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:

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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. 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:

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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.

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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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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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/

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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

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. 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

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

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

and now on Instagram, too:

https://www.instagram.com/lchf_rd

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.

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Carbohydrate Intolerance & the Chronic Disease Risk of High Insulin Levels

In the previous article titled When Normal Fasting Blood Glucose Results Aren’t Necessarily “Fine” I explained how normal results on a fasting blood glucose (FBG) test may simply mask ‘silent Diabetes’ and that even when fasting blood glucose is normal and results from a 2-hour Oral Glucose Tolerance Test (2-hr OGTT) do not indicate glucose intolerance, a person can still have a very abnormal blood sugar response after they eat refined carbohydrates. These ‘spikes’ can be seen between 30 minutes and 60 minutes on 2-hour glucose curves and are reflected by equally abnormal insulin curves. Chronically high circulating levels of insulin (called hyperinsulinemia) result from these blood sugar ‘spikes’ that occur every time the person eats carbohydrate-based foods, which is usually every few hours, for meals and snacks.

Insulin is released in order to take the excess sugar resulting from the digestion of carbs and move it out of the blood and into the cells and even though these people’s blood glucose returns to below the impaired glucose tolerance range by 2 hours, the abnormal glucose response particularly between 30 and 60 minutes drives hyperinsulinemia (chronically high levels of insulin) and is made worse by insulin resistance (which is the ignoring of insulin’s signal by the cells).  It is this hyperinsulinemia and insulin resistance that are the essence of carbohydrate intolerance; ; the varying degrees to which people can tolerate carbohydrate without their blood sugar spiking. It is not unlike other food intolerances such lactose intolerance or gluten intolerance which also reflect the body’s inability to handle specific types of carbohydrate in large quantities.

It is the hyperinsulinemia, rather than the high levels of blood sugar that puts people at risk for the serious chronic diseases of cardiovascular disease (heart attack and stroke), high cholesterol and high blood pressure[1] that people usually associate with Type 2 Diabetes. High blood sugar does have risks of course, including loss of vision, chronic kidney disease and amputation of limbs but if high blood sugar (hyperglycemia) is the “tip of the iceberg”, then high circulating levels of insulin (hyperinsulinemia) is the bigger part of the iceberg that can’t be seen. We can’t see it simply because it is rarely, if ever measured.

Most concerning is that based on a large-scale 2016 study which looked at the blood glucose response and circulating insulin responses from almost 4000 men aged 20 years and older and 3800 women aged 45 years or older during a 5-hour Oral Glucose Tolerance Test, 53% had normal glucose tolerance (normal fasting blood sugar and did not have impaired glucose tolerance (IGT) at 2 hours after the glucose load) but of these people, 75% had abnormal blood sugar results between 30 minutes and 60 minutes (two points in time that are not normally looked at in a standard 2-hour Oral Glucose Tolerance Test (2-hr OGTT).

In the previous article, I showed what the three abnormal glucose responses looked like compare to a normal glucose response and explained that a normal blood glucose curve represents Carbohydrate Tolerance, and the three abnormal glucose response graphs represent the Three Stages of Carbohydrate Intolerance; Early, Advanced, and Severe Carbohydrate Intolerance and culminates with the diagnosis of Type 2 Diabetes (T2D).

Hyperinsulinemia combined with insulin resistance form the heart of Carbohydrate Intolerance.

Insulin Resistance

In the early stages of Carbohydrate Intolerance, receptors in the liver and muscle cells begin to stop responding properly to insulin’s signal. This is called insulin resistance. Insulin resistance can be compared to someone hearing a noise such as their neighbour playing music, but after a while their brain “tunes out” the noise.  Even if the neighbour gradually turns up the volume of the music, the person’s brain compensates by further tuning out the increased noise. This is what happens with the body when it becomes insulin resistant. It no longer responds to insulin’s signal. To compensate for insulin resistance, the β-cells of the pancreas begin producing and releasing more and more insulin resulting in hyperinsulinemia, which is too much insulin in the blood.

Normal Insulin Response

The β-cells of the pancreas of healthy people are constantly making insulin and storing most of it until these cells receive the signal that food containing carbohydrate has been eaten. β-cells also constantly release small amounts of insulin in very small pulses called basal insulin. This basal insulin allows the body to use blood sugar for energy even when the person hasn’t eaten for several hours or longer. The remainder of the insulin stored in the β-cells is only released when blood sugar rises after the person eats foods containing carbohydrate and this insulin is released in two phases; the first-phase insulin response occurs as soon as the person begins to eat and peaks within 30 minutes and can be seen at 30 minutes on the graph below. The amount of the first-phase insulin release is based on how much insulin the body is used to needing each time the person eats. Provided a carbohydrate tolerant person eats approximately the same amount of carbohydrate-based food at each meal day to day, the amount of insulin in the first-phase insulin response will be enough to move the excess glucose from the food into the cells, returning blood sugar to its normal range of ~100 mg/dl (5.5 mmol/L). If there is not enough insulin in the first-phase insulin response, the β-cells will release a smaller amount of insulin within an hour to an hour and a half after the person began to eat.

Below is the same Carbohydrate Tolerance curve (normal glucose curve) as in Chapter 2. The solid black line is unlabeled here and is shown along with its corresponding normal insulin curve (dashed line). The insulin response more or less mirrors the glucose response; as glucose rises in the blood, insulin is released mainly as a first-phase insulin response, which results in the blood glucose level falling in

Carbohydrate Tolerance based on [1] 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.

Early Carbohydrate Intolerance

Below is the same Early Carbohydrate Intolerance curve as in Chapter 2, and the solid black line (glucose) is shown along with its corresponding abnormal insulin curve (dashed line). As glucose rises in the blood even more insulin is released; initially as a first-phase insulin release and then as a second-phase insulin release.  This results in blood glucose level falling but not to baseline (fasting level) by 2 hours afterwards. Notice too that the fall is not as a straight line, but there are two peaks in the glucose curve, before it falls.

It is insulin resistance of the liver and muscle cells which results in the β-cells of the pancreas making more insulin and as can be seen from the graph below it takes more insulin to move the same amount of glucose (carbohydrate) into the cell.

Early Carbohydrate Intolerance – based on [1] 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.

Advanced Carbohydrate Intolerance

By the time people have progressed to Advanced Carbohydrate Intolerance, the first-phase insulin response won’t produce enough insulin be able to clear the extra blood glucose after a carbohydrate load and even the second-phase insulin response won’t be enough to overcome the insulin resistance of the cells. At this point, the β-cells of the pancreas are unable to make enough insulin to clear the excess glucose from the blood and blood glucose rises well above the normal high peak of 126 mg/dl (7.0 mmol/L).  What is also apparent is that even with all the insulin release, blood sugar levels begin rising sooner and rise to much higher levels.

With ongoing high intake of carbohydrate every few hours, especially refined and processed carbohydrate such as bread, pasta and rice which are broken down quickly to glucose, the amount of insulin that must be released from the β-cells of the pancreas to handle a steady intake of carbohydrate-based foods increases substantially.  The dashed black line on the graph below shows the insulin curve of Advanced Carbohydrate Intolerance. While the Early Carbohydrate Intolerance glucose curve (above) doesn’t look significantly different then the Advanced Carbohydrate Intolerance curve (below), it’s easy to see that the insulin curves are very different.

The hyperinsulinemia (high levels of circulating insulin) present in Advanced Carbohydrate Intolerance is what makes these two states different.

Advanced Carbohydrate Intolerance  – based on [1] 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.
Most concerning is these people had normal fasting blood sugar and 2-hour postprandial blood sugar which did not indicate that they had impaired glucose tolerance.  On a 2-hr OGTT, these folks would be told they were not pre-diabetic and would assume that everything was find – yet they had both an abnormal glucose response between 30 minutes and 60 minutes and abnormally high levels of insulin which accompanies it.

This high insulin response occurs every time these people eat significant amounts of refined carbohydrate and puts them at increased risk of the chronic diseases associated with chronic hyperinsulinemia including heart attack and stroke, hypertension (high blood pressure), elevated cholesterol and triglycerides, non-alcoholic fatty liver (NAFLD), Poly Cystic Ovarian Syndrome (PCOS), Alzheimer’s disease and other forms of dementia, as well as certain forms of cancer including breast and colon cancer [1].

A standard 2-hour OGTT would not show the significant abnormality in terms of how the body is able (or rather, not able) to process carbohydrate because standard blood tests do not test either glucose or insulin at 30 and 60 minutes.  It’s not that there aren’t abnormalities, it is just that they are not measured!

 Severe Carbohydrate Intolerance

As Carbohydrate Intolerance progresses, some people’s glucose-insulin curves look like the ones below. Blood sugar levels don’t rise as high, but the β-cells of the pancreas are producing less insulin and releasing it much later. They have no idea, because their fasting blood sugar is still normal.

Severe Carbohydrate Intolerance II – based on [1] 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.

Type 2 Diabetes

Type 2 Diabetes (T2D) is the final stage of Carbohydrate Intolerance and is the natural outcome of a person continuing to eat a diet high in carbohydrate-containing foods at each of their meals and at snacks when their body is unable to tolerate it and is made worse by insulin resistance.

Too often this is the natural outcome of people following Dietary Guidelines (US or Canadian) which are designed for a healthy population, not people who are metabolically unwell. The problem is most people think they are healthy because they have normal blood glucose tests, and their metabolic dysfunction is never diagnosed. No one is looking for it.

The Dietary Guidelines recommend that people eat 45-65% of their dietary intake as carbohydrate and people in both countries dutifully eat considerable amounts of carbohydrate in the form of bread, cereal, rice and pasta, as well as fruit, milk and sweetened yogurt and starchy vegetables such as peas, corn and potato. Not knowing their body has become carbohydrate intolerant, this chronically high intake of carbs continues to put strain on their pancreas, until udder the pressure of the combination of hyperinsulinemia and insulin resistance, their β-cells burn out, resulting in Type 2 Diabetes.

Some Final Thoughts…

It has been said that Type 2 Diabetes is a “chronic, progressive disease”, but does it doesn’t have to be this way! It can be stopped LONG before fasting blood sugars become abnormal.

Diagnosing hyperinsulinemia is simple and can be done with existing standard lab tests; namely a 2-hour Oral Glucose Tolerance test with an extra glucose assessor and extra insulin assessor at 30 minutes and 60 minutes. When patients request this test because they are at high risk, too many are told that it is “a waste of healthcare dollars” when quite literally they could be spared the scourge of Type 2 Diabetes by having the changes in insulin and glucose response diagnosed in the 20 years before standard blood sugar begins show abnormalites [2].

It’s time to think about ways to implement dietary changes and lab testing procedures that will prevent Carbohydrate Intolerance and from developing the abnormal glucose and insulin responses and the host of metabolic diseases that go along with them.

In fact, it 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 reversing their symptoms, then 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

NOTE: The third article in this series titled “There Are Officially Two Stages BEFORE a Diagnosis of Type 2 Diabetes” can be read by clicking here.

You can follow me at:

       https://twitter.com/lchfRD

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

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

and now on Instagram, too:

https://www.instagram.com/lchf_rd

References

  1. 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.
  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!

When Normal Fasting Blood Glucose Results Aren’t Necessarily “Fine”

When people have a fasting blood glucose test and the results come back normal, they’re told (or assume) that everything’s fine. But is it? Certainly, a fasting blood glucose test is the least expensive test to find out if someone is already pre-diabetic, but for those wanting to avoid becoming Diabetic and to lower their risk of the other chronic disease associated with Type 2 Diabetes and high levels of circulating insulin (called hyperinsulinemia) noticing abnormalities in how we process carbohydrates is essential and these changes are estimated to take place a decade before our fasting blood sugar begins to become abnormal.

Our bodies have to maintain the glucose (sugar) in our blood at or below 100 mg/dl (5.5 mmol/L) but each time we eat or drink something other than water or clear tea or coffee, our blood sugar rises as our body breaks down the carbohydrate in the food from starch and complex sugars to glucose, a simple sugar.  Eating causes hormones in our gut, called incretin hormones to send a signal to our pancreas to release insulin, which moves the excess glucose out of our blood and into our cells. When everything is working properly, our blood sugar falls back down to a normal level within 2 hours after we eat (called 2 hours “postprandial”).

If we’re healthy and don’t snack after supper, our blood sugar falls to a lower level overnight but that too is maintained in a tightly regulated range between 60 mg/dl (3.3 mmol/l) and 100 mg/dl (5.5 mmol/l). During the night and as we approach morning, our body will break down our stored fat for energy and convert it to glucose in a process called gluconeogenesis.

When we have a fasting blood glucose test, it measures our blood sugar after we’ve fasted overnight and when we’re healthy, the results will be between 60-100 mg/dl (3.3-5.5 mmol/L). If it is higher than 100 mg/dl (5.5 mmol/l) but less than 125 mg/dl (6.9 mmol/L) we are diagnosed with impaired fasting glucose, but what if it’s normal? Is a normal fasting blood glucose test result enough to say that we’re not at risk for Type 2 Diabetes? No, because a fasting blood glucose doesn’t tell us anything about how our body responds when we eat.

A 2-hour Oral Glucose Tolerance Test (2 hr-OGTT) may be requested for people whose fasting blood glucose is impaired (higher than 100 mg/dl / 5.5 mmol/L) in order to see if it returns to normal after they consume a specific amount of glucose (sugar).

If their blood sugar returns to normal (less than100 mg/dl / 5.5 mmol/L) 2 hours after drinking a beverage containing 75 g of glucose (100 g if they’re pregnant) then the diagnosis remains impaired fasting glucose because it is only abnormal when fasting. However, if the results are greater than 140 mg/dl (7.8 mmol/L) but below 200 mg/dl (11.0 mmol/L), then they are diagnosed with impaired glucose tolerance which is called “pre-diabetes“.

If the 2-hour results are greater than 200 mg/dl (11.0 mmol/L), then a diagnosis of Type 2 Diabetes is made because their fasting blood glucose is > 7.0 mmol/L (126 mg/dl) and their 2-hour blood glucose is > 11.0 mmol/L (200 mg/dl).

But what if their fasting blood glucose is normal? Does that mean everything’s good? No, because we don’t know what happens to their blood sugar after they eat carbohydrate containing food, most notably between 30 minutes and 60 minutes.

A 2016 study looked at blood sugar and insulin response from almost 4000 men aged 20 years or older and 3800 women aged 45 years or older who had a 5-hour Oral Glucose Tolerance Test using 100 g of glucose. The study found that 53% had normal glucose tolerance; that is, they had normal fasting blood sugar and did not have impaired glucose tolerance (IGT) 2 hours after the glucose load. Of these people with normal glucose tolerance, 75% had abnormal blood sugar results between 30 minutes and 1 hour.

Normal Blood Glucose Pattern

A little less than 1000 people (990) out of the total with normal glucose tolerance (4030) had a normal glucose pattern (see graph below). It’s easy to see that the blood sugar rises to a moderate peak and then decreases steadily until it’s back to where it started from at 2 hours. This is what blood sugar is supposed to do.

Normal Glucose Curve (carbohydrate tolerance) – graph by Joy Y. Kiddie, MSc, RD (based on [1] 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.)

Abnormal Glucose Patterns

Almost the same number of people (961) as had normal glucose curves showed early signs of carbohydrate intolerance which can be seen most noticeably between 30 and 60 minutes. Keep in mind, this graph represents the average blood sugar response of these individuals. These folks had normal fasting blood glucose but after 2 hours blood glucose did not return to baseline but was not high enough to meet the criteria for impaired glucose tolerance. Unless someone was looking between 30 and 60 minutes, no one would know it not was not normal. Rather than blood glucose going up to a moderate peak and then falling gradually in a straight line, a two-stage rise in glucose can be clearly seen between 30 minutes and 60 minutes before beginning to drop.

Early Carbohydrate Intolerance (Early Abnormal Glucose Response) – graph by Joy Y. Kiddie, MSc, RD (based on [1] 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.)
A little more than 1200 people (1208) had the following abnormal glucose response which represents Advanced Carbohydrate Intolerance. These people had normal fasting blood glucose, but their blood glucose did not fall to baseline at 2 hours but was below the cut-offs for impaired glucose tolerance. Between 30 and 60 minutes their blood sugar went slightly higher at 60 minutes than at 30 minutes compared to the Early Carbohydrate Intolerance curve, before beginning to fall.

Advanced Carbohydrate Intolerance (Advanced Abnormal Glucose Response) – graph by  Joy Y. Kiddie, MSc, RD (based on [1] 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.)
Slightly more than 800 people (807) had an abnormal glucose response curve shaped as follows, indicating Severe Carbohydrate Intolerance.  They had normal fasting blood glucose and 2-hour postprandial blood glucose results that were higher than at baseline yet did not meet the criteria for impaired glucose tolerance. What was significant is that blood sugar was significantly higher at 60 minutes than at 30 minutes, compared to the Advanced Carbohydrate Intolerance curve.

Severe Carbohydrate Intolerance (Severe Abnormal Glucose Response) – graph by Joy Y. Kiddie, MSc, RD (based on [1] 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.)

The Significance of These Curves

The results of this study show that even if fasting blood glucose is totally normal and 2-hour postprandial blood glucose does not meet the criteria for impaired glucose tolerance, it often does not return to baseline and the blood sugar response between fasting and 2 hours is very abnormal. What can’t be seen from these graphs is what happens to the hormone insulin at the same time. This will be covered in the next chapter but suffice to say that Normal Carbohydrate Tolerance, blood sugar response mirrors what is happening with insulin but in Early, Advanced and Severe Carbohydrate Intolerance, insulin secretion is both much higher and lasts much longer. This is called hyperinsulinemia (high blood insulin) and contributes to many of the health risks associated with Type 2 Diabetes, including cardiovascular risks (heart attack and stroke), abnormal cholesterol levels and hypertension (high blood pressure).  This is like having “silent Diabetes“.

A “Waste of Healthcare Dollars”

As a Dietitian, when a person’s clinical symptoms and risk factors warrant it, I’ll request a 2-hour Oral Glucose Tolerance Test (2-h OGTT) with an extra glucose assessor at 30 minutes (and sometimes at 60 minutes) to determine how their glucose response compares to the above curves. While these blood tests are done with 75 g of glucose and not 100 g, the shape of the curves and the endpoint as well as the size of the peak between 30- and 60-minutes reveals much about their carbohydrate intolerance. Since these people have normal fasting blood glucose test results, a request for an Oral Glucose Tolerance Test (with or without the extra glucose assessor) is often declined as a “waste of healthcare dollars”. Unfortunately, this is where being “penny wise” can be “pound foolish” as these people don’t know they are at risk and as a result, are not motivated to change their eating habits or lifestyle.

What About Glycated Hemoglobin (HbA1C)?

A glycated hemoglobin test (HbA1C, also called A1C) measures a form of hemoglobin that binds glucose (the sugar in the blood) and is used to identify the person’s three-month average glucose concentration because blood cells turnover (get replaced) on average every 3 months.

While having a glycated hemoglobin test and a fasting blood glucose test is better than only having fasting blood glucose, it will still miss a significant percentage of people who are able to control their sugars between meals and overnight but who have significant spikes between 30 minutes and 60 minutes, immediately after eating carbohydrate-based food, but that return to normal by 2 hours. Most physicians will not requisition a HbA1C test if a person’s fasting blood glucose is normal, and even if they do, that test may miss that glucose ever spikes at all between 30 minutes and 60 minutes.

In the absence of available lab testing, I sometimes resort to using a Glucose Response Simulation.

Glucose Response Simulation

A simple, if somewhat crude means of assessing glucose response under a load can be done at home using an ordinary glucometer (a meter for measuring blood sugar) such as would be used by people with Diabetes, and either a 100 g of dextrose (glucose) tablets available at most pharmacies or the equivalent. As part of the services I provide to my clients, I work with those that want to do this type of estimate so that they can understand whether they fall into the 75% of people that have normal fasting blood sugar and do not have impaired glucose tolerance at 2 hours postprandial but do have an abnormal glucose response. I explain how to prepare for the test, step by step instruction for conducting the test and then I graph and analyze the data then teach them what the results mean.

Basis for Individualizing Carbohydrate Intake

These results are very helpful as firstly they help people understand the reason for reducing their carbohydrate intake over an extended period of time, in order to restore insulin sensitivity and insulin secretion. These results also enable me in time to individualize their carbohydrate intake once they have reversed some of their metabolic response, based on their own blood sugar response to a specific carbohydrate load.  In time, some of these individuals may want to add some carbohydrate back into their diet in small quantities, so with this information, I can guide them to test a standard size serving of rice, pasta or potato compared to their own blood glucose response to 100 g of glucose.

Below are three curves that I’ve plotted from individuals that used the same type of glucometer (Contour Next One) and a standard 100 g glucose load as dextrose tablets or equivalent to 100 g of glucose [2]. I provided each one with identical instructions on how to run this simulation, how to collect the results and ensured each one understood.

Example 1: The person below had a single glucose peak (similar to the early carbohydrate intolerance of the first abnormal curve, above) but blood glucose did not come back down to the fasting level even after 3 hours.

Early Abnormal Glucose Response – graph by Joy Y. Kiddie MSc, RD

Example 2: The person below had a single glucose peak  that reached abnormally high levels and that didn’t fall continuously downward but slowed, then dipped below baseline at 2 hours (mild reactive hypoglycemia) and that gradually came back to baseline over the following couple of hours.

Advanced Abnormal Glucose Response – graph by Joy Y. Kiddie MSc, RD

Example 3: This person had a similar initial rise as the person above, but no hypoglycemic dip however, this person’s glucose didn’t fall to baseline until almost 5 hours.

Some Final Thoughts…

An abnormal fasting blood glucose test may warrant further testing; however, a normal result is frequently dismissed as being a sign that “everything’s fine”. Data from this study indicates that as many as 75% of people with normal fasting blood sugar may have abnormal glucose responses and associated hyperinsulinemia, meaning they could have the same risks to other chronic diseases as someone who has already been diagnosed with Type 2 Diabetes. They simply don’t know it.

With reliable and relatively inexpensive glucometers, as well as continuous glucose monitors (CGM) people don’t need to wonder whether they have an abnormal glucose response to eating carbohydrate (are carbohydrate intolerant). They can use simulation tests, such as the ones I did above, to find out.

Not knowing one is at risk does nothing to provide motivation to make dietary and lifestyle changes, but knowing one has an abnormal response to carbohydrates not only enables people to want to make these changes, it also helps them to find which carbohydrates they can eventually add back into their diet, once they’ve lowered their glucose and insulin levels, and in what quantities.

If you have questions as to how I can help you get started in knowing your own glucose response and to lower risk factors, please send me a note using the Contact Me form located on the tab, above.

To your good health!

Joy

Note: The second article in this series explains what hyperinsulinemia is and why it’s a problem. It’s titled Carbohydrate Intolerance & the Chronic Disease Risk of High Insulin Levels and can be read by clicking here.

You can follow me at:

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

References

  1. 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.
  2. Lamar, ME et al, Jelly beans as an alternative to a fifty-gram glucose beverage for gestational diabetes screening, Am J Obstet Gynacol, 1999 Nov 18 (5 Pt 1): 1154-7

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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Will This Knock Me Out of Ketosis?

Earlier this week I heard someone ask in a low-carb Facebook group if eating a particular food would ‘knock them out of ketosis‘ and I decided it was time to write an article about this, but first I ran a short poll on Twitter to find out what my readers thought.

The first answer in the poll was my tongue-in-cheek reaction to hearing the question asked for the umpteenth time and the other three options were reasonable answers that people could choose from.

Twitter poll: “Will this knock me out of ketosis?”

So what’s the answer?

According to Dr. Stephen Phinney, MD, PhD. Professor of Medicine Emeritus at the University of California, Davis who has over 25 years of clinical experience studying multi-disciplinary weight management programs, including the use of a ketogenic diet;

“Carbohydrate tolerance varies among individuals.  Some people may need to limit themselves to no more than 30 grams of total carbohydrates per day to remain in nutritional ketosis and maintain its benefits; while others may be able to consume more.  However, most people with underlying metabolic issues find that they need to maintain a carbohydrate intake below 50 grams per day, especially if they have Type 2 Diabetes.”

For the most part, men who are insulin sensitive and seeking to follow a ketogenic diet can do very well on 50-100 g of carbohydrate per day and women who are insulin sensitive who want to follow a ketogenic diet can do well on 50-75 g of carbohydrates per day. As Dr. Phinney points out, those with metabolic issues such as Type 2 Diabetes will usually need to keep their carbohydrate intake less than 50 g per day.

People with epilepsy or seizure disorder or who have been prescribed a ketogenic diet as an adjunct treatment to chemotherapy for specific types of cancer will need to follow a very strict high-fat ketogenic diet and the level of carbohydrate restriction is specific for those conditions.  For those who are insulin sensitive who are simply seeking weight loss, a low carbohydrate diet is often sufficient. I’ve found over the last several years of designing low carbohydrate diets for my clients that insulin-sensitive individuals often do very well simply cutting the total amount of carbohydrate down significantly and altering the types of carbohydrate they eat. For those with pre-Diabetes and Type 2 Diabetes, the types and amounts of carbohydrates they eat can be individually determined by testing glycemic responses to specific foods and I help my clients do this and understand the results.

What is the difference between someone who is insulin sensitive and someone who is insulin resistance?

People who have Type 2 Diabetes or pre-diabetes or Metabolic Syndrome are by definition insulin resistant but for those without these conditions, how would someone know?  There are two blood tests that can be done together (fasting blood sugar and fasting insulin) that can help estimate the degree of insulin resistance but there are visual cues that can also help.

insulin sensitive (from Klöting N, Fasshauer M, Dietrich A et al, Insulin-sensitive obesity, Am J Physiol Endocrinol Metab 299: E506–E515, 2010, pg. 5)

People who store most of their fat as subcutaneous fat, rather than visceral fat (fat in their abdomen) are often insulin-sensitive — even those that are very obese. These are people whose fat is mostly the type that hangs loosely over their belt and jiggles when they walk or laugh. Surprisingly, these are not the people that necessarily have metabolic issues, provided they also don’t have significant amounts of visceral fat (where it can’t be pinched and where it wraps the organs, resulting in metabolic disruption).

insulin resistant (from Klöting N, Fasshauer M, Dietrich A et al, Insulin-sensitive obesity, Am J Physiol Endocrinol Metab 299: E506–E515, 2010, pg. 5)

Those who store most of their fat inside their abdomen as visceral fat rather are often insulin resistant and as a result may have high blood pressure, abnormal cholesterol (lipids) or been diagnosed as having either pre-Diabetes or Type 2 Diabetes.

In order to reverse the symptoms of these chronic diseases, people with insulin resistance often need to maintain their intake of carbohydrate at a lower level than those who are insulin sensitive.

As far as the question as to whether eating a particular food will “knock someone out of ketosis“, if that food contains more grams of carbohydrate than their daily limit then yes, they will temporarily burn glucose instead of producing ketones from burning fat.

That said, for a low-carbohydrate lifestyle to be sustainable long term for the average individual without metabolic issues seeking weight loss, I don’t understand why some are focused on how many ketones they are producing.  This is not one of those cases that ‘more is better’. The body is very good at not wasting energy, be it as glucose or ketones so if people have been in ketosis for a considerable length of time, their body will often stabilize and produce a lower level of ketones, so as not to produce more than is needed. A lower level is just fine.

If you have been prescribed a low carb or ketogenic diet for a specific health condition or are taking one of the medications that puts you at risk of developing ketoacidosis (a potentially life-threatening condition which is very different than ketosis!) then yes, tracking ketones is important, but for the average person, eating the foods are on your Meal Plan will enable you to enjoy your meals while keeping to the amount of carbohydrate that your body tolerates, without counting anything!

That’s the beauty of this style of eating! There’s no need to weigh and measure food, so why become focused on carbohydrate counting or on ketone measuring?

If it’s a special occasion and you want to have a piece of something that is not normally part of what you eat then decide if eating a small serving fits your own health and nutrition goals.  If it does, have a small piece and enjoy it. If it doesn’t than choose not to.

Overall, if you focus on eating real, whole foods including plenty of healthy animal protein, low carbohydrate vegetables and leafy greens with just enough fat to make it tasty, then relax, eat and enjoy!

If you would like to know more about what’s involved in me designing a Meal Plan for you, then please send me a note using the “Contact Me” form above and for information on the various in-person or distance consultation services I provide, please click on the “Services” tab.

To our good health!

Joy

You can follow me at:

 https://twitter.com/lchfRD

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Reference

Virta Health Blog, Dr. Stephen Phinney, https://blog.virtahealth.com/how-many-carbs-ketogenic-diet/

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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Cannabis’ Effect on Appetite, Blood Sugar and Insulin Levels

As of October 17th 2018, marijuana (cannabis sativa, cannabis indica) will be legal to be sold to or possessed by adults 18 years or older in Canada and to be consumed for recreational use.  Medical marijuana has been available for sometime in Canada (and in some US states) to those with authorization from their healthcare provider, but will now be widely available to the general adult population. So why am I, as a Dietitian writing about marijuana? Because food cravings, commonly referred to as the “munchies” are one of the known side-effects of cannabis and result in people eating even when they’ve just eaten.  For those who have made a decision to lose weight and keep it off, knowing how marijuana affects appetite is something that needs to be considered. As well, for those that are at risk for Type 2 Diabetes, knowing how marijuana impacts blood glucose and serum insulin levels is also important. So as a public service, this article is about the effect of marijuana and the “munchies” on blood sugar, serum insulin and weight gain.

The “Munchies”

Tetrahydrocannabinol (THC) is one of the active components in marijuana that is responsible for people feeling “high” and is also responsible for “the munchies”.  It’s been know for sometime that the THC in cannabis activates a cannabinoid receptor in the brain (called CB1R) which triggers an increased desire to eat but a 2015 study indicates that a group of neurons (nerve cells) called pro-opiomelanocortin (POMC) which normally produce feelings of satiety (no longer feeling hungry after eating) become activated and promote hunger under the influence of THC. As it turns out, cannabis “hijacks” the POMC neurons, resulting in them releasing hunger-stimulating chemicals rather than appetite-suppressing chemicals. This is why despite having just eaten a full meal and being satiated, ordering a pizza suddenly becomes a priority. It is thought that THC from the weed binds to mitochondria inside of cells (the “powerhouse of the cell” that generates energy) and this binding acts to switch the feelings of satiety to feelings of hunger. But how does marijuana use affect weight gain, blood sugar and insulin levels?

Marijuana’s Effect on Fasting Blood Glucose and Fasting Insulin, Insulin Resistance and Weight Gain

Interestingly, epidemiological studies (studies of populations) have found lower rates of obesity and Type 2 Diabetes in those that use marijuana compared to those that never used it, suggesting that cannabinoids play a role in regulating metabolic processes. A 2013 study that analyzed data from almost 4657 adult men and women who participated in the National Health and Nutrition Examination Survey (NHANES) study from 2005 to 2010 were studied; 579 were current marijuana users and 1975 were past users. Results indicated that current marijuana use was associated with 16% lower fasting insulin levels and 17% lower insulin resistance as measured by HOMA-IR  which is calculated from fasting blood glucose and fasting insulin. As for weight gain as a side-effect from the “munchies”, this study  reported significant associations between marijuana use and smaller waist circumferences.

Marijuana and Metabolic Syndrome

A 2015 study which looked at 8478 adults 20-59 years of age who also  participated in the National Health and Nutrition Examination Survey (NHANES) study from 2005 to 2010 reported that current marijuana users had lower odds of presenting with metabolic syndrome than those that never used marijuana. Current marijuana users in the 20-30 year old range were 54% less likely than those who never used marijuana to present with metabolic syndrome.

Marijuana’s Possible Role in Type 2 Diabetes Treatment?

The epidemiological studies above indicate that fasting insulin levels were reduced in current cannabis users but not in former cannabis users or in those that never used it. This leads to the question as to whether THC may be of medical benefit to those already diagnosed with pre-diabetes or Type 2 Diabetes. Given that epidemiological evidence demonstrates there may be a correlation but not provide proof of causation, further study is warranted.

Some Final Thoughts…

Certainly as a reasonable precaution, those who are Diabetic and who will begin using marijuana now that it is legal (or already use marijuana) should monitor their body’s blood sugar response, especially if they are also taking medications to lower blood sugar. Assuming that cannabis can lower blood sugar on it’s own, taking it along with medications to lower blood sugar may result in blood sugar dipping too low (hypoglycemia).

Perhaps you’re curious how I can help you achieve your weight-loss and other health goals such as lowering risk factors for Type 2 Diabetes by making dietary and lifestyle changes. I provide both in person services in my Coquitlam, British Columbia office as well as via Distance Consultation (Skype, telephone). You can find out details under the Services tab above or in the Shop.

If you have questions regarding getting started or would like more information, please send me a note using the Contact Me form above and I will be happy to reply as soon as I’m able to.

To your good health!

Joy

you can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/lchfRD/

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

Government of Canada, Cannabis Legalization and Regulation, http://www.justice.gc.ca/eng/cj-jp/cannabis/

Koch M, Varela L, Kim JG et al, Hypothalamic POMC neurons promote cannabinoid-induced feeding, Nature, Volume 519 (2015), pages 45–50

Penner EA, Buettner H, Mittleman MA, The Impact of Marijuana Use on Glucose, Insulin, and Insulin Resistance among US Adults, Amer J of Med, 126 (7) July 2013, Pages 583-589

Vidot DC, Prado D, Hlaing WM et al, Metabolic Syndrome Among Marijuana Users in the United States: An Analysis of National Health and Nutrition Examination Survey Data, Amer J of Med, 129 (2) Feb 2016, Pages 173-179

 

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ADA Deems Low Carb Diet Medical Nutrition Therapy for T2D

The American Diabetes Association (ADA) just released an updated position statement in conjunction with the European Association for the Study of Diabetes (EASD) which deems a low carb diet as Medical Nutrition Therapy for the treatment of Type 2 Diabetes in adults [1]. In fact, the joint position paper approves a diet of <130 g of carbs and states that a diet of >130 g carbs is ineffective for managing T2D.

The American Diabetes Association is responsible for educating over 30 million Americans diagnosed with Diabetes and the European Association for the Study of Diabetes (EASD) is responsible for overseeing the care of over 60 million Europeans and both now consider a low carbohydrate of < 130 g of carbohydrate not only safe, but effective therapeutic treatment. This recognition comes on the heels of Diabetes Australia having just released in late August their own updated position paper designed to provide practical advice and information for people diagnosed with Diabetes who are considering adopting a low carbohydrate eating plan [2].

What is Medical Nutrition Therapy?

Medical Nutrition Therapy (MNT) is defined as;

“nutritional diagnostic, therapy and counseling services for the purpose of disease management, which are furnished by a Registered Dietitian or nutrition professional” [3].

The American Diabetes Association and the European Association for the Study of Diabetes preface their updated position statement by saying;

“A systematic evaluation of the literature since 2014 informed new recommendations.”

That is, upon a review of the most current research, these two organizations have updated their prior position statements and now consider a low carbohydrate diet defined as <26%* of daily calories as carbohydrate [1] is suitable for the purpose of disease management of Type 2 Diabetes in adults.

*Note: based on an 1800-2000 calorie per day diet this amount of daily carbohydrate would be less than < 113-125 g daily. In fact, the position paper concludes that carbohydrate restriction of 26–45%  is ineffective.

The new joint position statement elaborates that Medical Nutrition Therapy (MNT) is made up of an education component and a support component in order to enable patients to adopt healthy eating patterns with the purpose of “managing blood glucose and cardiovascular risk factors” and “reducing the risk for Diabetes-related complications while preserving the pleasure of eating” [1].  The paper defines the two basic dimensions of MNT as diet quality and energy restriction and outlines the benefits of a low carbohydrate diet in the section on diet quality.

page 12 of the joint position statement (courtesy of Jan Vyjidak)

Furthermore, the joint consensus paper lists  under diet quality (Table 2, page 13) which is one of the aspects of Medical Nutrition Therapy, several diets considered suitable for adults with Type 2 Diabetes, including a low carbohydrate diet.

Table 2 —Glucose-lowering medications and therapies available in the U.S. or Europe

This move has far-reaching significance!

It moves a low carbohydrate diet from the realm of a popular lifestyle approach to Medical Nutrition Therapy.

Most importantly, this consensus paper means that qualified healthcare professionals throughout the USA and Europe can now recommend a low carbohydrate diet to their adult patients in order to enable them to manage their Type 2 Diabetes. This is a huge step forward from only being able to provide such a diet based on person’s individual preference to follow a low carbohydrate lifestyle.

Publication of this paper indicates that the current scientific literature supports that a low carbohydrate is safe and effective in lowering metabolic markers of Type 2 Diabetes, as well as  delaying or eliminating the need for blood-glucose lowering medications for up to 4 years [1].

Some final thoughts…

The American Diabetes Association, European Association for the Study of Diabetes and Diabetes Australia have collectively led the way for international Diabetes Associations the world over to re-evaluate their own treatment and dietary recommendations in light of the most current scientific evidence and update their position statements regarding the safe and effective use of low carbohydrate diets in the management of Type 2 Diabetes in adults.

Here’s hoping this will occur in a timely manner.


Perhaps you have wanted to follow a low carbohydrate lifestyle and have questions about how such a diet could help you manage some of your clinical conditions or lose weight. Please send me a note using the Contact Me form above and I will reply as soon as I am able.

Whether you live locally or away, I provide services in-person in my Coquitlam (British Columbia) office, as well as via Distance Consultation (Skype or phone).  You can find more information under the Services tab and in the Shop including the Intake and Service Option form to send in to get started.

To your good health!

Joy

you can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/lchfRD/

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
    Click here for pdf of the full article.
  2. Diabetes Australia, Low Carbohydrate Eating for People with Diabetes – Position Statement, August 2018,  https://www.diabetesqld.org.au/media-centre/2018/august/low-carb-position-statement.aspx and https://www.diabetesqld.org.au/media/583017/da-low-carb-statement-21-august-2018.pdf
  3. U.S. Department of Health and Human ServicesFinal MNT regulationsCMS-1169-FCFederal Register1 November 200142 CFR Parts 405, 410, 411, 414, and 415

 

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ADA & European Association Classify Low Carb Diets as Medical Nutrition Therapy

The new joint American Diabetes Association (ADA) / European Association for the Study of Diabetes (EASD) position paper [1] published online ahead of print on October 4th now classifies a low carbohydrate diet as Medical Nutrition Therapy. in the treatment of Type 2 Diabetes in adults. What this means is these two organizations which are responsible for educating over 30 million Americans and 60 million Europeans diagnosed with Diabetes consider a low carbohydrate not only safe, but effective therapeutic treatment. This recognition comes on the heels of Diabetes Australia having just released in late August their own updated position paper designed to provide practical advice and information for people diagnosed with Diabetes who are considering adopting a low carbohydrate eating plan [2].

What is Medical Nutrition Therapy?

Medical Nutrition Therapy (MNT) is defined as;

“nutritional diagnostic, therapy and counseling services for the purpose of disease management, which are furnished by a Registered Dietitian or nutrition professional” [3].

The American Diabetes Association and the European Association for the Study of Diabetes preface their updated position statement by saying;

“A systematic evaluation of the literature since 2014 informed new recommendations.”

That is, upon a review of the most current research, these two organizations have updated their prior position statements and now consider a low carbohydrate diet defined as <26%* of daily calories as carbohydrate [1] is suitable for the purpose of disease management of Type 2 Diabetes in adults.

*Note: based on an 1800-2000 calorie per day diet this amount of daily carbohydrate would be less than < 113-125 g daily. In fact, the position paper concludes that carbohydrate restriction of 26–45%  is ineffective.

The new joint position statement elaborates that Medical Nutrition Therapy (MNT) is made up of an education component and a support component in order to enable patients to adopt healthy eating patterns with the purpose of “managing blood glucose and cardiovascular risk factors” and “reducing the risk for Diabetes-related complications while preserving the pleasure of eating” [1].  The paper defines the two basic dimensions of MNT as diet quality and energy restriction and outlines the benefits of a low carbohydrate diet in the section on diet quality.

page 12 of the joint position statement (courtesy of Jan Vyjidak)

Furthermore, the joint consensus paper lists  under diet quality (Table 2, page 13) which is one of the aspects of Medical Nutrition Therapy, several diets considered suitable for adults with Type 2 Diabetes, including a low carbohydrate diet.

Table 2 —Glucose-lowering medications and therapies available in the U.S. or Europe

This move has far-reaching significance!

Publication of this paper indicates that the current scientific literature supports that a low carbohydrate is not only safe for use in adults, but is also effective in lowering metabolic markers of Type 2 Diabetes, as well as  delaying or eliminating the need for blood-glucose lowering medications for up to 4 years [1].

It moves a low carbohydrate diet from the realm of a popular lifestyle approach to Medical Nutrition Therapy.

Most importantly, this consensus paper means that qualified healthcare professionals throughout the USA and Europe can now recommend a low carbohydrate diet to their adult patients in order to enable them to manage their Type 2 Diabetes. This is a huge step forward from only being able to provide such a diet based on person’s individual preference to follow a low carbohydrate lifestyle.

Some final thoughts…

The American Diabetes Association, European Association for the Study of Diabetes and Diabetes Australia have collectively led the way for international Diabetes Associations the world over to re-evaluate their own treatment and dietary recommendations in light of the most current scientific evidence and update their position statements regarding the safe and effective use of low carbohydrate diets in the management of Type 2 Diabetes in adults.

Perhaps you have wanted to follow a low carbohydrate lifestyle and have questions about how such a diet could help you manage some of your clinical conditions or lose weight. Please send me a note using the Contact Me form above and I will reply as soon as I am able.

Whether you live locally or away, I provide services in-person in my Coquitlam (British Columbia) office, as well as via Distance Consultation (Skype or phone).  You can find more information under the Services tab and in the Shop including the Intake and Service Option form to send in to get started.

To your good health!

Joy

 

you can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/lchfRD/

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
    Click here for pdf of the full article.
  2. Diabetes Australia, Low Carbohydrate Eating for People with Diabetes – Position Statement, August 2018,  https://www.diabetesqld.org.au/media-centre/2018/august/low-carb-position-statement.aspx and https://www.diabetesqld.org.au/media/583017/da-low-carb-statement-21-august-2018.pdf
  3. U.S. Department of Health and Human ServicesFinal MNT regulationsCMS-1169-FCFederal Register1 November 200142 CFR Parts 405, 410, 411, 414, and 415

 

 

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American Diabetes Association & European Association Approve Low Carb Diets

The American Diabetes Association (ADA) & the European Association for the Study of Diabetes (EASD) have just released their new joint position statement which includes approval of low carbohydrate diets for use in the management of Type 2 Diabetes (T2D) in adults. This comes on the heels of Diabetes Australia having recently released an updated position statement in August titled Low Carbohydrate Eating for People with Diabetes (you can read more about that here).

This is huge!

By releasing this updated joint position statement, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) indicate that they now recognize a low carbohydrate diet as safe and effective lifestyle management of T2D in adults.

In the newly released joint position statement that was published online ahead of print on October 4, 2018 in the journal Diabetes Care, it was stated that the new recommendations were based on “a systematic evaluation of the literature since 2014” [1].  That is, approval for the use of low carbohydrate diets is based on current research.

A Full Range of Therapeutic Options

The new joint ADA & EASD position statement endorses “a full range of therapeutic options” including lifestyle management, medication and obesity management and indicate that:

“An individual program of Medical Nutrition Therapy (MNT) should be offered to all patients”.

The new joint position statement elaborates that Medical Nutrition Therapy (MNT) is made up of an education component and a support component to enable patients to adopt healthy eating patterns with the goal of “managing blood glucose and cardiovascular risk factors.” The goal is to reduce risk for Diabetes-related complications while preserving the pleasure of eating” with the two basic dimensions of MNT including diet quality and energy restriction.

Diet Quality and Eating Patterns

The joint American and European position paper on the management of T2D states clearly;

“There is no single ratio of carbohydrate, proteins and fat intake that is optimal for every person with Type 2 Diabetes.”

but

“Instead, there are many good options and professional guidelines usually recommend individually selected eating patterns that emphasize foods of demonstrated health benefit, that minimize foods of demonstrated
harm and that accommodate patient preference and metabolic needs, with the goal of identifying healthy dietary habits that are feasible and sustainable.”

Included in this category are;

  • the Mediterranean Diet
  • the Dietary Approaches to Stop Hypertension (DASH) Diet
  • Low Carbohydrate Diets
  • Vegetarian Diets

The joint position paper noted that;

“Low-carbohydrate diets (<26% of total energy) produce substantial reductions in HbA1c at 3 months and 6 months with diminishing effects at 12 and 24 months.”

Unfortunately the paper failed to note that the one-year Virta study data that reported that HbA1C continued to decline at one year but yes, a diminished rates.

The new joint ADA and European Association for the study of Diabetes also noted that moderate carbohydrate restriction was of no benefit;

“no benefit of moderate carbohydrate restriction (26–45%) was observed.”

page 12 of the joint position statement (courtesy of Jan Vyjidak)

The paper acknowledged that there are many different types of “low carbohydrate diets’ and the particular benefits of a low – carbohydrate Mediterranean eating pattern was in reducing the requirement for medication over 4 years;

“people with new-onset Diabetes assigned to a low carbohydrate  Mediterranean eating pattern were 37% less likely to require glucose-lowering medications over 4 years compared with patients assigned to a low-fat diet”.

The paper outlines that the primary physiological actions depend on which diet is followed.

It lists advantages of using diet, including a low carbohydrate diet in the management of T2D symptoms in adults is that dietary changes are inexpensive and have no side effects

Disadvantages of using diet, including a low carbohydrate diet in the management of T2D symptoms in adults is that it requires instruction, motivation, lifelong behaviour change and may pose some social barriers.

Yes, a well-designed low carbohydrate diet does require instruction, but for those that have the motivation to avoid the chronic health complications of Diabetes through diet and who are committed to maintaining the behaviour change, I can help!

Perhaps you’re curious about the types of services that I provide both in person in my Coquitlam, British Columbia office and via Distance Consultation (Skype, telephone)? You can find out more under the Services tab or in the Shop.  If you have questions regarding getting started or would like more information, please send me a note using the Contact Me form above and I will be happy to reply as soon as I’m able to.

To your good health!

Joy

P.S. Read here why the ADA and EASD classifying a low carb diet as Medical Nutrition Therapy is so significant!

you can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/lchfRD/

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
    Click here for pdf of full article.
  2. Diabetes Australia, Low Carbohydrate Eating for People with Diabetes – Position Statement, August 2018,  https://www.diabetesqld.org.au/media-centre/2018/august/low-carb-position-statement.aspx and https://www.diabetesqld.org.au/media/583017/da-low-carb-statement-21-august-2018.pdf
  3. Hallberg, S.J., McKenzie, A.L., Williams, P.T. et al. Diabetes Ther (2018). 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.  https://doi.org/10.1007/s13300-018-0373-9
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Silver Bullet for Addressing Carb Cravings

I was asked an interesting question recently which was “have you found the silver bullet for reducing carb craving“? This was an interesting way to phrase something I have been asked in many different ways the last few years.

Some people have been told that it really doesn’t matter what or how much they eat as long as they only eat “real” food. Others have heard that they need to eat plenty of fat each day, and that this will work to keep them full and reduce cravings. Some have read that what they need to do is eat mostly protein with some fat or only eat during a very small ‘eating window’.

So what is the answer?

There really isn’t a ‘silver bullet’ as much as there is the need for a well-designed low carbohydrate diet that is specific to each person’s physiological needs.

Every person has different nutrient needs based on their age, stage of life, gender and activity level. As well, each individual has different degrees of insulin resistance and hyperinsulinemia and each person’s blood sugar responds differently to a carbohydrate load (called glycemic response). Much of these depends on their specific family history, their medical history and the type of foods they normally eat. [You can read more about all three of these here.]

There isn’t a “once-size-fits-all low carb diet”.  Based on all of the above factors, some people will do better with a higher ratio of protein to fat, whereas others need plenty of natural, healthy fats and average amount of protein. The amount and type of carbohydrate each person can tolerate will also be different. Since everyone’s needs are different, in designing a Meal Plan for someone, I start by conducting a complete nutritional assessment (personal medical history, family medical history, review of recent lab tests, dietary and lifestyle review, etc.) so that the Meal Plan that I design is tailored to their individual needs.

If there was a ‘silver bullet’ to eliminate carb cravings it would be to understand what causes them. Carb cravings are driven by several different hormones that the body produces in response to the way each person eats, as well as how much and how well they sleep, how they manage stress (or don’t), as well as any conditions or diseases that they have and any medications that they take.  All of these affect the various hormones that impact cravings for carbohydrate-based food. When I design people’s Meal Plans, I take all of these into account.

A well-designed low carbohydrate diet designed specifically for each person and taking into account the various factors that are driving their specific carbohydrate cravings is the most effective means to addressing them.

A person’s Meal Plan is not carved in stone. If a person has a fair amount of weight to lose, their Meal Plan will change once they’ve lost a significant amount of weight or if they’ve hit a plateau where they haven’t lost either weight or inches in a while.  Achieving optimal body weight is a dynamic process not a static one — as people’s needs change, so should their diet.  It’s not that a person’s Meal Plan needs to be re-designed, as much as ‘tweaked’ or ‘adjusted’ to keep them moving towards achieving their goals. This is where follow-up can be helpful.

If you have questions as to how I can help you achieve your health and nutrition goals — either by taking service in-person in my office or via Distance Consultation please send me a note using the Contact Me form above and I will be happy to 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/

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 Trial of the Evidence

In a landmark decision yesterday the Australian Health Practitioner’s Regulation Agency (AHPRA) dropped all charges of wrong-doing against orthopedic surgeon Dr. Gary Fettke for recommending a low carb high fat lifestyle to his patients. This is great news for a physician who had tired of amputating the gangrenous limbs of patients with uncontrolled Diabetes when lifestyle changes could not only spare their limbs, but their lives. It was not only Dr. Fettke that was investigated, but also the strength of the scientific evidence behind his dietary recommendation of a low carbohydrate diet. That is the subject of this article.

It is great news that AHPRA ruled that Dr. Fettke had caused no patient harm by his recommendation of a low carb high fat (LCHF) diet:

“…no significant risks to public safety have been identified that require a regulatory response under the National Law. In the case of each of the three issues considered, there is no evidence of any actual harm and nor does the Board discern any particular risk to public health and safety moving forward. For these reasons, the Board has decided to take no further regulatory action.”

— AHPRA medical board

It is outstanding that AHPRA apologized in writing to Dr. Fettke for the 4½ years of distress caused to him by the investigative process;

“I would like to take this opportunity to apologize for the errors that were made when dealing with this notification. We recognize that these errors are likely to have compounded any distress that you experienced as a result of being the subject of this investigation. We appreciate your cooperation and engagement through the complaint management process, and the reconsideration of the previous decision.”

— AHPRA medical board

This is fantastic news and must come as a tremendous relief both to Dr. Fettke and to his family who have endured untold stress from this long ordeal.

Dr. Fettke’s exoneration comes on the heels of the results of not one, but two trials over a 4-year period against South African Professor Tim Noakes for his response to a tweet on Twitter social media from a breastfeeding mother in February 2014 where he recommended that good first foods for infant weaning are low carbohydrate high fat foods. As noted by Dr. Sarah Hallberg in a letter to the Health Professions Council of South Africa (HPCSA), low carbohydrate foods such as meat, chicken, fish and leafy green vegetables align closely with South Africa’s pediatric guidelines which advise that;

“From 6 months of age give your baby meat, chicken, fish, or egg every day as often as possible. Give your baby dark green leafy vegetables and orange coloured vegetables and fruit every day.”

—Food-based Dietary Guidelines for South Africa

In April 2017 and again in the appeal which concluded in June of this year, Noakes was cleared of all charges of professional misconduct by the HPCSA which confirmed that his advice to the breastfeeding woman in his tweet was neither “unconventional” nor “dangerous medical advice“.

In June, Noakes’ lawyer Adam Pike said in a statement that the HPSCA’s ruling;

“preserves the right of scientists and doctors to express scientific opinions and disseminate medical information”

— Adam Pike, Professor Tim Noakes’ lawyer

Phrased another way, Noakes acted as a scientist who tweeted scientifically based information.

While it was Dr. Gary Fettke and Professor Tim Noakes that have been investigated as individuals, what was largely on trial was the scientific evidence behind their recommendation of a low carbohydrate diet. This evidence indicates that well-designed low carbohydrate diets are both safe and effective for treating obesity and for managing the symptoms of Type 2 Diabetes.

In an article I wrote in January 2018 titled A Preponderance of the Evidence, I documented that not only is a low carbohydrate diet for the treatment of Diabetes not new, but almost a year ago there were already many research  studies and meta-analyses published in 76 publications which spanned 18 years which involved 6,786 subjects which used a low-carb intervention — which included 32 studies of 6 months or longer and 6 studies of 2 years or longer all of which indicated that a low carbohydrate diet is safe. Not only has it been amply documented that a low carbohydrate diet is safe, but a low carbohydrate diet performed as well, if not better than competing diets in all of the above studies.  Dr. Sarah Hallberg who compiled the above list is Medical Director at Indiana University Health Arnett and Virta Health Medical Director. She pointed out in a letter to the Health Professions Council of South Africa that data available from the US government as reported in a 2015 study indicates that in 1965 (which is just prior to the beginning of the current obesity and Diabetes epidemic) Americans ate 39% of their calories as carbohydrate and 41% of their calories as fat which is considered by many nutrition researchers today to fall within the realm of a “low carbohydrate high fat diet”. Dr. Hallberg is correct. Dietary Guidelines in both the US and Canada currently recommend that the diet be 45-65% of calories as carbohydrates and that up until 2015, the US recommended a upper limit of 35% calories as fat (<30% of calories as fat in Canada). Both countries currently still recommend limiting saturated fat to <10% of calories.

Nutrition researchers today generally consider diets less than 45% of calories as carbohydrate and >35% of calories as fat to be “low carbohydrate high fat diets”, so the average American diet that was 39% carbohydrate and 41% fat in 1965 would be considered “low carb high fat” by most nutrition research studies today. 

Given the much lower rates of overweight and obesity and Type 2 Diabetes in 1965 — at a time when the average American ate what is now considered a “low carb high fat diet”, should not such a macro distribution be granted “generally recognized as safe” (GRAS) standing?

For the last 40 years, the Dietary Guidelines in both the US and Canada have been counselled people to limit fat, especially saturated fat and to eat 45-65% of their calories as carbohydrate yet even a cursory look at the rates of overweight and obesity in both countries and the steadily increasing rates of Type 2 Diabetes indicates that something is terribly wrong. Clinicians (Physicians, Dietitians, Pharmacists) educated since 1977 which is the vast amount practicing in both countries (and in South Africa and Australia apparently, where Dr. Fettke and Professor Noakes are from) have all been educated within a “low fat paradigm”— where fat is vilified as the cause of cardiovascular disease and increasing carbohydrate intake is promoted as the ‘solution’ to reducing fat intake. Unless clinicians educated in this time period stayed current with the literature they simply keep teaching what they were taught; eat less fat, eat more carbs.

In the past number of years there are increasing numbers of clinicians around the world that have considered the evidence; both epidemiological and clinical studies that indicate that a low carbohydrate high fat diet not only has no adverse impact on individual health but is safe and effective for reducing overweight and obesity, as well as reducing (and in some cases reversing) the symptoms of Type 2 Diabetes. Two such clinicians are Australian orthopedic surgeon Dr. Gary Fettke and South African Professor Tim Noakes; both of whom were investigated for having recommended a low carb high fat diet which was viewed as “dangerous” and both of whom, when the scientific evidence was considered, were exonerated. To their credit both Dr. Fettke and Professor Noakes conducted themselves with integrity and transparency through the entire process and all charges of wrong-doing against them were dropped, but let’s not lose sight that it was also because of the amount and strength of the scientific evidence which indicates that a well-designed low carbohydrate high fat diet is both safe and effective for weight loss, as well as for reducing symptoms of Type 2 Diabetes.

Both men have no doubt been through a very distressing and incredibly stressful >4-year ordeal which forever changed them and their families that went through it with them, however this story is not only about them but what they believed about the safety and efficacy of a low carb diet. It was low carb high fat diets that were investigated and put on trial and the conclusion in both cases as that such a diet is neither unconventional nor dangerous.

Yes, there are other dietary options for weight-loss and targeting the reduction of symptoms of Type 2 Diabetes and diets such as the classic Mediterranean Diet or a very low-fat calorie-restricted plant-based diet are effective for those that maintain them long term. The issue is that a well-designed low carbohydrate diet is at least as effective as these and may be easier for some to stick with long term, making it more effective for those individuals. Since the scientific evidence indicates that all three of these diets are safe and to varying degrees effective for weight loss and glycemic control, it is time for clinical guidelines in both the US and Canada to be formulated to enable clinicians in both countries to offer their patients a well-designed low carbohydrate diet as an option.

Perhaps you have questions about whether a low-carbohydrate diet would be appropriate for you or wonder how medical conditions you have or medications you take may factor in? I provide both in-person services in my Coquitlam (British Columbia) office, as well as via Distance Consultation using Skype or phone and I would be happy to answer your questions and help you reach your goals. Please send me a note using the “Contact Me” form on the tab above and will reply as soon as possible.

To your good health,

Joy

 https://twitter.com/lchfRD

  https://www.facebook.com/lchfRD/

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. Fettke Free at Last, Foodmed.net, Sept 28 2018 (http://foodmed.net/2018/06/noakes-free-hpcsa-licks-wounds-lchf/)
  2. Noakes: Top Doctors Globally call on HPCSA to Stop Prosecuting Him, Foodnet.net, February 14, 2018
  3. Food-based Dietary Guidelines for South Africa, S Afr J Clin Nutr 2013;26(3)(Supplement):S1-S164
  4. Noakes Free at Last, Foodmed.net, June 10 2018 (http://foodmed.net/2018/06/noakes-free-hpcsa-licks-wounds-lchf/)
  5. Cohen E, Cragg M, deFonseka J et al, Statistical review of US macronutrient consumption data, 1965–2011: Americans have been following dietary guidelines, coincident with the rise in obesity, Nutrition (2015), Vol 31 (5), Pg 727-732.
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Low Carb and Ketogenic Diets – articles by topic

Are you looking for well-researched, credible articles about the therapeutic use and practical applications of Low Carbohydrate and Ketogenic Diets, as well as related topics? You’ve come to the right place!

I have written 100+ “Science Made Simple” articles that people without a science background can easily understand and apply and that can now be searched by the following tags;

Current list of topics includes:

-Low Carb High Fat (LCHF) Diets

-Ketogenic (Keto) Diets

-Therapeutic Low Carb Diets

-Low Calorie / Low Fat Diets

-Diet & Food Choices

-Myths about Low Carb / Keto Diets

-Low Carb / Keto Diets & Medications

-Dietary Fat

-Carbs & Carbs with Fat

-PUFA / Industrial Seed Oils

-Effects of Food Processing on Insulin and Blood Sugar

-Insulin Resistance

-Type 2 Diabetes

-Cardiovascular Disease (CVD)

-Older Adults & Diet

-Concerns and “Warnings”

-Clinical

-Setting Health and Nutrition Goals

-Anthropometrics (Body Measurements)

-Practical Applications

-Media

-Background & History

These articles are located under the Food for Thought tab located above or you can click here.

Perhaps you have questions about how I can support you in following either a low-carb or ketogenic diet — either remotely via Distance Consultation (Skype, long distance phone) or in-person in my Coquitlam (British Columbia) office? Please send me a note using the Contact Me form and I will reply shortly.

To your good health!

Joy


you can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/lchfRD/

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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Are Low Carbohydrate Diets Linked to Risk of Premature Death?

Once again, dire warnings about the alleged dangers of “low carbohydrate diets” scream out from headlines across the internet;

“Low-Carb Diets Linked to Higher Risk of Premature Death”

~Newsweek August 28, 2018, 12:51 PM

“Low carbohydrate diets are unsafe and should be avoided, study suggests”

~ScienceDaily, August 28, 2018

The general public relies on journalists to thoroughly research their stories before publishing them however in the above two examples and the other incidences of reporting this story it was not indicated that (1) there was no published study (2) the story was based on researcher’s conclusions in provided materials based on an Abstract from a Poster presentation and (3) the provided materials / Abstract didn’t define the term “low carbohydrate” (# of grams of carbohydrate per day) which is central to the claims of the researchers.

The supposed link to “premature death” of a “low carbohydrate diet” were said to be part of a large study that was presented at the European Society of Cardiology (ESC) Congress 2018 in Munich, Germany, but when I went to find the journal in which the study was published so I could read it, I discovered that it’s not even been published yet.  I even checked the lead author’s Publication page on ResearchGate and could not find the published study. Furthermore, the findings were not presented as one of the more than 500 Conference sessions of research studies at the European Society of Cardiology Congress, but was one of the 4,500 Abstract presentations — not even as a talk, but as a Poster Session.

A “Poster Session” at  an academic Conference is where 100s of researchers assemble in a large hall and stand in front of a poster summarizing their research. People walk by, look at the poster and if they wish, ask questions.

Journalists wrote stories based on “materials provided to them by the European Society of Cardiology” (see story source at bottom of ScienceDaily article) which is based on the Abstract available on the website of the European Society of Cardiology’s 2018 Congress from the yet-to-be-published study by M. Mazidi  (Gothenburg, Sweden), N Katsiki (Thessaloniki, Greece), DP Mikhailidis (London, Great Britain) and M Banach (Lodz, Poland) and also published the same day (August 28, 2018) in the European Heart Journal, Volume 39 Supplemental on pages 1112-1113.

The Abstract (viewable below) is downloadable from the journal’s website and the 2018 Congress website and clearly indicates that it was a “Poster Session”.

A glaring omission from the Abstract is that it is not stated anywhere how many grams of carbohydrate per day is defined as a “low carbohydrate diet”.

The Abstract and supplied press materials claim that there is a relationship between “low carbohydrate diets” (not defined!) and death from all-causes, as well as specific death from coronary heart disease, cerebrovascular disease (stroke) and cancer and that the data analyzed was based on a representative sample of 24,825 participants of the US National Health and Nutrition Examination Survey (NHANES) from 1999 to 2010.

The researchers conclude that compared to participants with the highest carbohydrate consumption (also not defined!), those with the lowest carbohydrate intake had a 32% higher risk of all-cause death during the ~6.4-year follow-up. As well, the risk of death from coronary heart disease from “low carbohydrate”diets was 51% higher, from cerebrovascular disease (stroke) was 50% higher and from cancer was 35% higher. They furthermore state that their results were confirmed by a pooled meta-analysis of 7 prospective cohort studies with 447,506 participants and which had an average follow-up of 15.6 years which indicated that risk of death from all causes resulting from “low carbohydrate diets” was 15% higher, from cardiovascular disease was 13% higher and from cancer was 8% higher compared to high carbohydrate diets.

Wait a minute…

The researchers found risk of death from coronary heart disease and cardiovascular disease (heart attack and stroke) as ~50% higher and the pooled data of the studies they compared it to found a 13% higher incidence. Even without defining what a “low carbohydrate diet” is, a 50% increased chance of death is not comparable to a 13% increased chance of death.  Similarly, the researchers found risk of death from cancer from a “low carbohydrate diet” was 35% greater and said their findings were comparable to an 8% higher incidence in the pooled data.

The researchers (1) did not define how many grams of carbohydrate per day was considered a “low carbohydrate diet” and (2) said their data was confirmed by studies that reported very different results.

Yet, they conclude;

Our study highlighted the unfavorable effect of low carbohydrate diets (LCDs) on total- and cause- specific mortality, based on both individual data and by pooling previous cohort studies. Given the fact that LCDs may be unsafe, it would be preferable not to currently recommend these diets. Further studies to clarify the mechanisms involved in these associations and to support our findings are eagerly awaited.

Which “low carbohydrate diet” did they study? How many grams of carbohydrate per day? We don’t know because the Abstract doesn’t say and the study hasn’t yet been published.

Some Final Thoughts…

It is not responsible journalism for the media to scream headlines warning of higher risk of premature death from “low carbohydrate diets” based on supplied press materials and an Abstract of a Poster Session of an unpublished study that doesn’t even define “low carb”.

There are many studies and meta-analyses using a low-carbohydrate or ketogenic dietary intervention that span 18 years and that are outlined in detail in 76 publications involving  6,786  subjects and that include 32 studies of 6 months or longer and 6 studies of 2 years or longer that demonstrate that low carb diets of a specified number of grams of carbohydrate per day are both safe and effective. You can read more about that here.

Perhaps you have questions such as is a low-carbohydrate diet appropriate for you given your health goals, medical conditions or medications you are taking? Please feel free to send me a note using the “Contact Me” form and I will reply as soon as possible.

I provide both in-person services in my Coquitlam (British Columbia) office as well as Distance Consultation services (via Skype / long distance phone) and I’d be happy to help you achieve your health and nutrition goals.

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.

Low carbohydrate diets and all cause and cause-specific mortality – page 1

 

Low Carb diets and all cause mortality – European Society of Cardiology_Page_2

 

Reference

Mazidi M, Katsiki N, Mikhailidis DP et al, Abstract (P5409): Low carbohydrate diets and all-cause and cause-specific mortality: a population based cohort study and pooling prospective studies, European Heart Journal, Volume 39 (Supplemental), pages 1112-1113.

 

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