Amputations, Gangrene and Carbohydrates

As an anesthesiologist I have spent more than 60,000 hours in the operating room and cared for over 30,000 patients. I often observe the end-results of bad dietary advice. I am referring to the liberal carbohydrate allowance that the American Diabetes Association and other agencies offer diabetics.

Today was a particularly poignant day as I cared for two diabetics who required amputations for complications of diabetes type II. These complications could have likely been avoided if our supermarkets were not stocked with high carb nutritionally deplete “food” AND if the ADA, physicians and nutritionists counseled diabetics to significantly reduce their carbohydrate intake. Instead, the low fat narrative has so predominated our culture, that we have taken our eyes off of the major dietary threats during the past 40 years, excessive carbohydrates and especially refined carbohydrates.

The leading cause of amputations in modern society are the complications of diabetes including peripheral arterial disease (atherosclerosis in the arteries to our limbs) and peripheral neuropathy (loss of sensation in the feet and hands). The combination of these two, or just one alone can lead to non-healing wounds and ulcers in the feet, then chronic infections and ultimately gangrene. Futile efforts to restore circulation to the legs with vascular bypass surgeries or arterial stents usually just briefly delay the inevitable series of amputations that start in the toes and progress up the leg, step by step until only a stump is left above the level once occupied by the knee.

Gangrene is an ugly thing. During the Civil War the major cause was trauma. Today the major cause is diabetes and indirectly, excess carbohydrate consumption.

The visual experience of gangrene results in a visceral reaction, even after more than 30 years of observation. The knowledge that most of these complications could be avoided by simply eating whole fresh foods instead of crap in a bag or crap in a box is frustrating. The human suffering and economic costs (lost wages, disability, medical expenses) are staggering. Diabetes type II is largely a disease of lifestyle. The lifestyle elements involved include poor dietary habits, lack of exercise, inadequate sleep, and stress. All of these contribute and all are modifiable and avoidable.

Type II diabetes is arguably reversible early in the disease process. As it progresses a patient reaches an irreversible point of no return where the pancreas has been exhausted and the insulin producing cells are no longer efficient and effective. Equally important,  the cells in the rest of the body do not respond in a normal fashion to what little insulin is produced. But even at this stage carbohydrate restriction can mitigate complications if only healthy fresh whole-foods are consumed and modest exercise is practiced on a daily basis.

Other complications of diabetes including blindness, painful neuropathy, kidney failure requiring dialysis, heart attack and stroke all are arguably avoidable with a whole foods paleolithic carbohydrate restricted diet and modest amounts of regular exercise.

What a pity, what a shame, what a waste.

Below are some links and research articles to back up my statements.

Peace, health, and harmony.


1. Type 2 Diabetes

2. American Diabetes Association Embraces Low-Carbohydrate Diets. Can You Believe It? | Richard David Feinman

3. Nutrition Science on Pinterest

4. Low-Carb for You: Low-Carb versus Low-Fat

And Many More:

Jenkins DJ, Kendall CW, McKeown-Eyssen G, Josse RG, Silverberg J, Booth GL, Vidgen E, Josse AR, Nguyen TH, Corrigan S et al: Effect of a low-glycemic index or a high-cereal fiber diet on type 2 diabetes: a randomized trial. JAMA 2008, 300(23):2742-2753.

Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR: The Effect of a Low-Carbohydrate, Ketogenic Diet Versus a Low-Glycemic Index Diet on Glycemic Control in Type 2 Diabetes Mellitus. Nutr Metab (Lond) 2008, 5(36).

Gannon MC, Hoover H, Nuttall FQ: Further decrease in glycated hemoglobin following ingestion of a LoBAG30 diet for 10 weeks compared to 5 weeks in people with untreated type 2 diabetes. Nutr Metab (Lond) 2010, 7:64.

Gannon MC, Nuttall FQ: Control of blood glucose in type 2 diabetes without weight loss by modification of diet composition. Nutr Metab (Lond) 2006, 3:16.

Gannon MC, Nuttall FQ: Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes 2004, 53(9):2375-2382.

Forsythe CE, Phinney SD, Feinman RD, Volk BM, Freidenreich D, Quann E, Ballard K, Puglisi MJ, Maresh CM, Kraemer WJ et al: Limited effect of dietary saturated fat on plasma saturated fat in the context of a low carbohydrate diet. Lipids 2010, 45(10):947-962.

Jakobsen MU, Overvad K, Dyerberg J, Schroll M, Heitmann BL: Dietary fat and risk of coronary heart disease: possible effect modification by gender and age. Am J Epidemiol 2004, 160(2):141-149.

Siri-Tarino PW, Sun Q, Hu FB, Krauss RM: Saturated fat, carbohydrate, and cardiovascular disease. Am J Clin Nutr 2010, 91(3):502-509.

Int J Cardiol. 2006 Jun 16;110(2):212-6. Epub 2005 Nov 16. Effect of a low-carbohydrate, ketogenic diet program compared to a low-fat diet on fasting lipoprotein subclasses. Westman EC, Yancy WS Jr, Olsen MK, Dudley T, Guyton JR.

Mol Cell Biochem. 2007 Aug;302(1-2):249-56. Epub 2007 Apr 20.Beneficial effects of ketogenic diet in obese diabetic subjects. Dashti HM, Mathew TC, Khadada M, Al-Mousawi M, Talib H, Asfar SK, Behbahani AI, Al-Zaid NS.



5 thoughts on “Amputations, Gangrene and Carbohydrates

  1. Michael Cogan

    Dear Bob,

    I respect and admire your your passion and caring. Thank you.

    Fondly, Michael

    Sent from my iPhone


  2. drp5

    My grandfather died a month after a leg amputation. My father was nearly blind when he died at 69. In 1999, I finally realized that the low-fat, low-calorie diet I had followed my entire adult life in order to avoid Type II Diabetes was leading right towards it. I shifted to a high-fat, low-carb diet and have never had an abnormal blood sugar reading. My diet has continued to evolve and I now follow a paleo, whole-food, ketogenic diet. At 61, I am an avid cyclist and just completed the Bike Ride Across Nebraska and rank 4th in my local group of the National Bike Challenge for the most days/miles in June. Thanks for this disturbing but necessary message..

    1. Bob Hansen MD Post author

      You are welcome Peggy. Although I do not manage diabetes I do spend time in the pain clinic treating chronic pain and I have made dietary recommendations to all of my patients. The diabetics who follow this advise come back to the office smiling and proud of their reduced blood sugars, HA1C, and reduced medication doses. Some have gotten off of all medications for diabetes and blood pressure by following a carb restricted paleo diet.

  3. ketogenicdiabetic

    Hi Bob

    A very thought provoking article and I agree with the basic tenets quite strongly. I understand that the majority of diabetic patients have type 2 and this is probably the greater percentage of patients that you see in the operating theatre but i’m puzzled as to why you didn’t widen the scope of this article to include those with type 1. The risk of long term diabetic complications through poor glycaemic control is applicable to any diabetic, not matter their type.

    I’m quite aware that it’s a condition that is not reversible through lifestyle changes but it can certainly be managed more successfully with the changes you outline above for type 2’s. As a type 1, I followed recommended dietary guidelines for 27 years and followed the ‘I can eat what I want as long as I cover it with insulin’ mantra. I had consistently high A1c’s, bounced between low and high glucose levels and just accepted poor glucose control and ever failing health as the natural progression of the condition. Thankfully, my eyes are now open and I realise it doesn’t have to be this way. It’s a very powerful message that you’re sending out but I believe that it needs to be addressed to all patients with diabetes, including type 1, 2, LADA, MODY and gestational.



    1. Bob Hansen MD Post author

      I agree with you completely Julie. All diabetics, Type I and II would benefit from a carbohydrate restricted paleo diet. Likewise anyone with metabolic syndrome, obesity, overweight, insulin resistance…Dr. Richard Bernstein has devoted his life to treating diabetes of all types with a carbohydrate restricted diet and medications with great success and has published a book written for the layperson but also very informative for physicians. My blogs are usually written at the end of a very busy day and there is always more to say. I was so distraught over what I had witnessed in the operating room, the unnecessary suffering that I had to complete that post before bedtime.


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