What to Eat? ADA Speakers Disagree

Diabetes-care professionals don’t seem to share their patients’ vigilance about food. Out of about 1,000 presentations at the American Diabetes Association’s (ADA) Scientific Sessions in San Francisco, only 20 or so concerned diet. And those presenters mostly disagreed with each other.


I went to session called “Carbohydrates: Are They All Created Equal When it Comes to Glycemic Control?” Julie Miller Jones, Ph.D., of the University of Minnesota says they’re not. She’s a leading activist for whole grains. She presented studies indicating that eating more whole grains is one of the best things you can do to prevent or manage diabetes.

Janine Higgins, Ph.D., of University of Colorado Children’s Hospital, sang the praises of cold carbs, what she calls “resistant starch.” Starches that might not be that good for you hot, like white rice or potatoes, can be great diet tools if served cold. They fill you up and aren’t easily absorbed. Then when they get to the large intestine, they ferment.

For some reason, this fermenting causes the liver to burn fat as fuel, instead of carbs. Higgins recommends increasing your starch intake and eating it cold. Both of these speakers, as well as dietitian Hope Warshaw, were advocating smart carbs, possibly even more carbs.

What About Protein?
Two M.D.’s, Osama Hamdy and Joel Kopple, slugged it out for 90 minutes on the question of how much protein people with diabetes should eat. Hamdy, of the Joslin Diabetes Center, gave a talk called “High Intake of Protein Is Good.” He framed the debate as between endocrinologists, who advocate low carbs to prevent weight gain and obesity, and nephrologists, who want low protein intake to protect kidneys.

Dr. Hamdy says that studies support eating moderately low protein if you have Type 1 diabetes and albumin in your urine, but that no studies exist to show protein intake is a problem in Type 2 diabetes. It’s also not a problem if you have normal kidney function, he said. He cited research showing that high fat intake is associated with kidney problems but high protein intake is not. You can see the slides of his presentation here.

When it comes to protecting the kidneys, controlling blood pressure is much more important than controlling protein intake, Hamdy reported. For people with Type 1 diabetes who have some renal symptoms already, it is probably good to limit protein, especially animal protein. Vegetable protein had a much weaker association with kidney symptoms.

Dr. Kopple took a harder view on protein. He thinks the vast majority of people with diabetes either have some kidney disease or are on the way to it. So in his view, they should be eating less protein. He has written a book on nutritional management of kidney disease which spells out the low-protein case.

When Experts Disagree
At this point, I turned to the doctor next to me, a woman from India, and asked, “So it sounds like nobody really knows anything, is that it?” She said that to her, the disagreement might mean that different people should eat different things. She was looking into the genetic differences between people of East Indian and Chinese descent in the way different foods affected them. She said they were finding some significant differences.

So my takeaway message from these debates was to eat healthy carbs and healthy proteins, and even some healthy fats and oils, and not trip about it too much. Find out what works for you. Obsessing about food doesn’t do you any good, unless you are competing on Top Chef.

One other thing people agreed on: Watch portion sizes, particularly with fruits. They’ve gotten so big that one fruit may be two, three, or even four servings.

Enter the Vegans
In the exhibit area afterward, a young doctor came up to me. She noticed my Diabetes Self-Management name tag. She handed me a copy of a study her group had published in Diabetes Care (“A Low-Fat Vegan Diet Improves Glycemic Control And Cardiovascular Risk Factors In A Randomized Clinical Trial In Individuals With Type 2 Diabetes”) and said, “Tell your readers about this.”

Her group’s study showed dramatic reductions in HbA1c and LDL (“bad”) cholesterol with a strict vegan (no animal products) diet. The main pathway to the lower HbA1c seemed to be that the vegan dieters lost a lot more weight.

In turn, the weight loss seems to have been due to the fact that the group eating vegan stayed on their diet better than the other group, which was eating a low-calorie ADA diet (15% to 20 % protein, less than 7% saturated fat, 60% to 70% carbohydrate and unsaturated fats). The researchers (apparently all vegans themselves) suggest that vegan diets might be easier to stay on. The high fiber content and larger quantities you eat may make you feel full and satisfied with less intake in calories. More about this next week.

What do you think about the protein debate? What about the cold carbs? Would you try, or have you tried a vegan diet? Let us know by commenting here.

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  • Philbur

    I’ll be honest, I am pretty skeptical about the cold carb theory. I imagine by the time the food hits my digestive system it will be pretty close to 98 degrees. Perhaps I’ll give that one a try. It’s been awhile since I had some potatoes just to have potatoes.

  • tmana

    I bought into the 15% protein deal when I was first diagnosed with T2, sticking to whole foods and minimizing animal proteins. I developed iron-deficiency anemia as a result. I found that I need at least 70 g protein on a daily basis, going up as high as 100 g when I am actively weight training — and that I need MFP (meat/fish/poultry) protein at least two or three times a week in order to maintain correct iron levels.

    As a result, I don’t buy into “low protein” unless/until kidney function is compromised.

    I do buy into whole grains/whole foods for multiple reasons — glucose control is just one of them. Even more important is their relatively low sodium content — much better for blood pressure control and interstitial fluid management.

  • acampbell

    Hi David,

    Thanks for the update on nutrition issues presented at ADA. Just an FYI that I posted some information on resistant starch recently (May 27) if anyone is interested in learning more about this. I’ve also written about vegetarianism in the past, too. I’m not sure it’s fair to imply that “nobody knows anything” when it comes to nutrition. While it does seem, at times, that advice and recommendations change or conflict, my take on it is that a)nutrition is a relatively new science and b)as someone put it, it’s highly likely that different people may need slightly different ways of eating. I work with Dr. Hamdy at Joslin, and he runs a weight management program that incorporates Joslin’s Nutrition Guideline; results thus far are quite good. We’re learning that people with type 2 don’t have quite the same nutritional needs than people with type 1. But many of the key recommendations, such as eating whole grains, eating less saturated fat, etc., are applicable to just about everyone.

  • CalgaryDiabetic

    Dear David.

    Well the cold patatos or rice may have some truth in it as the digestion of these start as soon as the are mixed with saliva in most people. From a chemical kinetics point of view it is likely that being cold this would slow the reaction also not chewing too much would help.

    A veggan diet I dont know. With age I find that I am loosing my muscle mass which is a disaster for a diabetic. A lot of exercise and 100 g of protein is probably good to counter this.

    However, historically you wonder if my ancestors in Slovakia ate only sauerkraut,(and recently mostly patatos), beans with very little meat and most important of all they would not have eaten too much except occaisionally. This is why America is toxic to most people since this constant availability of food has never occured in the past and our bodies are not equipped to deal with this.

  • Joan

    Hi David:

    I tend to believe more in what the doctor from India said about the differences in individual metabolic systems. It just depends on what type of carbs & protein work best and it is up to each of us to find which is best! No medical professional can tell us exactly what to eat but they can provide some “heads up” on certain food items that MAY be harmful. I know that white potatoes do not work well for me no matter how they are prepared. Pasta is another that depends on the quantity rather than the type of carb! Quantity is very important to loose weight!

    There is no ONE answer that fits any person with diabetes.

  • Ephrenia

    I think I’ll just go have my lunch now —- roast beef on low carb wheat tortilla roll-up and follow it with a serving of apple for desert.

    I don’t think I could make it without my animal proteins. Roast beef is not my usual though. I normally have a turkey roll-up for lunch, today is a treat.

  • Beth

    I think the doctor from India is exactly right. Some people seem to do very well on low-carb diets, but others of us do not. I do best on relatively low protein, whole grains, and lots of veggies, including naturally fermented sauerkraut and pickles. I think it’s similar to what my central European ancestors probably ate for centuries.

    (As an aside — I have never seen a study on naturally fermented foods, but I do find I do better when I eat them regularly. I suspect it helps build colonies of good microbes in the intestines, like yogurt.)

    Our ancestors were adapted to many different environments, with different foods available in different settings. To me it makes a lot of sense that we would have different nutritional needs.

  • markthehandyman

    Diet has been, by far, the most frustrating part of being diabetic.

    The ADA strikes me as almost criminal in continuing to push a ridiculously high amount of carbs. Our bodies have a problem processing carbs. To continue to advocate eating them at the recommended levels is plain malpractice.

    Our society is drowning in a sea of carbs. Just watch TV commercials or walk down the supermarket aisle. We’re so used to this situation we think it’s normal, and can’t even conceive of other ways of eating. Instead of helping address the underlying issues, the ADA simply raises the target BG range.

    I’m not an advocate for a Dr. Bernstein totalitarian approach to carbs, but I think a pretty severe limitation (at least compared to what we’re used to) is usually necessary, accompanied by weight loss and exercise, if one wants to reduce or eliminate medication (that’s my goal).

    That said, I’m in complete agreement with the commenters who say we each need to find what works best for us. I just wish I had met a medical professional (including dieticians) who had helped me do exactly that at the time of my diagnosis, instead of spouting off whatever their party line happened to be.

  • Gouda

    The cold carbs work. I was shocked, but they work for me.

    I was eating a low-carb Atkins diet and had an issue with cancer. I decided to cut back on meat and read about cold pasta and cold potatoes. My fasting went from about 105 on Atkins to in the 70s while eating a sweet potato every day! I now eat about 75% carbs, all whole grains, no meat, and even my postprandials are never over 120. Not what I expected!

  • David Spero RN

    Thanks for sharing that, Gouda. It’s so weird, but it seems to work for a lot of people. It just goes to show that everyone is different, and that a lot of different diets can work, if they’re right for you.

  • Babs

    I agree that different approaches will work for different people–and we all have to be tuned into our bodies enough to catch the clues if something is or is not working for us. I decided to take the 21 day challenge at PCRM.org to go vegan, and I’m finding it very easy and enjoyable to stick to the vegan diet. Dr. Barnard asserts that if you eat this way, you come to break the cravings for those foods that are unhealthy for you. I’m committed to giving this an honest try and see what it brings for me.