The Atkins of diabetes

August 1, 2006

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LORNE RUBENSTEIN

From Saturday's Globe and Mail

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When I was diagnosed with Type 2 diabetes four years ago, I immediately adopted

a new diet, carefully following Canadian Diabetes Association guidelines.

But despite sticking to the regimen, my blood sugar was still off the charts. I

feared blindness, a stroke. Or perhaps the loss of a leg.

Then I heard about Bernstein. The endocrinologist is often described as

a " maverick " for his diabetes treatments.

Flying in the face of guidelines set by the American Diabetes Association (and,

by extension, the Canadian Diabetes Association), the 72-year-old advocates

a radical decrease in blood-sugar levels through major carb-cutting. So major in

fact, that one could say Dr. Bernstein " out-Atkins " Atkins, recommending

a sustained ultralow-carb diet, rather than easing diabetics off and back onto

their bread baskets.

Though Dr. Bernstein is a Type 1 diabetic himself, his approach is of particular

interest to Type 2 diabetics. A Type 1 diabetic doesn't produce any insulin,

so has to take the hormone, usually by injection. A Type 2 diabetic, on the

other hand, either doesn't produce enough insulin to control blood sugar, or

doesn't use it efficiently - which means diet is crucial to controlling blood

sugar.

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The Globe and Mail

Type 2 diabetes accounts for 90 per cent of diabetes diagnoses, or about 1.8

million Canadians. That number is expected to rise to 2.7 million by 2010,

along with costs to the health-care system as diabetics who don't control their

blood sugar are forced to deal with complications.

In both Dr. Bernstein's Diabetes Solution and The Diabetes Diet (which he

recommends for non-diabetics as well), Dr. Bernstein argues that the ADA and CDA

have set blood-sugar controls too high and their diets allow for too many carbs.

The critical measure for blood sugar is hemoglobin A1C. The ADA and CDA

encourage A1C levels under 7. Dr. Bernstein believes diabetics should strive for

A1C levels that match sugar levels of those without the disease - which range

from 4 to 6. " I think diabetics should have the same chance to have normal

blood sugars as non-diabetics, " he says.

, a family medicine and endocrinology professor at the University

of Western Ontario, was the chair of the group that set the CDA's A1C guidelines

in 2003. He agrees that, ideally, a diabetic should strive for an A1C of under

6, and that proper eating is important for blood-sugar control.

But Dr. adds that people develop strong cravings while on diets, and that

it takes incredible willpower to overcome them in the long run. Ultimately,

he thinks Dr. Bernstein's approach is impractical for most people. He is also

not convinced by Dr. Bernstein's informal proofs (his patients are his study

group), calling his findings " expert opinion, " rather than " conclusive

evidence. "

Dr. Bernstein's A1C goals certainly seemed unrealistic to me when I was first

diagnosed at the age of 54. Even when I followed CDA eating recommendations

rigorously, my blood sugar often soared to 12.9, far beyond acceptable levels.

After eating carbs, in particular, my blood sugar seemed to spike.

Still, Dr. Bernstein's experience intrigued me. After all, he had become an

endocrinologist later in life as an answer to his own life-threatening

experience

with diabetes.

Dr. Bernstein's life expectancy was about 30 years when he was diagnosed with

Type 1 diabetes in 1946 at the age of 12. He carefully followed the ADA's

diet, but by his late 20s, he had both kidney stones and peripheral nerve damage

in his feet.

He realized then, as he writes in The Diabetes Diet, that " my death would not

have come from diabetes per se. I am pretty certain that I would have died

of kidney failure, a direct result of the low-fat, high-carbohydrate, ADA diet I

followed for 24 years after my diagnosis. "

Then Dr. Bernstein came across an ad in a scientific journal for a glucometer,

or blood-sugar monitor. It was used in hospital emergency rooms to distinguish

unconscious drunks from unconscious diabetics. The device cost $650, and only

doctors could purchase one.

Luckily, Dr. Bernstein's wife is a doctor (he was an engineer at the time). He

used her stationery to order a glucometer, and became the first diabetic

to monitor his own blood sugar. He checked his sugars five to eight times daily

for a year, to gauge the effect of different foods. Carbohydrates raised

his blood sugars. By restricting them dramatically, he achieved normal readings.

In 1976, Dr. Bernstein submitted his findings to the Journal of the American

Medical Association and the New England Journal of Medicine. The journals

refused

to publish his findings. " How many patients would use the electric device for

measurement of glucose, insulin, urine, etc.? " the JAMA editor wrote in a

letter. " You are a spartan and a paragon, but, I fear, not common clay. "

But Dr. Bernstein persisted. He enrolled in medical school at the age of 45,

specializing in endocrinology, and now treats diabetics from around the world.

I was a quick convert to his approach. After incorporating his suggestions -

eating much more protein and fat (more eggs in a week, for instance, than I'd

had in the previous six months) - my blood sugars came right down, and my lipid

profile improved.

I was concerned that a diet without fruit, which raised my blood sugar, wasn't

healthy. But my Toronto endocrinologist, Goldenberg, tells me that

no long-term studies show any problems associated with a diet lacking fruit.

At the same time, I was on, and remain on, medication for diabetes, blood

pressure and cholesterol, but I continue to notice that my blood sugar rises to

a worrisome level any time I cheat on my diet. Carbs make the difference. Low

carbs. Very low carbs.

But one question remained: An important long-term study showed that

complications are most likely to kick in only when one's A1C is above 7 - so why

go

lower, why not have that cheesecake or bagel?

And so last month I travelled to Dr. Bernstein's office in Mamaroneck, N.Y.,

where he has been practising for nearly 25 years.

His method is painstaking. His first consultation with a patient takes 13 hours,

over a couple of days. He asks every patient to complete a 100-item

questionnaire.

" Every 'yes' answer leads to a discussion, " he says.

In answer to my question about what can happen without tight control of blood

sugars, Dr. Bernstein was very clear: " Every tissue in the body is being damaged

by high blood sugars. "

As for his spartan diet, his meal plan allows for only six grams of

carbohydrates at breakfast, 12 at lunch and 12 at dinner. Four years ago, my

nutritional

counsellor recommended that, at 6 feet, 3 inches and a fit 202 pounds, I eat at

least 200 grams per day. One piece of whole-wheat bread alone includes

15 grams of carbohydrates.

Whenever I think of having a sandwich, I recall a demonstration Dr. Bernstein

did last February on a CNBC show about diabetes. In response to Hope Kershaw,

the author of The Complete Guide to Carb Counting, who was insisting that

whole-grain bread was fine for diabetics, Dr. Bernstein chewed on a slice just

long enough to mix it with his saliva. He then used a test strip to show that

the carbohydrates in the bread had turned to instant glucose.

" My blood sugar would go sky high if I ate this whole piece of bread, " he said.

Ms. Warshaw responded, " I feel that people need a realistic way of eating. "

Dr. Goldenberg, my own endocrinologist, agrees. " What raises blood sugar is

carbohydrate, " he says. But he adds, " The problem is that many people won't

live with the [very low] amount of carbohydrate Bernstein suggests. "

It's true that Dr. Bernstein's patients need to be unusually diligent. But after

following his diet, I can't revert to meals loaded with carbs. Besides,

his recipes are delicious. I have never felt deprived eating his Caesar salad

with Gruyere croutons (5.7 grams of carbs) or his sweet ricotta torte (4.7

grams of carbs).

And after spending four hours with Dr. Bernstein, I was even more motivated. I

had been watching my carbohydrate intake before our meeting, but wasn't eating

strictly according to his approach. My post-meal blood sugars ranged from 5.3 to

10.7. Now, after following the diet strictly for a couple of months, my

sugars have been in a tight range, from 4.2 to 6.7. I feel great.

" You're not overeating, and you're exercising, and if you're really following

the regimen, you probably have better blood sugars than a non-diabetic your

age, because they're eating all the sweet stuff that sends them up after every

meal, " Dr. Bernstein told me. " So, in a sense, we can do better than

non-diabetics. "

Lorne stein is The Globe and Mail's golf columnist.

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