In contrast, Prof. Feinman suggested that a carbohydrate intake of around 20% is most effective indiabetes. However, there is a prevailing concern that low-carbohydrate diets cause people to eat morefat, which has implications for cardiovascular disease (CVD).Prof. Feinman made the case that this is not an issue. "Keeping carbohydrates low would actuallyreduce the risk of CVD. In essence, fat in the presence of carbohydrate is where we find the problems,which is very different from fat in the absence of carbohydrate."He explained that carbohydrates, either directly or through insulin, are control elements in themetabolism. "They determine the disposition of fat — whether stored for obesity or whether having aneffect on lipoproteins and vasculature. The metabolic effect of reducing carbohydrates is that itpredisposes to oxidizing the fat rather than storing it, and in diabetes specifically, it prevents themetabolic state of high glucose and high insulin, which is detrimental across the board."In presenting data initially reported by colleagues, including Mary Gannon, PhD, from the University of Minnesota in Minneapolis, Prof. Feinman discussed the effect of a low-carbohydrate diet (20% of calories) on blood glucose control in people with type 2 diabetes. The results were compared withthose obtained in the same people after 5 weeks on a control high-carbohydrate (55%) diet. The low-carbohydrate group showed a significant decrease in fasting glucose, to near normal, and a decreasein hemoglobin A1c. Significantly, the diets were designed so that patients did not gain or lose weight,indicating the benefit even in the absence of weight loss.Discussing the pros and cons of different diets for diabetics, Dr. Astrup said that it depends on whether the patient is insulin-sensitive or insulin-resistant. "If someone is more insulin-resistant, they maybenefit more from a low-carbohydrate diet, but for insulin-sensitive patients, it is probably better tofollow the low-fat/high-carbohydrate diet that is more suitable for them."Agreeing with Prof. Feinman, Iris Shai, MD, from Ben-Gurion University in Beer-Sheva, Israel, addedthat several recent intervention studies, including the 2-year Dietary Randomized Control Trial(DIRECT), suggest that Mediterranean and low-carbohydrate diets are more beneficial than a low-fatdiet in improving long-term glycemic control, triglycerides, high-density-lipoprotein
cholesterol, the totalcholesterol/low-density-lipoprotein
cholesterol ratio, and weight."Within the first year, most type 2 diabetic patients have their biggest chance to be adequatelycontrolled by diet and physical activity alone and to delay the need for antihyperglycemic drugtherapy." As long as we succeed in tailoring an individual diet strategy to the patient (i.e., low fat/medto low carbohydrate), according to his or her preferences, goals, and diet history, the patient will moresuccessfully adhere to his or her way of life. This means that one diet doesn't fit all, she said.The ADA made a breakthrough when releasing a careful statement in 2008 about the effectivenessand safety of low-carb diets out to 1 year, Dr. Shai said. "I believe that the growing evidence-basedmedicine will eventually change the current perception of the recommended low-fat/high-carb diet.[When] patients can stick to this diet, [it] could help some proportion of the diabetics, as it is a calorie-restricted diet," she concluded.
Dr. Astrup's study was financed by the European Commission and foods for the trial were provided by a wide range of companies. Prof. Feinman, Dr. Astrup, and Dr. Shai have disclosed no relevant financial relationships.