Dissecting the Confusing World of Diabetes Diets
Keto, high-carb vegan, the "Mediterranean" diet — why do such opposing approaches all seem to "work" for type 2 diabetes? Are some better than others?
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Disclaimer: This content is not intended as treatment or support for any medical condition. Content for entertainment purposes only. Not medical or health advice.
“Ideally, things should make no sense until they make the right sense.”
- Ray Peat, PhD
Navigating the nutrition world as someone with type 2 diabetes, or as a family member of someone with type 2 diabetes, can be extremely exhausting considering that the various recommendations out there seem so insanely contradictory.
Some sources claim that a low-carbohydrate ketogenic diet with a heavy focus on fatty meats is best for diabetics and can lead to remission. Anecdotes from those following such diets show that they do in fact experience lower blood sugar levels, weight loss, and a general improvement in their diabetic symptoms.
Other sources claim that a high-carbohydrate low-fat vegan diet is the best for diabetics, and can similarly lead to remission. Similarly, there are many anecdotes of those whose diabetes seem to resolve on diets consisting of upwards of 80% of total daily calories coming from carbohydrates, mostly in the form of fruit.
Yet other sources bolster the benefits of “Mediterranean” diets in reversing diabetes, with similar positive anecdotes.
Could it be that the reason why such varied diets all seem to work for diabetics is that they are all arguably more nutrient-dense than the average highly processed Western diet, which is often built on staples such as white bread and chips? That is part of the answer. But there is a lot more to it.
Let’s not forget that apart from the above-mentioned “diabetes-busting,” diets the most common mainstream recommendation to combat diabetes is to just cut calories to lose weight. Even though the “weight loss at all cost by all means of restriction necessary” approach tends to worsen micronutrient deficiencies, in many diabetics, just losing some weight brings on improvements or even a remission of diabetes.
How could it be that such opposing approaches all seem to bring on remission in diabetics? Is it in fact because, as some like to claim, “we are all different”?
While there definitely is a degree of bio-individuality from person to person, it is not like some of us are gazelles and others are rhinoceroses, lending our species-appropriate diets to be vastly different from person to person. We, as humans, are still all one species, and considering the makeup of our digestive tract and our nutrient needs, the species-appropriate diet that seems to be the most supportive for humans is a pretty homogenous omnivorous diet that doesn’t completely eliminate any major food group.
Some research suggests that red meat causes diabetes, other research suggests that it doesn’t. Some research suggests that saturated fat contributes to insulin resistance, other research suggests that it doesn’t. Some research supports the inclusion of more fibre for improving blood sugar balance, other research shows that zero-fibre carnivore diets work much better than high-fibre diets.
Are the disparities between the various diets that seem to bring diabetes to remission the great paradox of nutritional science that we will never be capable of explaining? No, they are not. There is an explanation that ties all of these pieces together and finds the nuance in all of it, and it is provided in this article.
And lastly, are all of these approaches equally effective at reversing diabetes and supporting overall health? No, they are not.
Some of them work to solve the underlying root cause behind diabetes (being bad at burning carbs for energy), vs. others just “hide” the issue. And even though some of these approaches are better than others, at least as far as solving the root of the problem goes, none of them are optimal.
While most of these contradictory approaches have aspects to them that are genuinely health-promoting, there are also aspects to all of these dietary ideologies that not only make them mostly unsustainable long term, but can also lead to far worse health outcomes in the long run.
Is there a way where we could take the best things from each one of them and take away the aspects that suck to create a better, more balanced approach?
Yes there is! To understand what this better, more balanced and more optimal way is, we need to first understand the aspects of the above-mentioned dietary approaches that make them “work” as far as remediating diabetes goes. This article will do just that, by analyzing these approaches, explaining why they “work,” evaluating what we can learn from each of them, and summarizing all these learnings into an actionable guide at the end.
“It ain’t stupid if it works?”
If you’ve dealt with diabetes or a pre-diabetes diagnosis at some point in the past and managed to reverse it through becoming a low-fat vegan, or through eating nothing but steak and butter, or simply by slashing your calories in half and starting a jogging habit, it can be easy to not care very much about why your approach worked. You’re just happy that it worked, that you probably feel better, that your blood sugar readings are lower, and that your doctor is finally off your case about your blood labs.
While it’s incredible that you were able to start feeling better and get your labs into a better place, it’s important to ask - Is this approach sustainable as far as long-term health goes? Is this approach supportive of long-term metabolic health or is it actually destructive? And lastly, is this current approach getting to issues at the core of the diabetic condition, or is it simply just masking the dysfunction (while potentially silently worsening the dysfunction in the background)?
Understanding the mechanisms through which these varied approaches produce symptomatic improvements (temporarily at least, as is the case with some of these approaches) will help us answer these questions.
Diabetes 101
To start, let’s make sure that everyone is on the same page as far as having a basic understanding of the mechanisms of action at the core of type 2 diabetes.
There are many misconceptions about what diabetes is and about what causes it. Probably the biggest misconception about diabetes is in the colloquial perception of what causes insulin resistance. The mainstream explanation of insulin resistance is that as a “punishment” for eating too many carbohydrates, your cells get tired of responding to insulin’s signal to take up glucose and become insulin resistant. The misconception that carbohydrate consumption is what directly causes cells to become “desensitized” to insulin is why carbohydrates are so demonized in diabetes and often seen as the leading cause of it.
However, as you will see later in this article, very high carbohydrate diets (high in refined carbohydrates such as white rice and white sugar) have been shown to induce a remission of diabetes. If we stick to the mistaken belief that carbohydrates themselves are the cause of diabetes, the above becomes a paradox. Unless we reexamine our preconceived beliefs about diabetes. Then the “paradox” starts making lots of sense.
When cells struggle to take up and burn glucose for energy, glucose stays high in the blood
Diabetes is a condition of cells that are bad at burning sugar (glucose) for energy. While the cells of diabetics are generally bad at burning fuel as a whole (which can be seen by the high levels of glucose, fatty acids, ketones and lactic acid in the blood of diabetics), “diabetic” cells are particularly bad at burning glucose for energy.
Since “diabetic” cells struggle both to take up and to burn glucose, glucose accumulates in the blood, creating the most common manifestation of the diabetic condition - high blood sugar.
Even if the cells manage to take up glucose, cellular respiration (the process through which cells turn glucose into cellular energy) is often inhibited at one or multiple steps in the respiratory chain in diabetics.
When there are blocks along the respiratory chain, a few different things can happen to the glucose that enters the cell. If the block is at the level of the Krebs cycle, glucose will be converted into lactate instead of being burned for energy. This is why diabetics tend to have high lactic acid levels. When the respiratory chain is not moving as fast as it should, glucose can stay in the cell for too long, until it starts “crumbling” into intermediates that can become AGEs (advanced glycation end products) and contribute to glycation (high HbA1C). Either way, it fails to be fully burned for energy most of the time.
In summary, in diabetics glucose rarely manages to be fully burned up for energy due to the:
Failure of glucose to enter the cell
Blocks along the respiratory chain
This is why diabetics’ cells struggle to take up glucose
Understanding the factors that inhibit glucose uptake and cells’ ability to fully turn it into energy will set the tone for the rest of the article and help explain the mechanisms of action behind the soon-to-be-discussed diets.
Now, what can cause glucose to fail to enter the cell? This is where insulin becomes relevant. The cells of diabetics tend to struggle to take up glucose both because their pancreatic cells tend to underproduce insulin and because their cells fail to “respond” to insulin’s signal telling them to take up glucose.
The underproduction of insulin is often brought on by:
Micronutrient deficiencies (such as a deficiency of potassium or chromium)
Injury to pancreatic cells (for example, due to excess oxidative stress)
Cells failing to take up glucose at insulin’s signal is often brought on by:
Too much fat in the blood (fat and glucose compete for cell entry at the level of each cell)
High levels of adrenaline and cortisol (adrenaline dumps fat into the blood, and cortisol stimulates the liver to create more glucose)
Too much glucose being already present in the cell (due to the respiratory chain moving too slowly)
In cases where the pancreas can produce enough insulin but the reason for glucose remaining in the blood and failing to enter cells is either too much fat in the blood or blocks along the respiratory chain, the body will respond by overproducing insulin to try and “push harder” for glucose entry into the cell.
Only in cases of hyperinsulinemia (excess insulin production) do cells start downregulating the expression of insulin receptors.
Hyperinsulinemia is what can lead to dark skin patches in diabetics, such as dark skin patches behind the neck or around the groin area. This is because insulin is an anabolic hormone that stimulates growth. When too much of it is being produced, it can cause rapid cell growth, creating these dark skin patches. It’s worth noting though that long-term hyperinsulinemia is usually the step before developing diabetes.
This is why diabetics’ cells struggle to burn glucose
Moving onto impairments in cellular respiration, the main factors that can cause these impairments are:
Micronutrient deficiencies (vitamin B1, for example, is required for glucose to be burned for energy, and in a B1 deficiency, glucose gets turned to lactic acid instead)
Low levels of intracellular thyroid hormone, T3. T3 controls the speed of cellular respiration. (Micronutrient deficiencies, gut issues, liver problems and low-carb diets can lower T3 synthesis. High cortisol levels can deactivate T3. Polyunsaturated fats can prevent T3 from binding to its receptor, which would allow it to have an active effect on cells. Micronutrient deficiencies can lead to low levels of the carrier proteins needed to carry T3 to cells).
High levels of oxidative stress (Reactive oxygen species can deactivate the various parts of the cell involved in cellular respiration. Reactive oxygen species are formed most readily by metals reacting with polyunsaturated fats. The neutralization of reactive oxygen species depletes micronutrients involved in antioxidant defences).
Environmental toxins (Heavy metals, plastics and other chemical pollutants can deplete micronutrients, increase oxidative stress, interfere with thyroid hormone synthesis and cell entry, and downregulate the function of various cellular components involved in cellular respiration.)
Bacterial toxins (Toxins produced by bad gut bacteria, such as endotoxin, can upregulate the production of nitric oxide. Nitric oxide can block the mitochondrial complex at the bottleneck of energy production, complex IV. When these bacterial toxins reach the liver, they can impair the liver’s ability to detoxify estrogens and environmental toxins and to synthesize thyroid hormones).
Excessive EMF and blue light exposure can similarly elevate blood glucose levels by negatively affecting cells’ ability to make energy, but this point is out of scope for this discussion.
When glucose becomes stuck in the blood (because cells can’t take it up), the body experiences osmotic stress. In other words, there is an imbalance between the amount of fluid in the blood vs. the amount of other compounds in it.
The body will send some of the glucose to the kidneys to dispose of it. As per the etymology of the Greek and Latin words “diabetes” and “mellitus,” the name of the disease roughly means “peeing sweet,” and sweet pee is a key sign of sugar loss in urine. As the body tries to dispose of excess sugar via urine, the glucose pulls more water into the kidneys. This is why diabetics pee a lot and are also thirsty a lot. However, frequent urination depletes micronutrients, such as potassium and B vitamins, which are needed for glucose metabolism.
When cells struggle to take up and burn glucose, high blood glucose levels become a source of issues in and of themselves
When glucose stays high in the blood and the body is not able to burn it for energy, the body will also start sending glucose down pathways that dispose of it, such as the polyol pathway. However, this pathway depletes key nutrients (such as vitamin B1), and it creates intermediates that contribute to glycation (high HbA1C). Advanced glycation end products (AGEs) increase oxidative stress and the synthesis of various inflammatory cytokines. This pathway also depletes antioxidants, which can lead to more oxidative stress. This increase in oxidative stress and inflammatory cytokines can further inhibit cellular respiration. I talk about glycation, AGEs, and these pathways in more detail in my article “Eating Carbs Doesn’t Cause Glycation and High HbA1C.”
The numbing in the hands and feet of diabetics can be the result of inhibited energy production, oxidative stress and thiamine (vitamin B1) depletion, as thiamine is needed for proper nerve function.
The fatigue, hunger, slow wound healing and frequent infections experienced by type 2 diabetics are a direct result of inadequate cellular energy production, as adequate cellular energy (adequate levels of ATP) is needed to signal satiety, power the immune system, heal wounds, create hormones, and run every single other system in the body.
In summary, diabetes is a state in which the body struggles to burn glucose well. This inability and the consequent high blood glucose levels are not caused by glucose. They are caused by various stressors, as outlined above. Unfortunately, as the body becomes bad at burning glucose, the consequent chronically high blood glucose levels become a stressor themselves, in an awful feedback loop.
Curing diabetes…with sugar?
Since diabetes is often thought of as being caused by sugar, me saying that sugar does not cause it might raise some eyebrows.
Now, going even a step further, me telling you that in some instances diets of up to 90% of all calories from carbohydrates have been seen to actually cure diabetes, might have your eyebrow flying off your forehead and hitting the ceiling.
But don’t just take my word for it. Read on, and you will be introduced to the work of someone who has demonstrated that this works.