SWEET TOOTH, BITTER HARVEST: The Sugar and Diabetes Story

by Neil Nedley, M.D., taken from his book Proof Positive

She called the Lifestyle Center of America desperately for help. Thirty years of diabetes had taken a tremendous toll on her health. The high blood sugars had done their work silently for years, but now the bitter harvest was undeniably obvious. Jenny had kidney failure and resulting fluid accumulation. Of more concern to her, however, was that she was going blind. Her vision had been getting progressively worse, and the doctors had given her no hope. With those discouraging prospects ahead she became excited as she heard about a lifestyle approach toward reversing the effects of diabetes.

The Lifestyle Center of America, a place in Oklahoma that provides a three week therapy live-in program, is not unique in offering a program to reverse the ravages of diabetes. I have been giving my patients similar information for years and have seen some of the same dramatic results that the live-in centers achieve: people decreasing or getting off insulin and oral medications with a lifestyle approach to this killer disease. Sadly, however, there are many people like Jenny who come to me with advanced diabetes. In many of those cases we are not able to “turn back the clock” and restore their vision or their kidney function. Yes, we may be able to provide some help in those areas, but often the severe damage that has already been done is beyond the point of complete reversal.

What is tragic is that it often takes irreversible complications before people really get serious about doing all they can to control their diabetes. By then it is too late to accomplish all we could have if they had gotten serious years earlier. The cases of a thousand Jennys eloquently proclaim: diabetes needs to be promptly recognized and treated. Many newly diagnosed diabetics—as well as those struggling with the disease for longer periods of time—can control their diabetes without drugs by following an excellent lifestyle. Do not wait until a heart attack, or amputation, or blindness serves as a wake up call. The wake up call should be that first “borderline blood sugar”—the slightest suggestion of diabetes.

In this chapter we will look at important information about diagnosing and dealing with diabetes. Even if you do not have diabetes, you will want to give special attention to the closing sections of this chapter; there I focus on the dangers of eating sugar even for those who have no problem with diabetes. You will learn about the effects of sugar on the immune system, its role in weight gain, and other fascinating areas. Also in this chapter I contrast sugar with its two carbohydrate cousins: complex carbohydrates and fiber. We will look at some of the exciting benefits of these more healthful carbohydrates.

What Exactly is Diabetes?
Diabetes mellitus or “sugar diabetes” is a condition where an abnormal response to insulin and/or inadequate insulin production causes high blood sugar levels. This is usually defined by a fasting blood sugar of greater than 125 on two occasions,1 or a positive glucose tolerance test (the individual drinks a specified amount of glucose, usually 75 grams and their blood sugars are evaluated over a two hour period). Over time, these high blood sugar levels and the other metabolic changes that go along with diabetes are extremely taxing on the body. Consequently, diabetes dramatically increases one’s risk of death and disability.

Current statistics are sobering. In America there are now three times as many diabetics as there were in 1958.2 Estimates are that some 16 million Americans now have this condition, up from 11 million as recent as 1983. Depending on their type of diabetes and other characteristics, they run anywhere from 2 to 12 times the risk of death when compared to their non-diabetic peers.3 Diabetes increases the risk of heart disease and other diseases related to atherosclerosis such as stroke or the loss of an arm or leg from blood vessel blockage. Diabetes also dramatically increases one’s chances of infections, kidney failure, and an eye disease called retinopathy, which can result in blindness. The number of people in the U.S. that are afflicted by diabetes is shown in Figure 1: Diabetes in America - The Facts.4

The myriad of afflictions that result from diabetes is listed in Figure 2: Afflictions of Diabetes. 5,6,7,8,9

Although heart disease is the leading cause of death among diabetics,10 sometimes the debilitating effects of blindness and kidney disease are more frightening. Within only seven years of diagnosis, as many as 50 percent of children with diabetes have developed diabetic retinopathy, a disease of the eyes that can result in blindness.11 Diabetics need to get checked by eye doctors regularly. Diabetic eye disease is preventable, not only through lifestyle, but also by early treatment. Furthermore, diabetics run a significant risk of developing kidney disease. In any given year, some 55,000 Americans are suffering with what is called “end-stage renal disease” due to their diabetes.12, 13 These individuals have such poor kidney function that they are alive only by virtue of a transplant or regular dialysis treatments. End-stage renal disease among diabetics is increasing dramatically in the United States. Whereas 5,000 new cases were being diagnosed per year in the early 1980s, a decade later the figure had jumped to 18,000 new cases per year.14 In fact, over 35 percent of all patients with end-stage kidney disease are diabetic.15 Diabetic women are also more prone to develop breast and uterine cancer.16

No dollar amount can eclipse the thousands of personal tragedies due to diabetic complications. Nevertheless, in a nation where health care costs are skyrocketing, the financial impact of diabetes is truly relevant. The direct and indirect cost to society for diabetes is estimated to be between 90 and 130 billion dollars per year in America alone.17

All Diabetics Are Not the Same
Diabetics are often divided into four categories. Of these four categories, there are actually two main types of diabetes: insulin-dependent diabetes mellitus (IDDM), often referred to as Type I, and non-insulin-dependent diabetes mellitus (NIDDM), often designated Type II.18 Although some diabetes purists will take pains to use the terms IDDM and NIDDM, in this chapter I will use the terms Type I and Type II. A third type of diabetes occurs in pregnancy and is called gestational diabetes mellitus. The fourth category of diabetes takes in a host of rarer causes of the disorder such as those due to hormonal abnormalities or other medical conditions.

Type I diabetes is the most severe form of the disease. It typically occurs in childhood (but can develop at any age) and for this reason was previously called “juvenile diabetes.” The most common cause of Type I diabetes is destruction of the insulin-making cells in the pancreas by the person’s own immune system. This is referred to as “autoimmune destruction.” The specific factors that trigger this autoimmune process have proved elusive. Although some cases have been linked to viruses or chemical toxins, much is still unknown about the beginnings of the Type I diabetes process.19 There does seem to be a genetic susceptibility to the disease, plus an environmental factor that triggers the disease process. Some of the most interesting recent research links some cases of Type I diabetes to an abnormal immune reaction to milk protein. We now know that children who are breast fed for a shorter time or who are started on cow’s milk earlier have an increased risk for this type of diabetes.20 In fact, the drinking of cow’s milk may be the trigger that initiates the disease in over half of all Type I diabetics.21

Regardless of the cause of their Type I diabetes, affected individuals lose their ability to make adequate amounts of insulin and are left with an absolute life-and-death need for insulin shots. Without those shots, they go into a condition called diabetic ketoacidosis, which is fatal if not promptly treated. Because of their absolute need for insulin, individuals with Type I diabetes are usually diagnosed early in the disease process. Typically they have symptoms like excessive urination (polyuria), excessive thirst (polydipsia), excessive hunger, and excessive eating (polyphagia). They often are also bothered by fatigue and weight loss.

Why does the Type I diabetic develop these symptoms? The answer is best arrived at through a brief review of some of the main facts about blood sugar and how it is controlled. The main fuel for our bodies is a simple sugar called glucose. There is a potential problem, however, with this fuel source. It can only get into each cell of the body if insulin is present. Some have compared insulin to a key that opens “the doors” in body cells so that the vital fuel, glucose, can get into the cell. However, if there is an insufficient amount of insulin (as in Type I diabetes) or if the locks on the doors are “gummed up” so that the insulin key has difficulty opening them (as can occur with the insulin resistance of Type II diabetes), then blood sugar levels can rise. When blood sugar levels rise sufficiently, the ability of the kidney to contain the sugar is overwhelmed, and sugar comes out in the urine. The sugar takes water with it, thus leading to the excessive urination so familiar in uncontrolled diabetes. The loss of water results in another diabetes symptom: increased thirst. At the same time, sugar is not moving into the body’s cells adequately. In a sense, the body’s cells are starving for energy. This can cause fatigue, weight loss, and excessive hunger.

Fortunately, only about 5 to 10 percent of diabetics in America fall under the Type I diabetes category.22 The remainder are Type II diabetics. These individuals either have a problem called “insulin resistance” or a less severe underproduction of insulin than those with the Type I variety. In actuality, most fully developed Type II diabetics have both of these problems.23 There appear to be many different causes of Type II diabetes; most seem to have a genetic basis. The majority of individuals with this type of diabetes have a family member that had also been diagnosed with the disease. For example, many Native Americans have this genetic tendency; however, it appears they did not have diabetes until they adopted a Western diet with an overabundance of sugar and fat. Simply put, it usually takes a combination of two factors to develop adult onset diabetes. One is genetics, and the other is a poor diet—like that consumed by the average American.

Many individuals with Type II diabetes generate plenty of insulin but their body is resistant to it. This condition of insulin resistance can be addressed by lifestyle changes. By maintaining an excellent diet, achieving an ideal weight, and embarking on an exercise program, many Type II diabetics can control their blood sugars with these lifestyle changes alone. Some may need diet changes plus a pill to help control their blood sugar.

Because of the more subtle nature of Type II diabetes compared to Type I, it often goes undiagnosed. A person with Type II diabetes may not have any of the classic diabetes signs like excessive urination, excessive thirst, excessive hunger, fatigue, or weight loss. At any point in time, it is estimated that fully 50 percent of Type II diabetics have not yet been diagnosed.24 Of course, unrecognized diabetes still does its damage steadily and silently. About 20 percent of newly diagnosed Type II diabetics already had damage to their eyes (retinopathy).25 Sometimes an unsuspecting person will be told they have diabetes when a routine blood screening reveals high blood sugar. If the blood sugar is above 125 after an overnight fast, it indicates diabetes. Individuals can have diabetes, however, with fasting blood sugars below that level. If a doctor suspects diabetes in a person with a relatively low fasting sugar, further testing can be done. The oral glucose tolerance test checks for diabetes by measuring a person’s blood sugar response to a sugary beverage. Pregnant women routinely have such a test to make sure they are not diabetic. Some doctors recommend that others in the general population should have a glucose tolerance test. Depending on the physician, some will recommend the test for those with significant obesity and/or genetics. Others advise the glucose tolerance test in anyone with fasting sugars higher than a certain level. Some will check all those with fasting sugars over 105; some very conservative doctors will advise the test to all their patients who have fasting sugars consistently over 95, since this usually indicates that at least the individual has the gene for Type II diabetes. A glycosylated hemoglobin level (discussed later in the chapter) may be able to substitute for the glucose tolerance test in detecting diabetics with fasting blood sugars less than 125.26

Although Type II diabetes can be picked up by such blood tests for elevated sugar, many Americans do not seek out health professionals for such preventive services. They wait until they are sick. This is unfortunate. As a result, many Type II diabetics only become aware of their disease when they experience potentially irreversible problems like eye or kidney disease, nerve problems, or a heart attack.

Regarding gestational diabetes, two to five percent of all pregnant American women are affected.27 This translates into about 200,000 children being born to mothers with gestational diabetes each year.28, 29 This is significant, because those children experience an increased risk of health disorders such as birth trauma, lower blood sugars at birth (neonatal hypoglycemia), and even premature death in infancy (perinatal mortality).30 The message is clear: if you are a diabetic who becomes pregnant, or if you develop gestational diabetes, you should have your blood sugar monitored closely. Your diet and lifestyle need to be well regulated. Furthermore, any woman who develops gestational diabetes has a genetic tendency for diabetes. She is at high risk to develop full blown diabetes later in life.31 Practicing healthy habits throughout her life span thus becomes critical.

Controlling Diabetes: Can the Ravages of Diabetes be Prevented?

Recently, a landmark Diabetes Control and Complications Trial (DCCT) was completed. This six-year study looked at 1441 Type I juvenile diabetics. Those diabetics who strove to keep their blood sugars as close to normal as possible (using insulin and lifestyle changes) had 76 percent less chance of developing diabetic retinopathy, a serious eye disease.32 They also experienced 54 percent fewer cases of significant kidney disease and 60 percent fewer cases of nerve problems involving the hands and/or feet (peripheral neuropathy).33 The participants also significantly lowered their blood cholesterol levels, suggesting that tight control could decrease heart disease risk by up to 35 percent.34 These improvements are summarized in Figure 3: Results of Blood Sugar Control in Type I Diabetics.

Diabetics in this study who keep their sugars as close to normal as possible are said to be practicing “intensive therapy” or “tight control.” This begs a question: in the research just referred to, exactly how intensive was “intensive” (or how tight was “tight control”)? The DCCT had very clear blood sugar goals. Fasting blood sugars in the morning as well as blood sugars before each meal were to be between 70 to 120. After-meal levels were to stay below 180. Furthermore, a middle-of-the-night sugar at 3 AM was to stay above 65. To find out how well the participants were adhering to these goals, an additional blood test called glycosylated hemoglobin was taken regularly. This test measures the amount of sugar that becomes attached to a person’s red blood cells. The amount of attached sugar in turn is directly related to the average amount of sugar in the blood throughout the life span of the red blood cells. Since red blood cells typically live for 90 to 100 days, the glycosylated hemoglobin value gives an approximation as to the average blood sugar level over a three-month period. In the DCCT study, levels were about 6.05 percent. This compares favorably with a value of 7.5 percent, which is considered the upper limit of normal in a non-diabetic population.35

How does intensive therapy differ from the standard or conventional way of treating diabetes? First, intensive therapy always refers to treatment using insulin. Second, with intensive therapy there are no fixed doses of insulin. For example, a diabetic on this type of program does not take a fixed amount of insulin every morning. The amount of insulin is adjusted according to the level of blood sugar at the time the insulin is given. This differs from the old way of giving insulin that is still called a “conventional fixed dose program.”36 That approach assumed that insulin requirements would be the same each day. In fact, we now know that insulin needs can vary tremendously from day to day. This knowledge of changing insulin needs provides the rationale for intensive therapy.

Intensive insulin therapy attempts to artificially simulate how our bodies’ insulin-producing organ, the pancreas, works: the pancreas constantly secretes insulin into the blood so that there is always some insulin present. This is what is called the basal insulin level. The pancreas also secretes extra insulin in response to the food we eat.37 To reproduce this effect of basal insulin some diabetics will use a long-acting insulin shot, while others will use an insulin pump that works continuously to deliver this basal insulin level. To reproduce the food-related insulin surge, whether on shots or on the pump, additional regular insulin or a new short-acting insulin (Humalog) is given. If the shot method is used, at least three shots per day are given on the intensive insulin program. To evaluate the body’s needs for insulin, frequent blood sugar monitoring is necessary. Blood is obtained for this purpose by pricking the finger with a small needle-like instrument called a lancet. Then this blood is analyzed by a home sugar-monitoring device. The diabetic who is on an intensive schedule usually pricks his or her finger a minimum of four times and an ideal of seven times per day: before each meal and at bedtime, plus ideally an hour after each meal.38

Although tight control makes a profound difference for the Type I diabetic, it is a much more cumbersome and expensive process in the short run. Many have felt that the DCCT results could be extended to apply to Type II diabetics; this interpretation is not based on any facts obtained from that study.

In my opinion, we should not be too quick to try to rigorously control the blood sugars of a Type II diabetic with an intensive insulin program. In addition to the time, expense, and discomfort involved in finger pricks and multiple injections, there are even more pressing concerns. Before we look at those concerns, some words of explanation are in order. Although Type II diabetics are called “non-insulin dependent,” remember, this simply means that they do not have a life or death need for insulin shots. Many doctors nonetheless put these individuals on insulin to better control their blood sugars. In fact, the National Institutes of Health indicate that 50 percent of known Type II diabetics in America are either using insulin alone or insulin in combination with oral medications.39 This greatly confuses many in lay circles. They erroneously think that just because someone is on insulin, they are a Type I diabetic. More often than not, a diabetic who is on insulin has the Type II variety. After all, estimates are that there are over 3.5 million insulin-using Type II diabetics in our nation. This compares with only 800,000 Type I diabetics in total.40 Now that we have paused to recognize that many Type II diabetics use insulin, we need to look at one of the most worrisome problems with this practice. It is what I call “the vicious cycle of insulin use.” The cycle begins with a sobering fact: using insulin aggressively stimulates weight gain. In the DCCT, the average participant on the intensive program weighed 10 pounds more than the control subjects after 5 years.41 This is especially ominous for the Type II diabetic. Type I diabetics are often thinner and more resistant to weight gain relative to the Type IIs. However, some tend to gain weight after the onset of the disease. Type IIs often have overweight problems at the onset of diabetes, and experience further weight gain as the disease progresses.

In my medical experience, when I am asked to see a Type II diabetic who has been placed on insulin to try to improve blood sugar control, I generally expect them to have gained a significant amount of weight. This introduces the next part of that vicious cycle. Weight gain contributes to the Type II diabetic’s resistance to the effects of insulin; thus, as weight increases so do insulin needs. The cycle comes full circle when insulin dosages are further increased, only to stimulate further weight gain. The significance of this dilemma has been appreciated by the National Institutes of Health. Because of the tendency of intensive insulin therapy to promote weight gain, they have stated, “Intensive treatment may not be appropriate for diabetics who are overweight,”42 which includes most Type II diabetics.

The tight control of diabetes with insulin also introduces other problems. The DCCT study participants ran a much higher risk of low blood sugar (hypoglycemic) reactions than those who were not practicing intensive therapy. Although hypoglycemia is usually no more than a physically uncomfortable inconvenience, severe reactions can actually be life threatening.
At this point, someone may point out: yes, there are problems with insulin therapy for the Type II diabetic, but is it possible for these individuals to keep their blood sugars in an ideal range by using oral medication—without all the finger sticks and insulin? It is true that early in the course of the disease it is often possible for a Type II diabetic to use medication to optimally control their sugars. However, over time, the oral medications often become insufficient to keep blood sugars in the tight control range demanded by intensive treatment.

Even if blood sugars can be controlled with pills by mouth, this does not prove the wisdom of using them. Although I do use oral medications in some of my diabetic patients, the practice is part of one of the longest standing controversies in medicine. The main drugs that continue to be used for blood sugar control belong to a class called the sulfonylureas. Common drugs in this family include DiaBeta, Micronase, Glucotrol, Glynase, Amaryl and Diabinese. Today, if you look up any of these drugs in the Physician’s Desk Reference, you will find a warning in bold print entitled “Special warning on increased risk of cardiovascular mortality.”43 That warning goes on to explain the findings of a study published back in 1970 by what was called the University Group Diabetes Program (UGDP). Researchers found that diabetics who took tolbutamide, an oral pill used in the study, had more than double the risk of dying from heart disease as those who treated their diabetes with diet alone. Today, some urge that the drugs in this family are vastly different now than the tolbutamide of the 1960s. However, the FDA still requires that even the newest drugs in this class carry a bold print warning that reads, “Although only one drug in the sulfonylurea class (tolbutamide) was included in this [UGDP] study, it is prudent from a safety standpoint to consider that this warning may also apply to other oral hypoglycemic drugs in this class, in view of their close similarities in mode of action and chemical structure.” Some of the newer medications for diabetes such as Precose, Glucophage, and Rezulin are not in the same class and have differing mechanisms of action. Thus they may be less likely to increase the risk of heart disease, although they have not been on the market long enough to make a firm determination in this regard.

My conclusion, based on published medical research and my personal experience, is that careful blood sugar control is important in Type II diabetics. However, the use of insulin and oral agents in these individuals carries the potential to do more harm than good. Thus, the most important question in my mind always is: how can I help my Type II diabetic patients control their sugars without drugs? Such an approach stands to reduce the complications of high blood sugars while decreasing the risk of problems from treatment.

Non-Drug Approach Brings Startling Results

Many seem to think that using a non-drug approach would increase the risk of diabetic complications and decrease the likelihood of attaining optimal blood sugar control. Ironically, the evidence suggests that the opposite is true: an optimal lifestyle program seems to help many diabetics more than any drugs available. One recent example of the power of a comprehensive lifestyle program comes from Weimar Institute in California. Researchers there studied the benefits of a live-in 25 day comprehensive lifestyle program on Type II diabetic patients. A frequent complication of diabetes is peripheral neuropathy, a condition that often manifests itself as burning or aching sensations in the feet and legs and may also involve the hands and arms. The pain is often described as excruciating and sharp. The disease can later progress to numbness, as heat, cold, and pain can no longer be felt in the affected areas. Although medications may sometimes help the condition, they often make no significant impact. The study’s lead researcher was Dr. Milton Crane (an endocrinologist who specializes in reversing the effects of diabetes through lifestyle changes). He showed that a meatless diet, free from all animal products and high in unrefined total vegetarian foods, will bring complete relief to painful neuropathy in over 80 percent of diabetics with this condition in just 4 to 16 days.44 Other elements of the program included: regular exercise, hydrotherapy treatments, cooking classes, group lectures, exclusion of a variety of beverages (coffee, tea, and alcohol), exclusion of tobacco, and for those who desired it, religious counseling. Previously, diabetic neuropathy was thought to be incurable. This study shows that the condition can actually be reversed through a comprehensive lifestyle program that includes diet and exercise. Blood sugars and cholesterol also dramatically improved on this diet. The benefits of complete relief of diabetic painful neuropathy continued according to a one to four year follow-up program.45

Keeping blood sugars as close to normal as possible is one of the keys to kidney health in the diabetic. A comprehensive lifestyle approach will greatly assist this process. Furthermore, an optimal diet, which is total vegetarian, generally has much less protein in it than the standard American fare. Such a lower protein diet tends to put less stress on the kidneys, again providing a boon to kidney health46 (see Chapter 7, “The Great Meat and Protein Myth,” for more information). Not only can a comprehensive lifestyle program help accomplish these goals, but such a broad-based lifestyle approach will also likely diminish other risk factors that could in time further worsen kidney function.

Examples of some of the other factors that can worsen diabetic kidney problems include high blood pressure, cigarette smoking, and elevated blood fats (LDL cholesterol and triglycerides).47 One little-recognized factor that also seems to increase the risk of kidney problems in diabetics is the use of Tylenol or other brands of acetaminophen. Studies show that using as little as two pills once a week doubled the risk of severe kidney disease in diabetic patients.48 Controlling diabetes pain with an approach like that used at Weimar would be expected to result in a decrease or elimination of the need of such drugs among affected diabetics.

Exercise - First Element Needed in a Comprehensive Diabetes Lifestyle Program
Exercise plays a powerful role in lowering blood sugar levels. Evidence suggests that muscles in motion reduce resistance to insulin; that is, insulin sensitivity is improved by regular physical exercise.49 More simply put, exercise—in a sense—works like insulin in a diabetic: it helps sugar go out of the blood and into the muscle tissue. In fact, the prestigious Joslin’s Diabetes Medical textbook indicates that lack of exercise is “a key factor” in the development of insulin resistance as people get older.50 Since diabetics need insulin on a daily basis (either their own body’s insulin or injected insulin) so do diabetics need daily exercise to optimally control their blood sugars and their disease.

Exercise not only helps diabetics control their blood sugars, it also helps non-diabetics decrease their risk of ever developing diabetes in the first place. One study showed that exercise dramatically decreased the risk of developing diabetes among those who were at high risk for the disease.51 As the amount of energy expended in exercise increased from 500 calories per week to 3500 calories per week, the risk of developing diabetes dropped by 48 percent. In other words, regular exercise nearly cut the risk of developing diabetes in half, as shown in Figure 4: Exercise and Risk of Diabetes. Interestingly, those who were at the highest risk of developing diabetes benefited the most from regular exercise. Individuals classified as high risk in this study included those who were overweight, had a family history of diabetes, or had high blood pressure. The bottom line is that exercise is important for everyone. However, it is especially critical for the diabetic and for those at high risk of developing the disease.

Proper Diet-Second Element in a Comprehensive Diabetes Lifestyle Program
Until recently, diabetics were told that in order to control their blood sugars they had to eliminate most of the carbohydrates from their diet. They were told to avoid sugar, but the message did not stop there. Plant foods—naturally rich in complex carbohydrates—were also on the “hit list.” The result left diabetics gravitating to a heavy meat diet.52 The medical community did not realize at that time what we have already noted; namely, a high protein diet promotes kidney destruction. With heavy meat consumption also came increased ingestion of cholesterol and saturated fat. Galloping atherosclerosis then followed close behind. “Missing the forest for the trees” was certainly true in this case. The trees were the high blood sugars, the forest was the whole patient. Yes, eating a low carbohydrate (high meat) diet can control the blood sugars, but the number one cause of death among diabetics is heart and blood vessel disease. In fact, the American Heart Association has gone on record that fully 80 percent of diabetics die of some form of heart or blood vessel disease.53 The root cause of heart and blood vessel disease is atherosclerosis. This process is, of course, accelerated by meat with its high content of cholesterol and saturated fat. Ironically, then, by treating his or her blood sugar with a high meat diet, a diabetic may likely trade the control of blood sugar for an early death from heart disease. Since it is the complications and afflictions of diabetes that need to be particularly avoided (not just the control of blood sugars) the diet needs to be tailored to avoid or treat these complications as well as control the blood sugar.

Obesity is often one of the main determinants of insulin resistance (the primary cause of Type II diabetes). Thus it is imperative for an obese diabetic to lose weight if control of the disease is to be obtained by lifestyle changes alone. Meat is also dense in calories and makes weight loss more difficult. On the other hand, whole fruits, vegetables, and grains (without fatty toppings) are much less dense in calories, thus facilitating an excellent weight loss program.

Meat and Death from Diabetes
Notwithstanding the fact that meat can help control blood sugars in diabetics, a large Southern California study done among Seventh-day Adventists showed that those that ate meat six or more times per week were at 3.8 times greater risk of dying from diabetes than those who ate meat less than once per week, as illustrated in Figure 5: Meat and Death from Diabetes.54 Other research indicates an additional benefit to diabetics who avoid meat and animal products. These animal-derived items have no fiber in them whatsoever. And fiber is emerging as a critical ingredient in the control of blood sugar. In fact, some are suggesting that an abundant supply of fiber is one of the main reasons that a vegetarian diet benefits diabetics.

Fiber Facts
Fiber is a term that refers to plant constituents that are resistant to human digestive enzymes.55 Almost all of the different types of fiber are actually indigestible carbohydrates (the only exception is a fiber called lignin).56 Some of the other fiber types include cellulose, hemicellulose, pectins, and gums.57 Fiber is generally classified as either soluble (dissolves in water) or insoluble. As we will see shortly, these two types of fibers have different benefits. One of the bonuses of eating a balanced diet of natural plant foods is that we tend to get liberal amounts of both the soluble and insoluble fibers.
There are many foods rich in fiber. A high content of insoluble fiber is found in wheat (especially the bran) and bananas. Foods strong in soluble fiber include most fruits, vegetables, legumes (fresh or dried), oats, brown rice, and barley. Most foods that are strong in soluble fiber are also strong in insoluble fiber. Examples of foods high in fiber are shown in Figure 6: Good Sources of Soluble and Insoluble Fiber.58

Fiber, Insulin, and Blood Sugar
Research makes evident that foods that are high in fiber lead to a slower rise in blood sugar, and as a result, require less insulin to handle the meal.59 Fiber, especially soluble fiber like the pectins and gums, slows the emptying of food from the stomach60 and helps to slow the absorption of simple sugars in the small intestine.61 This should be contrasted with high fat meals that can result in high blood glucose levels for up to 5 hours after the meal.62

Addition of these types of fibers to the diet has been demonstrated to improve diabetes control.63 Indeed, eating a low fat, high fiber, vegetarian diet keeps blood sugars low even when fruits are eaten. Dr. James Anderson and colleagues at the University of Kentucky found that by using a high carbohydrate and high fiber diet, the need for insulin was greatly reduced. Blood sugar control was better and fasting levels of cholesterol and triglycerides fell. These and other benefits of the high carbohydrate, high fiber diet are listed in Figure 7: Diabetic Benefits of a High-Carbohydrate, High-Fiber Diet.64, 65, 66

Many nutrition experts recommend that our diets should contain between 20 and 35 grams of fiber per day when it comes to issues like cancer prevention.67 However, even higher amounts of fiber seem optimal for diabetes control. Studies that demonstrate consistent decreases in insulin requirements by improving fasting and post-meal blood sugar levels have used between 25 and 35 grams of fiber for every 1000 calories eaten.68 This can easily bring daily fiber consumption into the range of 50 to 100 grams per day.
Consumption of soluble fiber also appears to be important in non-diabetics. As we have already noted, whether or not a person has diabetes, these fibers prevent the rapid rise in blood sugar, with a resulting lower peak level. Therefore, insulin requirements are actually decreased when these fibers are added to the diet.69 This is no small matter. As important as insulin is in controlling our blood sugar, ongoing research demonstrates that higher blood insulin levels increase the speed at which the blockages of atherosclerosis develop.70, 71 Thus, we should help our bodies by placing fewer demands for high insulin output. One way we can do this is by eating less sugar and choosing more fiber-rich foods.

One group of non-diabetics that may especially benefit from the insulin-sparing effects of a high-fiber vegetarian diet consists of those with high blood pressure. Individuals with elevated blood pressure (so called “essential hypertension”), even if they are not overweight and not diabetic, tend to have tissues that are less sensitive to insulin.72 The body responds to this lack of tissue sensitivity by making more insulin to get the job done. Therefore, if hypertensives adopt a better diet, their blood vessel walls will be exposed to a reduced amount of insulin.

Other Benefits from Fiber

Fiber from plant foods helps dilute, bind, inactivate, and remove toxic substances and carcinogens found in our food supply. Fiber helps prevent colon cancer, and may help against several other cancers as well.73 A diet rich in fiber helps in healing peptic ulcer disease.74 Fiber is effective in curing and preventing chronic constipation. It can also be effective in curing chronic diarrhea.

We have come a long way since fiber gained worldwide attention in 1970. It was then that Dr. Denis Burkitt, a renowned British physician, published a report that very effectively sounded the alarm. He observed that in countries where diets include large amounts of fiber, there were few cases of the many degenerative diseases common in the Western world today. These diseases are listed in Figure 8: Diseases Associated with a Low Fiber Diet.75

Remember, fiber is found only in plant foods such as fruits, vegetables, grains, and nuts. Fiber is not present in any animal products. There is no fiber in meat, milk, eggs, or cheese. Yes, a cow eats plenty of fiber and is a vegetarian by nature, but it retains no fiber in its flesh or its milk.

More on Proper Diet: Meal Timing on an Optimal Lifestyle Program
Most people do not realize that their glucose tolerance decreases as the day progresses. This means that toward evening, your body’s ability to handle sugar decreases. In a study of subjects with Type II diabetes, absolute blood sugar levels were 10 to 15 percent higher when eating six times a day (three meals and three snacks) compared to just three meals a day.76 Years ago, before very precise insulin types were available, a snack at bedtime was recommended for diabetics because the insulin levels peaked in the middle of the sleep period. The bedtime snack helped prevent hypoglycemia, or low blood sugar. Today, with the types of insulin available, this is not only unnecessary, but counterproductive. Our heaviest meal should be in the morning, emphasizing fruits and grains. This prepares us for the most active part of the day. A substantial meal for lunch, including several servings of vegetables, is also important. As the day progresses, our ability to handle blood sugar decreases, so a lighter meal in the evening (ideally, for obese Type II diabetics, no evening meal) with no refined sugar is the best rule to follow. Asking your doctor to tailor your insulin injections so that this program can be followed can produce great benefits.

Is Sugar OK for the Diabetic?
Many doctors who treat diabetes seem to have grown more lenient about sugar consumption. Therefore, it is not uncommon for diabetic patients to walk away with the idea that eating sugar “in moderation” is OK.

This seemed to be the attitude of Lois, a 75 year old Type II diabetic. Although she was taking about 50 units of insulin per day she saw no problem with an occasional ice cream. There was a major wrinkle, however; Lois had what I would call an addictive relationship with ice cream. She could not control her consumption of that high fat, high sugar “treat.” When she adopted a healthful program, she left out her ice cream and made other healthful changes in her lifestyle. Consequently, she lost weight and saw her insulin needs drop by over 60 percent in less than three weeks. Part of Lois’ success was due to the fact that she finally faced the realization that high sugar foods were a real problem for her and her diabetes.

What Other Problems Does Sugar Present?

It is important to recognize that when eaten apart from fiber, simple sugars are associated with dental cavities, obesity, high triglycerides, malnutrition, and decreased resistance to disease. This is true whether the simple sugar is in the form of white sugar, brown sugar, honey, molasses, corn syrup, maple syrup, milk, or fruit juice. Furthermore, there is concern that higher amounts of sugar in the blood can combine with LDL cholesterol to produce a compound that is damaging to the lining of blood vessel walls, thus stimulating atherosclerosis. This “glycated LDL” (LDL combined with sugar) may become oxidized LDL that increases the risk of heart disease.77 See Chapter 3, “Heart Disease—Conquering the Leading Killer,” for information on the problems with oxidized cholesterol.

Refined sugar has effects that also impact our quality of life. A high sugar diet and the consuming of fruit juices and sodas increase the severity of premenstrual syndrome symptoms in college girls.78 Sugar also may decrease cognitive or intellectual function, especially in children.79 Some hypothesize that the reason for this mental deterioration is a result of the body overreacting to refined sugar consumption. A load of sugar stimulates the pancreas to release excessive amounts of insulin, which in turn leads in a few hours to a blood sugar that is lower than normal.80 Therefore, children may get poor grades on their tests although they are well prepared. Eating natural but not refined sugar, such as is found in apples, oranges, pears, etc., should be encouraged because these foods are packed with nutrients, including fiber, along with the unrefined sugar. At the risk of being redundant, let me reiterate: fiber slows the rate of simple sugar absorption, allowing utilization of the energy from the food we eat at a steadier rate.

One classic study examined the effects of eating apples in one of three different physical forms: as whole apples, as applesauce, or as apple juice. Even though the same number of calories was consumed from each preparation, eating the apples kept blood sugars steadier than drinking apple juice or using applesauce alone. The change of blood sugar levels through a period time after eating apples in the three forms is shown in Figure 9: Effects of Food Processing on Blood Glucose Levels.81

Note that the blood sugar levels peaked for all three at the same level 30 minutes after eating. Then all levels decreased as sharply as they rose, but each to a different low point. The level for the apple juice consumer fell the lowest, to 50. The level for the apple sauce eater went down to 61, while the whole apple eater had a high 66 level as his lowest point. The raw apple eater’s level stayed constant at the high level for the remaining two hours, while the level for the other two stayed at lower values. Although this study was done in non-diabetics, the blood sugar peaks are more pronounced (higher) in diabetics consuming the juice or sauce in comparison with the whole apple, thus indicating that the natural whole apple will produce a steadier blood glucose that the body can more easily handle. This study demonstrates that eating food in its natural state is the safest and—ultimately—the most satisfying way to enjoy sugar.

More on Sugar and Diabetes
Another concern with sugar for the diabetic is that sugar itself provides plenty of calories, but very little in the way of trace minerals and other nutrients. There are growing concerns that certain minerals may help with diabetes control. Two examples are zinc and vanadium.82 Other minerals and vitamins suggested to have an important role in diabetes include magnesium, manganese, chromium, potassium, and pyridoxine (vitamin B6).83 The more you fill up on sugar, the less capacity you will generally have for the nutrient-rich foods like fruits, grains, and vegetables.

Sugar and the Immune System
Researchers performed a series of studies that examined how sugar consumption weakens the ability of white blood cells to destroy bacteria. The studies showed that the capacity for white blood cells to destroy bacteria is weakened as sugar consumption rises. Results of the white blood cell study are tabulated in Figure 10: Sugar Weakens White Blood Cells' Ability to Kill Bacteria.84

Note that if a person consumed no sugar for 12 hours, each white blood cell could destroy an average of fourteen bacteria. If that same individual ate the equivalent of six teaspoons of sugar (such as found in a half-cup of pudding or a mere two ounces of candy85), each white blood cell could only eliminate ten bacteria—a 25 percent decrease in killing power. Progressive deterioration in the white cells’ bacteria fighting capacities beyond 25 percent occurred when 12 teaspoons and then 18 teaspoons were ingested. When 24 teaspoons of sugar were consumed (the amount in a medium piece of cheesecake or a milk shake86), the white blood cells were so compromised that they could only destroy an average of one bacterium each. That represents a 92 percent reduction. This effect is similar to what happens in a diabetic who has uncontrolled high blood sugars. This provides one explanation why diabetics frequently get foot infections and other types of infections. Keeping a healthy immune system is simply a personal choice that each one of us is free to make.

The above study provides further insight into why the immune system is weakened when blood sugar levels rise in diabetics. The researchers further demonstrated that sugar’s impairing effects on white blood cells are not short-lived. The impairment lasted a full five hours in normal subjects.87 This means that during that five-hour period the white blood cells could not perform optimally. When you consider how often throughout the day some people consume sugar, it becomes apparent that their white cells are not functioning very effectively for many hours of each day. These researchers also discovered an interesting sidelight: a 36 hour fast seemed to significantly increase the ability of the white blood cells to kill off bacteria. When you are sick and not hungry, it may thus be to your advantage to avoid eating, or at least to eat very sparingly for a day or two.

One other sobering linkage involves sugar and cancer.88 A number of different cancers have been statistically linked to sugar consumption in scientific studies. A listing of these cancers is shown in Figure 11: Eight Cancers Linked to Sugar Consumption.

There are a number of theories why these linkages exist; however, a full explanation for them is not yet clear. However, the data that is available provides an additional reason to think seriously about being aware of your intake of sugar, and making adjustments as indicated.

In light of all this research it is interesting to note the cautions of Ellen White. Over a hundred years ago she wrote: “…sugar, when largely used, is more injurious than meat.”89 Predating White by many centuries, the Holy Scriptures also recorded reservations about simple sugars. Although honey was mentioned, the principle seems to apply with equal force to any simple sugar: “It is not good to eat much honey.” Proverbs 25:27.

Americans are beginning to heed the warnings regarding meat, but somehow we have failed to make it clear that sugar at the levels consumed by the average American may be, in some respects, even more harmful than consuming meat. The emerging data on sugar suggests that we should not take lightly the counsel of modern day scientists that concur with the reservations voiced by the Scriptures and Ellen White about the dangers of excessive sugar intake. Sugar, indeed, seems to be a problem for most Americans, whether diabetic or not.

Is Sugar Consumption Really a Problem for Me?
If you are like most Americans, you are eating large amounts of sugar without even realizing it. The average U.S. citizen eats over 147 pounds of sugar each year.90 This translates into a whopping 46 teaspoons per day. The trends are even more disturbing. Americans today are eating nearly 70 percent more sugar than their grandparents did in 1909.91 Despite all the emphasis on healthier living and healthier eating, since 1970 the average American yearly sugar consumption has continued to increase by 25 pounds.92 One reason for this is that even while we may speak more about health, Americans are consuming more candy and soft drinks per person today than ever before.93

These foods seem to be replacing the healthful cereal grains. While the average U.S. citizen in 1909 ate 300 pounds of flour and cereal products, today we average only 199 pounds annually.94 All told, 38 percent of the total carbohydrates in the American diet now come from refined sugars. This compares to 40 percent of our total carbohydrates coming from grain.95 There is cause for serious concern in view of the problems associated with so much sugar in the diet.

Virtually no one eats 46 teaspoons per day from the sugar bowl. How is it possible, then, to consume this much sugar? Most of the sugar in our diet is “hidden.” Its presence in the foods we eat often goes unnoticed. Some of these hidden sources are listed in Figure 12: Hidden Sugars in Foods (Teaspoons).96

Notice that one of the main sources of hidden sugar is soft drinks or soda pop. Soft drinks were unknown until modern times. However, in 1994 the average American consumed 52.2 gallons of soft drinks, with 40 gallons of it in the form of regular (non- diet) beverages.97 This amounts to the equivalent of 427 twelve ounce cans per year, or more than one per day for every man, woman, and child. Since a typical non-diet soft drink packs 150 calories,98 each year the average American consumes over 64,000 calories of sugar from soft drinks alone. This is no small matter when you recognize that it takes only 3,500 excess calories in our diet to gain one pound.

What nutritional qualities do soft drinks contain? Very little. They are the source of a liberal amount of simple carbohydrates that must be classified as “empty calories.” In fact, they aptly illustrate what an empty calorie food is: it contains many calories but is largely devoid of vitamins and minerals. What, then, makes soda pop so popular? It is tasty and cheap, well advertised, and available almost everywhere. Furthermore, many soft drinks are caffeinated, making them part of an addictive process.

Complex Carbohydrates: A Better Choice than Sugar
The main sources of food energy originate from three categories of nutrients: carbohydrate, fat, and protein. The body can most easily convert carbohydrate into energy for our everyday activities. Sweet, empty calorie foods give the blood sugar a quick boost, but this rise is not sustained. To the contrary, we have learned that the boost may be followed by a sharp drop in blood sugar. We would do well to make carbohydrates the largest percentage of our diet, but not the empty calorie ones. Our energy should come from quality carbohydrates (called “complex” carbohydrates) like natural fruits, grains, and vegetables. We have already looked in detail at many of the benefits of foods with these kinds of carbohydrates—one of the most important being that they tend to be packed with liberal amounts of fiber along with other nutrients.

The conclusion is that for diabetics and non-diabetics alike, complex carbohydrates should make up the major part of a healthful diet. Most Americans consume 10 to 15 percent of their calories from protein, (eight percent would be more healthful), and plant sources of protein are the best. An ideal amount of fat consumption is approximately 25 percent of calories with an emphasis on the unsaturated and omega-3 fats. One recent study from Australia has shown that a diet high in monounsaturated fat (such as is found in olive oil) using 38 percent total fat and 21 percent monounsaturated fat can adequately control blood sugars in diabetics without adversely affecting the cholesterol and triglycerides, as long as the total calorie intake remains controlled.99 Figure 13: Foods High in Monounsaturated Fats lists foods that are high in monounsaturated fat.100

Carbohydrates should make up the bulk of the diet at approximately 55 to 70 percent. They provide the most efficient and readily available source of energy for our bodies. The brain and nervous system tissues use carbohydrates almost exclusively for energy. Carbohydrates will act to detoxify harmful substances that are manufactured by or taken into our bodies. Complex carbohydrates are abundant in vegetables as well as in whole grains such as rice, whole grain pasta, and potatoes.

A diet rich in complex carbohydrates and fiber is also the best way to address the problem of obesity, which, as previously mentioned, is one of the major reasons for the insensitivity to insulin that characterizes diabetes. In fact, the Joslin Diabetes Center’s textbook states: “the most common and important cause of insulin resistance is obesity.”101 That may be why, as important as exercise is in an overweight individual, weight loss seems to be even more important, at least in preventing heart disease, improving HDL cholesterol (the good cholesterol), and in reducing blood pressure and blood sugars.102 There is, however, an old myth in America that says that if you eat starchy foods you will gain weight. The fact is, starchy foods in moderate amounts should be part of a weight loss diet. The extra fats and calories that we add to the starchy foods make them fattening.

For example, it would take 60 potatoes to equal the amount of fat in one tablespoon of butter. One medium sized potato has only 145 calories and a mere trace of fat, 2/10 of a gram. If we add just one tablespoon of butter, that one potato jumps up to 247 calories with 12 grams of fat.103

Eating a liberal supply of complex carbohydrate and fiber-rich fruits, whole grains, and vegetables will go a long way to provide benefits beyond improving blood sugars. As we have seen, these foods have a desirable short-term effect in decreasing insulin needs. But they also have long-term benefits, in that they form the optimal diet for weight loss. When combined with regular exercise and optimal meal timing (people lose more weight if they eat lightly—or not at all—in the evening), such a diet can help the overweight diabetic to shed a significant number of pounds. As the weight comes down, so do the insulin needs.

Artificial Sweeteners
What about artificial sweeteners? Today many believe artificial sweeteners are a good alternative to sugar in everything from soft drinks to cakes and candies because they contain fewer calories. NutraSweet, for example, is the brand name of a synthetic amino acid called aspartame. In small amounts it can mimic the taste of sugar.

Do the low calorie soft drinks really work? Current research says “no.” In fact, those who drink the most diet drinks have the most problems with their weight. And it seems to be more than just a situation where heavier people are choosing lower calorie items. One study of over 75,000 women ages 50 to 69 found that users of artificial sweeteners were significantly more likely than non-users to gain weight over time.104 In another study, 30 volunteers drank four diet sodas daily for two weeks. Surprisingly, these diet soda users ate more food and gained more weight than when they were free to drink regular sugar-sweetened soft drinks. Researcher Michael Tordoff reported that artificial sweeteners increase the appetite. “We found that hunger increases after drinking just a liter of aspartame sweetened soda,” he said.105 Simply put, artificial sweeteners just seem to increase the desire for the real sweeteners. This is a problem of obvious significance. In our country, an average of over 20 pounds of artificial sweeteners are consumed per person per year,106 but despite this increase in consumption of artificial sweeteners, actual sugar consumption continues to rise.

A Better Alternative
Research studies as well as my personal experience as a physician make an eloquent point: if we adopt new and better ways of eating and living—and stick with them—we will likely develop an enjoyment for that new lifestyle. In other words, instead of continuing to eat foods that are characterized by excessive sweetness, regardless of whether the sweet taste comes from sugar or from artificial sweeteners, why not let your taste develop for foods that are naturally sweet? Try to find more enjoyment in a crisp apple, a ripe banana, or perhaps even a home grown carrot or a garden-fresh squash. Our taste buds are trainable.

Although I can think of many examples among my patients of “trainable taste buds,” there is one example from someone who is not my patient that is especially “close to home”—my father. When I was growing up in Michigan, my father, although not a diabetic, was suffering from a number of minor health problems. As a mechanical engineer, he was not acquainted with medical or health subjects. He happened across a book called “Sugar Blues” and became convinced that his overweight condition and health problems were related to his high sugar intake. He had always been an avid milkshake drinker, and an ardent consumer of Reese’s peanut butter cups and chocolate covered cherries, among other sugary foods. One evening he intrigued the family by announcing he had decided to give up refined sugar entirely. My mother, however, continued to cook for our family the way she always did. When it came time for the dessert, my father would leave and go work in the garden. When he came home from work and chocolate-chip cookies were baking he would go outside and do some chore to avoid the aroma and accompanying temptation. We all quietly wondered how long he could continue with his decision.
After about four months, my father came home and another sweet dessert was baking, but the appeal and desire were no longer present. In fact, he described the odor as a “sickening sweet.” He now enjoyed apple pies made without sugar (my mother finally broke down and would make him desserts with no refined sugar) as much as he had enjoyed his former desserts. My uncle, who would frequently visit us from Texas, commented on how it was worth the trip just to see how “Bud” obviously relished and delighted in plain simple foods. My father’s weight came down and his health problems disappeared, but his enjoyment for food and life, if anything, improved. As a young boy, this obvious “before and after” difference that I had observed in my own father launched my interest in lifestyle and health. Although it required disciplined sacrifice for a few months, the results demonstrate that taste buds can be trained for the better.

Putting It All Together: Principles of Diabetic Nutrition
Many of my diabetic patients request that I give them a very specific menu that will help control their diabetes. However, for most diabetics, menus are not as important as knowing (and practicing) the dietary principles of diabetic control. This is especially true for the non-insulin dependent Type II diabetic. The principles are really very basic—we have looked at all of them in this chapter. The more natural fruits, vegetables, and whole grains the better (nuts are also good in moderation). The less meat and dairy products the better. The less refined sugar the better. The more fiber the better. Eat a good breakfast and little if any supper. If you are overweight it is of utmost importance that you reduce your weight to your ideal weight (thus, the less fat in the diet the better) and follow an eating style that allows you to attain and maintain this reasonable weight. Aerobic exercise, at least 30 minutes in duration, should be part of the daily diabetic routine.

I am happy to provide my patients with delicious recipes incorporating the balanced low fat, low sugar, high fiber vegetarian diet that is best for diabetes. I avoid giving them a menu, however. Once they understand the principles, I let them thoughtfully plan their own meals. I would give the same advice to each reader. Do not feel bound to some restrictive way of eating. Take the principles to heart. Experiment with different options. You will be surprised at how enjoyable a healthy lifestyle can really be.

The Surprising Truth - Even for Non-Diabetics
Some people find it hard to believe this simple truth: the diabetic lifestyle I have been describing is also the best lifestyle for non-diabetics. Whether you are concerned about preventing diabetes or merely trying to optimize your health, this program will also pay you rich dividends. And you will not have to sacrifice pleasure either.

Almost every day at the Lifestyle Center of America in Oklahoma you will find diabetics enrolled in our live-in programs for the purpose of reversing their disease process. You will also find some others—individuals from the surrounding communities who come to enjoy a meal in our dining room. They are often eating the very same fare that the diabetic across the room is enjoying.

Often our fear of change is largely driven by ignorance. Pick up a good cookbook or find a friend who can make some tasty meatless entrees, and embark today on a more vegetarian-type of eating program. A list of cookbooks that specialize in healthful menus can be found in Appendix II. You will find what our neighbors around the Lifestyle Center of America have found: food can taste good, your life can have enjoyment, and you can still be on the finest diet and lifestyle to reverse, control, or prevent diabetes, in addition to reducing your risk of many other diseases.


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