ADA: Brain’s need for glucose can be fulfilled by the body

In its recently published Consensus Report (April 18, 2019), the American Diabetes Association confirmed something that I have written about in several previous articles, including How Much Carbohydrate is Essential in the Diet and that is that the body has no essential need for dietary carbohydrate.

From the top of page 4 of the Consensus Report:

“The amount of carbohydrate intake required for optimal health in humans is unknown. Although the recommended dietary allowance for carbohydrate for adults without diabetes (19 years and older) is 130 g/day and is determined in part by the brain’s requirement for glucose, this energy requirement can be fulfilled by the body’s metabolic processes, which include glycogenolysis, gluconeogenesis (via metabolism of the glycerol component of fat or gluconeogenic amino acids in protein), and/or ketogenesis in the setting of very low dietary carbohydrate intake.”

Body can make all the glucose it needs for the brain

That is, the body can make all the glucose the brain needs from the glycogenolysis (which is the breakdown of glycogen to glucose), via  gluconeogenesis (which is the generation of glucose from glycerol or glucogenic amino acids) and via ketogenesis (which is from ketones generated in a very low dietary carbohydrate [ketogenic] diet).

In short, dietary intake of carbohydrate is not essential. While there is no biological need to eat carbohydrate-based food, one certainly can and there are many good reasons to include some types of carbohydrate-containing food in the diet.

Because there is no essential need to eat carbohydrate because the body can make all the glucose it needs itself, the American Diabetes Association includes among its eating patterns both a low carbohydrate pattern (26-45% daily calories as carbohydrate) and a very low carbohydrate (ketogenic) eating pattern (20-50 g carbohydrate / day).

How much carbohydrate is a major consideration for those who are pre-diabetic or Diabetic because as the ADA stated in this new consensus report;

“Carbohydrate is a readily used source of energy and the primary dietary influence on postprandial blood glucose. 

That is, it is the carbohydrate in a meal that is the biggest predictor of how high blood sugar will rise after a meal, and how quickly.

For those who want to improve their blood sugar levels (glycemia) the same report also makes it clear that;

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

For those adults with Type 2 Diabetes who are not meeting their blood sugar targets or who need to, or want to have their physician reduce their need for Diabetes medications, a low carbohydrate or very low carbohydrate (keto) eating pattern is a viable option;

“For select adults with type 2 diabetes not meeting glycemic targets or where reducing anti- glycemic medications is a priority, reducing overall carbohydrate intake with low or very low- carbohydrate eating plans is a viable approach.”

Remember, carbohydrate-based foods are not necessary for your brain because your body can make all the glucose it needs from the metabolic processes listed above. That’s not to say one has to avoid carbohydrate-based foods, but how much and how often can and is best determined based on people’s individual needs and glycemic response to carb-based foods.

Remember too as outlined in the article posted yesterday , that in the US a well-designed low carb or ketogenic diet prescribed to lower blood sugar need not have all the same foods or food groups as a diet based on The Dietary Guidelines for Americans because it is used as Medical Nutrition Therapy (i.e. is a therapeutic diet). While these are the guidelines for those with pre-Diabetes or Type 1 or Type 2 Diabetes in the US, in Canada individuals have the ability to choose a low carbohydrate lifestyle if that is their personal preference.

If you would like some professional support to begin eating this way or to continue eating this way,  I can help. I provide Registered Dietitian services to those in any province in Canada (except PEI), and for those in the US, I can provide nutrition education to help you know how to eat according to a low carb eating pattern.

You can learn more about my services including individual hourly appointments and sessions as well as packages above under the Services tab or in the Shop and if you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

Here are the links to other articles that I wrote about the new ADA Consensus Report:

April 24, 2019 – ADA Eating Patterns Differ from The Dietary Guidelines for Americans

April 23, 2019 –  ADA includes use of a Very Low Carb (Keto) Eating Pattern in New Report

April 19, 2019 –  New ADA Report: reducing has intake has most evidence for improving blood sugar

You can follow me on:

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Facebook: https://www.facebook.com/lchfRD/ Instagram: https://www.instagram.com/lchf_rd

Reference

Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014

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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ADA Eating Patterns Different from Dietary Guidelines

In its recently published Consensus Report (April 18, 2019)[1] the American Diabetes Association emphasized that Medical Nutrition Therapy (MNT) is “fundamental in the overall Diabetes management plan” [2], but what exactly is Medical Nutrition Therapy?

According to the report, the National Academy of Medicine defines Medical Nutrition Therapy (MNT) as ‘the treatment of a disease or condition through the modification of nutrient or whole-food intake’ [1].

In contrast, The Dietary Guidelines for Americans (DGA) “provides advice for healthy Americans ages 2 years and over about food choices that promote health and prevent disease [3]. The Consensus Report says (pg. 2) that The Dietary Guidelines for Americans (DGA) 2015-2020 “provide a basis for healthy eating for all Americans and recommend that people consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level”, but for people with Diabetes;

“recommendations that differ from the DGA are highlighted in this report”.

That means that the eating patterns listed in the American Diabetes Association’s new Consensus Report knowingly differ from the Dietary Guidelines for Americans because they are Medical Nutrition Therapy used in the treatment of a disease (i.e. Diabetes).

The Consensus Report outlines several eating patterns that are effective to varying degrees for achieving different Diabetes-related management goals, including HbA1C reduction, weight loss, lowered blood pressure, improved lipids (higher HDL-c, lower LDL-c), lower triglycerides (TG), but says that low carb eating patterns show the most evidence for blood glucose control [1].

As outlined in the previous article, the Consensus Report includes among the choices of Medical Nutrition Therapy various eating patterns, including a low carbohydrate eating pattern and very low carb (keto) eating pattern and the various eating patterns with their different potential benefits are summarized below [1];

 
Table 3 – Eating Patterns reviewed for this report [1]

Role of a Registered Dietitian and Healthcare Team in Providing Medical Nutrition Therapy

The Consensus Report highlights (pg. 2) that it is the role of a Registered Dietitian/ Nutritionist (RDN) to provide Medical Nutrition Therapy (MNT), but that other members of the healthcare team (physicians, nurses and pharmacists) can and should complement this with evidence-based guidance (pg. 2);

“To complement diabetes nutrition therapy, members of the health care team can and should provide evidence-based guidance that allows people with diabetes to make healthy food choices that meet their individual needs and optimize their overall health.”

The Consensus Report specifies that the essential components of Medical Nutrition Therapy are;

“assessment, nutrition diagnosis, interventions (e.g., education and counseling), and monitoring with ongoing follow-up to support long-term lifestyle changes, evaluate outcomes, and modify interventions as needed.”

…and that the goals of Medical Nutrition Therapy (from Table 1 [1]) are ;

“To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and specifically to:

Improve A1C, blood pressure, and cholesterol levels (goals differ for individuals based on age, duration of diabetes, health history, and other present health conditions. ○ Achieve and maintain body weight goals ○ Delay or prevent complications of diabetes

To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, willingness and ability to make behavioral changes, as well as barriers to change

To maintain the pleasure of eating by providing positive messages about food choices, while limiting food choices only when indicated by scientific evidence

To provide the individual with diabetes with practical tools for day-to-day meal planning

The Consensus Report also states that the Registered Dietitian/Nutritionists (RDN) is the preferred member of the health care team to provide diabetes MNT and to lead an inter-professional team;

“The unique academic preparation, training, skills, and expertise make the RDN the preferred member of the health care team to provide diabetes MNT and leadership in inter-professional team-based nutrition and diabetes care.”

…but implied in this is that the whole healthcare team needs to work in concert together to choose and customize an eating pattern to the individual’s metabolic needs and personal preferences.

Remember, if you have pre-diabetes or Diabetes (Type 1 or Type 2) and are following any of the eating patterns outlined as Medical Nutrition Therapy (including a low carb or very low carb (ketogenic) eating pattern, then it is understood that these will not be like the food groups and portions of the “food pyramid” of The Dietary Guidelines of Americans because they are therapeutic diets for the treatment of a disease.

If you have been diagnosed as pre-diabetic or as having Type 2 Diabetes (T2D) and would like some professional support to work on reversing the symptoms through a low carbohydrate or very low carbohydrate eating pattern,  I can help.  I don’t believe there is a “one-sized-fits-all” approach to either of these and will work within you needs to design an individual plan just for you.

You can learn more about my services including individual hourly appointments and sessions as well as packages above under the Services tab or in the Shop.

If you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

Here are the links to other articles that I wrote about the new ADA Consensus Report:

April 25, 2019 – ADA: Brain’s need for glucose can be fulfilled by

April 23, 2019 –  ADA includes use of a Very Low Carb (Keto) Eating Pattern in New Report

April 19, 2019 –  New ADA Report: reducing has intake has most evidence for improving blood sugar

 

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: 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. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
  2. https://www.nap.edu/catalog/9741/the-role-of-nutrition-in-maintaining-health-in-thenations-elderly.
  3. Dietary Guidelines for America, https://health.gov/dietaryguidelines/dga95/9DIETGUI.HTM
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ADA: Very Low Carb (Keto) Eating Pattern in New Report

On April 18, 2019, the American Diabetes Association published a new Consensus Report which not only includes the use of a low carbohydrate eating pattern of 26-45% of total daily calories as carbohydrate, but in this report also includes the use of a very low carbohydrate (ketogenic) eating pattern of 20-50 g carbs per day.

The report is clear that there is no “one-size-fits-all” eating pattern for the prevention or management of diabetes, and that it unrealistic to expect that there should be just one eating pattern for everyone; especially given the wide variety of people affected by diabetes and pre-diabetes, including their varied cultural backgrounds, personal preferences, co-occurring conditions and the variety of socio-economic backgrounds from which they come.

The new report underlines several eating patterns that are effective to varying degrees for achieving different goals, with potential benefits including HbA1C reduction, weight loss, lowered blood pressure, improved lipids (higher HDL-c, lower LDL-c), lower triglycerides (TG), but says clearly that low carb eating patterns show the most evidence for blood glucose control;
 

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

The new Consensus Report includes low carb eating patterns and very low carb (keto) eating patterns among the choices of eating patterns for those with pre-diabetes as well as adults with Type 1 or Type 2 Diabetes.
 
The various eating patterns with their different potential benefits are summarized in Table 3, below;
 
Table 3 – Eating Patterns reviewed for this report [1]
 
The report also indicates that for adults with Type 2 Diabetes not meeting their blood sugar targets, or where there is a need to lower anti-glycemic medications that lower blood sugar, that
 
reducing overall carbohydrate intake with low- or very low- carbohydrate eating plans is a viable approach.”
 
If you have been recently diagnosed as pre-diabetic or as having Type 2 Diabetes (T2D) and would like support to reverse the symptoms through a low carbohydrate or very low carbohydrate eating pattern, then I can help.  I also don’t believe there is a “one-sized-fits-all” approach to either of these and will work within you needs to design an individual plan just for you. 
 
You can learn more about my services including individual hourly appointments and sessions as well as packages above under the Services tab or in the Shop.
 
If you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.
 
To your good health!
 
Joy
 

Here are the links to other articles that I wrote about the new ADA Consensus Report:

April 25, 2019 – ADA: Brain’s need for glucose can be fulfilled by the body

April 24, 2019 – ADA Eating Patterns Differ from The Dietary Guidelines for Americans

April 19, 2019 –  New ADA Report: reducing has intake has most evidence for improving blood sugar

 
You can follow me on:
Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: 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.

Reference

Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
 
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Stanford Study Documents Abnormal Glucose Spikes in ‘Healthy’ People

This week Stanford University published a study which substantiates the huge glucose spikes that “healthy” people with normal blood sugar levels experience and that Dr. Joseph Kraft began documenting 45 years ago [2,3,4] — until just before his death in 2017 [5].  To those of us that are familiar with the research of Dr. Kraft, this is a bit like the 1969 Apollo 11 lunar astronauts ‘discovering’ the existence of craters and mountains on the moon that were documented by Galileo in 1609.

Kraft called these abnormal glucose spikes along with the corresponding abnormal spikes of insulin ‘occult diabetes‘ or ‘diabetes in situ‘ [4] and used the term ‘occult diabetes’ to describe it since ‘occult’ in this context means “not accompanied by readily discernible signs or symptoms“.  It is these ‘covert’ glucose spikes that Stanford university researchers reported this week.

The Stanford Study

Stanford researchers gave 57 healthy subjects without prior diagnosis of diabetes continuous glucose monitors (CGM) that recorded their blood sugar fluctuations in their normal environment for two weeks. There were 32 women, 25 men — ranging in age from 25 to 76, with an average age of 51 years [1].

Subject’s Blood Sugar Upon Screening

Upon screening for the study, 5 of the subjects were discovered to have met criteria for having type 2 diabetes, as defined as HbA1c ≥6.5%, fasting blood glucose ≥ 126 mg/dL (7.0 mmol/L), or 2-hour glucose during 75 gram Oral Glucose Tolerance Test (OGTT) ≥ 200 mg/dL (11.1 mmol/L); 14 subjects were found to meet the criteria for prediabetes, defined as HbA1c > 5.7% and < 6.5%, fasting blood glucose 100–125 mg/dL (5.5 mmol/l-6.9 mmol/L) , or 2-hour glucose during OGTT 140–199 mg/dL (7.8-11.0 mmol/L). The remaining 38 subjects had normal blood glucose defined as fasting and 2-hour OGTT plasma glucose and HbA1c below the diagnostic thresholds for prediabetes and diabetes. Average fasting glucose was 93 mg/dL (5.2 mmol/L), 2-hour glucose 125 mg/dL (6.9 mmol/L) and HbA1c 5.4%[1].

Huge Variations in Blood Sugar Response

Researchers found that there was huge inter-individual (between individuals) and intra-individual (in the same individual at different times) variation in blood sugar response which is exactly what a 2015 Israeli study that fitted 800 people with CGMs reported [6]. In light of only the glucose part of Kraft’s findings as well as the data from the Israeli study with a study population more than 10x the size, the Stanford findings are not ‘new’.

Using mathematical techniques including spectral clustering and dynamic time warping, researchers defined 3 clusters of glucose patterns which were said to capture 73% of the variation [1]. Based on the amount of variability in glucose levels in each cluster, researchers classified the 3 patterns as low, moderate and severe variability.

Some People had lots of Abnormal Glucose “Spikes”

The researchers found that each of the 3 patterns showed a progressive increase in both the severity and magnitude of the blood sugar fluctuations. As well, some subjects mainly stayed in the low variability range, whereas others were mostly in the moderate to severe variability range. These are basically rankings of blood sugar “spike” intensity [7].

Of significance, blood sugar in the individuals that were considered healthy fluctuated a lot more than what is normally picked up by standard ‘finger-prick’ methods of blood sugar testing and these fluctuations come in the form of “spikes’; which are rapid increases in the amount of glucose (sugar) in the blood, especially after eating specific foods — most commonly carbohydrate [7].

Dr. Michael Snyder, professor and chair of genetics at Stanford and senior author of the study said;

“There are lots of folks running around with their glucose levels spiking, and they don’t even know it. The covert spikes are a problem because high blood sugar levels, especially when prolonged can contribute to cardiovascular disease risk and a person’s tendencies to develop insulin resistance, which is a common precursor to diabetes.”

“We saw that some folks who think they’re healthy actually are misregulating glucose—sometimes at the same severity of people with diabetes—and they have no idea [7].”
~ Dr. Michael Snyder

Stanford researchers documented that abnormal glucose responses were more common than they previously thought [7], but these results come as no surprise to those of us familiar with Kraft’s research [2-5] and the findings of the 2015 study from Israel [6].

You can read more about the significance of these covert glucose and corresponding insulin spikes in this article titled When Normal Fasting Blood Glucose Results Aren’t Necessarily “Fine”.

Cornflakes For Breakfast?

The Stanford researchers conducted a sub-study in 30 subjects whose prior blood sugar tests indicated that they were “healthy” (i.e. not prediabetic or diabetic). They were fitted with continuous glucose monitors (CGMs) and alternated between 3 breakfasts; (1) a bowl of cornflakes with milk, (2) a peanut butter sandwich and (3) a protein bar.

Significantly, more than half of the “healthy” group had blood sugar spikes at the same high levels as those who were diagnosed as prediabetic or diabetic  [1,7].

Dr. Michael Snyder, professor and senior author of the study said;

“We saw that 80% of our participants spiked after eating a bowl of cornflakes and milk. Make of that what you will, but my own personal belief is it’s probably not such a great thing for everyone to be eating[7].”

Ordinary Blood Tests Available to Detect These Abnormal “Spikes”

Different people respond to carbohydrate based foods differently and even the same individual can respond to the same carbohydrate-based food differently — depending on part on the degree of processing it has undergone, or whether it is eaten alone or after eating protein-containing foods (see two articles on the Perils of Food Processing for more information).

As elaborated on in a previous article titled “Are You Pushing Your Pancreas Too Hard, abnormalities in insulin, including insulin resistance and/or hyperinsulinemia begin to occur as much as 20 years before a diagnosis of Type 2 Diabetes [8]; while blood sugar results are still normal and the results of this new Stanford study underscores the need to diagnose these abnormalities by capturing the blood glucose and insulin spikes well in advance of that!

The problem is, if we only monitor people’s fasting blood glucose and glycated hemoglobin (HbA1C) as a screening tool, we can miss that someone’s pancreas is overworking by constantly producing too much insulin.

Even if a standard 2 hour Oral Glucose Tolerance Test (OGTT) is run, if a person’s blood glucose results are normal at fasting and normal at 2 hours (such as was the case in the Stanford study!), we will miss the “spike” that occurs 30 minutes to 1 hour after the glucose is consumed in those with covert glucose spikes. The way to capture those “spikes” is to run a 2 hour Oral Glucose Tolerance Test with simultaneous glucose and insulin and do the two measurements at baseline (fasting), 30 minutes / 1 hour, and at 2 hours. When we detect these “spikes”, we can implement dietary changes to avoid further β-cell damage or β-cell death whose end-result is type 2 diabetes.

The Cost of Documenting These “Spikes” – penny wise and pound foolish

For less than $130 (cost in British Columbia, Canada), a physician can order a 2-hour OGTT with both glucose and insulin measured at (a) fasting, (b) 1 hour and (2) 2 hours which will capture abnormal glucose spikes at 1 hour, as well as the underlying hyperinsulinemia.

When there are clinical reasons to suspect that a person may be insulin resistant and/or hyperinsulinemic, a blood test that assesses simultaneous glucose and insulin response to a glucose challenge can provide sufficient motivation for individuals to implement dietary changes that can prevent progression to Type 2 Diabetes.

is such a test that costs <$130 to the public healthcare system not good value when the cost per person per year of having Type 2 Diabetes in Canada ranges from $1611 to $3427 ( more about that here)?

In British Columbia, the cost of a standard 2 hour Oral Glucose Tolerance Test is $11.82 before tax and $13.36 with HST.

Each additional glucose assessment is $3.48 before tax and $3.93 after tax.

Each insulin assessment costs $32.82 before tax and $37.09 after tax, so a 2 hour Oral Glucose Tolerance Test with additional glucose assessor at 1 hour and 3 insulin assessors at fasting, 1 hour and 2 hour costs as follows;

2 hour Oral Glucose Tolerance (fasting, 2 hours)           = $  13.36  with GST
additional glucose at 1 hour                                                       = $   3.93   with GST
3 insulin assessors at fasting, 1 hour, 2 hours                   = $111.27  with GST
TOTAL                                                                                                   = $128.56 with GST

The reason often given by physicians for NOT requisition the above tests is that it is “saving healthcare system dollars”, but in those with clear risk indicators, how is it wise to ignore what can’t be detected with standard screening tests?

More Info?

If you would like more information about determining how you respond to carbohydrate containing foods and whether you are at risk for prediabetes type 2 diabetes especially if your blood sugar values appear normal on standard screening tests, I can help.

You can learn more about my services under the Services tab or in the Shop.

If you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchf-rd/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 The Low Carb Healthy Fat 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. Hall H, Perelman D, Breschi A, et al, 2018, Glucotypes reveal new patterns of glucose dysregulation. PLOS Biology 16(7). https://doi.org/10.1371/journal.pbio.2005143
  2. Kraft JR, Glucose Insulin Tolerance. A routine Clinical Laboratory Tool Enhancing Diabetes Detection. In O.B. Hunter. Jr. (ed): Radio assay: Clinical Concepts. Skokie, IL. Professional Education Dept. G.D. Searie & Co., 1974. Pp 91-106.
  3. Kraft JR, The Glucose Tolerance Examination: An Obsolete Procedure. read at the Symposium on Radioimmunioassay in Diagnostic Medicine.” Annual Convention, American Medical Association, Chicago, IL. June 26, 1974
  4. Kraft JR, Detection of Diabetes Mellitus In Situ (Occult Diabetes), Laboratory Medicine, Volume 6, Issue 2, 1 February 1975, Pages 10–22, https://doi.org/10.1093/labmed/6.2.10
  5. Crofts C, Schofield G, Zinn C, Wheldon M, Kraft J., 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. Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094.
  7. Medical Press, July 24, 2018, Diabetic-level glucose spikes seen in healthy people, study finds, https://medicalxpress.com/news/2018-07-diabetic-level-glucose-spikes-healthy-people
  8. 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.

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