In May of last year, Diabetes Canada released a new Position Statement acknowledging that a low carb and very low carb (keto) diet is both safe and effective for adults with diabetes. The purpose of the Position Statement was to summarize the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) or very low- carbohydrate diets (<50g carbohydrate/day) in the management of people diagnosed with type 1 and type 2 diabetes.
In their Position Statement, Diabetes Canada made five recommendations;
Diabetes Canada’s Five Recommendations
- Individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences.
- Healthy low carb or very-low-carb diets can be considered as one healthy eating pattern for individuals living with type 1 and type 2 diabetes for weight loss, improved blood sugar control and/or to reduce the need for blood sugar lowering medications. Individuals should consult with their health-care provider to define goals and reduce the likelihood of adverse effects.
- Health-care providers can support people with diabetes who wish to follow a low-carbohydrate diet by recommending better blood glucose monitoring, adjusting medications that may cause low blood sugar or increase risk for diabetic ketoacidosis and to ensure adequate intake of fibre and nutrients.
- Individuals and their health-care providers should be educated about the risk of diabetic ketoacidosis while using SGLT2 inhibitors along with a low carbohydrate diet, and be educated in lowering this risk.
- People with diabetes who begin a low carbohydrate diet should seek support from a dietitian who can help create a culturally appropriate, enjoyable and sustainable plan. A dietitian can propose ways to modify carbohydrate intake that best aligns with an individual’s values, preferences, needs and treatment goals as people transition to- or from a low carbohydrate eating pattern.
Since that time, I hadn’t seen any announcements from Diabetes Canada providing support for Canadians with diabetes to follow a low carb or very low carb (ketogenic) diet — until this week, when I saw the following ad on Facebook:
Clicking on the link associated with the ad, the text reads;
“Current evidence suggests that a low-carbohydrate diet can be safe and effective for people with diabetes. This dietary pattern can help with weight loss and blood sugar management. Keep in mind that a low-carbohydrate diet can also reduce the need for certain diabetes medications. People living with diabetes who want to follow a low-carbohydrate diet should seek professional advice from their healthcare provider to avoid any adverse effects, such as hypoglycemia (low blood sugar) or an increased risk for diabetic ketoacidosis (DKA).
This meal plan features healthy plant-based foods, low glycemic index carbohydrates, and less than 130 grams carbohydrates per day. [1]”
At the bottom of the meal plan it indicates;
Diabetes Canada’s 7-day Low-Carbohydrate Meal Plan
While the promotion of Diabetes Canada’s meal plan on Facebook indicates that it features ‘plant-based foods’, it is not a plant-based menu. It includes eggs and yogurt, fish (tuna, fish fillet, salmon), a (bun-less) cheeseburger, beef or pork meatballs, and chicken breast — along with tofu, legumes such as chick peas and black beans. Not surprisingly given one of the sponsors of the menu, each day includes servings of plant-based beverages.
At least once per day, there are meals which include sides of starches such as bread, potato, rice, pasta or legumes — none of which are considered part of any established “low carb” diet. Starches like bread, pasta and rice are just long chains of sugar molecules strung together like pearls on a thread and as I explain below, even usual servings of “whole grain” ones do not have a low glycemic load, just lower than the refined white version.
Breakfast on day 1, 3 & 5 of the menu features a smoothie made with 200 ml Silk Soy Original Beverage, a sugar-sweetened soy beverage manufactured by one of the menu’s sponsors, along with 2 kinds of pureed fruit. This is hardly the best way for someone with diabetes to begin the day. While the recipe boasts that is has 7 g of fiber, subtracting the fiber from total carbohydrate is only appropriate in intact, whole foods, not acellular foods (i.e. ground up) such as a smoothie. As elaborated on in a previous post, The Perils of Food Processing a whole apple, the same-sized apple pureed into apple sauce, or the same-sized apple turned into apple juice have a very different effect on blood sugar — with the juiced fruit causing the largest blood sugar and insulin spike (see Perils of Food Processing Part 1 and Part 2). If not to promote the product of one of the sponsors, why else why would such a smoothie be recommended to someone with diabetes to have 3 times a week for breakfast?
Lunches and Dinners include either a slice of whole-grain bread, 1 small baked potato, 1/2 cup cooked brown rice, 3/4 cup (150 ml) cooked pasta, 1/2 cup (125 ml) mashed sweet potato or chick peas or black beans. First of all these are not “low carb” foods — not on any established low carbohydrate diets. Second of all, even so-called “low glycemic foods” such as brown rice has a glycemic load of 20 per cup, which most people consider a usual serving. The same is true with spaghetti (which on this menu isn’t specified as being whole grain or white). One cup of cooked whole grain spaghetti (which most people consider to be a usual serving) has a glycemic load of 14, compared to white spaghetti with a glycemic load of 25 — which is still high, just lower than white spaghetti. Someone following this menu could easily choose 1/2 cup of white spaghetti for a glycemic load of 12.5, which is considered high, not low.
Note: One usual serving of a food is considered to have a very high glycemic load if it is ≥20, a high glycemic load if it is between 11-19 and a low glycemic goad if it is ≤10.
Sure, small amounts of sweet potato can be appropriate as part of a real, whole food low carbohydrate meal plan, and a small amount of chick peas or black beans can be included from time to time, but there is no established “low carb” diet that includes bread, rice or pasta, nor does it need to.
In addition, given the other sponsor of this plan, it is understandable why food is recommended to be cooked using ‘vegetable oil’ (i.e. canola oil) or that canola oil in particular is specified. Why not leave people to choose avocado oil or olive oil or some other fat, except to promote the product of one of the sponsors?
Diabetes Canada – reduced sodium, lower fat, optional added sugar, dairy substitutes
A closer look at the recipes in this 7-day menu indicate that ingredients are specified as being reduced-sodium* and light** / lower fat, and include the optional inclusion of granulated sugar***.
When specified, beverages at meals feature soy or oat plant-based beverages and while I understand the reason for this given that one of the sponsors is a plant-based beverage producer, why the emphasis on reduced sodium, and reduced fat ingredients?
* recipes specify the use of canned reduced-sodium diced tomatoes, reduced-sodium chicken broth or reduced-sodium vegetable broth, and reduced-sodium black beans.
**the Indonesian Tofu Stew specifies using “light” (i.e. reduced fat) coconut milk.
***the stir-fried eggplant with miso recipe includes 1½ tbsp. (23 mL) granulated sugar, although it is listed as ‘optional’.
What is the basis for recommending lower fat coconut milk when a state of the art review published last year in the Journal of the American College of Cardiology reported no beneficial effect on either cardiovascular disease (CVD) or death of lowering saturated fatty acid (SFA) intake, and that saturated fat intake was found to be protective against stroke [2]? A meta-analysis of 43 cohort or nested case-control studies published in 2019 did not find that higher saturated fat intake was associated with higher risk of cardiovascular disease (CVD) events [3], and data from the November 2017 Prospective Urban and Rural Epidemiological (PURE) Study [4] — the largest prospective epidemiological study to date involving 90,000 people from 18 different countries found that dietary saturated fat was actually beneficial; with those who ate the largest amounts of saturated fat having significantly reduced death rates, and that those that ate the lowest amounts of saturated fat (6-7% of calories) had increased risk of stroke [4].
Why the recommendation for using reduced-sodium ingredients, when the 2018 results from the Prospective Urban and Rural Epidemiological (PURE) Study mentioned directly above found that average intakes of three to five grams of sodium per day were not linked with higher rates of blood pressure or stroke [5]?
Why the recommendation for the daily inclusion of carbohydrate-centric foods such as bread, potato, rice or pasta in a “low carb” diet? What other established “low carb” diet includes these foods? Including these continues to perpetuate the belief that somehow carbohydrate-based foods are ‘necessary’ — even though the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids[6] has established there there no requirement for eating carbohydrate provided that adequate amounts of protein and fat are consumed (more about that here). For what it’s worth, carbohydrates in a well-designed low carbohydrate meal plan are available in the servings of low-carbohydrate vegetables and small servings of starchy vegetables (such as squash and yam). Bread, pasta, and rice need not be added.
We Can Do Better – changing the paradigm
A low carbohydrate meal plan of <130 g carbohydrate per day (and a very low carbohydrate / ketogenic meal plan) can easily be designed centering on real, whole foods. — I do it all the time!
Breakfast can be built around eggs dishes including a frittata or omelette, or Greek yogurt with a few berries.
Lunches and dinners can feature a wide variety of low-carb vegetables, small servings of higher carbohydrate vegetables such as yam or squash, along with servings of animal- or plant-based protein. These are meals that are consistent with Diabetes Canada’s first recommendation that “individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences”. Certainly, there is no need to encourage those with diabetes to use cane sugar sweetened milk substitutes with two types of fruit to start their first meal of the day! We can do better. We need to do better.
Except for those with very specific health conditions outside of type 2 diabetes, there is no need for Diabetes Canada to recommend that people choose “low fat” or “light” products, or “reduced-sodium” foods. Real, whole food as outlined above is naturally high in potassium and low in sodium — furthermore, when people lower their carbohydrate intake to less than 130 g per day, the body loses sodium in the urine and there is a need to add sodium to replace it. Studies do not support that for most people, eating the fat that comes naturally with animal-based foods such as cheese, meat or coconut milk poses any health risk. Coffee can be enjoyed with a splash of cream if someone chooses or with a plant-based substitute, if that is their choice.
Without article “sponsorship”, people following a low-carbohydrate diet can be encouraged to choose from a a wide range of cooking fats — from avocado oil and butter to coconut oil (which is not, as some claim, “pure poison”) — without the need to consider using a sponsor’s seed oils.
Final Thoughts…
We need to communicate that there is a wide range of low carb options available, including plant-based ones for those with that preference — while not perpetuating the outdated paradigm that saturated fat and sodium are automatically ”bad”, or that carb-based food such as bread, pasta and rice are an essential part of a meal, even a “low carb” meal.
Canadians with diabetes deserve much more appropriate low carb guidance than this industry-sponsored meal plan provides.
UPDATE (February 1, 2021):
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To your good health!
Joy
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References
- Diabetes Canada, 7-day low carbohydrate meal plan, https://diabetes.ca/nutrition—fitness/meal-planning/7-day-low-carbohydrate-meal-plan
- , , , DM, et al, Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art Review, J Am Coll Cardiol. 2020 Jun 17. Epublished
- Zhu Y, Bo Y, Liu Y, Dietary total fat, fatty acids intake, and risk
of cardiovascular disease: a dose-response meta-analysis of cohort studies, Lipids in Health and Disease (2019) 18:91, https://doi.org/10.1186/s12944-019-1035-2 - Dehghan M, Mente A, Zhang X et al, The PURE Study — Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062
- Mente A, O’Donnell M, Rangarajan S, et al. Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. Lancet (London, England). 2018 Aug;392(10146):496-506. DOI: 10.1016/s0140-6736(18)31376-x.
- National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005), Chapter 6 Dietary Carbohydrates: Sugars and Starches”, pages 265-275
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