Book Synopsis: Dr. Bernstein's Diabetes Solution

This 500 page volume is subtitled The Complete Guide to Achieving Normal Blood Sugars. The gist of the book is this: The damaging effects of diabetes are due to high (and fluctuating) levels of sugar in the blood. By keeping blood levels normal and steady, the complications of diabetes can be prevented and reversed.

The author, Richard Bernstein, provides a highly detailed and comprehensive picture of all the ways in which blood sugars can be kept at normal levels in both Type 1 and Type 2 diabetics, including the use of diet, exercise and medications. As well as being a physician whose practice is solely devoted to diabetes treatment, Dr. Bernstein has Type I diabetes himself.

Here is my chapter by chapter synopsis of Dr. Bernstein's Diabetes Solution. Chapter titles are in bold. Quotes from the book are in italics.

My Life with Diabetes
This is a pretty incredible story of how a patient refused to let his disease dictate his fate and took matters into his own hands. Bernstein was diagnosed with diabetes at the age of 12 in 1946. He writes an eye-opening essay about what it was like to be a diabetic in those days, using a test tube and alcohol lamp to test his urine, injecting himself with large doses of insulin slowly and painfully using a large syringe. For him, diabetic complications started in his twenties and thirties. At the time, he was an engineer working for a biomedical company. Reading a trade journal, Bernstein came across an ad for a blood sugar meter. It was only sold to doctors and hospitals, not to patients, so he got his physician wife to order it for him in her name. He started testing his blood sugar and saw that it fluctuated wildly. This led him to read the scientific literature on diabetes and he saw that diabetic complications can be reversed in animal models by normalizing blood sugars. He started experimenting on himself, measuring his blood sugar and making small changes in his diet and insulin, retaining whatever changes improved his blood sugar. "I had the new sensation of being the boss of my own metabolic state, and began to feel the same sense of accomplishment and reward I had in engineering when I solved a difficult problem. I had taught myself how to make my blood sugars whatever I wanted them to be and was no longer on the roller coaster. Things were finally under my control".

Bernstein's findings went against conventional wisdom. In his mid-40s, he quit his engineering career, entered medical school and became a physician.

Before and After: Fourteen patients share their experiences
"You're the only person who can be responsible for normalizing your blood sugars. Although your physician may guide you, the ultimate responsibility is in your hands. This task will require significant changes in lifestyle that may involve some sacrifice. "

This chapter has patient stories and I found them very interesting and inspiring. They provide different perspectives on coping with life with diabetes. People write with complete honesty that the changes are not always easy but they become easy to stick to once you see and feel the results.

Diabetes: The Basics
Although diabetes is still an incurable, chronic disease, it is very treatable, and the long-term "complications" are fully preventable.

Certainly everyone has to die of something, but you needn't die the slow, torturous death of diabetic complications, which often include blindness and amputations. If one aggressively monitors and normalizes blood sugar levels, there are dramatic reductions in diabetic complications.

This chapter has a good, easy to understand overview of  diabetes, both Type 1 (thought to be an auto-immune disorder in which immune cells attack and destroy the beta cells of the pancreas that produce insulin) and Type 2 (insulin-resistant diabetes, though some Type 2 diabetics have an auto-immune component also). There is a good explanation of the vicious circle of insulin resistance and its relationship to body fat, especially belly fat. Type 2 diabetics are resistant to the blood-sugar lowering effects of insulin but not to its fat-building effects.

Tests: Baseline measures of your disease and risk profile
This is another important chapter. It details tests that can help a person in understanding the extent of their disease, to provide a picture of their health status and to give a baseline against which to measure improvement once changes in diet, lifestyle and medication are made.

The next three chapters in the book are geared towards those already diagnosed with diabetes: Your diabetic tool kit, How and when to measure blood sugar (this chapter explains the importance of blood sugar self-monitoring and also how to do it painlessly), Recording blood sugar data.

Strange Biology: Phenomena peculiar to diabetes that can affect blood sugar
Sometimes, even when you think you're doing everything right, your blood sugars may not respond as you expect. The purpose of this chapter is to acquaint you with some real phenomena that can confound your plans, but which you can frequently circumvent if you are aware of them.

The Laws of Small Numbers
Big inputs make big mistakes, small inputs make small mistakes. This chapter emphasizes how it is easier to keep blood sugar stable with small "inputs", whether the inputs are the carbs one eats or the insulin doses being injected.

Establishing a Treatment Plan
This chapter provides different levels of treatment plans that increase in complexity depending on how severe the person's disease is. For instance, level 1 can be treated with diet, while level 2 has diet plus exercise, and levels 3 and 4 add oral medications and insulin respectively. He also discusses how to set a blood sugar target and goals for treatment.

The Basic Food Groups
This chapter talks about how specific kinds of foods affect blood sugar. The calories we consume fall into three groups: proteins, fats and carbohydrates. Carbohydrates affect blood sugar most profoundly. Proteins can also be converted to blood sugar, but rather slowly and inefficiently. Fats cannot be converted to blood sugar at all.

The sub-chapter on fat attempts to make a distinction between dietary fat and body fat. It used to be thought that dietary fat led to body fat, which was the rationale for low-fat diets that are popular even today. However, body fat primarily comes not from dietary fat but from carbohydrates, which get converted to blood sugar. And then via insulin, the fat-storing hormone, whatever blood sugar is not burned off gets converted to body fat. Diabetics do not need to fear or unnecessarily restrict dietary fat.

The sub-chapter on carbohydrates explains the obvious thing- which is that this is the food group with the most relevance for diabetics, since diabetes is a disorder of glucose control, and carbohydrates are broken down to glucose. Bernstein further explains the relationship between carbohydrates and obesity. Much of this obesity is due to "pigging out" on carbohydrate-rich snack foods or junk foods, or even on supposed healthy foods like whole-grain bread and pasta. It's my belief that this pigging out has little to do with hunger and nothing at all to do with being a pig....certain people have a natural, overwhelming desire for carbohydrate that doesn't correlate to hunger. These people in all likelihood have a genetic predisposition toward insulin resistance and diabetes. 

Diet Guidelines Essential to the Treatment of all Diabetics
No matter how mild or severe your diabetes, the key aspect to all our treatment plans for normalizing blood sugars and preventing or reversing complications of diabetes is diet...the single largest "input" you can control is what you eat. 

Bernstein advocates a severely carbohydrate-restricted diet. On his "strict no-no" list are all fast-acting carbs, including sugars (desserts, candy), grains (bread, rice, pasta, breakfast cereals), milk, vegetables like beets, corn, carrots, potatoes and tomatoes.

So What's Left to Eat is the next sub-heading, a very apt one. This list includes non-starchy vegetables, meat, poultry, eggs, seafood, tofu and meat substitutes, cheese, butter, cream, yogurt, nuts, and assorted other things like tea, coffee, spices, herbs, sugar-free jello and what not.

Bernstein is nothing but fanatically single-minded about foods and blood sugar levels. I mean, for good reason and all that. He goes so far as to say: Onions are high in carbohydrate and should only in small amounts for flavoring. He's not so concerned about processed/non-processed food. Whatever doesn't raise blood sugars is in the diet. Whatever does is out. End of story.

To be sure, Bernstein's been following this diet for decades himself; he even mentions that he hasn't eaten fruit since the 1970s. Here's the ending of the chapter: How do people react to the new diet? Most of my patients initially feel somewhat deprived, but also grateful because they feel more alert and healthier. I fall in this category myself. My mouth waters whenever I pass a bakery shop and sniff the aroma of fresh bread, but I am also grateful simply to be alive and sniffing. 

Creating a Customized Meal Plan
This chapter starts with a caution to diabetics that when they switch to a low (or lower) carb eating plan, they should monitor their blood sugars and adjust their medications to avoid their blood sugar from dropping too low, since the diet usually causes a dramatic and immediate drop in blood glucose following meals. Then some specific meal ideas are discussed.

Weight Loss- If You're Overweight
Obesity, especially abdominal obesity (the familiar belly fat) is a important contributor to insulin resistance and type 2 diabetes. Weight reduction can make one more insulin sensitive and can even reverse glucose intolerance in some cases. Bernstein emphasizes that it is difficult to lose weight if you don't understand why or how you are overweight or obese.

When I see a very overweight person, I don't think, "He ought to control his eating". I think, "He has the thrifty genotype". This is the phenomenon where those with "thrifty genes" can store fat and have a survival advantage during famines. But in modern societies that don't see famines but instead see endless feasts in the form of overflowing supermarkets and buffets and spacious fridges, these people now find that their genes make them chronically obese. What was once an asset is now a serious liability.

Many of the people who follow our low-carbohydrate diet find that their carbohydrate craving ceases almost immediately, possibly because of a reduction in their serum insulin levels. 

Bernstein recommends very gradual weight loss in which you follow a weight-reduction diet that matches as closely as possible what you'll be eating for the rest of your life.

How to Curb Carbohydrate Craving or Overeating
Bernstein reports that 25% of his Type 2 diabetes patients find it very difficult to stay on a low-carb diet. For them, he recommends self-hypnosis (!) or some newly developed medications.

Using Exercise to Enhance Insulin Sensitivity
This chapter lists the wide-ranging benefits of exercise- physical, mental and social. A lot of details are given about the effects of exercise on blood glucose (it is more complicated than I had thought it was). Bernstein recommends daily activity, with progressive exercise, meaning it gets more intense with time (be it weeks or years).

Insulin resistance, which is the hallmark of type 2 diabetes, is enhanced in proportion to the ratio of abdominal fat to lean body mass. One of the best ways to improve this ratio in order to lower your insulin resistance is to increase your lean body mass. Therefore, for most type 2 diabetics, the most valuable type of exercise is muscle-building exercise. 

The next few chapters are all about medications and medical care for diabetics: Oral insulin-sensitizing agents, Insulin-mimetic agents and other options, Insulin: the basics of self-injection, Information about various insulins, Simple and intensive insulin regimens, How to prevent and correct low blood sugars, How to cope with dehydration and infection, Delayed stomach emptying (gastroparesis), Routine follow-up visits to your physician.

What You can Expect from Virtually Normal Blood Sugars
This is a chapter full of hope for those who are starting to make changes, often very difficult ones, to bring their blood sugar levels to the normal range. Bernstein reports that his patients feel more alert and are no longer chronically tired, those with numbness in their toes feel their sensation return, there are vision improvements and improvements in cardiac risk factors. They are not doomed to die prematurely or suffer from disabilities and complications.

I have long maintained that diabetics are entitled to the same blood sugars as nondiabetics. But it is up to us to see that we achieve this goal. 

The final chapter has recipes, followed by informative appendices on foot care for diabetics and polycystic ovarian syndrome.

After I wrote this post, I realized that portions of this book are available here on the author's website.

The diet prescribed in this book is very strict and wouldn't work for me, as it excludes beans and legumes and severely restricts vegetables. However, I get the principle of the diet and realize that cutting down carbs is helping me cope with insulin resistance.

What I loved about this book:
It is packed with incredibly detailed practical tips for diabetics- such as how to test blood sugar as painlessly as possible.
It treats diabetes as the very serious disease that it is, but emphasizes the options that the patient has to control it.
It has a good perspective on medication, especially insulin- that it can be used judiciously to supplement diet and exercise. Medications are not to be feared but to be used wisely as needed.