lost sight of these basic truisms. Our obsession with convenience foods has been compounded by experts’ advice to increase our intake of processed carbs. But how can anyone who claims an understanding of nutrition seriously believe that a diet of bread, pasta, breakfast cereals, etc, provides the quality of fuel our bodies need to operate, repair and regenerate efficiently & effectively – let alone stabilise blood sugar?!
As far as diabetics are concerned they must be encouraged to take control of their health, just as others on here have successfully done, rather than trusting to experts. Use those BS monitors throughout the day and see what happens when standard dietary advice is followed. And should anyone want to try an alternative approach these two books contain all the supporting information needed: ‘Dr Bernstein’s Diabetes Solution: Complete Guide to Achieving Normal Blood Sugars’, and ‘Atkins Diabetes Revolution: Control Your Carbs to Prevent and Manage Type 2 Diabetes’.
Sally
Superberger,
Show me a peer reviewed diet for the Standard Diabetic Diet as advocated by Diabetes UK that produces stable blood sugars and good health. You will not find such evidence for a type 2 diabetic who manages their condition by diet and exericse alone – or if you do it will be very much the exception to the rule.
The same is almost certainly true for a type 1. Just for clarity, I would regard stable control as a hba1c around or below 5, with no, or very few episodes of hypoglycemia. The diabetes target of 7 is far too high and all but guarantees the developmnet of diabetes related complications.
Very few people argue that Dr Bernsteins regime doesn’t work. The main criticism levelled against it is that is austere, too restrictive and that many patients won’t comply with it. I would suggest that patients should be made aware that this is an approach that they might wish to consider and adopt: better to have a good quality of life on a restricetd diet than eat a high carb diet and suffer from a host of long term complications.
Paul.
that’s not an answer to my question sally.
interesting review
Diabetes Care 25:148-198, 2002
from the summary
“With regard to the glycemic effects of carbohydrates, the total amount of carbohydrate in meals or snacks is more important than the source or type.”
“Although the use of low”glycemic index foods may reduce postprandial hyperglycemic, there is not sufficient evidence of long-term benefit to recommend use of low-glycemic index diets as a primary strategy in food/meal planning.”
“Carbohydrate and monounsaturated fat should together provide 60”70% of energy intake. However, the individual’s metabolic profile and need for weight loss should be considered when determining the monounsaturated fat content of the diet.”
“The long-term effects of diets high in protein and low in carbohydrate are unknown. Although such diets may produce short-term weight loss and improved glycemia, it has not been established that weight loss is maintained long-term. The long-term effect of such diets on LDL cholesterol is also a concern.”
“Standard weight-reduction diets, when used alone, are unlikely to produce long-term weight loss. Structured, intensive lifestyle programs are necessary.”
“There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies. Exceptions include folate for prevention of birth defects and calcium for prevention of bone disease.”
“Routine supplementation of the diet with antioxidants is not advised because of uncertainties related to long-term efficacy and safety.”
so, that’s a fairly long review which seems to bear out many of the key points of the D-UK diet. It also casts doubt on some of the low-carb high protein diets and “GI” based diets (although, of course, the evidence may change) and it certainly rules out vitamin supplements (including dr briffa’s formullation?)
I would stress that this is a review of other peer reviewed work, and has itself been peer reviewd. Some recommendations carry less weight than others (particulary the 60-70% carb advice, which i think is where some people’s confusion arises from) – although fwiw suspect the caveat that all dietry choices should be supervised by dieticians/physicians and that individual metabolism and (any) need for weight loss are most important.
So it remains to be seen if sally, dr briffa, paul anderson et al can offer a good evidence based alternative to the standard diabetic diet and in particular if dr briffa would like to justify his formulation of SucroGuard in the light of this work.
can i just ask what qualifications sally taylor has as regards nutrition? not an aggressive question, but i was wondering if you just take the paleo diet as read or have some grounding in biochemistry, nutrition, etc
Thanks.
superburger – here is an answer for you: http://www.sciencedaily.com/releases/2007/06/070627225459.htm
But I’ve copied and pasted it below in case you don’t want to go to the link. The “Mediterranean-like prudent diet” that was compared to the Paleolithic ‘Stone Age’ diet (Paleo) is the type of diet Diabetes UK recommends.
Original Human ‘Stone Age’ Diet Is Good For People With Diabetes, Study Finds
ScienceDaily (June 28, 2007) ” Foods of the kind that were consumed during human evolution may be the best choice to control diabetes type 2. A study from Lund University, Sweden, found markedly improved capacity to handle carbohydrate after eating such foods for three months.
During 2.5 million years of human evolution, before the advent of agriculture, our ancestors were consuming fruit, vegetables, nuts, lean meat and fish. In contrast, cereals, dairy products, refined fat and sugar, which now provide most of the calories for modern humans, have been staple foods for a relatively short time.
Staffan Lindeberg at the Department of Medicine, Lund University, has been studying health effects of the original human diet for many years. In earlier studies his research team have noted a remarkable absence of cardiovascular disease and diabetes among the traditional population of Kitava, Trobriand Islands, Papua New Guinea, where modern agrarian-based food is unavailable.
In a clinical study in Sweden, the research group has now compared 14 patients who were advised to consume an ‘ancient’ (Paleolithic, ‘Old stone Age’) diet for three months with 15 patients who were recommended to follow a Mediterranean-like prudent diet with whole-grain cereals, low-fat dairy products, fruit, vegetables and refined fats generally considered healthy. All patients had increased blood sugar after carbohydrate intake (glucose intolerance), and most of them had overt diabetes type 2. In addition, all had been diagnosed with coronary heart disease. Patients in the Paleolithic group were recommended to eat lean meat, fish, fruit, vegetables, root vegetables and nuts, and to avoid grains, dairy foods and salt.
The main result was that the blood sugar rise in response to carbohydrate intake was markedly lower after 12 weeks in the Paleolithic group (”26%), while it barely changed in the Mediterranean group (”7%). At the end of the study, all patients in the Paleolithic group had normal blood glucose.
The improved glucose tolerance in the Paleolithic group was unrelated to changes in weight or waist circumference, although waist decreased slightly more in that group. Hence, the research group concludes that something more than caloric intake and weight loss was responsible for the improved handling of dietary carbohydrate. The main difference between the groups was a much lower intake of grains and dairy products and a higher fruit intake in the Paleolithic group. Substances in grains and dairy products have been shown to interfere with the metabolism of carbohydrates and fat in various studies.
“If you want to prevent or treat diabetes type 2, it may be more efficient to avoid some of our modern foods than to count calories or carbohydrate,” says Staffan Lindeberg.
This is the first controlled study of a Paleolithic diet in humans.
Adapted from materials provided by Lund University.
Why do people who would not conceivably endorse creationism, still seem to think that carb diets are God-given?
Superburger (#72), I am interested in a quote from the your extract above:
“The long-term effects of diets high in protein and low in carbohydrate are unknown.”
Notwithstanding that the paleo approach is specifically low in refined carbohydrate rather than simply being low in carbohydrate, I think a little look at history will tell us all we need to know about the benefits of such a diet – it is a template for our ancestral nutrition. Also, a look at the health of hunter-gatherer tribes around the world will also add to anecdotal evidence. However, I will agree that yes, there does need to be some formal long-term research.
“Although such diets may produce short-term weight loss and improved glycemia, it has not been established that weight loss is maintained long-term.”
I have yet to see evidence of obesity in hunter gatherer populations who follow their traditional ‘paleo’ eating patterns. (Conversely I have seen a lot of morbid obesity in populations who have moved to a conventional western diet in the last century. I have also seen the same people fail to lose weight following conventional low fat high and high complex-carb nutritional advice). I lost body fat (I am down to well under 10% BF) by eating ‘paleo’. This has been a two-year state of affairs – anecdotal evidence, but I am one of MANY people who expericen such dramatic, sustainable and effective drops in BF (note I say bodyfat NOT weight).
“The long-term effect of such diets on LDL cholesterol is also a concern.”
This line concerns me as I suspect this statement is NOT based on medical science and I have yet to see ANY evidence that a paleo diet has a negative effect on LDL. In the last two years I have had two cholesterol tests (once of which was compared against the Framingham template). They both came back with ‘No Further Action’ – ie, my cholesterol was fine – even after over a year eating paleo. In fact Cordain contends that paleo diets improve LDL profiles (also evident in the Masai):
http://www.thepaleodiet.com/articles/Am%20J%20Cardiol%202006.pdf
I still wouldn’t eat SucroGuard though! 😉
couple of comments, anne.
Firstly sciendaily is not a source of peer reviewed leiterature. it’s an online newspaper.
I think i’ve tracked down the work that you refer to (doi: 10.1007/s00125-007-0716-y) I’m sure you’ve read it too…..
Interesting – but bear in mind the following – it was a minute study (total sample size of 29) and all the participants were suffering heart disease (and not all of the sample actually had type II diabetes either) and the study only lasted 12 weeks.
I’m not sure that the conclusions of this work contrast strongly with the conclusion of the review I pointed out, which included
“The long-term effects of diets high in protein and low in carbohydrate are unknown. Although such diets may produce short-term weight loss and improved glycemia, it has not been established that weight loss is maintained long-term. The long-term effect of such diets on LDL cholesterol is also a concern.”
Who knows? Maybe this is the start of a new approach to management of diabetes. Maybe it’s not. The point is that Dr Briffa’s blog post tries to imply some motive for D-UK’s actions when really they seem to be grounded in generally good evidence.
skeptictactoe said
““The long-term effect of such diets on LDL cholesterol is also a concern.”
This line concerns me as I suspect this statement is NOT based on medical science and I have yet to see ANY evidence that a paleo diet has a negative effect on LDL.”
Ref. 204 in the review
J Am Diet Assoc. 1980 Sep;77(3):264-70
What is more relevant, I think, is that there is no evidence whatsoever that the much touted low fat, high carbohyrdate diet results in sustained weight loss. Indeed, as fat consumption has reduced and carbohydrate consumption has increased there has been a steep rise in obesity, and the majority of the UK population is now oveweight. This is in marked contrast with previous generations who ate more fat, red meat, butter, eggs, lard and cheese.
I am not aware of any society where a low carbohydrate diet is consumed where there the population suffers from obesity and other western lifestyle dieseses.
Voluntary starvation, as followed by many people following a reduced calorie low fat dietary regime is almost guaranteed to fail in the long term.
Where are the peer reviewed studies that show a low fat high carb diet results in long term sustained loss – they don’t exist, despite their widespread adoption of this approach by health authorities throughout the world. This doesn’t stop them being recommended for weight loss. It seems to me that double standards are applied when dietitions, etc discuss the effects of low carb diets, and caution about possible long term negative effects of these diets.
Paul.
Hello Adam…
I’ve studied nutritional therapy and nutritional biochemistry both formally and through autonomous learning, but don’t hold a degree in any subject. I’ve practised as a diet therapist, advising clients (as well as other natural health practitioners and some private doctors) on dietary matters relating to health, well-being and nutrition. Why diet therapy? Because, unlike many nutritionists, my approach concentrates on dietary modification to correct underlying imbalances that lead to poor health, rather than on supplements to address specific symptoms.
My original interest stemmed from a personal battle with weight, which was solved when I discovered the Atkins’ Diet seven years ago. Up to that point I ate pretty much the orthodox ‘healthy’ diet, and ended up 3.5-stone overweight. I’ve eaten low-carb ever since, as paleo as is practical for me, and maintained my weight loss. Being the sort who has to know how and why things work, I was driven to study the subject in depth, and study I did, and do.
Both my parents are Type 2 diabetics (hence my particular interest in this area), and both have CVD & arthritis. At 49 years old I have no health problems and more energy than most people half my age. Given my genetic inheritance, I believe I am a good example for others to follow.
Please don’t get me wrong – I’m far from perfect and certainly no earth-mother type. I live in the real world. I lead a busy, stress-filled life and have four school-aged children who, left to their own devices, would subsist on a diet of processed carbs and spend all day glued to a TV / PC. I was moved to post here because I feel passionately that we need to spread the message that our high-carb, convenience food lifestyle is killing us. I’m fed-up with my kids being told at school that a healthy breakfast comprises corn flakes, skimmed milk, orange juice, and toast spread with butter-substitute, jam, marmalade or lemon curd.
So, those are my ‘qualifications’ for daring to voice an opinion that contradicts the establishment line.
And Superburger…
All the references you require are cited in ‘The Diet Delusion’ by Gary Taubes. In my opinion, blinding people with science is what got us into this predicament in the first place. We need to cut the crap and explain the issues in terms that every man, woman and child in the street can understand. However, if you really are interested in the science, rather than in appearing clever, invest £12 and read it. And if you’ve any qualms about accepting my recommendation, look at the reviews on Amazon.
Sally
“I have yet to see evidence of obesity in hunter gatherer populations who follow their traditional ‘paleo’ eating patterns. (Conversely I have seen a lot of morbid obesity in populations who have moved to a conventional western diet in the last century”
First up, how would you propose we could have measured rates of obesity in paleo populations with any degree of accuracy?
Second, would you agree that the abundance of food in the western idiet is probably far higher than our paleo ancestors – couldn’t your supposed rates of obesity in either population be explained simply by higher calorific intake?
Groovey,
I think the anwer to you question is no, its not simply a question of higher calorific intake. Some foods are easier to consume over consume than others – you could say, almost addictive, eg sugar, wheat. You are very unlikely, the the other hand to binge on meat, or fish for example, or brocolli or lettuce.
The calorie issue is just too simplistic, in my opinion. You cannot really expect to regulate calories by counting everything you eat. If you think about it a 40 year old who is 1 stone overweight, has accumulated 49,000 surplus calories (stored as fat) during their life to date. That means that, on average they have consumed just over 3 suprlus calories per day on average over their lire to date. If you accept the calories argument, that person would not have gained their weight if they had eating 1997 calories a day, rather than 2000. In theory, if they had eaten 20 calories a day less they would weigh approximately 6 stone less. Do you know anyone who is capable of calculating their calorie intake (and level of activity) with that level of precision.
My suggestion would be that if you eat the correct foods – natural, unprocessed and low GI your body can evolved to regulate weight effectively. On the other hand if you eat processed and high GI foods you body’s weight regulation mechanism will, eventually, go haywire, resulting in weight gain and metabolic disturbances.
If you are in perfect health and at a perfect weight I guess you have found a diet that works for you. If not, why not give it a go for a week or to and see for yourself jow you feel. Even the mainstream medical establishment concede that a low carb approach is effective for short term weight loss and that it is safe to follow in the short term. They have, more or less, had to given to accumulating number of studies indicating its effectiveness.
Paul Anderson.
Also Groovey, the active lifestyle of hunter gatherers (all that hunting and gathering for instance) contrasts markedly with the modern sedentary lifestyle. It would be interesting to know if this confounding factor been taking into account in the research.
(I’d like to see some research on the paelo diet – is there any good quality peer reviewed literature in the public domain?)
sally,
I don’t think i would say I’m blinding you, or anyone else, with science.
You might not like the arguments I present, nor the scientific papers which have been peer reviewed, but i note that you choose not to engage with them, instead claming you are being blinded with science and say that i am trying to ‘appear clever’ by pointing out things which you seem not to agree with.
I would argue a compehensive literature review, peer reviewed, and offering a bullet pointed summary section, written in accesible language, is an excellent way of communicating a complex subject.
It says a lot about the level of debate you are capable of engaging in when, once questioned about the actualy hard evidence for your claims, you can only point to online newspapers, books with positive reviews on amazon! and your own conjecture and anecdote.
You try to point to a piece of work (the Lund Univ study) – when i tracked down the reference and offered some honest criticism you fail to engage with it.
So again, I would ask you to point towards some peer-reviewed evidence that a paleo diet offers a safe, long term solution towards the management of diabetes and why it is better advised than the current recommendations.
“Also Groovey, the active lifestyle of hunter gatherers (all that hunting and gathering for instance) contrasts markedly with the modern sedentary lifestyle. It would be interesting to know if this confounding factor been taking into account in the research. ”
Absolutely Ross.
“My suggestion would be that if you eat the correct foods – natural, unprocessed and low GI your body can evolved to regulate weight effectively. On the other hand if you eat processed and high GI foods you body’s weight regulation mechanism will, eventually, go haywire, resulting in weight gain and metabolic disturbances.”
Fair.
superburger,
Read The Diet Delusion and you’ll see how the current thinking on diet is so infuriatingly wrong.
Superburger
The Medical Journal of Australia is a peer-reviewed journal and while this doesn’t substitute for a prospective trial there have been many instances around the world that indigenous peoples derive myriad health benefits from returning to their traditional hunter-gatherer diet.
There is also conflicting evidence as to whether Aboriginal HG diet was/is actually low in fat[1], but that dispute aside:
“OBJECTIVE: To examine the published data on the impact of westernisation on obesity, non-insulin dependent diabetes mellitus (NIDDM), and coronary heart disease (CHD) in Australian Aborigines. DATA SOURCES: Fifty-five articles from Australian and international sources (primarily peer-reviewed journals) are cited. STUDY SELECTION: Twenty-eight reports providing data on the diet, lifestyle, health and “lifestyle diseases” of Australian Aborigines before and after westernisation are included in this review. A further 27 articles on obesity, NIDDM, CHD, insulin resistance, and the impact of diet and exercise were used to help interpret the Aboriginal data. DATA EXTRACTION: Information on dietary composition, anthropometry, disease and risk factor prevalence, and relevant biochemical measurements were used for comparative and interpretive purposes. DATA SYNTHESIS: The traditional hunter-gatherer lifestyle of Australian Aborigines, characterised by high physical activity and a diet of low energy density (low fat, high fibre), promoted the maintenance of a very lean body weight and minimised insulin resistance. In contrast, for most Aborigines a Western lifestyle is characterised by reduced physical activity and an energy-dense diet (high in refined carbohydrate and fat) which promotes obesity and maximises insulin resistance. When they make the transition from their traditional hunter-gatherer lifestyle to a westernised lifestyle, Aborigines develop high prevalence rates for obesity (with an android pattern of fat distribution), non-insulin dependent diabetes, impaired glucose tolerance, hypertriglyceridaemia, hypertension and hyperinsulinaemia. The striking improvements in carbohydrate and lipid metabolism in diabetic and non-diabetic Aborigines after a temporary reversion to a traditional hunter-gatherer lifestyle highlight the potentially reversible nature of the detrimental effects of lifestyle change, particularly in young people who have not yet developed diabetes. CONCLUSION: It is suggested that insulin resistance was important to the survival of Aborigines as hunter-gatherers, but is also the underlying metabolic characteristic predisposing them to obesity, NIDDM and CHD after westernisation. Intervention strategies to prevent chronic diseases related to insulin resistance should be directed at lifestyle modification. To be effective such programmes will have to be developed and implemented at the community level.”[2]
Furthermore, intervention studies in these populations that promoted low fat, high carbohydrate diet were successful in reducing “risk factors” like hypercholesterolaemia, hypertension etc. but did not reduce diabetes prevalence.[3]
1. Brand-Miller, J., Holt, S, Australian Aboriginal plant foods:a consideration of their nutritional composition and health implications. Nutr Res Rev, 1998. 11: p. 5-23.
2. O’Dea, K., Westernisation, insulin resistance and diabetes in Australian aborigines. Med J Aust, 1991. 155(4): p. 258-64.
3. Rowley, K.G., et al., Improvements in circulating cholesterol, antioxidants, and homocysteine after dietary intervention in an Australian Aboriginal community. Am J Clin Nutr, 2001. 74(4): p. 442-8.
Hi Superburger,
You wrote:
“Firstly sciendaily is not a source of peer reviewed leiterature. it’s an online newspaper.”
I was looking for the original study, I read it when it first came out, but since I couldn’t find it the other day for you, that’s why I used Scienedaily.
And you wrote:
“Although such diets may produce short-term weight loss and improved glycemia, it has not been established that weight loss is maintained long-term.”
I don’t believe weight loss should be brought into this discussion. We’re talking about glycaemic control. Yes I know lots of type 2 diabetics are overweight, but there are type 2’s who are thin. I am a type 2 diabetic who is thin and I’ve always been thin. Weight is not an issue for me or other thin type 2’s, it is glycaemic control that is the only issue. A low carb Paleo diet keeps my blood glucose very well controlled, the Diabetes UK type diet raises my blood glucose…I know I’ve checked my blood sugar after eating the complex carbohydrates so highly recommended by Diabetes UK.
I don’t know why I developed diabetes but I would guess that it could well be the Diabetes UK type diet that did it. For years and years before my diagnosis I followed the high complex carbohydrate diet that is recommended as being so healthy. I not only ate wholemeal bread I made it. I made all my own bread, and yoghurt,….I was a real fan of that kind of diet. I’d eat brown rice, wholewheat pasta, wholewheat bread, other whole grains, lots of fruit and vegetables, not much meat and only low fat things and in exactly the proportions recommended by Diabetes UK ! In theory I should never have developed diabetes following that kind of diet !
Anne
cathy – interesting work you point to – although I would say that the change of lifestyle (high to low physical activity) could be as, or more important than dietary factors. There is nothing in their description of “low fat, high fibre” coupled with high physical activity that contradicts the recommendations made by D-UK. Plus there is the obvious possibilty of genetic differences between australin aborignes and UK population.
Anne – not sure the relevance of your personal anecdote here – you still haven’t engages with any substantial point i have made. Glad your diabetes is well managed though.
>>Dr B – I don’t think you answered Andy’s question – “Would Dr. Briffa like to suggest foods containing carbohydrates that are not disruptive to blood sugar levels?”
Non-starchy vegetables
Thank you Michael
“Would Dr. Briffa like to suggest foods containing carbohydrates that are not disruptive to blood sugar levels?”
Do you think that a fundamental ignorance of nutritional matters (as demonstrated by a failure to be able to answer this question) is behind why some seem not to be able to accept that Diabetes UK’s dietary advice is woefully inadequate and potentially detrimental to health?
it is you that failed to answer, dr briffa!
would you, personally, care to name a “non-starchy” vegetable that is also a significant source of carbohydrate – and will not affect blood sugar?
you’ve also not been able to describe an alternative diet, differing from the broad advice of D-UK, which would suit diabetics better. In particular, it would be interesting if you were able to offer the reasons why the recommendation in this review are incorrect.
Diabetes Care 25:148-198, 2002
the recommendations in which are generally the same as offered by D-UK.
>>Research has shown that by reducing carbohydrate consumption, the amount of fat they eat tends to increase drastically, particularly saturated fat.
um.. Two Points!
1. Please provide links to this research.
2. Please show that fat and/or saturated fat in a low carbo diet is a problem.
Seriously, it does appear that saturated fat and a high carbo diet is an evil combination.
I have seen NO EVIDENCE that saturated fat is a problem in a low carbo diet. None.
If any of the dieticians lurking here can point to any studies showing problems with saturated fat in very low carbo diets, I would like to see the studies.
The common pattern in low carbo diets is a drastic fall in Triglycerides, a significant rise in HDL and improvement in LDL particle size.
See:
http://jn.nutrition.org/cgi/content/full/135/6/1339
To all the dietitians lurking here – Yes, we all know what you were taught in school.
The point is that we don’t believe it.
Low-carb has certainly improved my BG control.
Nobody can produce evidence that increasing carb intake would reduce blood sugar levels.
Low-carb has also drastically improved my lipid profile.
Triglycerides dropped from 300 to 88
HDL improved from 38 to 61
LDL has dropped and more significantly LDL particle size has increased.
If saturated fat is still a demon, I don’t understand how.
I am very open to a science based, evidence backed discussion supporting what you dietitians were taught in school.
Links to current studies would help illuminate the discussion a lot more than just repeating the standard low-fat dogma.
Thanks,
Michael
“It is telling that all the “refutations” of Dr. B’s post are ad hominem – they attack the man by pointing out that he is not specially trained in appreciating the emperor’s clothes.”
AC – care to give an example?
>>Do you think that a fundamental ignorance of nutritional matters (as demonstrated by a failure to be able to answer this question) is behind why some seem not to be able to accept that Diabetes UK’s dietary advice is woefully inadequate and potentially detrimental to health?
What gets these folks upset is your acceptance of evidence rather than current low-fat dogma.
So, to answer your question, it seems more like willful ignorance than fundamental ignorance.
Dr. B, does it ever get lonely to be the one pointing out that the emperor has no clothes?
Superburger I am sure physical activity plays a role but why avoid the issue of glycaemic load?
The same authors I quoted above took issue with that review’s conclusions being incorporated into the ADA’s position statement:
“Recently, the American Diabetes Association published the following statement: “”with regard to the glycemic effects of carbohydrates, the total amount of carbohydrate in meals and snacks is more important than the source or type” (1). However, the revised glycemic index (GI) table published in the July 2002 issue of the Journal (2) indicates that even when foods contain the same amount of carbohydrate (ie, carbohydrate exchanges), there are up to 10-fold differences in the glycemic effect among them. Moreover, prospective observational studies found that the risk of developing diseases of affluence (eg, type 2 diabetes, cardiovascular disease, and some cancers) is independently related to the overall dietary GI and glycemic load (GL), but not to the total carbohydrate content (3).”
http://tinyurl.com/5bqzv7
The review dismisses post-prandial glucose excursions as unimportant; I find this incredible in light of the fact that post-prandial glucose excursion is a stronger predictor of macrovascular complications and mortality than fasting plasma glucose. http://tip.org.pl/pamw/issue/article/56.html
Given that so much of what informs public health policy is based on epidemiology and not prospective studies then the recommendation to ignore glycaemic load is untenable. If post-prandial glucose is so unimportant why has the pharmaceutical industry spent so much money on developing drugs (short-acting insulin secretagogues) that specifically blunt this response? And if this response can be blunted by dietary means surely that is a safer, more efficacious option regardless of the lack of long-term confirmatory studies ” or am I being too logical?
superburger
“name a “non-starchy” vegetable that is also a significant source of carbohydrate – and will not affect blood sugar?”
That wasn’t the question, and the original question has already been answered by Michael Cummings.
“you’ve also not been able to describe an alternative diet, differing from the broad advice of D-UK”
My views on this were made explicitly clear in the original blogpost. Do read the bit about including starchy carbohydrates at every meal and see if you can work out how my suggested diet might differ from that recommended by Diabetes UK…
Is this what you’ve resorted to now, superburger, asking questions that have already been answered or don’t need answering because the answer is obvious?
Michael
“Dr. B, does it ever get lonely to be the one pointing out that the emperor has no clothes?”
Never – it seems from the comments here and elsewhere that there are plenty (including yourself) who seem willing and able to demonstrate the erroneous nature of much dietetic dogma.
And even if I was the only one pointing it out, loneliness would be something I’d gladly put up with as this would be more than compensated for by knowing that the exchanges here only further serve to reveal to truth (as well as the apparent attempts of some to obfuscate it).
>>would you, personally, care to name a “non-starchy” vegetable that is also a significant source of carbohydrate – and will not affect blood sugar?
That would be self-contradicting.
“Significant source of carbohydrate” = Starchy (or sugary)
Any non-starchy vegetable won’t affect blood sugar significantly because there is so little carb and the carbs that do exist are very low glycemic (slow acting)
The point of a low-carbo diabetic diet is to get the nutrition you need with as little carbohydrate as possible.
sue
“superburger,
Read The Diet Delusion and you’ll see how the current thinking on diet is so infuriatingly wrong.”
You’ll be lucky!: superburger doesn’t seem able to read and inwardly digest the information here (see comment 97).
Superburger, you say:
“cathy – interesting work you point to – although I would say that the change of lifestyle (high to low physical activity) could be as, or more important than dietary factors.”
– I don’t thinks so! Its a diabetic epidemic with the aboriginals. Its definitely the western diet!
“There is nothing in their description of “low fat, high fibre” coupled with high physical activity that contradicts the recommendations made by D-UK. ”
– There is no way their diet was low in fat and high in fibre- so I dispute that. They ate lots of meat from kangaroos etc.
“Plus there is the obvious possibilty of genetic differences between australin aborignes and UK population.”
– Its the old genetic differences line! I don’t think we as a human race are all that much different when it comes to which foods we do best on.
Read the Diet Delusions and it will all make sense!
Michael re post 97
Seems like you’ve had to give superburger another lesson in elementary nutrition.
Strange how he/she seems to purport to know what’s best for diabetics to eat, don’t you think?
It is telling that all the “refutations” of Dr. B’s post are ad hominem – they attack the man by pointing out that he is not specially trained in appreciating the emperor’s clothes.
The refutations would be more persuasive if they referred to evidence based science and cited studies rather than just repeating the current standard thinking.
Can anybody point to studies that show better health in diabetics by raising their blood sugars? Sorry to be so rude as to point it out, but that is exactly the “standard” line of reasoning.
>>Strange how he/she seems to purport to know what’s best for diabetics to eat, don’t you think?
Indeed.
The logical jump from “Diabetics usually die of coronary disease” to “eat a low-fat diet” is not supported by evidence based science.
The evidence and the logic fail at several points of that chain of reasoning.
It all seems to be founded on a “fear of fat” orthodoxy.
It would be humorous if it were not so tragic.
Michael
“The refutations would be more persuasive if they referred to evidence based science and cited studies…”
Some common sense would be nice too, but I suppose that’s too much to ask for too.
Dr briffa,
I still don’t think you have provided clear answers to any of the following questions, and have instead chosen to dull ad-hom attacks on other people., whilst failing to engage with the science.
Perhaps you have missed the point of my posts, so I will give three questions that would be really interesting if you could anwer.
1) What diet do you propose that diabetics should follow, and what *evidence* do you have that this will be more beneficial than the current D-UK advice.
2) I pointed you towards a review article which contained a series of recommendations for diabetic lifestlye/diet – these were in broad agreement with D-UK’s. Do you agree or disagree with this review and for what reasons?
3) If it is possible that D-UK’s judgment/advice is clouded by their relationship with pill-makers, is it also possible that your advice is clouded by your relationship with pill-maker, BioCard for whom you formulate ‘SucroGuard’
superburger
Glad to see you’ve stopped asking the vegetable/blood sugar question at last (seeing as it had been answered here already and more than once).
“What diet do you propose that diabetics should follow, and what *evidence* do you have that this will be more beneficial than the current D-UK advice.”
As I’ve stated before, my recommendations here are obvious from the blogpost above. Also, take a little trawl through this site and you’ll see that I’ve made similar recommendations many times before.
As regards the evidence, you might start by looking here http://www.drbriffa.com/blog/2008/04/14/doctors-details-the-benefits-of-carbohydrate-restriction-in-diabetics/
and here http://www.drbriffa.com/blog/2008/01/11/meta-analysis-show-superiority-of-lower-carb-diets-in-diabetes-but-further-studies-said-to-be-needed-why/
Also, perhaps you might likes to read and inwardly digest the comments of many here who believe that low-carbohydrate regimes have helped them control their diabetes (which utterly mirror my own experience in practice, by the way).
Oh, and then there’s the little matter of common sense.
But why do I think none of this will matter much to you, superburger? I mean, what could matter more than what looks like your attempts to obfuscate the truth and discredit me? I’ll tell you what: other people’s lives. Because that is the real issue at the root of this blogpost, in case the fact passed you by.
“I pointed you towards a review article which contained a series of recommendations for diabetic lifestlye/diet – these were in broad agreement with D-UK’s. Do you agree or disagree with this review and for what reasons?”
This blog post wasn’t about this review article, was it? It was about Diabetes UK’s advice. Would it be all right with you if we stuck with the subject matter here?
Can you point to the science which specifically demonstrates that my suggestion that Diabetes UK’s advice is flawed (as detailed above) is just plain wrong?
“If it is possible that D-UK’s judgment/advice is clouded by their relationship with pill-makers, is it also possible that your advice is clouded by your relationship with pill-maker, BioCard for whom you formulate ‘SucroGuard'”
First of all ‘formulate’ should be ‘formulated’ (it’s not an ongoing process, superburger, it was something that was done, if my memory serves me correctly, about a decade ago and has not been revisited since).
With regard to whether my advice is clouded by this fact, would you please care to articulate how this might be? Just explain how me formulating a nutritional product that may help diabetics is inconsistent with my desire for diabetics to get the truthful and accurate nutritional advice.
Dr B – the timing of these comments seem to be all over the place, I posted this afer 108 but it turned up as 94. I’m reposting as I didn’t want Michael to miss it:
“It is telling that all the “refutations” of Dr. B’s post are ad hominem – they attack the man by pointing out that he is not specially trained in appreciating the emperor’s clothes.”
MC – care to give an example?
“First up, how would you propose we could have measured rates of obesity in paleo populations with any degree of accuracy?”
Good point, but I specified morbid obesity – which I think is the proverbial elephant in the room. We know it when we see it. Basically obesity to the point that a person is incapacitated (such that they cannot run, jump or climb), due to their fat levels.
“Second, would you agree that the abundance of food in the western idiet is probably far higher than our paleo ancestors – couldn’t your supposed rates of obesity in either population be explained simply by higher calorific intake?
No. There is little evidence that there was a lack of food in hunter-gatherer societies. I mean, why not kill two mammoth/bison rather than one? Have you ever watched Ray Mears or Bush-Tucker Man? There is food all around – you just have to know where to look. I don’t believe HGs went around in a state of chronic starvation. In fact nobody can remain in a state of chronic hunger for long. That is why most calorie restricted diets fail. There comes a point when you HAVE to address hunger. I would agree that in one way or another they compel us to eat more – refined carbs seem to mislead our appetite (such that we can eat ourselves in to a state of immobility). I think it is likely that refined carbohydrates offer ‘poor satiaety’. I guess that as we evolved in a carbohydrate-scarce environment, our bodies have had little chance to adapt to this food source. I can see a case for our bodies compelling us to over indulge on such a valuable energy source that would only be available on occasion (such as honey). Refined carbs promptly allow us to replace glycogen.
Superburger, by “a negative effect on LDL.” I meant an increase in LDL Subtype B (the small dense LDL), rather than an increase in LDL per se.
I followed your link but it did not seem to differentiate between subtypes of LDL – although I only saw the abstract! I should also point out that the study observed an increase in LDL after 8 weeks on a paleo style diet. I have been on a similar diet for over a year and according to the Framingham template, my cholesterol is fine. This makes me think that the study you point to does not look at LDL subtypes and so misses an acknowledged marker for CHD etc…. as I am sure my LDL must have responded similarly, but the Framingham Template gave me a thumbs up for my health – so I guess the increase in LDL was of the benign type (Subtype A).
Cheers,
Michael
Oh, don’t worry about the tragic nature of the advice: it’s only other people’s lives that are at stake, after all.
>>Oh, don’t worry about the tragic nature of the advice: it’s only other people’s lives that are at stake, after all.
Yes, there is that small issue.
dr briffa,
your blog post claims there are flaws with D-UK’s advice and you imply that their relationship with pill-makers may be the reason for this apparently flawed advice. Correct?
I suggest to you that there *is* an evidence base for the broad approach that they suggest – evidence for this is, for example, the large review article I point towards. Do you agree?
You have still failed to engage with contents of this review – because it prevents evidence contrary to your own position. Whilst it isn’t in the blog post – it *does* offer a rationale for D-UKs advice. Do you agree?
Of course, it is possible that the current approach advised by D-UK is wrong, or at least not wholly correct. There’s no harm in suggesting so, and discussing the benefits of the low-carb approach. (although in your blog post you failed to provide any evidence for your position in the form of references to peer reviewd journals). I think you would have to agree with this.
w.r.t. the meta-analysis (kirk et al), the main problem, to me, seems to be that most of the studies included were short duration, so the long term effects of low-carb diets are still unlcear (and diabetics are a diverse group so D-UK’s advice needs to be the best for the broadest range of people. That doesn’t prevent the work being interesting or exciting, of course. Fair comment?
Personally, i would place a lower weight than you on personal anecdote, as personal experience carries quite a low weighting on the evidence base scale (though of course, is a starting point for further study). Do you agree with my thoughts on this?
However, the tone of your blog post is that it is a relationship with drug companies which is clouding the judgement of D-UK.
But, what is sauce for the goose, must also be sauce for the gander – you too have a relationship with a drug company (Sucroguard is still on sale) so why is it not possible that *your* judgment is clouded by your commercial relationships. Why is this not a legitimate question?
i have no reason to wish to discredit you, I hope you can accept this. The science and the ideas are interesting, not dull ad-homs.
superburger
“You have still failed to engage with contents of this review – because it prevents evidence contrary to your own position. Whilst it isn’t in the blog post – it *does* offer a rationale for D-UKs advice. Do you agree?”
That’s not the point, is it? The real point (in case you missed it) is that the there is evidence (and common sense) which contradicts Diabetes UK’s advice and shows that the advice to be inadequate.
“Of course, it is possible that the current approach advised by D-UK is wrong, or at least not wholly correct. There’s no harm in suggesting so, and discussing the benefits of the low-carb approach.”
It seems we’re actually getting somewhere with you, superburger. Seems like the nutritional lessons imparted here are having some effect.
“(although in your blog post you failed to provide any evidence for your position in the form of references to peer reviewd journals). I think you would have to agree with this.”
That’s true, but there is quite a lot of evidence discussed on my site which does support my assertions. I think you would have to agree with this.
“w.r.t. the meta-analysis (kirk et al), the main problem, to me, seems to be that most of the studies included were short duration, so the long term effects of low-carb diets are still unlcear (and diabetics are a diverse group so D-UK’s advice needs to be the best for the broadest range of people. That doesn’t prevent the work being interesting or exciting, of course. Fair comment?”
No, not really, unless you have better evidence that proves my assertions to be wrong. Fair comment? So, if you have such evidence, then please quote it here.
“Personally, i would place a lower weight than you on personal anecdote, as personal experience carries quite a low weighting on the evidence base scale (though of course, is a starting point for further study). Do you agree with my thoughts on this?”
No, I don’t. It’s not just personal anecdotes, is it? It’s the science, also. And then there’s the matter of common sense. Put all three together and you’ll maybe see the rationale for my opinion regarding the best diet for diabetics.
“you too have a relationship with a drug company (Sucroguard is still on sale) so why is it not possible that *your* judgment is clouded by your commercial relationships. Why is this not a legitimate question?
As I said, just tell me HOW the fact that I formulated a nutritional supplement that might benefit diabetics (for which I have never received any financial remuneration) might be clouding my judgment regarding the best diet for diabetics.
Ross,
Post 29:
“Catherine Collins RD says:
Sarah Spiers and Adam
Welcome to the ‘Curious World of Dr Briffa and friends’! ”
The rest of the post continues the same way – implying that Dr Briffa and all the low carbers are crackpots.
And yet, somehow the idea of pushing carbs on somebody with a broken carb metabolism is supposed to make sense?
———
““You have still failed to engage with contents of this review – because it prevents evidence contrary to your own position. Whilst it isn’t in the blog post – it *does* offer a rationale for D-UKs advice. Do you agree?”
That’s not the point, is it? The real point (in case you missed it) is that the there is evidence (and common sense) which contradicts Diabetes UK’s advice and shows that the advice to be inadequate. ”
———
for me, dr briffa, that *is* the point.
There is a body of evidence which suggests that D-UK’s advice is sensible. You don’t acknowledge this, but it is true.
There is also some evidence that, for example, a low-carb diet is effective. However, the large review does discuss this, and suggests that there is not enough evidence to recommend it to the broad spectrum of diabetics.
Dietary advice is not an article of faith, and nothing would make me happier if new dietary model (perhaps not even a model discussed here at all!) was proven to be effective and made diabetics lives longer and healthier (my own grandmother is type II, broadly follows D-UK-type advice and is as healthy as any woman pusing 90 can be, but that’s just an anecdote!)
I have consistantly agreed that work on alternative diets is interesting and important and engaged with the science as much as possible. You, on the other hand, seem blind to the notion that D-UK have based their advice on science too.
———-
““w.r.t. the meta-analysis (kirk et al), the main problem, to me, seems to be that most of the studies included were short duration, so the long term effects of low-carb diets are still unlcear (and diabetics are a diverse group so D-UK’s advice needs to be the best for the broadest range of people. That doesn’t prevent the work being interesting or exciting, of course. Fair comment?”
No, not really, unless you have better evidence that proves my assertions to be wrong. Fair comment? So, if you have such evidence, then please quote it here.”
——–
I didn’t say you were ‘wrong.’ I just pointed out a fact relating to the meta-analysis (i.e. short duration of studies gives no indication of long-term effectiveness). It doesn’t prevent it being exciting work though and worth persuing.
w.r.t your relationship with BioCare. I will spell it out very simply.
If D-UK have a relationship with drug companies, and you imply that their judgement could be clouded by this relationship – then why is it not possible that your judgement is clouded by your own continuing relationship with BioCare – because the more SucroGuard they shift, the greater the awareness of your own ‘personal brand’.
I do not, in any circumstance claim that either you, or D-UK, are in any way affected by your business dealings (although D-UK are a charity)
Like i say, what is sauce for the goose……..
superburger
““You have still failed to engage with contents of this review – because it prevents evidence contrary to your own position. Whilst it isn’t in the blog post – it *does* offer a rationale for D-UKs advice. Do you agree?”
Perhaps you need to re-read the above blogpost ” it’s centred around the notion that starchy carbohydrates should be included in diabetics’ every meal. Does the review you cite address this point specifically, because if it doesn’t, it’s essentially irrelevant to the debate here, right? So, please quote the science that disproves my assertions, or let’s move on.
“There is a body of evidence which suggests that D-UK’s advice is sensible. You don’t acknowledge this, but it is true.”
I just don’t agree with this, on the basis of the science, clinical experience and common sense. As I said, if you have evidence that specifically disproves my assertions, then quote it. The specific studies please.
“(my own grandmother is type II, broadly follows D-UK-type advice and is as healthy as any woman pusing 90 can be, but that’s just an anecdote!)”
Yes, it is just an anecdote, so why mention it at all, seeing as you have some a dim opinion of anecdote? What’s sauce for the goose, and all that…
“I have consistantly agreed that work on alternative diets is interesting and important and engaged with the science as much as possible. You, on the other hand, seem blind to the notion that D-UK have based their advice on science too.”
That’s just not true as it relates to the point about how much carbohydrate diabetics should eat. So please stop suggesting it is. I suggest it is you who is blind.
“I didn’t say you were ‘wrong.’ I just pointed out a fact relating to the meta-analysis (i.e. short duration of studies gives no indication of long-term effectiveness). It doesn’t prevent it being exciting work though and worth persuing.”
Again, it seems we’re perhaps getting somewhere with you, superburger.
“If D-UK have a relationship with drug companies, and you imply that their judgement could be clouded by this relationship – then why is it not possible that your judgement is clouded by your own continuing relationship with BioCare – because the more SucroGuard they shift, the greater the awareness of your own ‘personal brand’.”
So, how does greater awareness of my ‘personal brand’ (which you assert but which I think is a spurious diversion) potentially cloud my judgment regarding the nutritional advice I give diabetics? Please do explain, because I am not getting it. No, really.
MC “Post 29: “Catherine Collins RD says: Sarah Spiers and Adam Welcome to the ‘Curious World of Dr Briffa and friends’! ”The rest of the post continues the same way – implying that Dr Briffa and all the low carbers are crackpots. And yet, somehow the idea of pushing carbs on somebody with a broken carb metabolism is supposed to make sense?”
Firstly, you said all the refuatations of Dr B’s arguments were ad hom. Clearly they aren’t. Secondly, the Catherine Collins post criticises Dr B’s approach to debate. Whether you agree with the tone she has adopted or not, or whether you think those criticims are warranted or not, it’s not an ad hom argument.
Superburger – I don’t want really want to get drawn in to this argument – I, like a lot of people, have drawn my own conclusions about what constitutes a balanced diet and all health indicators (thus far), suggest I am doing something right. (And I am not evening taking Sucraguard) 😉
However, my question is that do you not think that DUK’s nutritional advice is given as “an article of faith”? There is little on their site to suggest that their nutritional advice is anything other than ‘one size fits all’.
Personally speaking, if I had diabetes (or any disease/illness),
I would be absolutely furious if I was not informed of an alternative solution to a medication approach – particularly if other patients with the same condition had removed their need for medication completely – with something as simple as a change to diet. This comes back to an idea of treating the cause rather than the symptom.
Looking at it another way, has ANYONE ever managed to control their diabetes to the extent of not requiring medication, simply by following the official DUK nutritional advice?
By association, if ANY diabetic has completely removed their need for medication by following an alternative nutritional pattern, why aren’t DUK heavily researching it given their objectives? As you say, a particular diet may not suit everyone, but if a particular diet assists 5, 10 or 20% of the diabetic population to a point of not needing medication, then is this not a worthy area for study? Given their objectives you’d think it would be encumbent on DUK to investigate this approach because if they don’t investigate the long term consequence of paleo-type diets, who will? By doing so, DUK will have fullfilled their objectives to ALL their demographic by being able to offer more precise/personalised advice without causing further damage (someing that their current advice clearly does in some cases).
I am glad your own grandmother is doing well on DUK advice but how do you know she wouldn’t do better on a paleo diet? Given that she has type II, I would not say she “is as healthy as any woman pusing 90 can be”, as diabetes is not inevitable with age.
ross
Here’s a more fulsome version of Catherine Collins’ (RD) comments:
“Welcome to the ‘Curious World of Dr Briffa and friends’!
Sarah – I hope you weren’t hoping to join some meaningful debate on the relative merits of one dietary approach versus another. If so, I hate to disillusion you – but this really isn’t the website on which to do it.
Dr B doesn’t do meaningful debate. He does mocking comments (based on his own unique interpretation of the medical research) and deliberate misinterpretation of your comments readily supported by his band of merry supporters (you have already met ‘Cathy’, ‘Hilda’ and ‘John’).
All in the hope that by your 4th patient, evidence based reply to his facetious/ insulting/ incorrect comments you will admit defeat, and kindly go away so Dr B and friends can post unpleasant comments about yourself, your organisation, and any collateral bodies.”
Here is what my Chambers dictionary defines as the meaning of ad hominem:
1. appealing to one’s audience’s prejudices rather than their reason
2. attacking one’s opponent’s character rather than their argument
Now read Catherine Collins’ comments again. They seem pretty ad hominem to me.
And anyway, this matters very little compared to the fact that she and Sara Spiers (and others) have singularly failed to produce anything in terms of science (or common sense) to refute my claim that it’s not good advice to suggest that diabetics include starchy carbohydrates with every meal.
So, let not get too diverted from that, however unpalatable that truth may be for you and others.
And while we’re on the subject of diversion, please do get back to us on your identity and potential conflicts of interest, as well as the ‘good evidence’ you claim exists which supposedly vindicates MMR with respect to autism.
See here: http://www.drbriffa.com/blog/2008/06/23/bmj-article-explores-the-cosy-relationship-that-drug-companies-often-have-with-doctors-considered-%e2%80%98key-opinion-leaders%e2%80%99/
We’ll have to agree to disagree about Catherine’s comments. I read them as valid criticism written in a somewhat gladitatorial style, not as the usual ad hom logical fallacy.
But you must agree that MC’s argument that all refutations of your position are ad hom attacks is a false one?
I’ve already got back to you, here:
http://www.drbriffa.com/blog/2008/06/23/bmj-article-explores-the-cosy-relationship-that-drug-companies-often-have-with-doctors-considered-%e2%80%98key-opinion-leaders%e2%80%99/
Juts to be clear, you state:
‘as well as the ‘good evidence’ you claim exists which supposedly vindicates MMR with respect to autism.’
My actual assertion, as you quoted in the other post, was
“…there is a lot of good evidence that shows no correlation between MMR and autism.”
I’d hate for my position on this to be misrepresented.
dr briffa,
if you want to go back to MMR/autism, that’s fine – i still believe you were going to write a blog about the experiments you would like to see done to prove/disprove a link between MMR and autism. In particular it would be interesting yo know what result(s) would demonstrate beyond rational doubt that MMR is not linked to autism. I think you acknowledged that such a result existed, but were’nt ready to reveal it?
anyway, as for D-UK’s advice. As my last post went missing in the electronic ether, i will cut it down to this
your blog post here is ca 50% about the relationship between D-UK and drug companies and the implication is that their advice is clouded because of this relationship.
I suggest to you that the overhwhelming majority of D-UKs advice is based on sound evidence (don’t smoke, physical activity good, excess alcohol bad). Their specific advice on carbs has a genuine evidence base – and w.r.t low carb diets there is an excellent review which acknowledges possible benefits but cannot recommend for long term as not enough evidence. I think this is a fair summary.
Now, key to all of this is your notion that the drug company link may cloud D-UK’s thinking. i say to you that ther advice is evidence based, but obviously can and should change in the face of any significant weight of new evidence.
I believe ‘carbs at every meal’ advice is based upon the need to make dietary advice easy to follow for a large number of people(including the elderley) and it has been suggested that a qualitiative ‘plate’ approach at each meal is useful (camelon et al, J Am Diet Assoc, 1998, 98, 1155-1158). I think D-UK are very aware that individual diabetics should be managed by GPs/RDs/nurses, but aim to offer broad advice.
if D-UK’s advice should be viewed through the prism of their relationship with a pill-seller, then surely all advice re: diabetes should be viewed through the prism of the advisors relationsip with a pill-seller. None of which means that briffa, D-UK or anyone else has their advice distorted, of course.
cheers.
superburger
Common sense, science and my clinical experience all demonstrate that Diabetes UK’s advice for diabetics to include starchy carbohydrates with every meal is bad advice. Never mind, just keep attempting to divert us from this with your talk about this body’s ‘broad’ advice and the need to make things ‘simple’.
“if D-UK’s advice should be viewed through the prism of their relationship with a pill-seller, then surely all advice re: diabetes should be viewed through the prism of the advisors relationsip with a pill-seller.”
Except that Diabetes UK’s ‘corporate sponsors’ may stand to gain from this charity dispensing bad dietary advice, while I don’t. Hit a bit of a dead end with this one, didn’t you?
dr briffa,
i’m not trying to divert, I just don’t think you recognise the shades of grey that exist. D-UK’s advice is evidence based – although contrary evidence does exist and is acknowledged.
I would say that it is extremely important to make diabetic dietary advice simple – given the age range of people who suffer diabetes. i point, for example, to the ‘plate’ model as a method of giving qualitative advice to groups who may not have the capacity to think in terms of percentages and grams every day, or when confronted with ‘difficult’ choices when dining socially.
i fully appreciate that you don’t agree with D-UKs advice -but i am suprised that you don’t conceed that it is evidence based and much of thei other advice is excellent for the general population too! (don’t smoke, exercise more, cut down on alcohol, plenty of fresh veg and oily fish, don’t waste money on vitamin tablets and supplements unless indicated).
Given your obvious interest and concern for the topic – have you considered putting together a short communication / letter to one of the diabetes journals to raise the topic in the open academic literature?
Perhaps that is the best way to raise your concerns to the widest possible audience of people able to have the most influence?
Hypothetically, if you did submit such a communication for peer review would you declare your relationship with BioCare (as formulator of SucroGuard) as a conflict of interest?
cheers.
superburger
On the point regarding Diabetes UK’s advice for diabetics to include starchy carbohydrates in every meal, I don’t think there is much in the way of “shades of grey’ here. It’s just bad advice. And, yes, you are diverting, and my sense is that I’m not the only one who had noticed.
“Hypothetically, if you did submit such a communication for peer review would you declare your relationship with BioCare (as formulator of SucroGuard) as a conflict of interest?”
Still banding on about this, superburger, even though you hit the buffers with it before? Oh, the desperation!
dr briffa,
i think i pointed out to you an evidence base for both the carbohydrate levels and spacing recommend by D-UK. You haven’t acknowledged or discussed them. That’s your choice.
but, seriously, have you thought about writing up a short communication to put your concerns across to a wide audience? If your concerns are real and think there is a scientific case for making D-UK change their advice, surely the best thing to do is submit a communication or letter, detaling the evidence. Maybe even a mini-review?
is that something you are interested in?
*Hypothetically* if you did submit such a communication for peer review would you declare your relationship with BioCare (as formulator of SucroGuard) as a conflict of interest?”
superburger
Still the same (lame) lines, and a failure to concede that the advice Diabetes UK dispenses regarding starchy carbohydrates at every meal is not support by science, common sense or clinical experience.
dr briffa,
I think i’ve pointed you towards the reason i have for suggesting D-UK have evidence to suggest that using a ‘plate’ model at meal times has advantages (hence starchy-carbs at meals) along with the scientific evidence supporting DUKs other advice for their diet and lifestlye advice. I shan’t do so again.
it seems we’ve reached an impasse, you have strong views about the flaws in D-UKs advice. With the best will in the world, this blog won’t change a thing.
If you have “science, commen sense and clinical experience” on your side why don’t you write it all up, submit it for peer review and publish it? Youve stated before that ‘lives are at stake’.
If the evidence is as compelling as you make out, then a good communication, or mini-review submitted could start D-UKs proverbial ball rolling.
Is there any particular reason preventing you putting together a communication or letter? (appreciate reviews might be rather time demanding)
When writng such an article would you declare any CoIs? (clue, it’s a yes/no asnwer)
cheers,
superburger
So, after asking questions that have already been answered as well as others that don’t need answering because the answer is obvious, you’ve resorted to asking hypothetical questions (more than once).
Gosh, how some will do all they can to divert attention away from the truth, it seems.
Do please persist with these tactics though, superburger, because they do serve again and again to draw our attention to the assertions that I made in the original post, as well as the fact that no-one (including you) has been able to prove them wrong.
“Still the same (lame) lines, and a failure to concede that the advice Diabetes UK dispenses regarding starchy carbohydrates at every meal is not support by science, common sense or clinical experience.”
The way you have presented such a distorted version of the Diabetes Uk website would leave the casual reader with the impression that your assertions in the above article are fair. They are not; the information presented on D.Uk is fully inline with best clinical practice and is supported by solid peer reviewed science.
I find it rather sad that you have failed to engage rationally with the points superburger has raised and particularly troubling that you seem unable to produce *any* peer reviewed data that would support your claims re low carb diets; your attempts at smoke screen with inversion of proof deflection and patronising ad-hominem attack are beneath contempt – especially for a ‘qualified’ medical doctor.
But perhaps most tragic of all is your stamped-foot arrogance that your association with Sucroguard does not present a conflict of interest when it clearly does so.
grooverider
Do please quote the ‘solid peer reviewed science’ which demonstrates that including starchy carbohydrates with every meal is the best dietary advice for diabetics. And do inject some common sense too here. Or some of your clinical experience (if you have any). And perhaps comment on the experiences of individuals here who have benefited from carbohydrate control? Preferably, do ALL of these things.
And I’ll ask you, like I asked superburger, HOW me formulating Sucroguard may have influenced the advice I give to diabetics that would be of benefit to me and of detriment to them? Note how superburger was unable to address this point in any meaningful way. Perhaps you’ll have better luck.
dr briffa, rather than attempt to prove you wrong, i’ve attempted to explain why D-UK’s advice is evidence based and valid. Anyone reading these posts will notice how, not once, have you chosen to engage with any of the papers I point to, or arguments I raise. Indeed, i readily agreed that there is lots of interesting work pointing towards alternative approaches to diabetes and they may yet prove to be a new way forward. I don’t see that as a mark of failure, incidentally.
By contrast, you have failed to point directly to any peer reviewed evidence to support your position. You indirectly pointed to an interesting meta-analysis, and I discussed its merits and drawbacks and pointed out that the concepts it raised were (possible benefit of low-carb high protein diet) also discussed in a large review article in diabetes care.
I suspect this could go on forever. So i shall ask just a couple of questions, and let blog-readers interpret your answers for themselves.
1) Given you say “lives are at stake” will you consider submitting a piece of work for peer review, detailing the failings of the DUK approach based on “science, commons sense and clinical experience.” If not, why not? Nowhere have you answered this question, not has anyone answered on your behalf….
2) given the overall theme of this blog was, inter alia, conflicts of interest. Would you declare a CoI if you were to submit something for peer review? This has not been answered directly.
cheers.
superburger
Again you attempt to lead us away from the point that telling diabetics to eat starchy carbphydrates at each meal looks like singularly bad advice.
And, again, you round off with a hypothetical and irrelevant question.
I do want to thank you for one thing, though: my sense is that your persistent attempts to divert attention from the real issue at hand here will cause even more individuals to question the validity of the dietary advice so commonly given to diabetics. And that HAS to be a good thing, I reckon.
Cheers.
“Again you attempt to lead us away from the point that telling diabetics to eat starchy carbphydrates at each meal looks like singularly bad advice.”
dr briffa,
why do you disagree with the D-UK ideas of carbohydrate based meals with general advie to facour the low GI carbs?
http://www.diabetes.org.uk/Guide-to-diabetes/Food_and_recipes/Food_and_diabetes/Eating_well/
The below meta analysis suggest this is a valid approach with good evidence. I suggest your readers study it themeselves and make their own conclusions.
Anderson et al, Journal of the American College of Nutrition, Vol. 23, No. 1, 5-17 (2004)
(the every meal concept is also supported by the camelon et al paper on food ‘plates’)
cheers.
superburger
From the abstract it appearts the Anderson paper doesn’t even consider low-carbohydrate diets, so how is it relevant here? The answer, of course, is that it isn’t.
Cheers!
Dr Briffa wrote:
“Do please quote the ‘solid peer reviewed science’ which demonstrates that including starchy carbohydrates with every meal is the best dietary advice for diabetics. ”
A distortion of my post, which clearly states that “the information presented on D.Uk is fully inline with best clinical practice and is supported by solid peer reviewed science.” Superburger has already provided link to review articles.
“And I’ll ask you, like I asked superburger, HOW me formulating Sucroguard may have influenced the advice I give to diabetics that would be of benefit to me and of detriment to them?”
Well, presumably you could recommend this product, which has no evidence base behind it, to be taken by those needing ‘blood glucose support’, which could include diabetics? Of course I could be horribly mistaken, and if this is the case please feel free to advise me which individuals Sucroguard may offer a beneficial and cost-effective means of ‘blood glucose support’.
Superburger the Anderson review beautifully demonstrates the statistical shenanigans the low fat brigade resort to when trying to shore up the hypothesis
They claimed that the meta-analysis included 12 studies with a “low carb” group defined as < 30% carb calories:
Let’s see…
26) Anderson compared 70% HF carb vs 43% in 10 patients in a ward study for a few days
27) Anderson compared 70% HF carb vs 43% in 20 lean diabetics a ward study for a few days and both diets were hypocaloric (~1800 calories)
28) and 29) 30) no abstracts
31) Hoffman, 68% vs 42% carbs, conclusion “These studies indicate that short-term HFHC diets without caloric restriction were ineffective in improving glycemic control or lessening insulin resistance in very obese patients with type II diabetes.”
32) Ward 7 type 2 diabetics for 6 weeks ” no values given for carbs
33) Taskinen, 10 IDDM patients, 60% carbs vs no control period/group defined. Conclusion “[A] high-carbohydrate, high-fiber, low-fat diet did not deteriorate the diabetic control, and it had no unfavorable effects on serum lipids or lipoproteins.”
34) Pacy ” “Comparison of the hypotensive and metabolic effects of bendrofluazide therapy and a high fibre, low fat, low sodium diet in diabetic subjects with mild hypertension.” No mention of carbs.
35) Anderson, no control and looked at adherence 14 subjects
36) Simpson, 13 subjects, poorly controlled obese type 2, 60% HF vs 28% LF (pre diet values), 22 days duration. Insulin binding ” no change, FFAs ” no change, TC ” lower, HDL-C lower
37) 10 type 2 diabetics, 2 weeks of 28% vs 65% carb (and 2X2 weeks using other ratios. Conclusion: “The results of this study confirmed the importance of high fiber and low fat in improving metabolic control in Type II diabetes. In conclusion, if high-carbohydrate, low-fat diets are to be recommended to patients with diabetes, it is essential that the type of carbohydrate recommended be unrefined and high in fiber.”
38) Anderson, 10 lean IDDM subjects, 70% HF (a whopping 72g) vs 38% LF (11g) carbs. Various drugs that alter glucose metabolism given to subjects during the study confounding to some extent.
So not many of these studies met their own < 30% stipulation and appeared to be typical SAD diets. I’d call that dishonest, as is including the Hoffman study when it doesn’t support his theory at all. Not only that but in all the above studies bodyweight did not change. How does this support weight loss in fat diabetics?
If they wanted to compare low vs high carb they should have left other variables like fibre the same because it is a huge confounder.
Study 27: ” what the researchers neglect to mention is the higher fibre diet would yield butyrate, propionate and acetate, which are readily absorbed through the intestinal wall. In the right ratios these short chain fatty acids can have a hypocholesterolaemic effect by themselves. At normal intakes ~25g fibre can provide up to 10% SCFA contribution to daily caloric intake. This study used 65g fibre ” potentially providing 26% of the calories from FAT! Added to the ingested fat level of 9% gives 35% fat. Instead of a carb:protein:fat ratio of 70:20:10 it looks more like 44:20:35 which is almost exactly the same as the control (SAD) diet with one notable difference ” most of the 37% fat in the control group was monounsaturated but as described above most of the fat in the “high carb” was SCFA ” i.e. saturated. In study 38 the SCFA contribution from 72g fibre would have been even higher. It does mention SCFA in the discussion “Whereas the mechanisms by which dietary fiber increases insulin sensitivity are not well delineated, alterations in gastrointestinal function (52) and short-chain fatty acids (50, 51) may make major contributions.”
Number 50 is his own rat study “Thus propionate, which inhibits hepatic acetate metabolism, acts to increase glucose use and decrease glucose production.”
So he is well aware of fibre’s confounding effects when waxing lyrical on the benefits of high carbohydrate ” when the beneficial effects would be achieved by drinking Metamucil daily: http://tinyurl.com/5w9875
And why leave out this low carb study (20%) with 31 subjects, a control group and 44-month follow-up when it fit their criteria?
“We have previously reported the results of these dietary changes over 6 months in 16 obese type 2 diabetes patients with a control group. In 2003, the 16 were advised to lower their carbohydrate intake to 20% of energy. In the course of 6 months, they achieved significantly better control of hyperglycemia and bodyweight than a control group of similar patients (n = 15) advised to follow the official guidelines where 55% carbohydrates is recommended [5]. We have further reported that the improvements were stable over 22 months [6].” http://tinyurl.com/684c9r
In summary, the “weight of the evidence” that low carbohydrate diet is “bad”, or that a high carbohydrate diet per se is “good” is not really there at all.
“The most effective diabetes diet, based on a detailed review and meta-analysis of the literature, is a higher carbohydrate, higher fiber diet.”
I don’t agree – its not the most effective – if it works at all. If the Anderson paper looked at low carb it would have found it the most effective diet for diabetes.
Read the Diet Delusions:
“Taubes traces how the common assumption that carbohdrates are fattendng was abandoned in the 1960s when fat and cholesterol were blamed for heart disease and then – wrongly – were seen as the causes of a host of other maladies, including cancer. He shows us how these unproven hypotheses were emphatically embraced by authorities in nutrition, public health, and clinical medicine, in spite of how well-convceived clinical trials have consistently refuted them.”
Peer-reviewed are supposed to be the be all in studies – well take a read of this post from Dr Michael Eades:
http://www.proteinpower.com/drmike/obesity/another-china-study/
grooverider
“Do please quote the ‘solid peer reviewed science’ which demonstrates that including starchy carbohydrates with every meal is the best dietary advice for diabetics. ”
A distortion of my post, which clearly states that “the information presented on D.Uk is fully inline with best clinical practice and is supported by solid peer reviewed science.” Superburger has already provided link to review articles.”
The point I made in the blog (please read it if you haven’t already) is that it’s bad advice (I think) to advise diabetics to consume starchy carbs with every meal. You have failed to deal with it. So has ‘superburger’. The rest is a diversion. Nice try, but I’m (and others) are not buying it.
“Well, presumably you could recommend this product, which has no evidence base behind it, to be taken by those needing ‘blood glucose support’, which could include diabetics?”
Yes, I could recommend Sucroguard to diabetics in my practice. But, please answer how that might influence the dietary advice I give diabetics in a way that might be to their detriment and/or my gain?
dr briffa, you seem to have become confused.
firstly, i offered the Anderson metaanalysis to show *that there is evidence* to support to high carb approach suggested by D-UK. Do you dispute that this article constitues a body of evidence?
secondly, if one reads the paper (it’s open access so no reason not to) there is actually some discussion of lower-carb diets with higher carb diets (they compare “medium carb high fibre” and “high carb high fibre” diets). They concluded the higher carbohydrate diet improved all indicators of glycaemia.
Dr briffa, you see, there *is* evidence for the D-UK approach. Whether you agree or not, is your choice, but to say there is no evidence supporting the DUK approach is simply not true.
superburger
Seems like you’ve not read Cathy’s critique of the Anderson paper above (perhaps you should).
Also, ‘lower’ (with respect to carbohydrate intake) does not necessarily mean ‘low’.
But that’s fine, you keep up the good work of supporting and defending the idea that individuals whose primary problem is handling sugar in the body should include foods that are generally disruptive to blood sugar at every meal.
Nice work (unless, of course, you’re a diabetic and your life depends on getting the best and most appropriate dietary advice).
dr briffa, i really don’t think you understand why i point towards the anderson metaanalysis.
It provides, whether you like it or not, evidence that the high carb, high fibre, low fat, tend towards low GI approach suggested by the major western diabetes associations and charities does have an evidence base. Do you agree with this?
But in any case, i would say the strength of this metanalysis is that it demonstrates the existance of the evidence base for D-UKs approach – not that it ‘disproves’ any other position per se.
In any case, dr briffa, if as you say “lives are at stake” and you have “science, common sense and clinical experience” to demonstrate that DUKs position is wrong, have you thought about submitting your findings for peer review, in order to change the DUK position?
Think that would be more productive and benefical than a blog on this interesting topic….
“Seems like you’ve not read Cathy’s critique of the Anderson paper above (perhaps you should).”
She said:
“Not only that but in all the above studies bodyweight did not change. How does this support weight loss in fat diabetics?”
A brief skim through the abstracts reveals:
26) “followed them for an average of 15 months while they were on maintenance diets at home…” #
(So this just just a ‘ward study for a few days’?)
27) “Diets were designed to be weight-maintaining”
31) “The short-term effects of a weight-maintenance diet high in fiber and carbohydrate (HFHC) was studied in seven very obese individuals with type II diabetes mellitus”
32) “There was no significant difference in weight during either (traditional low carbohydrate or isocaloric high carbohydrate, high fibre) dietary period.”
33) Weight was not a measured outcome of the study
34) “Both groups lost weight, the weight loss being greater in those receiving dietary therapy.”
35) Weight was not a measured outcome of the study
36) Weight was not a measured outcome of the study
37) Weight was not a measured outcome of the study
38) Weight was not a measured outcome of the study
I think we should all look a bit more closely at Cathy’s critique.
Dr Briffa;
Having read the exchange between yourself and superburger I’m have to say you are the one clearly dodging the issue.
If you feel that D-UK’s advice is wrong write up your evidence, they already have a body of evidence for their approach. If they are influenced by their association with pharmaceutical companies, how are you immune?
I have type 2 diabetes that I control by diet and exercise and have found that the best diet for me is low-carb. Even so, there is no evidence that D-UK’s advice (which I also got when I was first diagnosed) is motivated by anything other than concern for my health. My personal hobby horse is that type 2s should use a glucose monitor and find out for themselves what elevates their blood sugar but I do not maintain that what works for me will work for everybody because my personal experience is not evidence!
Mike Kelly
Science, common sense and my clinical experience show that low-carb is best for diabetics. You found the same yourself. Many others (some of whom have posted here) also find the same thing. There are countless forums on the web with accounts from diabetics who have successfully controlled their condition with low-carb eating.
Now, Diabetes UK recommends that starchy carbs should be eaten with every meal, and encourages, to all intents and purposes a high-carb diet.
And you state: “…there is no evidence that D-UK’s advice (which I also got when I was first diagnosed) is motivated by anything other than concern for my health.” I don’t suppose I’ll be the only one to have spotted the disconnect in your thinking here…
Dr Briffa
Science is a method as well as a body of knowledge and is designed to protect you from being mislead by “experience and common sense”. You may well be right and what appears to be working for me may be more generally applicable but you will not find out by standing on a soapbox (or blog) and proclaiming the “truth” to the world. If you believe you’re right, do the work and write it up.
Your habit of avoiding the questions asked of you does not encourage me to think that you’ll take this route; after all you might be wrong, would you be able to cope with that?
Ulf_s. I believe type 2 was only recognised as a separate disease in the 1930s. But you’re quite right, before Banting and Best type 1s were put on low carb diets and mostly died young.
It’s likely that there’s more than one type of NIDDM and maybe not everybody will respond well to the regime I’m on, and maybe in 10 years time I’ll find myself in exactly the same situation I would have been in if I followed the UK-D guidelines plus metformin/avandia/actos/insulin. I note that the recent ACCORD study found that stricter control of blood sugar was associated with higher death rates. This may or may not be relevant. But I’m more than a little convinced, on the basis of the published evidence, that one solution does not fit all.
I’m not pushing my regime, Dr Briffa is pushing his, he should supply the evidence (not anecdote, not “common sense”, not what his personal understanding of the very complicated biochemistry of lipids and carbs would suggest to him). Do the work, publish the work, stop being an arse.
Cathy: “They claimed that the meta-analysis included 12 studies with a “low carb” group defined as < 30% carb calories”
The study does state:
“The levels of carbohydrate intake were classified as follows: high carbohydrate, 60% of energy; moderate carbohydrate, 30% to 59.9% of energy; low carbohydrate, <30% of energy.”
However, I can’t find a reference to 12 studies. Instead it says:
“Twenty-four studies met the inclusion criteria and summary characteristics are presented in Table 2”
It then goes on to say:
“Thirteen studies (Table 2) examined high carbohydrate, high fiber diets (HCHF) with lower carbohydrate, lower fiber diets”
Not, you will notice “low carbohydrate, lower fiber diets”.
So, do you think that the authors erroneously included 13 studies that didn’t fit their review criteria?
Or do you think it more likely that the raw data were classified as per the criteria they have stated, but that the 13 studies selected for review were selected to compare high carbohydrate, high fibre diets with lower carbohydrate, lower fibre diets. As the review authors state.
Dr B – superburger said, ref. the Anderson review:
“Dr briffa, you see, there *is* evidence for the D-UK approach. Whether you agree or not, is your choice, but to say there is no evidence supporting the DUK approach is simply not true.”
You replied:
“Seems like you’ve not read Cathy’s critique of the Anderson paper above (perhaps you should).”
I’ve had a quick look at the review and Cathy’s critique. The review’s evidence still looks solid despite Cathy’s criticisms, i.e. there is evidence to support the DUK approach. Do you have any more substantial criticisms to add? Or would you agree with superburger that:
“It provides, whether you like it or not, evidence that the high carb, high fibre, low fat, tend towards low GI approach suggested by the major western diabetes associations and charities does have an evidence base.”
>>They concluded the higher carbohydrate diet improved all indicators of glycaemia.
I cannot understand how “adding fuel to the fire” can bring the fire under control.
Please explain the mechanism.
A hundred years ago, or just a few decades ago, carb restriction was the obvious answer for diabetics. And they stayed quite healthy on their fatty low carb diets!
Now there’s insulin so diabetics can have all the carbs they want (and they’re encouraged to eat them!) so there’s no need for anyone to feel deprived. And they get all kinds of complications from high blood sugar/high insulin that are considered inevitable, a natural progression…
So what if you, as a diabetic, would end up blind and amputated in a wheelchair because you didn’t want to “restrict” yourself to a low carb diet? Would you think back and fondly remember all the delicious breads, cakes and pasta you enjoyed, and think it was all worth it?
Maybe not.
>>end up blind and amputated in a wheelchair
Tsk Tsk!
You forgot the kidney transplant and heart bypass.
Cathy also states:
“So not many of these studies met their own < 30% stipulation and appeared to be typical SAD diets. ”
There wasn’t a <30% stipulation. The stipulation was to compare high carbohydrate, high fibre diets with lower carbohydrate, lower fibre diets.
“I’d call that dishonest”
I’d be more circumspect in future if I were you.
“as is including the Hoffman study when it doesn’t support his theory at all.”
That’s not dishonest! That was the whole point of the meta-analysis, to review the evidence, not to only review evidence that supports a particular hypothesis.
Mike Kelly might have been wise enough to follow a low carb approach but what about all the others who take everything the Diabetes Educators take as gospel.
Cathy said:
“And why leave out this low carb study (20%) with 31 subjects, a control group and 44-month follow-up when it fit their criteria?”
Nielsen & Joensson, Low-carbohydrate diet in type 2 diabetes: stable improvement of bodyweight and glycemic control during 44 months follow-up.
http://www.nutritionandmetabolism.com/content/3/1/22
Published: 14 June 2006
You mean leave it out of the Anderson review? Anderson et al. Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of the Evidence?
http://www.jacn.org/cgi/content/abstract/23/1/5
Published in the Journal of the American College of Nutrition, Vol. 23, No. 1, 5-17 (2004)?
What a lamentable reflection of modern medical scientific culture is Mike Kelly’s remark that his personal experience isn’t evidence. How very confused we have become.
Ross you completely missed my point. I wasn’t “hiding” the fact they were maintenance diets, just making the observation that it seems pointless to use such diets to recommend very high carb eating when so much of what D-UK recommends is based around losing weight. I don’t know what your Diabetes clinics look like but mine are full of very large people. How are they supposed to follow the dictum “lose weight” when they are being told to eat the high carb diet that DOES NOT promote weight loss?
Think about it Ross ” if these diets promoted weight loss don’t you think the study design would have factored this as an endpoint? It’s akin to taking a snowplough into the desert to prove it doesn’t work. My inner sceptic tells me they deliberately designed the diet as “weight maintenance” to obfuscate the fact that these diets cannot promote weight loss. So using this perverse circular logic how can you claim Anderson’s review supports the notion that high carb diet is good for diabetes when 2 of 3 type 2 diabetics are being told to also lose weight. I have repeatedly heard dieticians telling patients that weight loss is especially important for diabetics because fatness impacts their health more than non-diabetics. What dietary advice should they give to the majority of type 2 diabetics Ross given their fatness is so deadly?
Also, the inference that diabetics are too thick to understand anything more complicated than the plate example is grossly insulting ” is that how you want to be treated by a health professional? Patient = dumb?
Mike Kelly I am pleased you can control your diabetes on diet and exercise alone and I agree that the dieticians and other health professionals are not generally “motivated” (not consciouslessly anyway) by anything other than trying to help people. I have worked in diabetes for years and while some dieticians can be arrogant cows (fair comment because I never met a male one) I’d say most were genuinely trying to help. The problem occurs because the drug industry is so intimately involved in the day-to-day activities of these health professionals ” not just wining and dining but in CME too. These drug company reps were not monsters; they were very personable people and I can say with my hand on my heart that (apart from a couple of exceptions) I genuinely liked them. The system is what I have a problem with ” if most “education” comes from drug reps and pharmaceutical monographs, especially when you work in a resource-limited setting and are “grateful” for these “gifts”, then a large amount of bias seeps into the equation. A bias shown by Anderson’s review ” meta-analyses are supposed to include all studies that fit the criteria, favourable or not, but Anderson et al. stuffed their credibility by cherry-picking ” which is unacceptable in such a large review with such far-reaching consequences.
I have also worked in medical publishing and have seen first-hand how institutions that are supposed to be independent are also a bit too beholden to the drug industry, and how medical and statistical data can be manipulated to look perfectly reasonable and acceptable to health professionals.
Lastly, at the risk of hogging the blog here, I want to recount some very real experience of working in diabetes.
1) Adolescent type 1 diabetics that repeatedly and deliberately under-used insulin because they figured out fairly early on that insulin caused weight gain ” this put them at serious risk of complications due to hyperglycaemia as well as death from DKA.
2) Type 1 diabetes patients that had figured out the carbohydrate-insulin issue by their own endeavours and were controlling BG quite nicely with insulin in single-digit IU ” compared to other patients I had needing > 100 IU twice per day!
3) Both type 1 and 2 diabetics being advised sorbitol-sweetened “diabetic foods” are acceptable when sorbitol is deadly to diabetics (if you want more info on this just ask).
4) Advising both type 1 and 2 diabetics to substitute diet cola for HFCS-sweetened cola as a less-fattening option, when pre-formed caramel is extremely high in advanced glycation end-products, which are also highly problematic for diabetics (ditto above).
So Mike, do you think these adolescents deserve to know that insulin-induced weight gain doesn’t have to be inevitable and they don’t have to risk their own precious lives, limbs, sight (the worst retinopathy I saw was in a 16-year-old doing the sub-optimal insulin thing), kidneys and hearts to avoid it? Or that the big picture is not restricted to macronutrient ratios, or should we just all sit back, put our feet up and let D-UK take this mostly erroneous albeit “well-meaning” stance?
“Ross you completely missed my point.”
Cathy, I think that you have completely missed the point of the Anderson review. You seem to want it to be something it isn’t and then criticise the authors of the review and the individual studies because it doesn’t provide the results you want.
I think it would be more valid to bemoan the lack of studies and evidence for the low carb approach to diabetes management rather than criticise a review of the good studies that have been done examining other approaches.
The Anderson review looks fine to me and I can’t find any examples of the authors engaging in ‘statistical shenanigans’ or being ‘dishonest’. Do you want to retract those words?
I also wouldn’t expect to find the kind of massive error that you accuse the Anderson review of (incl. 13 studies that don’t fit their own reviwe criteria) in an open access peer reviewed journal, certainly I would have expected it to have been picked up after 2 years. If you still think you are correct on this point are you going to write a letter to JACN pointing out this massive howler?
“I wasn’t “hiding” the fact they were maintenance diets”
Well, you said that “Not only that but in all the above studies bodyweight did not change. How does this support weight loss in fat diabetics?”. Not only was this statement incorrect (study 34) but I believe that this was misleading when none of the studies had weight loss as objectives, many didn’t have weight loss as measured outcomes and several required maintenance diets to measure the outcomes that were being studied.
Hence your statement “if these diets promoted weight loss don’t you think the study design would have factored this as an endpoint” doesn’t really make sense when the studies were looking at very specific outcomes or were even looking at the effects of a maintenance diet (31). For example:
27) The effects of high-carbohydrate, high plant fiber (HCF) diets on glucose and lipid metabolism
31)The short-term effects of a weight-maintenance diet high in fiber and carbohydrate (HFHC) was studied in seven very obese individuals with type II diabetes mellitus
31)In comparison to a traditional low carbohydrate diet (LC), the effect of an isocaloric high carbohydrate, high fibre diet (HC) upon the insulin binding to mononuclear blood cells of seven non-insulin-dependent diabetics was examined.
33) The response of blood glucose and serum lipids and lipoproteins to a high-carbohydrate, high-fiber, low-fat diet was assessed in 10 insulin-dependent diabetic subjects.
“My inner sceptic tells me they deliberately designed the diet as “weight maintenance” to obfuscate the fact that these diets cannot promote weight loss.”
OK. So when a study is designed to look at ‘the short-term effects of a weight-maintenance diet high in fiber and carbohydrate (HFHC)…in seven very obese individuals with type II diabetes mellitus” or another states that “diets were designed to be weight-maintaining and there were no significant alterations in body weight” and both are in the peer reviewed literature, we should disregard this because you have a suspicion that the authors were up to no good? Forgive me for asking, but do you have any evidence to support this hunch of yours?
Do you still want to insist that the Anderson review should have included a study published 2 years in the future?
“A bias shown by Anderson’s review ” meta-analyses are supposed to include all studies that fit the criteria, favourable or not, but Anderson et al. stuffed their credibility by cherry-picking ” which is unacceptable in such a large review with such far-reaching consequences.”
Cathy, please explain your reasons for making this claim. I’d be very interested in your assessment of the biases, particularly when you call Anderson ‘dishonest’ for “including the Hoffman study when it doesn’t support his theory at all.”. Not a great example of bias is it?
cathy,
D-UK recommend weight loss, because, again, there is solid evidence that a BMI (as imperfect a metric as that may be) > 25 is regarded as a Bad Thing for diabetics.
It is not insulting to suggest the ‘plate’ approach, because, again, there is evidence that it is useful tool in encouraging diabetics to think in terms of proportions (whatever the correct ones may be!) when planning meals. It is not insulting the intelligence of diabetics, but a recognition that for some groups thinking in percentages and grams is not easy – or practical in some social situations.
Obviously for well motivated and attentive diabetics other approaches may work better.
I’m not sure that Anderson et al *do* ignore data that fit the selection criteria. Have you any evidence for this? (as ross points out, they can’t really be blamed for not including data not available at the time). Nor is it a valid criticism to say they include data which doesn’t support their position (that’s part of metaanalysis).
w.r.t your point about ‘diabetic foods’ D-UK are very clear that there is no evidence to recommend them and do not do so. That is their stated position. You at least share some common ground there!
The problems of diabetic misusing insulin for weight loss are not really relevant to the D-UKs positions statements. any diabetic misuing their illness for weight loss needs urgent help.
The relationship between drug companies, health care profs, charities and patients is always important to consider. Dr briffa, in his blog post makes the implication that the reason D-UK reccommend ther carb approach may be clouded by drug company patronage.
Other people have pointed out there is solid, peer-reviewed evidence for their approach.
Dr briffa, of course, has a relationship with a pill-maker and was involved in the formulation. It seems only fair that one considers his relationships when reading his blog post.
John Stone “What a lamentable reflection of modern medical scientific culture is Mike Kelly’s remark that his personal experience isn’t evidence. How very confused we have become.”
Personal experience is a very poor guide to determine truth. The easiest person to fool is yourself. My personal experience could form a data point of a larger controlled study but without that control it tells you only that I think it’s what’s helping me. That is why we use the scientific method.
Cathy
The examples you give are tragic but I’m not clear that they got that way by following the D-UK advice (maybe I’m mis-reading it). The point I’m trying to make here is related to John Stone’s mis-understanding of science. You could be 100% right but you need to do the study to find out. Biochemical obviousness, common sense, personal (even clinical) experience may indicate that there’s something worth investigating but it doesn’t give you the answer.
Mike Kelly
My preference (and Cathy’s, I think) is for low-carb/carb-restricted diets for diabetes (though this is clearly not a view held by Diabetes UK). If it’s science you’re looking for, then you might care to click on the links in comment 107. The conclusions here do seem to be in line with clinical experience and common sense.
Personally, I think we have the answer, but whether anyone listens is obviously another matter.
er, dr briffa, I offered some discussion of the kirk et al metaanlysis in post 112.
Essentially (and the authors suggest this) it seems more work is needed to asses the long term benefits and risks of low-carb approach. How, for example, will the increased protein affect diabetics with renal complicactions? Perhaps low-carb is appropriate for certain sections of diabetics, but not for others? exciting work to be done, i think.
So, do you think there is a sufficient body of evidence to justify D-UK changing its advice?
A body of evidence so large, it can overturn the established body of evidence that exists supporting the current D-UK, american diabetic association, canadian, australian, japanes, indian and european diabetes groups’ positions re: carbohydrate intake and long term nutritional managment of diabetes in type I and II diabetics (how many man-hours of common sense, science and clinical experiene formulated those, i wonder?)
If so, the only mechanism I can see for you to address these concerns is to submit something for peer-review in one of the diabetes journals. A paper with such an exciting set of conclusions should waltz into any high-impact journal, i would have thought?
A real blockbuster of a paper could get into Nature if pitched correctly.
Mike Kelly
No, if a substance makes you ill which is shown to be safe and effective in a study with other people, it still is not illusion that it has made you ill. It is a real effect, like eating rotten fish.
John Stone
Your example does not then allow you to predict what will happen the next time I eat fish. Or what will happen when someone else eats fish.
If a study has shown a treatment to be safe and effective it will have put error bars around both of these parameters allowing you to assess the risk/benefit of the treatment.
A collection of individual anecdotes does not allow you to do this.
I have noticed that intelligent and well informed people can become victims of fraudulent treatments because they equate personal experience (their own or others) with evidence. Please try to accept that the purpose and methodology of the scientific method is to overcome this most damaging of blind spots.
>> So, do you think there is a sufficient body of evidence to justify D-UK changing its advice?
Yes.
The American Diabetes Association has (grudgingly) changed its advice and advocated low-carb diets under certain circumstances.
http://care.diabetesjournals.org/cgi/content/full/31/Supplement_1/S61
My guess would be that more changes will follow.
“In an interesting twist this week, in an updated WedMD article, American Diabetes Association spokesman Nathaniel G. Clark, MD acknowledged in an interview that carbohydrate restricted diets help people with type II diabetes control blood sugar.” http://weightoftheevidence.blogspot.com/2006/06/ada-acknowledges-low-carb-diets-help.html
Best,
Michael
Carbohydrate restriction is the way to treat diabetics!
From Taubes’ book:
“1986 FDA exonerated sugar of any nutritional harm saying “no conclusive evidence demonstrates a hazard” yet the 200-page report had hudreds of articles re sugar causing higher risk of heart disease and diabetes. The FDA interpreted the evidence as inconclusive. Sugar – innocent until proven guilty, fat assumed guilty until proved innocent – so the existence of ambiguous evidence was considered sufficient reason to condemn fat in the diet, particularly saturated fat, while the existence of ambiguous evidence was simultaneously considered reason enough to exonerate sugar”.
There is something a bit weird going on with the way in which these posts have appeared.
I apologise unreservedly for missing the dates between Anderson’s review and the Neilson study.
Isn’t there also the point to be made that by quoting Anderson’s 2004 review as the definitive evidence that high carb/high fibre is beneficial you are ignoring all the evidence since then?
The discussion re high vs lower carb diet was then followed by the statement “High-carbohydrate, high-fiber (HCHF) diets provide even greater benefits on glucose and lipid values for diabetic individuals when compared to low or moderate carbohydrate, low or moderate fiber diets.”
Please note they specifically state “low” when the studies they included did not support the statement at all so no, I don’t retract my statement on dishonesty. While I admittedly made a mistake on dates I am not writing a (several months’ work) review that has long-reaching implications for a large section of the community.
The only thing this study proves IMO is that if you are going to eat a moderate or high carbohydrate diet, high fibre will improve glycaemic parameters over low fibre (but possibly leave you rather flatulent). Confounding factors include the production of large amounts of SCFA (as I mentioned before and nobody has addressed) that Anderson acknowledged as a “major” factor in a previous paper but omitted from the review, and also that the high fibre diet likely included fresh whole foods where the low fibre diet was probably more like SAD ” full of processed junk foods.
I completely agree that long-term studies are needed for low carbohydrate diet, but I don’t see that happening any time soon as there isn’t an economic benefit to do such a study.
Superburger you are repeating a common misunderstanding regarding Paleo diets ” they are not overly loaded with protein so your question re diabetic nephropathy is redundant. And I don’t think the “body of evidence” on low carb eating needs to be larger than that which exists in the prevailing paradigm ” it only needs to contradict the hypothesis. If something were “absolutely true” there would be no contradiction.
I agree that while shopping for food it is difficult for people to think in terms of grams/% of carb/fat/protein unless they are food scientists with vast databases tucked away in their brains, but what most mainstream advice ignores is 1) the science is not “unanimous” in what constitutes healthy macronutrient ratios and 2) that it isn’t just about macronutrient ratios anyway.
And you say “D-UK recommend weight loss, because, again, there is solid evidence that a BMI (as imperfect a metric as that may be) > 25 is regarded as a Bad Thing for diabetics.” ” That is my point; how does a diet that doesn’t promote weight loss get to be the Holy Grail of diabetes diets?
What is wrong with D-UK giving this information (in addition to the “other stuff”) to patients? ” “There is some limited evidence that dietary control of type 2 diabetes with low carbohydrate diet reduces or eliminates the need for oral hypoglycaemic agents, and assists in weight loss, but long-term studies have not been conducted.” That at least would be more honest and balanced.
People have been brainwashed by media hysteria into believing weight is the be-all and end-all when it comes to health, so much so that they resort to the use of dangerous weight loss medications (phen/fen anyone?) ” so it seems long-term effects of synthetic chemicals need only provide short-term and minimal benefit, but low carb diets should be regarded with extreme caution ” talk about a double standard!
Mike the examples I gave were indeed tragic and while the advice wasn’t dispensed by D-UK as such, in this country the D-UK recommendations are pretty much followed. While GI and GL have been incorporated into dietary advice here the 60-65% energy as carbs remains unchanged.
Dr Briffa ” yes I favour low carb eating; not just in a theoretical kind of way but because I had GD through both my pregnancies despite being skinny and gaining very little weight. It wasn’t until I was writing about diabetes about 10 years ago that I realised how high risk I was for type 2 diabetes (along with family history of type 2 diabetes) as I approached my forties. I can only thank my natural tendency to have always eaten fairly high fat/low carb diet ” especially after the birth of my children when my BMI plummeted to 15.5kg/m2 that 1) GD disappeared post pregnancy and 2) diabetes has never reappeared thanks to my “natural” way of eating. I am fairly convinced if I followed “standard” advice I’d be a sulphonylurea-munching patient now.
Mike, I am a non-diabetic, follwoing this from the side lines, but I was struck by your line:
“A collection of individual anecdotes does not allow you to do this.”
I agree with this statement to a point, but the the thing about diabetics is that their condition may be so serious that there are immediate consequences to poor nutritional choice. They also have access to specialised and precise medical equipment to quantify and determine the state of their BG and the effects of vasrious foods upon it.
Thus, I would apply a great deal more credibility to the ‘anecdotal evidence’ of this group than, for example that of a group of dieters who can underestimate and ‘cheat’ on a diet with little immediate consequence, and who have no precise technical instrumentation (scales are crude), to quantify the effect of their diet.
What I am trying to say is that a diabetic has a more ‘scientific’ way of coming to his/her conclusion on nutritional than would a dieter.
Given the number of diabetics who have come to the conclusion that a ‘paleo diet’ is optimal for them, and given the objectives of DUK, don’t you think that DUK should be looking to resource some form of research in to this area or at least encouraging it?
“Isn’t there also the point to be made that by quoting Anderson’s 2004 review as the definitive evidence that high carb/high fibre is beneficial you are ignoring all the evidence since then?”
The point was to demonstrate that there is an evidence base for DUK’s approach, Which there is. Nobody stated that the evidence is definitive.
“The discussion re high vs lower carb diet was then followed by the statement “High-carbohydrate, high-fiber (HCHF) diets provide even greater benefits on glucose and lipid values for diabetic individuals when compared to low or moderate carbohydrate, low or moderate fiber diets. Please note they specifically state “low” when the studies they included did not support the statement at all so no, I don’t retract my statement on dishonesty.”
Your original point was “the Anderson review beautifully demonstrates the statistical shenanigans the low fat brigade resort to when trying to shore up the hypothesis. They claimed that the meta-analysis included 12 studies with a “low carb” group defined as < 30% carb calories”
The review doesn’t have a <30% stipulation. The stipulation for the 13 studies you refer to was to compare high carbohydrate, high fibre diets with lower carbohydrate, lower fibre diets.
But OK, let’s look at the statement in ‘Comments’ section of the review:
“High-carbohydrate, high-fiber (HCHF) diets provide even greater benefits on glucose and lipid values for diabetic individuals when compared to low or moderate carbohydrate, low or moderate fiber diets. HCHF diets are accompanied by significant decreases in all aspects of glycemic control including HbA1c. Of course, these benefits result from increases in both carbohydrate and fiber intakes. Earlier studies have documented the glycemic and lipidemic benefits of increases in carbohydrate and decreases in fat intake [38,40,41]”
So if we look at the abstract of (38) it says:
“The metabolic effects of high-carbohydrate (70%), high-fiber (70 g) (HCHF) and low-carbohydrate (39%), low-fiber (10 g) (LCLF) diets were examined for 10 subjects with insulin-dependent diabetes mellitus (IDDM).”
The abstract of (41) says:
“The findings support the hypothesis that high-fat, low-carbohydrate diets are associated with the onset of non-insulin-dependent diabetes mellitus in humans. Am J Epidemiol 1991 ;134:590-603.”
You said “Please note they specifically state “low” when the studies they included did not support the statement at all”.
It seems pretty clear that they specifically state ‘low’ when the studies they are referring to do support the statement.
You seem to have confused the review methodology. The data were classified as follows:
“The levels of carbohydrate intake were classified as follows: high carbohydrate, 60% of energy; moderate carbohydrate, 30% to 59.9% of energy; low carbohydrate, <30% of energy.”
The reviews were stated as:
“Twenty-four studies met the inclusion criteria and summary characteristics are presented in Table 2. Eleven studies compared moderate carbohydrate, high fiber (MCHF) to moderate carbohydrate, low fiber diets…Thirteen studies (Table 2) examined high carbohydrate, high fiber diets (HCHF) with lower carbohydrate, lower fiber diets”
So, once again, the Anderson review looks fine to me and I can’t find any examples of the authors engaging in ‘statistical shenanigans’ or being ‘dishonest’. Do you want to retract those words?
If you still think the review is dishonest or wrong (including 13 studies that don’t fit their own review criteria) then a) as it’s been available in an open access peer reviewed journal for 2 years why do you think that nobody has picked up on this before? b) are you going to write a letter to JACN pointing out that the review authors are dishonest or wrong and c) if not, why not?
er mike, the ADA position statement recognises that low-carb or low-fat diets are useful for *weight loss* in short term (25 is a risk factor, even if BMI is a crude indicator.) Any eating plan in which calories in < calories burnt will result in weight loss.
Exercise is the other key factor, as not only aids weight loss be important for cardiac disease.
skeptictactoe – of course more diabetes research is needed -on every aspect of the disease – and D-UK have a role to play in that alongside all the other interested parties.
But to those (including Dr Briffa?) who think D-UKs advice is in need of urgent change then why not write it up and submit it for peer-review. Far bigger audience than this blog…..
Cathy “The only thing this study proves IMO is that if you are going to eat a moderate or high carbohydrate diet, high fibre will improve glycaemic parameters over low fibre (but possibly leave you rather flatulent).”
Cathy, the study certainly says:
“For diabetic subjects MCHF diets compared to MCLF diets are associated with significantly lower values for: postprandial plasma glucose”
But then it also gives significantly lower values for “total and low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides.”
But wouldn’t you also agree with the other findings?
“HCHF diets compared to MCLF diets are associated with lower values for: fasting, postprandial and average plasma glucose; hemoglobin A1c; total, LDL-cholesterol, HDL-cholesterol and triglycerides.”
Mike Kelly
I mentione rotten fish – not fish.
There is the reverse problem that evidence which hold good for populations may be useless for individuals, and medicine has to treat individuals. It is nonsense to suggest that the diet which suits you is not evidence, at least in regard to you.
Superburger,
“”er mike, the ADA position statement recognises that low-carb or low-fat diets are useful for *weight loss* in short term (25 is a risk factor, even if BMI is a crude indicator.) Any eating plan in which calories in < calories burnt will result in weight loss.”
Duh.
There is no study in the world that would make them reverse course overnight.
The only legally and politically safe course for them is to very slowly shift position “as current science emerges.”
“Short Term” and “for weight loss only” are both meaningless qualifiers that will slowly be dropped.
Cigarette companies were in the same position – admitting to actively and knowingly killing people is not a way to keep your job.
michael, so what your saying is that if the weight of evidence becomes greater (assuming it does) then the ADA, D-UK, etc, etc, will change their positions to reflect this?
Because that sounds like they will genuinley take on board new evidence, consider very carefully new science and generally do the right thing.
Couldn’t agree more – sounds very sensible. Good science always ‘shifts its position’ as and when evidence emerges.
(although, sometimes, a single piece of work can change the course of science – the british doctor’s study on smoking, watson and crick on DNA, jenner on smallpox, for example)
You cigarette smoking analogy seems a little unfair – there is plenty of honest peer-reviewed evidence for the D-UK position.
Sadly, dr briffa seems to prefer to imply that D-UK’s position is clouded by their relationship with drug companies and that there is already sufficient evidence for D-UK to change their position.
Cathy, I’d just like to ask some questions and would appreciate honest answers to them:
Do you think your analysis of the Anderson review was accurate?
Are you still accusing the Anderson authors of dishonesty?
Are you still accusing the Anderson authors of statisitcal shenanigans?
Are you still accusing the authors of (38) and(41) of deliberately and fraudulently designing their studies?
Given the fact that the Anderson review provides an evidence base for DUK’s advice (albeit advice you don’t agree with) do you still think theyare ‘merely self-serving do-gooders’ that ‘actually do more harm than good’?
Are you still suggesting Ms Spears has blood on her hands?
>>You cigarette smoking analogy seems a little unfair – there is plenty of honest peer-reviewed evidence for the D-UK position.
Once you stop buying in to the “fear of fat” hypothesis, there are many studies that do not support their own conclusions.
This is fairly common in science, or any human endeavor.
There are some “well known truths” that color all thinking.
Social scientists call this an “Information Cascade.”
See Thomas Kuhn’s work on Paradigm Shifts:
http://en.wikipedia.org/wiki/Paradigm_shift
We saw it not that long ago with Ulcers – it was “well known” that the problem was acid, stress, and spicy food.
These “well known facts” were in fact false.
Helicobacter Pylori is the culprit, and the “acid, stress, spice” hypothesis was false.
Everything that doctors had learned about ulcers in school and practice was false.
No evil intent or conspiracy.
All the studies about acid reduction.
All the studies comparing alternate surgery techniques.
All the psychotherapy for stress.
All the bland cooking techniques.
ALL FALSE.
We may well see the implosion of the low-fat theory of heart disease. It is not getting good results in practice. Once that theory is no longer supported, the justification for high carb intake for diabetics is gone.
Nature Publishing Group’s “International Journal of Obesity” just published a chinese study comparing vegetable intake.
They found a correlation higher carbs = higher BMI.
Amazingly, they concluded it was the fat.
Here is a great discussion about how the facts were tortured to fit the current low-fat paradim:
http://www.proteinpower.com/drmike/obesity/another-china-study/
I will find the references to some other studies that found bad things about saturated fat in a high carb diet, and concluded it was the fat. The perfectly reasonable alternative, that refined carbs might be the problem was just not explored at all – it did not fit the paradigm.
>>Sadly, dr briffa seems to prefer to imply that D-UK’s position is clouded by their relationship with drug companies and that there is already sufficient evidence for D-UK to change their position.
Well, he did show my old theory on this mess to be false.
I was thinking it was a conspiracy by general practitioners, kidney transplant surgeons, heart surgeons, and laser eye surgery doctors to keep their waiting rooms full and extract the maximum revenue per diabetic client.
It is just so sad how the high-carb push coupled with lots of medication manages to keep diabetics well enough to work and have health insurance, but sick enough to consume lots and lots of medical services.
Perhaps it is not an evil conspiracy after all.
But the result is the same.
You are claiming that D-UK has its recommendations based on solid science and “the weight of the evidence”. Why are the studies with piffling (~13) numbers of subjects with short follow-up considered “weighty” enough to generalise to large populations? Why is it that small, short-term studies on the “benefits” of high carb are deemed weighty enough but studies such as Samah’s [1] must be interpreted with caution? ” Double standards IMO.
Was Anderson dishonest? ” Yes, especially for omitting the issue of high fibre and SCFAs (which I note you have still not addressed) out of his discussion when he knew it was a significant factor. A very high fibre diet is essentially a high fat diet so it cannot be used to extrapolate the advice to “include starch at every meal”. And he was also dishonest in the comment that his review included “low-carb diet” because clearly it didn’t.
Soft, surrogate endpoints do not convince me of very much anyway. Consider that the ACCORD study found that more intensive BG control was correlated with higher mortality. Soft endpoints do not suffice to prove overall benefit ” I want to know that if I take D-UK’s advice, it will reduce mortality and morbidity. This isn’t theoretical for me; I had gestational diabetes 20 years ago and don’t particularly want to encourage the development of type 2 diabetes now I am in my forties ” so, as for others on this blog, it’s my health and welfare at stake here.
A prospective, randomised, long-term (life-long) human lab study would be impossible (not to mention unethical), so the next best thing is long-term observational studies of large populations. The Harvard Nurses’ Study and the Women’s Health Initiative Study (with some hard endpoints) certainly do not convince me high-carb, low-fat is the optimum diet for human beings.
Nor do I think the long-term effects of such high (70-80g) levels of dietary fibre are known. All fibre is not created equal; some types may be beneficial while other types may actually be harmful. Advising people to eat 70-80g without addressing or specifying which is which is irresponsible and hardly scientific.
I have never accused these health professionals of being motivated by anything other than wanting to “help” the patient ” that doesn’t preclude them having blood on their hands if their recommendations do in fact harm people. Nor does it absolve them of their ignorance of the growing body of evidence on vitamins and supplements in the treatment of disease. Dieticians advise that vitamins and supplements are worthless when there is plenty of evidence for benefits [2, 3], including potentially preventing diabetes in the first place according to experimental studies [4].
In the Anderson review they had a decrease in glycosylated haemoglobin but what happened to their fructosylated haemoglobin and other AGEs or ALEs? Large intakes of vegetables and fruit are known to increase AGEs [5] so excuse me if I don’t wet my pants over the FPG, PPG or lipid reductions.
“If so, the only mechanism I can see for you to address these concerns is to submit something for peer-review in one of the diabetes journals. A paper with such an exciting set of conclusions should waltz into any high-impact journal, i would have thought?”
This statement is either very naïve or disingenuous ” anyone who has been in the system or read anything on the politics of science would know that the peer-reviewed literature does not readily publish dissenting views.
1. Samaha, F.F., et al., A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med, 2003. 348(21): p. 2074-81.
2. Afkhami-Ardekani, M. and A. Shojaoddiny-Ardekani, Effect of vitamin C on blood glucose, serum lipids & serum insulin in type 2 diabetes patients. Indian J Med Res, 2007. 126(5): p. 471-4.
3. Rodrigo, R., et al., Decrease in oxidative stress through supplementation of vitamins C and E is associated with a reduction in blood pressure in patients with essential hypertension. Clin Sci (Lond), 2008. 114(10): p. 625-34.
4. Lautt, W.W., et al., HISS-dependent insulin resistance (HDIR) in aged rats is associated with adiposity, progresses to syndrome X, and is attenuated by a unique antioxidant cocktail. Exp Gerontol, 2008.
5. Krajcovicova-Kudlackova, M., et al., Advanced glycation end products and nutrition. Physiol Res, 2002. 51(3): p. 313-6.
cathy,
“A very high fibre diet is essentially a high fat diet”
how so? Do no high fibre, low fat foods exist?
The smith paper is for obese people – not all were diabetic for a start – and the authors themselves are extremely cautious about reccomending the diet for long term use. And weight loss was the primary measured outcome. Do you think it fitted Anderson’s inclusion criteria?
But as i think I’ve repeatedly said, new work is interesting and important – and if and when a substantial new body of evidence is created maybe D-UK (and every other western diabetes association) will change their advice. That’s science.
But i still think dr Briffa is wrong to suggest that drug company links were the reason for D-UK to give the advice that they do.
re: submitting for peer-review
“This statement is either very naïve or disingenuous ” anyone who has been in the system or read anything on the politics of science would know that the peer-reviewed literature does not readily publish dissenting views.”
Not my experience, I’m afraid. And even if true, that’s not a reason not to try. Dr Briffa makes some serious allegations about the dietary advice of D-UK, if “lives are at stake” and he has evidence based on “science, common sense and clinical experience” then I don’t see a reason not to challange the status quo by submitting these sources of evidence for peer review.
Cathy – “And he was also dishonest in the comment that his review included “low-carb diet” because clearly it didn’t.”
The review refers, accurately, to “low carb” studies when those studies are described by their own authors as “low carb”. It refers, accurately, to “lower carb” when it states that it will review studies that examine high carbohydrate, high fibre diets with lower carbohydrate, lower fibre diets.
Please explain how this is dishonest. Please point out the statistical shenanigans.
You set up a strawman argument when you say I am “quoting Anderson’s 2004 review as the definitive evidence”. Please point out where somebody has stated that the evidence is definitive.
You set up another strawman argument when you say I am claiming “that D-UK has its recommendations based on solid science and “the weight of the evidence”. ” I haven’t mentioned the ‘weight of evidence’ so why put the phrase in quote marks?
I said “The point was to demonstrate that there is an evidence base for DUK’s approach”. If there isn’t an evidence base for DUK’s approach, please supply the evidence.
You said: “A bias shown by Anderson’s review ” meta-analyses are supposed to include all studies that fit the criteria, favourable or not, but Anderson et al. stuffed their credibility by cherry-picking ” which is unacceptable in such a large review with such far-reaching consequences.”
Cathy, again please explain your reasons for making this claim. I’d be very interested in your assessment of the biases, particularly when you call Anderson ‘dishonest’ for “including the Hoffman study when it doesn’t support his theory at all.”. Not a great example of bias is it?
You cherrypick the results of the review to suit your preconceived notions when you state “The only thing this study proves IMO is that if you are going to eat a moderate or high carbohydrate diet, high fibre will improve glycaemic parameters over low fibre (but possibly leave you rather flatulent).”
You ignore the rest of the findings.
Your statement that “in all the above studies bodyweight did not change. How does this support weight loss in fat diabetics?”. Was incorrect (34) and misleading – none of the studies had weight loss as objectives, many didn’t have weight loss as measured outcomes and several required maintenance diets to measure the outcomes that were being studied.
You display a misunderstanding of the what he objectives of the Anderson review were “especially for omitting the issue of high fibre and SCFAs…out of his discussion when he knew it was a significant factor.” Your reason for bringing this issue into your argument is “If they wanted to compare low vs high carb they should have left other variables like fibre the same because it is a huge confounder.” This is another strawman argument. They didn’t want to compare LC vs HC, they wanted to “review international nutrition recommendations with a special emphasis on carbohydrate and fiber, analyze clinical trial information, and provide an evidence-based recommendation for medical nutrition therapy for individuals with diabetes.” Your criticism seems to hinge on the fact that the review isn’t what you want it to be.
This is backed up by your statement “In the Anderson review they had a decrease in glycosylated haemoglobin but what happened to their fructosylated haemoglobin and other AGEs or ALEs” etc etc. How is the Anderson review responsible for the measurable outcomes of the included studies when all they say they have done is “evaluated all clinical trials that provided glycemic outcome data.”?
Your statement “Dieticians advise that vitamins and supplements are worthless when there is plenty of evidence for benefits [2, 3], including potentially preventing diabetes in the first place according to experimental studies [4].” is also a strawman argument. Dieticians do not advise that vitamins and supplements are worthless.
Instead of defending your view that Ms Spears has blood on her hands you talk instead about ‘these health professionals’ who you accuse of ignorance “of the growing body of evidence on vitamins and supplements in the treatment of disease.” Have the 3 studies you quote changed your clinical practice? Should they have changed the advice DUK give? Wouldn’t you prefer to see “long-term observational studies of large populations” for this kind of supplementation? Or does this only apply to the current advice and evidence base?
In light of the above I’d appreciate it if you could answer these questions, a number of which I note you still have not addressed:
Do you think your analysis of the Anderson review was accurate?
Are you still accusing the Anderson authors of dishonesty?
Are you still accusing the Anderson authors of statistical shenanigans?
Are you still accusing the authors of (38) and(41) of deliberately and fraudulently designing their studies?
Are you still suggesting Ms Spears has blood on her hands?
Research can be interesting and lead to amazing insights, but most of the time they’re fairly useless epidemiological studies that don’t really give any answers…
The reality is that carbohydrates do raise blood sugar. It’s a simple fact. Anyone disagree?
If you’re insulin resistant/diabetic your blood sugar will rise to damaging levels when you eat “normal” amounts of carbs, even if you choose so called slow carbs. The body counteracts this by releasing huge amounts of insulin, or you need to inject insulin.
The problem here is that both high blood sugar and high insulin levels are damaging. I really shouldn’t have to point this out, but it seems like this gets ignored or forgotten a lot of the time, along with basic human biochemistry.
There is no way a high carb diet can be beneficial to a person with a damaged sugar metabolism. It’s a simple fact.
Mike Kelly, you said the following: “Ulf_s. I believe type 2 was only recognised as a separate disease in the 1930s. But you’re quite right, before Banting and Best type 1s were put on low carb diets and mostly died young.”
Diabetes, particularly type 1 of course, was a much more dangerous disease to live with before the discovery of insulin. Insulin has certainly saved a lot of lives and has been a true blessing for countless diabetics!
Before injectable insulin was available, the only treatment was a low carb diet. This works very well for most type 2s, but like you say many type 1s died young. I hope you’re not suggesting that they would have been better off eating a low fat, high carb diet…?
But even though insulin is a real life saver, it shouldn’t be abused. High levels are damaging.
The best way for a diabetic to remain as healthy as possible is to minimize carbs so that the blood sugar stays in the lower range at all times, which minimizes the need for insulin.
Really basic and simple.
Would Ross or somebody here explain to me how eating starchy foods can improve glycemic control?
Seriously.
My meter says that starchy food raises BG rapidly.
Any non-tiny portion of starchy food raises BG too high.
I must be missing something…
Ross, stop complicating the issue. carbohydrate restriction is the best treatment for diabetics – that’s it!
Do you think your analysis of the Anderson review was accurate?
Are you still accusing the Anderson authors of dishonesty?
Are you still accusing the Anderson authors of statistical shenanigans?
Are you still accusing the authors of (38) and(41) of deliberately and fraudulently designing their studies?
Are you still suggesting Ms Spears has blood on her hands?
YES
sue, i disagree. I think there is solid evidence to support D-UKs position at the present time.
Think the authors of the anderson metaanalysis are academics trying to look through a vast body of often confusing evidence and trying to come to some evidence based conclusions.
You disagree (which is fine). But i think you need to accept that the scientists who disagree with you are not fools, do not have a particular agenda (and acknowledge conflicts of interest where present), and also have a genuine interest in good evidence for diabetics.
When two competing ideas exist, it doesn’t mean both positions are honestly held, but sometimes one position has more evidence.
Accusing acadmics of dishonesty is a serious allegation. I strongly suggest you think about the allegation you make and admit it is unfair and unjustified.
>>Accusing acadmics of dishonesty is a serious allegation. I strongly suggest you think about the allegation you make and admit it is unfair and unjustified.
Correct.
Simple “confirmation bias” and groupthink is sufficient to produce this sad state of affairs.
Gary Taubes’ book lays out a compelling case.
Go read it.
superburger, the “solid evidence” you’re talking about is anything but solid, since it’s based on epidemiology. As you say the “evidence” is often confusing. Guess what? Epidemiology can’t prove anything! The “evidence” would likely be a lot more consistent if it came from carefully designed, properly conducted studies.
And please remember: whatever epidemiological studies “prove” is probably bogus if it goes against human biology…
superburger, do you agree that carbohydrates raise blood sugar?
If you do agree, would you please explain the basic biological mechanisms that make them healthy to eat for a diabetic? Why would/should a diabetic eat a lot of fruit, bread or pasta? (And I don’t mean references to epi. studies that may or may not include actual diabetics.)
Sorry, make that “mostly based on epidemiology, junk science or reviews of them” on the second line…
John Stone (back at 175, sorry, I have a job so big gaps inevitable)
Look up lutefisk. Not exactly rotten but it made me vomit every meal I’ve had since I was six; I’m pretty sure my last heave had my socks and underpants in it.
So, using your criteria, all Scandinavians should immediately cease eating the rotten gelatinous mess?
You can’t extrapolate from anecdote to treatment.
Personally, I think there are two separate arguments going on here; both highly interesting:
1) Is low-carb the best method of controlling diabetes?
Of huge personal interest to me and I keep a very close eye on the literature. There’s a lot of work yet to be done here especially as the ACCORD study showed just focussing on the surrogate markers (blood glucose, Hb1Ac, blood lipids etc.) may not indicate better outcomes for the real markers (Dying!!, blindness, Look Ma! No Kidneys!111!eleven).
2) Is D-UK deliberately giving bad advice when they know better and…
2a) Are they influenced by ties to Big Pharma.
I think the other commentators (Superburber et al) have done a good job showing that D-UK are advising consistent with the current evidence base and even if the advice they give turns out to be sub-optimal there is no reason to assume bad faith.
As for 2a I’m still confused over Dr. Briffa’s immunity to the influence of the pharmaceutical ties he points out in others.
Bit of a classic Tu Quoque there, but I’m reminded of an old interview with Mary Whitehouse where she was asked how she resisted the depraving influence of the films she reviewed. Apparently having Jesus in your heart protects you, I suspect I’m seriously screwed then.
Ulf_s
“And please remember: whatever epidemiological studies “prove” is probably bogus if it goes against human biology…”
We know everything about human biology?
Some comments about the ACCORD study: http://diabetesupdate.blogspot.com/2008/06/giant-step-backwards-misinterpreting.html
In short: the people in the trial were pretty sick from the beginning, were advised to eat a high carb/low fat diet and were put on just about every diabetes medication that is known to mankind. No wonder they dropped like flies…
#193: I certainly don’t…
But I do know that a diabetic shouldn’t eat large amounts of carbs, even if some studies claim they are terrific and good for you.
Why feed sugars to someone who can’t metabolise them properly…?
Can anyone of you who advocate a high carb diet please explain the thinking behind this? I simply do not get it.
I can measure my own blood sugar and see how carbs make it go up, so how can it be good for me to eat them?
Good stuff Ulf_s
But I note that the people in the study already being pretty sick is the opinion of the blogger and not one I picked up from the study (unless the assumption is that an American study automatically means sicker people?)
I haven’t seen a study with non-surrogate endpoints looking at carb content so I don’t feel I’m in a position to take a position. I’m handling my disease in such a way as to minimise my blood sugar without drugs but I’m not an evangelist for it. I COULD BE WRONG.
>>Why feed sugars to someone who can’t metabolise them properly…?
Can anyone of you who advocate a high carb diet please explain the thinking behind this? I simply do not get it.
The only rational reason I have ever heard is the fear of fat.
As best I can tell, the idea that fat is so very dangerous that we should allow high blood sugar levels to get low fat.
That whole line of reasoning is flawed – the studies “proving” the dangers of fat… are all in the context of a high carb diet.
#196: I don’t think I’ve ever seen a well-designed study which compares a traditional low carb/high fat diet with the new high carb/low fat diet that can actually show that the high carb diet is superior.
And this relatively new high carb diet is still what is recommended today. Isn’t it scary?
I’ll stick with the traditional advice until some other approach is proven to be healthier…
New Israeli low-carb vs Mediterranean vs low-fat study
http://www.dailymail.co.uk/news/article-1035779/Atkins-diet-safe-far-effective-low-fat-says-study.html
“The low-carb diet was best for reducing levels of bad cholesterol, while all three diets had the same beneficial effect on liver and inflammation function, the researchers said. … The researchers concede that the study has some flaws. Around 85 per cent of the volunteers were men – and the effects could be different for women, they say.”
Dr Eades has posted up a link to a paper detailing the advantages of long-term low-carbing (44 months) for obese, type 2 diabetics:
http://www.nutritionandmetabolism.com/content/5/1/14