Keto Corn-Style Tortillas

This recipe is posted as a courtesy to those following a variety of low-carb and ketogenic diets (not necessarily Meal Plans designed by me). This recipe may or may not be appropriate for you.

Keto Corn-Style Tortillas

INGREDIENTS

  • 1 cup almond flour
  • 3 Tbsp coconut flour
  • 1 teaspoons xanthan gum
  • 1/4 cup powdered* psyllium husk
  • 1 Tbsp baking powder
  • 1/4 teaspoon salt
  • 2 teaspoons apple cider vinegar
  • 1 egg
  • 1 Tbsp water

INSTRUCTIONS

  1. *Place 1/4 cup of whole psyllium husk in a clean, dry coffee grinder and pulse several times until it’s a fine powder.
  2. In the bowl of a food processor, add the almond flour, coconut flour, xanthan gum, powdered psyllium husk, baking powder and salt and pulse until well mixed.
  3. Add the egg, apple cider vinegar and water and pulse the food processor until the dough forms a mass, then pulse the food processor a few more times until it forms a ball on the blade.
  4. Remove the dough from the food processor and then knead it as you would regular masa harina dough (the corn flour dough used to make regular corn tortillas) until it forms a smooth ball. Place the dough in a clean plastic bag and let it rest for a full 15 minutes before beginning to make tortillas.
  5. Preheat a stick proof skillet to a medium-high heat. 

6. Cut the ball of dough in half and then each half in 1/4 so that there are eight 1” balls. Lining a tortilla press with a piece of heavy plastic**, place one of the 1″ balls in the press and press well until it is the thickness of a standard corn tortilla. Be careful not to press it too thin or it will break when you try to get it off the plastic). If you don’t have a tortilla press, it can be rolled out between sheets of heavy plastic* until each is 5-inches in diameter.

**Note: I cut open a large freezer weight zipper-style bag to use in the tortilla press when pressing the dough. By peeling one side open, it makes it easy to peel off the other side before transferring the dough to the preheated skillet

7. Immediately transfer the pressed dough onto the preheated non-stick skillet and bake for 20 – 30 seconds (it will have the characteristic char marks!) then flip it over using a spatula and cook until “just” cooked (maybe another 10-15 seconds, maximum.  It is very important not to overcook these or they will not be pliable and will crack when folded. Place on a baking rack for a few minutes to cool, if saving for later or keep them warm wrapped in kitchen cloth until serving.

Can be wrapped in a heavy duty zipper plastic bag and refrigerated or frozen for future use.

Macros (per tortilla)

Energy: 119.2 kcals
Protein: 4.1 g
Net Carbs: 3.8 g
Fat: 8.1 g

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LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

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Reflections on Being a Nutritional Centrist

INTRODUCTION: In a recent article titled Carbohydrates are not Evil I referred to myself as a “nutritional centrist” and in this post I’ll elaborate on what I mean by this. This post is more of an editorial than a standard ‘Science Made Simple’ article. References can be found in the previous articles by using the search feature.


Much of the discussion about nutrition these days on social media seems to take an “all-or-nothing” stance.

As in politics, there are those that tend towards a “left-wing” (liberal) position and others who tend towards a “right-wing” (conservative) position; some who are libertarian (let people decide for themselves) and others who are very authoritarian (dictate what they believe is best).

When it comes to nutrition, I am a centrist.

Defining Nutrition Centrism
In this article, I am using the term "centrism" to include a very wide range of nutritional positions apart from any at extreme ends of the spectrum. I believe that a wide range of nutritional centrists positions are supported by current, evidence-based science.

Veganism and Carnivory – two ends of the spectrum

In the food world there are vegans on one hand and carnivores on the other.  One eats only plant-based food with nothing coming from animals (no eggs, milk or cheese) and the other eats only animal flesh food (no fruit, vegetables or dairy). These can be looked at as the nutritional equivalents to ” left wing” and “right wing” political positions. While I respect people’s individual right to choose veganism or carnivory as a lifestyle, for health reasons, or on the basis of ethical or religious beliefs, in my understanding there are significant nutritional challenges to both ends of the spectrum.

Nutritional centrists – vegetarians, pescatarians and omnivores

Somewhere between veganism and carnivory are vegetarians
(who eat mostly plant-based foods but will also eat eggs, milk and cheese because no animal is killed or harmed in the making of these) and those who are omnivores (that will eat food from a wide variety of plant and animal sources). Somewhere in the middle of these two are pescatarians who are like vegetarians but who will also eat fish (perhaps because they are not mammals, and sometimes only when they are wild species i.e. not man raised).

From my perspective, people who chose any of these lifestyles fall somewhere in the “nutritional centrist” position. I find it easy to support people following any of these lifestyle or ethical choices because it is possible to design a diet that ensures adequate nutritional intake of a wide range of macro- and micro-nutrients from the foods they choose to eat.

Whole-food-plant-based

Those who follow a “whole-food plant-based diet” can be either vegan or vegetarian so in my understanding, whole-food plant-based vegetarians fall somewhere in the “nutritional centrist” position, whereas whole-food plant-based  vegans are vegans with an approach that falls at one end of the spectrum.

Low Carb High Fat and Ketogenic diets – a centrist approach

As I’ve mentioned in numerous previous articles, there are several different types of “low carb” and “ketogenic” diets.

For example, if a client comes to me with a dietary prescription from a physician for a specific type of ketogenic diet to support a specific medical or metabolic condition that is a very different scenario than someone who wants me to help them with “quick weight loss” using a “keto diet”.

As a “nutritional centrist” my approach to supporting people in following a low carbohydrate lifestyle for weight loss is to start at a moderately-low level of carbohydrates (130 g carbohydrate per day) and lower the amount of carbohydrate as needed to achieve clinical outcomes. If individuals are insulin sensitive, this level of carbohydrate intake often works very well, especially at first when people were formerly eating ~300+ g of carbohydrate per day. For those who are insulin resistant or have Type 2 Diabetes, I start at a moderately-low level of carbohydrate intake and with self-monitoring of blood sugar and follow-up and oversight from their doctor with respect to any medications taken, will gradually lower carbohydrate intake as needed to achieve the desired clinical outcome(s).

It is not a “one-sized-fits-all” approach. As documented in several previous articles, people’s glycemic (blood sugar) response to carbohydrate varies significantly, even among those who are insulin sensitive and also in those with Type 2 Diabetes, so determining individual blood sugar response to carbohydrate is the best way to determine which types and amounts of carbohydrate people respond best to. I don’t believe it is appropriate or necessary for everyone to follow a “keto diet”.

Nutritional Centrism with respect to added fat

Amongst those that teach and support a “low carb” lifestyle, there are those that promote lots of added fat from a wide variety of sources.  These are people that believe in adding coconut oil and butter to beverages, butter to top meat and vegetables and using whipping cream copiously. From the beginning this is not an approach I have taken. In light of the recent scientific evidence (such as the large-scale PURE epidemiological study and others), I do not believe that moderate saturated fat intake is harmful to cardiovascular health. At the same time, I see no reason that if added fat is helpful in a particular person’s diet, that fats such as cold-expressed olive and avocado oil as well as nut and seed oils such as macadamia, walnut and almond oil aren’t suitable options.

I don’t see the need for extremes with regards to added fat. I encourage people for whom the recommendation is appropriate to add enough good quality healthy fat to make the vegetables or salad taste interesting enough that they will want to eat a fair amount of them and enjoy them. After all, eating isn’t only about getting enough nutrients, but enjoying the foods that are eaten.

Fat that comes with protein

Unless there is a medical or metabolic condition involved which precludes it, I encourage people to eat the fat that comes naturally with their protein source if they enjoy doing so.

I encourage folks to trim excess external fat off a fatty cut of steak, but if they enjoy chewing on the bone on a rib steak to ‘go for it’. The yolk in an egg or the fat in cheese is not harmful when eaten in moderate amounts so unless there are strong risk factors, I don’t believe people need to avoid or limit these foods.

While the new Canada Food guide recommends limiting foods with saturated fat based on the fact that dietary saturated fat raises total-LDL cholesterol, as I’ve documented in several previous articles I don’t believe when considering all the recent evidence that there is compelling reason to advise all people to limit foods containing cheese or to select plant-based foods over foods that contain saturated fat.

As mentioned in a few recent articles, Canada Food Guide is directed towards a healthy population in order to help them stay metabolically well and I believe that the whole-food approach of the new Guide which avoids refined grains, fruit juice and processed foods is a good evidence-based approach to accomplishing this, and one I support in my practice.

My concern as covered recently is that as many as 88% of Americans are already metabolically unwell (with presumably a slightly lower percentage in Canada due to our slightly lower obesity statistics) so in those that already have indications of insulin resistance (which is a large percentage of my client base), I do recommend a whole-foods approach but with a lower percentage of carbohydrate intake.  In my understanding, this is a “nutritional centrist” approach which is supported by the American Diabetes Association and the European Association for the Study of Diabetes who both support the use of a low carbohydrate diet as Medical Nutrition Therapy in the management of Type 2 Diabetes and for weight loss.

Supporting lifestyle choices

Veganism, like carnivory is a lifestyle choice that is sometimes made for religious or ethical reasons and sometimes for health reasons.  Regardless of the reason for the choice, these are lifestyles that need to be respected and supported by healthcare professionals who are qualified to do so.

As a “nutritional centrist” I can help healthy individuals follow the new Canada Food Guide and provide meals for their family along those lines if they so choose, as well as to support those who are already metabolically unhealthy using everything from a Mediterranean diet, a whole-food plant-based approach or a low carbohydrate or ketogenic diet. There is no “one-sized-fits-all” diet for any of these approaches and each should be tailored to individual needs.

No Conspiracy Theories

Conspiracy theories abound in many areas from religion to politics and there are plenty in the nutrition arena, as well. As a “nutritional centrist“, I don’t believe that “big-pharma” and “big-food” are behind everything, but at the same time I am also not naive enough to think that industries and special interests groups don’t attempt to influence the marketplace or government funding or policies by the types of research they fund, or by other means. I give scientists and researchers the benefit of the doubt that their intentions are in the interest of good science and the public interest, even though on occasion it is found out otherwise.

No Conspiracy Theories

My writing about topics such the funding of the Harvard studies by the sugar industry does not mean that I believe the scientists involved deliberately wrote biased reports. The articles were written to document the fact that researchers were funded by the sugar industry to write articles about why saturated fat was the underlying issue with respect to cardiovascular disease. Likewise, the recently translated French language newspaper report that shed light on why the government (e.g. Agriculture Canada or a political party’s leadership) may have been motivated to encourage the highlighting of legumes does not mean anything inappropriate occurred.  In my understanding, conspiracy theories are not compatible with a “nutritional centrist” position.

I would encourage my readers to give scientists and researchers the benefit of the doubt when it comes to their intentions; unless there is very credible and verifiable reasons to believe otherwise.

Libertarian versus Authoritarian Approach – a centrist approach

libertarian approach to dietary choice supports each person’s individual’s right to choose the most suitable dietary approach for themselves whereas an authoritarian approach essentially tells a person what is best for them.

As a “nutritional centrist“, I am frequently in the scientific literature, reading and reviewing the latest studies and evaluating these in light of what is already known about nutrition. My motivation in writing articles that put these studies into “plain English” is that so ordinary people can evaluate these in light of what they know and choose what they feel is best for them. From my perspective, the current available quality research on the subject is the “authority” but by no means should this be used in an authoritarian way to tell a person what is best for them. My position as a “nutritional centrist” is that people should be presented with the range of available evidenced-based options and the supporting science behind those options, but in accordance with a libertarian approach, the choice is theirs to make.

I hope that as a result of reading this article, you have a fuller understanding of what I believe and why and that I support a range of evidence-based dietary approaches including those who want to follow the Canada Food Guide, a Mediterranean approach, a whole-food vegetarian plant-based approach or a low carbohydrate approach and that include moderate amounts of healthy fats of all types. There certainly isn’t a “one-sized-fits-all” dietary approach suitable for everyone so from my perspective, the issue is which one may be best suited to help you achieve your health and nutrition goals, within your personal food preferences.

If you would like to know more about the services I offer, please click on the Services tab and if you have questions related to those, please feel free to send me a note using the Contact Me form located on the tab above.

To your good health!

Joy

Feedback and question from Dr. Andrew Samis, MD, PhD – shared with prior permission

UPDATE: February 1, 2019 13:20

Dr. Andrew Samis, MD, PhD, a surgeon and critical care specialist from Kingston, Ontario asked a very interesting question on Twitter, in response to this article;

Could the same eating strategy be healthy for one person, and make a second metabolically unhealthy?”

This was my response;

Yes, I believe there is ample evidence that the same eating strategy could be healthy for one person and make a second person metabolically unhealthy. Monitoring metabolic markers enables us to catch this early and make adjustments, as necessary.

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LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

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Quebec newspaper:”no coincidence” dried beans so prominent in new Canada Food Guide

DISCLAIMER: (February 1, 2019) The views expressed in the translated editorial are solely the opinions of the Journal de Montréal and its editors.

Today, the French language populist newspaper Le Journal de Montreal published an article that states that it is “no coincidence” that Health Canada featured dried beans so prominently in the new Canada Food Guide; ‘certainly they are good for health’, but there is also an ‘obvious economic benefit and benefit to local agricultural interests'[1].

The pea arguments

[translation] “This is not well known, but Canada is the major supplier of legumes (pulses) on the planet.  Between 35% and 40% of world production comes from here, essentially from the prairie  provinces. Quebec is participating by growing dry beans.”

Economic and Local Interest

The article states that in addition to the health benefits there are two reasons why legumes (pulses) feature so prominently in the new Canada Food Guide;

I – Economic interests – the first “because”

The Journal de Montreal article states that one of the additional reasons  legumes (pulses) were highlighted in the new Canada Food Guide was because Agriculture Canada had forecast a 20% decrease in production of legumes during 2019[1]. The reason for this decrease production is outlined below.

“Because of falling production”

II – benefit to local agriculture – the second “because”

The article also states that growing legumes benefits local agricultural interests[1] because;

“legumes contain bacteria that allow them to transfer nitrogen from the air to the ground and this nitrogen is needed for growth of vegetables.”

This means that by growing legumes one season, the soil becomes enriched with nitrogen which helps the growing of other food crops the following growing season.


BACKGROUND TO THE FIRST “because”

Last March, the CBC reported that India, a top importer of Canadian chickpeas and lentils imposed a huge tariff on legumes which resulted in Canadian producers facing duties of 33% on lentils and 50% on desi chickpeas. The type that Canada produces are kabuli chickpeas, which have a slightly lower tariff of 40% [2]. These tariffs resulted in a decreased demand for Canadian legumes (pulses), as well as a price decline.

CBC also reported [3] that India’s imposed tariffs on pulses has sent “a huge ripple effect through the whole industry” as dried beans are a 1.1 billion dollar industry in Saskatchewan alone and India is it’s biggest customer[3].

“Farmers are calling on Prime Minister Justin Trudeau for help to make sure that business continues and to consider the importance of agriculture in Canada”[3].

New Canada Food Guide – free of influence?

The article in Le Journal de Montreal raises the question as to how much of the prominent inclusion of legumes (pulses) in the new Canada Food Guide has to do with their reported health benefits and how much may have been driven by industry or lobby groups influence on various levels of government due to decreased demand and resulting falling production.

UPDATE:(February 3, 2019): While it is evident from the CBC report[3] above that the pulse industry was exerting pressure on various levels of the Federal government to address decreased demand for its product, decreased legume production would have been factored into the design of the new Canada Food Guide as both (1) the role of legumes and plant-based dietary patterns on health and (2) food availability of legumes in light of decreased production would have necessarily been evaluated i.e. two of the four of the direct influences involved Dietary Guidance design. [see “Evidence Review for Dietary Guidance: Summary of results and implications for Canada’s Food Guide, 2015” – available here) which on page 2 refers to the longer document “Colapinto CK, Ellis A, Faloon-Drew K, Lowell H Developing an evidence review cycle model for Canadian dietary guidance. Journal of Nutrition Education and Behavior. 2016;48:77-83)” that has Figure 2, below. This figure indicates that Food Availability of the Food Supply is one of the four direct influences in the development of Dietary Guidance. Figure 2 Adapted Framework for Developing Dietary Guidance – Evidence Review Cycle Model for Canadian Dietary Guidance, from Colapinto et al 2016 While decreased legume production (i.e. food availability) would have been factored into the decision for Canadians to include more legumes in their diet for health benefits on the new Canada Food Guide, I can find no evidence that legume’s benefit to agriculture was ever evaluated. Some thoughts… I think it is important to know what is said in the populist press about important issues such as this because a large segment of the population relies on such sources, as well as the internet for their news. Often times such stories are based on truth but leave what isn’t said up to the audience (readers or listeners). Knowing the facts behind the story enables us to tease out conjecture from fact.

If you would like to learn more about what I do and how I can help, please have a look at the Services tab to learn more about the hourly consultations and packages that I offer. If you have questions about my services, please send me a note using the Contact Me form located on the tab above and I will reply as soon as I can.To your good health!

Joy

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Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Le Journal de Montreal – 29 January 2019 0600 https://www.journaldemontreal.com/2019/01/29/des-arguments-de-pois?
  2. CBC News – Pulse industry worries about precedent as India slaps 60% tariff on chickpeas – March 02, 2018 3:50 PM CT  https://www.cbc.ca/news/canada/saskatchewan/india-chickpea-tariff-pulse-industry-1.4559947
  3. CBC News – Prairie farmers want Canada’s trade dispute with India ‘straightened out’ – February 25, 2018 4:00 AM CT

 

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Carbohydrates are Not Evil

Much of the discussion about nutrition these days on social media seems to take an “all-or-nothing” stance on carbohydrates.  On one hand there are those who promote a plant-based diet that necessarily comes with a large amount of carbohydrate as grains, legumes (pulses) such as beans and lentils as well as carbohydrate-containing vegetables and fruit, and on the other hand there are those who eschew anything with the remotest amount of carbohydrate.

In politics, there are left-leaning ‘liberals’ and right-leaning ‘conservatives’, as well as those that hold a moderate position called “centrists”.

I am a centrist when it comes to my position regarding carbohydrates. In this article, I will elaborate on the following;

  1. Carbs are not evil or single-handedly responsible for the obesity epidemic or metabolic diseases. If that were the case, then the traditional diets of much of Asia and West Africa would have resulted in obesity and diabetes and they did not. It is the degree of processing of the carbohydrate-based foods that impacts the blood glucose and blood insulin response of carbohydrate-containing foods.
  2. Carbohydrate-based foods combined with fat in the same food ‘hijack’ the reward center of our brains (striatum), resulting in over-consumption.
  3. Carbohydrates are not essential macronutrients.

Part 1 – Degree of Processing

Processing carbohydrate even in simple ways such as cooking or grinding means that more of the carbohydrate is available to the body to be digested. As pointed out in an earlier article which I will refer to throughout this section, when grains are cooked they become much more digestible – meaning that more of the nutrients in the grain is available to be absorbed. In the case of potatoes, there is double or triple the amount of energy (calories) available to the body when they are cooked versus when they are raw.

Mechanical processing, such pounding, grinding or pureeing are also forms of food processing which have an effect on how many nutrients are available to be digested. The nutrients available to the body when food is eaten raw and whole versus raw and pounded is significant.

Glucose Response – based on the amount of food processing

Mechanical processing of a food doesn’t change the amount of carbohydrate that is in it. That is, when 60 g of whole apple are compared with 60 g of pureed apple or 60 g of juiced apple, there are the same amount of carbohydrates in each and the Glycemic Index of these are similar, however when these foods are eaten the blood glucose response 90 minutes later is significantly different. As outlined in the earlier article, in healthy individuals, blood glucose level goes very high with the juiced apple and in response to the release of insulin, blood glucose then goes very low, below baseline. The response that we see with the juiced apple in healthy individuals is typical of what is seen with other forms of ultra-processed carbohydrates.

This is why it is preferable for metabolically healthy people to eat carbohydrate-based foods as whole, unprocessed foods with a minimum of disruption to the cell structure.

Insulin Response with Mechanical Processing

When healthy individuals eat grain-based meals, the plasma insulin response is inversely related to the particle size of the grain.  That is whole, unprocessed grain releases less insulin than the same amount of cracked grain, which is still less than the same amount of course flour. The highest amount of insulin is released in response to eating the same amount of fine flour.

This increased insulin response of eating grains that are highly processed can drive chronic hyperinsulinemia (chronically high levels of insulin) that eventually results in insulin resistance; the beginning of the metabolic disease process.

It is for this reason that for metabolically healthy individuals, eating whole, unrefined grains is recommended.

Effect or Lack of Effect of Fiber

It is the lack of disruption to the cell structure of the grain that limits the insulin response and not the fiber content that makes the difference.

As mentioned in the earlier article (link above), studies have been done with bread where the fiber was added back in (such as in so-called “whole wheat bread” which is essentially white bread with added bran) and the insulin response was the same as with white bread, so it is not the amount of fiber in the grain that makes the difference, but the lack of disruption to the grain structure itself. I find it helpful to think of it in terms of ‘the fiber that counts is that which is part of the whole, undisrupted grain’.  (Note: it is for this reason that I only factor “net carbs” for food whose fiber is in this undisrupted form. For all other products where fiber is added, I don’t deduct the fiber).

The disruption of the structure of the grain also has an adverse effect on GIP response (an incretin hormone released from the K-cells high up in the intestine that triggers the release of insulin). Bread made with flour (as opposed to whole, intact grains) results in a much larger and earlier plasma GIP response, which in turn results in a higher and earlier insulin response, than bread made with whole kernel grains, such as artisanal rye or wheat breads.

In metabolically healthy individuals, the eating of whole, intact minimally processed carbohydrate-containing food is preferable, as opposed to eating processed carbohydrate-containing foods (be it grains or fruit) with significant disruption to the cell structure.

Part II – Carbohydrate and Fat Combined

In nature, there are very few foods in the human diet that contain a combination of both carbohydrate and fat in substantial quantities. Human breast milk is one of those few natural foods, along with some nuts and seeds. When humans began drinking the milk of other mammals such as goats, sheep and cows, milk became one of those foods.

Also as outlined in a previous article foods with both fat and carbs together result in much more dopamine being released from the reward-center of our brain, called the striatum. Dopamine is the same neurotransmitter that is released during sex and that is involved in the addictive “runner’s high” familiar to athletes so this is a very powerful neurotransmitter.

It is believed that there are separate areas of the brain that evaluate carb-based foods and fat-based foods but when carbs and fat appear in the same food together, this results in what the researchers called a “supra-additive effect“. That is, both areas of the brain get activated at the same time, resulting in much more dopamine being released from the striatum and a much bigger feeling of “reward” being produced. This combination of carbs and fat in the same food is why we find foods such as French fries, donuts and potato chips irresistible and this powerful reward-system is why we’ll  choose French fries over baked potato and why we have no difficulty wolfing back a few donuts, even when we’ve just eaten a meal.

This “supra-additive effect” on the pleasure center of our brain along with the fact that more insulin is released when both carbs and fat are eaten together helps explain the roots of the current obesity epidemic and the metabolic diseases such as Type 2 Diabetes that go along with it. The high rates of obesity seen more recently in places like China (as covered in this article) are due to the adoption of Western eating habits (refined, processed foods) that are notoriously high in both carbohydrates and fat.

When foods that are rich sources of carbohydrate are eaten it is best that foods that are also rich sources of fat are not eaten at the same time in order to avoid this supra-additive effect.

I do not believe that carbohydrate-based foods in and by themselves in metabolically healthy individuals are the underlying cause of obesity and metabolic disease. I believe that it is the (1) consumption of carbohydrate-based foods that have undergone some kind of food processing (grinding, milling, pureeing, etc) that has disrupted their cell structure and (2) the consumption of foods that combine both carbohydrate and fat in the same food that have driven both.

Part III – Carbohydrates are Not Essential Macronutrients

With all the arguing about eating more carbs or less carbs, it needs to be emphasized that carbohydrates are not essential nutrients. Yes, the body needs a certain amount of glucose for the brain, but the body can make this glucose from protein and fat through a process called gluconeogenesis.

This is not simply my opinion, but is stated by the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005) on page 275;

The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed. 

That is, there is no essential need for dietary carbohydrate provided there are adequate amounts of protein and fat provided in the diet.

The Recommended Dietary Allowance (RDA) for carbohydrate is set at 130 g / carbohydrate per day based on the average minimum amount of glucose utilized by the brain— however the body can manufacture this glucose from protein or fat. A well-designed low carbohydrate diet provides sufficient amounts of fat and  protein such that the body can manufacture the glucose it needs.

Carbohydrate – to eat or not to eat

For Healthy Individuals

For those who are healthy and metabolically flexible, consumption of whole, unprocessed carbohydrate-containing foods such as whole grains, tubers, starchy vegetables such as peas, squash and corn and whole fruit are of no concern. Due to the ‘supra-additive’ effect of fats with carbohydrate, I recommend that when eating carbohydrate-based foods, to avoid foods that are a rich source of fat.

For Metabolically Unhealthy Individuals

As mentioned in the two previous articles related to the new Canada Food Guide (here and here), 88% of Americans are already metabolically unwell, with presumably a large percentage of Canadians as well.

That is, only 12% have metabolic health defined as;

  1. Waist Circumference: < 102 cm (40 inches) for men and 88 cm (34.5 inches) in women
  2. Systolic Blood Pressure: < 120 mmHG
  3. Diastolic Blood Pressure: < 80 mmHG
  4. Glucose: < 5.5 mmol/L (100 mg/dL)
  5. HbA1c: < 5.7%
  6. Triglycerides: < 1.7 mmol/l (< 150 mg/dL)
  7. HDL cholesterol: ≥ 1.00 mmol/L (≥40 mg/dL) in men and ≥ 1.30 mmol/L (50 mg/dl) in women

For the large majority who are metabolically unhealthy, knowing which carbohydrate-based food raise one’s blood glucose levels is important. Even if lab tests show one’s fasting blood glucose is still normal, blood glucose levels after eating carbohydrate may be quite abnormal, and even more significantly insulin levels may be as well. You can read more about that here. As mentioned previously in this article, these high insulin levels are what drives metabolic disease by driving insulin resistance.

Eating a low carbohydrate diet can be very helpful to lower blood glucose response and lower chronically high levels of insulin. Which carbohydrates can be tolerated and in what quantities varies considerably between people, but is easy to determine and I help people do this.

For those that already have Type 2 Diabetes, reducing carbohydrate intake for a considerable length of time will enable them to reduce their overall blood glucose and insulin response, which will help them reverse the symptoms of Diabetes as well as other metabolic diseases that often go along with it, such as high blood pressure and high triglycerides. In time, some carbohydrates may be able to be eaten again however the amount and type will vary between individuals.

Final Thoughts…

Carbohydrates aren’t “evil”.  In and by themselves, they don’t result in obesity or metabolic disease. It is the amount of food processing that carbohydrate-containing foods have undergone that results in cell-wall disruption that will determine how much of a glucose- or insulin-response they will cause. In metabolically healthy people, eating minimally processed whole grains, starchy vegetables and fruit without a source of fat is fine.

For those who are metabolically unhealthy, especially those who have a measurably abnormal glucose- or insulin-response, the amount of carbohydrate that can be tolerated is individual and will need to be determined.

For those who have Type 2 Diabetes and follow a low carbohydrate diet to reduce the symptoms of high blood sugar or metabolic diseases that often go along with it, eating the amount of tolerated carbohydrates as minimally processed ones, without a source of fat is also best.

There is no “one size fits all” diet that is suitable for everyone.

For metabolically healthy individuals, following the new Canada Food Guide and selecting carbohydrate sources using the above principles can provide people with a healthy diet. For those that are already metabolically unhealthy, I can help design a Meal Plan that will meet your energy and nutrient needs and that provides the amount of carbohydrate that you can tolerate. If you would like more information, please send me a note using the Contact Me form, above and I’ll be happy to reply soon.

To your good health!

Joy

You can follow me at:

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Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

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New Canada Food Guide – carbohydrate estimate of the sample plate

There has been some discussion on Twitter that the macronutrient estimated in the previous article of an average ~325-350 g of carbohydrate per day based on a 2000 kcal per day diet for the new Canada Food Guide was “too high”, so in the interest of determining whether it was accurate, I’ve evaluated the carbohydrate content of the illustrated plate.

Actual Number, Standard Cup Measure and Scale of Reference

Since no portion sizes are provided with the new guide, both scale of reference or when available, the actual number of items was used.

The actual number of chickpeas, kidney beans, nuts and seeds were used and determine in terms of the portions of a standard cup measure.

For items such as vegetables and fruit, actual portions were measured using a standard set of stainless steel measuring cups.

For any remaining quantities, since a quarter of an egg is featured on the illustration of a healthy plate and a large sized egg is the standard on which nutrient analysis is based and this is of a known size, I used the 1/4 of a large egg as the scale of reference for other items,when the actual number was not available.

Carbohydrate Content of the Protein Group

The protein group contributed~37 g of carbohydrate to the sample plate.

Carbohydrate content of the protein group on the sample plate

Carbohydrate Content of the Whole Grains Group

The whole grains group contributed more than~58 g of carbohydrate to the sample plate.

Carbohydrate content of the whole grains group on the sample plate

Carbohydrate Content of the Vegetable and Fruit Group

The vegetable and fruit group contributed more than~53 g of carbohydrate to the sample plate.

Carbohydrate content of the vegetable and fruit group on the sample plate

The sample plate used as an illustration for the new Canada Food Guide has close to 150 g  of carbohydrate on it— and this is for only one meal. The carbohydrate content of lunch and dinner (the two generally mixed meals of the day) already totals as much as 300 g of carbohydrate — and there’s still breakfast to add! Whether it’s a couple of whole grain toast (30 g carbs), 2 tbsp unsweetened nut butter (6 g carbs) or some whole grain cereal (30 g carbs) and 1/2 cup of low fat unsweetened yogurt (6 gm carbs), there’s another 42 g of carbs (plus the carbs for the milk or nut or soy milk to pour on the cereal); bringing the average for the three meals alone to 337+ g of carbs which is exactly what it was estimated as in the previous article — as between 325 – 350 g carbohydrate per day.

And this is just for 3  MEALS.

What about snacks?

Yes, snacks are mentioned  TWICE on the first page under the link for “eating habits” in the section on “how to make a meal plan and stick to it”;

Recommendations for meals and snacks

Assuming a person eats a “healthy whole grain” muffin without any dried fruit in it for coffee break in the morning (~50 g of carbs) and a single piece of fruit like an apple or orange mid-afternoon (15 g of carbs), these add another 65 g of carbohydrate to this day, bringing the average total to over 400 g of carbohydrate for one day.

UPDATE (January 26, 2019) Given the sample plate is there to demonstrate proportions, not portions — looking at the grain group alone, the proportion of grain is 1/4 of the dietary intake. Based on a 2000 kcal/day diet, that’s 500 calories per day / ~125 g of carbohydrate from the grain group alone. Add in the carbohydrate from the largely plant-based protein group, that’s another ~100 g carbohydrate per day, on average. Since half the plate should be vegetables and fruit and both starchy vegetables such as squash, yam, potato, peas and corn contain 15 g of carbohydrate per half cup, as does the same amount as fruit, it is reasonable to assume that on average, half of the vegetable servings will be comprised of a mixture of starchy vegetables — along with the fruit servings and the other quarter of the plate of non-starchy vegetables. That is, 1/4 of the vegetable and fruit side of the plate will be carbohydrate-containing, adding another ~125 g of carbohydrate per day to the diet. Of course, there will be days where people will eat lower carbohydrate grains like quinoa and lower carbohydrate plant-based protein such as tofu, but equally there will be days where vegetable servings are starchy ones such as peas and corn along with plant-based proteins that are higher in carbohydrate, such as legumes like kidney beans. So, the numbers above are averages.  Whether one uses the portions on sample plate as a basis for estimating the carbohydrate content or uses the proportion of the diet that is carbohydrate, the results fall in the same range of an average of 325 – 350 g carbohydrate per day, based on only 3 meals (without snacks).

Real Life Meals

Despite there being no “portion sizes” in the new Canada Food Guide, some insist that a “serving of pasta is 1/2 cup” because that is what is illustrated on the sample plate. Okay, let’s go with that for the sake of argument.

If a person ate twice that amount of pasta (instead of also eating some wild rice or rice or bread, for example), this is what the size of that portion would look like (of course it would be “whole grain”):

1 cup of cooked pasta – size of a tennis ball

I’ve been in private practice a long time and in my experience only children and women who are portion restricting eat pasta in amount the size of a tennis ball.  More than 90% of my clients report eating servings of pasta that are significantly larger than that. In fact, the usual ‘smaller-sized’ servings are about a cup and a half when eaten along with salad or a cooked vegetable (bigger if eaten alone). What does a cup and a half of pasta look like? It looks like this;

1 1/2 cups of whole grain pasta

…and this amount of pasta without sauce has 45 g of carbohydrate in it — which is still less than the 53 g of carbs illustrated in the Canada Food Guide sample plate.

Naturally, no one is expected to eat exactly like the “sample meal”, but whether one eats their “whole grains” as all brown rice, wild rice, Bulgar wheat or something else, 1/4 of the plate all have the same amount of carbohydrate per 1/2 cup serving as pasta.

Add to the pasta the vegetables and fruits above on the sample plate (or corresponding assortment of a mix of starchy, non-starchy vegetables and fruit) and that adds up to 100 g of carbohydrate …and we still haven’t added any protein into the meal, yet.

Add another 37 g of carbohydrate for an assortment of legumes, nuts and seeds as well as a bit of meat and “low fat” cheese for the pasta sauce (because after all, we are encouraged to eat animal protein “less often”) and that totals more than 135 g of carbs for just this one “real life” meal. Eat a meal like the one in the sample illustrations, it adds up to 150 g of carbs!

The question I’ve been asked is if it is “healthy whole grain”, then what’s the concern?

For metabolically healthy adults, none. For metabolically healthy adults, the new Canada Food Guide is a huge improvement from it’s predecessor! It eliminates refined carbs, sugary drinks including fruit juice and encourages eating whole foods, cooked at home as much as possible.

The problem is, most adults are not metabolically healthy.

Majority of Adults Metabolically Unhealthy

As mentioned in the previous article research indicates that as many as 88% of Americans[1] are already metabolically unwell, with presumably a large percentage of Canadians as well. That is, only 12% of the adult population would be considered metabolically healthy [1]”.

Metabolic Health is defined as [1];

  1. Waist Circumference: < 102 cm (40 inches) for men and 88 cm (34.5 inches) in women
  2. Systolic Blood Pressure: < 120 mmHG
  3. Diastolic Blood Pressure: < 80 mmHG
  4. Glucose: < 5.5 mmol/L (100 mg/dL)
  5. HbA1c: < 5.7%
  6. Triglycerides: < 1.7 mmol/l (< 150 mg/dL)
  7. HDL cholesterol: ≥ 1.00 mmol/L (≥40 mg/dL) in men and ≥ 1.30 mmol/L (50 mg/dl) in women

Given the slightly lower rates of obesity in Canada (1 in 4) as in the United States (1 in 3), presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy. For the sake of argument, let’s assume that there are TWICE as many metabolically healthy adults in Canada, which would mean that only slightly over 75% of adults are metabolically unhealthy.  Since Canada’s Food Guide is intended for a healthy population in order to reduce the risk of overweight and obesity as well as chronic diseases manifest as the markers above, that means that the new Canada Food Guide — as beautiful as it is, is only appropriate for ~1/4 of the adult population.

For the other 75% of adults that are presumably metabolically unwell, a diet that provides 342 g of carbohydrate per day for meals alone (based on a 2000 kcal per day diet) and as much as 400 g of carbohydrate per day with 2 “healthy” snacks is not going to address the large percentage of adults who are already demonstrating symptoms of being carbohydrate intolerant.

Carbohydrate Intolerance

As outlined in detail in a previous article, based on a large-scale 2016 study that looked at the blood glucose response and circulating insulin responses from 7800 adults during a 5-hour Oral Glucose Tolerance Test, 53% had normal glucose tolerance at 2 hours but of these people, 75% had  abnormal blood sugar results between 30 minutes and 60 minutes  demonstrating that they were already hyperinsulinemic, although it went undetected on standard assessors that only look at glucose and insulin responses at baseline (fasting) and at 2 hours.

These people are already exhibiting symptoms of not tolerating a normal carbohydrate load of 100 g.

How does it make sense to encourage adults that already have abnormal glucose response to eat 150 g of carbohydrate per meal when these people already have an impaired first-phase insulin response? How will eating “whole grains” and the “added fiber from plant-based proteins” improve their first-phase insulin response (which likely results from dysfunction in the release of the incretin hormone GIP (Glucose-dependent Insulinotropic Polypeptide) from the K-cells?

For these people, continuing to eat a diet high in carbohydrate, irrespective of the amount of fiber or the glycemic load will not restore their insulin response, and in time is likely to make it worse. This is my concern.

Canada Food Guide is for a healthy population to avoid the risk of chronic disease and based on these statistics most adults are not metabolically healthy.

Final Thoughts…

For the ~1/4 of adults that are metabolically healthy, I think the new Canada Food Guide is beautiful and focuses on real, whole food, preparing food at home, avoiding refined grains and avoiding high sugar beverages such as fruit juice (formerly seen as “healthy”).

For the high percentage of adults that are already metabolically unwell and who already demonstrate abnormal glucose responses, I don’t see that advising them to eat a diet that is between 325-350 g of carbohydrate per day (meals without snacks) helps them to avoid the progression to Type 2 Diabetes.

If you are part of the majority of Canadians that are already struggling with overweight and/or being metabolically unwell and would like to know more about how I may be able to help you achieve a healthy body weight and restore metabolic markers then please send me a note using the Contact Me form, on the tab above.

To your good health!

Joy

You can follow me at:

         https://twitter.com/lchfRD

          https://www.facebook.com/lchfRD/

           https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

References

  1. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  2. Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

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The New Canada Food Guide – high carbohydrate & limited saturated fat

The new Canada Food Guide was officially released in Montreal today, January 22, 2019 and the suite of Food Guide resources includes;

  • Canada’s Dietary Guidelines for Health Professionals and Policy Makers
  • Food Guide Snapshot
  • Resources such as actionable advice, videos and recipes
  • Evidence including the Evidence Review for Dietary Guidance 2015 and the Food, Nutrients and Health: Interim Evidence Update 2018
Canada Food Guide “plate”

Canada Food Guide – directed towards healthy Canadians

According to Eating Well with Canada’s Food Guide – A Resource for Educators and Communicators the goal of Canada’s Food Guide is to ‘define and promote healthy eating for Canadians’ and to ‘translate the science of nutrition and health into a healthy eating pattern’. By definition, Canada’s Food Guide is directed towards a healthy Canadian population so they can meet their nutrient needs and reduce their risk of obesity and chronic diseases.

“By following Canada’s Food Guide, Canadians will be able to meet their nutrient needs and reduce their risk of obesity and chronic diseases such as type 2 diabetes, heart disease, certain types of cancer and osteoporosis.”

The New Canada Food Guide – no more rainbow

The familiar “rainbow” visual has been replaced with clear, simple photography illustrating food choices. In response to feedback from focus groups that the draft of the Guide focused too much on “how to eat” but didn’t provide adequate direction on “what to eat”, the final version clearly illustrates the proportion of vegetables and fruit, grains and protein foods to eat on a plate.

“Protein Foods”

As anticipated in the draft, the new Canada Food Guide dropped the Meat and Milk groups replacing it with an all-inclusive Protein food group which includes approximately equal amounts of animal-based and plant-based proteins.

Protein Foods Group

Animal-based proteins included beef, poultry, fish, egg and yogurt. Noticeably absent from animal-based proteins was cheese.

Plant-based proteins included legumes and pulses (beans and lentils), nuts and seeds and tofu.

Whole Grains

Whole Grains Food Group

The Whole Grain group is visually exemplified by whole grain bread, pasta, rice, wild rice, and quinoa and the link that relates to “whole grain foods” contains the following information;

  • Whole grain foods are good for you
  • Whole grain foods have important nutrients such as: fiber, vitamins and minerals
  • Whole grain foods are a healthier choice than refined grains because whole grain foods include all parts of the grain. Refined grains have some parts of the grain removed during processing.
  • Whole grain foods have more fibre than refined grains. Eating foods higher in fibre can help lower your risk of stroke, colon cancer, heart disease and type 2 diabetes
  • Make sure your choices are actually whole grain. Whole wheat and multi-grain foods may not be whole grain. Some foods may look like they are whole grain because of their colour, but they may not be. Read the ingredient list and choose foods that have the word “whole grain” followed by the name of the grain as one of the first ingredients like; whole grain oats, whole grain wheat. Whole wheat foods are not whole grain, but can still be a healthy choice as they contain fibre.
  • Use the nutrition facts table to compare the amount of fibre between products. Look at the % daily value to choose those with more fibre.

Vegetables and Fruit

Vegetable and Fruit Food Group

The new Guide illustrated that 1/2 the plate should be comprised of vegetables and fruit and the plate showed mostly non-starchy vegetables as broccoli, carrot, shredded peppers, cabbage, spinach and tomato, with a small amount of starchy vegetables as potato, yam and peas.

Fruit as blueberries, strawberry and apple was illustrated as a small proportion of the overall.

Beverage of Choice – water

The place setting showed a glass of water with the words “make water your drink of choice”; which indicates that fruit juice and pop (soft drinks) are not included as part of a recommended diet, but what about milk?

It is good that water is promoted as the beverage of choice, but why does the Guide doesn’t also illustrate a small glass of milk? The absence of milk in the new Guide seems odd.

Note: with both cheese and milk being limited in this new food guide, adequate calcium intake may be of concern; especially since vegetables that are high in calcium will have that calcium made unavailable to the body due to the high amounts of phytates, oxylates and lectins that are contained in the grains, nuts and seeds that are also in the diet.

Healthy Food Choices

The link for “healthy food choices” indicates;

  • Make it a habit to eat a variety of healthy foods each day.
  • Eat plenty of vegetables and fruits, whole grain foods and protein foods. Choose protein foods that come from plants more often.
  • Choose foods with healthy fats instead of saturated fat
    Limit highly processed foods. If you choose these foods, eat them less often and in small amounts.
  • Prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat
  • Choose healthier menu options when eating out
  • Make water your drink of choice
  • Replace sugary drinks with water
  • Use food labels
  • Be aware that food marketing can influence your choices

Eating Habits

The link for “healthy eating habits” indicates;

  • Healthy eating is more than the foods you eat. It is also about where, when, why and how you eat.
  • Be mindful of your eating habits
  • Take time to eat
  • Notice when you are hungry and when you are full
  • Cook more often
  • Plan what you eat
  • Involve others in planning and preparing meals
  • Enjoy your food
  • Culture and food tradition can be a part of healthy eating
  • Eat meal with others

Additional links on the web page include, Recipes, Tips and Resources.

First Impressions of the New Canada Food Guide

Overall, I think the new Canada Food Guide is visually clear, well illustrated and in terms of a communication tool is a huge improvement over its predecessor. It promotes a whole food diet with minimum processing, advises people to limit refined carbohydrates and sugary beverages as well as encourages people to cook their own food. It is neat, clean and appealing to look at and use.

I have two main concerns with respect to the Guide;

(1) the percentage of carbohydrate in the diet given the number of Canadians who are already metabolically unwell
(2) the focus on avoiding saturated fat as presumably a risk to health

Percentage of Carbohydrate in the Diet

At first glance, it would appear that the overall macronutrient distribution of the new Guide is ~10-15% of calories as protein, 15-20% as fat, leaving the remaining 65-75% of calories as carbohydrate (based on estimates by Dr. Dave Harper, visiting scientist at BC Cancer Research Institute, social media post). While no portions are set out in this new Guide, based on the carbohydrate (and protein) content of the legumes and pulses (beans, lentils) and nuts and seeds contained in the Protein food group, as well as their proportion of the food group, and the fact that they are encouraged to be eaten ‘more often’ than meat, the protein estimate seems accurate. As well, the carbohydrate content seems accurate based on the proportion of the Whole Grain group and carbohydrate-containing other foods relative to the proportion of other foods.

While this diet may be fine for those who are metabolically healthy, research indicates that as many as 88% of Americans [1] are already metabolically unwell, with presumably a large percentage of Canadians as well.

That is, only 12% have metabolic health defined as have levels of metabolic markers “consistent with a high level of health and low risk of impending cardiometabolic disease“. Metabolic Health is defined as [1];

  1. Waist Circumference: < 102 cm (40 inches) for men and 88 cm (34.5 inches) in women
  2. Systolic Blood Pressure: < 120 mmHG
  3. Diastolic Blood Pressure: < 80 mmHG
  4. Glucose: < 5.5 mmol/L (100 mg/dL)
  5. HbA1c: < 5.7%
  6. Triglycerides: < 1.7 mmol/l (< 150 mg/dL)
  7. HDL cholesterol: ≥ 1.00 mmol/L (≥40 mg/dL) in men and ≥ 1.30 mmol/L (50 mg/dl) in women

When looking at only 3 of the above 7 factors (waist circumference, blood glucose levels and blood pressure) more than 50% in this study were considered metabolically unhealthy [1]. Given the slightly lower rates of obesity in Canada (1 in 4) as in the United States (1 in 3), presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy, but the similarity of our diets may make that difference insignificant.

This would indicate that for a large percentage of Canadians that are  metabolically unwell, a diet that provides provides ~325-375 g of carbohydrate per day (based on a 2000 kcal per day diet) is not going to adequately address the underlying cause. While there is evidence that a high complex carbohydrate diet with very low fat and moderately-low protein intake (called a “whole food plant based” / WFPB diet) will improve weight and some markers of metabolic health, there is also evidence that a WFPB diet doesn’t work as well at improvements in body weight and metabolic markers as a low carbohydrate higher protein and fat (LCHF) diet. This will be addressed in a future article.

The purpose of Canada’s Food Guide is to provide guidance for healthy Canadians so in actuality, this diet may only be appropriate for ~15% of adults.

Saturated Fat

The indication to “choose foods with healthy fats instead of saturated fat” and to “prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat” sends the message that saturated fat is unhealthy.

It is well-known that saturated fat raises LDL-cholesterol however it must be specified which type of LDL-cholesterol increases. There are small, dense LDL cholesterol which easily penetrates the artery wall and which are associated with heart disease [2,3,4,5] and large, fluffy LDL cholesterol      which are not [6,7].

The long-standing and apparently ongoing recommendation to limit saturated fat is based on it resulting in an increase in overall LDL-cholesterol and not on evidence that increased saturated fat in the diet results in heart disease.

What do recent studies show?

Eight recent meta-analysis and systemic reviews which reviewed evidence from randomized control trials (RCT) that had been conducted between 2009-2017 did not find an association between saturated fat intake and the risk of heart disease [8-15] and the results of the largest and most global epidemiological study published in December 2017 in The Lancet [16] found that those who ate the largest amount of saturated fats had significantly reduced rates of mortality and that low consumption (6-7% of calories) of saturated fat was associated with increased risk of stroke.

UPDATE: There are 44 randomized controlled trials (RCTs) of drug or dietary interventions to lower total LDL-cholesterol that showed no benefit on death rates. (Reference:  DuBroff R. Cholesterol paradox: a correlate does not a surrogate make. Evid Based Med 2017;22(1):15–9.

Canadians are being encouraged to limit foods that are sources of saturated fat. In fact, cheese and milk aren’t even illustrated as foods to regularly include.

Where is the evidence that eating foods with saturated fat is dangerous to health — not simply that it raises overall LDL-cholesterol? I believe that for Canadians to be advised to limit cheese and milk which are excellent sources of protein and dietary calcium and to limit other foods high in saturated fat necessitates more than proxy measurements of higher total LDL-cholesterol.

Dr. Zoe Harcombe a UK based nutrition with a PhD in public health nutrition wrote an article this time last year about saturated fat [17] which is helpful to refer to here.

People have the idea that meat has saturated fat and foods like nuts and olives have unsaturated fats, but Dr. Harcombe points out that;

“All foods that contain fat contain all three fats – saturated, monounsaturated and polyunsaturated – there are no exceptions.”

This article explains may explain why cheese was not included as part of the visual representation of animal-based Protein Foods in the new Guide and why milk was not visually represented because “the only food group that contains more saturated than unsaturated fat is dairy”.

A link off the main page of the new Canada Food Guide explains how to “limit the amount of foods containing saturated fat” such as;

Limit foods that contain saturated fat

“Limit the amount of foods containing saturated fat, such as:

cream

higher fat meats
.
.
.
cheeses and foods containing a lot of cheese

Are Canadians being encouraged to avoid cheese and milk because they are high in saturated fat? Where is the evidence that saturated fat contributes to heart disease?

There is proxy data that saturated fat raises total LDL-cholesterol, but not that saturated fat causes heart disease.  In fact, a review of the recently literature finds that it does not (see above).

If saturated fat actually puts one’s health at risk, then Canadians should be warned that olive oil has 7 times the amount of saturated fat as the sirloin steak illustrated below and the mackerel has 1- 1/2 times the saturated fat as the sirloin steak [16] yet the new Guide recommends that Canadian’s choose foods with “healthy fats” such as fatty fish including mackerel and to use “healthy fats” such as olive oil.

from Reference #17

Final thoughts…

In generations past, Canada food Guide helped Canadians make food choices in order to achieve adequate nutrition for themselves and their families, especially in the early years after WWII.  With current rates of overweight, obesity, Type 2 Diabetes and other forms of metabolic dysregulation, I wonder how few this beautiful new Guide is appropriate for.

If you would like to learn more about how I can help you or a family member achieve and maintain a healthy body weight and to achieve metabolic health, please send me a note using the Contact Me form located on the tab above.

To our good health!

Joy

In the following post, I validate the average amount of carbohydrate in this new Canada Food Guide.

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

Copyright ©2019 The LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  2. Tribble DL, Holl LG, Wood PD, et al. Variations in oxidative susceptibility among six low density lipoprotein subfractions of differing density and particle size. Atherosclerosis 1992;93:189–99
  3. Gardner CD, Fortmann SP, Krauss RM, Association of Small Low-Density Lipoprotein Particles With the Incidence of Coronary Artery Disease in Men and Women, JAMA. 1996;276(11):875-881
  4. Lamarche B, Tchernof A, Moorjani S, et al, Small, Dense Low-Density Lipoprotein Particles as a Predictor of the Risk of Ischemic Heart Disease in Men, 
  5. Packard C, Caslake M, Shepherd J. The role of small, dense low density lipoprotein (LDL): a new look, Int J of Cardiology,  Volume 74, Supplement 1, 30 June 2000, Pages S17-S22
  6. Genest JJ, Blijlevens E, McNamara JR, Low density lipoprotein particle size and coronary artery disease, Arteriosclerosis, Thrombosis, and Vascular Biology. 1992;12:187-195
  7. Siri-Tarino PW, Sun Q, Hu FB, Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease, The American Journal of Clinical Nutrition, Volume 91, Issue 3, 1 March 2010, Pages 502–509
  8. Skeaff CM, PhD, Professor, Dept. of Human Nutrition, the University of Otago, Miller J. Dietary Fat and Coronary Heart Disease: Summary of Evidence From Prospective Cohort and Randomised Controlled Trials, Annals of Nutrition and Metabolism, 2009;55(1-3):173-201
  9. Hooper L, Summerbell CD, Thompson R, Reduced or modified dietary fat for preventing cardiovascular disease, 2012 Cochrane Database Syst Rev. 2012 May 16;(5)
  10. Chowdhury R, Warnakula S, Kunutsor S et al, Association of Dietary, Circulating, and Supplement Fatty Acids with Coronary Risk: A Systematic Review and Meta-analysis, Ann Intern Med. 2014 Mar 18;160(6):398-406
  11. Schwingshackl L, Hoffmann G Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and meta-regression BMJ Open 2014;4
  12. Hooper L, Martin N, Abdelhamid A et al, Reduction in saturated fat intake for cardiovascular disease, Cochrane Database Syst Rev. 2015 Jun 10;(6)
  13. Harcombe Z, Baker JS, Davies B, Evidence from prospective cohort studies does not support current dietary fat guidelines: a systematic review and meta-analysis, Br J Sports Med. 2017 Dec;51(24):1743-1749
  14. Ramsden CE, Zamora D, Majchrzak-Hong S, et al, Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73), BMJ 2016; 353
  15. Hamley S, The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials, Nutrition Journal 2017 16:30
  16. Dehghan M, Mente A, Zhang X et al, The PURE Study – Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062
  17. Harcombe  Z, Saturated Fat,  http://www.zoeharcombe.com/2018/01/saturated-fat/
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EAT-Lancet Diet – inadequate protein for older adults

We’ve come to expect that as people age they will gain more fat, loose bone mass and have decreased muscle strength which in time leads to difficulty in them getting around on their own, a greater risk of falls and eventually to physical disability. We commonly see older people with spindly little legs and bony arms and we think of this as ‘normal’. It is common in the United States and Canada, but this is not ‘normal’.

Sarcopenia is the visible loss of muscle mass and strength that has become associated with aging here, but what we see as ‘common’ here in North America is not ‘normal’ in other parts of the world where seniors in many parts of Asia and Africa are often active well into their older years and don’t have the spindly legs and bony arms of those here.

Here in North America, we celebrate ‘active’ seniors by posting photos of them in the media sitting in chairs and lifting light weights — when people their age in other parts of the world continue to raise crops, tend their grandchildren and cook meals for their extended family, even gathering fuel and water to do so.

The physical deterioration that we associate with aging here doesn’t  develop suddenly, but takes place over an extended period of time and is brought on by poor dietary and lifestyle practices in early middle age –  including less than optimal protein intake and insufficient weight bearing activity from being inactive.

Protein Requirement in Older Adults

The Recommended Dietary Allowance (RDA) for protein is set at 0.8 g protein/kg per day is not the ideal amount that people should take in, but the minimum quantity of protein that needs to be eaten each day to prevent deficiency. Protein researchers propose that while sufficient to prevent deficiency, this amount is insufficient to promote optimal health as people age[1].

There have been several position statements issued by those that work with an aging population indicating that protein intake between 1.0 and 1.5 g protein / kg per day may provide optimal health benefits during aging [2,3]. For an normal-sized older woman of my size, that requires ~65-95 g of high quality bioavailable protein per day and for a lean older man of ~185 lbs (85 kg) that would require between 85 – 125 g of high quality bio-available protein per day

High bioavailability proteins are optimal to preserve the lean muscle tissue and function in aging adults and animal-based proteins such as meat and poultry are not biologically equivalent to plant-based proteins such as beans and lentils in terms of the essential amino acids they provide.

Animal-based protein have high bioavailability and are unequaled by any plant-based proteins. Bioavailability has to do with how much of the nutrients in a given food are available for usage by the human body and in the case of protein, bioavailability  has to do with the type and relative amounts of amino acids present in a protein. Animal proteins (1) contain all of the essential amino acids in sufficient quantities.

Anti-nutrients such as phytates, oxylates and lectins are present in plant-based protein sources and interfere with the bioavailability of various micronutrients.

The recommendations above for older adults to eat 1.0 – 1.5 g protein / kg per day distributed evening over three meals would be on average ~30-40g of animal-based protein at each meal to provide for optimal muscle protein synthesis to prevent sarcopenia as people age.  In an aging population, this maintenance of muscle mass as people age is critical to consider.

The Eat-Lancet Diet

Dr. Zoe Harcombe, a UK based nutrition with a PhD in public health nutrition analyzed the “Healthy Reference Diet” from Table 1 of the Eat-Lancet report using the USDA (United States Department of Agriculture) all-food database and found that in terms of macronutrients, it had only 90g  Protein per day (14% of daily calories) which is below the 100g – 120 g per day that is consider optimal for older adults to maintain their lean muscle mass and as importantly, most of that protein is as low bioavailable plant-based proteins.

The Eat-Lancet Diet recommends only;

  • 1 egg per week
  • 1/2 an ounce of meat per day (equivalent to a thin slice of shaved meat)
  • an ounce of fish or chicken per day (equivalent to 1 sardine)
  • and 1 glass of milk

This is not an optimal diet to prevent sarcopenia in adults as they age.

A diet that puts seniors at significant risk of muscle wasting contributes to the loss of quality of life, significant costs to the healthcare system, as well significant cost and stress to individual families that need to care for immobile seniors.

This diet may be beneficial for those living with consistent under-nutrition (malnutrition) but this diet is anything but optimal for healthy, independent aging for the seniors of the US and Canada.

As mentioned in the previous article, the EAT-Lancet Diet also provides way too much carbohydrate intake for the 88% of Americans (and presumably a similar percentage of Canadians) who are metabolically unwell.

Final Thoughts…

For reasons mentioned above, the EAT-Lancet diet is not optimal for health for mature adults or older adults and as mentioned in the previous article, has way too high a carbohydrate intake for the vast majority of people who are already metabolically unwell.

If you would like to learn more about eating an optimal diet to support an active, healthy older age, please send me a note using the Contact Me form, above.

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Volpi E, Campbell WW, Dwyer JT, et al. Is the optimal level of protein intake for older adults greater than the recommended dietary allowance? J Gerontol A Biol Sci Med Sci. 2013 Jun;68(6):677-81
  2. Fielding RA, Vellas B, Evans WJ, Bhasin S, et al, Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249-56
  3. Bauer J1, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
  4. Harcombe Z, The EAT Lancet diet is Nutritionally Deficient,  http://www.zoeharcombe.com/2019/01/the-eat-lancet-diet-is-nutritionally-deficient/
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The New EAT Lancet Diet – a healthy & sustainable diet for whom?

A new report released on January 16, 2019 by the EAT-Lancet Commission on Food, Planet and Health sets out what it calls a “healthy and sustainable diet” [1] for the whole world. The EAT-Lancet report proposes what it calls the “Planetary Health Diet”; a largely plant-based diet which aims to address the simultaneous global problems of malnutrition (under-nutrition) and over-nutrition; specifically that “over 820 million people continue to go hungry every day, 150 million children suffer from long-term hunger that impairs their growth and development, and 50 million children are acutely hungry due to insufficient access to food” and that at the same time “over 2 billion adults are overweight and obese”[2]. The “Planetary Health Diet” intends address both under-nutrition and over-nutrition simultaneously by promoting a 2500 kcal per day diet that focuses on high consumption of carbohydrate-based grains, vegetables, fruit, legumes (pulses and lentils) — while significantly limiting meat and dairy. This sounds a lot like the proposed draft of the new Canada Food Guide (which you can read more about here).

The Planetary Health Diet

The Planetary Health Diet – aka the EAT-Lancet Diet [4]
Here is the food per day that can be eaten per adult on the “Planetary Health Diet”;

  1. Nuts: 50 g (1 -3/4 ounces) /day
  2. Legumes (pulses, lentils, beans): 75 g (2-1/2 oz) /day
  3. Fish: 28 g (less than an ounce) / day
  4. Eggs: 13 g / day (~ 1 egg per week)
  5. Meat: 14 g (1/2 an ounce) / day / Chicken: 29 g (1 ounce) / day
  6. Carbohydrate: whole grain bread and rice, 232 g carbohydrate per day and 50 g / day of starchy vegetables like potato and yam
  7. Dairy: 250 g (the equivalent of one 8 oz. glass of milk)
  8. Vegetables: 300 g (10.5 ounces) of non-starchy vegetables and 200 g (almost 1/2 a pound) of fruit per day
  9. Other: 31 g of sugar (1 ounce), ~50 g cooking oil

On this diet, you can have twice the amount of sugar than meat or egg, and the same amount of sugar as poultry and fish.

While is is understandable how the above diet may address the problems of under-nutrition in much of the world’s population, what about the effect of such a diet on the average American or Canadian — when 1 in 3 Americans[5] and 1 in 4 Canadians is overweight or obese[6]?

Vast Majority (88%) of Americans are Metabolically Unhealthy

A study published in November 2018 in Metabolic Syndrome and Related Disorders reported that 88% of Americans are already metabolically unhealthy[3]. That is, only 12% have metabolic health defined as have levels of metabolic markers “consistent with a high level of health and low risk of impending cardiometabolic disease“. Metabolic Health is defined as [3];

  1. Waist Circumference: < 102 cm (40 inches) for men and 88 cm (34.5 inches) in women
  2. Systolic Blood Pressure: < 120 mmHG
  3. Diastolic Blood Pressure: < 80 mmHG
  4. Glucose: < 5.5 mmol/L (100 mg/dL)
  5. HbA1c: < 5.7%
  6. Triglycerides: < 1.7 mmol/l (< 150 mg/dL)
  7. HDL cholesterol: ≥ 1.00 mmol/L (≥40 mg/dL) in men and ≥ 1.30 mmol/L (50 mg/dl) in women

When looking at only 3 of the above 7 factors (waist circumference, blood glucose levels and blood pressure) more than <50% of Americans were considered metabolically unhealthy [3]. Given the slightly lower rates of obesity in Canada[6] as in the United States[5], presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy, but the similarity of our diets may make that difference insignificant. As well, it was not only those who were overweight or obese who were metabolically unhealthy;

“Even when WC (waist circumference) was excluded from the definition, only one-third of the normal weight adults enjoyed optimal metabolic health.”

For the 12% of people who are metabolically healthy, a plant-based low glycemic index diet is not problematic, but it’s a concern to recommend to the other 88% to eat that way — especially if they are insulin resistant or have Type 2 Diabetes.

Is the “Planetary Health Diet” an advisable diet for the average American or Canadian adult who is already metabolically unhealthy? To answer this question, let’s look closer at the macronutrient and micronutrient content of this diet. Below is the “healthy reference diet” from page 5 of the report [7], which is based on an average intake of 2500 kcal per day;

Table 1 – Healthy reference diet, with possible ranges, for an intake of 2500 kcal/day (from Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems)

Nutritional Deficiency of the Eat-Lancet Diet

Dr. Zoe Harcombe a UK based nutrition with a PhD in public health nutrition analyzed the above “Healthy Reference Diet” from Table 1 of the Eat-Lancet report using the USDA (United States Department of Agriculture) all-food database and found that in terms of macronutrients, it had [8]; Protein: 90 g (14% of daily calories) Fat: 100 g (35% of daily calories) Carbohydrate: 329 g (51% of daily calories) Dr. Harcombe also reported that in terms of micronutrients, the diet was deficient in retinol (providing only 17% of the recommended amount), Vitamin D (providing only 5% of the recommended amount), Sodium (providing only 22% of the recommended amount), Potassium (providing only 67% of the recommended amount), Calcium (providing only 55% of the recommended amount), Iron  (providing only 88% of the recommended amount, but mostly as much lower bio-available non-heme iron, from plant-based sources), as well as inadequate amounts of Vitamin K (as the most bio-available comes from animal-based sources).

High Carbohydrate Content

The “Planetary Health Diet” contains on average approximately 329 g of carbohydrate per day which is of significant concern — especially in light of the extremely high rates of overweight and obesity in both the United States and Canada, as well as the metabolic diseases that go along with those, including Type 2 Diabetes (T2D), cardiovascular disease, hypertension, and abnormal triglycerides. Since 1977, Canada Food Guide has recommended that Canadians consume 55-60% of daily calories as carbohydrate and the Dietary Goals for the United States recommending that carbohydrates are 55-60% of daily calories and in 2015, Canada Food Guide increased the amount of daily carbohydrate intake to 45-65% of daily calories as carbohydrate. What has happened to the rates of overweight and obesity, as well as diabetes from 1977 until the present? In the early 1970s, only ~8% of men and ~12% of women in Canada were obese and now almost 22% of men and 19% of women are obese. As mentioned above, 1 in 4 in Canada is obese and 1 in 3 in the US is and with those, Type 2 Diabetes as well as the metabolic diseases mentioned above.

Final Thoughts…

The Dietary Guidelines of both Canada and the US have spent the last 40 years promoting a high carbohydrate diet that has provided adults with between 300 g and 400 g of carbohydrate per day (based on a 2500 kcal / day diet). EAT-Lancet’s “Planetary Health Diet” may seem to be good for the planet, and for those facing under-nutrition in many parts of the world, but with 88% of Americans already metabolically unhealthy (and presumably the majority of Canadians as well), this diet which provides 300 g of carbohydrate per day is going to do nothing to address the high rates of overweight and obesity and metabolic disease that is rampant in North America.

If you would like to learn more about a low carbohydrate diet for weight loss or for putting the symptoms of Type 2 Diabetes and associated metabolic diseases into remission, please send me a note using the Contact Me form.

To our good health!

Joy

If you would like to learn why this diet provides inadequate protein for older adults and seniors, please click here.

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. The EAT-Lancet Commission on Food, Planet and Health,  https://eatforum.org/eat-lancet-commission/
  2. The EAT-Lancet Commission on Food, Planet and Health – EAT-Lancet Commission Brief for Healthcare Professionals,  https://eatforum.org/lancet-commission/healthcare-professionals/
  3. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  4. BBC News, A bit of Meat, a lot of veg – the flexitarian diet to feed 10 billion, James Gallagher, 17 January 2019, https://www.bbc.com/news/health-46865204
  5. State of Obesity, Adult Obesity in the United States, https://stateofobesity.org/adult-obesity/
  6. Statistics Canada, Health at a Glance, Adjusting the scales: Obesity in the Canadian population after correcting for respondent bias,  https://www150.statcan.gc.ca/n1/pub/82-624-x/2014001/article/11922-eng.htm
  7. Willet W, Rockstrom J, Loken B, et al, Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems, The Lancet Commissions, http://dx.doi.org/10.1016/ S0140-6736(18)31788-4
  8. Harcombe Z, The EAT Lancet diet is Nutritionally Deficient,  http://www.zoeharcombe.com/2019/01/the-eat-lancet-diet-is-nutritionally-deficient/
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Getting to Know Me – a short video introduction

This 1/2 hour video interview was filmed January 4, 2019 for a conference I was appearing at remotely that was held in Charlottetown, Prince Edward Island on January 12, 2019.  I thought that it would make an excellent introduction to my background (both educational and clinical) and how and why I came to practice and offer a low carbohydrate dietary approach.

In this video, I am interviewed by pharmacist Angela Doucette and the topics I cover are;

  • my educational and clinical background and the nature of my Dietetic practice before being exposed to a low carbohydrate dietary approach (focus on Mental Health Nutrition & food sensitivities / food allergies, IBS etc.) i.e. my being obese had no bearing on my Dietetic practice as it was not weight management focused
  • the impetus to change: visit from a retired MD girlfriend who wanted my opinion about using a low carbohydrate dietary approach to improve the symptoms of Type 2 Diabetes (T2D) and cardiovascular risk factors
  • First exposure was to blog of Dr. Jason Fung, Canadian nephrologist (kidney specialist), before he published his first book, his assistance in me getting started
  • my initial reservations regarding some of the approach i.e. safety and efficacy of using long term intermittent fasting, very high saturated fat intake, moderate protein intake (especially in post menopausal women due to predisposition to sarcopenia i.e. muscle deterioration with aging)
  • how and why I decided to take a slightly different approach; taking components of what I learned from Dr. Fung and others
  • influence of lectures by Dr. Eric Westman, MD and Dr. Ted Naiman, MD on limiting ‘added fat’ especially during weight-loss phase
  • influence of Dr. Stephen Phinney MD, PhD and Dr. Jeff Volek RD, PhD in the process of modifying my initial approach
  • starting to apply knowledge to my own clinical practice gleaned from reading clinical studies and listening to lectures by above and others
  • took 3 months off to rethink how I was going to implement this knowledge before using it in my practice i.e. changes needed to be evidence-based
  • success of initial clients long before I implemented the changes in my own life, clients still maintaining weight loss today
  • transformation to following a low carbohydrate dietary approach myself; March 5, 2017; a crisis in my own metabolic health
  • reality was brought “home” as a result of the deaths of two girlfriends both of whom also worked in healthcare
  • how I felt when I was faced with the need to lose a foot off my waist to achieve a healthy waist to hip ratio;

“I don’t have to lose a foot now, I only have to lose 1/2 an inch at a time”

  • how much weight and inches I’ve lost in 22 months following a low carbohydrate dietary approach
  • having put my Type 2 Diabetes into remission (not cured)
  • my MDs reaction to me having lost 50 pounds (was very skeptical at first!), why he referred me recently to an endocrinologist
  • 16:00 an IMPORTANT SECTION on the different types of low carbohydrate and ketogenic diets and some clinical limitations I noticed in those that followed a very high fat diet (not loosing weight, sometimes gaining weight) even though carbohydrate content remained low. Selection of the appropriate macrodistribution is selected based on a person’s age, gender (whether they’re male or female), their stage of life (post partum, breast-feeding, pregnant, older adult), whether they are athletic or sedentary (i.e. desk job). There’s no one-size-fits-all low carb or keto diet.
  • Dietary Reference Intakes (DRIs) based on needs of those that eat a large percentage of carbohydrate intake, unknown what the difference in biological needs are of those that follow a low carbohydrate dietary approach
  • role of lab tests in dietary assessment along with a thorough dietary history
  • need to lower carbohydrate intake to below 130 g per day is not always required
  • special considerations for those of South Asian background “thin on outside, fat on inside TOFI)
  • why I create multi-ethnic recipes (i.e. roti)

“There are lots of different ways to do low carb and lots of different ways to do keto, and everyone’s nutrient needs are different; it depends on their age, their gender (whether they’re male or female), their stage of life (post partum, breast-feeding, pregnant), whether they are athletic or sedentary (i.e. desk job). There’s no one-size-fits-all

  • reflections on the role of therapeutic nutrition with other healthcare disciplines i.e. physicians, pharmacists, nurses, LPNs, physiotherapists, chiropractors, even dentists
  • role of Canadian Clinicians for Therapeutic Nutrition (CCTN)

You can watch the video interview here:

If you have specific questions about how a low carbohydrate approach may be helpful for you to achieve weight loss, or aiming to put your own high blood sugars into remission, lower blood pressure or triglycerides then please feel free to send me a note using the Contact Me form located on the tab above. For more information about the types of consultations and packages I offer, as well as their prices you can find out more under the Services tab or in the Shop.

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

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Different Ways to Measure Success – a Dietitian’s Journey

There are different ways to measure ‘success’ and not all of them involve weight.

Six weeks ago, I wrote about my overall progress in reaching the non-diabetic range for HbA1C after ten years since being diagnosed with Type 2 Diabetes, my improvements in blood pressure and other markers.

A month ago, I wrote about my changes in body measurements over the last 12 months and where the 25 pounds I lost came from.

Two weeks ago ‘success’ was documented with a series of composite of photos from when I was obese until now, along with some other details.

 

Last week, ‘success’ was comparing a series of videos that I have taken since the beginning of my journey until now.

 

 


Just have look at me in the first video (just a little over 1 minute long, link below) and even the first few minutes of the most recent video (a little over 1/2 an hour, link below) back to back!

This first video was taken March 16, 2017, just two weeks after I began my health and weight-loss journey. As significant as my size, listen to how out of breath I was!

This most recent video was filmed a week and a half ago (January 4, 2019) for the Keto-Solutions Bootcamp in Charlottetown, Prince Edward Island. Sure, I’m not walking in this one but trust me, I can do that and so much more now without getting winded!

Weight loss update

Yesterday, my weight dropped to a BMI of 24 (well into the normal weight category) which was pretty exciting given when I started it was around 32 (in the obese category) and as I suspected from the number of times I needed to get up last night, my weight dropped again today. I normally weigh myself only once a week, unless I know my weight has dropped.

Body Mass Index (BMI) changes from January 2018 – January 2019

With the drop in weight over the last few days (even with adjustments for body water fluctuation) and am around 3  1/2 pounds from my goal weight — well actually my third goal weight.

When I first started my journey, I set as a preliminary “goal weight” as the weight I would like to get to, if possible.  That was the weight I was a year ago!

Having achieved that, last January I set a new “goal weight” of what I’d like to get to where I thought my waist circumference would be 1/2 my height. Once I reached that weight, I revised my “goal weight” downward — closer to the lowest adult weight that I was where I once looked best. Currently, I am just a little over 3 pounds from that weight.

Below is a graph of what my weight loss progress looks like over the past year (since the beginning of January 2018).

I’ve lost 27.5 more pounds on top of the 24 pounds I lost from March 5, 2017 until January 2018.

Weight loss – January 2018 to January 2019

To date, I’ve lost a total of 51.5 pounds and to be honest I have no idea what my final weight will be!

My focus over the next several months is on achieving optimal health and that is about building additional muscle and continue to lose about 10 pounds of excess fat. It’s hard for me to know what “weight” I will be when I’ve accomplished that, but in the end, I don’t think it matters much.

Building muscle for me is all about health — and of reducing my risk of sarcopenia as I age (you can read more about that here). Continuing to lose the excess fat is all about further reducing any insulin resistance and continuing to lower my HbA1C even lower into the normal range with the goal of achieving full remission from Type 2 Diabetes (you can read more about that here).

At this point in my journey it is about striving for “optimal” rather than some measure of “ideal”.

The way I look at it, optimal is what makes sense for a ‘woman of a certain age’ who is newly in remission from Type 2 Diabetes almost 10 years after being diagnosed.  Optimal is based on the exercise I am capable of doing now — after having both knees operated on in the past, as well as a back injury 8 years ago. Given my age, my knees and my back, what is optimal won’t be anywhere near what I was capable at 25 years old when I was doing 10 hours of karate a week! Those days are gone, but what is ahead is whatever I make of it now.

Pushing for the muscle gains now will factor into what what kind of “old age” I will live and losing the rest of the fat may enable me to achieve full remission from Type 2 Diabetes. This is more important than how I look!

And so begins another calendar year in my journey – a journey now focused on achieving optimal, not ideal.

If you’d like to know more about how I can help you accomplish your health and nutrition goals please have a look at the Services tab to learn more about the sessions and packages I offer and feel free to send me a note using the Contact Me form located on the tab above, if you have specific questions about how I can help.

To our good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

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Beyond Appearance to Health – 22 months of A Dietitian’s Journey in video clips

Tomorrow will be 22 months to the day (March 5, 2017-January 5, 2019) that I realized that I was metabolically very unwell; having a resting blood pressure in the hypertensive emergency category and uncontrolled blood sugar which was topping 13 mmol/L (235 mg/dl) after a meal. As I have said in every podcast and interview that I have done since and have written in several articles, what I should have done at that point was to go straight to my doctor and let him put me on the medications required and then have changed my diet and lifestyle, but I was frightened with the prospect of coming out of denial and decided instead to immediately change how I ate and recover my own health. That was a risky thing to do as my risk of heart attack and stroke was very high and in retrospect it is not what I would have done.  It is certainly not something I would recommend anyone else to do! Knowing what I know now, I should have started on medications and then adopted the same dietary and lifestyle changes and as my health improved, had my doctor lower the dosages and then eventually discontinue them. But that as they say is water under the bridge now.

In my first entry in “A Dietitian’s Journey” simply titled “The Beginning” I set the following goals;

I want;

(1) blood sugar in the non-diabetic range

(2) normal blood pressure

(3) normal / ideal cholesterol levels

(4) a waist circumference in the “at or below” recommended values of the Heart and Stroke Foundation

Will I meet all these goals?  Who knows?! But I won’t know if I don’t try and the alternative of a life of medication for blood sugar, blood pressure and eventually cholesterol too does not appeal to me!

March 16, 2017 I posted my second entry titled The Road to Better Health about why I decided to add a walking routine to my dietary changes and this was where I posted my first video.

You have to see this to believe it!

It’s not only how I look but how I sound!  Its evident that I am unable to walk at a reasonable pace and talk without being out of breath.

Here is my second video, posted July 25, 2017, just 4 months into eating a low carbohydrate (not ketogenic) diet.  As you can see, I had already lost some weight and could talk without being totally winded while walking.

At this point, I had lost 10 pounds, my HbA1C (3 month average blood sugar level) was down from an average of 12 mmol/L to 8.5 mmol/L. My blood pressure which had dropped to ~140/80 mmHg had begun to rise to in the 160/90 mmHg range so I decided to ask my doctor to put my on Ramipril (Altace) until diet and weight loss is sufficient to maintain it at a normal level on its own. My goals at that point were;

I still have at least another 30 pounds to go to get to the “goal weight” that I set at the beginning of this journey, and am now aiming to lose another 40-45 pounds instead in order to reach my ideal (healthiest) waist to height ratio.

By my one-year anniversary of following a low carbohydrate diet, this is what I had achieved;

So far, I’ve lost;

  • 32 pounds
  • 8 inches off my waist
  • 2 inches off my chest
  • 3 inches off my neck
  • 1 inch off my arms
  • 1/2 inch off my thighs.
  • I no longer meet the criteria for Type 2 Diabetes
  • I have blood pressure that ranges between normal and pre-hypertension
  • I have ideal triglycerides and excellent cholesterol levels.

While I’m still overweight and have approximately another 20 pounds to lose to reach a healthy waist circumference, I am not as desperately unhealthy as I was this time last year.

I am alive, much healthier and committed to continuing this journey.

July 25, 2018, a full year after the previous video above and 16 months into A Dietitian’s Journey, I posted the next video update. By this point I had lowered the amount of carbohydrate in my diet down considerably in order to achieve the metabolic recovery I sought. The difference between the very first video from March 16, 2017 and this one is remarkable; not just in the way I look, but how I sound!

By this date, I had lowered my fasting insulin from when I began where it was 54 pmol/L (7.8 μU/ml) to 33 pmol/L (4.8 μU/ml) which was in the ideal range, between 2-6 μU/ml. My HbA1C had dropped from 7.5% to 6.3% which was finally below the cutoffs for Type 2 Diabetes, which is 6.5%. Using diet alone and without taking any medication, I was finally in partial remission of Type 2 Diabetes.

This brings us to today. Five months have passed since the last video update above and tomorrow will be 22 months since I began A Dietitian’s Journey. I recently achieved my last two health goals of (a) having my waist circumference that is half my height and (b) having lost the last 20 pounds. Yesterday, my doctor took my blood pressure and it was in the normal range (still taking a “baby dose” of Ramipril) and next week I will be having my HbA1C done, which will be the first time since I voluntarily started on Metformin after having reached partial remission from Type 2 Diabetes with diet alone. I chose to do this for several reasons, including my dad’s recent Alzheimer’s diagnosis and it’s relationship to glucose dysregulation, as well as because I was still having difficulty lowering my early morning fasting blood glucose due to my liver’s gluconeogenesis (making glucose) in the wee hours of the morning.

Yesterday I taped a 1/2 hour talk with a Pharmacist colleague in Prince Edward Island who is holding a one-day workshop in Charlottetown on Saturday, January 12th, called Keto Solutions Bootcamp. Since I was unavailable to appear ‘live’ that day, I taped the segment yesterday that will be shown during my scheduled slot.

I gave her my word that I would not post the video until after the workshop but posted a screenshot instead.

UPDATE: January 13, 2019

Here is the link to the video:

Some final thoughts…

I have also demonstrated that even for someone who was overweight and obese for YEARS, it is entirely possible to achieve a healthy body weight eating whole, real food.

I didn’t deprive myself. I ate burgers and pizza, Chinese, Thai, Indian and Canadian food, and even some treats once in a while like batter fried fish and New York Style Cheesecake; all adapted to be low carb (see the recipe section for details).

As I coach my clients to do, I ate if I was hungry but didn’t eat just because it was “time” if I wasn’t. I ate delicious real food with a wide range of diversity in tastes and textures and made sure to get sufficient micronutrients (vitamins and minerals) not just “macros” (protein, fat and carbohydrate).  I didn’t have bulletproof coffee once and never ate a “fat bomb”. Yes, there is a lot more to a low carbohydrate diet than bacon, cream and butter!

If you’re curious to learn more, please have a look around my web page.  Have a read of some of the articles under the Food for Thought tab. Most are fully referenced and written in my “Science Made Simple” style so that anyone can understand.

If you are interested in knowing more about the packages and hourly consultations that I provide, please click on the Services tab to find out more.  Should you decide you want to get started, everything you need is there, including the Intake and Service Option Form to download and complete.  If you would like a password protected one to secure the completed information so you can email it to me, please drop me a note and I will be glad to send it to you.

Finally, if you have questions about how I can help you, please send me a note using the Contact Me form on the tab above and I will reply as soon as possible.

My “A Dietitian’s Journey” is my “sample set of one” (n=1) account of what I was able to accomplish, but everyone’s journey is different.  Some people take less time than I did to reach their goals and some take more depending on where they start from, but this is about recovering one’s health and achieving a healthy body weight and the way I look it is if it took us years to get to the place of ill-health we begin from, are we not worth the investment to take whatever time it takes to get well?  I think so!

Please let me know if I can help you restore your own health or help a loved one.

To your good health!

Joy

You can follow me at:

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https://www.instagram.com/lchf_rd

 

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

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There’s Something About Real Life Personal Stories

NOTE: This article is an editorial but is cross-posted under Science Made Simple to make it easy to find.

Critics of the use of a low carbohydrate diet for weight loss and for putting the symptoms of Type 2 Diabetes into remission will often say that there are no randomized control trials (RCTs) showing that this diet is safe and effectiveness over the long-term, but what they often don’t realize is that there were no randomized controlled studies demonstrating safety and efficacy underlying the recommendation that people consume 45-65% of their daily calories as carbohydrate, while limiting their fat intake. What we do have in both Canada and the US since 1977 (when the Dietary Guidelines in both countries changed) is 40+ years of epidemiological data showing a massive increase in the incidence and prevalence of obesity and Type 2 Diabetes that shows no sign of letting up, and a millions of people that are fed-up of feeling “sick and tired”. Is it simply that people stopped “moving” as much or could it be the diet?

Recently, the therapeutic use of a low carbohydrate diet as a dietary option for reducing blood sugar, use of blood-sugar lowering medications and for weight loss has been recognized by the American Diabetes Association  (ADA) in the release their 2019 Standards of Medical Care in Diabetes (you can read more about that here. In addition, in October 2018 the ADA and the European Association for the Study of Diabetes (EASD) released a joint position paper that classifies a low carbohydrate diet as Medical Nutrition Therapy for the treatment of Type 2 Diabetes in adults (more about that here). This means that physicians and healthcare professionals in Europe and the United States can recommend a low carbohydrate diet as one of the treatment options for their patients.  This moves a low carbohydrate diet from the realm of popular lifestyle choice to Medical Nutrition Therapy for the purpose of disease management.

You can get a one-page downloadable summary (with references) of both the American Diabetes Association (ADA) 2019 Standards of Medical Care in Diabetes and the ADA and the European Association for the Study of Diabetes (EASD) joint position paper here.

As covered in previous articles, there are ample studies showing that a well-designed low carbohydrate diet is both safe and effective for putting Type 2 Diabetes into remission and for weight loss.

In fact, there was a list compiled by Dr. Sarah Hallberg at the end of January 2018 of studies that involved a low carbohydrate diet which spanned  18 years, 76 publications involving 6,786 subjects, including 32 studies of 6 months or longer and 6 studies of 2 years or longer. Now, it is a year later and there are numerous other studies including very recent two-year data from the Virta Health study which demonstrates that a low carbohydrate diet is not only safe, but effective long term.

But there’s something about real-life, personal (n=1) accounts of ordinary people losing weight and putting their Type 2 Diabetes and other metabolic conditions into remission that people find very compelling.

Diet Doctor, a well-known website dedicated to a low-carb high fat / “keto” approach has a whole section of “success stories”, and a very popular ketogenic Facebook page from Nigeria which promotes a “keto” diet (mostly self-defined) does as well.

What about when the “ordinary people” that lose weight and put their own metabolic disorders into remission also happen to be healthcare professionals? It seems many find this particularly compelling because we know the full range of dietary options and have chosen the method we have after careful consideration.

As many of you know, I was recently the featured guest on the Low Carb MD Podcast which was hosted by Dr. Tro Kalajian and Dr. Brian Lenzkes. As outlined on the article at the link above, both of these doctors struggled with obesity their whole lives and both have lost weight and found improved metabolic health, and are now helping their patients to do the same.

Then there’s me, a Registered Dietitian in private practice who’s lost almost 50 pounds and put my Type 2 Diabetes of 10 years into remission.

The three of us are just ‘two Docs and a Dietitian’ who were sick of being sick, but there are many more healthcare practitioners just like us that have done similarly, including some of the more than 1500 that are part of the Canadian Clinicians for Therapeutic Nutrition (CCTN) Facebook group and members of CCTN.

We are ordinary people who as clinicians are knowledgeable about the therapeutic benefits of following a low carbohydrate diet and who have implemented it in our own lives. Our stories are not scientific case studies, nor are they part of a randomized controlled trials or research of any kind.  Our single subject (n=1) anecdotal stories and those of hundreds of thousands of ordinary people from all walks of life are powerful because they stand in sharp contrast to the large percentage of the population that are overweight or obese just like we were, but who keep eating the same way and getting sicker.

We offer people choices.

The choice of turning things around.

The option of getting healthy.

The ability to achieve a healthy body weight and in the process be able to have our doctors reduce or eliminate medications for metabolic diseases.

If you’re tired of being “sick and tired” then I’d encourage you to listen to the podcast above or to have a look through some of the “Science Made Simple” articles on this web page under the Food for Thought tab. There you can learn about the different types of “low carb” and “keto” diets and get a feel for what eating this way is like.

If you would like medical support in the US, be sure to check out Dr. Kalajian and Dr. Lenzkes, other physicians such as Dr. Eric Westman and Dr. Ted Naiman, as well as the Virta Health Clinic, as well as many others who are knowledgeable and experienced to provide you with support in this area. If you are in Canada and are looking for a therapeutic nutrition practitioner, you can search the list on the CCTN website (link above) and if you’d like to know how I can help (either in-person or from where you are via Distance Consultation) then feel free to send me a note using the Contact Me form above and I’ll reply as soon as possible.

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

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2018 in Review – a Dietitian’s Journey

This morning I went to do my exercises and realized that it’s been 10 months since I took my last photo in gym clothes and decided it was a good time for an update.

During the first year of my “journey”, I didn’t exercise at all except for walking and had set the goal of implementing some weight and resistance training beginning March 5th, 2018 (my one year “anniversary” of adopting a low carb lifestyle). I was inspired by some doctor colleagues in the Canadian Clinicians for Therapeutic Nutrition group and decided to start slow HIT (slow high intensity training) following the method of Dr. Doug McGuff (Body By Science) but in hindsight, given my age and the number of years I had not exercised, I probably should have started by retraining major muscle groups and strengthening my core first.  I didn’t and ended up aggravating an old back injury and spent most of the summer going through physiotherapy for that. I was in so much pain that even walking was difficult at first, so exercise outside of daily physio was set aside.

As a result of my back injury, I engaged the help of a terrific kinesiologist, and asked her for exercises to build up my knees and shoulders, as well as my back as I knew these were “weak links”.  I faithfully worked on training one of those areas daily, until I ended up injuring one of my knees (also an old injury!) getting out of one of my son’s low-slung car! Sheesh, I felt like I couldn’t ‘win’. Years ago I had each of my knees operated on (torn meniscus in each) after various injuries from years of dance, horseback riding and karate, so my best made plans for exercise this year did not turn out as I  intended.

February 2, 2018 – December 30, 2018

Even without doing most of the exercise that I planned to do during this past year, my body shape evolved, as can be seen in these two photos.  The one on the left was taken February 2, 2018 and the one on the right, this morning (Dec 30, 2018).

For the last 6 weeks, I have been both resting my knee injury as any amount of weight bearing hurt and only worked to gently build up the supporting muscles in that knee. Last week after much patience and frustration, I was finally able to walk up the stairs without pain (provided I didn’t try to carry anything heavy at the same time)!

Since I didn’t want to overdo it but knew I needed to start moving forward with my exercise commitment, I began by doing a few slow deep-knee bend squats each day; first 5 at a time.  The last week, I began adding a set here and there whenever I went upstairs for something (a random excuse which served as a reminder).  By the end of this week I was doing 20 – 30 full-knee bend squats per day, 5 at a time.  This is HUGE progress! My goal now is to begin exercising regularly WHILE NOT injuring anything by not being adequately focused on my body mechanics!

While my exercise plans this year didn’t turn out as I hoped, in the end I did end up strengthening my core muscles and building up my knees, lower back and shoulders (one of which is still causing me a bit of grief). I am not letting these setbacks deter me — any more than I let past weight loss stalls deter me.

My goal is to get as healthy as I can and that takes me being dedicated to the process regardless of setbacks.  Setback happen.  They happen to everyone.

Here’s my recap of my progress so far;

In the first year (March 5, 2017 – 2018) I lost a total of 32 pounds and lost 8 inches off my waist. I no longer met the criteria for Type 2 Diabetes (when I began my blood sugar was uncontrolled) and at the end of the first year my blood pressure ranged from between normal and pre-hypertensive  (when I began it was dangerously high). At the end of the first year, my triglycerides were ideal and I had excellent cholesterol levels (details here).

This past year, I lost an additional 18.5 pounds and another 4 inches off my waist; making it a foot in total! My waist to height ratio is now below .50 so I am satisfied. I am 1.5 inches from my final goal weight and am trying to decide if I want to lose another 5 pounds or if I want to focus on toning up my muscles, or both.  For details on exactly what I lost from my arms, legs, belly etc. you can read more here.

Two and a half years of change – from April 2015 – September 2017

Twenty-two months ago this coming week, I was an obese, metabolically very unwell Dietitian with Type 2 Diabetes, very high blood pressure and abnormal cholesterol.

February 2, 2018 – December 30, 2018

I certainly haven’t “arrived” by any means, but I am a whole lot healthier and feel better than I have in years.

As I tell my clients, its about “progress”, not “perfection”.

 

 

I hope my journey has inspired you that losing weight and getting healthy can be done and while it’s not a straight-forward line of progress all the time, and stalls and setbacks do occur, goals that are realistic set CAN be accomplished. Sometimes they just take a little longer than planned.

If you’d like to know more about how I can help you accomplish your health and nutrition goals this coming year, please have a look at the Services I offer and if you have questions, please send me a note using the Contact Me form located on the tab above. If you’d like some help setting some realistic goals for this coming year, please have a look at the special package I put together which is at a special price during the month of January.

Wishing you and yours the very best for a healthy and happy New Year!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

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A Goal Without a Plan is a New Year’s Resolution

It is said that the definition of “insanity” is doing the same thing over and over again expecting different results, yet with the best of intentions many of us make a New Year’s Resolution each January 1st saying “this will be the year“!  The problem is, that by the end of the first week in January 50% of us will have already given up on our resolution to lose weight, exercise more or eat healthier[1]. By the end of the month, 83% have given up[1].  In fact, a study on New Year’s Resolutions found that only 8% of those that make these types of health-related commitments will actually achieve them[1], which are  pretty discouraging statistics.

If we want to lose weight, get in shape and start eating healthier the way NOT to do it is by making a New Year’s Resolution.

We need a plan; a plan that is specific, with outcomes that are measurable and achievable and that are relevant to our overall life goals and realistic, and we need them to be accomplished in a timely manner. These are the essence of SMART goals! You can read more about those here.

New Year’s Resolutions; a desire without a commitment

Saying “I’m going to lose weight this year” says nothing about how much weight, in what period of time, by what means, nor what “success looks like”.  It’s not a goal, but a wish. It’s expressing a desire without a commitment. This also applies to exercising more or eating healthier.

How convincing would it be to us if someone said “I want to spend the rest of my life with you” but made no commitment to a relationship, or to live in the same city as us or to spending time with us?  Why should we put confidence in our ourselves when we also express desires without commitment?

We may WANT to lose weight, we may WANT to exercise more and WANT to eat healthier but all the “wanting” in the world won’t move us closer to any of those goals because a goal without a plan is just a wish.

…and a goal without a plan is a New Year’s resolution.

If you want to lose weight, exercise more and eat healthier this year, then what I’d recommend is rather than making a New Year’s resolution this year, make a commitment to yourself to take the month of January to design an implementable plan built on SMART goals.

If you do this, by the end of the month when 83% of people that have made New Year’s Resolutions have already given up, you will be ready to begin implement a well thought out plan!  When most people have forgotten their wish, you will have what you need to be successful.

If you would like help setting SMART health and nutrition goals for yourself, I offer a one-hour session that is especially for this purpose that is available via Skype or telephone. I’ll help you set goals for yourself that are specific, measurable,  achievable,  relevant /realistic and timely. These will be your goals and success will look like however you decide to measure it.  I will assist as a coach helping you set goals for yourself that are achievable, relevant and that can be achieved in a realistic amount of time.

If you would like to know more, please click here or if you have questions, please send me a note using the Contact Me form located on the tab above.

Wishing you and yours the very best for a healthy and happy New Year!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Norcross, JC et al, Auld lang syne: success predictors, change processes, and self-reported outcomes of New Year’s resolvers and nonresolvers. J Clin Psychol. 2002 Apr;58(4):397-405

 

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How Many People Will Achieve Their New Year’s Resolution?

If you are one of the many people that will be making a health-related New Year’s resolution this year, I’ve got some bad news for you. Half of people that make this type of resolution will have given up after only a week and 83% will have thrown in the towel by the end of January[1].

Why is that?

For one, it takes ~ 66 days (more than 2 months) for a new habit to become ingrained[2] and two, most New Year’s resolutions are wishes, more than a plan. More on that in a bit…

Yesterday I asked a question on Twitter:

 

 

“Are you making a New Year’s resolution this year and if so, is it to:

  • lose weight
  • exercise more
  • eat healthier
  • something else”

Of the 62 people that completed the survey, here are the results:

As you can see, they are pretty close, but of these 62 people, how many will actually meet their New Year’s Resolution? Based on a study on the outcome of New Year’s resolutions[1] referred to above, only 8% of people will meet their New Year’s resolution so at the end of 2019, of the 62 people above;

  • not even one person (0.94%) will have successfully achieved the weight loss they set out to
  • a little more than one person (1.44%) will have been successful at consistently exercising more
  • a little more than one person (1.54%) will have been successful at consistently eating healthier
  • one person (1.04%) will have met their other health-related goal

This is not very encouraging, is it?

As I said above, most New Year’s resolutions are wishes, more than a plan. A wish is along the lines of “I’d like to” but without a well-thought out, realistic plan to make that a reality.

There is hope!

Yesterday, I wrote an article titled Avoid Making These New Year’s Resolutions which explains how to set goals that will transform your health-related wish into an achievable goal. The steps are very straight-forward and if you want they can be completed between now and New Years  or can be worked through during the month of January so that by the time 83% of people have given up on their New Year’s Resolutions, you will be primed to begin implementing your plan!

What I’d recommend is that you read through the article I wrote yesterday (link directly above) and if you need or want some help designing a plan, I have a special New Year’s SMART goal session that can help.  You can click here to learn more or send me a note using the Contact Me form located on the tab above.

I provide both in-person services in my Coquitlam (British Columbia) office and via Distance Consultation (Skype, phone), so whether you live in the Greater Vancouver area or away, I’d be happy to assist you.

Wishing you and yours the very best for a healthy and happy New Year!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Norcross, JC et al, Auld lang syne: success predictors, change processes, and self-reported outcomes of New Year’s resolvers and nonresolvers. J Clin Psychol. 2002 Apr;58(4):397-405
  2. Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W. and Wardle, J. (2010), How are habits formed: Modelling habit formation in the real world. Eur. J. Soc. Psychol., 40: 998–1009.

 

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Avoid Making These New Year’s Resolutions

Why on earth would a Dietitian suggest to avoid making New Year’s resolutions to lose weight, exercise more or eat healthier? The reason is that research indicates that half of those that make these types of health-related  New Year’s Resolutions give up just a week into the new year [1] and by the end of January, 83% will have given up [1]. A New Year’s resolution will see only 8% of people reach their goal, with 92% failing[1]. I want people succeed and since it takes approximately 66 days (that’s more than 2 months!) to create a new habit[2] having my support during the critical planning and implementing stage can make a huge difference!

Rather than making a New Year’s resolution, I recommend that people set SMART goals. Ideally if they want to lose weight during the new year, they will have done this in November and begun to implement their plan in December but it’s not too late!  Setting SMART goals in January and beginning to implement them in February works great!

What are “SMART” goals?

SMART is an acronym for goals that are specific, measurable, achievable, relevant (or realistic) and time-bound.

SMART goals

Goals that are Specific

When setting a goal, it needs to be specific.

If your goal is weight loss, then think about exactly what you are trying to accomplish in terms of how much weight in what amount of time.

If your goal is to exercise more, than decide how often you will exercise, for how long at each session , and what types of exercise you will do (weights, resistance, cardio, etc).

If your goal is to eat healthier, then define what that means to you.  Is it “clean eating”; then what is that, exactly?  If you want to eat to lower your blood sugar or cholesterol or blood pressure or to reduce your risk to specific diseases that run in your family, then you need to define it that way.

Goals that are measurable

When setting a goal it is necessary to define what is going to be used to measure whether the goal will have been met.  If the goal is weight loss, then it can be measured by a certain number of pounds or kilos lost or by a specific waist to height ratio.

If the goal is to exercise more, then it can be measured in times per week at the gym, the number of hours spent exercising each week or how many fitness classes you attend each month.

If the goal is to eat healthier, then how are you going to measure that?  It could be measured in how many times you eat fatty fish (like salmon or mackerel) in a week, or how many grams of carbohydrate you eat per day or how many servings of leafy green vegetables you eat per day.  How will you measure it?

What does success look like?

Goals that are achievable

For goals to be be successfully accomplished, they need to be realistically achievable from the beginning, otherwise people get discouraged and give up.

When it comes to setting weight loss goals, it is not uncommon for people to decide they want to lose 20 pounds in a month before a special social function, but is it achievable?

When it comes to exercising more, is it achievable to set a goal of working out an hour a day, 7 days per week or is there a different goal that is more achievable and will still keep you progressing?

It’s the same with eating healthier; the goal needs to be achievable.  When I started my personal weight loss and health-recovery journey in March 2017, one of the goals I set was to put my Type 2 Diabetes into remission by a year. Based on the research and how I decided to eat, that was achievable. It actuality it took me 13 months to accomplish, but I was not discouraged that I didn’t actually achieve it in the time frame I planned because the goal was achievable. I was close at a year, just not “there” yet.

Goals that are relevant or realistic

For a goal to be relevant it needs to fit within a person’s broader goals.

If I have a goal to lose weight but I have a larger goal to eat with my kids, then I need to plan to make food for myself that is the same as what I make for them, with some modifications for my weight loss goals

If one of my goals is to spend more time with my kids in the evening then planning to go running each evening as a way of exercising more does not fit within my broader goals. If my goal is to buy only locally-sourced food and I want to eat mangoes as part of my plan to eat healthier, I will face challenges if I live in the northern US or Canada and it’s wintertime. We need to know our broader goals and set our individual ones in that context.

For a goal to be realistic it needs to be achievable and for this step, it is often best to consult someone that would know.

Goals that are time-bound

Setting a goal to “lose weight” is one thing.  That’s pretty generic.  Setting a goal to lose a given amount of weight in a specific amount of time means that a lot of planning and implementing needs to occur for that goal to be successfully realized.  It is the planning and implementing to achieve a specific, measurable, achievable and realistic goal in a specific time-frame that makes it successful.

A Dietitian’s Journey – SMART Goals

Back in March 2017 when I set out to restore my own health and lose weight, these were the goals that I set;

(1) blood sugar in the non-diabetic range

(2) normal blood pressure

(3) normal / ideal cholesterol levels

(4) a waist circumference in the “at or below” recommended values of the Heart and Stroke Foundation

While they don’t appear as SMART goals, as a Dietitian I knew what the “normal range” for these was and the time-frame I set was one year.

At the one year mark, my progress report as posted on Diet Doctor on March 14, 2018:

I did reach my goal of having my waist circumference at or below the recommended values of the Heart and Stroke Foundation, but still had a way to go to get it in a healthier range based on waist to height ratio;

I have not yet reached a low-risk waist circumference (one where my waist circumference is half my height).  I still have to lose another 3 inches to lose (having already lost 8 inches!), so however many pounds I need to lose to get there, is how much longer I have to go.

I am guessing that will be in about 20-25 pounds which may take another 6 months or so, but I’m not really concerned about the time because this “journey” is about me getting healthy and lowering my risk factors for heart attack and stroke, and any amount of time it takes is what it will take.

It took years to make myself that metabolically unhealthy and it will take time for me to get to a healthy body weight and become as metabolically ‘well’ as possible.

(from “A Dietitian’s Journey”)

As it turned out, it was only a week ago last Monday that I finally got to a place where my waist circumference was half my height; 8 months after my first year update. That was 2 months more than I thought it would take, but only 20 pounds more that I needed to lose to accomplish it, so I was close.

Was I discouraged at 6 months when I hadn’t “arrived”?

No, because  from the beginning my goals were SMART which made them rooted in what was possible.

I was very specific as to what I wanted to accomplish, how I was going to measure success, that the goals were achievable based on the available research, were relevant to my larger life goals and were time-bound. That said, just because reaching my goals was possible did not guarantee that I would achieve all of them in the time I planned. I achieved most of them within a year, and achieved the rest with a little more patience and time.

Some final thoughts…

Instead of setting a New Year’s resolution to lose weight, exercise more or eat healthier, perhaps spend the month of January setting very specific SMART goals. At the end of January, when 83% of the people have already given up on their New Year’s resolutions to improve their health, you will about to implement your well-thought out, realistic plan and may have already engaged me as your Dietitian or hired a personalized trainer to help you implement your exercise goals. Now THAT is a whole lot more than wishful thinking!

In setting your SMART goals, ask yourself;

  1. “What specifically do I want to accomplish”
  2. “How will I measure success?”
  3. Is this achievable? Do I know? Where can I find out?
  4. Is this goal relevant to my larger life goals?
  5. What time-frame do I want to accomplish this by?

Write out what you can about each of your goal(s) and then if achieving your goal will take more than a few months or a year or more to achieve, then I’d recommend engaging a professional to support you.

When it comes to weight loss and eating healthier I can certainly help, and if your goal is to lower risk to specific types of diseases I can certainly share with you the information I have gleaned as to which types of exercise are the most helpful in that regard.

If you would like some help to set your own SMART goals, please click here to learn more about the session I am offering during January to help. This session is available via Distance Consultation (Skype, phone) so whether you live close by or far away, I’m able to help.

If you would like more information about my hourly services or the packages I offer, please click on the Services tab, above and if you have questions about those, please send me a note using the Contact Me form and I’ll reply when I am able.

Wishing you the very best for a healthy and happy New Year!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Norcross, JC et al, Auld lang syne: success predictors, change processes, and self-reported outcomes of New Year’s resolvers and nonresolvers. J Clin Psychol. 2002 Apr;58(4):397-405
  2. Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W. and Wardle, J. (2010), How are habits formed: Modelling habit formation in the real world. Eur. J. Soc. Psychol., 40: 998–1009.
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Episode 7 Low Carb MD Podcast – interview with Joy Kiddie, LCHF-Dietitian

Episode 7 of the LowCarbMD podcast (recorded Nov 2, 2018) has just been released and features yours truly as the invited guest of two of the hosts, Dr. Tro Kalajian and Dr. Brian Lenzkes.

For those of you who don’t know them, Dr. Tro Kalajian is a board certified physician in Tappan, New York who struggled with obesity his whole life. Over the past 2 years, Tro lost 155 pounds following a very low carbohydrate (ketogenic) diet along with the addition of high intensity interval training, resistance training, intermittent fasting and time-restricted eating. Tro recently opened Dr. Tro’s Medical Weight Loss clinic where he provides medically supervised weight loss.

Dr. Brian Lenzkes is a board certified physician in San Diego, California who has been in practice for 15 years and who has been voted one of the Top Doctors in that city for 11 of those years. Brian also had his own struggles with obesity since childhood which culminated with him being diagnosed as pre-diabetic in February 2017. He stumbled across a YouTube video by Canadian nephrologist (kidney specialist) Dr. Jason Fung (now a co-host of the LowCarbMD podcast) and immediately changed how he ate. His lifestyle modifications have significantly impacted his own health as well as the way he practices medicine. Brian now helps his patients achieve better health and quality of life.

For those who don’t know me yet, I am Joy Kiddie, a Registered Dietitian with a post graduate degree in Human Nutrition who has been in private practice for more than a decade in British Columbia (originally from Montreal, Quebec). I first heard about the current use of a low carbohydrate diet from a retired physician-friend who came to speak with me regarding my thoughts about using this approach to improve the health of a family member. My personal ‘turning point’ was March 5, 2017 when I came to the harsh realization that I was metabolically very unwell and needed to change my diet and lifestyle. I began that day and haven’t looked back. I provide both in-person and Distance Consultation (Skype, phone) services related to following a low carbohydrate diet for lifestyle or therapeutic purposes. Note: the above ‘after’ photo was taken several months ago. I have since lost an additional 12 pounds.


Episode 7 of the LowCarbMD podcast lasts just over an hour and includes the three of us discussing a variety of topics, including how I first came to hear about a low carb diet and to offer it as a therapeutic diet and lifestyle choice in my practice, the changes I’ve made since that time with respect to macronutrient distribution and why, the first 21 months of my personal journey as a formerly obese Dietitian with Type 2 Diabetes, how I see my past research in ADHD nutrition dove-tailing with obesity and food addiction, and why I believe that some people may not best be served by incorporating low carb or keto versions of sweets and desserts into their diets on a regular basis.  The interview ends with a brief outline of the book I’m currently working on which focuses on prevention, reversal and remission of Type 2 Diabetes.

A Listener’s Feedback

[update: December 24 2018]

After listening to Episode 7, a LowCarbMD podcast follower mentioned to Dr. Tro Kalajian that this was “probably my favorite (podcast) to date” to which Tro replied;

” I’m glad you liked it. Was it the topics?”

Her reply was;

” it was the combination of Joy’s professional expertise and personal experience.”

I am delighted that both my professional expertise and personal experience are what made this episode so unique for this listener.

Note: I deliberately keep my personal health and weight loss experience (located under the “A Dietitian’s Journey” tab) separate from the researched, referenced articles that I write (located under the Food for Thought tab) because my own journey is simply my anecdotal experience. Each person’s “journey” will be different, but the evidence on which the low carbohydrate diets I design for my clients and for myself are based on the scientific evidence.


I hope you enjoy the interview and many thanks to both Dr. Tro Kalajian and Dr. Brian Lenzkes for inviting me to be a guest. Just click the MP3 player bar below to listen to the interview.

Many thanks to Dr. Brian Lenzkes for permission to post it here. Their podcast is self-funded and can be supported by following this Patreon link. Be sure to visit the site of the Low Carb MD podcast to listen to more great interviews.

If you have questions about my services, please feel free to drop me a note through the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

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American Diabetes Association Low Carb Recommendations – one page printout

This post contains a one page downloadable printout that you can bring to your doctor or other healthcare professional which summarizes the American Diabetes Association’s new clinical recommendations concerning the use of low carbohydrate diets for adults with Type 2 Diabetes and is based on;

(1) the ADA’s October 2018 joint Position Statement with the European Association for the Study of Diabetes (EASD) which approved use of a low carbohydrate diet of <130 g of carbohydrate/day (<26% of daily calories as carbohydrate) as Medical Nutrition Therapy (MNT) for adults with Type 2 Diabetes [1]. You can read about this position statement here.

and

(2) the ADA’s recently released 2019 Standards of Medical Care in Diabetes – Lifestyle Management [2] which includes the use of low carbohydrate diets as Nutrition Therapy and which reflects the organization’s emphasizes on a patient-centered, individualized approach. You can read about the updated Standards of Care here.

This one-page printout has the references that the ADA used to support their recommendations so that your doctor or other healthcare professional can verify them and summarizes the conclusion of the American Diabetes Association [2] that a low carbohydrate diet may result in

(a) lower blood sugar levels
(b) lower the use of blood sugar lowering medication
and
(c) is effective for weight loss

References include the one-year study data by Virta Health [3] which used a ketogenic approach (<30g carbohydrate/day), as well as two other studies [4,5].


Click here to download the one-page printout to bring to your doctor or other healthcare professional.

 

 

 

 

DISCLAIMER: This handout is intended for information purposes only and is not affiliated with the American Diabetes Association in any way.

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Davies M.J., D’Alessio D.A., Fradkin J., et al, Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), Diabetes Care, October 2018, https://doi.org/10.2337/dci18-0033
  2. American Diabetes Association, Lifestyle Management Standards of Medical Care in Diabetes – 2019. Available at: http://care.diabetesjournals.org/content/42/Supplement_1. Accessed: Dec. 17, 2018.
  3. Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583–612
  4. Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes 2017;7:304
  5. Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239–252

 

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Low Carb Diet in 2019 American Diabetes Association Standards of Care

On Monday, December 17, 2018, the American Diabetes Association released its new 2019 Standards of Medical Care in Diabetes including its Lifestyle Management Standards of Care which includes use of a low carbohydrate diet saying it may result in lower blood sugar levels and also has the potential to lower the use of blood sugar lowering medications[1] in those with Type 2 Diabetes. In support, they cite the one-year study data by Virta Health[2], as well as two other studies [3,4].

“…research indicates that low carbohydrate eating plans may result in improved glycemia and have the potential to reduce antihyperglycemic medications for individuals with type 2 diabetes…”

The new 2019 Standards of Care reflect the American Diabetes Association’s change in approach which began in 2018 to revise the guide throughout the year as new scientific evidence warrants it, rather than to wait annually to update guidelines. Towards that end, in November 2018, the American Diabetes Association launched a joint partnership with the American Heart Association to raise awareness about the increased risk of cardiovascular disease for those diagnosed with Type 2 Diabetes and in October, the American Diabetes Association in conjunction with the European Association for the Study of Diabetes (EASD) released a joint Position Statement which approved use of a low carbohydrate diet as Medical Nutrition Therapy (MNT) for adults with Type 2 Diabetes (you can read more about that here).

The American Diabetes Association’s newly released 2019 Lifestyle Management  Standards of Medical Care in Diabetes builds on this joint consensus paper released with the EASD by including use of a low carbohydrate diet in the section on Nutrition Therapy where it emphasizes a patient-centered, individualized approach based on people’s current eating patterns, personal preferences and metabolic goals;

“Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, macronutrient distribution should be based on an individualized  assessment of current eating patterns, preferences, and metabolic goals. Consider personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) as well as metabolic goals when working
with individuals to determine the best eating pattern for them.”

The ADA deemphasizes a focus on specific nutrients; whether fat or carbohydrate and stresses that a variety of eating patterns are acceptable.

“Emphasis should be on healthful eating patterns containing nutrient-dense foods, with less focus on specific nutrients. A variety of eating patterns are acceptable for the management of diabetes”.

The Lifestyle Management Standards of Care underscores the importance of having a Registered Dietitian involved in the process of assessing a person’s overall nutritional status, as well designing an individualized Meal Plan for them that is tailored to their health, cooking skills, financial resources, food preferences and health goals and that is coordinated with the person’s physician who is responsible for prescribing and adjusting their medications.

“…a referral to an RD or registered dietitian nutritionist (RDN)
is essential to assess the overall nutrition status of, and to work collaboratively with, the patient to create a personalized meal plan that considers the individual’s health status, skills, resources, food preferences, and health goals to coordinate
and align with the overall treatment plan including physical activity and medication.”

They outline a few eating patterns that are examples of  healthful eating
patterns that have shown positive results in research, including the Mediterranean diet, the DASH diet, plant-based diets and add that

“low-carbohydrate eating plans may result in improved glycemia (blood sugar) and have the potential to reduce anti-hyperglycemic medications (medications to lower blood sugar) for individuals with type 2 diabetes.”

The documents emphasizes again that individualized meal planning should focus on personal preferences, needs, and goals rather than focusing on any specific macronutrient distribution.

Without citing any references, the Standards of Care state that there are challenges with the ability of people to continue to follow a low carbohydrate diet long term and as a result that it’s important to reassess people who adopt this approach.

“As research studies on some low-carbohydrate eating plans generally indicate challenges with long-term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach.”

It’s unfortunate that the ADA did not have access to the very recently released two-year data from Virta Health’s study which showed a 74% retention rate in the low carb intervention.

The ADA takes the position that a low carbohydrate meal plan is not recommended for women who are pregnant or breastfeeding, people who have- or are at risk for eating disorders, or have kidney disease and that caution should be taken with those taking SGLT2 inhibitor medication* for management of Type 2 Diabetes, as there is the potential risk of a condition known as diabetic ketoacidosis (DKA).

*This article outlines the risk of SGLT2 inhibitors, as well as other medications used to treat high blood pressure and some mental health disorders that need supervision when following a low-carbohydrate diet.

Low Carbohydrate Diets for Weight Loss

The ADA’s new 2019 Lifestyle Management Standards of Care also includes use of a low carbohydrate diet in the Weight Management section of the document, which underscores the benefit in blood sugar control, blood pressure and cholesterol (lipids) of weight loss of at least 5% body weight in overweight and obese individuals and that weight loss goals of 15% body weight may be appropriate to maximize benefit.

In this section dealing with Medical Nutrition Therapy (MNT), the role of a Registered Dietitian (RD) / Registered Dietitian Nutritionist (RDN) is emphasized;

“MNT guidance from an RD/RDN with expertise in diabetes and weight management, throughout the course of a structured weight loss plan, is strongly recommended.”

The ADA’s Lifestyle Management Standards of Care indicates that studies have demonstrated that a variety of eating plans with different macronutrient composition can be used safely and effectively for 1-2 years to achieve weight loss in people with Diabetes, including the use of a low-carbohydrate diet and that no single approach has been proven to be best;

“Studies have demonstrated that a variety of eating plans, varying in macronutrient composition, can be used effectively and safely in the short term (1–2 years) to achieve weight loss in people with diabetes. This includes structured low-calorie meal plans that include meal replacements and the  Mediterranean eating pattern, as well as low-carbohydrate meal plans. However, no single approach has been proven to be consistently superior.”

It is concluded that more study is needed to know which of these dietary patterns is best when used long-term and which is best accepted by patients over a long period of time.

“more data are needed to identify and validate those meal plans that are optimal with respect to long-term outcomes as well as patient acceptability.”

In the section dealing specifically with Carbohydrates, it is indicated that for people with Type 2 Diabetes or prediabetes that low-carbohydrate eating plans show the potential to improve blood sugar control and cholesterol outcomes for up to one year, and that part of the problem in interpreting low-carbohydrate research has been due to the wide range of definitions of what “low-carbohydrate” is (i.e. <130 g of carbohydrate, <50 g carbohydrate).

Point of Interest: No where in the Lifestyle Management Standards of Medical Care in Diabetes does the American Diabetes Association define what they mean by “low carbohydrate diet”. The fact that they cite the one-year study data from Virta Health[2] (see above) as evidence for safety and efficacy in lowering blood sugar and Diabetes medication usage when that study clearly employs a ketogenic approach is most interesting.

” For people with type 2 diabetes or prediabetes, low-carbohydrate eating plans show potential to improve glycemia and lipid outcomes for up to 1 year. Part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan.”

The Standards of care stated that because most people with Diabetes say they eat between 44–46% of calories as carbohydrate, and that changing people’s usual macronutrient intake usually results in them going back to how they ate before, that they recommend designing meal plans based on the person’s normal macronutrient distribution, because it is most likely to result in long-term maintenance.

“Most individuals with diabetes report a moderate intake of carbohydrate (44–46% of total calories). Efforts to modify habitual eating patterns are often unsuccessful in the long term; people generally go back to their usual macronutrient distribution. Thus, the recommended approach is to individualize meal plans to meet caloric goals with a macronutrient distribution that is more consistent with the individual’s usual intake to increase the likelihood for long-term maintenance.”

NOTE: Most people are likely to indicate they eat within the recommended range of carbohydrate intake (45-65% of calories as carbohydrate) because that is how they were counselled to eat when they were diagnosed with Type 2 Diabetes, but stating that they should continue to eat that way because they are most likely to be compliant makes no sense. If a person realizes they are not able to meet optimal blood sugar levels eating that level of carbohydrate intake and are interested and motivated to lower it, then as healthcare professionals, we need to be equipped to support that in an evidenced-based manner.

In this section on Carbohydrates, it was emphasized that;

“…both children and adults with Diabetes are encouraged to minimize intake of refined carbohydrates and added sugars…”

and

“The consumption of sugar-sweetened beverages (including  fruit juices) and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged.”

Protein

With respect to protein intake, it was emphasized that;

(1) there isn’t any evidence to suggest that adjusting protein intake from 1–1.5 g/kg body weight/day (15–20% total calories) will improve health.

(2) research is inconclusive regarding the ideal amount of dietary protein to optimize either blood sugar control or cardiovascular disease (CVD).

(3) “some research has found successful management of type 2 diabetes with meal plans including slightly higher levels of protein (20–30%), which may contribute to increased satiety.”

Caution for those with diabetic kidney disease (i.e. urine albumin and/or reduced glomerular filtration rate) advise that dietary protein should be maintained at the recommended daily allowance of 0.8 g/kg body weight/day.

Fats

The Standards of Care acknowledged that the ideal amount of dietary fat for individuals with diabetes is controversial and underscored that the National Academy of Medicine has defined an acceptable macronutrient distribution for total fat for all adults to be 20–35% of total calorie intake. They stated that the type of fats consumed are more important than the total amount of fat when looking at metabolic goals and cardiovascular (CVD) risk and recommended that the percentage of total calories from saturated fats be limited. It was recommended that people with Diabetes follow the same guidelines as the general population when it comes to intakes of saturated fat, dietary cholesterol and trans fat and they recommended a focus on eating polyunsaturated and monounsaturated fats for improved glycemic (blood sugar) control and blood lipids (cholesterol) and that there does not seem to be a CVD benefit of supplementing with omega-3 polyunsaturated fatty acids.

Other Points of Interest

It is interesting that the Lifestyle Management Standards of Care indicated that the literature concerning Glycemic Index (GI) and Glycemic Load (GL) in individuals with Diabetes often yields conflicting results and that “studies longer than 12 weeks report no significant influence of glycemic index or glycemic load independent of weight loss on A1C”.

Conclusion

The American Diabetes Associations 2019 Lifestyle Management Standards of Medical Care in Diabetes emphasis on a patient-centered, individualized approach is under-girded by an acknowledgment that based on the current evidence, a low-carbohydrate diet is both safe and effective used as Medical Nutrition Therapy for up to two years in adults in order to lower blood sugar, reduce Diabetes medication usage and support weight loss.


I’m a Registered Dietitian that has years of experience working with non-insulin dependent individuals with Type 2 Diabetes. I can assess your overall nutritional status, review your personal and family medical background and lifestyle habits and create a individualized Meal Plan just for you that considers your health status, cooking skills, food preferences, resources as well as your health and weight goals. I even offer a single package (the Complete Assessment Package) that will do just that.

I provide in-person services in my Coquitlam (British Columbia) office as well as via Distance Consultation (Skype, long distance) for those outside of the Lower Mainland area.

You can find out more about the hourly consultations and packages I offer by clicking on the Services tab above and if you have questions, feel free to send me a note using the Contact Me form, and I will reply as soon as I am able.

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/lchfRD/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. American Diabetes Association, Lifestyle Management Standards of Medical Care in Diabetes – 2019. Available at: http://care.diabetesjournals.org/content/42/Supplement_1. Accessed: Dec. 17, 2018.
  2. Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an  open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583–612
  3. Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes 2017;7:304
  4. Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239–252
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Long-Term Benefits of a Ketogenic Diet – 2 year update

A pre-publication of the long-awaited 2 year update from the Virta Health study has just been released[1] and indicates that there were improvements in body weight while following a ketogenic diet the first year which were largely sustained into the second year, with some minor rebound. Improved blood sugar control was also largely sustained and that significant metabolic markers and health improvements occurred using a ketogenic approach over the usual care model approach.

This article briefly outlines the study and baseline data and compares the newly-released two-year data to the one-year data, as well as comparing the 2 year data using a ketogenic diet to the data from the “usual care” control group.

Baseline Details

There were 238 participants enrolled in the continuous care intervention at the beginning of the study and all had a diagnosis of Type 2 Diabetes (T2D) when the study began with an average HbA1c of 7.6% ±1.5%. Participants ranged in age from 46 – 62 years of age (mean age = 54 years). Sixty-seven (67%) of participants were women and 33% were men.

Weight ranged from 200 pounds to 314 pounds (117±26 kg), with an average weight of 257 pounds (117 kg).  Average Body Mass Index (BMI) was 41 kg·m-2 (class III obesity) ±9 kg·m-2, with 82% categorized as obese.

The majority of participants (87%) were taking at least 1 glycemic (blood sugar) control medication at the beginning of the study.

Intervention

Each participant in the continuous care group received an Individualized Meal Plan for nutritional ketosis, behavioral and social support, bio-marker tracking tools and ongoing care from a health coach with medication management by a physician.

Subjects typically required <30 g per day of total dietary carbohydrate. Daily protein intake was targeted to a level of 1.5 g / kg based on ideal body weight and participants were coached to incorporate dietary fats until they were no longer hungry (satiety). Other aspects of the diet were individually tailored to ensure safety, effectiveness and satisfaction, including consumption of 3-5 servings of non-starchy vegetables and enough mineral and fluid intake. Use of time restricted eating or intermittent fasting by subjects was not mentioned. The blood ketone level of β-hydroxybutyrate (BHB) was monitored using a portable, handheld device.

Participants

There were 238 participants enrolled in the continuous care intervention at the beginning of the study. At the end of a year, 218 participants (83%) were still enrolled in the  continuous care intervention group. At the end of two years, 194 participants (74%) remained enrolled in the continuous care intervention group.

There were no reported serious adverse events between one and two years in this study that were attributed to the dietary intervention or that resulted in the need to discontinue participation in the study; including no reported episodes of ketoacidosis or severe hypoglycemia requiring assistance.

Medication Use

At baseline, 87% of participants were taking at least one medication for Diabetes, with ~56% (55.7%) taking Diabetes medications excluding Metfomin. After one year, Type 2 Diabetes medication prescriptions other than Metformin declined from 56% to just below 30%. At two years, Type 2 Diabetes medication prescriptions other than Metformin declined to 27% (26.8%).

Insulin therapy at baseline was 30% (29.8%) and at two-years was 11.3%. Use of sulfonylureas was 23.7% at baseline and was entirely eliminated in the continuous care intervention group at one-years and remained at 0% at two-years.

No changes in use of any Diabetes medication (excluding Metformin) or individual diabetes medication classes were observed in the usual care control group from baseline to 2 years.

Glycosylated Hemoglobin (HbA1C)

At baseline, the average HbA1c level of the intervention group was 7.7%,  with less than 20% of participants having a HbA1c level of <6.5% (with medication usage). On average after one year, participants in the intervention group lowered HbA1c from 7.7% to 6.3%. At two years, HbA1C of participants in the intervention group increased to 6.7%.

By comparison, HbA1C of the usual care control group was 7.5% at baseline, 7.6% at one-year and 7.9% at two years.

Fasting Blood Glucose

At baseline, fasting blood glucose of the intervention group was 164 mg/dl (9.1 mmol/L). On average after one year, participants in the intervention group lowered fasting blood glucose to 127 mg/dl (7.0 mmol/L). At two years, fasting blood glucose of participants in the intervention group increased to 134 mg/dl (7.4 mmol/l).

By comparison,fasting blood glucose of the usual care control group was 151 mg/dl (8.4 mmol/L) at baseline,160 mg/dl (8.9 mmol/L) at one-year and 172 mg/dl (9.5 mmol/L) at two years.

Fasting Insulin

At baseline, fasting insulin of the intervention group was 28 pmol/L(4.4 uU/ml). On average after one year, participants in the intervention group lowered fasting insulin to 16.5 pmol/L (2.4 uU/mL). At two years, fasting insulin of participants in the intervention group was further reduced to 16 pmol/L (2.3 uU/mL).

By comparison, fasting insulin of the usual care control group was also 28 pmol/L(4.4 uU/ml), and at a year was 26.5 pmol/L (3.8 uU/ml) and at two years was 24.2 pmol/L (3.5 uU/ml).

Weight Loss

At baseline, body weight of the intervention group averaged at 115 kg (254 pounds). On average after one year, participants in the intervention group lowered body weight to 100.3 kg  (221 pounds). At two years, body weight of participants in the intervention group increased slightly to 102.6 kg  (226 pounds).

By comparison, body weight of the usual care control group was 111 kg (244 pounds) at baseline, 112 kg (247 pounds) at one-year and stable at two years.

Cholesterol and Triglycerides

LDL-cholesterol

At baseline, LDL cholesterol of the intervention group averaged 103.5 mg/dl (2.68 mmol/L). On average after one year, LDL of participants in the intervention group had increased LDL of 114 mg/dl (2.95 mmol/L). At two years, LDL of participants in the intervention group increased very slightly to 114.5 mg/dl (2.96 mmol/L).

By comparison, LDL cholesterol of the usual care control group was 100 mg/dl (2.59 mmol/L) at baseline, 88.9 mg/dl (2.30 mmol/L) at one year, and 90.0 mg/dl (2.33 mmol/L) at two years.

HDL-cholesterol

At baseline, HDH cholesterol of the intervention group averaged 41.8 mg/dl (1.11 mmol/L). On average after one year, LDL of participants in the intervention group had increased HDL of 49.5 mg/dl (1.28 mmol/L). At two years, HDL of participants in the intervention group were stable at 49.5 mg/dl (1.28 mmol/L).

By comparison, HDL cholesterol of the usual care control group was 38.7 (1.00 mmol/L) mg/dl at baseline, decreased to 37.2 mg/dl (0.96 mmol/L) at one year and 42.5 mg/dl (1.10 mmol/L) at two years.

Triglycerides

At baseline, triglycerides of the intervention group averaged 197.2 mg/dl (2.23 mmol/L). On average after one year, triglycerides of participants in the intervention group had decreased to 148.9 mg/dl (1.68 mmol/L). At two years, triglycerides of participants in the intervention group were slightly higher at 153.3 mg/dl (1.73 mmol/L).

By comparison, triglycerides of the usual care control group was 282.9 (3.19 mmol/L) mg/dl at baseline, increased to 314.5 mg/dl (3.55 mmol/L) at one year and decreased to 209.5 mg/dl (2.37 mmol/L) at two years.

Summary of Results and Significance

The main criticism for use of a ketogenic diet for the management of Type 2 Diabetes is that it is “unsustainable”, however a 74% retention rate of participants into the second year in the study demonstrates that the diet is sustainable long term and that most of the gains achieved in the first year are maintained in the second year.

While HbA1C increased slightly for the intervention group from year one (6.3% to 6.7%), the usual care group had an average HbA1C of 7.6% at one year which increased to 7.9% at two years.

CONCLUSION: While an average HbA1C of 6.7% on a ketogenic diet is not as good as it could be with better dietary adherence, it is significantly better than the 7.9% of the usual care group in this study.

Fasting blood glucose of the intervention group increased slightly from  127 mg/dl (7.0 mmol/L) at one year to 134 mg/dl (7.4 mmol/l) at two years and fasting blood glucose of the usual care group which was 160 mg/dl (8.9 mmol/L) at one-year and 172 mg/dl (9.5 mmol/L) at two years.

CONCLUSION: While an average fasting blood glucose of 134 mg/dl (7.4 mmol/l) at two years on a ketogenic diet is not nearly as good as it could be with better dietary adherence, it is significantly better than the fasting blood glucose of the usual care group which was 172 mg/dl (9.5 mmol/L) at two years.

Fasting insulin in the intervention group decreased from 28 pmol/L(4.4 uU/ml) at baseline to 16 pmol/L (2.3 uU/mL) at two years whereas in the usual care control group, fasting insulin decreased from 28 pmol/L(4.4 uU/ml) at baseline to 24.2 pmol/L (3.5 uU/ml) at to two years.

CONCLUSION: An average fasting insulin value of 16 pmol/L (2.3 uU/mL) at two years for the ketogenic diet group is significantly better than the average fasting insulin of the usual care control group of 24.2 pmol/L (3.5 uU/ml).

Weight loss in the ketogenic group was 12.4 kg (28 pounds) in two years; most of which was achieved in the first year maintained during the second year, except for very slight increase of 2.3 kg (5 pounds). No weight loss occurred in the usual care group in either the first year or the second year.

CONCLUSION: Use of a ketogenic diet resulted in significant weight loss during the first year which was largely maintained during the second year, whereas the usual care control group did not lose any weight during the course of the study.

LDL cholesterol increased in the ketogenic group from 103.5 mg/dl (2.68 mmol/L) at baseline to 114.5 mg/dl (2.96 mmol/L) at two years, but during the same time period, HDL cholesterol increased from 41.8 mg/dl (1.11 mmol/L) at baseline to 49.5 mg/dl (1.28 mmol/L) at 2 years. In the usual care control group, LDL cholesterol decreased from 100 mg/dl (2.59 mmol/L) at baseline to 90.0 mg/dl (2.33 mmol/L) at two years and HDL cholesterol only increased to 42.5 mg/dl (1.10 mmol/L) at two years from 38.7 (1.00 mmol/L) mg/dl at baseline.

At baseline, triglycerides in the ketogenic group decreased from 197.2 mg/dl (2.23 mmol/L) at baseline to 153.3 mg/dl (1.73 mmol/L) at two-years, and in the usual care control group decreased to 209.5 mg/dl (2.37 mmol/L) at two years from 282.9 (3.19 mmol/L) mg/dl at baseline.

CONCLUSION: Triglyceride to HDL ratio (a proxy measurement for LDL particle size [2,3]) went from 2.01 to 1.35 in the ketogenic intervention group and in the usual care control group only lowered from 3.19 to 2.9.  While the two-year TG:HDL ratio of 1.35 in the ketogenic group is over the recommended 0.87 ratio (which indicates mostly large-fluffy LDL versus small-dense LDL), the 2-year TG:HDL ratio of 2.9 in the usual care control group indicates increased cardiovascular risk compared to the ketogenic intervention group.

This study indicates that improvement in body weight following a ketogenic diet is largely sustained into the second year with some minor rebound. Improved glycemic (blood sugar) control was also largely sustained and that significant metabolic markers and health improvements occurred using a ketogenic approach over the usual care model approach.

This study also establishes that a ketogenic diet is sustainable over the long term.

Personal Reflections

There are many anecdotal results from people such as myself that follow a similar type of dietary intervention in order to improve their health and metabolic markers and through more disciplined adherence have been able to achieve improved results than those reported in this study.

As I posted about after one year following a comparable dietary intervention as the Virta study, I lost 35 pounds in the first year and have lost an additional 15 pounds so far during the first 9 months of the second year. I know of those who have lost even more than I have during the second year, so it is by no means common for weight loss not to continue, if required.

As with participants in the Virta study, in the first year I also lowered my HbA1C to below the cut-off for Type 2 Diabetes (< 6.5%) but did so without any medication support (subjects in the Virta study were able to use Metformin support to achieve their results). Since adding Metformin in July in order to address my high morning fasting glucose resulting from Dawn Phenomena, three quarters the way into my second year, I my three month average blood glucose is ~5.5%.

Based on my lipid panel done in July,  both my LDL and TG were significantly lower than these results and my HDL was also significantly higher but individual genetic variation seems to account largely for those whose LDL increase following a ketogenic diet. As I’ve said in previous articles, the issue is which LDL is increased; the large fluffy ones or the small, dense (atherosclerotic) ones.

Some Final Thoughts…

Each person is unique and each one’s commitment to continuing to follow dietary and lifestyle interventions into the second year and following will largely determine the degree of their long term success.

Those who have been following my personal story to reclaim my own health (under A Dietitian’s Journey) will know my degree of commitment is related to having had two girlfriends diet within 3 months of each other and realizing that because I was overweight, had Type 2 Diabetes for a number of years and having added high blood pressure to that mix put me at high risk for heart attack and stroke. Changing my lifestyle was critical in reversing those risks. In addition, the recent diagnosis of one of my parents with Alzheimer’s Disease added to my motivation to continue to improve my blood sugar and blood insulin levels, in order to lower my risk to that as well. But A Dietitian’s Journey is my n=1 (sample set of 1) story. Everybody is different.

What the two-year data from the Virta study shows it that following “usual care” for Type 2 Diabetes does not result in weight loss nor the significant improvement in metabolic health as following a well-designed ketogenic diet does. It’s no wonder that with an average HbA1C of almost 8% and fasting blood glucose of 172 mg/dl (9.5 mmol/L) that “usual care” results in Type 2 Diabetes being a “chronic, progressive disease”.  As indicated by the results of the ketogenic intervention group, it doesn’t have to be that way.

If you are seeking to improve your own health, metabolic markers or body weight and would like to do so using a low carbohydrate approach, I can help. To find out more about the packages I offer, please have a look under the Services tab or in the Shop.

If you have questions, please send me a note using the Contact Me form on this web page and I will reply as soon as I’m able.

To our good health!

Joy

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Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

References

  1. Athinarayanan SJ, Adams RN, Hallberg SJ et al, Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 2-year Non-randomized Clinical Trial. bioRxiv preprint first posted online Nov. 28, 2018; doi: http://dx.doi.org/10.1101/476275.
  2. Bittner V, Johnson BD, Zineh I, Rogers WJ, Vido D, Marroquin
    OC, Bairey-Merz CN, Sopko G (2009) The triglyceride/highdensity
    lipoprotein cholesterol ratio predicts all-cause mortality
    in women with suspected myocardial ischemia: a report from the
    Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J
    157:548–555
  3. Yokoyama, K., Tani, S., Matsuo, R., & Matsumoto, N. (2018). Increased triglyceride/high-density lipoprotein cholesterol ratio may be associated with reduction in the low-density lipoprotein particle size: assessment of atherosclerotic cardiovascular disease risk. Heart and Vessels.
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The Difference Between Reversal and Remission of Type 2 Diabetes

Some speak of having “reversed” Type 2 Diabetes (T2D) as a result of dietary changes whereas others refer to having achieved “remission”. What is the difference and why is the distinction important?

What is meant by Type 2 Diabetes “reversal”

“Reversal” of a disease implies that whatever was causing it is now gone and is synonymous with using the term “cured”.  In the case of someone with Type 2 Diabetes, reversal would mean that the person can now eat a standard diet and still maintain normal blood sugar levels. But does that actually occur? Or are blood sugar levels normal only while eating a diet that is appropriate for someone who is Diabetic, such as a low carbohydrate or ketogenic diet, or while taking medications such as Metformin?

If blood sugar is only normal while eating a therapeutic diet or taking medication then this is not reversal of the disease process, but remission of symptoms.

We do see Type 2 Diabetes reversal in a majority of T2D patients who have undergone a specific kind of gastric bypass surgery called Roux-en-Y; with 85% having achieving normal blood sugar levels within weeks of having the surgery, without taking any blood sugar lowering medications or following any special diet[1]. The mechanism that is thought to make Type 2 Diabetes reversal possible with this type of surgery are (a) that the operation results in more of the incretin hormone GIP being released in the upper part of the gut (duodemum, proximal jejunum) which results in less insulin resistance [2,3] or (b) that the presence of food in lower gut (terminal ilium, colon) stimulates the lower incretin hormone GLP-1, which results in more insulin being secreted [3], which lowers blood sugar levels.

Is Type 2 Diabetes “reversal” possible with diet alone?

It is currently believed that T2D may be reversible by non-surgical intervention if diagnosed very early on in the progression of the disease.

One matter that needs to be overcome is that both the mass and function of the β-cells of the pancreas that produce insulin are thought to be reduced by 50% by the time someone is diagnosed with Type 2 Diabetes [5]. Furthermore, the β-cells are thought to continue to deteriorate the longer a person has Type 2 Diabetes.

It is unknown for how long or at what stage T2D becomes irreversible [6].

What is meant by Type 2 Diabetes “remission”

There is evidence that indicates that weight loss of ~15 kg (33 pounds) can result in remission of Type 2 Diabetes symptoms and that β-cell function can be restored  to some degree either by (a) dormant β-cells being reactivated through a variety of means or (b) by existing β-cells functioning better [6].

Type 2 Diabetes “reversal” defined

In 2009, the American Diabetes Association defined Type 2 Diabetes partial remission, complete remission and prolonged remission as follows;

Remission is defined as being able to maintain blood sugar below the Diabetic range without currently taking medications to lower blood sugar and remission can classified as either partialcomplete or prolonged.

Partial remission is having blood sugar that does not meet the classification for Type 2 Diabetes; i.e. either HbA1C < 6.5% and/or fasting blood glucose 5.5 – 6.9 mmol/l (100–125 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.

Complete remission is a return to normal glucose values i.e. HbA1C <6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.

Prolonged remission is a return to normal glucose values (i.e.
HbA1C <6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 5 years while not taking any medications to lower blood glucose.

Remission can be achieved after bariatric surgery such as the Roux-en-Y procedure outlined above or with dietary and lifestyle changes such as a low-carbohydrate or ketogenic diet, weight loss and exercise.

According the American Diabetes Association, people who are able to achieve normal blood sugar through diet, weight loss and exercise but also take blood sugar lowering medication such as Metformin do not meet the criteria for either partial remission or complete remission.*

Those who have achieved normal blood sugar levels as a result of following a low-carbohydrate or ketogenic diet and are also taking the medication Metformin are sometimes referred to in published studies as having “reversed” their Type 2 Diabetes.  I think this is problematic because clearly if these people go back to eating a standard diet again, their blood sugar would not remain normal. As well, in some well-designed ketogenic diet studies subjects are allowed to use Metformin but no other blood sugar-reducing medication, but based on the American Diabetes Association definition the use of Metformin which helps regulate blood sugar (largely via reducing gluconeogenesis of the liver and making the muscles less insulin resistant) precludes these cases from being referred to as either partial remission or complete remission*.

Don’t get me wrong; having normal blood sugar (and insulin) levels as the result of a well-designed low carbohydrate or ketogenic diet with or without the use of Metformin enables people to reap significant health benefits and lower their risk of the chronic diseases related to hyperglycemia (high blood sugar) and hyperinsulinemia (high circulating levels of insulin) but it’s not reversal unless the people can then eat a standard diet without an abnormal glucose response.  It is normal glycemic control achieved through diet with or without the use of Metformin. Perhaps a term such as “partial remission with Metformin support” would be a more accurate descriptor.

Some final thoughts…

I think it’s important what terms we use.

There are genuine cases of Type 2 Diabetes “reversal” and we should use that term for those who can now eat a standard diet and maintain normal blood sugar levels, without the use of any medication or diet.

There are also genuine cases of “partial remission” or “complete remission” according to the American Diabetes Association definition that are a result of dietary and lifestyle changes and these terms should be reserved for cases where the defined criteria is met.

There are also genuine cases of “partial remission with Metformin support” that have been achieved as the result of people implementing dietary and lifestyle changes plus the use of Metformin that should be acknowledged and celebrated, but calling these either “Type 2 Diabetes reversal” or “Type 2 Diabetes remission” is confusing, at best.

Yes, Type 2 Diabetes a) reversal, b) partial remission and complete remission as well as c) partial remission with Metformin support are all possible. It may well be that people such as myself who had been Type 2 Diabetic for many, many years can eventually transition to genuine partial remission with eventual discontinuation of Metformin. That is my hope, at any rate!  The bottom line is that maintaining normal blood glucose levels and normal circulating levels of insulin is necessary in order to put the symptoms of Type 2 Diabetes into remission, as well as to reduce the risks to the chronic diseases associated with high blood sugar and insulin levels — and for that there are well-designed dietary and lifestyle changes. This is where I can help.

If you have Type 2 Diabetes or have been diagnosed as being pre-diabetic (which is the final stage before a diagnosis, not a “warning sign” — more about that here) and would like to work toward putting your symptoms into remission, then please send me a note using the Contact Me form above to find out more about how I can help.

I offer both in-person and Distance Consultation services (via Skype or long distance phone) and would be glad to help you get started as well as support you as you achieve your health and weight loss goals.

To yours and my good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

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Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Xiong, S. W., Cao, J., Liu, X. M., Deng, X. M., Liu, Z., & Zhang, F. T. (2015). Effect of Modified Roux-en-Y Gastric Bypass Surgery on GLP-1, GIP in Patients with Type 2 Diabetes Mellitus. Gastroenterology research and practice2015, 625196.
  2. Schauer P. R., Kashyap S. R., Wolski K., et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. The New England Journal of Medicine2012;366(17):1567–1576
  3. Lee W. J., Chong K., Ser K. H., et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Archives of Surgery2011;146(2):143–148.
  4. Laferrère B., Heshka S., Wang K., et al. Incretin levels and effect are markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese patients with type 2 diabetes. Diabetes Care2007;30(7):1709–1716
  5. Taylor R. Banting Memorial lecture 2012: reversing the twin cycles of type 2 diabetes. Diabet Med. 2013;30:267-275
  6. Watson J., Can Diet Reverse Type 2 Diabetes? December 12, 2018 https://www.medscape.com/viewarticles/905409_print
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Where the Last Twenty-Five Pounds of Weight Came From

When I set out on my “journey” on March 5, 2017 I didn’t have a particular weight loss goal in mind.  I just knew that I was metabolically unwell and very overweight and that something needed to change (you can read a summary of that story here)!  For years, I’d look in the mirror and long to see someone that looked like “me” looking back.

Over the first year since adopting a low carbohydrate and then a ketogenic therapeutic diet (March 2017-March 2018) I lost 32 pounds, put my Type 2 Diabetes into remission and significantly improved my blood pressure, but I didn’t reached the goal of getting my waist to height ratio (i.e. waist circumference half my height) so I knew I wasn’t “done” yet.

Since last December, I’ve lost 25 pounds (45 pounds in total) and today while cleaning a shelf over my desk, I found a piece of paper on which I had been keeping track of my body measurements since June 2017, including those taken from this time last year.  That’s when I decided to see where on my body these last 25 pounds came from.

Of course, where my body took the weight from is specific to me, but for those reading this who are ‘women of a certain age’ or the friend of one, you might find this encouraging.  It was a physician who teaches a low carbohydrate approach to her patients who suggested two summers ago that I take my measurements periodically to see where I am losing fat from and suggested measuring at my umbilicus*, chest (under my bust-line), neck, bicep and thigh. And so I have.

*umbilicus isn’t the same as “waist”.  Waist is measured in a particular location explained in this article and umbilicus is the region where one’s “belly button” is.

taken November 2017

Since December of last year, I lost 6.5 inches off my umbilicus region. That’s pretty cool and yes, it shows as I recently had to punch 4 holes in my belt which I hadn’t worn since then. I’ve lost an additional 1 inch off my chest and 1 inch more off my neck (that shows too), 1.5 inches off my bicep (while adding muscle!) and here’s where it’s crazy; I lost 4 inches off my thighs — also while gaining muscle. In the first year I had only lost a total of a 1/2 an inch off my thighs, as can be seen here.

taken November 2018

When I look at these measurements over the last year and a half (from June 2017 until now), it is very encouraging.  I’ve lost 9 inches off my umbilicus region, 2 inches off my chest (below my bust-line), a whopping 4 inches off my neck, 2.5 inches off my bicep while gaining muscle, and 4.5 inches off my thighs also while gaining muscle.

It’s my opinion that weight loss, like improved metabolic health is best done gradually but consistently.  I don’t promote “rapid weight loss” even though a low carbohydrate or ketogenic diet is often promoted that way in the media.  I also don’t believe that a ketogenic diet is necessary for all people, or even for most people. In fact, those who do not have significant metabolic health issues often do just great on a low carb diet, so my view is why limit good whole-foods that happen to contain carbohydrates if it is not needed to improve metabolic outcomes?  In the four and a half years that I have been teaching this lifestyle, I have only had a handful of clients who were metabolically unwell enough for a long period of time that needed to keep lowering their carbohydrate intake down, some to a ketogenic level. Necessarily, each is being overseen by their own doctors — especially when it comes to monitoring (and adjusting the dosage of) their medications.

I approached my health as if I were my own ‘client’, so I didn’t start off at a ketogenic level of intake. I started “low carb” and only lowered the level of my carbohydrate intake gradually and only as much as necessary to achieve the metabolic improvements necessary.  Since I had been overweight for 25 years and was diagnosed as Type 2 Diabetic 10 years earlier, I ended up needing to lower my carbohydrate intake to a ketogenic level but did so under the supervision of my doctor and with the oversight of my endocrinologist.

Whether you have a few pounds or like I did — many to lose or want to put one or more metabolic conditions such as high blood pressure, blood sugar or cholesterol into remission, you may want to find out more about how a low-carbohydrate approach can help, and why.

Feel free to send me a note using the Contact Me form above and I will reply as soon as I’m able.

To our good health!

Joy

You can follow me at:

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Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

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Twenty One Months – a major goal achieved

From the beginning of my ‘journey’, I’ve said that I had no specific “ideal weight” in mind — that my goal was to reach a body weight where my waist circumference was half my height; whatever weight that was.  This week, I reached that goal; 21 months from when I began.

This story began March 7, 2017.  I was sitting at my office desk and didn’t feel well.  I dug out my blood pressure machine (sphygmomanometer) which I had not used in ~ 2 years and took my blood pressure.  The reading defied comprehension. I rested a bit and took it again.  It was nominally lower, but still in the “hypertensive emergency” category.  A hypertensive emergency  is where the top number (systolic pressure) is at or over 180 millimeters of mercury (mm Hg) and the bottom number (diastolic pressure) is at or above 120 mm Hg, or higher. Mine systolic pressure was significantly higher than 180 mm Hg! I was seriously concerned that I could have a stroke! I was scared.  Then I went to dig out my glycometer to measure my blood sugar.

Hint: it is never a good thing when someone with Type 2 Diabetes does not know where their sphygmomanometer or glycometer are!

I should have known where my glycometer and sphygmomanometer were and should have been using them regularly, but I was in denial. After all, I was eating “properly”; lots of fruit and vegetables, whole grain bread and rice and while I was overweight, my weight had been stable for a long time. Okay, I was obese, but was consistently fat.  Like I said, I was in denial!

My blood sugar after lunch was 13.0 mmol/L (234 mg/dl). That was bad. I was clearly not tolerating the amount of carbohydrate in the fruit and whole grain crackers and it didn’t matter how many salad vegetables and lean protein I ate with it!  I was carbohydrate intolerant.

A few months earlier,  two women I had known from school died suddenly. Both were in healthcare.  One was a public health nurse who retired on the Friday and was dead on the Monday and the other was a care aid working in long-term care who died alone in her home of a massive heart attack.  She had been diagnosed about 8 months earlier with Type 2 Diabetes and was working with her “Diabetes Dietitian” and was diligently following the recommendations and eating 65 g of carbohydrate at each meal and 45 g at each snack. When I mentioned I had been doing a lot of reading in the literature about the application of a low carbohydrate diet in controlling Type 2 Diabetes, she said “I’m going to follow this for one year. If it doesn’t bring my numbers down enough, I will look into it“.  She didn’t live long enough for either.

Obviously she didn’t die from following the recommendations, but I have to wonder what difference 6-months on a well-designed, supervised low carb diet might have had.

The fact is, I was no example! Why should she listen to me? I was as overweight as she was (okay, we were both obese!) and I had Type 2 Diabetes for 10 years.  Who was I to suggest it if I wasn’t actually doing it?  All the scientific literature and knowledge isn’t convincing coming from an obese Dietitian.

As I sat there March 7, 2017 reflecting on my astronomical blood pressure and blood sugar, I realized I could be next in having a heart attack or stroke if I didn’t DO something. As I’ve said many times before in this blog, I should have gone to my doctor and let him prescribe blood pressure medication, medication for lowering my blood sugar and the statins for my cholesterol that would have come along with them (as he’d been recommending those for a while), but I didn’t.  What I did instead was immediately adopt a low carbohydrate diet. I designed myself a Meal Plan, as I do for my clients, based on the best evidence at the time. I’ve never looked back.

Without using any medication, here is what I was able to accomplish in one year’s time, as it appeared on Diet Doctor.

The full measurements are there, but in short, I had lost 32 pounds and lost 8 inches off my waist.  I still had 4 inches to go until my waist circumference would be half my height, but I no longer met the criteria for Type 2 Diabetes and my blood pressure ranged from between normal and pre-hypertensive. My triglycerides were ideal and I had excellent cholesterol levels.

Here is my “before” and “after” pictures now, at 21 months. I’ve lost the additional 4 inches off my waist – a foot in total! I lost a FOOT off my waist!!

In total, I’ve lost 45 pounds.

My 3-month average fasting blood glucose is 5.1 mmol/L (92 mg/dl) and 3-month overall average blood sugar is 5.4 mmol/L (97 mg/dl). I am below the diagnostic criteria for Type 2 Diabetes provided I limit the amount of carbohydrate-based foods I eat.  I expect these numbers will continue to improve now that (based on my waist circumference being half my height) it is unlikely I have fatty liver (NAFLD) disease. It will still take more time for my liver to continue to get well, as well as my pancreatic beta-cells, if recovery is possible.

I am not an “angel” when it comes to eating.  I do indulge in some dark chocolate after meals each weekend and I do taste non-low carb treats like pizza and cake. After all, this is not a diet, but a lifestyle and to be a lifestyle, it has to be sustainable.  The question for me is the same as for anyone: “how much” and “how often”.

Was it difficult? No. It really wasn’t…isn’t.

I eat real, whole food that can be as simple or complicated as I feel like preparing. It can be some store-bought BBQ chicken and a boxed salad or moussaka from scratch (which is what I’m making for dinner, tonight). I eat animal-based sometimes, plant-based other times, I eat nuts and seeds, fish, poultry of all types and a wide range of vegetables and some fruit and I include some “starchy” vegetables like winter squash and yam from time-to-time. I eat dairy such as cheese and plain Greek yogurt and I occasionally eat eggs (I am not a big “egg person”!). I eat grass-fed beef when I get it and supermarket meat, pastured chicken and the one that goes on sale when I’m picking up staples. My butter is regular, local and unsalted (not fancy imported butter) and I don’t slather it on everything.  It is just one of my fat choices along with really good olive oil and other pressed oils such as avocado oil and the occasional macadamia nut oil. If I’m craving a really good pizza, I make my Crispy Keto Pizza which is 85% the texture of a yeasty flour-based pizza. If I feel like one that’s a little less rich, I make my Crispy Cauliflower Pizza (see Recipe tab).

I usually don’t make “low carb bread”, although one of the most popular recipes on my recipe blog are my  Low Carb Kaiser buns. Here’s a picture, so you can see they are pretty legit for a sandwich and are great as hamburger buns.

I even make the occasion dessert, with my most requested being my low  carb New York Style Cheesecake (also under Recipes).

Low carb or not, I think desserts are “sometimes foods”, not “everyday foods”.  As a formerly obese person, I don’t think it’s helpful to think of dessert as a necessary part of an everyday meal.  I think they’re great for a special occasion, and make special occasions…well, special. After all, what’s not to love about a slice of cheesecake with the same number of carbs as a slice of bread, but the added fat, above and beyond what is found in the whole foods I eat is still an ‘extra’.

I invent recipes for myself that my ethnic clients find really helpful, including things such as Low Carb Roti (Indian flatbread) and Low Carb Chow Mein Noodles because I believe that a low carb lifestyle is not a “one-sized-fits-all”.

 

 

 

 

 

Everybody’s nutritional needs are different based on their stage of life, age,  gender and health conditions and people have different food preferences. What works for me may not be what’s best for you.  I design people’s Meal Plans based on the evidenced-based principles and their own preference, because it has to be sustainable.

Low Carb as a Maintenance Lifestyle

So, I’ve finally entered that wonderful phase known as “maintenance”; of needing to balance intake so I don’t continue to lose significant amounts of weight, but continue to achieve a more idea body composition (less extra fat, more muscle).  That involves adjusting my “macros” (the percentage of protein, fat and carbohydrate) as I do for my clients when they reach this stage, and continuing to engage in activity that challenges my muscles.

It’s also about continuing to evaluate (as I do for my clients) which carbohydrates I can or cannot successfully eat, and in what quantities. I know that from research studies, carbohydrate is best tolerated after eating some protein and low carb veggies (you can read more about that here) but even then a 2105 study showed that each person’s response to carbohydrate is very different (discussed in this article). For example, I found that my blood sugar is great with whole, cooked chickpeas cooked from dried but is terrible with hummus as the grinding of the chickpeas makes the starch in them more available to digestion and absorption (you can also read more about that here). So, just like I follow-up my clients who are seeking long-term weight loss and healthy improvement, I do the same for myself.

Low carb is not “magic”. It’s not like the food you eat somehow doesn’t “count”.  It has more to do with the different way our body metabolizes carbohydrate, compared with protein and fat and finding the mix of those that best achieves our goals.  For me, that setting my intake in a way that maximized lowering my blood sugar and blood pressure and achieving a normal body weight.  For someone else, it will be different. That’s why I say there is no one-sized-fits-all “low carb (or ketogenic) diet.

What are your weight loss and nutrition goals? Depending on your health and metabolic conditions, most can be realized using a well-designed, individualized, low carbohydrate Meal Plan.

Have questions?

Why not send me a note using the Contact Me form on the tab above and I will reply as soon as possible. Remember, I provide both in-person services as well as via Distance Consultation, using Skype or phone.

To our good health!

Joy

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Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

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Insulin Resistance, Hyperinsulinemia and Hyperglycemia

The distinction between insulin resistance and hyperinsulinemia is often unclear because these terms are frequently lumped together under “insulin resistance“, but they are separate concepts. Hyperinsulinemia (“too high insulin”) is when there is too much insulin secreted from the pancreas in response to high levels of blood sugar (hyperglycemia) and insulin resistance is where the taking in of that glucose into the cells is impaired.

Blood glucose is a tightly regulated process. A healthy person’s blood glucose is kept in the range from 3.3-5.5 mmol/L (60-100 mg/dl) but after they eat, their blood sugar rises as a result of the glucose that comes from the broken-down carbohydrate-based food. This triggers the hormone insulin to be released from the pancreas, which signals the muscle and adipose (fat) cells of the body to move the excess sugar out of the blood. What happens in insulin resistance is that the cells of the body ignore signals from insulin telling it to move glucose from broken down from digested food from the blood into the cells. When someone is insulin resistant, blood glucose stays higher than it should be for longer than it should be (hyperglycemia).

The Process of Moving Glucose Inside the Cell

A special transporter (called GLUT4) that can be thought of as a ‘taxi’ exists in muscle and fat cells and is controlled by insulin. This ‘taxi’ moves glucose from the blood and into the cells. GLUT4 ‘taxis’ are kept inside the cell until they’re needed. When ‘taxis’ are required, they go to the surface of the cell, bind with insulin and pick up their ‘passenger’ (glucose) and moves it inside the cell. Both the ‘taxi’ (GLUT4 receptor) and the insulin are also taken inside the cell and then replaced on the surface of the cell with new receptors. As long as there are GLUT4 ‘taxis’ available on the surface of the cell to transport glucose inside everything’s good, but when blood sugar is quite high, the pancreas keeps releasing insulin to bind with the GLUT4 ‘taxis’, but those ‘taxis’ may not appear fast enough on the cell surface to pick up the glucose. In this case, blood sugar remains higher then it should be for longer, a state called hyperglycemia. When there are insufficient receptors to move glucose into the cell, this is called insulin resistance. It may be temporary, as in the example above, or may be long-term. If it is temporary, the rise in blood sugar (hyperglycemia) is short but if the receptors don’t respond properly long-term, then blood sugar remains higher for a longer period of time, until the ones that do work can bring the glucose inside. In one case, the blood sugar may be quite high for a short time or may be moderately high for a long time. In both cases, the body is exposed to higher blood sugar than it should be, and this causes damage to the body. It isn’t known whether insulin resistance comes first or hyperinsulinemia does. It is believed that it may be different depending on the person.

What Triggers Hyperinsulinemia?

It is known that excessive carbohydrate intake can trigger hyperglycemia, as well as hyperinsulinemia. Eating lots of fruit, for example or foods that contain fructose (fruit sugar) will cause the body to move that into the body first in order to get it to the liver, before it deals with glucose. This causes glucose levels in the blood to rise, resulting in both hyperglycemia and hyperinsulinemia. Lots of processed foods contain high fructose corn syrup (HFCS) which contributes to problems with high blood sugar and hyperinsulinemia.

There are other things that can also trigger hyperglycemia and hyperinsulinemia include certain medications (like corticosteroids and anti-psychotic medication) and even stress. Stress causes the hormone cortisol to rise, which is a natural corticosteroid. It is thought that long-term stress may lead to hyperinsulinemia, which increases appetite by affecting neuropeptide Y expression. This may explain why people eat more when they’re stressed and are very often drawn to carbohydrate-based foods that are quickly broken down for energy.

Diseases Associated with Hyperinsulinemia

It is well known that hyperglycemia that occurs with Type 2 Diabetes contributes to problems with the eyes, kidneys and nerves of the extremities, especially the feet and toes. Less known are the diseases and metabolic problems that can occur due to hyperinsulinemia.

Hyperinsulinemia has a well-establish association to the development of Type 2 Diabetes and Gestational Diabetes (the Diabetes of pregnancy), but also to Metabolic Syndrome (MetS).

Metabolic Syndrome (MetS) is a cluster of symptoms that together put people at increased risk for cardiovascular disease, including heart attack and stroke.

These symptoms of MetS include having 3 or more of the following;

  1. Abdominal obesity (i.e. belly fat), specifically, a waist size of more than 40 inches (102 cm) in men and more than 35 inches (89 cm) in women
  2. Fasting blood glucose levels of 100 mg/dL (5.5 mmol/L) or above
  3. Blood pressure of 130/85 mm/Hg or above
  4. Blood triglycerides levels of 150 mg/dL (1.70 mmol/L) or higher
  5. High-density lipoprotein (HDL) cholesterol levels of 40 mg/dL (1.03 mmol/L) or less for men and 50 mg/dL (1.3 mmol/L) or less for women

Hyperinsulinemia is also an independent risk factor for obesity, osteoarthritis, certain types of cancer including breast and colon/rectum, Alzheimer’s Disease and other forms of dementia[1], erectile dysfunction[2] and polycystic ovarian syndrome (PCOS)[3].

The damage associated with hyperinsulinemia is due to the continuous action of insulin in the affected tissues[4].

Risk factors for developing insulin resistance include a family history of Type 2 Diabetes, in utero exposure to Gestational Diabetes (i.e. an unborn child whose mother had Gestational Diabetes), abdominal obesity (fat around the middle) and detection of hyperinsulinemia.  Assessors of insulin resistance using blood tests such as the Homeostatic Model Assessment (HOMA2-IR) test which estimates β-cell function and insulin resistance (IR) from simultaneous fasting blood glucose and fasting insulin or fasting blood glucose and fasting C-peptide[1]. As well, incorporation of some forms of exercise including resistance training may lower insulin resistance in the muscle cells and weight loss – even when people are not very overweight can increase uptake of glucose, due to lowered insulin resistance of the liver.

Detection of hyperinsulinemia can occur using an Oral Glucose Sensitivity Index (OGIS), which is similar to a 2-hr Oral Glucose Tolerance Test (2-hr OGTT) which is a test where a fasting person drinks a known amount of glucose and their blood sugar is measured before the test starts (baseline, while fasting) and at 2 hours. In the OGIS, both blood glucose and blood insulin levels are measured at baseline (fasting), at 120 minutes and at 180 minutes [5].

Glucose and insulin response patterns that result after people take oral glucose can also be used to determine hyperinsulinemia status. Between 1970 and 1990, Dr. Joseph R. Kraft collected data from almost 15,000 people which showed five main glucose and insulin response patterns; with one being the normal response. Kraft’s methodology was to measure both glucose and insulin response over a 5-hour period, noting the size of both the glucose and insulin peaks, as well as the rate that it took the peaks to come back down to where it started from. Kraft concluded that a 3-hour oral glucose tolerance test with both glucose and insulin measured at baseline (fasting), 30, 60 120 and 180 minutes was as accurate as a 5-hour test. Most striking about the original study and recent re-analysis of this data found that up to 75% of people with normal glucose tolerance have carrying degrees of hyperinsulinemia [9]. You can read more about that in this recent article.

Hyperinsulinemia and insulin resistance together are the essence of carbohydrate intolerance; the varying degrees to which people can tolerate carbohydrate without their blood sugar spiking. This is not unlike other food intolerance such lactose intolerance or gluten intolerance which reflect the body’s inability to handle specific types of carbohydrate in large quantities.

Some final thoughts…

Insulin resistance and hyperinsulinemia are present long before a diagnosis of pre-diabetes and are now are considered an entirely separate stage in the development of the disease (you can read more about that here). A recent study reported that abnormal blood sugar regulation precedes a diagnosis of Type 2 Diabetes by at least 20 years [6] which means that long before blood sugar becomes abnormal, the progression to Type 2 Diabetes has already begun. Knowing how to recognize the symptoms of insulin resistance and hyperinsulinemia and to have them measured or estimated, as well as to detect the abnormal spike in blood glucose that often occurs 30 to 60 minutes after eating carbohydrate-based food is essential to avoiding progression to Type 2 Diabetes as well as the complications associated with hyperglycemia and hyperinsulinemia.

If you would like my help in lowering your risk to developing Type 2 Diabetes and the chronic disease risks associated with hyperinsulinemia or in reversing their symptoms, please send me a note using the Contact Me form on the tab above. I provide both in-person consultations as well as by Distance Consultation,using Skype and phone.

To your good health!

Joy

You can follow me at:

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https://www.instagram.com/lchf_rd

References

  1. Crofts, C., Understanding and Diagnosing Hyperinsulinemia. 2015, AUT University: Auckland, New Zealand. p. 205.
  2. Knoblovits P, C.P., Valzacci GJR,, Erectile Dysfunction, Obesity, Insulin Resistance, and Their Relationship With Testosterone Levels in Eugonadal Patients in an Andrology Clinic Setting. Journal of Andrology, 2010. 31(3): p. 263-270.
  3. Mather KJ, K.F., Corenblum B, Hyperinsulinemia in polycystic ovary syndrome correlates with increased cardiovascular risk independent of obesity. Fertility and Sterility, 2000. 73(1): p. 150-156.
  4. Crofts CAP, Z.C., Wheldon MC, et al, Hyperinsulinemia: a unifying theory of chronic disease? Diabesity, 2015. 1(4): p. 34-43.
  5. Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.
  6. Sagesaka H, S.Y., Someya Y, et al, Type 2 Diabetes: When Does It Start? Journal of the Endocrine Society, 2018. 2(5): p. 476-484.

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

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There Are Officially Two Stages BEFORE a Diagnosis of Type 2 Diabetes

This past Wednesday (November 28, 2018) the American Association of Clinical Endocrinologists (AACE) announced publication of a new Position Statement[1] which identifies four separate disease stages associated with an abnormal glucose response including Type 2 Diabetes;

Stage 1: Insulin Resistance
Stage 2: Prediabetes
Stage 3: Type 2 Diabetes
Stage 4: Vascular Complications — including retinopathy (disease of the eyes that can result in vision loss),  nephropathy (disease of the kidneys which can lead to kidney failure) and neuropathy (disease of the nerves —especially of the toes and feet which can lead to amputations), as well as other chronic disease risks associated with Type 2 Diabetes.

For those who have read the first two articles in this series (links below), the existence of a stage before blood sugar becomes abnormal (Prediabetes) and two stages before a diagnosis of Type 2 Diabetes will sound very familiar!

In the two previous articles, I explained the findings of a recent a large-scale study which found that 3 out of 4 adults with normal fasting blood glucose test results and whose 2 hour blood glucose after after a standard glucose load is below the cutoff for impaired glucose tolerance have very abnormal glucose spikes after eating and very abnormal levels of circulating insulin (“hyperinsulinemia”) associated with these dysfunctional glucose spikes.

It has been reported that abnormal glucose responses are present as long as 20 years before a diagnosis of  Type 2 Diabetes [2], so it should come as no surprise that it is now recognized that there are two stages BEFORE that diagnosis. Those who have read the two preceding articles will know that it is the hyperinsulinemia that leads to the insulin resistance, so in effect the first stage in this disease process really includes both of these together.

This Position Statement also recognizes;

“According to a recent analysis using data from the
U.S. National Health and Nutrition Examination Surveys
(NHANES; 1988-2014), patients with prediabetes have
increased prevalence rates of hypertension, dyslipidemia,
chronic kidney disease and cardiovascular disease (CVD)
risk.”

The Position Statement focuses on early intervention to reduce chronic disease risk which include diet and lifestyle changes as well as weight-loss. The goal of the release of the statement is to prevent the progression to Type 2 Diabetes, cardiovascular disease (CVD) and the metabolic diseases associated with it.

What is the importance of these two early stages?

What these stages mean is that long before blood sugar becomes abnormal, the progression to Type 2 Diabetes has already begun.

What it also implies is that people need to be given additional lab tests when their fasting blood sugar results are still normal in order to detect the presence of abnormal glucose spikes 30 minutes and 60 minutes after a glucose load as well tests measuring the abnormal insulin spikes associated with it as it is chronic hyperinsulinemia (high insulin levels) that leads to insulin resistance and the progression to Type 2 Diabetes as well as the associated chronic diseases.

Since 3 out 4 adults may have normal fasting blood glucose but with hyperinsulinemia, if we are going to stop the tsunami of Type 2 Diabetes, we must start treating it when fasting blood glucose is normal.

As I said in my last article, the time to think about implementing dietary changes and using updated lab testing procedures is now. We must act to  keep people from becoming carbohydrate intolerant and from developing hyperinsulinemia, Pre-diabetes, Type 2 Diabetes and the host of metabolic diseases that go along with it. This proactive approach is long overdue.

If you would like my help in lowering your risk to developing Type 2 Diabetes and the chronic disease risks associated with hyperinsulinemia or in reversing their symptoms, please send me a note using the Contact Me form on the tab above. I provide both in-person consultations as well as by Distance Consultation,using Skype and phone. Please let me know how I can help.

To your good health!

Joy

Note: If you haven’t yet read the two related previous articles, I would encourage you to have a look. The first article explains the existence of ‘silent Diabetes’ in those with normal Fasting Blood Glucose test results and is titled When Normal Fasting Blood Glucose Results Aren’t Necessarily “Fine” and can be read here.

The second article titled Carbohydrate Intolerance & the Chronic Disease Risk of High Insulin Levels explains what hyperinsulinemia (chronically high levels of circulating insulin) is and why it’s a problem and can be read here.

You can follow me at:

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and now on Instagram, too:

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Reference

  1. American Association of Clinical Endocrinologists Announces Framework for Dysglycemia-Based Chronic Disease Care Model, November 28, 2018, AACE Online Newsroom, url: https://media.aace.com/press-release/american-association-clinical-endocrinologists-announces-frameworkdysglycemia-based-c
  2. Sagesaka H, S.Y., Someya Y, et al, Type 2 Diabetes: When Does It Start? Journal of the Endocrine Society, 2018. 2(5): p. 476-484.

Copyright ©2018 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Feel free to share!