Keto? Low carb? Neither? What is the best diet for diabetes?

The other day I was reflecting upon the fact that when it comes to diet and health no matter what the question might be, the answer is always the same: 

Q:  I want to minimize my risk of experiencing a heart attack. What should I eat? 
A:  A whole food, plant-based diet.

Q:  I want to lower my chances of developing cancer. What should I eat? 
A:  A whole food, plant-based diet.
 
Q:  I want to avoid dementia. What should I eat? 
A:  A whole food, plant-based diet.
 
Q:  What do people who live long well eat?
A:  A whole food, plant-based diet.

You get the idea: The eating plan that consistently supports better health and healthy longevity celebrates regular and preferential consumption of beans, greens, nuts, seeds, fruits, vegetables and grains in their most whole and unprocessed forms. It's an eating plan that is naturally high in carbs and relatively low in fat.

And yet when it comes to diabetes and prediabetes, the answer for some reason is the polar opposite.

Q:  I want to lower my blood sugar. What should I eat?
A:  A purposefully low carb diet. In fact, the more keto-like the better!

And it occurred to me that this makes no sense. Why is one way of eating so good for EVERYTHING except the one condition that is most often caused by poor diet in the first place?

Well, one obvious answer is that low carb/high fat diets have been documented to help lower blood sugars and insulin needs – and yield real reductions in hemoglobin A1C.  And the dogma steering doctors to recommend a carb restricted diet to diabetics and prediabetics is entrenched and undisputed. 

But does this mean that a low carb/high fat diet actually cures diabetes? 

In short, no. High blood sugar, insulin needs and HbA1C are symptoms of diabetes, not its cause. The cause of diabetes (in part or in whole) is insulin resistance. And here’s something that will shock you: Do you know how scientists induce insulin resistance in lab animals? By feeding them a high fat diet. (yes, you read that right).  In other words, we’re advising patients with diabetes and prediabetes to eat in a way that might improve symptoms but might also perpetuate their disease! 

No wonder diabetics who have been following a ketogenic diet see a giant spike in blood sugar if they eat a piece of fruit. Their HbA1C might be perfect, their fasting glucoses in a normal range, and they may have lost a bunch of weight – but their insulin resistance is just as messed up as ever.

Remember, ketogenic diets were originally devised for children with intractable seizures. And even though ketosis works to reduce seizure burden, the near term and long term side effects of this eating pattern including constipation, high cholesterol, hair loss, kidney stones, muscle cramps, poor concentration, weight loss, stunted growth, osteopenia and osteoporosis, heart arrhythmias and menstrual irregularities (to name a few) means that most children are unable to stick with this nutrition plan.  So why, exactly, is this the perfect solution for managing diabetes?

I need to state at this point that I am not a diabetologist.  I’m a cardiologist – I don’t manage diabetes directly and I don’t pretend to be an expert in the field.  However, I am a logical thinker and it’s not logical to me that a whole food plant-based diet, which is so beneficial for health on every other level, would be essentially contraindicated for diabetics.  Especially since heart disease (the number one killer of diabetics) is otherwise prevented by eating a whole food plant-based diet. 

Just some food for thought….