2.
Refined carbohydrates raise blood glucose levels more than any other foods.
So type 2 diabetics should eat the very foods that raise blood glucose the most? “Illogical” is the only word that comes to mind.
Yet, not just the USDA, but also the Diabetes UK, European Association for the Study of Diabetes (EASD), Canadian Diabetes Association, American Heart Association, and National Cholesterol Education Panel recommended fairly similar diets.
All of them suggested keeping carbohydrates at a lofty 50 to 60 percent of total calories and dietary fat at less than 30 percent.
The 2008 American Diabetes Association position statement on nutrition advised: “Dietary strategies including reduced calories and reduced intake of dietary fat, can reduce the risk for developing diabetes and are therefore recommended.”4 The logic is hard to follow.
Dietary fat does not raise blood glucose.
Reducing fat to emphasize carbohydrates, which are known to raise blood glucose, could protect against diabetes?
How they believed that would work is unknown.
It further advised, against all common sense, that “intake of sucrose and sucrose-containing foods by people with diabetes does not need to be restricted.” Eating sugar was okay for type 2 diabetics?
This could not realistically be expected to lower blood glucose, and the proof came soon enough.
WHY THE LOW FAT ERA BACKFIRED
THE 2012 TREATMENT Options for Type 2 Diabetes in Adolescents and Youths (TODAY) randomized study5 reduced caloric intake to a miniscule 1200 to 1500 calories per day of a low-fat diet, combined with increased exercise.
This followed precisely the recommendations made by the 2008 ADA guidelines.
Intensive dietary counseling was provided to ensure compliance in this group of motivated teenagers.
Massive effort by both patients and study staff failed to improve blood glucose, and the failure rate was astronomically high.
Almost 50 percent of patients required increased doses and numbers of medications.
Whether or not patients followed the recommended lifestyle recommendations did not matter at all.
Regardless, their diabetes was getting worse, not better.
The scariest part of the study was that if these teenagers couldn’t do it, what hope did middle-aged or elderly adults have?
This classic “Eat Less, Move More” strategy failed yet again.
But the fact that this diet would not work should have been fairly obvious from the beginning.
Reducing dietary fat means increasing dietary carbohydrates, since it is difficult to eat protein alone.
In the Westernized world, these carbohydrates were not leafy greens but the refined grains and sugars that increase blood glucose and insulin maximally.
What was certainly behind the recommendation of a low-fat diet was the belief that lowering dietary fat could protect against heart disease and stroke.
The most common cause of death in type 2 diabetes is cardiovascular disease, which had been falsely attributed to dietary fat.
It
must surely have been predicted that diabetes would worsen on this low- fat but high-carbohydrate regimen, but presumably the benefits were felt to be worth this risk.
Upon closer inspection, these illusory benefits burst like a ripe abscess.
By 1997, the Nurses’ Health Study (see chapter 4), a massive observational study from Harvard University, found no relationship between dietary fat or dietary cholesterol and heart disease.6 The final nail in the coffin was the 2006 Women’s Health Initiative (also in chapter 4).7 Almost 50,000 women followed this low-fat, calorie-reduced diet for more than eight years,8 yet the rates of heart disease and stroke did not improve whatsoever.
And despite good compliance with years of calorie restriction, on average women lost less than a quarter of a pound.
There were absolutely no tangible benefits to long-term compliance with a low-fat diet.9 Other studies quickly reached the same conclusions.
Despite forty years of research trying to link dietary fat, dietary cholesterol, and heart disease, not a single shred of evidence could be found.10 In diabetic patients, the story was the same.
The Action for Health in Diabetes (LookAHEAD) clinical trial studied more than 5000 obese patients with type 2 diabetes at sixteen sites across the U.S.
The researchers compared a control group receiving standard diabetes intervention with a second group that ate only 1200 to 1800 calories per day, less than 30 percent of them from fat, and did 175 minutes per week of moderate- intensity physical activity.11 This was the recommended “intensive lifestyle intervention” of every diabetes association in the world.
Would it reduce heart disease as promised?
In a word, no.
In 2012, the trial was stopped early after 9.6 years of high hopes.
The data indicated there was no chance patients would show cardiovascular benefits and continuing the study was futile.
Researchers threw in the towel.
The low-fat, calorie-reduced diet had failed yet again.
All the scientific evidence has consistently refuted the dearly held belief that reducing dietary fat would lead to weight loss and reduce heart disease.12 Finally, the 2015 Dietary Guidelines for Americans (the most recent) have removed the limits on dietary fat intake to reflect this new understanding, recognizing that there are a number of healthy fats, such as those found in olive oil, nuts, and avocados.
The low-fat, calorie-
reduced diet was a bust.
THE EXERCISE APPROACH
LIFESTYLE INTERVENTIONS, TYPICALLY a combination of diet and exercise, are a universally acknowledged mainstay of type 2 diabetes treatments.
These two stalwarts are often portrayed as equally beneficial, and why not?
Exercise improves weight-loss efforts, although its effects are much more modest than most assume.
Nevertheless, physical inactivity is an independent risk factor for more than twenty-five chronic diseases, including type 2 diabetes and cardiovascular disease.13 Low levels of physical activity in obese subjects are a better predictor of death than cholesterol levels, smoking status, or blood pressure.14 And the benefits of exercise extend far beyond simple weight loss.
Exercise programs improve strength and balance, blood pressure, cholesterol, blood glucose, and insulin sensitivity, without involving medications and their potential side effects.
Trained athletes have consistently lower insulin levels, and these benefits can be maintained for life, as demonstrated by many studies on older athletes.
These seem like good returns for a low-cost investment.
Yet results of both aerobic and resistance exercise studies in type 2 diabetes are varied.15, 16 Meta-analyses show that exercise may significantly reduce A1C, without a change in body mass.
This finding suggests that exercise does not need to reduce body weight to have benefits, which echoes clinical experience with patients.
However, the corollary is that exercise programs have minimal effect for weight loss.
With all the proven benefits of exercise, it may surprise you to learn that I think this is not useful information.
Why not?
Because everybody already knows this.
The benefits of exercise have been extolled relentlessly for the past forty years.
I have yet to meet a single person who has not already understood that exercise might help type 2 diabetes and heart disease.
If people already know its importance, what is the point of telling them again?
The main problem has always been noncompliance.
Many real issues may deter someone from embarking on an exercise program: obesity itself, joint pain, neuropathy, peripheral vascular disease, back pain, and
heart disease may all combine to make exercise difficult or even unsafe. Overall, however, I suspect the biggest issue is lack of visible results. The benefits are greatly overhyped and exercise doesn’t work nearly as well as advertised. Weight loss is often minimal. This lack of results despite great effort is demoralizing.