Two Clinical Reactions: seeing the possibilities or being a pessimist

Yesterday, a client of mine who was on insulin 13 weeks ago and who went off of it with her Endocrinologist’s knowledge and oversight to follow a low carbohydrate diet had her regular two-month follow-up visit, where she saw both the Dietitian and the Endocrinologist. Their respective reactions to her progress really highlights how some clinicians can be transformed by seeing the clinical possibilities of what can be accomplished by someone following a well-designed low carbohydrate diet, whereas others remain pessimistic regardless of the clinical evidence.

This is the 4th article about this young woman’s incredible progress from injecting insulin to following an individually designed low carbohydrate diet. You can read about the first two weeks at the start of her journey here, about her achieving normalized blood glucose in 10 weeks here, and about here achieving target HbA1C in less than 12 weeks here.

NOTE: The different reactions that these clinicians had are in no way reflective of their respective professions; it could have easily been in reverse. It could have been entirely different healthcare professions. There are clinicians in every field who are willing to consider emerging evidence and respond by being open to the clinical possibilities, and there are others who are not.


When this young woman arrived for her appointment, she saw the Dietitian first, which was the same one that she saw the visit before, and who told her that she should be eating ‘60 g of carbohydrate per meal plus snacks’ (see Sept 6 update, here). At yesterday’s visit, the Dietitian only looked at her blood glucose numbers from the last two weeks and not the last 8 weeks since she was last seen. She said her ‘numbers look good’, and asked the name of the Dietitian she was seeing, and my client told her my name.  She responded and said “I hope she told you that you can’t get your numbers under 7 with just Metformin“. My client pointed out that she recently got TWO fasting blood glucose of 4.7 mmol/L, and the Dietitian said she didn’t see that. My client pointed out the two dates where she did, to which the Dietitian said nothing, as she was only considering the numbers from the last two weeks. My client said to me that at this point, she “just shut down” and waited to see the Endocrinologist.

My client then saw her Endocrinologist who had a medical student with him. This is the same Endocrinologist that told her 8 weeks ago that it was unrealistic for her to think that she could lower her HbA1C to below 7 mmol/L following a low carbohydrate diet, and that she should go back on insulin (see more here). The endocrinologist said to her yesterday “these numbers are amazing! What are you doing?”. My client responded by saying she was following a low carbohydrate diet designed by me. He also asked her who her Dietitian was, and my client told her my name.  He said “it would be great if you could get those fasting blood glucose numbers under 7 so keep doing what you’re doing”.  He then added, that should my client get pregnant, that he “might need to talk to her about taking insulin, if she doesn’t continue to eat a low carbohydrate diet”. He added, “you are going down the right path. Keep doing what you’re doing!”.

The contrast between the reactions of these two clinicians is striking. As I said above in the disclaimer, it has nothing to do with their respective professions, but about their willingness as individual clinicians to be open to different clinical possibilities, in light of the evidence. Some are, and some aren’t.

As a Dietitian, I wonder how the advice to someone with type 2 diabetes to “eat 60 g of carbs per meals plus snacksandget fasting blood glucose under 7.0 mmol/L” can be reconciled without prescribing insulin. I don’t see that it can be. It is still expected that “Diabetes is a chronic, progressive disease” and it need not be.

By recognizing a low carbohydrate and very low carbohydrate (keto) diet as two of the options of Medical Nutrition Therapy in the treatment of diabetes (both type 1 and type 2), the American Diabetes Association (ADA) has opened the way for Diabetes to NOT be a chronic, progressive disease! (For more information about the policy changes at the ADA, you can read any one of several articles from April 2019 that are posted under the Science Made Simple tab above, including this one.)

As to the belief that “you can’t get your blood glucose under 7 with just Metformin”, people with type 2 diabetes routinely have fasting blood glucose well under 7.0 mmol/L (126 mg/dl) following a well-designed low carbohydrate diet — both with and without Metformin, and clinicians should be current with the literature to know this. In fact, in the April 2019 Consensus Report on Diabetes and Pre-Diabetes the ADA said;

Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences.”

The ADA’s Guidelines do not apply in Canada, but as healthcare professionals, we need to know they exist.

We also need to know that at their annual National Conference, hundreds of Certified Diabetes Educators (CDEs) in the US were recently taught to use a low-carbohydrate diet and a very low carbohydrate (ketogenic) diet as Medical Nutrition Therapy with people with both type 1 and type 2 diabetes, as well as how to manage the many medications prescribed for people with diabetes (you can read about this in this post and this one). As clinicians we need to be aware that a low carbohydrate and a very low carbohydrate (keto) diet are both safe and effective for those with Diabetes, even if it is not public policy in Canada yet.

There are plenty of peer-reviewed studies demonstrating the safety and effectiveness of a well-designed low carb or ketogenic diet for weight loss, as well as for normalizing blood glucose and blood pressure. Many have been reviewed on this site (for more information, please click on the For Physicians & Allied Health Providers tab above).


As I’ve done in previous articles about this client’s progress, I asked her on our weekly call to write in her own words what her visit was like yesterday. This is what she wrote;

“I was excited for my Endocrinologist to see my lowered A1C number and decreasing blood glucose numbers. I went into the appointment knowing that I would see the Dietitian first to review my numbers. She mentioned that the numbers were better, but my fasting glucose was still not ideal. I discussed that they are definitely coming down, although I realize they are not where they should be, and I even got a few under 7 in the past month. This Dietitian was only interested in the past two weeks and mentioned that Joy would not be able to enable me get my fasting glucose under 7 with just Metformin. Seeing the Dietitian really shut me down to discussing anything further with her. I let her gather her information and wanted to move on to my Endo.

Seeing my Endo was a turnaround. He was so amazed with my results, especially with my A1C having come down so much, that he encouraged me to just keep going. I felt so proud and encouraged. He gave me the motivation I was looking for and now I am ready to continue down this path to show him (and that Dietitian!) that it can be done without insulin.”

She has every reason to be proud of her accomplishments! She has been very intentional; about what she eats, about testing her blood sugar and in tweaking the timing of her Meformin.

If you would like more information about my services, please have a look under the Services tab or in the Shop. If you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

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