The Divisive Discourse on Carbs
Updated: Aug 7, 2024
A recent article in the Guardian posited the following question: If people with diabetes were told clearly and unambiguously that if they stopped eating carbohydrate-rich foods…could thousands of lives and billions of dollars be saved?
The tone of the article implied a hard yes. However, due to the rampant misunderstanding about low-carb diets, the more probable answer is no. In part because the low-carb diet is repeatedly misrepresented in the media. Research results are often reported out of context, without background, and most disappointingly, without guidance for the reader. Non-nutrition health professionals are not off the hook either, as many often oversimplify the information as well. Many tell their patients to “watch the carbs” without a referral to a registered dietitian who can explain how to safely and effectively do so.
The Consequences of Oversimplification
Without proper guidance, the public is left to interpret that information on their own. Without a discussion about balanced nutrition and the impact of food on overall health—not just blood glucose—many believe that taking the bun off their burger, or eating a crustless pizza laden with cheese and high-fat toppings, or unlimited meat are healthy choices. Without a comprehensive explanation, people mistake a flat blood glucose graph as synonymous with overall health.
As a registered dietitian nutritionist, I am inundated daily with the latest research on nutrition. As a practitioner in a busy diabetes clinic, I also have the privilege of hearing directly from people about what they hear, know, feel, and apply about food—along with their related lab results and diagnoses. Patient perspectives range from a lack of information to extreme application of misinformation. People either do not know what to eat, or they follow nutrition trends all the way to the hospital. I recently had a patient with diabetes hospitalized for acute kidney injury because she was pounding the protein so hard without proper guidance about what was right for her in the context of her health profile.
Unfortunately, discussions about the low-carb diet are often only ambiguous. For people without training in medical nutrition therapy, from health professionals to well-meaning friends and family, the language of nutrition is a second language at best, with much lost in translation. Generalized statements like “watch your carbs” or “cut carbs” are conveyed to people who, in turn, interpret that to mean “carbs are bad.” Consequently, many healthy foods are avoided, and other foods are exalted and absolved of responsibility, resulting in yet another imbalanced perspective of nutrition. One needs only to recall the low-fat days of the eighties to understand that not one nutrient can be held responsible for the ills of the world. Nor can one nutrient be the savior. Today, the pendulum has swung. Carbs have been vilified and the Ketogenic diet, which is also characterized as a high-fat diet, wears the cape.
The Missing Piece
The piece often missing in the discussion about carbs is what, exactly, defines a low-carb diet. Part of the confusion is that people consider “low carb” and the Ketogenic diet as synonymous. While the Ketogenic diet is a very low carb diet, not all low carb diets are Ketogenic. Mainstream articles often fail to mention that many of the research studies defined “low carb” as under 130 grams per day. This is much higher than the 50-gram limit of Ketogenic approaches. Without this distinction, people often feel that the Ketogenic diet is their only low-carb option to improve their diabetes, when in fact they have much more flexibility with carbs than they realize.
The Plate Method is a Low Carb Option
The Plate Method suggests that a balanced meal will include a half-plate of non-starchy vegetables, a quarter-plate protein, and a quarter-plate carbohydrate. Compared to a typical American eating pattern, a quarter plate of carbohydrates looks, feels, and by definition is a low-carb meal. At about 30-40 grams per plate, applying this strategy to breakfast, lunch, and dinner would total about 90-120 grams, which aligns with many of the low carb studies.
In comparison, consider the average American meal: A plate full of spaghetti, perhaps with a breadstick or two can total over 100 grams of carbs; burritos from fast casual restaurants, made with large tortillas stuffed with rice and beans, are easily 120 grams; a typical burger entrée served with large french fries can clear 100 grams easily. Add a sugary soda to these meals and it becomes clear that carbs are not specifically the issue, but it’s how we eat them that is suspect.
Then there’s the issue of sustainability. Many people find that maintaining the Ketogenic diet for the long-term is challenging, even though they see results. Unfortunately, instead of transitioning to a well-balanced, low carb diet, many end up returning to old habits, going from one extreme to another.
In comparison, the Plate Method is a low carb approach that allows more variety, which people may find more sustainable in the long run. Therefore, when discussing nutrition for diabetes, describing the Plate Method will provide people with more guidance about what a healthy, balanced, low carb diet actually looks like. And with an emphasis on lean proteins, fiber, and plant foods, the Plate Method benefits not only blood glucose levels, but also blood pressure, cholesterol levels, the GI tract, the gut microbiome, and ultimately overall health.
Emphasize the Good Carbs
To clarify, watch carbs, yes. Cut down on carbs, yes. Choose healthy carbohydrates that are minimally processed, high in fiber and low in added sugars, unequivocally and unambiguously yes. But avoid carbs? Why? Legumes like beans and lentils, which are about 15 grams of carbs per half cup, are high in fiber and good sources of protein and minerals like calcium, iron, and phosphorus. Fruit, which is about 15 grams per serving, also provides protective vitamins, minerals, antioxidants, phytochemicals and fiber. The same can be said for starchy vegetables like sweet potato and squash. And whole grains—let’s face it, a turkey sandwich on whole wheat bread is not the culprit of chronic disease.
Don’t Take the Easy Way Out
When discussing nutrition, overall balance should be emphasized. It’s easy to tell people to avoid carbs, and people may do so--for a hot minute. That alone, however, will not protect people’s health. Plant foods, portion control, and mindfulness must all be part of the discussion for any meaningful impact on health. However, in answer to the question posed at the beginning of this article, knowledge is not enough to affect behavior change. Unlike research studies where participants are provided with meals or monitored for compliance, most people are on their own, balancing meal planning with the other priorities in their lives. People may have intrinsic motivation to eat healthy and exercise but may be equally motivated to put their family and/or their work first. The stress of managing these priorities often impacts what and how we eat. And when foods are vilified and restricted, or if the act of meal planning is confusing and guilt-ridden, the effort of healthy eating may feel too burdensome to bear.
For non-nutrition professionals, be cautious about oversimplifying nutrition information or omitting the importance of balanced nutrition. Understand that what you say and what your patients or readers hear will be two different things if not discussed with care. Refer to registered dietitians who are trained in medical nutrition therapy and behavior change counseling.
For those reading nutrition articles, if you are feeling confused or frustrated by conflicting nutrition information, you are not alone. Again, media articles about nutrition is often biased or misrepresented. Be leery of authors who have no credentials or training in medical nutrition therapy. Registered dietitian nutritionists are recognized by the credentials “RDN.” Some RDNs are also diabetes specialists who can be recognized by the credentials “CDCES” for certified diabetes care and education specialist, or “BC-ADM” for board-certified in advanced diabetes management. But most importantly, meet directly with a dietitian or specialist in person. Only with your medical chart in hand can any health professional truly help you.
And consider this question:
If people with or at risk for diabetes were referred to registered dietitian nutritionists, and those services were covered by health insurance, could thousands of lives and billions of health care dollars be saved?
I posit yes. Clearly and unambiguously.
J. Barretto Patterson, MPH, RDN, BC-ADM, CPT is author of Think Like a Dietitian: A Nutrition Counseling Starter Kit.
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