People With Diabetes Can Eat Everything, Really?

There’s a four-letter word lurking behind many conversations about diabetes – and, at the risk of offending people with my language, it’s spelled c-a-r-b.

Before I was diagnosed with diabetes in 2001, I rarely thought about carbohydrates – and when I did, my associations were usually positive. I’d gather with my swim team to binge on pasta before big meets, or bake brownies and cookies for my classmates in my spare time. In my mind, carbohydrates=energy=good (or, at very least, delicious). Then, one cold, Saturday morning 13 years ago – the moment when I was diagnosed with Type 1 diabetes — that relationship was abruptly and permanently changed.

Carbohydrates were now mathematical problems to be managed, challenges hiding in every meal. I was surprised by many social occasions I now realized were focused around carbohydrates – happy hours, ice cream socials, birthday parties, late-night college pizza breaks. Joining friends for dinner became a balancing act: did I make special requests because of my diabetes and potentially inconvenience people, or did I go along with the group’s Chinese/Indian/Thai/Ethiopian/pizza/sushi plans, and suffer the blood sugar consequences afterwards?

For a while – years, actually – I tended toward the latter. (Even today, when plenty of people make special requests based on vegetarianism or other dietary preferences, I find it difficult to ask people to go to a different restaurant because of my diabetes.) Like many people with diabetes, I’d internalized the message, meant to be encouraging, that today’s insulin pumps and glucose meters mean that we can eat whatever we want. Granted, I soon found that many foods simply weren’t worth the effort – I just don’t like bagels that much, and don’t find anything particularly delicious about rice. But deep down, I still adhered to the philosophy that diabetes wasn’t supposed to limit me in any way, including in my choice of food. And I certainly didn’t want to impose a burden on anyone else.

The idea that today people with diabetes can eat everything is supposed to be a liberating philosophy – and certainly, compared to the restricted diets of the past, it is. I’m grateful for faster acting insulins, blood glucose meters and continuous glucose monitoring systems. But unfortunately, this supposed liberation can only go so far: even today, every meal requires you to correctly guess how much insulin to take, and to monitor and check yourself multiple times afterwards to make sure that you’ve succeeded. As Dr. Richard Bernstein has pointed out, the greater the amount of carbohydrates in your math problem dinner, the more likely you are to get it wrong.

This, I realized, leads to a contradiction in supposed liberation: while part of me was grateful for the flexibility that today’s medications and technology allow, another part of me felt oppressed.  Here’s why: if diabetes itself is supposedly no longer restricting me, if I supposedly have all the tools at hand to eat whatever I want, then any time I finish a meal with high blood sugar or a scary low, then I must have done something wrong. The problem, in other words, isn’t my diabetes, it’s me. 

Eventually, like many other people with diabetes, I learned that the easiest way to “succeed” at diabetes was not to eat whatever I wanted; it was to restrict carbs. It’s a philosophy brought up by others on ASweetLife – check out Leo Brown’s piece A Touch Less Insulin For Diabetes Awareness Month or Kerri Sparling’s Sticking It to Diabetes or Jess Apple’s (highly controversial!) Diabetes and Ice Cream: Fighting the Wrong Battle.

But it’s also a philosophy that’s often shunned by mainstream nutritional advice, from the Institute of Medicine’s recommendation that 45-65% of an adult’s calories come from carbs to the American Diabetes Association’s meal-planning guidelines, in which most menus include a “moderate” 45% of carbohydrate, and most meals contain between 45 and 60 grams. (The ADA’s 2013 Nutrition Therapy Recommendations finally began to challenge the assumption that there’s one ideal blend of macronutrients for people with diabetes, and that a low-carb diet might have benefits, but its meal plans haven’t yet caught up.) Couple these “official” recommendations with the idea, drummed into us since the 1960s, that dietary fat (particularly saturated fat) is dangerous, and it can be difficult to balance the everyday recognition that life with diabetes is easier on fewer carbs with the fear that somehow, by restricting carbohydrates, you might be harming your health.

Thank goodness, then, for the work of people like Gary Taubes, David Lutwig, and Peter Attia, writers and researchers who propose a hypothesis that seems to fly in the face of all that we’ve been taught (but which, when you read into it, seems quite convincing): that carbohydrates aren’t just problematic for diabetics; they are problematic for everyone. As such, the fact that I find high-carb meals so difficult to handle doesn’t reflect poorly on me (or my diabetes); it reflects the fact that none of our bodies were meant to eat that many carbs. 

According to Gary Taubes’s argument in his excellent book, Why We Get Fat (and his controversial cover story for the New York Times Magazine, “What If It’s All Been a Big Fat Lie?”), a lot of this has to do with insulin. As a refresher, when we eat carbohydrates – whether they’re sweet or starchy — they break down into glucose in our blood. (That’s true for anyone, regardless of whether their pancreas works.) Insulin is the hormone that allows our bodies to absorb this glucose. If we don’t take enough insulin to control the spike, our blood sugar will be high, leading to possible complications over time. Too much, and we can go dangerously low.

But insulin also has another purpose in the body, as Taubes points out. As he explains in Why We Get Fat, the whole calories-in, calories-out hypothesis of weight management (i.e. if you eat more than you need, you gain weight; if you eat less, you lose it) is incorrect, because it doesn’t take into account how our body regulates when and where to store fat. (If you’re skeptical of this idea, ask yourself why women store fat in different places than men, or why we put on weight differently as we age, or why you will develop a pocket of fat if you continuously inject insulin into the same site). As Taubes points out, our fat storage is regulated by our hormones. And the primary fat storage hormone – the one that guarantees the food we eat will be turned to fat is, you guessed it, insulin. In a nutshell, Taubes’ argument boils down to this: we secrete insulin in response to carbohydrates. Insulin makes us store fat. Therefore, in order to limit the amount of insulin in your body – and amount of fat your body stores – you should restrict carbohydrates. 

Taubes goes into much, much more detail – pointing out, among other things, the fallacy of the idea that fat is dangerous, and the fact that until the 1960s (when the low-fat dogma became popular), the fattening effects of carbohydrates were widely known and accepted. He also makes a convincing case that low-carbohydrate diets (even super-low carbohydrate diets) are actually not dangerous to health — in part because fats, even saturated, are not the recipes for heart attacks that they’ve been made out to be. (Trans-fats are an exception: nearly everyone agrees they’re dangerous.) Yes, saturated fat will raise LDL levels, but Taubes argues that the connection between LDL and cardiovascular risk is less robust than we’ve been made to think. Instead, low HDL levels (the “good” kind of cholesterol) and high triglyceride levels are much more strongly associated with cardiovascular risk. And guess what macronutrient lowers your HDL and raises your triglycerides? Carbohydrate.

For more detail on these ideas, I recommend looking into the work and lectures of these three men. But getting back to my own relationship with carbohydrate, here’s what they’ve helped me to realize: the fact that my body reacts poorly to high carbohydrate meals, it isn’t just because I have diabetes; it’s because high carbohydrate meals might be bad for everyone. A high carbohydrate meal will cause a spike in blood glucose in all people; it’s just that if you’re not diabetic, you’ll never see it, because your body will spurt out insulin to cover it. Being diabetic, therefore, turns us into the nutritional equivalent of a fish tank: our lack of insulin makes it possible to see, via the rise in our blood sugars, what happens to our bodies when we eat carbohydrates. And if carbohydrates and insulin spikes are as fattening and dangerous as these writers and researchers so convincingly suggest – and if I know firsthand how goddamn hard it is to manage my blood sugar when I eat lots of them – then you know what? I’m just going to restrict carbs.

This doesn’t, of course, get past the fact that many carbohydrates are delicious, and that resisting the smell of a fresh-baked cookie requires nearly inhuman levels of self-control.  But it’s turned the burden of avoiding carbohydrates into a source of empowerment for me (whenever I have the willpower and food choices to achieve it). And it’s changed my attitude from “ I want to eat carbohydrates so I can be like other people,” to “other people can learn a lot from the way that I have to eat.” For me, that is a liberating thought. 

http://asweetlife.org/

Graham