Research & Education

Dietary Advice for Type 2 Diabetes: Conflicting and Confusing

It’s not easy being a healthcare professional in the 21st Century. We’re the beneficiaries of technological advancements our predecessors could only dream of. But along with increasingly available contraptions for people to measure glucose ketones heart rate and more at home any time they want comes an endless amount of data and information that leaves people more confused than ever.

In a past post we looked at conflicting advice from respected nutrition and health organizations regarding sodium intake. It’s no wonder so many patients suffer from “paralysis by analysis” – inundation with information to the point that they don’t know what to believe. Low fat? Low carb? Vegetarian? Paleo? For every scientific study supporting one of these dietary approaches there’s an equal and opposite study suggesting it’s a one-way ticket to an early grave. One area in particular that suffers from advice schizophrenia is dietary recommendations for type 2 diabetics.

On one hand we have researchers and physicians saying that carbohydrate restriction should be the first approach and the default treatment for type 2 diabetes (T2D) and metabolic syndrome. But on the other hand we have writers and dietitians recommending bread cereal and oatmeal for those with T2D. It’s no wonder people tune out and just give up.

It’s hard to believe that carbohydrate-dense foods would be recommended for individuals living with a condition whose primary pathological features include chronic hyperglycemia and hyperinsulinemia. This is not to equate steel-cut oats and sweet potatoes with gummy bears but the fact is they’re all almost entirely carbohydrate. Yes the oats and potatoes provide fiber a small amount of protein and vitamins & minerals but they’re still very dense in carbohydrate. And while no one would claim that sweet potatoes and oats are primary contributors to the development of T2D once someone is already afflicted and they have an exaggerated response to dietary carbohydrate they are probably best advised to avoid or at least decrease their intake of even these otherwise wholesome foods. (Maybe not permanently but at least for some period of time until their insulin sensitivity is improved.) 

In the interest of seeing the kind of conflicting advice patients routinely encounter in the mass media let’s take a look at some questionable recommendations for breakfasts for people with T2D.   

The article starts out well enough with the author writing “Diabetes management requires attention to sugar and carbohydrates.” But it quickly takes an odd turn with the first suggestion being smoothies. And while lip service is given to using leafy green vegetables in these drinks along with good fats from avocado or chia seeds we’re then told to “Layer on sweetness by adding frozen berries bananas apples or peaches.” The recipe provided calls for two cups of raspberries blueberries or strawberries with an avocado and a scant half-cup of kale. (No information is provided about the number of servings this is supposed to be—one? Two?) This smoothie is presented as a better alternative to fruit juices which according to the author “contain rapidly absorbed sugar.” It’s not clear how much less rapidly a type 2 diabetic would absorb the sugars from fruits that have been blended into a consistency that doesn’t even require chewing. Fortunately individuals with diabetes can use a home glucometer to determine whether a fruit smoothie is any easier on their blood sugar than the standard orange or apple juice.

Moving on the next recommendation is for oatmeal. As mentioned earlier oats come with fiber and a little bit of protein. Readers are told to “Sprinkle on cinnamon for flavor but avoid loading oatmeal with honey or brown sugar. Instead sweeten the oatmeal with raspberries blueberries or cherries. Fresh fruit is best.” Translation: add some carbohydrate to your carbohydrate. (Why not just stop at the cinnamon? As Robert Lustig MD of fructose fame said “Breakfast is not the time for your sugar fix.”)

We’re also told that because cooked oatmeal provides around 5.5 grams of protein per cup this is “a nutrient-dense breakfast option.” Perhaps those with diabetes should be told that they can get more protein from just one egg with far less carbohydrate along for the ride. If someone’s looking for a protein-rich food—particularly if they need to watch their blood sugar—oats aren’t what spring to mind first. Again a handy-dandy glucometer is a diabetic’s best friend for assessing which foods impact them most.

Oddly enough the very next foods recommended are eggs! No argument there; let’s give credit where credit is due. (Although we might make an exception for the recommendation to use cayenne or diced jalapeños in lieu of salt to provide seasoning. Chronically elevated insulin rather than sodium intake is a powerful driver of hypertension with sugar having far greater detrimental effects than salt.)

The next suggestion is a real whammy: cereal. To the author’s credit she emphasizes avoiding high-sugar cereals and looking for varieties that are high in fiber. But cereals that are low in sugar still consist primarily of wheat rice oats or corn—almost entirely carbohydrate. Some cereals touted as “high protein” contain soy protein which may be problematic for some people. Plus even those high protein cereals are still mostly carbohydrate. (For example one popular cereal brand has an offering marketed for its protein content but one serving—a little over a cup of cereal—contains 41 grams of carbohydrate compared to a measly 7 grams of protein.) 

We’re back on track with the next recommendation which is for unsweetened yogurt. Greek yogurt is mentioned as a better source of protein than regular varieties. Whew! All hope is not lost! And the final suggestion is pretty good too: “Fruit can be a good option for breakfast but large quantities of fruit can cause blood sugar spikes.” (Apparently the author doesn’t see a conflict between this and the fruit-heavy smoothie recipe provided in the very same article. When experts present this kind of disjointed advice it’s really no wonder people are so confused.) Avocados are recommended as a low-sugar fruit which we’re on board with.

The article finishes up with the usual misguided parroting of conventional advice regarding dietary cholesterol and salt and suggests soy and other vegetable-based substitutes for meat products. There’s a little light in the darkness though when it’s acknowledged that while there are high-fiber sprouted-grain breads available now some people with T2D do best avoiding all bread. It would’ve been even better if it were acknowledged that it’s entirely possible to eat a nutritious and satisfying breakfast without any significant carbohydrate. But a meal of eggs ham and sausage would lead to a great deal of cognitive dissonance and would force healthcare professionals deeply invested in advice from a bygone era to consider the possibility that animal proteins cholesterol and saturated fat aren’t deadly. 

But perhaps this consideration is long overdue. Conventional dietary advice has failed people with type 2 diabetes insulin resistance and obesity for too long.

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For more information related to this topic please listen to the following Nutrient Roundtable discussion: