The Hope Warshaw Issue

The low carb world has been abuzz with the news that Diabetes Health Magazine recently published an article by a registered dietician and diabetes educator named Hope Warshaw. Ms Warshaw wrote this article, she says, to debunk two what she calls “common old dogmas” regarding diabetes management.

The second “old dogma” she mentions, and the one drawing fire from the low carb community, is the idea that low carbohydrate diets are effective for glucose control. Gee, where could we have gotten the idea that a disease that is characterized by profound carbohydrate intolerance might be treated by not eating carbohydrate? How could we be so crazy as to think that not eating food that turns directly into glucose might help control blood glucose levels?

The low carb community has pointed out, rightly, that this supposed “old dogma” is actually contrary to everything the medical establishment and the American Diabetes Association have been saying for the past few decades, at least. For a very long time, diabetics have been told that since they are at high risk for heart disease, they must eat a low fat, low cholesterol diet, and should base that diet on carbohydrate. No option for controlling blood sugar is offered other than medication in increasing doses, as the disease progresses, and glucose control worsens. If there’s an “old dogma” from the standpoint of virtually everyone in medicine today, that’s it.

But Warshaw is right that advocating a low carb diet is old dogma – if you go all the way back to a time before there was any hypoglycemic medication, or even injectable insulin. Back then it was clear, it was well-known, that the only hope for survival for diabetics was a very low carbohydrate diet. It was a standard prescription, because it worked. But since both injectable insulin and metformin were first developed in the 1920s, it seems unlikely that many doctors who learned that old dogma of prescribing a low carb diet for diabetes are still practicing now. Indeed, the doctors I know who embrace carbohydrate restriction as a tool for managing diabetes and other illnesses all say that they had to discover it on their own; it certainly was not taught to them in their medical training.

Warshaw is actually recommending that diabetics get 45-65% of their calories from carbohydrates. The only solution she offers for the massive glucose load that represents is to cover it with medication.

The madness goes further, however. In a debate with Dr. Richard Bernstein, author of Dr. Bernstein’s Diabetes Solution, Warshaw stated that diabetics had a “right” and “deserved” to eat their favorite delicious foods. A WHAT? A right? To eat food that requires them to take more and more medication? They deserve to go blind and lose their toes and their kidneys? Quite honestly, this is one of the stupidest, most wrong-headed statements I have ever heard. It is very much analogous to saying that children with peanut allergies have a “right” and “deserve” to enjoy delicious peanut butter sandwiches, peanut butter cups, and peanut butter cookies, so they should go ahead, and just inject epinephrine every time they do. Sound insane? It is. So is the statement that diabetics “deserve” to eat high-carb foods. “Deserve” doesn’t enter in to it, for crying out loud. (My thanks to Fred Hahn of SlowBurnFitness.com for the analogy. It’s remarkably apt.)

Since I talked about “Old Dogma” number 2 first, what’s Old Dogma Number One? That weight loss will lower blood sugar. Warshaw says “Research shows that the greatest impact of weight loss on blood glucose is in the first few months and years after diagnosis.” She goes on to say, “Large studies have shown that with loss of five to seven percent of body weight (approximately 10 to 20 pounds) and 150 minutes of physical activity (30 minutes five times a week), people can prevent or delay the progression to type 2. Once insulin production is on a dwindling course (particularly after 10 years with type 2), weight loss has less impact on glucose control.”

My question would be “Weight loss HOW?” Weight loss with a low fat, low calorie diet centered on “healthy carbs,” which has been – dare I say it – the dogma for thirty years now? Because if that’s the case, then yes, I can see that there would be little long-term benefit from weight loss achieved that way. Especially if we’re talking about 10-20 pounds as 5% of body weight – that’s 10 pounds lost for a 200 pound person, or 20 pounds lost for a 400 pound person. That doesn’t strike me as terribly significant in the long run.

Does Ms. Warshaw have statistics for the long term results with people who have lost weight eating a low carbohydrate diet? I very much doubt it. Indeed, she says: “Countless research studies do not show long term (greater than six months to a year) benefit of low carb diets on blood glucose, weight control, or blood fats.” Ignoring that despite her claim of “countless studies” she doesn’t cite a single one, as my friend and fellow blogger Tom Naughton pointed out, there are few studies of low carbohydrate diets that have lasted longer than six months to a year. So the studies fail to show benefits after the study ended. Big shock.

Ms Warshaw goes on to cite the legendary difficulty of maintaining a low carbohydrate diet. I must be a person of uncommon will, because I’ve found it remarkably easy to remain low carb for nearly sixteen years now. But it should be pointed out that most people find any dramatic dietary change difficult. Indeed, I’ve known for a long time now that most people would quite literally rather die than change the way they eat. I know this because they do it every day. People don’t just drift away from low carbing. They drift away from low fat diets. They drift away from calorie control. They drift away from vegetarianism. Regain rates for weight lost top 95%, regardless of how it’s done. Old habits die hard; big surprise.

However, it seems to me that there is at least some increased motivation to stick with a dietary program that yields results. Not necessarily “I’m miraculously cured and fashionably skinny!” results, but “My A1C dropped dramatically, my blood pressure is down, my blood fats have normalized, I need less medication, and I’ve dropped three sizes” results? Yeah, that’s pretty motivating for a lot of people. Too, I for one find it vastly easier to stick to a diet that doesn’t require me to be hungry all the time, and deal with nasty blood sugar swings. Feeling good is a powerful motivator.

Clearly, some people find the lure of carbs more motivating, or have a difficult time with feeling like the odd one out when the pizza is passed around. That’s too bad. And yeah, if they can’t resist, they’ll have to up their medication to compensate; that beats running high blood glucose levels all the time. But to actually state that diabetics should all get 45-65% of their calories from carbohydrate, and just figure medication will deal with it? And that a low carbohydrate diet is useless? That’s irresponsible in the extreme.

Heck, I might go so far as to call it homicidal.

The outcry from the low carb and diabetic communities about Ms. Warshaw’s article has been so vociferous that the magazine felt the need to run an editorial statement on the matter. In an article titled Righteous About A Diabetes Diet, Nadia Al-Samarrie commented on the fire Warshaw’s article drew. She states that she is pleased that a passionate, vocal group of low carbers follows Diabetes Health, and tries to deflect accusations that Diabetes Health is anti-low-carb by citing coverage of Dr. Richard Bernstein and Dr. Atkins twenty years ago.

Then she makes a statement that invariably makes me want to bang my head on my keyboard: “Different diets work for different people.” This may be true for weight loss – many approaches to weight loss will work for at least a time, usually because paying attention to diet in general results in reduced consumption of the most egregious junk, regardless of the program chosen. But weight loss is not glucose control. There is simply no logical, valid argument to be made that there is some magic way that eating carbohydrates will not raise blood glucose. Increased glucose means increased medication, and increased diabetic complications. It’s a very simple equation.

Ms. Al-Samarrie continues, “Despite the well documented merits of a low carb diet, the reality is that it's not successful for everyone... We will soon publish an article about a type 1 who diligently tried the low carb diet and still suffered from a high A1C. Low carb did not work for her. It wasn't until she persuaded her physician to prescribe metformin for her (which is generally prescribed for people with type 2, not type 1) that she achieved success. After going on metformin, she finally realized normal blood sugar. What works for one may not work for another.”

Way to obviate the issue. I don’t know of anyone who has said that all type 2 diabetics can be entirely medication-free with a low carbohydrate diet, and I certainly don’t know anyone who has said that type 1 diabetics can all be medication-free with a low carbohydrate diet. What we have said, and what is inescapably true, is that if you don’t consume foods that dramatically raise blood glucose, you will need less medication to lower blood glucose. Some people will wind up medication free, some will continue to need medication. But the vast, vast majority will have better glucose control when not eating foods that create glucose. How could it be otherwise?

She, too, trots out the “difficulty” of low carbing: “Personally, I have not been successful on a low-carb diet, and that's true of many other people with whom I am familiar. A low carb diet is difficult to stick to.” That blanket statement about how “difficult” low carbing is makes me want to throw things. There are many of us who find it simple as can be. In sixteen years of eating this way, I have never been forced to eat anything I did not wish to eat, and that includes a period of about 18 months when I was on the road, eating in airports, fast food places, and hotels much of the time. The truth is, low carb food is everywhere. It is simply a matter of choosing it.

I suspect what Ms. Al-Samarrie means is “Breaking addictions is difficult,” and this is certainly a valid statement for many, if not most, people. It is not, however, a valid reason to tell people that breaking a damaging addiction is a bad idea, or even inessential. Quitting smoking is legendarily hard, yet I know of no one who says, “Quitting smoking is hard, so it’s unfair to say it’s the only option for treating emphysema. It’s fine to tell people to simply switch to organic tobacco, and keep their oxygen tank at hand.”

Furthermore, Ms. Warshaw’s article did not simply offer alternatives, as lame as those alternatives might be. It flatly stated that a low carbohydrate diet was ineffective for long-term glucose control, and that all diabetics should get 45-65% of their calories from carbohydrates, simply relying on medication to control the resultant glucose spikes. That this approach is patently less effective than breaking the addiction to the substance causing most of those glucose spikes apparently matters to her not at all.

Nor does the fact that this advice will inevitably lead to more lost eyesight, amputated limbs, failing kidneys. That human toll is apparently less important than the “right” to eat the food that is causing the damage. I wonder if Ms. Warshaw would be willing to tell that to the grieving children of a diabetic who has died early of complications? “Oh, but it was all worth it, because she didn’t have to give up Oreos!”

The casual cruelty this represents is staggering. Damned right I feel righteous about it.

I am proud of the low carb community, and how we have rallied to shout down this dangerous nonsense. Because we have had dramatic, profound changes in our health, physical and mental, from a low carbohydrate diet, our passion is intense. Many of us, too, fear for the lives of loved ones who still buy the garbage put out by “experts” like Warshaw and the ADA. There is a desire to do something, anything, to speed change.

I have two recommendations for useful action: First, join the Nutrition and Metabolism Society . With its dedication to research, and to presenting the science of carbohydrate restriction, they are reaching doctors and other medical professionals in a way that many of us, as private citizens, cannot. Secondly, speak up. Speak out. Tell your story. When people refer to low carb as a “fad diet,” or mention that they’re on a low fat diet and not doing as well as they’d hoped, say, in a friendly, conversational way, “Here’s what happened to me.” When people in positions of real or assumed authority – like Hope Warshaw – spew nonsense about carbohydrate restriction, the friendly tone becomes optional. The raising of our voices and the telling of our stories is not.

As Gandhi wisely pointed out, what we, as individuals, can do seem insignificant – but, never the less, it is important that we do it.

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Explain this

One year ago the doctor wanted to start me on insulin...I was already taking 2 diabetes medications. I asked her to wait and give me 6 weeks to try to drop weight, begin more exercise and lower my A1C. I began with your cookbooks & blog and went Lo-Carb. Today (one year later) I have lost 57 pounds and my A1C is 5.6 and the doctor is amazed, but still wants me to continue the medication! I guess it shouldn't surprise me. I am convinced that lo carb is for me, for life and am discontinuing the medication. How can they argue with results like mine???

Keep spreading the truth,
Kathy

OMG Typical Doc attitude

Hi Kathy -
I am not a bit surprised your doc wants to keep you on meds, even with with an A1C of 5.6. I am a nurse and can tell you the mindset of the majority of the medical community on diabetes. "Once diabetic, always diabetic, and you must control it with meds." And they are so rigid these days about diagnosing it - you are "pre-diabetic" with a fasting sugar of 101 and "diabetic" at 126. Period. A normal A1C is supposed to be 4.5-6, but they call you pre-diabetic from 5.7-6.4, and guess what happens at 6.5? You are diagnosed diabetic. Try getting that changed. It may not be possible for all type 2's, but I believe at least some can get off their meds with this diet and exercise.
I totally believe in controlling carbs, especially the processed junk types. And Dana knows her stuff. :-D
This article by the dietician/diabetes educator is no surprise, either. Same mentality. I read it and did not know whether to laugh or cry. I really enjoyed the editor's defensive comments, too.

Hooray, Kathy!

-

I need to vent now too:

See what the Canadian Diabetes Association says about diet and diabetes at http://www.diabetes.ca/files/JTB17x_11_CPGO3_1103.pdf. While the CDA says here that "The more sugar you eat, the higher your blood glucose will be," they also say that "Choose starchy foods such as whole grain breads and cereals, rice, noodles, or potatoes at
every meal. Starchy foods are broken down into glucose, which your body needs for energy."

No wonder people are struggling... all the misinformation is so confusing!

Your article reminded me of this article

I came across this article last fall and I think it augments what you're saying. (I don't remember - I may have found this article through you.) Please don't feel the title of the article is an insult to anyone. The follow-up comments are also fascinating.
http://www.huffingtonpost.com/justin-stoneman/post_868_b_720398.html

or type "America: A Big, Fat, Stupid Nation" into the Huffington Post search bar.

Sharing LC Knowledge

Hi Dana,

I've stopped trying to explain LC to overweight people. I just give them a copy of your book "How I Gave Up. . ." I can't tell you how many friends have read it and lost weight as a result. It's good to pull it out from time to time to refresh the memory as well.

How I Gave Up My Low Fat Diet

:-D :-D :-D :-D :-D

Deserve?

When Warshaw says the word "deserve," she's just telling some people what they want to hear. In real life--any part of real life, whether you deserve something doesn't count for much.

I'm keeping my father's example in mind!

My father developed type-2 diabetes in his 60s, injecting himself daily with insulin the last several years of his life, until dying at age 72 of a heart-attack. He was one of those people who went on eating desserts, such as ice cream, and all kinds of carbohydrates despite his condition. If you asked him, he'd say his blood sugar was under control. All he had to do was take his shot. A couple of times, he had dangerous low glucose levels from not eating enough after injecting the insulin. He at least kept his vision and all of his limbs until the end. Whatever diet advice he got was the standard low-fat, low-calorie, which admittedly he didn't follow and which wouldn't have helped much if he had. I'm sure no one ever said the words "low carb" to him. I guess 72 is not all that young to go, and we all go sometime, but it would be nice not to have to stick a needle in your arm every day or worry about losing your eye-sight. So aside from wanting to lose weight, I also want to keep my pancreas in good working order, and the best way to do that is to avoid the carbo-loading that would over-tax it. Low carb is about preventing type-2 diabetes, as well as treating it. Jim Anderson.

Familial Loss

So sorry for your loss Jim. I must say though, 72 is too young and I'm sure you are doing everything in your power to avoid what happened to your father. I am speaking as a 71 year young NIDDM who has been low-carbing since dx. in 2003. You have the right idea!

We're putting the cart before

We're putting the cart before the horse on weight loss vs. glucose control anyway. If someone's weight gain is related to their typical glucose levels vs. their typical insulin levels, then controlling blood sugar *will* cause weight loss since that's the obstacle standing in the way of same.

It's not that the weight loss leads to the sugar control. It's that the sugar control leads to the weight loss.

If someone's trying to lose weight with a low-fat, low-calorie diet, chances are good the proportion of carbs in the diet is high, and it doesn't matter that they're not eating a lot of food--if they're eating enough carb to get that blood sugar high, and therefore their insulin high as well, they're not going to lose much weight because they never gained blood sugar control. At most, if they exercise a lot, they might lose some lean mass. Not exactly the results they are looking for.

Oh, and they'll be very hungry too.

Incidentally, I have stopped looking at the A1C as the gold standard for blood sugar control unless I also know the person's hemoglobin level and whether they were dehydrated. Both anemia and dehydration skew the number and cause an inaccurate result. Chris Kessler has mentioned this a time or two at his Healthy Skeptic blog. Also, I need to know what the person typically eats and what their blood sugar is after the meal. Absent that information, I don't know much and I can't say with any authority whether they really succeeded or failed.

It'd be like a Kimkins survivor saying low-carb doesn't work because of their experience on that diet. How many different ways are there to do low-carb? Might it not be reasonable to assume that some methods will be more successful than others? I would think so.

These people are so silly. And I should have made this into a blog post rather than hijack yours. :P