Cover Story


August 8 - 14, 2018

Gulf Weekly Mai Al Khatib-Camille
By Mai Al Khatib-Camille


A pioneering study into the cause of type 2 diabetes (DM2), which is known by many as the scourge of Bahrain and the Gulf region as a whole, has uncovered that carbohydrates is one of the main culprits.

A Bahrain-based researcher and a group of professors and public health professionals from around the globe believe that their revelation could change the way people fill their shopping bags and dine out.

The findings modestly favour carb restriction over fat restriction as a first nutritional treatment of DM2.

Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas stops producing enough insulin. Exactly why this happens is unknown, although genetics and environmental factors, such as excess weight and inactivity, seem to be contributing factors. It’s more common in adults but is increasingly affecting children due to obesity.

“It is well accepted that DM2 results from interactions between our genes and the way we live and behave,” explained Esther van Zuuren, a dermatologist at the Leiden University Medical Centre in the Netherlands who was a member of the team involved in conducting the systematic review.

“Indeed, wrong nutrition is at the heart of this disease. Since weight loss is of major importance for better metabolic control, low fat diets have been advocated in guidelines for years, based on the premise that fat has more calories per gram than protein or carbohydrate, and therefore low fat diets were supposed to be most effective for losing weight.

“However, recent reports argued that processed carbohydrates in food are the only direct source of glucose in blood and restriction of food containing processed starch and sugar therefore is superior to fat restriction.”

Esther was joined by her husband Hanno Pijl, an endocrinologist and professor in diabetes at the Leiden University Medical Centre, Ton Kuijpers, an epidemiologist who works for the Department of Guideline Development and Research of the Dutch College of General Practitioners in Utrecht and former Cochrane Bahrain director Professor Zbys Fedorowicz, who recently retired back to the UK after 31 years in the kingdom.

The team evaluated the currently available evidence comparing the impact of diets containing less than 40 per cent energy carbohydrates versus those containing less than 30 per cent energy fat on glucose and other metabolic variables in people with type 2 diabetes.

Zbys and Esther have worked together on more than 20 research projects and published many articles. When Zbys and his wife Ruri invited Hanno and Esther over to Bahrain, they gave presentations on diabetes at the Bahrain Specialist Hospital as well as in the King Hamad University Hospital.

The trio decided to carry out a systematic review on diets, diabetes and clinical trials evaluating the effects of nutritional approaches to the management of DM2.

For years the default diet in guidelines for diabetes was the so called ‘low fat diet’ but it now appears that a ‘low carbohydrate diet’ might be a better option for those dealing with the disease.

The low-fat guidelines introduced in 1977 were not based on solid evidence.

It included advice to avoid butter, limit dressings, gravies and sauces and choose low-fat and non-fat products, such as low-fat mayonnaise.

However, nutritionists have found that we all need some fat in our diet, not least because it makes our food more palatable and tasty. Fats do more than simply supply calories, some are important for maintaining healthy blood vessels, making hormones and for the correct functioning of our nervous system. The fat in our diet also helps us absorb certain vitamins, the fat-soluble ones, which include A, D, E and K. Following a very low-fat diet makes you more likely to be low in these vitamins and that can impact your immunity, limit the body’s ability to heal itself and have an influence on bone health.

While recent studies have weakened their scientific foundation even further, the debate continues.

Look at spinach or an avocado; they are full of nutrients yet extremely low in digestible carbohydrates (which turn to sugar in the body). By the same token, bread or rice have a few nutrients, but not so many. Added to that, they also contain a significant amount of digestible carbohydrate which raises blood sugars incredibly.

One thing is clear. Eating less fat is not always the best way to lose weight. Low-carb diets tend to be more effective for most people.

Eating carbohydrates has the biggest impact on our blood sugar and insulin levels. Restricting carbohydrates in diets has a direct result in lowering sugar levels and insulin needs.

High sugar levels play a part in almost all chronic diseases such as type 2 diabetes, dementia, cancer and cardiovascular disease.

By lowering carbohydrate intake, blood sugars are controlled and insulin levels are minimised. This is incredibly beneficial for those with diabetes and those with insulin resistance.

Up until now, no one had ever summarised all existing evidence to compare the two diets. The trio asked Ton to join the team and he provided help regarding the quality or certainty of the evidence of the conclusions that were made. 

The whole project took a year to complete and a further six months to get it published after being submitted to the eminent American Journal of Clinical Nutrition.

“We found that 36 trials met our inclusion criteria. It appeared based on the data of these studies that taking less carbohydrates was better for blood glucose and blood lipids than a diet low in fat in people.” Esther added.

“It seems logical that restriction of carbohydrates reduces blood glucose levels, since carbohydrates are the most important source of blood glucose. There is data suggesting that starch and particularly sugar are addictive, but we believe that this position needs further research for definitive confirmation.”

Clinical experts suggest many suffering with DM2 can recover from the condition by taking appropriate lifestyle measures. However, it is important to note that not everyone can do it without medication. It depends, among other factors, such as the duration of diabetes and even those needing medication can reduce the amount by making changes to the diets, losing weight and increasing exercise.

“As we said before, there are data suggesting that sugar and probably starch, albeit to a lesser extent, may be addictive,” Esther added. “It appears to activate neural circuits involved in reward.

“However, we think that this hypothesis needs further study. It seems likely from an evolutionary point of view that biological instincts drive our liking of sugar. It’s an easily digestible source of glucose, an important fuel for our body, but scarcely available in natural foodstuffs – only honey and ripe fruit contain sugar.

 “Do we blame the food industry for this? No, we don’t, although it plays an important role.

“The low fat dogma has dominated nutrition science for a very long time. Low fat products were made palatable by adding sugar. It was not considered a problem until a couple of years ago.

“We believe that evolving science now tells us that too much sugar and starch are at least as bad as too much fat. Industry has to act upon this knowledge now.”

Unfortunately, DM2 has reached record levels in the region and Esther believes it is because of some wrong lifestyle components in the Middle East, such as consuming foodstuff with too much sugar.

As of February 2018, a report was released that up to a quarter of the Arabian Gulf population risks developing diabetes by 2030.

Supreme Council for Health chairman Shaikh Mohammed bin Abdullah Al Khalifa stated during the annual United Against Diabetes annual scientific forum that 14.7 per cent of adults in Bahrain already suffer from the condition and highlighted Bahrain’s national plan to combat the chronic diseases including diabetes, which in turn are intended to reduce healthcare spending.

He also added Bahrain was seeking to provide advanced care to patients living with the disease, while running preventive programmes and community awareness campaigns endorsing healthy lifestyles, physical activity and healthy eating habits.

Apparently, 425 million people have diabetes in the world and more than 39 million people are in the MENA region. The fear is that by 2045 this will rise to 67 million. There were 165,300 cases of diabetes in Bahrain as of 2017.

The research team hopes that their latest study will inspire people to make changes. “We would like to see task forces in many areas of the world developing and implementing lifestyle medicine in health care systems to shift from care to cure of lifestyle-related disease,” added Esther.

“We also hope that it may inspire people to conduct more definitive studies comparing (very) low carbohydrate with low fat diets in the treatment of DM2.”


Diabetes Symptoms:


Signs and symptoms of type 2 diabetes often develop slowly. In fact, you can have type 2 diabetes for years and not know it. It is the most prevalent type with about 90 per cent of cases diagnosed as type 2.

Look for:

Increased thirst and frequent urination. Excess sugar building up in your bloodstream causes fluid to be pulled from the tissues. This may leave you thirsty. As a result, you may drink — and urinate — more than usual.

Increased hunger. Without enough insulin to move sugar into your cells, your muscles and organs become depleted of energy. This triggers intense hunger.

Weight loss. Despite eating more than usual to relieve hunger, you may lose weight. Without the ability to metabolise glucose, the body uses alternative fuels stored in muscle and fat. Calories are lost as excess glucose is released in the urine.

Fatigue. If your cells are deprived of sugar, you may become tired and irritable.

Blurred vision. If your blood sugar is too high, fluid may be pulled from the lenses of your eyes. This may affect your ability to focus.

Slow-healing sores or frequent infections. Type 2 diabetes affects your ability to heal and resist infections.

Areas of darkened skin. Some people with type 2 diabetes have patches of dark, velvety skin in the folds and creases of their bodies — usually in the armpits and neck. This condition, called acanthosis nigricans, may be a sign of insulin resistance.



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