Oftentimes I will have patients with diabetes whose blood sugars are high, and they think, logically, that if they eat very few (or no) carbohydrates, that will help. Unfortunately, they are working against themselves, and here’s why:

The body has what I like to refer to as a savings account of glucose in the liver. When the cells in the body aren’t getting the glucose they need for energy (like when someone skips a meal or when their cells are resistant to insulin), they start complaining all over the body trying to get someone to fix their problem. Word gets to the liver that the cells are starving and he wants to help. The trouble is, liver is a busy guy. He’s got many, many jobs. I often joke that managing this savings account is his “side gig.” He’s not particularly good at it.

In people with diabetes, liver sometimes starts dumping glucose from his savings account into the blood when he doesn’t really need to, and also he doesn’t know when to stop. He just keeps pouring and pouring sugar into the blood and before you know it, this poor person who is trying their darnedest to avoid eating carbs in order to get their blood sugars down has a sky-high blood sugar because they haven’t eaten!

It’s the most frustrating thing in the world because it’s totally backwards to what we would naturally think.

Moral of the story: don’t skip meals, and don’t over-restrict carbohydrates! It’s just as important to eat enough as it is to not eat too much to manage blood sugars in diabetes (side note: that’s true for weight loss as well!).

Bonus sub-moral of the story: If you have something frustrating going on with your blood sugars or your weight that you can’t explain, seek out a Registered Dietitian or a Certified Diabetes Educator to help explain all the funky things that your body might be doing without your realizing it! You don’t have to be frustrated and helpless. You can be empowered to better understand your body!


What a great question. I get asked about sugar alternatives all the time and it is one of the more frustrating areas of nutrition for me.

Image from http://www-tc.pbs.org

Image from http://www-tc.pbs.org

As a dietitian, I am held to practice evidence-based nutrition, which means providing recommendations to patients based on the information that research provides. The tricky part with research is that, darn it, it doesn’t always agree with itself. One study will say something is fine, another will say it will cause you cancer (a great reason not to change your eating habits based on one single news clip, health news article, or Dr. Oz show).

We are only as good as the research that we have, and when it comes to sugar alternatives, I don’t feel that what we have is great. We have a lot of research in some areas, and not as much in others, but I struggle with the research we have because some of it is funded by industries that have a financial stake in the results (think sugar companies or artificial sweetener companies) and the methods aren’t always great assessments of real-life application.

So what I end up giving my patients is the information that we do have on all of their choices, and advise them to make a personal decision. Here is what we have so far:

Artificial sweeteners like sucralose (Splenda®), aspartame (Equal®, Nutrasweet), and saccharin (Sweet‘N Low®)

  • Pros: Do not raise blood sugar significantly (1, 2) do not provide calories. (3, 4)
  • Cons: Do not occur naturally, some have an unpleasant aftertaste, sucralose may worsen insulin resistance. (5)
  • What is unclear: conflicting research on whether artificial sweeteners may increase hunger (the first two references say it does, the latter four found it did not) (6, 7, 8, 9, 10, 11), aspartame has been linked to increased occurrence of cancer, though in the spirit of full disclosure the methods of this study have been debated. (12)

Stevia (Truvia®)

  • Pros: Does not raise blood sugar, provide calories, or increase hunger (13), some researchers claim it may have anti-hypertensive, anti-inflammatory, and anti-carcinogenic benefits (14), comes from a leaf that grows naturally.
  • Cons: The safety of consuming stevia in large amounts has not been well-studied, though preliminary reviews have considered it safe (15).

Agave Nectar

    • Pros: May have a lower glucose and insulin response than sugar and cause less weight gain than sugar (16), occurs naturally.
    • Cons: Provides calories, raises blood sugar and can lead to insulin spikes in large amounts, causes inflammation, contains high levels of fructose which may increase BP (17) and worsen insulin sensitivity (18).

Honey

    • Pros: Unprocessed raw local honey is generally easy to find (albeit expensive), has higher antioxidant content than other sweeteners including sugar (19), occurs naturally.
    • Cons: Provides calories, raises blood sugar and can lead to insulin spikes in large amounts, causes inflammation.

Sugar (including raw sugar/turbinado sugar, cane sugar, and brown sugar)

  • Pros: Tasty – that’s about it. Raw sugar and brown sugar have slightly more antioxidants than refined sugar (19).
  • Cons: Provides calories, raises blood sugar and can lead to insulin spikes in large amounts, causes inflammation, offers empty calories without micronutrient value (20).

So there you have it. It’s unfortunately not as simple as “which is the best sweetener to use?” Your goals, personal convictions, and body all play in to that choice.

Other tips: work on decreasing your use of sweetening agents in general, and don’t put all your sweetener eggs in one basket. In other words, moderate. Small amounts of a few different kinds of sweeteners in your diet is less likely to cause the damage that might occur from getting all your sweetening from one particular source.

Sources (Yes, I know – lazy, linked sources without full citations):

  1. http://care.diabetesjournals.org/content/19/9/1004.short
  2. http://www.sciencedirect.com/science/article/pii/S0002822303013646
  3. http://ajcn.nutrition.org/content/51/6/963.short
  4. http://www.sciencedirect.com/science/article/pii/S0273230009000786
  5. http://www.healio.com/endocrinology/obesity/news/online/%7Bd976c2ee-06ee-425f-b1eb-aa3b6cbc2891%7D/non-nutritive-sweetener-effects-may-contribute-to-insulin-resistance-in-consumers-with-obesity
  6. http://agris.fao.org/agris-search/search.do?recordID=US8466072
  7. https://www.researchgate.net/profile/Jacquie_Lavin/publication/14185276_Lavin_JH_French_SJ_Read_NW._The_effect_of_sucrose-_and_aspartame-sweetened_drinks_on_energy_intake_hunger_and_food_choice_of_female_moderately_restrained_eaters._Int_J_Obes_Relat_Metab_Disord_21_37-42/links/541c1ece0cf241a65a0bb530.pdf
  8. http://www.sciencedirect.com/science/article/pii/S0195666310000826
  9. http://www.sciencedirect.com/science/article/pii/0031938490902542
  10. http://www.sciencedirect.com/science/article/pii/003193849090350D
  11. http://www.sciencedirect.com/science/article/pii/0031938488902077
  12. http://www.jstor.org/stable/4626891?seq=1#page_scan_tab_contents, http://jnen.oxfordjournals.org/content/55/11/1115.abstract
  13. http://www.sciencedirect.com/science/article/pii/S0195666310000826
  14. http://www.academicjournals.org/article/article1386344782_Gupta%20et%20al.pdf
  15. http://www.sciencedirect.com/science/article/pii/S1572599502800394
  16. http://online.liebertpub.com/doi/abs/10.1089/jmf.2013.0162
  17. http://hyper.ahajournals.org/content/10/5/512.short
  18. http://www.sciencedirect.com/science/article/pii/0026049580900414
  19. http://www.sciencedirect.com/science/article/pii/S0002822308018919
  20. Gropper, S. A. S., Smith, J. L., & Groff, J. L. (2009). Advanced nutrition and human metabolism. Australia: Wadsworth/Cengage Learning.

No matter how you say it, it’s serious. Diabetes is common and can wreak havoc on someone’s body, so I’m more than happy to spend some time focusing on this condition and how to manage blood sugars by counting carbohydrates.

For anyone who is looking for a review of what carbohydrates are or what they do in the body, check out this post. Carbs are the numero uno focus when it comes to managing diabetes and reducing risk of complications.

To understand how diabetes works, let’s go back to the house/insulin key/sugar explanation I wrote about here. Check it out because my upcoming explanation will likely not make sense if you’re not in on the metaphor. Let’s also bring my highly sophisticated representative drawing back for a second look:

insulin

 In people with diabetes, the sugar people are not able to get into the house, causing a buildup of sugar people in the streets. They get crowded and angry and start flipping cars, breaking windows, and rioting all over the place. It makes for a pretty hostile environment.

This buildup of sugar people in the streets typically happens for one of three reasons:

  1. The person has an autoimmune condition that prevents the body from being able to make insulin keys at all. This is called Type 1 diabetes.
  2. The person’s locks are all rusty and take a long time to open. While the lock and key are fumbling around, sugar people build up in the street. This happens for a variety of reasons including genetics, obesity, stress, and inflammation, among others. This is called Type 2 diabetes.
  3. The person’s locks are temporarily rusty because of the effects of hormones associated with pregnancy. This is called Gestational diabetes and most of the time it goes away after the baby is delivered, though it does increase a woman’s risk of having type 2 diabetes later in life.

 

In order to keep there from being too many angry sugar people in the blood, nutrition recommendations include portioning total amounts of carbohydrates eaten at one time. In other words, we send sugar people into the street single file all polite-like rather than stampeding en masse. That is why, in support of my patients and anyone with diabetes, I will be counting and moderating intake of carbohydrates at each meal and snack starting on Monday. We’ll also be going over more specifics about what types of foods are carbohydrates.

There are several other things we can do to help keep the sugar people from building up and rioting – look for more info in upcoming posts!


Feeling BadThe paleo diet in and of itself is not a “high-fat, low-carbohydrate” diet; however, many people utilize paleo thinking as a method of achieving a low-carbohydrate way of eating. The paleo meal plan I’m currently using is based on that method. One of the premises of high-fat, low-carbohydrate is that your body enters into a state of ketosis. That means that your body is switching fuels from using primarily carbohydrate to mainly fat.

Remember in this post when I talked about how your body breaks down carbohydrates to use for energy? Well, here begins chapter 2: After your body turns the carbohydrates into glucose and your cells pick up the glucose, a bunch of active little proteins called enzymes start changing the glucose by adding and taking away chemical bonds. At the end, the glucose is converted to something called Acetyl CoA which then goes on into another process known as the TCA cycle (or Kreb’s cycle, or citric acid cycle, but that’s neither here nor there). This nifty little pathway is the major energy factory in your body. In fact, my metabolism textbook* says that “over 90% of the energy released from food is estimated to occur as a result of TCA cycle oxidation.” Basically, it’s where carbs, fats, and proteins all go to die. They are broken down until there is just water, carbon dioxide, and energy left. Pretty cool, huh?

Since Paleo is considered a high-fat diet, I’ll start with fat. After making its way into the cells, the fatty acids undergo a conversion to (guess what?) acetyl CoA. That molecule then has two possible destinations: it can either go through the TCA cycle just like the former glucose molecules do, or in the presence of extra acetyl CoA the liver can convert it into something called ketones. Ketones can then travel throughout the body to other tissues where they are actually converted back into acetyl CoA and used for energy there.

Starting Wednesday morning (paleo day #3), I started having hot flashes, brain fog, nausea, lightheadedness, and a mild headache. All of these are symptoms described by paleo-diet promoters as the “low-carb flu”. Others complain of such maladies as muscle soreness, extreme fatigue, poor sleep, and digestive disturbances. Doesn’t that just sound like a barrel of monkeys?

Anyway, these ailments are due mostly to chemical shifts in my body (that are super complicated) and the adjustment from using well-oiled glucose burning machinery to my dusty, rusty fat/ketone users. Most of my symptoms have gone away by now, but I now have a bad taste in my mouth (all the time) and occasional hot flashes. My next quest is to investigate the long-term implications of this way of eating and how it affects the body over time. Here goes nothing!

*Gropper, Smith, and Groff. Advanced Nutrition and Human Metabolism. 2009. 5th edition. Wadsworth, Cengage Learning. Belmont, CA.

UPDATE (3/1/14): A friend of mine made a good point that prompted me to edit the original post. I had originally referred to the paleo diet as a high-fat, low-carbohydrate diet, but paleo in and of itself is not “high-anything” or “low-anything.” If one wanted to not eat a low carbohydrate diet and still be paleo, he or she could eat loads of fruit, for example. In my case, the meal plan I chose only included fruit 3 times in the first week, so I have ended up on a high, fat low carbohydrate diet though paleo would not necessarily require that. I updated the post above to reflect this.


As I’ve been focusing on carbohydrates in my research thus far, I wanted to build a “foundation of physiology”, if you will, to build all the dietary recommendations on. If you’re a science geek, I hope you’ll enjoy this with me. If you’re not a science geek and you’d rather mow grass with fingernail clippers than read about the way your body works, stop reading and come back tomorrow. I promise to post a delicious new recipe for you then. Now, on to the nitty-gritty.

Carbohydrates are the primary source of energy in grains, fruits, dairy, starchy veggies (potatoes, beans, etc.), and sugar. Depending on the type of food, the carbohydrates are either long chains of molecules (complex carbohydrates), or short chains or single molecules (simple carbohydrates). Once you put these in your mouth, your body gets right to work. An enzyme in your saliva starts breaking the bonds between the molecules. It usually doesn’t get very far, because most of us swallow before it has a chance to break all of the chains apart. My sixth grade science teacher used a neat trick to demonstrate this breakdown by giving us each a saltine cracker and told us to chew on it for at least a minute. Eventually, it started to taste sweet because the carbohydrates were being broken down into their individual sugar bits…pretty neat, huh?

Anyway, then you swallow and the food goes into your stomach. Not much happens here in the way of breaking apart the carb chains, because your stomach contents are too acidic for the enzymes to work. After your stomach has done its thing, the food passes into your small intestine where most of the magic happens. Another enzyme (dispatched from your pancreas) goes to work breaking the rest of the bonds in the chains of carbohydrates. You are basically left with single molecules known as monosaccharides. You may be familiar with their individual names: glucose, fructose, and galactose. I’m only going to talk about glucose for now, because that’s the most prominent player in your energy pathways. Glucose molecules are transported into your intestinal cells and then pass from there into your blood through a variety of methods. If you have ever heard of someone testing their blood glucose or their blood sugars, they are essentially measuring how many of these glucose molecules are floating around in their blood at any given time. Some of the glucose then goes to the liver for storage, and some of it needs to get into your body’s cells to provide you with energy. To get out of the blood and into most of those cells, glucose needs help from a hormone called insulin.

Insulin action

Think of the glucose molecules in your blood as people walking on the street, and the cells of your body as locked houses. The glucose can’t get into the houses without a key – in this case, insulin (as you can see in my highly sophisticated diagram above). Once it’s in your cells, it can either be used to make energy right away, or stored away in long chains called glycogen until your body needs energy later.

If there is more glucose left over when all of your body’s glycogen stores are full, then your body converts the glucose into fatty acids and stores it away as body fat. Furthermore, that extra glucose actually tells your body to use less of your body’s stored fat for energy. Now before you go scolding your body for this process, remember that it came from the survival instincts of our ancestors who often lived in times of either feast or famine. While there was plenty to eat, their bodies stored fat to sustain them in times of hunger. The problem for many modern-day people is that they constantly live in times of plenty. When people go on low-calorie weight-loss diets, their bodies will start to use that fat (and unfortunately, muscle) to fuel them. Now I’m definitely not advocating that we all just run off and haphazardly quit eating carbohydrates to lose weight. There are definitely pros and cons to be weighed, and for now I’m an advocate of age-old moderation. In agreement with the information I referenced in previous posts, my textbook on metabolism states that (as of 2009) researchers have yet to determine the ideal balance between carbohydrate, fat, and protein intakes for fat loss. Clearly, there is a balance to be achieved.

So there you have it – a snippet of your body’s complex innerworkings. Maybe now you and your body will have more to talk about!