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Carbohydrate

No doubt you've heard the endless talk in the popular media about carbohydrate. Books tout the value of a high "complex carbohydrate" diet. Athletes "carbo-load" before big games or marathons. TV and radio commercials extol the virtues of Brand X sport drink over Brand Y because it contains more "carbos."

What if I, a physician, told you, a diabetic, to eat a diet that consisted of 60 percent sugar, 20 percent protein, and 20 percent fat? More than likely, you'd think I was insane. I'd think I was insane, and I would never make this suggestion to a diabetic (nor, in reality, would I even make it to a nondiabetic). But this is just the diet to which I was subjected for many years. The ADA made this recommendation to diabetics for decades. On the surface, these recommendations seemed to make sense because of kidney disease, heart disease, and our elevated lipid profiles. But this is what is known as single-avenue thinking. It seemed logical to insist that dietary intake of protein and fat be reduced because no one had looked at elevated blood sugars and the high levels of insulin necessary to bring them down as the possible culprits.

So if you eat very little fat and protein, what's left to eat? Carbohydrate.

As I discovered in my years of experimentation on myself, and then in my medical training and practice, the real dietary problem for diabetics is fast-acting or large amounts of carbohydrate, which result in high blood sugars requiring large amounts of insulin to try to contain them.

So what are carbohydrates?

The technical answer is that carbohydrates are chains of sugar molecules. The carbohydrates we eat are mostly chains of glucose molecules. The shorter the chain, the sweeter the taste. Some chains are longer and more complicated (hence, simple and complex carbohydrates), having many links and even branches. But simple or complex, carbohydrates are composed entirely of sugar.

Sugar? you might ask, holding up a slice of coarse-ground, seven-grain bread. This is sugar?

In a word, yes, at least after you digest it.

With some important exceptions, carbohydrates, or foods derived primarily from plant sources, such as vegetables, grains, and fruits, have the same effect on blood glucose levels that table sugar does. (The ADA has recently recognized officially that, for example, bread is as fast-acting a carbohydrate as table sugar. But instead of issuing a recommendation against eating bread, its response has been to say that table sugar is therefore okay, and can be "exchanged" for other carbohydrates. To me, this is nonsense.) Whether you eat a piece of the nuttiest whole-grain bread, drink a Coke, or have a dollop of mashed potatoes, the effect on blood glucose levels is the same—blood sugar rises, fast.

How can this be?

As noted in the introduction to this chapter, the digestion process breaks each of the major food groups down into its basic elements, and these elements are then utilized by the body as needed. The basic elements of most carbohydrates are glucose molecules. We usually think of simple carbohydrates as sugars and complex carbohydrates as fruits and grains and vegetables. In reality, most fruit and grain products, and some vegetables, are what I prefer to talk about as "fast-acting" carbohydrates. Our saliva and digestive tract contain enzymes that can rapidly chop the longer chains down into the shorter, sweeter chains. We haven't the enzymes to break down some carbohydrates, such as cellulose, or "undigestible fiber." Still, even our saliva can break down starches into the shorter chains on contact.

Pasta, which is often made from durum wheat flour and water (but can also be made from plain white flour and egg yolks, or other variants), has been touted as a dream food—particularly for runners carbo-loading before marathons—but it quickly becomes glucose, and can raise blood sugar very rapidly.

In the Type II diabetic with impaired phase I insulin response, it takes hours for the pancreas to catch up with the levels of sugar in the blood, and day after day, during that time, the high blood sugars can wreak havoc. In the diabetic who injects insulin, there is a tremendous amount of guesswork involved in finding the proper dosage of insulin and timing it to cover a carbohydrate-heavy meal, and the injected insulin doesn't work fast enough (see Chapter 7, "The Laws of Small Numbers").

Some carbohydrate foods, like fruit, consist of high levels of simple, fast-acting carbohydrates. Maltose and fructose—malt sugar and fruit sugar—are slower-acting than sucrose—table or cane sugar—but they will cause the same increase in blood sugar levels. It may be the difference between nearly instant elevation and elevation in 2 hours, but the elevation is still high, and still requires a lot of insulin to bring it into line. Despite the old admonition that an apple a day keeps the doctor away, I haven't had fruit in more than twenty-five years, and I am considerably healthier for it. Some foods, like broccoli, contain lots of cellulose, or undigestible fiber, which slows the digestion and dilutes the small amount of digestible carbohydrate they contain.

As noted previously, most Americans who are obese are overweight not because of dietary fat, but because of excessive dietary carbohydrate. Much of this obesity is due to "pigging out" on carbohydrate-rich snack food or junk foods, or even supposed healthy foods like bread and pasta. It's my belief that this pigging out has little to do with hunger and nothing at all to do with being a pig.

I'm convinced that people who crave carbohydrate have inherited this problem. To some extent, we all have a natural craving for carbohydrate—it makes us feel good. The more people gorge on carbohydrates, the more people will become obese, even if they exercise a lot. But certain people have a natural, overwhelming desire for carbohydrate that doesn't correlate to hunger. These people in all likelihood have a genetic predisposition toward carbohydrate craving, as well as a genetic predisposition toward insulin resistance and diabetes. This craving can be reduced for some by embarking upon a low-carbohydrate diet.

Some Words About Alcohol

However, ethyl alcohol can indirectly lower blood sugar of a Type I diabetic if consumed at the time of a meal. It does this by paralyzing the liver and thereby inhibiting gluconeogenesis so that it can't convert the protein of the meal into glucose. For the average adult, this appears to be a significant effect with doses greater than 1.5 ounces, or one standard shot glass. If you have two 1.5-ounce servings of gin with a meal, your liver may be partially unable to convert protein into glucose. If you're insulin-dependent, and your calculation of how much insulin you'll require to cover your meal is based on, say, two hot dogs, and those hot dogs don't get 10 percent converted to glucose, the insulin you've injected will take your blood sugar too low. You'll have hypoglycemia, or low blood sugar.

The problem of hypoglycemia itself is a relatively simple matter to correct—you just eat some glucose and your blood sugar will rise. But this gets you into the kind of messy jerking up and down of your blood sugar that can cause problems. It's best if you can avoid hypo- and hyperglycemia (high blood sugar) entirely.

Another problem with alcohol and hypoglycemia is that if you consume much alcohol, you'll have symptoms that could indicate either alcohol intoxication or hypoglycemia— light-headedness, confusion, and slurring of speech. The only way you'll know the cause of your symptoms is if you've been monitoring your blood sugar throughout your meal. This is unlikely. So you could find yourself with dangerously low blood sugar and just think you've consumed too much alcohol. Remember, that early blood sugar–measuring device I got was developed in order to help emergency room staffs tell the difference between unconscious alcoholics and unconscious diabetics. Don't make yourself an unconscious diabetic. A simple oversight could turn fatal.

Many of the symptoms of alcohol intoxication mimic those of ketoacidosis, or the extreme high blood sugar and ketone buildup in the body that can result in diabetic coma. The buildup of ketones causes the diabetic to have a sweet aroma, rather like someone who's been drinking. If you don't die of severe hypoglycemia, then you might easily die of embarrassment when you come to and your friends are aghast and terrified that the emergency squad had to be called to bring you around.

In small amounts, alcohol is relatively benign—one glass of dry wine or a light beer with dinner—but if you're the type who can't limit drinking, it's best to avoid it entirely. For the reasons already discussed, alcohol can be more benign between meals than it is at meals.

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