I recently came accross an article in the Journal NEPHROL. DIAL. TRANSPLANT. VOL 13 (1926-1927), 1998 which expressly concludes that individuals with Type I diabetes (IDDM) should not exceed a protein intake of 20% of total energy consumed as they run the risk of developing renal disease -as measured by the individual's Albumin Excretion Rates (AER) - even if they have no existing indication of kidney malfunction, i.e. do not depict microalbuminuria; the study is based on results from 2868 Type I patients accross several European countries. The Article can be found in the following link: http://ndt.oupjournals.org/cgi/reprint/13/8/1926.pdf

How do you comment on that? Do I understand correctly that based on this research Type I diabetics should refrain from Atkin's or Dr. Bernstein's Diet?

Thread moved to the study and research forum for comments.

Diabetic nephropathy is a complicated issue. I wasn't able to access the article you attached, but would like to point to Dr. Bernstein himself as an example. He is a type 1 diabetic himself who was beginning to develop diabetic complications when he began experimenting with low carbing as a means to control his diabetes 40+ years ago. Not only have his kidneys not failed (nor those of any of his patients that I'm aware of), but they have actually gotten better.
As I understand it, it's not dietary protein that causes the intial kidney damage in diabetics, it's chronically elevated blood sugars which are usually less well controlled in type 1 diabetics than in type 2 (much wider and larger fluctuations) which would go a long ways towards explaining why type 1 diabetics suffer end stage renal disease more than type 2's. The current dietary recommendations for diabetics are far too liberal on carbs which contribute to wide swings in blood glucose. Blood glucose attaches itself to small protein molecules that would normally be too large to fit through the glomerulus of the kidney (the filtering mechanism), but when blood glucose rises the body tries to get rid of the excess through the kidneys. The protein/glucose complex is too large to fit, but the pressure building up behind it from blood can force it through the small pores beginning the damage. As this happens over and over, the damage increases and albumin begins to leak through the glomerulus (a condition known as albuminurea) which is the first sign of kidney damage.
Dr. Bernstein doesn't feel that type 1 diabetics should refrain from a low carb WOE and I agree. The best way to prevent kidney damage is tight blood sugar control, not dietary protein restrictions. Once kidney damage has progressed to a certain stage, then dietary restriction of protein may become necessary.

Maybe I have been too hasty, so for reasons of conclusiveness I provide you a bit more information on this article; it's title is "Protein intake -New evidence for its role on diabetic nephropathy" by Monika Toeller & Anette E. Buyken from the Clinical Department, Diabetes Research Institute at the Heinrich Heine University, Dusseldorf, Germany. You need Acrobat Reader in order to download from the provided link the copy of the Nephrology Dialysis Transplant. journal which also includes other articles; the aforementioned is located at page 14 of your Acrobat document. The link is:

http://ndt.oupjournals.org/cgi/reprint/13/8/1926.pdf

The case of Dr. Bernstein is well known and I have no doubt regarding the validity of his arguments as far as his own health is concerned. As a Type I myself I have read the book and I am following a lot of his very useful recommendations. Nevertheless, the sole case of one individual cannot provide substantial evidence on the efficacy of the recommendations included in his book. Futhermore, Dr. Bernstein has failed to provide so far statistical analysis regarding the validity of his hypothesis i.e. that a high protein intake for IDDM patients does not affect their AER (albumin excretion rates) to a malignant degree, or at least I am not aware of such a publication in any medical journal. Please advise me if I am wrong...

In contrast, the above mentioned article is based on the study of 2886 IDDM patients accross several European countries, called EURODIAB Complications Study, designed to explore risk factors for diabetic complications, in which nutritional intake has been assesed in >2800 IDDM patients. As quoted in this article "pressumably, due to the size of the stratified sample could we demonstrate a clear assosiation between AER and protein intakes, which former smaller studies were not able to identify."

Finally, the opening comment of this article definitively agrees with Dr. Bernstein's basic beliefs: "Blood pressure and glycaemic control are well established factors influencing the development and progression of diabetic nephropathy." The question not statistically proved by Dr. Bernstein is whether a high protein intake for a Type I patient might be hazardous for her kidneys, as measured by the AER. Maybe Dr. Bernstein's kidneys are super kidneys and after 40 years of hazard they managed to maintain their efficacy, but maybe mine are not... Why should I risk it?

Any ideas?

Question: How 'tight' is your control on your sugars? Dr.Bernstein isn't the only one who cites it isn't the protein per se that damages the kidneys, but lack of control of the sugars. Dr.Atlkins covers it as well as the Eades. I think probably the best thing for you to do would be to follow a combination of the low-carb diet (but keep protein to the minimal side) and the alkalizing diet. The goal of the alkalizing diet is to keep body pH as close to neutral/alkaline as possible. There are several folks out there with that philosophy. Of course they all want you to buy their products, but one can alkalize without them. Which means you eat more veggies of the low-starch kind and begin juicing. I read 'The pH Miracle' and while I just can't *quite* agree with his vegetarian recommendations, I have noticed since I started adding juicing my BG readings are quite good. I truly expected them to go up since I'm getting many more carbs in the juice, but the opposite seems to be true...I've only been doing it for about a month now, and not consistently. But when I drink my 'green' drink on a regular basis, I get better BG readings. If I can't take the time to juice, then I drink powdered 'green' drink. There are lots of them out there. None of them actually taste good, but they are tolerable. That might be a better route for you. I can recommend the Omega 8001 masticating juicer, no heat involved as is with most other juicers.

Question: If 20% of your daily calories are coming from protein and no more than 30% from fat (the recommended dietary standard), guess what the rest is? That leaves 50% of your daily calories from carbs. Far too much for a diabetic IMHO.
I don't have Acrobat reader, so was still not able to read the study you refer to. Would it be possible to copy and paste it into the forum here?
I'm curious if the study measured what the daily carb intake for those studied was. Also, what was the average blood sugar of each participant? Could it be that they are pointing the finger at protein consumption when it should be pointed at less than good blood sugar control instead?
Do type 2 diabetics consume less protein than type 1 diabetics? If not, then what is the explanation for why type 1 diabetics get diabetic nephropathy much more than type 2s?
Studies done on diabetic rats have shown that those rats who had their blood glucose maintained at 100 or less could eat all the protein they wanted and never developed diabetic nephropathy. Those rats with both high blood sugar and high protein intake developed diabetic nephropathy rapidly, but if their blood sugars were normalized again to 100 or less, the nephropathy reversed itself. This seems to point heavily to blood sugar control as the problem, not protein consumption.

Thanks all of the above for your helpful insights!

My current diet consists of 20% fish or dairy protein and 30-40% soy protein for a total of 50-60% protein intake! Huge?

I can provide you with a link for a free download of Adobe Acrobat Reader; it is the following:
http://www.adobe.com/products/acrobat/readstep.html

This article seems very interesting with respect to its findings that pertain strictly to Type I diabetics (IDDM). Its bottom line is that "Dietary advice given to individuals with diabetes should always discourage excessive protein intakes, regardless of microalbuminuria." Furthermore, regarding which level should be deemed excessive it states:"The rationale for the recommendation not to exceed a protein intake of 20% (according to ADA and DNSG guidelines) was largely based on the consumption commonly observed in the general population. This recommendation is now confirmed by our finding that protein intakes >20% are associated with elevated levels of AER in European individuals with type I diabetes. However, since mean AER increased to levels in the microalbuminuric range when the patients' protein intakes exceeded 20% of energy, more attention should be directed towards the avoidance of such high protein intakes." Finally their practical recommendation for avoidance of excessive protein intake is: "...Generally, a modification of protein intake should be explored as a feasible therapeutic approach to reduce the adverse effects of a high protein ingestion, since specifically animal protein appears to exert deleterious effects on renal function. Therefore, substitution of vegetable protein for protein from animal sources should be considered."

Maybe the trick is what I am currently doing, i.e. a soy-based Dr. Bernstein's diet? Time will tell...

The tone in this article is strongly anti-meat in my opinion. From start to finish the focus is on limiting the intake of animal protein.

To quote the article with emphasis added “In comparison to the key approaches for an effective prevention of diabetic nephropathy – the optimization of blood pressure and glycaemic control – the association of protein intake to the progression of nephropathy is MUCH WEAKER.” Also, “…in the study we could show that the trend of AER (urinary albumin excretion rates) was particularly pronounced in patients WITH HPERTENSION AND/OR ELEVATED HbA1c values.”

Yet the conclusion they reach is that Type I diabetics need to limit their intake of meat. The message I get from this is that bloodpressure and bloodsugar control is much more important than the limitation of protein intake. If eating more animal protein and fat allows you to meet these goals, as suggested by Dr. Bernstein, then you are better off health wise than limiting the intake of animal protein and fat at the risk of elevated bloodpressure and poor glycaemic control, which is so common on a high-carbohydrate, low-meat diet.

Regardless, dietary fat should be providing the bulk of your calories (Type I or otherwise), not protein and definitely not carbohydrate.

Alan

After downloading and reading the article, I have to agree with Arkie's assessment. Since they recognize that abnormal AEC levels were much more pronounced in the presence of uncontrolled hypertension and elevated HbA1C levels, how they came to the conclusion that limiting dietary protein was the answer is beyond me unless they were coming from the mindset of "we can't get tight blood sugar control with the current dietary recommendations, so we'll recommend dietary protein restrictions instead." The article also does not mention what the daily carb intake and average blood sugars of the study participants were.
Decreasing dietary protein would mean by default that something else must be increased to maintain an adequate daily caloric intake; either carbs or fat. Since there is such a huge fat phobia, that must mean that daily carb intake would have to be increased. This is supposed to help??? I'd also like to point out that as a type 2 diabetic, I was on a diet similar to what they are recommending for several years and all it got me was more weight and my blood sugars and blood pressure out of control with a need for medications to get them back in line again. Since low carbing, I am off both of those medications and maintaining a normal blood pressure and an average HbA1C of 5.3 (it was 11.8 when I began low carbing). I also have my liver and kidney function tested every 6 months and so far they have been nothing but normal.
I also have to comment that getting 60% of your daily caloric intake from protein is probably too high. Generally, I get about 30% of my daily caloric intake from protein, 3-5% from carbs and the balance from fats.
Dr. Bernstein also uses his dietary approach for all of his patients and if they were all developing kidney problems, I'd hope that he would have re-thought his approach long ago (or been sued for medical negligence) and there is no mention in his book (or even cautions) of developing the types of kidney problems addressed in this article if carbs-and therefore blood sugars-are tightly controlled . As for the "super kidneys" comment, when it comes to something like this, everyone pretty much reacts the same way to the same type of diet even if some may take longer to develop problems than others, I would think that 40+ years would be long enough to see if something untoward was going to happen.
Goodness...if my kidney function and health are still as good as his in 40+ years, I'll be one happy 81 year old!

But Dr.Bernstein *didn't* have 'super kidneys'!!!! His kidney readings were quite bad. He knew all the stern warnings regarding increasing protein intake for someone with kidney readings like his and he decided to 'go for it' anyway believing firmly that the only way to control the BG was to reduce carbs severely and the only way to do that was to increase the intake of fats and proteins. So he experimented on himself and lo an behold, he not only got his BG under control he also *improved* his kidney function! I have to agree with him--it's the sugars that cause all the problems, not the protein. Get the sugars under complete control, allow enough time for healing to take place and the body will try to become normal again.

Thanks a lot for your helpful insights!
I am afraid that the fact of a single documented(?) case -by the author of the book Dr. Bernstein himself- of a pro-low carb/high protein diet carrying no complications of his renal function does not provide scientific proof but only anecdotal evidence! I am a Bernstein follower myself, albeit I am afraid that, after having read this article, I might be "betting" on the wrong horse, as Dr. Bernstein's approach has not been scientifically proven as complications-free, allowing for his own and allegedely his patients' anecdotal evidence. In contrary, the study I have mentioned above, performed by an accredited European institution accross 31 medical centers in various countries, based on 2800 Type1 (IDDM) patients, purports to provide scientific evidence on the adverse effect of a protein intake in excess of 20% to renal function. I have no access to the full details of the studies undertaken, regarding levels of glycaemic controls and hypertension of the subjects, but the authors are quite clear about excluding these two influential factors on renal function for IDDM patients in their study on the effects of the nutritional intake. After all, they are explicit about the adverse effect of poor glycaemic control and hypertension on renal function for Type 1s.
As we can all appreciate, this article's clear cut view is that we are all jumping on a big leap of faith and I dread to think what the ramifications of such an exercise might be for all of us -Type 1 followers of Bernstein. Dr. Bernstein offers a single case of an individual who managed to improve his glycose control through a particular diet and hence reversed the adverse effects of diabetes; this does not prove that his own renal function now is standing at a better level than it would have been had he not followed his high-protein nutritional doctrine in favor of, let's say, the Zone diet but still managed to maintain an adequate glycose control; "adequate" glycose control is not the sole privilege of extremely low-carb diets, as measured by patients' HB1a. This could be only ratified by extensive medical research and rigorous statistical analysis accross a statistical sample of patients and not on just a single case. Having said that, there are a variety of helpful insights on Type 1 diabetes management included in his book that urge me to strongly recommend it to anyone with Type 1 diabetes. My questionmarks arise on the diet part, which might have not affected Dr. Bernstein kidneys in terms of an explicit onset of albuminuria but we don't see anywhere in his book data about his own or his patients' GFR (Glomerular Filtration rate) -a predictor of forthcoming micoalbuminuria for Type 1s- before and after this diet, as well as its rate of change over the 40+ years.

Still on the leap of faith myself, but worried

I guess I'm wondering why you would consider anything over 20% of daily caloric intake "high" protein? Granted what you are doing IS high protein, but that isn't the recommendation for either Bernstein or Atkins.
Bernstein's recommendation for protein intake is roughly 8-10 ounces a day from whichever sources you wish to choose, although I calculate my protein requirements based on 0.6 grams per pound of body weight (which for me comes to about 78 grams a day...NOT considered "high" by most standards, but adequate).
Atkins recommends that your protein intake be between 25 and 30% of your daily caloric intake...again, not HIGH but adequate .
I guess you'll have to weigh the risks of poor glycemic control (which are many) against the possible risks of increased AEC based on one study where other contributing factors (glycemic control and hypertension) are not given for yourself.
As for myself, I no longer consider this a leap of faith as after more than 18 months of following this WOE, my lab tests continue to be either improved to the normal range (HbA1C and blood pressure) or maintained in the normal range (liver and kidney function).
The "recommended" diet made me worse. This has made me normal again. For me it's a no-brainer.