Diane Kress, RD CDE has authored a new book, The Diabetes Miracle, which takes aim at the national standard for daily carbohydrates and discusses how regulating carbs in terms of quantity, quality, and timing may be the answer to preventing and controlling the disease as well as aiding in permanent weight control.

By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net 

Diane Kress (pictured, left) was sitting at her desk one day thinking she was extremely thirsty. She realized she had been thirsty quite a bit of late and she was going to the bathroom more frequently. At that moment, she realized she was having the two telltale signs of the disease she had been helping her clients fight for years. She took out a blood glucose monitor and tested herself: her number was 200. She couldn’t believe it. She washed her hands and retook the test with the same results.

That week, Kress confirmed the news with her physician that she had type 2 diabetes. Kress was 38 years old.
She felt shock and disbelief. She had practiced what she preached during her years as a registered dietitian and certified diabetes educator. But even with regular exercise, and following a 1,200 calorie diet using the American Diabetes Association (ADA) daily recommendations (50-55% carbohydrates, 20% proteins, and 30% fats), she had to admit that she had not lost appreciable weight or reduced her cholesterol, and blood pressure. And now, the ADA`s recommendations didn`t even protect her from type 2 diabetes.
Instead of unquestionably accepting the diagnosis, she began to research the forward progression of metabolic syndrome to prediabetes to type 2 diabetes. What she found was that the modern diet espoused by the USDA’s food pyramid as well as the ADA’s carb recommendation could send many people, including herself, down the road to a diagnosis of type 2 diabetes. 
In a larger context, both the medical community and people with diabetes have been engaged in an ongoing, lively debate for years about the daily total allowance for carbs. There are those who still practice the ADA’s recommendations, and there are others who advocate for lower percentages of carbs in varying amounts. In her search for answers, and based on her years of research and development, Kress developed several new theories.
For starters, she believes the ADA’s daily carb recommendation is too high. She maintains that adding large amounts of carbs to a body with escalating hormonal imbalance is akin to putting kindling on a fire. Kress believes that the metabolic makeup of a person with type 2 diabetes cannot routinely handle high glycemic index carbs; hence, her program promotes low/medium glycemic choices that allow for a gradual rise in blood sugar. She also contends that the timing of carb ingestion is of paramount concern for those with insulin issues. And there must be a period of rest and rehabilitation for the overtaxed pancreas and liver before the body can reasonably handle carbohydrates again.
Kress reworked the diet protocol and developed her own program to rest, reprogram, and rejuvenate the metabolism of those with insulin imbalance. She offered a choice of learning this new program or the traditional program to her patients. After teaching and tracking over 3,000 patients, she wrote her first book, The Metabolism Miracle. Realizing she had struck a chord in weight management, but simultaneously witnessing the exploding prevalence of type 2 diabetes in U.S., she decided to turn her attention to the burgeoning epidemic, and has written a new book, The Diabetes Miracle (pictured, lower right). 
This new book is written for those who have prediabetes or type 2 diabetes, and contains a three step program that begins with readers following a low carb program for 8 weeks to rest the overworked pancreas and liver. In Step 2, carbs are reintroduced based on glycemic index and glycemic load. After the desired weight goal is reached, blood sugar is in the healthy range with little to no medication, and the person likes the way he or she looks and feels, people move to Step 3: the maintenance or lifetime step.
In step 3, the daily carb allotment is based on the reader’s age, height, and desired weight. This last step promotes a truly “balanced” intake of about 30-35% of carbs, lean protein, heart healthy fats, and liberal servings of neutral vegetables. Instead of counting calories or every gram of carbohydrates, the reader learns the carb servings recommended per day as well as options to space them out to maintain blood sugar and insulin equilibrium.
With her differing take on carbs, DiabetesCare.net sat down with Kress to talk about how she came up with her unique program, her thoughts on why the ADA’s carb recommendation is too high, and how the quality and quantity of carbs can make a huge difference in peoples’ diets and their overall health.
DiabetesCare.net: Can you talk about why you decided to write The Diabetes Miracle?
Kress: I never in my wildest dreams thought that I would one day find it necessary to rework the traditional diet for diabetes that had been the center of diabetes teaching since the ADA began the “Exchange List Diet” in the 1950’s.
I taught “by the book” for over half my career, but I noticed something during those first 15 years. The patients I taught who were just diagnosed with type 2 diabetes, and those who had the disease for years before I met them, seemed to be on a train with a one way ticket to acquiring worsening blood sugar, more medications and a cohort of co-morbidities.
No one ever really improved despite following the prescribed diet and lifestyle program.
Somewhere in the back of my mind, I thought that it had to be non-compliance. There should be no way these patients did not lose weight, did not improve their blood sugar for more than a honeymoon period, and got sicker with metabolic syndrome if they were living the program I taught them.
I practiced what I preached. I followed a 1,200 calorie diet with ADA low fat and low cholesterol recommendations. I chose that particular calorie level because I was gaining weight around the middle, despite my healthy diet and daily exercise.
No matter what,  I still didn’t lose weight. I was never a saturated fat eater, and I hadn’t eaten red meat or used butter since I was in elementary school—and yet my cholesterol began to rise. Over the years, my once low blood pressure rose to normal and then hypertension. The coup de grace was a diagnosis of type 2 diabetes.
A quote I’d read many times over the years began to worry me: “if you are lucky enough to live long enough with type 2 diabetes, you will require insulin.”
At that point, I began to collect data on my patients. Sure enough there was a commonality.  Most had increasing indices of metabolic syndrome that worsened on the traditional protocol. I spent years working on the ADA diet including taking apart its components, reviewing the physiology of diabetes, reworking theories, collecting more data, until at last, I had a prototype I wanted to test.
On the program I created my patients flourished. All of their objective markers improved, and they also told me that they had more energy, less depression, and looked younger and healthier than they had in years. The number of their medications and doses dropped. Many type 2’s on insulin were now on oral medication, and many oral medication patients required no medication.
After I taught the program to over 3,000 patients, I decided it was time to write a book.  My plan was to begin the program for those with metabolic syndrome, and my book, The Metabolism Miracle was released in April 2009.
After writing a companion cookbook, I decided to write The Diabetes Miracle.This self management book is an all inclusive lifestyle program for anyone with prediabetes or type 2 diabetes. It contains the core Miracle program but also covers all the components of information needed by someone trying to prevent or control type 2 diabetes.
DiabetesCare.net: Can you provide an overview of the book and what The Diabetes Miracle really means?
Kress: Dating back to the 1950’s, metabolic syndrome (midline adiposity, elevated blood lipids, elevated blood pressure, elevated blood sugar) is a real phenomena. Uncontrolled, it can lead to atherosclerosis, obesity, hypertension, and type 2 diabetes.
The theory had always been since patients with metabolic syndrome become obese around the middle and the fat levels in their blood rose over time, metabolic syndrome must be linked to excess calorie intake, inadequate physical activity, and excessive saturated fat intake. Thus began the birth of the controlled calorie, low fat, low cholesterol diet.
If a diet was to be controlled with calories and fat, it was natural that protein and fat would have to decrease, which left carbohydrates to increase. Afterall, the macronutrient carbohydrate is low in calories (4 kcals/gram) and contains no fat or cholesterol.
A dietary intake that is high in carbohydrates will not work for metabolic syndrome and, in my opinion, is a major cause of the epidemics of obesity and type 2 diabetes.
As it turns out, those with metabolic syndrome develop an inherent imbalance of insulin. Excess insulin causes increased fat deposition in the blood and on the body. Excess insulin and increased fat storage cause insulin resistance. The nutrient that causes insulin release: carbohydrates.
The core miracle program is broken up into 3 steps. Step 1 is a necessary 8 week “rest period” for the overworked pancreas/liver combination. A person’s carb intake is kept to a level that allows for rest of metabolic mayhem. Step 2 is the reintroduction of carbohydrates based on the following factors: a specific amount of carb grams; low glycemic index, low glycemic load of carbohydrates; and proper timing of carbohydrates throughout the entire day.

When you reach your desired weight, the program continues in maintenance fashion with a truly balanced diet.  
The Diabetes Miracle discusses physical activity as a method to control weight by utilizing blood glucose and minimizing insulin release. However, no gym membership is required; I focus a lot on exercise that can be worked into a busy day.
DiabetesCare.net: The book was written for people with prediabetes and type 2 diabetes. Why the decision to address both groups?
Kress: Thankfully, we now know that there is often a period of time when fasting blood sugar is over the normal range, but is not yet high enough to be diagnosed as irreversible type 2 diabetes.
Years ago, this stage was called “a touch of diabetes.” We now know that this period (fasting blood glucose 100-125mg/dL) is a last chance to stop the train speeding down the tracks to type 2 diabetes. 
Following this program can help return fasting glucose and hemoglobin A1Cc into their normal ranges.
DiabetesCare.net: One of the things you take exception with is the ADA’s daily carb recommendations. Can you explain why?
Kress: The problem is the 1950’s theory of calories and fat intake. When the position was taken that the healthy diet should be lower calories and fat the entire food line in the U.S. changed. Low calorie, low fat, fat free products were everywhere and the “balanced diet” was changed to a “food pyramid” with carbohydrates at the base of the pyramid!
However, after 60 years of data proving that this diet doesn’t work, it’s time to use the current science and open our minds to an idea that does. My program is based in real science, has no downside, and allows for objective measures.
DiabetesCare.net: Are there other specific elements to the American dietary problem that is leading to the increased prevalence of type 2 diabetes or do you see it mainly coming from too many carbs over an extended period of time?
Kress: I believe it’s a combination of a large daily carb intake, refined carbs (high glycemic index/high glycemic load), lack of activity, and lots of stress--all superimposed on genes that cannot tolerate this lifestyle that leads to metabolic syndrome and eventually type 2 diabetes.
DiabetesCare.net: In Step 2, you recommend 11-20 daily carbs. Why so low?
Kress: Well, you have to realize that Step 2 of the program follows eight weeks of a low carb diet that is intentionally limiting carbs to a point that the dietary intake of carbohydrate foods and the liver`s glycogen release cannot stress the pancreas for insulin release. (On The Diabetes Miracle, we don’t count every carb gram ingested; incidental carb grams in primary proteins, fats, and neutral veggies are not counted so the program’s Step 1 is not carb free by any means).
After this rest period, I found that it is not prudent to progress to a glycemic load over 20 net carb grams, nor is it beneficial to have a carb intake per meal of less than 11 grams. I worked and reworked this program until I found that 11-20 grams of lower glycemic index carbs gives excellent results; not too much to demand excess insulin, but high enough to keep the liver from releasing glycogen stores.  
DiabetesCare.net: Can you explain why the traditional standard of carb counting and a low fat diet does not work? 
Kress: One of the first steps an RD uses to configure a diet is to calculate the number of calories a person needs to lose or maintain healthy weight. Unfortunately, we haven’t been taking into account that a person with metabolic syndrome or type 2 diabetes doesn’t handle calories the way someone with a normal metabolism does.
If you are on a 1,200 calorie diet, for example, but you don’t take into account the macronutrients that make up those calories, it stands to reason you will most likely choose a high percentage of calories from carbs.
Since carbs have no appreciable fat or cholesterol and are lower in calories than fats or most proteins, chances are that a person on a calorie based, low fat, low cholesterol diet is going to be following a high carbohydrate diet. These carb choices are not necessarily unhealthy‑-whole grains, legumes, fruit, plain yogurt, brown rice are very healthy foods--but for those with insulin imbalance, excesses can wreak havoc.
In addition to over-responding to blood sugars rising from carbs, many people don’t realize that the human body has a “self-feed” survival mechanism. Whenever a person goes more than 5 hours without eating any carbs, the brain signals the pancreas to release the hormone glucagon. This hormone then signals the liver to release glycogen stores into the blood to raise the blood sugar.

This survival mechanism occurs whether a person has normal metabolism or insulin imbalance. The difference? Those with insulin imbalance will once again over-react with insulin. Excess insulin is released in response to the ingestion of carbohydrates and as a reaction to skipping carbs!
There is great hope in 2012 for those with prediabetes or type 2 diabetes. It’s time we admit that the diet advice we’ve been revamping since the 1950’s has not met the test of time. We are facing a global epidemic of obesity and type 2 diabetes. Insulin imbalance is at the root of a great percentage of those who suffer from obesity and at the core of everyone with type 2 diabetes. In the world of those with diabetes, balance is everything. 
To learn more about The Diabetes Miracle, visit: www.thediabetesmiracle.com.