The ADA does not have a specific dietary protocol, that they endorse, for the treatment of diabetes. They have implied the benefits of caloric restriction, low fat diets, Mediterranean style diets, vegetarian diets, etc., without committing to any one of them. Dietary options are pretty much left to the diabetic, along with the vague caveat of choosing a "healthy" diet of "moderation", with plenty of "fruits and vegetables" and the replacement of sugar with artificial sweeteners. No other solid definition, of what constitutes a "healthy diet", has ever been given by the ADA.
As far as carbohydrate restriction is concerned, in December 2008, the ADA issued its 'Clinical Practice Recommendations', with an option for following a low carbohydrate diet for controlling blood glucose levels and weight loss. The difference from their previous recommendation is that, this one, has actual recommended values for guidance. The recommendation for the United States, at that time, was for daily caloric intake from carbohydrates to be less than 45%. They consider this to be a "moderate" amount of carbohydrate. They keep the option to go lower in carbs open and at the discretion of your healthcare provider.
In December 2018, the ADA issued its new 'Standards of Medical Care in Diabetes', including its 'Lifestyle Management Standards of Care', which again, included the use of a low carbohydrate diet, for the lowering of blood glucose and medications, in the management of Type II diabetes. They used the one year study data by Virta Health, along with two other studies, as the basis for this decision.
Again, no hard values are given to guide yourself by, but there is a range for carbohydrate restriction, which can be anywhere below 130 grams a day and less than 26% of daily caloric intake. If you eat 3 meals a day, that is up to 43 grams of carbohydrate, per meal. They do not claim that any benefit in blood glucose control will go beyond one year following this diet. On the contrary, they mention that blood glucose control begins to decline with time, while still remaining on a low carbohydrate protocol and, once again, the Mediterranean Diet takes the trophy for its long term benefits in glucose control.
The ADA also makes its usual statement that the ability to adhere to a dietary protocol is much more important than the protocol itself and some people are able to adhere to a low carbohydrate diet, while others are not. I suspect they are being generous, on this front, because I can almost guarantee that most cannot, but let's continue to keep it vague. The ADA loves vagueness. They hate to be held accountable for any solid advice, so they know how to cover their ass very well. Vagueness permits them to never be brought to task on anything they say.
Other than this tiny section on diet, with no specific recommendations for any one of them, the rest of the paper consists primarily of information on medication management. I don't blame them. Patients want that magic pill and certainly don't want to put in the work, if they don't have to. Any doctor can attest to that.
So, what's wrong with all of this? Nothing. Absolutely nothing. First, limiting carbohydrates to 130 grams a day, and to no more than 26% of your daily caloric intake, is low carbohydrate considering that the typical Standard American Diet (SAD) consists of 300 - 400 grams of carbohydrates a day and more than half of daily caloric intake. If you want to restrict carbohydrates further, that's your prerogative, but to claim that anything that's higher, than a ketogenic percentage of carbohydrates, is not low carbohydrate is utterly asinine.
The ADA does not have to, nor should it, make a ketogenic diet recommendation, as they have to take into account a patient's medications, which are already bringing down blood glucose to very low levels, and the patients that are Type I diabetics on insulin. The ADA's shenanigans have nothing to do with its dietary recommendations.
Rather, the problems with the ADA is exclusively limited to its lack of accountability, both for itself and diabetics. It continues to spout the mantra of "you can still have dessert, if you are diabetic." and "you can eat anything you want, even with diabetes." This is a disservice to diabetics everywhere. The ADA continues to stand behind the position that you can just "hide" your bad dietary choices with medications. This doesn't promote a lifestyle change for the management of diabetes. This promotes complacency. When you think of the ADA, you think of desserts, pastries and junk food. Its insistence on caring more about its donors, mainly Big Pharma and Big Food, than the people with diabetes, it claims to be trying to help, is the true problem with the ADA.
2. Does "excess protein" turn into body fat?
You will hear many people repeat this and find it written in multiple mediums. Even legitimate sources will repeat this fallacy, from dietitians to nutritionists to doctors, etc. But, like I have stated before, repetition does not make things true. The available research does not support this claim.
Biochemically, the body has the capacity of turning protein into fat, but it never does. Just like biochemically, the body has the capacity to live to 130, but it never does. No one has yet seen protein being converted to fat, in any human study, even when protein was overfed by 4 to 5 times the recommended daily values. So, no one yet knows how high protein must go for this biochemical process to kick in. The only thing that was seen in people, who were overfed protein, was an increase in weight due to an increase in lean body mass. Body fat never increased. In fact, the more protein, the leaner people get.
Having said that, people with metabolic syndrome experience hyperglucagonemia after eating protein. This can disrupt blood glucose homeostasis and this disruption can cause more weight gain. This is due to insulin resistance and avoidance of protein does not solve this. Rather, daily protein intake should be divided as follows per Dr. Bernstein's recommendations:
- Breakfast: 6 grams carbohydrate, 3 ounces protein
- Lunch: 12 grams carbohydrate, 4 ounces protein
- Dinner: 12 grams carbohydrate, 5 ounces protein
Also, remember that protein comes with fat, so if you are purposely choosing fatty cuts of meat and adding even more fat to them, basal insulin levels will begin to rise. This will disrupt blood glucose homeostasis and this disruption will cause more weight gain. So watch the type of meats you eat and how much fat you add to them. Fat is not a free food.
3. Does fat really burn in the flame of carbohydrate?
This goes into the weeds of biochemistry and beyond the scope of this blog. There are many great blogs, out there, that are run by real biochemists and even some keyboard ones, but that's not the goal of this one.
Having said that, as you make your rounds on the internet, you might come across this statement and it's usually used as a way to try and "disprove" the fact that carbohydrates inhibit fat burning. So, for the sake of newbies that might become confused, I will explain where this statement goes wrong, as simply as I can, without getting too deep into the technical jargon.
First, let's go through some basic knowledge, before we continue. Anything that the body burns, whether it's glucose or fat, is burned to produce adenosine triphosphate (ATP); the energy currency used by our cells. There are many metabolic cycles involved, all run through different feedback loops, to produce ATP from the foods we eat.
The term "fat burns in the flame of carbohydrate" would be better described as "fat burns in the flame of oxaloacetate (OAA)". Oxaloacetate is a metabolic intermediate that is formed from pyruvate; a metabolite that can be derived from many different sources. Glucose is just one of those sources, as glucose can be converted to pyruvate. But, amino acids from proteins also convert to pyruvate, either from the use of their substrates or from their conversion to glucose.
So, you don't need to consume carbohydrate to light your fat burning flame. Your body can produce all the glucose it needs from protein, for pyruvate synthesis, and create all the OAA it needs to burn fat. This is why there is no essential, exogenous carbohydrate. You do not need them for any metabolic cycle.
4. I was told that unless I have high ketone levels, I am not burning fat.
This statement is better described as "unless you can keep your basal insulin low, you are not burning fat." Again, this is quite technical, so I will keep it as simple as possible.
Ketones are a byproduct of fat burning, but they are the result of incomplete oxidation of fatty acids. In other words, your liver is exporting unburned fat as ketones, into the bloodstream, for use by other cells in the body, mainly the brain. If ketones are low, it doesn't mean that you aren't burning fat, it just means that you have less unburned fat. As long as you have enough OAA (see above), you will be burning fat and you will not have any fat "spillover" to convert to ketones.
5. I am getting older, so I don't need much protein.
If you are getting older, you definitely need protein. In fact, you would need more protein, since the older you become the harder it is for the body to utilize proteins. This is why there is a marked decline in lean muscle mass, as you get older.
Older people are frail and weak, because of lean muscle mass loss. Young people are strong, because their muscle mass is intact. The main differences in the young and the old is visceral fat accumulation and lean muscle mass loss. Both go hand in hand. The less lean mass you have, the more fat you are.
6. Can I eat all of my macronutrient requirements in one meal?
You will not be able to obtain or sustain proper blood glucose regulation eating one meal a day. Not only would you have to eat too much in one sitting, which disrupts insulin/glucagon ratios, but you will end up fasting for an extended period of time daily. This is a recipe for blood glucose disaster. Aside from that, you also will not be able to consume your daily requirement of protein this way.
For this reason one meal a day (OMAD) protocols are not recommended on this blog.
For this reason one meal a day (OMAD) protocols are not recommended on this blog.
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