Ed. note: This article is written in Aleksandra’s voice but has been written by both authors.
Last year, when I was diagnosed with Type 1 diabetes, all I could think about was, “Where did I go wrong?” After all, I was a runner, a passionate mountain climber and had eaten reasonably well my whole life.
I remember weeping for hours after receiving my antibody results. Everything I learned about diabetes during my training as a nurse clinician and seeing countless patients with diabetic complications in the emergency department made this diagnosis feel like a death sentence. Little did I know that being diagnosed with this terrible illness may have been a blessing in disguise.
Type 1 and 2 diabetes are chronic diseases that represent 9 per cent of Canada’s health-care spending. Earlier this year, Diabetes Canada estimated that close to 12 million Canadians live with undiagnosed diabetes, pre-diabetes or diabetes compared to 11 million in 2017-2018 and 1.3 million in 2000-2001. These latest numbers represent about 30 per cent of the population, a 3.5 per cent annual increase in prevalence since 2000, and a direct health-care cost of $27 billion in 2018. By 2028, the number of people living with the illness is expected to rise to 13.1 million Canadians and a projected cost of $40 billion.
Diabetes Canada’s clinical practice guidelines recommend a multi-prong approach that includes nutritional therapy, physical activity and pharmacological interventions. Contrary to nutritional treatment before the invention of insulin – carbohydrate restriction to prolong life in Type 1 diabetics and reduce glucosuria – the current guidelines promote flexible macronutrient distribution and refer diabetics to Canada’s Food Guide. The Canada Food Guide, in turn, promotes fruits and whole grains, i.e., carbohydrates, foods that are directly implicated in postprandial hyperglycemia in diabetics – a key contribution to elevated A1C. This liberal intake of carbohydrates is deemed appropriate if patients are taking anti-diabetic medications and/or covering carbohydrates with insulin.
However, when taking insulin, patients are at an increased risk of hypoglycemic episodes due to carbohydrate counting and dosing errors. This elevated A1C and excursions into the extremes are independent risk factors for micro- and macrovascular complications such as diabetic foot ulcer, retinopathy, stroke, myocardial infarction and chronic kidney disease.
That same night as my diagnosis, my devastation led me to look outside my traditional medical sources. It was sheer luck that I learned about an alternative approach to diabetes management that would avoid all those complications. To live a long, happy, and healthy life, I would have to abandon all of what my nursing training had taught me about diabetes, and with it, the nutritional therapy recommended by Diabetes Canada.
This alternative approach, which has demonstrated superior blood glucose control to the standard approach, was championed by Richard K. Bernstein – a 90-year-old Type 1 diabetic and an endocrinologist who pioneered the basal-bolus insulin dosing method and the use of a personal glucometer.
The crucial part of his treatment involves a very low carbohydrate and high protein diet. Due to the low carbohydrate content, the need for insulin is reduced; thus, the chances of making an error and experiencing hypoglycemia are lower. Other benefits of this approach are weight loss and stable blood glucose levels.
To live a long, happy, and healthy life, I would have to abandon all of what my nursing training had taught me about diabetes.
To reverse and avoid diabetic complications and subsequent hospitalizations, Bernstein calls for keeping blood sugars in the normal range, 4-5.5mmol/L, versus what is known as the “diabetic range” of 4-10 mmol/L. Hence, unlike diabetics who follow the widely adopted standard nutritional guidelines and rarely meet the standard, targets for Hemoglobin A1C (per cent of hemoglobin molecules in red blood cells that have sugar attached), diabetics who have adopted his approach have demonstrated A1C results as low as 4.6 per cent (below 5.7 per cent is considered normal) and virtually no hypoglycemic episodes – the highest source of daily stress and disruption for millions of diabetics and their families.
Critics of the Bernstein approach claim the diet is too restrictive to adhere to and can cause nutritional deficiency, ketoacidosis and hypoglycemia – misconceptions associated with a lack of knowledge of and practice with low carbohydrate diets. Thus, a low-carbohydrate diet for diabetes management has had limited adoption and is often not offered as an alternative option upon diagnosis, even to those like me who may be willing to embrace it in the name of health and longevity.
Less than 20 per cent of diabetic adults achieve an A1C of less than 7 per cent. The inability of the current standard treatment to help patients meet glycemic targets and the reports of severe side effects of commonly prescribed diabetic medications (weight gain, hypoglycemia, etc.), as well as emerging evidence in favour of low carbohydrate diets, has led some researchers and clinicians to consider different strategies and a revision of dietary guidelines.
In their meta-analysis of five studies, Jessica Turton and her colleagues found that a low-carbohydrate diet had a clinically significant reduction in total insulin requirements. In another study on obese patients with Type 2 diabetes, a two-week low-carbohydrate diet immediately improved 24-hour blood glucose profiles, insulin sensitivity, and hemoglobin A1C. Additional studies further found that a low-carbohydrate diet reduced or even eliminated diabetes medications in up to 95 per cent of participants.
Canadian physicians are no strangers to treating diabetes mellitus with very low carbohydrate diets. One of those physicians, nephrologist Jason Fung, and author of the New York Times bestselling book, The Obesity Code, has even gained worldwide recognition for his success in treating metabolic syndrome with a low-carb diet that has resulted in weight loss and Type 2 diabetes reversal in thousands of his patients. Evelyne Bourdua-Roy is another Canadian physician who successfully reversed Type 2 diabetes in more than 1,000 patients and took them off blood pressure medications, despite facing resistance and criticism from health-care peers.
In the United Kingdom, the NHS adopted a digitally delivered Low Carb Program for adults with Type 2 diabetes, pre-diabetes, and obesity. Its study showed the program improved glycemic control and enabled weight loss. Similarly, the Commonwealth Scientific and Industrial Research Organization (CSIRO), the Australian government agency responsible for scientific research, created its own scientifically proven CSIRO Low-Carb Diet.
Considering this history of evidence and current successful initiatives, why don’t the clinical guidelines recommend a low-carbohydrate diet to prediabetics and newly diagnosed patients?
In anticipation of November’s Diabetes Awareness Month, Health Minister Jean-Yves Duclos tabled the Diabetes Framework in an effort to better recognize, collaborate with, and support those impacted by diabetes in Canada. The framework is an opportunity for low-carbohydrate nutrition therapy to become a central, cost-effective strategy in preventing, reversing or treating diabetes and eliminating its complications.
Diabetes Canada’s current position clears doctors to support their diabetic patients if they wish to follow a low-carbohydrate diet. Nevertheless, it cautiously recommends that more research is urgently required to demonstrate long-term benefits and risks. Thus, the framework should prioritize researching this historically well-known, promising approach to diabetes management.
The key to the diabetes crisis is well within our reach. It is a century-old wisdom that we have forgotten amidst the whirlwind of pharmacological and technological advances. Despite its success, low-carbohydrate diets have been blatantly ignored and rejected by establishments such as the American Diabetes Association, Diabetes Canada and medical associations.
We can win the fight against diabetes by embracing a low-carbohydrate diet as the first-line medical nutrition treatment. I dream of sharing with other diabetics the joys of having an A1C in the healthy, non-diabetic range while eating delicious, hearty and healthy foods. My diabetes control makes me feel empowered and hopeful about the future. I wholeheartedly believe that diabetics have the right to pursue normal blood glucose levels, and that eradicating the deleterious complications of diabetes should be our foremost goal.