Triglycerides are the key to heart disease and stroke not cholesterol. 

Carbs will kill you.

Diabetic Diet Paradox Untangled
Low-Fat, High-Carb Diet Worsens Lipid Profile of NIDDM Patients

By Dan Hurley

From Medical Tribune for the Internist and Cardiologist

When the results of a multicenter trial published last year showed that a low-fat, high-carbohydrate diet actually worsened
the lipid profile of patients with non-insulin-dependent diabetes mellitus (NIDDM) , many physicians wondered how that seemingly paradoxical finding could be true. Now researchers at one of the centers involved in that trial think they have the
answer.

In a Rube Goldberg-like series of reactions, the high-carbohydrate diet in NIDDM patients leads to increased postprandial plasma insulin levels, which cause an increase in
hepatic production of very-low-density lipoprotein (VLDL) cholesterol, which in turn results in increased plasma triglycerides (TG), researchers at Stanford University School of Medicine concluded in Diabetes Care (1995; 18; 1:10-16). 

This mechanism was proposed to explain the study's results involving nine NIDDM patients randomly assigned to one of two diets for six weeks followed by crossover to the other diet.  One diet drew 55% of calories from carbohydrate and 30% from fat, including 10% from monounsaturated fat. The other drew only 40% of calories from carbohydrates and 45% from fat, with
all the extra fat being monounsaturated.

Mean hourly concentration of glucose, insulin and TG were all significantly higher after the 55% carbohydrates diet, as was intestinal productions of VLDL-TG.

The researchers concluded that the higher-carbohydrate diet  officially recommended by the American Diabetes Association
until last year - could lead to an increased risk of cardiovascular disease, while the diet higher in monounsaturated fat could lower cardiovascular risk.

"A lot of dialectologists say to me, 'of course you're right,' " said the senior author of the study, Gerald M. Reaven, M.D., professor of medicine at Stanford University Medical
Center in Palo Alto, Calif. "The more a physician is close to the field, the easier it is to understand. The farther they are, the more they're into low-fat is good, everything else is
bad."

The president of the American Diabetes Association said that while further research is necessary, a diet drawing 25% of calories from monounsaturated fat is within the ADA's new dietary guidelines and might be appropriate for NIDDM patients willing to try it under the guidance of a physician and a
dietician.

"Some of my patients have attempted to follow this diet,"
said Kathleen Wishner, M.D., associate clinical professor of medicine at the University of Southern California in Los
Angeles. "These are individuals who like a Mediterranean diet, who enjoy salads with olive oil and avocados."

But an attending physician at the Joslin Diabetes in Boston said that the views represented in the study were "controversial" and not widely accepted.

"The message that you can eat more fat is an unpopular view," said Gordon Weir, M.D., who is also a professor of medicine at Harvard University. "One of the great dangers is that people will say olive oil is great and just add it to whatever else they're eating. That's the wrong message for diabetics to take." 

Dr. Wishner agreed that "you have to be very careful when you tell a patient to increase fat in the diet. The problem is, many patients don't decrease their carbohydrate intake." 

But a co-author of the study, Ann M. Coulston, M.S., R.N., senior research dietician at Stanford, said , "We're not telling anybody to increase their dietary fat. What we're saying to diabetics is that decreasing fat intake markedly may not correct the risk factors for heart disease that they have."

Both Coulston and Dr. Reaven were quick to point out that for overweight diabetics, changing the types of food they eat is less important than reducing the total calories.

"There's no question that changes in weight are much more important than variations in caloric composition," Dr. Reaven said.

He also emphasized that all researchers recommend against getting more than 10% of calories from saturated fat. The real question, he said, is "If you want to reduce
saturated fat, what do you replace it with carbohydrates. But if you do that, you're likely to have an increase in triglycerides."

The other option, he said, is to replace the saturated fats with monounsaturated fats, which would improve virtually all measures of fats in the blood, he said. "Everybody's intrigued by the research on monounsaturated fats," Dr. Weir said. "But Dr. Reaven's hypothesis has not been
fully accepted. It's not clear what the long-term effects of his dietary recommendations will be.'

Dr. Reaven has been investigating the benefits of a diet high in monounsaturated fats for nearly 15 years. Last May, his
center was one of four around the country involved in a study published in JAMA (1994; 271: 1421-1428) showing that after 14
weeks, NIDDM patients on a diet high in monounsaturated fats had 24% lower triglycerides and 23% lower triglycerides and 23% lower VLDL than patients on a high-carbohydrate diet.