The End of the High Carbohydrates Era for Type 2 Diabetes Prevention and Management

By RebDee Latest Reply 2015-02-23 16:17:28 -0600
Started 2015-02-22 12:32:40 -0600

Nutrition Revolution: The End of the High Carbohydrates Era for Type 2 Diabetes Prevention and Management
Posted on February 20, 2015 by Joslin Communications
This entry was posted in Diabetes Day2Day, Type 2 Diabetes and tagged carbohydrates, diabetes diet. Bookmark the permalink.
This post is written by Osama Hamdy, M.D., Medical Director, Obesity Clinical Program, Director of Inpatient Diabetes Management at Joslin Diabetes Center, Assistant Professor of Medicine at Harvard Medical School. Dr. Hamdy is also the Director of the Why WAIT program where he works with people to improve their diabetes management through weight loss.

In 1977, the Select Committee On Nutrition and Human Needs of the US Senate recommended that people increase their carbohydrate intake to 55 to 60 percent of the total caloric intake, while reducing fat consumption from approximately 40 percent to 30 percent of the total daily calories. The aims of these recommendations were to reduce health care costs and maximize the quality of life of Americans, as stated by George McGovern, the chairman of that committee.

The proposed cost saving was predicted to result from the possible reduction in the incidence of heart disease, cancer and stoke, as well as other killer diseases. Despite controversy that the recommendations were based on weak scientific evidence, the United States Department of Agriculture (USDA) created in 1980 a food pyramid representing the optimal number of servings to be eaten each day from each of the basicfood groups. Carbohydrates were placed at the base of the pyramid (making up the largest portion of caloric intake, 6 to 11 servings per day), and fats were placed at the tip of the pyramid to show that they should be “used sparingly.”

Unfortunately, the results of these recommendations turned out to be the opposite of what the USDA expected.

What has been aptly described as a “national nutritional experiment” contributed, as we know now, to the increased prevalence of obesity. And, contrary to the main aims of the recommendations, the prevalence of type 2 diabetes — and cardiovascular disease — went up significantly.

Why did this happen? Physiologically, an increase in carbohydrate intake results in an increased insulin response to carbohydrates, which through its fat-storage promoting action increases obesity. And, it has been shown, that accumulation of fat inside the belly (visceral fat) is associated with chronic inflammation that is directly related to type 2 diabetes and heart attacks.

The problem is equally bad for people who already have type 2 diabetes. We know today that increasing the carbohydrate load in the diabetes diet increases what is called glucose toxicity and consequently increases insulin resistance, triglycerides level and reduces beneficial HDL-cholesterol.

The widely recognized food pyramid may now be falling out of favor
The widely recognized food pyramid may now be falling out of favor
At the turn of the twentieth century (way before the USDA recommendations represented by the food pyramid) what we now know as type 2 diabetes was predominantly defined as a carbohydrate intolerance disease and was mainly treated by reducing carbohydrates intake. Carbohydrates restriction was particularly successful in treating diabetes before the discovery of insulin. Drs. Elliot P. Joslin and Fredrick Allen, the fathers of diabetes science, successfully treated their patients diagnosed with fatty diabetes (later known as type 2 diabetes) with a diet very low in carbohydrates. Today, Elliott Joslin’s diet would be considered eccentric, as seen by the reaction in the medical community to its reincarnation as the Atkins Diet.

Such extreme reduction of carbohydrates, despite being very successful in treating type 2 diabetes before insulin discovery, was in fact shown to be associated with some uncomfortable side effects, like constipation, headache, bad breath and muscle cramps. But, although the recommended amount of carbohydrates intake was significantly relaxed after the discovery of insulin in 1922, it never exceeded 40% of the daily caloric intake, an amount that was shown to reduce blood glucose and triglycerides. Thus, it was absurd that when the USDA recommendations were published several medical societies recommended increasing carbohydrates and decreasing fat intake for patients with diabetes.

Since 2003, many clinical trials have confirmed that reducing carbohydrates is still superior to reducing fat in decreasing body weight and improving glucose control. It has also been shown that reducing carbohydrates for patients with type 2 diabetes improves their sensitivity to their own insulin; reduces belly fat and triglycerides; and increases good cholesterol (HDL-cholesterol).

Recently an analysis of several studies (meta-analysis) showed that reducing carbohydrates load (amount) and glycemic index (the effect of particular carbohydrates-containing food on blood glucose) was associated with reduced risk of developing type 2 diabetes. After weight reduction, maintaining a diet that lowers the consumption of high glycemic-index foods and is higher in protein was shown to better maintain weight loss for longer duration than any other dietary composition.

The Joslin Guidelines

Since 2005, the Joslin Clinic has been recommending a reduction of carbohydrate intake to 40-45% of the total daily calories and avoidance of food that rank high on the glycemic index of carbohydrates (see glycemic index table). Joslin’s 2005 guidelines for overweight and obese patients with type 2 diabetes or those at risk to develop type 2 diabetes, which were revised in 2011, continue to recommend reducing carbohydrates intake to prevent and treat patients with type 2 diabetes and weight problems.

Recently, most medical societies departed from the recommendation of high carbohydrates intake and recommended individualization of the nutrition needs. At Joslin we have clinical proof that this is the right decision. Since 2005 we have been following the Joslin Guidelines in our weight management program (Why WAIT). The 44 groups of type 2 patients who have gone through the Why WAIT program and follow the Joslin Guidelines have lost a total of 10,000 lbs., have improved their diabetes control and cut their medications significantly.

Unfortunately, many healthcare providers and dietitians across the nation still recommend high carbohydrate intake for patients with diabetes, a recommendation that may harm their patients and contribute to increasing obesity and worsen diabetes control and consequently increase the chance of developing diabetes complications.

It is now clear that a major mistake was made in the 1970’s in recommending an increase in carbohydrates to >40% of the total daily calories. This era should come to an end if we seriously want to reduce obesity and type 2 diabetes epidemics.

To learn more about the Why WAIT program click here.


1- U. S. Government Printing Office: Stock No. 052-070-03913-2/catalog No. Y 4.N95:D 63/3 accessed at

2- U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. Home and Garden Bulletin No. 232, 1980.

3- Flegal KM1, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord. 1998;22(1):39-47.

4- Hedley AA1, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291(23):2847-50.

5- Flegal KM1, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307(5):491-7.

6- Aldhahi W, Hamdy O. Adipokines, inflammation, and the endothelium in diabetes. Curr Diab Rep. 2003;3(4):293-8.

7- Osler W & McCrae T, The Principles and Practice of Medicine, 1923; Westman EC, Perspect Biol Med, 2006

8- Yancy WS Jr1, Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med. 2004;140(10):769-77.

9- Gannon MC1, Nuttall FQ, Saeed A, Jordan K, Hoover H. An increase in dietary protein improves the blood glucose response in persons with type 2 diabetes. Am J Clin Nutr. 2003;78(4):734-41.

10- Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS, Szapary PO, Rader DJ, Edman JS, Klein S. A randomized trial of a low-carbohydrate diet for obesity.

N Engl J Med. 2003;348(21):2082-90.

11- Stern L, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J, Williams M, Gracely EJ, Samaha FF. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med. 2004;140(10):778-85.

12- Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, Kraemer HC, King AC. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007;297(9):969-77.

13- Miyashita Y1, Koide N, Ohtsuka M, Ozaki H, Itoh Y, Oyama T, Uetake T, Ariga K, Shirai K. Beneficial effect of low carbohydrate in low calorie diets on visceral fat reduction in type 2 diabetic patients with obesity. Diabetes Res Clin Pract. 2004;65(3):235-41.

14- Larsen TM1, Dalskov SM, van Baak M, Jebb SA, Papadaki A, Pfeiffer AF, Martinez JA, Handjieva-Darlenska T, Kunešová M, Pihlsgård M, Stender S, Holst C, Saris WH, Astrup A; Diet, Obesity, and Genes (Diogenes) Project. Diets with high or low protein content and glycemic index for weight-loss maintenance. N Engl J Med. 2010;363(22):2102-13. doi: 10.1056/NEJMoa1007137.

15- Ludwig DS. Clinical update: the low-glycaemic-index diet.Lancet. 2007;369(9565):890-2.

6 replies

Fefe12 2015-02-23 16:17:28 -0600 Report

Wow, I never knew any of this. My doctors were great and my educator was like a friend. Although I didn't have a problem adjusting to my new way of life, my questions were answered and truths about how to take care of myself reveled. I never did much research, I really didn't care. I knew what I was and just went with it. I followed all the advise I was given and am now in the best health of my life. I excercise, eat right and take all my meds, ok I may be a bit late sometimes. But this life style isn't much different from what I did before. Just no more white chocolate mochas everyday anymore! If anyone brings up the subject about weight loss, I tell them to cut the carbs. I wonder what the world would be like if we all eat a diebetic diet? I personally believe we would be much better off. So my family eats what I eat, I teach my grandchildren the same. Food has way to much control over us, we need to break that chain. We are bigger then food. Like anything unhealthy we need to push it away and move on. Life is too short to fuss and worry about little things. All that love you claim to have for others, turn it on yourself or you won't be around long enough to love them.

Grandmama16 2015-02-22 14:46:09 -0600 Report

Carbs in that era were recommended for energy, like for athletes, totally ignoring it's actual effect on normal people and those with diabetes and I just can't understand that reasoning. Yes, good carbs such as fruit and whole wheat bread are important but where were their brains? I can't believe a diabetes educator now would suggest a high carb diet tho I can understand low fat for heart problems. I eat low carb and normal fat and have lost 20 lbs since being diagnosed. We even use real butter but I was raised on margarine and so were my kids, also Kool Aid (dyed sugar water). Where were my brains? The Amer Diabetes Assoc always emphasizes low fat everything so in their recipes I ignore that. Twice in about 40 years I've gone on a very low carb diet and lost, but gained it back. Now with just keeping carbs on the low side I'm hoping the weight will stay off. I try to avoid rice, pasta and potatoes and don't eat much of it if I do have it. But…my BG is not low enough, 144 this AM. OK, I had potato chips, a rarity for me. I take Metformin but was off of it while I had an intestinal bug so still not up to 2000 mgs.. I also take Cymbalta which I've heard can raise BG. Who knows, maybe some other of my meds do too. We're kind of at the mercy of what our Drs say to take even tho I've read all of what's sent by the drug companies. We aren't likely to learn everything that way. Interesting to read that article.

RosalieM 2015-02-22 13:55:03 -0600 Report

Thank you so much for that article. I was caught in that debacle. I thought I was really working on being healthy when I took the fat out of everything like they said. I gained 55 lbs and my blood sugar was going up. I didn't know back in the mid eighties that they weren't diagnosing diabetes until blood sugar got much higher. Mine was already too high. When my blood sugar started going up I lost the weight and kept it off for 10 years. Then I put the weight back on and was diagnosed diabetic in 1994. It was the 10 years that I didn't even know I was diabetic but kept the weight off that protected me or I would have been in big trouble by now if I would even stil be alive. I feel like I have walked through a mine field and made it. I cringe every time someone on this board tells a diabetic to see a nutritionist or diabetes educator as they and the American Diabetes association is still preaching that crap. The American Heart Association is too. Don't listen to those people. If the USDA has there name on something, run the other direction. I have a story to tell about the USDA,
diabetics and dementia. I will write it in a discussion.

camerashy 2015-02-22 13:39:10 -0600 Report

I don't go by "recommendations". I have figured out what's good for me, and I count carbs. I know that some carbs are important, but lots of carbs are bad, bad, bad. Good article. Thanks for sharing.