What is the best diet for prevention and treatment of diabetes?
For ages, diabetics have been routinely advised to eat a diet based on carbohydrates, artificial sweeteners and also to consume diabetic food products with added fructose. However, their condition gradually got worse, or at best remained stable. For that reason, it has also been recommended for doctors to prescribe medications when diabetes was diagnosed. Outside of the Czech Republic, we can find more and more scientific papers by doctors, dietitians and patients, who propose revolutionary changes of the standard diabetic diet and experiment with it.
“Reversing diabetes starts with ignoring the guidelines.”
This is the key message of Sarah Hallberg MD in her TEDtalk. According to Hallberg, a diabetic diet based on a regular intake of carbohydrates is entirely inappropriate, because it merely promotes the progression of the disease. Today’s epidemics of Type 2 Diabetes is primarily caused by obesity and the development of insulin resistance, which is significantly helped by overeating of carbohydrates. I fully agree with Dr Hallberg that most of us would benefit from reducing carbohydrate intake, and that real foods should be the basis of a healthy diet, as opposed to industrially processed packaged products. I would also suggest that good quality fats are not an enemy and we could consume a lot more. We can debate as to whether it is advisable or even necessary to consume as much fat as outlined in the talk. We could also discuss if the decades old irrational lowfat dietary recommendations are the main cause of carbohydrate overeating. Likewise, it is unclear if those people who ignored these low fat dietary recommendations promoted by doctors and industry and simply enjoyed basic quality foods, need to change anything today.
I am delighted to see a survey organised by Jan and David aiming to understand patients’ views on the benefits and risks of different dietary options. They are trying to compare dietary recommendations for people with diabetes in different countries around the World, and also compare the efficacy of these dietary therapies.
Jan and David, may I ask you to please introduce yourselves? What do you do, what sparked your interest in dietary therapies and why did you organise this survey?
Jan Vyjidak: By background, I am a lawyer and a solicitor, I also worked at White & Case law firm in Prague. I have always been fascinated by medicine and health systems, and ended up studying medical law and international health management. Since 2009, I have worked as a management consultant in healthcare quality improvement. I focus on all things hospital management, particularly on quality improvement methods inspired eg. by Virginia Mason Medical Center, one of the global leaders in terms of systematic patient outcomes improvement.
I work for Dr Foster, an organisation which in 2001 revolutionised the health system in the UK when we published the Dr Foster Hospital Guide. Dr Foster provides hospitals in the UK and also in other countries with intelligent data related to patient outcomes, and our mission is to improve quality of care.
I first came across with diet and health thanks to a close encounter with liver cancer in 2005. I was intrigued that among other methods, doctors also used PET/CT imaging to diagnose cancer. As PET/CT scanners leverage differential rate of glucose metabolism of tissues, I began to follow the scientific literature on energy metabolism. A milestone came in 2009 when I first came across with the concept of macronutrient composition of diet as a therapeutic option in the treatment of a wide variety of diseases, from cardiovascular and neurologic to autoimmune.
In 2012, I worked with an excellent team of paediatric neurologists and dietitians at St George’s Hospital in London, and have since been in touch with leading doctors and scientists who investigate the effects of diet on human health and in the context of different diseases. I was blown away by just how much top quality clinical studies and data already existed on this topic, and how already in 1850, doctors such as Claude Bernard knew far more about diet and energy metabolism than many doctors and dietitians know in 2016. Just like in any other field, generating new knowledge in medicine goes hand in hand with forgetting of older knowledge, often still valid and relevant.
The prevalence of diabetes in the Czech Republic is 10%, which represents almost 1 million people. Their treatment, and particularly the treatment of diabetic complications, costs over 40 billion CZK (IDF 2015), almost 20% of the total annual health expenditure (NDP 2012). Diabetes is a massive problem, and irrespective of the great successes of medicine, doctors perform some 8,000 lower limb amputations every single year (DACR 2013).
The survey is part of our research into diabetes and carbohydrate restriction, and David and I would like to show what kind of dietary options people with diabetes opt for in different countries, and also how they evaluate the effects of these diets on their disease. We assume that in the Czech Republic and Slovakia, it is often extremely difficult for patients and also for doctors to access quality information regarding different dietary options, and suggest that with better information available, patients could broaden their understanding, and perhaps be in a better position to control their diabetes, hopefully also with better outcomes. The most important aspects for people with diabetes are improved quality of life, the lowest possible doses of medication required to optimise blood glucose without avoidable peaks and troughs, and a reduction of the risk of complications, such as cardiovascular disease, retinopathy or amputations.
David Liska: I am currently a student of physiotherapy at the Slovak Medical School in Banska Bystrica. I am interested in a wide variety of medical problems. In my field, I am particularly intrigued by the effects of physiotherapy on different diseases states, such as the impact of TENS waves on pain, the effects of laser therapy on hypothyroidism, the use of hyperbaric chambers, and of course the effects of physical exercise. I am also interested in the implications of different diseases for the musculoskeletal system.
I am totally fascinated by the importance of nutrition in the treatment of different diseases, such as rheumatoid arthritis, idiopathic bowel disease, irritable bowel syndrome, ankylosing spondylitis (M. Bechterev), gastroesophageal reflux (GERD), bacterial overgrowth syndrome (BOS), hypothyroidism, non-alcoholic fatty liver disease (NAFLD), epilepsy, Lyme disease, but also in the context of psychiatric illnesses, and of course in diabetes.
I am also very intrigued by the variable response of the intermediate metabolism across the population. Every person is an individual and I suggest that each patient should therefore be considered as an individual, as is clear also from the highly individual response to the digestion of starch (diploid gene amylase polymorphism), histamine intolerance, FODMAPs intolerance or lactose intolerance. I am of course referring to evidence-based approaches and not to highly suspicious diagnostic tests such as food detective, which are commonly available on the market. Incredibly, in Slovakia, some of these tests are also co-funded by a health insurance fund, despite no valid studies to support it. For this reason, I believe we should highlight all cases of misinformation.
Diabetes mellitus is one of the conditions which can be effectively improved by diet and lifestyle. More and more doctors and patient groups outside Slovakia have been discussing the positive effects of low carbohydrate and ketogenic diets in the treatment of diabetes. Ketosis is a physiological state when our bodies derive energy primarily from fat (beta hydroxybutyrate, acetoacetate and acetone). One of the biggest proponents of a low carbohydrate diet for diabetics outside Slovakia is Richard Bernstein MD, who at the age of 54 completed a medical degree (I might follow his path one day).
We are undertaking the study primarily out of our own interest. My personal view is that the issue of nutrition and diseases is not sufficiently discussed. I think we need to be opening these topics and search for solutions which may benefit patients. Michal Pijak MD in Slovakia is a great example of constructive work, he keeps highlighting numerous problems aiming to improve patient outcomes, and this is also why he is my big hero.
Who is this survey for? Who can participate?
David: The survey is for all patients with a diagnosis of diabetes mellitus. It focuses on general questions relating to diet and diabetes. We will compare groups of patients abroad (outside CZ/SK) and at home (CZ/SK). It is of course important to note that any cohort observational study has several limitations, for example due to confounding factors. However, that does not prevent us from writing a paper and for the results to maybe form a basis of further studies. We are not coming up with any new physiology, but would like to explore problems, which, in our opinion, remain underestimated. We are intrigued by the responses from the patients, and also by the effects of different diets. It is worth noting that there is not one single diet which would suit everyone. However, we suspect that high carbohydrate diets should not be a default blanket recommendation for all diabetic patients. We are yet to see what conclusions we arrive to in our paper. We would also welcome constructive criticism of our work, from both patients and doctors. In our view, dietary therapy plays a fundamental role in medicine, especially so in chronic diseases. We do not like the term diet when used in terms of a restriction, though. The most important thing is for these problems to be discussed, much more than they have been to date.
How will you use the data, where will you introduce it?
David: Jan loves working with data, and will be able to answer this question more accurately. We will happily make the results public, including on this blog, for example.
Jan: David is right, I like working with data, we plan to summarise it and show what type of diets diabetics choose in different countries, how they assess the cost involved, the difficulties in preparation, and effects on their condition. We would also like to find out how well do patients understand the basic clinical results in relation to their health, eg. glycated haemoglobin (HbA1c), serum triglycerides and cholesterol. We anticipate some stark differences between countries, partly also due to the level of difficulties with which it may be difficult for patients in CZ/SK to obtain good quality information.
Do you work directly with doctors?
David: Yes. Collaboration is a basic ingredient of any good work. Hana Krejci MD an experienced diabetologist has kindly agreed to become our medical adviser. Once our paper is completed, we will also seek an input from Michal Pijak MD, to ensure that we do not include any misinformation. We would of course welcome an opportunity to collaborate with other diabetologists and medical doctors, who would like their patients to participate in the survey.
Jan: I totally agree with David, we would not make it far without a collaboration with doctors and scientists. Indirectly and remotely, we absorb information from medical doctors, dietitians and scientists who are directly involved in clinical research or have several years of experience in treating diabetic patients. We are also in touch with some patients-experts, a term describing patients who are also medical doctors or understand their condition in great detail due to their education or self-study, such as physicists, biochemists and pharmacologists. For example, we could mention Tim Noakes from South Africa, who is a Type 2 diabetic (profile) – his depositions on insulin resistance, diabetes, energy metabolism and diet before the HPCSA are now available to anyone who is interested (Part 1).
I am glad that David mentioned Richard Bernstein (CV, the latest book and a web page Diabetes Solution 2011). He is a wonderful example of what can happen when a mathematician, engineer, physicist, computer designer and also a Type 1 diabetic gets hold of one of the first home glucometers – yet, he was lucky to be married to a medical doctor, otherwise would not have had any chance, being an “ordinary patient”, to get access to the glucometer. Using the classic trial and error approach (still today, a cornerstone of engineering and also of scientific and technological progress, see Tim Harford in a brilliant TED talk Trial, error and the God complex), Richard found out that the dietary recommendations by American Diabetes Association do not help control his glycaemia. In a few days, using data from his own glucometer, he came up with a prototype of a low carbohydrate diet, which helped control his glycaemia very well. At the time, he did not realise that he had only rediscovered a diet which Russell Wilder a genius doctor at the renowned Mayo Clinic (Primer for Diabetics, 1922) had designed for his diabetics already in early 1900s. Today, Richard is 82, does not suffer from any common diabetic complications and still practices medicine in his famous diabetic clinic, and also keeps adding new lectures in his Diabetes University, available for free on Youtube (Diabetes University).
I would encourage everyone to participate in the survey (English version here). We will make the results, as well as a summary of a recent medical conference Food, the forgotten medicine at Royal Society of Medicine in the UK, which Jan attended, available on my blog margit.cz. Thanks!