Why Your Doctor May Question a Low Carb Diet

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 Why Your Doctor May Question a Low Carb Diet

 

I am a retired physician who graduated from Emory University School of Medicine in 1986. A vast majority of physicians I’ve encountered during my career have the patient’s best interest in mind and want to improve their health.

So if you learn about the benefits of a low carbohydrate lifestyle from books, articles published in medical journals, or God forbid, the INTERNET, you might wonder why your doctor is either not supportive or even cautions you against it.

The answer is simpler than you might think. It is not that your doctor does not want you to experience the benefits. It is most likely that your doctor was not educated about the effect of diet on disease. To understand this, let me give you some background about medical education.

In order to get into medical school in the first place, you have to be an excellent student. In our current education system, being an excellent student means being able to learn and retain lots of information in a short period of time and accurately recall that information on a test or later in medical training with their patients. It does not require that they be creative thinkers or innovators, or question what they are being taught. Once a student enters medical school, the amount and pace of learning is accelerated further. There is literally no time to question the validity of the material.

Most medical students have heard from their wise professors the phrase, “half of what you just learned is wrong, but we don’t know which half.” However, that is a difficult concept to accept given the time and effort spent learning all that material. In essence, the overwhelming feeling at the end of medical school is, “I know I don’t know everything, but at least I know what matters the most.”

The next piece to this puzzle is to know that nutrition is barely discussed in most (not all) medical schools. At Emory, in 1982, we had about 2 weeks of education in “nutrition.” But what was covered was how the body metabolizes protein, carbohydrate, and fat, nutritional deficiency diseases, and the nutritional requirements to prevent those diseases. The fact that many chronic diseases like cancer, heart disease, diabetes, and digestive diseases were rare prior the adoption of the Western diet was not covered. I did not learn this until 2011 when I read Good Calories, Bad Calories by Gary Taubes.

So by the time a medical student graduates, they think they know most of what they need to know, that some of it may be wrong, and that they will need to continue learning. But how does all that work out in practice? Next comes internship and residency. This is the time when the young doctor learns how to care for sick patients in the hospital and outpatient clinic. The caseload starts low but quickly builds. We are taught about how to diagnose and treat a wide range of medical conditions from self-limited to life threatening. These treatments usually involve one or more medications. In order to learn new therapies or understand which current therapies are not very effective one must spend extra time and effort reading the medical literature, neither of which are in abundant quantity. What little time remains to read a small subset of the vast medical literature is usually devoted to one’s specialty, leaving topics of nutrition and its influence on chronic disease off the radar.

Some physicians will be familiar with the low carbohydrate diet already and others may be willing to learn about it and support you especially when they see your condition is improving as a result. However, other physicians may immediately recognize it is not part of their armamentarium, therefore it must be either not effective, or possibly dangerous, especially if the word “ketosis” or “ketones” is mentioned. Although doctors should know the difference between “nutritional ketosis” and “ketoacidosis,” the term “nutritional ketosis” is only mentioned in the context of a low carbohydrate ketogenic diet and therefore is not discussed in medical school. So the only context in which most doctors know about “ketosis” is one of the following: starvation ketosis, diabetic ketoacidosis, or alcoholic ketoacidosis, none of which are good.

The final thing you should know about the practice of medicine is that physicians are constantly aware of being sued for malpractice. One of the criteria for malpractice is when a physician does not follow “standard of care.” So if a therapy is safe and effective, but not generally recognized as “standard of care,” the physician could be accused of malpractice should something adverse happen to the patient whether or not it was causally related to the low carb diet.

Overall I would say that despite the mounting evidence of the benefits of a low carbohydrate diet for many medical conditions, it has not yet been accepted as “standard of care” in 2016. I doubt there will ever be a sudden declaration of its benefits and safety. Rather, there will be a gradual move over to its acceptance in small steps. For example, the American Diabetes Association in its Standards of Medical Care in Diabetes-2016  states the following: “As there is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total calorie and metabolic goals in mind.” I hope you can appreciate the subtlety of this statement. It is not a specific endorsement of low dietary carbohydrate, but it is acceptance of it. However, physicians who may read that one sentence of the 112 page document might not interpret it in the same way.

I know many physicians who enthusiastically endorse a low carbohydrate diet for many medical conditions. The great majority of them have experienced personal health benefits from actually adopting the diet for themselves and that includes me. Although physicians are taught to ignore anecdotal evidence, it is difficult to do when it applies to oneself.

How to approach your doctor in supporting your low carbohydrate lifestyle

For reasons that are beyond the scope of this article, it is best to have your physician on board with your low carbohydrate lifestyle. It will affect the need for or lack thereof of many of your medications. There can be side effects that are easily corrected with knowledge of how the diet works.

With the above as a background, I think the best approach to getting your less-than-enthusiastic doctor on board is to gently encourage your physician to read a few selected references about the benefits of a low carbohydrate lifestyle for your specific medical condition(s). PubMed is a good source of articles published in the medical literature. A skeptical physician will be less likely to read a book about low carbohydrate diets although you can give that a try, too. However, every low carbohydrate book I have read has many references to the medical literature that you can find on PubMed and print out for your doctor. There will be some physicians who will not be convinced despite being shown numerous articles. At that point, you might want to seek a second opinion with a physician who has experience with low carbohydrate diets. This is only list I am aware of. The low carbohydrate ketogenic diet may not be right for everyone, but for me, and numerous others with diabetes (and a host of other medical conditions), it has been a life-changer.

Dr. Keith Runyan is a retired physician who practiced Emergency Medicine, Internal Medicine, Nephrology, and Obesity Medicine during his 28 year career. In 1998, he developed type 1 diabetes at the age of 38 and struggled to manage his blood glucose due to hypoglycemic episodes. When he started regular exercise in 2007, his sports nutrition (sugar) exacerbated his glycemic control further. While preparing for an ironman distance triathlon, he discovered the ketogenic low carbohydrate diet that had been used for all persons with diabetes prior to the discovery of insulin in 1921. It was resurrected by Dr. Richard K. Bernstein and Dr. Runyan adopted his method of diabetes management. To Dr. Runyan’s surprise, his hypoglycemic episodes dramatically improved as did his glycemic control. He remains active with swimming, cycling, scuba diving, and more recently olympic weightlifting. He writes about his experiences to help educate others with diabetes in his blog, Ketogenic Diabetic Athlete.

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Comments (13)

  1. One solution to this problem is to tell your doctor you’re carb counting, which is true. You don’t mention that your counts are low.

  2. J. Litzinger at

    Thank-you for an excellent article Dr. Runyan! We are only two months into our T1D journey with our 10 year old son. While we believe it is important to work with our doctors – they were thrilled with his numbers – they did not seem to grasp the fact that those numbers could not be achieved by giving him a diet that included starches and whole grains. We will continue to share our experience with our doctors and hope that they will begin to accept this way of treatment. Thanks for your encouragement and wisdom!

  3. Mark Cupples at

    My doctor was amazed at the weight loss, the improvement in blood pressure and the great improvement in cholesterol ratios.

    SLIM BUSINEZ

  4. Katy at

    Thanks for this! I’d like to hear more about this—I’m confused about our dietician’s recommendation for a child w celiac and T1d to eat 200+ g CHO/day, in order to grow. Is this just standard of care/slow to change? Is there something about growth in children that requires tons of carbohydrate? Anecdotally, they seem to grow on any kind of food.

  5. Keith Runyan, MD at

    You are correct Katy, children grow with protein and fat and small amounts of carbohydrates from vegetables, nuts, seeds, low sugar fruits, as your child tolerates. Having controlled blood sugar also promotes growth in children with T1D since poorly controlled blood sugar represents an insulin deficient state and insulin is an anabolic (growth) hormone.

  6. Wow! This now helps me understand why I’ve had to educate some of my “willing” doctors over the years when taking a different approach to my health! One thing, I’m Canadian, and we don’t have all the legal sueing stuff like Americans do. Why don’t doctors allow those patients that want to go outside of the colour lines, to sign a contract stating that neither party will sue each other down the road? I am going to be sending this article to my CDE and dietician to pass hopefully onto my endo (who I only see visually over a desktop screen since I live in a small town where no endo’s exist for T1D’s) – and perhaps they’ll stop telling me that I don’t eat enough carbs! Been doing this for many years, and have no complications after almost 50 years!!! Sssh! It works for some of us and maybe not for others, but at least it’s worth a try!

  7. I can concur with Anna… My endo basically boils it down to too much fat. He is convinced that if I just cut out all the fat, closed my mouth, that I would be okay.
    I think that my problem comes from lack of exercise and lack of sleep. That and all the crap that I eat because I am so bored of food. It’s so much easier to dig into the prepare stuff. Of course, full of fat, but also packs a lot of flavor.

  8. jack at

    I found their 2013 position statement enlightened and direct.
    American diabetic association
    Position Statement
    http://care.diabetesjournals.org/content/36/11/3821.full.pdf+html?with-ds=yes
    Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes;
    therefore, goals should be individualized; fat quality appears to be far more important than quantity.

    In people with type 2 diabetes, a Mediterranean-style, MUFA-rich [mono fat-rich] eating pattern may benefit glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern.

    Carbohydrates Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes. C

    The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating and should be considered when developing the eating plan.

    Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control.

  9. jack at

    American diabetic association
    Position Statement

    replace the * with t h*tp://care.diabetesjournals.org/content/36/11/3821.full.pdf+html?with-ds=yes
    Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes;
    therefore, goals should be individualized; fat quality appears to be far more important than quantity.

    In people with type 2 diabetes, a Mediterranean-style, MUFA-rich [mono fat-rich] eating pattern may benefit glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern.

    Carbohydrates Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes. C

    The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating and should be considered when developing the eating plan.

    Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control.

  10. jack at

    The 2016 care plan on page 33, misquotes the 2013 position statement by deleting these two sentences.

    “The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating and should be considered when developing the eating plan. (A)

    Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control. (B)”

    I found this disappointing and a biased spin.

  11. RWill at

    A very helpful article! Thank you.

  12. Charles Grashow at

    What do you say to someone who had a worse lipid panel (ApoA1/ApoB ratio, LPL-P) on a LCHF diet?

  13. Keith Runyan, MD at

    In response to Charles Grashow.
    A small percentage of persons see an increase in LDL-P and increase in ApoB. Sometimes, getting fat from olive oil and nuts rather than animal sources helps. In others, these lipid changes improve over time as one adapts to the change in diet. If these lipid changes persist, it is unclear whether that represents a risk for CVD as it hasn’t been studied in persons on a LCHF diet. Also, should one ignore the improvements in triglycerides, HDL cholesterol, C-reactive protein, and just focus on the two that did not appear to improve? Just something to think about. I don’t have the definitive answer.

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