Beyond “Eat to Your Meter” For Better Blood Sugar Control

“Eat to Your Meter” is an established method used by those with type 2 diabetes or pre-diabetes to find out how different foods affect their blood sugar.  In its common application, “eat to your meter” requires taking one’s blood sugar before a meal, and then two hours after beginning to eat the meal. Some methods also test blood sugar again 4 hours after the meal. By comparing the blood sugar result two hours after a meal to what it was before beginning to eat, we can determine how much blood sugar rose as a result of what we ate. Likewise, if we also test blood sugar again at 4 hours, we can see whether our blood sugar came back down to what it was before the meal, and if not, now much it was still elevated by. In it’s usual application, eating to our meter enables us to determine how much a particular meal affects our blood sugar.

If for example, our blood sugar was 5.0 mmol/L (90 mg/dl) before we ate and 11.0 mmol/L (198 mg/dl) afterwards, we know it went up by 6.0 mmol/L (108 mg/dl) due to what we ate.

Let’s say another time our starting blood sugar is 7.0 mmol/L (126 mg/dl) before we eat and then also goes up to 11.0 mmol/L (198 mg/dl) afterwards, we can determine that it only went up by 4.0 mmol/L (72 mg/dl) as a result of what we ate.

When we compare these two meals, it can be seen that even though both times our blood sugar went up to 11.0 mmol/L (198 mg/dl) the second meal caused a smaller rise at 2 hours. That is, blood sugar started off higher, meaning it didn’t rise as much.

“Eat to Your Meter” is a simple way for people to know how much a specific meal affects their blood sugar, but the same method can be used for individualizing people’s diet!

If you’ve been following me for a while, then you know that the order we eat components of our meal (carbohydrate-based food, protein foods and low carb vegetables) has a significant effect on how much our blood sugar will rise when eating a meal. So will how much the carbohydrate-containing food is ground (an apple compared to apple sauce, for example). Something as simple as when in the meal we eat the carbohydrate-containing can have a significant effect on blood sugar afterwards! You can read more about both of these in a previous the two-part article titled The Perils of Food Processing.

Also as briefly mentioned in an earlier article, how our body handles carbohydrate-based foods eaten in the morning is significantly different than how it is able to handle carbohydrate-based foods in the afternoon or evening [1-3]. This means that our blood sugar response to carbohydrate-containing food (not only grains but including fruit, milk or below-ground vegetables) eaten at breakfast in the morning will be different than if eaten later in the day and knowing this in theory and seeing it in real life when we “eat to our meter” can be very helpful in planning whether “breakfast for dinner” is a good idea!

Eating to Your Meter in Pre-Diabetes

A glucometer (blood sugar meter) can also be a very helpful tool for those who have been told they are “pre-diabetic”. Someone who is pre-diabetic might have higher than normal fasting blood sugar (called Dawn Phenomena) and “eating to your meter” will enable them to see which foods eaten at supper results in a morning spike, and which don’t.

Beyond the Usual – when blood sugar tests are “normal”

“Eating to your meter” also has a helpful application for those who have been told their blood sugar results are “normal”.

As I covered in detail in this previous article titled “When Normal Fasting Blood Glucose Results Aren’t Necessarily “Fine”, fasting a blood glucose test coming back “normal” doesn’t necessarily mean that blood sugar response is optimal and the reason is simple. We don’t know what happens to blood sugar between 30 minutes and 60 minutes after they eat carbohydrate-containing food.  

As discussed in the above linked article, a standard 2-hour Oral Glucose Tolerance Test (OGTT) will “miss” spikes at 30- or 60 minutes because it is not being tested for. Not testing for it does not mean there isn’t a possible reason for concern, only that we don’t know. Abnormal spikes at 30 or 60 minutes after eating a standardized carbohydrate (glucose) load indicates increased risk of developing type 2 diabetes, even when fasting blood sugar and 2 hours after a meal (called post-prandial) blood sugar is completely normal [4,5].  A simulation can be done using an established glucose load and an ordinary glucometer which enables one to see whether there are spikes occurring at 30- or 60 minutes. This can go a long way to helping people understand their risk, even when standard blood tests are still normal.

NOTE: Such a simulation is NOT a substitute for an Oral Glucose Tolerance Test, with extra glucose assessors at 30 minutes or 1 hour. A simulation can provide some indication of whether additional lab testing would be helpful.

If after a standard glucose load, people experience a blood sugar spike higher than 7.0 mmol/L (126 mg/ml) at 30 minutes or 6.5 mmol/L (117 mg/dl) at 60 minutes, or a delayed peak later than 30 minutes they can know based on current research [5] that they already have an early indication of insulin resistance and hyperinsulinemia (insulin levels being too high).  As well, current literature [4] indicates that a 1- hour post prandial blood sugar spike > 8.6 mmol/L (155 mg/dl) is a better predictor of risk of developing diabetes, cardiovascular disease or of dying than a 2 hour post prandial level of > 7.8 mmol/L (141 mg/dl).

Using an ordinary glucometer and an established glucose load can enable people to know whether their blood sugar level at 30- or 60 minutes may indicate a possible concern, enabling them to make changes in how they eat long before their blood sugar is flagged as abnormal.

Final thoughts…

“Eat to Your Meter” in it’s simplest application can be a very helpful method for those diagnosed with pre-diabetes or type 2 diabetes to determine which foods or meals spike their blood sugar. As significantly, use of a glucometer with a standard glucose load can enable those with totally normal lab results to know if they have early indications of being at risk.

More Info?

If you would like more information about how I can help you to lower your risk of developing type 2 diabetes or to help you lower your blood sugar readings, please have a look under the Services tab or in the Shop for more information on the packages I offer. If you have service-related 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/lchfRD/
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Copyright ©2020 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

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

References

  1. Bo S, Fadda M, Castiglione A, et al. Is the timing of caloric intake associated with variation in diet-induced thermogenesis and in the metabolic
    pattern? A randomized cross-over study. Int J Obes 2015;39:1689—1695
  2. Jakubowicz D, BarneaM, Wainstein J, Froy O. High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity (Silver Spring) 2013; 21:2504—2512
  3. Morgan LM, Shi JW, Hampton SM, Frost G. Effect of meal timing and glycaemic index on glucose control and insulin secretion in healthy volunteers. Br J Nutr 2012;108:1286—1291
  4. Manan PareekDeepak L. Bhatt, et al, Enhanced Predictive Capability of a 1-Hour Oral Glucose Tolerance Test: A Prospective Population-Based Cohort Study,
  5. Hulman A, Vistisen D, Glumer C et al, Glucose patterns during an oral glucose tolerance test and associations with future diabetes, cardiovascular disease and all-cause mortality rate, Diabetologia; 2018;61(1), pp 101-107, https://doi.org/10.1007/s00125-017-4468-z

A Dietitian’s Journey – update of lab tests and metabolic markers

Recently, my endocrinologist requisitioned a fasted c-peptide and a fasting blood glucose (FBG) lab test which enabled comparison with results done fasted and at the same time of day 4-1/2 years ago. At that point in time, I had been type 2 diabetic for 4 years. This article is an update.

In August 2015, my FBG was 9.7 mmol/L (175 mg/dl) and my c-peptide was 569 nmol/L (1.72 ng/mol).

Using Oxford’s HOMA2-IR calculator, it is easy to see that I was quite as I was well over the 1.00 to be insulin resistant (IR=1.56) and my estimated steady state beta cell function (%B) was only 32.7%.

With my endocrinologist’s encouragement, knowledge and support, I began to implement a low carb dietary approach. Unfortunately, in November of that year, a family matter ended up derailing things, and while I could have (should have!) restarted a therapeutic low carb in January 2016, when I could, I didn’t.  As written about in an early entry to this journal, I was in classic denial as to just how metabolically unwell I was.

It wasn’t until March 5, 2017 when my blood pressure had reached a hypertensive emergency that I changed. At that point, I was obese, had uncontrolled type 2 diabetes and severe hypertension. You can read about this in the first entry to this personal account. My life literally depended on me improving my off-the-chart metabolic markers, and for me sticking with my endocrinologist’s recommendations was essential.

If you’ve read though my “journey”, then you already know how two years later, I had lost over 50 pounds, lost 12 inches off my waist, and brought my HbA1C down to the high end of the normal range, but that I still had moderately high blood pressure. Over the past year, I adopted changes to my daily routine based on the research of circadian biologist, Dr. Sachidananda Panda of Salk Institute’s research, as it had evidence for lowering cortisol and blood pressure. It did. After 3 months, my GP halved my high blood pressure medication and it’s been 3 months since I have been off them completely, with absolutely normal blood pressure. My 3-month glycated hemoglobin (HbA1C) results have remained just about 6.0% for the last year, which is good (i.e. normal for a non-diabetic), but not as good as I would like it. I still have work to do.

As mentioned above, recently my endocrinologist re-ran the above tests and in December 2019, my FBG was 5.2 mmol/L (94 mg/dl) which is normal for someone who is non-diabetic and my c-peptide was was 531 nmol/L  (1.6 ng/mol).

Using Oxford’s HOMA2-IR calculator again, here is the update:

I was almost completely below the threshold of 1.00 definition of being insulin resistant (IR=1.19) and my estimated % beta cell function (%B) had gone up to over 98%. I was encouraged by this update.

Comparing my August 2015 and 2019 update results, my muslin resistance significantly improved, and my steady state beta-cell function did too (from 33% to 98%), while FBG fell to well below the normal cutoff of 5.5 mmol/L (99 mg/dl). This seems to indicate that I regained some beta-cell capacity.  In 2015,  when my FBG was 9.7 mmol/L (175 mg/dl), my pancreas “wanted” to do more, but couldn’t. What this update shows is that at the end of 2019, my pancreas was able to do what was required.

It is reasonable to assume, that in another year or so that when I update these labs again (given I continue to minimize carbs) that my FBG is going to be lower, which could actually make my steady-state beta-cell function lower (yes, lower) because with the improved insulin sensitivity, less insulin will be needed. My pancreas will have to work less hard, leaving more capacity for a second phase  insulin response (which clearly I don’t have yet, from my recent half-a-donut story, available here).

Theoretically, if I wanted to assess my body’s actual insulin response to a carbohydrate load, I could have a 3-hour Kraft Assay performed, which would measure my blood sugar and insulin response at fasting, and every 30 minutes for 3 hours. You can read more about that here. This test is quite costly and I would need to justify the need in order for my endocrinologist to requisition it. As well, since I normally eat low carb in order to manage my blood sugar levels, I likely have what is called “physiological insulin resistance”, which is where the body spares glucose by reducing glucose uptake. This is very different than the “pathological insulin resistance” I referred to above, which is due to the body ignoring insulin’s signals to uptake glucose due to hyperinsulinemia (chronic high levels of circulating insulin) which accompanies uncontrolled type 2 diabetes and pre-diabetes. I have several previous articles about this topic that you can read by searching for “hyperinsulinemia” in the search bar in the lower left hand corner of this web page. In any case, if I wanted to have a 3-hour Kraft Assay to assess my first and second stage insulin response (and by proxy, beta-cell function) I would need to eat between 100 and 130 g of carbohydrate per day for a week or 10 days, in order to lower physiological insulin resistance prior to the Kraft Assay.  At this point in time, this is not something I feel is necessary, but maybe in a year or more, when my FBG and HbA1C comes down even more, it may be interesting to do.

While I have been in partial remission of type 2 diabetes for about 6 months (explained here), my donut adventure clearly indicates that I have not reversed (“cured”) it.

While I many not ever recover my pre-diabetic beta-cell function, being in remission is a very good thing! My symptoms of the disease are gone, lab tests are in the normal (non-diabetic range), and I have lowered my cardiovascular and metabolic risks. Remission, in my option, is the next best thing to reversal.

Some final thoughts…

Critics of a low carb / very low carb (ketogenic) diet say that it is ”not sustainable” but for me (and many others too), eating real, whole food is very sustainable! For me, my life and my health depend on me remaining in remission, and that is all the motivation I need.

More Info?

If you would like more information about the services I offer, please have a look under the Services tab or in the Shop for more information. If you have service-related 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/lchfRD/
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Copyright ©2020 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

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

Two Clinical Reactions: seeing the possibilities or being a pessimist

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

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

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


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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
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.

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Achieving the “Impossible”: from injecting insulin to achieving target HbA1C

A few weeks after requesting that her endocrinologist take her off insulin so that she could begin a low carbohydrate diet with his and her GP’s oversight (article here), this young woman was told she needed to get her HbA1C to ≤7.0%, which is the therapeutic target for adults with type 2 diabetes. She was told that it was unrealistic for her to think that she could do so following a low carbohydrate diet, and that she should go back on insulin.  She replied that she wanted to continue to eat a low carbohydrate diet for a total of 12 weeks, and her endocrinologist replied that more than likely he would need to put her back on insulin then, because it was not realistic for her to accomplish those goals using diet, even with Metformin support.

*Metformin doesn’t lower blood sugar, but helps the body become more insulin sensitive and to keep it from manufacturing glucose from stored fat or protein which is what underlies high morning blood sugar.

Well, she achieved the “impossible”!

She had her blood tests yesterday and when she checked her results on-line last night she could not believe it!! Her results were below the 7.0% therapeutic target. . . and this was (1) despite me starting her on a moderate low carbohydrate diet for the first several weeks and only gradually lowering carbohydrate content in order to meet clinical outcomes*, and (2) despite her having two weeks of weddings in mid-July where she ate a little ‘off-track’, which caused her blood sugar levels to rise).

In spite of these, she did it!!

Note: weight loss was only ~5% of her original weight, so would not account for her significant improvement in HbA1C results.

Here are her results:

from injecting insulin to HbA1c within target

*I was asked on social media after the previous update on her progress why I didn’t start this young woman on a very low carbohydrate, ketogenic diet from the outset. This is what I replied; “Diabetes Canada has not (yet?) deemed a LC or very LC diet as safe and effective medical nutrition therapy. I start people at 130 g of carbs, then reduce carbs as necessary to achieve clinical outcomes as a prudent approach. Hence why I conclude the article w/ hope of future policy change.

After this young woman picked up her blood test results last night, she sent me this short email which I have her permission to share here;

“JOY!!!

Such overwhelming feelings right now. We will talk tomorrow but I took my blood test today and have attached the results! Please tell me I am seeing the number I am seeing because it is hard to believe! Also, for the graph this week, I had to change the minimum limit from 5 to 4 to account for my TWO readings of 4.7!! “

As relayed in the second article about her progress (posted here), in 10 weeks this young woman went from a fasting blood glucose of 16.8 mmol/L (303 mg/dl) to 4.7 mmol/L (85 mg/dl). . . and this past week she had her second fasting blood glucose reading of 4.7 mmol/L! Twice in one week, she achieved normal fasting blood glucose numbers; the first time since being diagnosed as having type 2 diabetes in 2017.

As she said in the previous article, she is “invested” in her health and that investment translated to her own determination and hard work to follow her Meal Plan, to speak to her endocrinologist about adding an extra dose of Metformin at bed-time, and to determine when was the best timing to take her before bedtime dose and her early morning dose, in order to prevent her blood sugar from spiking in the morning due to Dawn Phenomena. Yes, I helped but she did the work! 

I asked her to write in her own words what it was like to get her blood test results last night, and this is what she wrote:

“I feel so happy and proud of myself. Patience and consistency has paid off.

Typically, if I were doing this on my own or changing how I was eating, I never stuck with it long enough to see changes.  The number on the scale or one bad meal would take me further back than when I started.  However, keeping track of my blood sugars and being accountable to someone have kept me going, and I feel like nothing can hold me back now.

I am so motivated to keep going and giving myself time to progress. I know I can do this!”

I am so proud of her hard work and accomplishments!

I look forward a day when Diabetes Canada updates its Clinical Practice Guidelines to enable clinicians to recommend a low carb or ketogenic diet as a therapeutic option for those with diabetes ⁠— just like the American Diabetes Association (ADA) did last year.

For more information about the clinical changes at the ADA, you can read any one of several articles from April 2019 that are posted under the Science Made Simple tab above, including this one.

UPDATE (Sept 6, 2019): During our weekly call, this young woman told me that she is meeting her endocrinologist this week and is looking forward to his reaction to her accomplishments, as well as that of his diabetes nurses.  She said during her last visit 8 weeks ago (4 weeks after coming off insulin and beginning a low carbohydrate diet) her doctor told her that she is ‘not eating rice and needs to be eating that’ and reminded her that the ‘insulin will cover that’.  The diabetes nurse also told her ‘she should be eating 60 g of carbohydrate per meal plus snacks’ (which is still the recommendations for those with diabetes in Canada). She assured them that she is carefully monitoring her blood sugar multiple times per day and that they are coming down, and she feels great.

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
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.

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US Assn. of Diabetes Educators Taught Person-Centered Low Carb Plans

This past weekend, thousands of American Certified Diabetes Educators (CDE) gathered at the American Association of Diabetes Educators (AADEs) annual conference in Houston, Texas. Objectives of the conference were for CDEs to learn how to implement novel and innovative ways to advance chronic disease prevention and management, and one of those novel ways was through the use of a Low Carbohydrate Diet.

It is very exciting that CDEs are now learning how to implement the American Diabetes Association’s (ADA) new 2019 Standards of Medical Care in Diabetes that was released this past December and which includes use of a low carbohydrate diet (you can read more about that here).

This conference provided education to enable CDEs to apply the content outlined in the ADA’s April 18, 2019 Consensus Report, which added the use of a very low carbohydrate (ketogenic) diet of 20-50 grams of carbs to the choice of meal patterns to manage both type 1 and type 2 diabetes. You can read more about the Consensus Report here.

As mentioned in the previous post, there were two Educational Sessions this past Saturday, August 11, 2019 about the use of a Low Carbohydrate Diet to manage and treat diabetes. The first session was titled Low Carbohydrate Diets; Fad or Evidence Based Course of Action and was given by Dr. Jim Painter, PhD, RD and Professor Emeritus from Eastern Illinois University, in Charleston, Illinois and this article covers that presentation in detail, including each of the slides and references used.

The second session was titled Person-Centered Implementation of Low Carbohydrate Eating Plans and was given as a joint-session by Dawn Noe, RDN, CDE and Diana Isaacs, PharmaD, CDE, both from Cleveland Clinic Diabetes Center. This second session is the subject of this article.

Copies of the slides and speaking notes for this presentation were sent to me by Dawn Noe, RDN, CDE. Many thanks to her and her colleague Diana Isaacs, PharmaD, CDE for sharing them with us!

The first part of the presentation was given by Registered Dietitian Nutritionist Dawn Noe and is covered in Part A and the second part was given by Doctor of Pharmacy Diana Isaacs and is covered in Part B.

Note: In a few places below, I have added my own clarifications that are clearly marked as *Note (bolded red asterisk *).

Person-Centered Implementation of Low Carbohydrate Eating Plans

Slide 1

The first slide was a disclosure of financial relation / financial conflict of interest, as well as a statement of non-endorsement of products.

Slide 2 – The second slide was a photo of each of the presenters, along with their credentials.

 

Part A: Nutritional Approach – Dawn Noe, RD, CDE

Slide 3 – list of learning objectives.

 

 


Key Points from the American Diabetes Association’s Consensus Report

Slide 4 – Summarized some key points from the American Diabetes Association’s (ADA) Consensus Report

 

(Evert AB et al. Diabetes Care 2019; 43: 731-754.)

Speaking Point Summary
  • There is no ‘ideal percentage of carbs’ shown in the literature, but despite this
    many people with diabetes are told to eat ~60 grams of carbs at each meal, assuming 3 meals per day.
  • These numbers are essentially calculated to be 50% of the calories coming from carbohydrate on a 1500 calorie meal plan.
  • The 130 grams of carb per day recommended for adults without diabetes (which is determined in part by the brain’s requirement for glucose) can be fulfilled by the body’s metabolic processes with include glycogenolysis, gluconeogenesis, and/or ketogensis in the setting of very low dietary carbohydrate intake.

Note: This previous article outlines the ADA’s updated position that the brain’s need for glucose can be fulfilled by the body.


Slide 5 – The Evidence for Low Carb in Type 2 Diabetes and Type 1 Diabetes

Speaking Point Summary
  • Low carb and very low carb eating patterns are among the most studied eating patterns for type 2 diabetes (T2D).
  • Long-term outcomes of Virta Health’s  2-year data published in May 2019 were not included in the new ADA Consensus Report.
  • For those with type 1 diabetes (T1D), no trials met the inclusion criteria for the ADA’s Consensus Report, however one small study limited carbs to 47 grams per day, and another limited carbs to 75 grams per day with positive results relating less glycemic variability, and lower HbA1C respectively.
  • The ADA Consensus Report states that this evidence suggests that a very low carb eating pattern may have potential benefits for adults with type 1 diabetes, but clinical trials of sufficient size and duration are needed to confirm prior findings.
From 2019 Standards of Care
  • Providers should maintain consistent medical oversight and recognize that certain groups are not appropriate for low-carbohydrate eating plans, including pregnant or lactating women, children, people who have renal disease or disordered eating behavior.
  • Low carb and very low carb eating plans should be used with caution for those taking SGLT2 inhibitors due to potential risk of ketoacidosis.
  • There is inadequate research about dietary patterns for type 1 diabetes to support one eating plan over another at this time.

Slide 6 – Different Ways to Define “Low Carb”

Speaking Points Summary

In the ADA’s Consensus Report, Nutrition Therapy for Adults included 2 meta-analysis where “low carb” was defined differently (≤ 45% calories, < 40% of calories) and 1 meta analysis where “ketogenic” was defined as 5-10% calories / ~20-50 grams carbohydrate per day.

In general, the presenters define “low carb” as being ~50 – 130 grams carbs per day, since < 50 grams of carbs could be a ketogenic for some people.

Feinman et al defined three categories of reduced-carbohydrate diets:
(a) very low carbohydrate ketogenic: carbs limited to 20—50 g per day or < 10% of total energy intake.

(b) low carbohydrate: carbs limited to < 130 g per day or < 26% of total energy intake.

(c) moderate carbohydrate: carbs limited to 130—225 g per day or 26—45% of total energy intake.

(Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13.)


Slide 7 – Teaching Low Carb

Speaking Points Summary
  • Food Lists: customize to  each patient / client. Some people prefer to stop buying / eating certain foods which automatically limits their carb choices, e.g. they don’t want to buy bread or keep it in the house
  • Carb Counting: could vary and be personalized depending on the client / patient’s post-prandial (after meal) glucose responses, e.g. up to ___ carbs per day versus set number of carbs at each meal
  • Food Label Reading: focusing on carbs and/or sugars in the ingredient list
  • Track Macros: use of an app such as MyFitnessPal or CarbManager, can be individualized to be gluten free, Mediterranean, etc.

Slide 8 – Teaching Low Carb (cont’d) – shows a handout used in practice to show lower carb options for traditional pasta.


Slide 9– Teaching Low Carb – making it easy

e.g. using leftover vegetables from dinner for breakfast, sample meal plans with carb amounts, resources with recipes and pictures, no—cook put together meal ideas.


Slide 10 – Clinical Pearls for Providing Support

  • real food when possible
  • option when convenience is needed
  • ways to make carb foods less carb-based; e.g. substituting plain yogurt with vanilla for sweetened vanilla yogurt

Slide 11 -Low Carb Empowered Eater

This slide gave an example of a person with diabetes who started eating lower carb on his own by using a Continuous Glucose Monitor (CGM).

i.e. eats the topping off a pizza to minimize glucose spike and is empowered to do so because he can see the results in real-time.


Slide 12 -Virta Health Type 2 Diabetes Trial was not included in the ADA’s Consensus Report because subjects self-selected which group they would be in, i.e. not randomized.

However, the 1-year data showed HbA1C declined 1.3% concurrently with elimination of non-metformin medications in the continuous care intervention group which is notable.

The 2-year data was published in 2019, just prior to the ADA Consensus Report but was not included.


Slide 13 – slide from Virta Health

Data from people who completed 2 years of the Virta Health clinical trial (intervention group versus usual care group)

This slide represents the actual percentage point reduction in prescription (Rx) costs, HbA1C and Body Weight of intervention group compared to the usual care group.


Slide 14 – What people think “keto” is, versus what keto actually is.

The idea here is that people think that all one eats on a ketogenic diet is meat, eggs, butter and lots of bacon, but there is a variety of foods one can eat, including vegetables, nuts, avocado (amongst other things).

 

 

 


Slide 15Well Formulated Ketogenic Meal Plans

A well formulated, ketogenic meal plans can be a great way for people to learn to eat whole, less-processed, and plant foods such as vegetables, nuts and olives and to learn about carbohydrates; a win-win for people with diabetes.


Slide 16 – Ketogenic Meal Plans

  • 20-50 grams carbs per day: 5-10% carbohydrate, 70-85% fat*, 10-25% protein*

[*Note: this is not the only way to define a “ketogenic diet”, but the one the presenters use. Some clinicians use a higher protein/lower fat approach. What makes a diet ketogenic is the number of grams of carbs being ; 50 g per day or less, for men / 35 g of carbs per day or less, for women.]

  • adequate electrolyte supplementation: sodium; 2,000-5,000 mg per day, plus potassium, magnesium
  • can include sample plans, food lists, recipes, pictures, carb counting, tracking macros

Slide 17 – Ketogenic Meal Plans (cont’d)

Keto meal plans can be customized and individualized to the client’s / patient’s food preferences.

(e.g. gluten free, Mediterranean, etc.)


Slide 18 – Ketogenic Meal Plans – keeping it simple.

Many people benefit from basic simple food lists (eg. a “vegetable” list with types of vegetables, a place for them to list their 5 favourite types, along with some pictures).

These food lists can also be used to teach low carb eating.


Slide 19 – Examples of how to include options such as dessert, alcohol, etc. in very low carb eating plans.

 

 


Slide 20 – Recommendations:

  • supplement with multivitamin
  • drink 64 oz / 2 liters water/day, add potassium / magnesium
  • use electrolyte drinks or bone broth to minimize symptoms of “keto flu”
  • the first week: fat / protein to satiety to address hunger
  • after the first week: either eat fat until satisfied and/or limit fat and total calories for weight management*

*Note: Some clinicians encourage people to eat lean protein until satiated, then add some fat for taste. Many clinicians do not limit total calories, but focus on increasing satiety instead, as the end result will be a decrease in overall calories (as a result rather than as an input).


Slide 21 – What is an Individualized Plan (slide credit: Shamera Robinson, RDN)

The following components should all be
considered when assessing, teaching and coaching with any nutrition intervention;

  • energy deficit*
  • dietary preferences
  • health literacy / numeracy
  • resources
  • food availability
  • cooking skills
  • disordered eating
  • sustainability

*Note: Many clinicians do not create an energy deficit (i.e. do not limit total calories) but focus on increasing satiety. Increasing satiety ends up resulting in an energy deficit as a result, which some clinicians prefer over restricting calories as an input.


Slide 22  – Transitioning to a Low Carb (from a Keto) Meal Plan

  • Some people will not want to do very low carb / keto diet forever and/or may benefit from taking planned breaks
  • this requires a period of transitioning from a ketogenic meal plan to other meal plan (e.g. low carb), depending on client / patient’s wishes/needs
  • transition should be customized to the individual
  • can be a mixture of carbohydrate food (e.g. 1/2 baked potato*, 1/2 pita bread*) along with low-carb alternatives (e.g. cauliflower “rice”, zucchini “zoodles”)

* Note: in this type of case, some clinicians would recommend low Glycemic Index / high fiber carbohydrates such as winter squash or peas, instead of potato or bread.


Slide 23  – Clinical Pearls for Providing Support

  • aim for real food when possible
  • convenience options could be protein shakes, pre-portioned cheese or nuts, ready-made mashed cauliflower, ready-made low-carb pizza or low carb wraps
  • emphasize protein, fiber, fat for satiety, electrolyte needs
  • keto dessert ideas
  • how to handle vacations, emotional / stress eating
  • consider incorporating “mindful eating” / “intuitive eating”; rating hunger levels to teach clients to listen to their bodies, eat when they are hungry and stop when full*, etc.

*Note: this approach may not be suitable for those with very high insulin levels that drive food cravings, or addiction to specific foods.


Part B: Pharmacology Approach – Diana Isaacs, PharmaD, CDE

 

Slide 24  – Medication Adjustment for Low Carb Eating

 


Slide 25 – ADA Consensus Report nutrition guidelines

  • adopting a very low carb eating plan can cause increased production of urine (diuresis) and a rapid reduction in blood glucose
  • consultation with a knowledgeable practitioner at the onset is necessary to prevent dehydration, reduce injected insulin and blood sugar lowering medications in order to prevent hypoglycemia (low blood sugar)

(Evert AB et al. Diabetes Care 2019; 43: 731-754.)


Slide 26 – Medication Adjustments for Type 2 Diabetes (T2D)

The first speaking point was to confirm that the patient is truly a type 2 diabetic

i.e. not LADA (Latent Autoimmune Diabetes of Adulthood) which is a form of type 1 diabetes that develops later into adulthood

Medication Adjustments for Type 2 Diabetes (T2D)
  • limit medications that cause hypoglycemia, such as insulin, sulfonylureas, meglitinides (more on that below)
  • other medication likely not needed / not preferred: alpha glucosidase inhibitors (prevent carb digestion), thiazolidinediones (TzD), also known as glitazones (more on that below)

(Clinical Guidelines for Therapeutic Carbohydrate Restriction, August 1, 2019,  Standard of Care Clinical Guidelines, www.lowcarbusa.org/clinical-guidelines)


Slide 27 – Medications to Stop on a Very Low Carbohydrate Diet

  • sulfonylurea, increase insulin release e.g. GlyburideⓇ
  • meglitinide (also called glinides), e.g. PrandinⓇ
  • bolus (meal time) insulin
  • combo insulins: 70/30, convert to basal only
  • alpha glucosidase inhibitors (acarbose), prevent carbohydrate absorption, e.g. GlucobayⓇ

(Clinical Guidelines for Therapeutic Carbohydrate Restriction, August 1, 2019,  Standard of Care Clinical Guidelines, www.lowcarbusa.org/clinical-guidelines), Murdoch C et al, British Journal of General Practice, July 2019)


Slide 28 – Medications to Use Caution on a Very Low Carbohydrate Diet

  • Sodium-glucose co-transporter protein 2 inhibitors SGLT-2 inhibitors (also called gliflozins), e.g. InvokanaⓇ, JardianceⓇ
  • basal insulin (initial 30-50% decrease)
  • insulin U500: cut dose in half
  • thiazolidinediones (TzD), also known as glitazones (risk of weight gain)

(Clinical Guidelines for Therapeutic Carbohydrate Restriction, August 1, 2019,  Standard of Care Clinical Guidelines, www.lowcarbusa.org/clinical-guidelines), Murdoch C et al, British Journal of General Practice, July 2019)


Slide 29 – Medications that are Okay to Use on a Very Low Carbohydrate Diet

  • MetforminⓇ
  • Glucagon-like peptide 1 inhibitors (GLP-1 agonists) e.g. VictozaⓇ, SaxendaⓇ
  • Dipeptidyl peptidase 4 inhibitors (DPP-4 inhibitors) e.g. JanuviaⓇ

(Clinical Guidelines for Therapeutic Carbohydrate Restriction, August 1, 2019,  Standard of Care Clinical Guidelines, www.lowcarbusa.org/clinical-guidelines, Murdoch C et al, British Journal of General Practice, July 2019)


Slide 30 – Medications Adjustments for Type 1 Diabetes on a Low Carbohydrate Diet

  • bolus insulin: may need to intensify carb ratio, ? bolus for protein
  • monitor ketones
  • avoid sodium-glucose co-transporter protein 2 inhibitors (SGLT-2 inhibitors), also called gliflozins, e.g. InvokanaⓇ, JardianceⓇ
  • caution with hybrid closed loop pumps
  • close follow-up required

(Eisworth M et al, Endocrinol Diabetes Metab Case Rep 2018, 2018:18-0002, Krebs JD et al, Asia Pacific Journal of Clinical Nutrt 2016 25:78-84, Nielsen JV et al Upsala Journal of Medical Sciences 2005; 110 267-273)


Slide 31 – Blood Pressure Medications

  • important to keep in mind the initial diuretic effect of a low carb or very low carb diet
  • consider cutting dosage in half or stopping diuretic (e.g. HCTZ or chlorthalidone)
  • monitor blood pressure

(Hussain TA et al, Nutrition 28 (2012) 1016-1021, Evert AB et al. Diabetes Care 2019; 43: 731-754.)


Slide 32 – Other Concerns

  • drink > 2 liters (64 oz /) water/day
  • to avoid muscle cramps, supplement magnesium 200-400 mg/day
  • watch for deficiency in vitamin K, sodium, chloride, vitamin B12, folate, calcium, vitamin D

(Clinical Guidelines for Therapeutic Carbohydrate Restriction, August 1, 2019,  Standard of Care Clinical Guidelines, www.lowcarbusa.org/clinical-guidelines)


Note: Slide 33 and Slide 34 were part of a case study of a 52 year old woman with T2D along with several co-morbid conditions, and on multiple medications who planned to start a ketogenic diet the follow day. The case study reviewed the medications that should be stopped or the dosage changed, and what her new medication regimen would look like. They are not included here.


Many thanks once again to Dawn Noe, RDN, CDE and her colleague Diana Isaacs, PharmaD, CDE for sharing their slides and speaking points with us.

More Info?

If you have been diagnosed with pre-diabetic or as having type 2 diabetes and would like to adopt a low carb diet, I can help.

Please note that I am not a CDE and as a result do not provide clinical services to those with type 1 diabetes, or to those with type 2 diabetes who are currently on insulin or insulin-analogue.

For those with T2D who have only been recently prescribed insulin, I have experience working with people’s endocrinologists and GPs as they seek to transition over to a low carbohydrate / ketogenic diet to manage and treat their diabetes.

You can learn more about my services 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.
To your good health!

 

Joy

 

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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.

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US Association of Diabetes Educators Teaches Evidence for Low Carb Diet

This weekend, thousands of American Certified Diabetes Educators (CDE) gathered at the American Association of Diabetes Educators (AADEs) annual conference in Houston, Texas.

AADE 2019 Learning Objectives – Page 3 of Final Program

One of the Learning Objectives of the conference was for CDEs to learn how to implement novel and innovative ways to advance chronic disease prevention and management, and one of those novel ways was through the use of a Low Carbohydrate Diet.

CDEs are healthcare professionals from a variety of backgrounds who are specialized in diabetes prevention and management and include Registered Dietitians,  Registered Nurses, Pharmacists, Physician Assistants and Nurse Practitioners. 

This is very exciting news indeed!

It means that CDEs are now learning how to implement the American Diabetes Association’s (ADA) new 2019 Standards of Medical Care in Diabetes that was released this past December, and which includes use of a low carbohydrate diet (you can read more about that here).

This conference provided education to enable CDEs to apply the content of the ADA’s April 18, 2019 Consensus Report which added the use of a very low carbohydrate (ketogenic) diet of 20-50 grams of carbs to the choice of meal patterns to manage both type 1 and type 2 diabetes. You can read more about the Consensus Report here.

Two Educational Sessions on Use of a Low Carbohydrate Diet

AADE 2019 Final Program – page 13 – two low carb educational sessions, Saturday August 10 2019

Saturday, August 11, 2019 there were two Educational Sessions at the AADE 2019 Annual Conference related to therapeutic use of a low carbohydrate diet.

The first session was titled Low Carbohydrate Diets; Fad or Evidence Based Course of Action and was given by Dr. Jim Painter, PhD, RD and Professor Emeritus from Eastern Illinois University, in Charleston, Illinois.

The second session was titled Person-Centered Implementation of Low Carbohydrate Eating Plans and was given by Diana Isaacs, PharmaD, CDE and Dawn Noe, RD, CDE both from Cleveland Clinic Diabetes Center. Link to this presentation, including the slides and speaking notes is at the bottom or this article.


This post is a summary of Dr. Jim Painter’s educational session at the AADE’s 2019 Annual Conference titled Low Carbohydrate Diets; Fad or Evidence Based Course of Action.

Note: Photos of the slides were posted on Twitter® on August 10, 2019 by Jake Kushner, MD (@JakeKushnerMD). 

 


Low Carbohydrate Diets: Fad or Evidence Based Course of Action

Slide 1

Dr. Painter’s first slide demonstrates using National Health and Nutrition Examination Survey (NHANES) data (adapted from Ford 2015 Am J Clin Nutr) how carbohydrate content of the US diet increased dramatically after 1980 and continued high, while protein content (and fat content, not visible in this slide) remained stable.

The increase in calories during the obesity epidemic was due largely to carbohydrate intake.

Slide 2

Dr. Painter’s second slide pointed out that not only did carbohydrate consumption increase (dotted graph), the percentage of carbohydrate from fiber decreased (bar graph).

The point Dr. Painter made is that “carbohydrates that lack fiber are high glycemic index” carbs — and these highly refined carbs result in a higher increase in blood sugar than carbohydrates that contain fiber.

Slide 3

Dr. Painter then defined what a “low carbohydrate diet” is according to the American Diabetes Association and the Academy of Nutrition and Dietetics.

What is a low-carbohydrate diet?

The American Diabetes Association defines a low-carbohydrate diet as a diet that contains < 130 grams of carbohydrate per day (including 25-30 grams of fiber)

i.e.  ~100-105 net grams of carbs

Note: Dr. Painter didn’t define a very low carbohydrate diet, which the American Diabetes Association defined in its new Consensus Report as 20-50 g carbs per day. You can read more about that here.

The Academy of Nutrition and Dietetics defined low carbohydrate diets as ≤  35% of energy from carbohydrates.

In the scientific literature, low-carbohydrate diets range from 20 grams of carbohydrate per day up to ~150 grams per day (~20-25% of energy).

Slide 4

Dr. Painter then explained how low carbohydrate diets seek to minimize insulin secretion in the pancreas via their very low glycemic response, and how the reduced insulin affects;

  • weight control
  • type 2 diabetes
  • coronary heart disease (CHD)

Slide 5

Dr. Painter explained how an initial concern with a low carbohydrate diet was with the higher fat aspect, particularly for weight loss, as fat provides 9 kcals / gram and carbs only provides 4 kcals/grams, however;

  1. Fat slow gastric emptying and stimulates the secretion of cholecystokinin (CCK) and Peptide YY (PYY) — which are satiety hormones that result in people feeling full.
  2. Dietary proteins, short chain fatty acids and free fatty acids increase GLP-1 (which is one of the incretin hormones). Glucagon-like Peptide-1 (GLP-1) acts on the brain to decrease appetite, increase satiety (feeling full) and decrease food intake. You can read more about that here.
  3. Branched Chain Amino Acides (BCAA) found in protein reduces appetite.
  4. Ketone bodies (produced in very low carbohydrate diets) such as beta-hydroxybuterate suppress appetite.

Slide 6

Dr. Painter then outlined the findings of a 2014 study titled Effects of low-carbohydrate and low-fat diets: a randomized trial (Baranna LA, Hu T, Reynalds K et al, Ann Intern Med. 2014 Sep 2;161(5):309-18. doi: 10.7326/M14-0180).

Participants in this study had a BMI of between 30-45 kg per meter squared (meaning they were obese to morbidly obese), but did not have any metabolic diseases such as diabetes or cardiovascular disease (CVD).

The low carb group had carbohydrate intake of < 40 grams/day and the low fat group was allowed 55% of energy from carbohydrate (which is with the Recommended Dietary Intake of 45-55%), but restricted calories from fat.

There were 59-60 participants in both the low carb or low fat group…

Slide 7

…and after a year, those in the low carb group had a greater decrease in weight, fat mass, ratio of total-high-density lipoprotein (HDL) cholesterol, triglyceride level, and greater increases in HDL cholesterol level than those on the low-fat diet.

Dr. Painter highlighted that at the end of 12 months; these were the results of the two groups;

Low-carbohydrate diet
  • 5.3 kg weight loss
  • 1.2 kg loss of fat mass
  • 1.3 gain lean body mass
Low-fat diet
  • 1.8 kg weight loss
  • 0.3% gain in fat mass
  • 0.4% loss in lean mass

Slide 8

Dr. Painter then went over the results from a 2006 study by Gannon MC and Nutall FQ, titled Control of Blood Glucose in Type 2 Diabetes Without Weight Loss by Modification of Diet Composition ( (2006 Mar 23;3:16. doi: 10.1186/1743-7075-3-16) which found that even without weight loss, altering the diet composition to a low carb diet (carbs < 20% of energy) can enable people with type 2 diabetes to lower their blood sugar level without weight loss or diabetes medications, and achieve significantly better glycated hemoglobin (HbA1C) levels.

Slide 9

In this slide, Dr. Painter addressed a prevailing concern among many healthcare professionals that a low carbohydrate diet increase cardiovascular disease risk.

Does a Low-Carbohydrate Intake Increase Cardiovascular Disease Risk?

Dr. Painter outlined that a 2017 by Chui demonstrated that HDL cholesterol increases in a low carb diet and that while LDL cholesterol does increase, it tends to be the large buoyant LDL that increase, with no change in the athlersclerotic small, dense LDL.

He also outlined that a 2012 meta-study analysis of 19 randomized control trials (RCTs) by Santos et al reported a global decrease in triglyceride levels of 29.71 mg/dL (0.34 mmol/L) and that a 2014 study by Bazzano reported that a low carbohydrate diet had a greater decrease in 10-year cardiovascular heart disease (CHD) risk score based on the Framingham Risk Score, than those on the low fat diet.

Slide 10

Dr. Painter then elaborated on a study from 2008 by Forsythe CE et al titled Comparison of Low Fat and Low Carbohydrate Diets on Circulating Fatty Acid Composition and Markers of Inflammation that was published in the Journal Lipids ( 2008 Jan;43(1):65-77. Epub 2007 Nov 29).

In this study overweight men and women were put on either a low carb or low fat ~1500 kcal / day diet for 12 weeks. Results indicated that the low carb diet had a 3-fold higher dietary intake of saturated fatty acids (SFA) (36 grams/day versus 12 grams/day) yet the low carb group had a significantly greater reduction in their serum saturated fat levels.

That is, people in the low carb group they ate 3x the amount of saturated fat yet had a significantly greater reduction in their blood levels of saturated fat.

Slide 11

Dr. Painter then reviewed  a 2004 study by Volek JS et al titled Dietary Carbohydrate Restriction Induces a Unique Metabolic State Positively Affecting Atherogenic Dyslipidemia, Fatty Acid Partitioning, and Metabolic Syndrome which indicated how a very low carbohydrate (VLCKD) compared to a low carbohydrate diet (LCD) significantly improved body mass, abdominal fat, triglycerides (TG), ApoB:ApoA1 ratio, small dense LDL, TG:HDL ratio, insulin levels, and HOMA-IR score.

Slide 12

Dr. Painter then looked at the “why” for using a low carbohydrate diet for type 2 Diabetes Mellitus (T2DM).

Dr. Painter outlined the results of a 2015 study titled Prevalence of and Trends in Diabetes Among Adults in the United States, 1988-2012 by Menke A et al ( 2015 Sep 8;314(10):1021-9. doi: 10.1001/jama.2015.10029) which indicated that;

Recent data indicates 52% of the American population is either diabetic or prediabetic. The cost of diabetes (in the US) is estimated to be over $320 billion annually”.

Slide 13

Dr. Painter then cited a 2013 systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes (Ajala et al) titled Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes, Am J Clin Nutr. 2013 Mar;97(3):505-16. doi: 10.3945/ajcn.112.042457. Epub 2013 Jan 30.).

This paper looked at 20 randomized control trials (RCTs) across 3460 randomly assigned subjects and which found that a low-carbohydrate diet, low-GI diet, Mediterranean diet, and high-protein diet all led to a greater improvement in glycemic control and with the low-carbohydrate diet and Mediterranean diet leading to greater weight loss.

Dr. Painter indicated that each of these dietary philosophies show effectiveness of lower carbohydrate and lower GI diets for treating T2DM.

Slide 14

Dr. Painter then outlined the findings of a 2017 study by Snorgaard O et al titled Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes (

“Upon subgroup analysis, it was found that carbohydrate of < 26% of energy produces the greatest reduction whereas carbohydrate reduction of 26-45% of total energy produces no additional benefit over low-fat diets.”

Slide 15

In Dr. Painter’s next slide, he summarized the finding of a 2018 systematic review and meta-study paper by Sainsbury E et al with respect to medication use, titled Effect of Dietary Carbohydrate Restriction on Glycemic Control in Adults with Diabetes: A systematic review and meta-analysis ( 2018 May;139:239-252. doi: 10.1016/j.diabres.2018.02.026. Epub 2018 Mar 6).

“There was a greater reduction in medication use for participants on carbohydrate-restricted diets compared with high carbohydrate diets at every time point.”

  • reduced the dosage of oral medication and/or insulin
  • or an elimination of medication

Sainsbury 2018

Slide 16

Dr. Painter then outlined some highlights of a 2015 review paper titled Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base by Feinman RD, et al; namely;

  • The benefits of carbohydrate restriction in diabetes are immediate and well- documented
  • Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss…and leads to the reduction or elimination of medication.

Slide 17

Dr. Painter next slide highlighted Table 2 from the consensus report of October 2018 by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) where they classified a low carbohydrate diet as Medical Nutrition Therapy (covered in this previous article). Table 2 outlines the full range of therapeutic options, including lifestyle management, medication and obesity management and lists a low carbohydrate diet as one of the available therapeutic diets.

Slide 18

Dr. Painter then went over the 2019 American Diabetes Association’s Lifestyle Management; Standards of Medical Care in Diabetes which was released on December 17, 2018 (covered in this previous article) and which outlined key recommendations regardless which of the different types of approved eating patterns people choose, namely;

“As for all individuals in developed countries, both children and adults with diabetes are encouraged to minimize intake of refined carbohydrate and added sugars and instead focus on carbohydrate from vegetables, legumes, fruit, dairy (milk and yogurt) and whole grains. The consumption of sugar-sweetened beverages (including fruit juices) and processed “low fat” or “non-fat” food products with high amounts of refined grains and added sugars is strongly discouraged.”

Slide 19

The next slide was a continuation from the 2019 American Diabetes Association’s Lifestyle Management; Standards of Medical Care in Diabetes, and Dr. Painter highlighted that;

 

“In addition, research indicates that low carbohydrate eating plans may result in improved glycemia and have the potential to reduce anti-hyperglycemic medications for individuals with type 2 diabetes.”

Slide 20

Dr. Painter next highlighted the necessity of medication adjustment soon after initiating a low carbohydrate diet in order to prevent hypoglycemia.

Box 1 from Adapting Diabetes Medication for Low Carbohydrate Management of Type 2 Diabetes: a practical guide by Murdoch C et al (2019), was presented and is as follows;

Summary guidance on adapting diabetes medication for low carbohydrate management of type 2 diabetes

Dr. Painter highlighted the following on his slide;

“Practice expertise suggests a 50% reduction of daily insulin dose at initiation of the low carbohydrate diet (LCD) is appropriate in most cases. In individuals whose HbA1C is markedly elevated, a smaller reduction of perhaps 30% may be appropriate, with further reductions over time…”

Slide 21

Dr. Painter’s next slide simply read;

“Be encouraged! Reversal of Type 2 Diabetes??”

…as if to challenge his listeners to consider that diabetes reversal using a low carbohydrate diet is possible.

Slide 22

Dr. Painter then reviewed the DiRECT randomized control trial by Lean et al, titled Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial (The Lancet, 391 (10120). pp. 541-551. ISSN 0140-6736).

In that study, the 300+ participants from almost 50 primary care sites in the UK were randomly assigned to either a weight management program (which was the intervention group) or to best-practice care by guidelines (which was the control group).

Slide 23

Dr. Painter outlined the results of the DiRECT trial, which found that at 12 months, 24% of the  participants in the intervention group lost 15 kg or more, with no weight loss in the control group.

Diabetes remission varied with weight loss;

  • no remission in those who gained weight
  • 7% achieved remission with under 5 kg of weight loss
  • 34% achieved remission lost between 5—10 kg
  • 57% achieved remission with 10—15 kg loss
  • 86% achieved remission with weight loss of 15 kg or more

“Our findings show that, at 12 months almost half of participants achieved remission to a non-diabetic state and off anti-diabetic drugs. Remission of type 2 diabetes is a practical target for primary care“.

Slide 24

Dr. Painter then proceeded to addressed 3 common misperceptions about low carbohydrate diets, namely;

  1. A low carbohydrate diet puts participants at risk of ketoacidosis…
  2. Low carbohydrate diets ignore the principles of moderation and result in a nutrient-deficient diet…
  3. The majority of weight loss comes from water and lean body mass…

Slide 25 – addressing the misperception that a low carbohydrate diet puts participants at risk of ketoacidosis…

Dr. Painter cited a 2013 study titled Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean diet and Mediterranean Diet Maintenance Protocol by Paoli A et al ( 2013 Dec 18;5(12):5205-17. doi: 10.3390/nu5125205).

Using the data from that study, Dr. Painter demonstrated how the glucose range, insulin rang and ketone body range in a ketogenic diet is nothing like the ranges in Diabetic Ketoacidosis.

Normal Diet

Glucose (mg/dl)                       80-100
Insulin (uU/L)                                6-23
Ketone Bodies (mmol/L)         0.1

Ketogenic Diet

Glucose (mg/dl)                        65-80
Insulin (uU/L)                                5.5-9.4
Ketone Bodies (mmol/L)          1-8

Diabetic Ketoacidosis

Glucose (mg/dl)                       >300
Insulin (uU/L)                                ~0
Ketone Bodies (mmol/L)         >25

Slide 26 – addressing the misperception that low carbohydrate diets ignore the principles of moderation and result in a nutrient-deficient diet…

Dr. Painter cited the paper by Zinn C et al, titled Assessing the Nutrient Intake of a Low-Carbohydrate, High-Fat (LCHF) Diet: a hypothetical case study design and highlighted that despite macronutrient proportions not aligning with current national dietary guidelines, that when well-designed a low carbohydrate diet provides all of the essential micronutrients needed by the body.

Even at the lower end of the carbohydrate spectrum, you can still get all of the essential nutrients and energy your body needs by selecting from a broad array of nutrient-dense vegetables and fruit, e.g.:

      • raspberries
      • strawberries
      • blueberries
      • tomatoes
      • olives
      • avocados
      • plain greek yogurt
      • nuts/seeds

“Zinn et all demonstrated that a well-planned Low-Carbohydrate, High-Fat (LCHF) meal plan can be considered micronutrient replete.”

Slide 27 – addressing the misperception that the majority of weight loss comes from water and lean body mass…

Dr. Painter cited the 2014 study by Bazzano LA et al, titled Effects of Low-Carbohydrate and Low-Fat Diets: a randomized trial which found that of the ~60 subjects randomized to either the low-carbohydrate diet (<40 grams/day) or low-fat diet (<30% of daily energy intake from total fat [<7% saturated fat])  which found that at 12 months, participants on the low-carbohydrate diet lost 3.5 kg more weight and lost 1.5% more fat mass, than those in the low-fat diet group.

Slide 28

Dr. Painter concluded his talk by saying that he feels that most low carbohydrate diets are ‘harmful in practice’ because they are low in fiber, but that that can be addressed by;

 

  1. Start with a foundation of 6-8 servings of non-starchy, fiber-rich vegetables (~ 15 grams net carbs per day)
  2. Include additional calories from added fats. Nuts and seeds can provide additional fiber
  3. Depending on weight loss and healthy goals, low glycemic carbohydrates found in whole grains and fruit can be used to provide additional fiber.

For those who want to make sure to meet current fiber consumption recommendations while eating a low carbohydrate diet, please have a look at the article I wrote titled Surprising Ways to Get Adequate Fiber Eating Low Carb High Fat (LCHF), located here.

Final Thoughts…

Just a few years ago, it was viewed as quite ‘radical’ for healthcare professionals to consider a well-designed low carbohydrate or very low carbohydrate (ketogenic) diet as therapeutic, but now organizations in Europe (such as the EASD), the UK and Australia — along with the American Diabetes Association (ADA) consider both meal patterns Medical Nutrition Therapy for management of diabetes and for treating overweight and obesity.

What an exciting time!

Here it is, less than a year after the ADA released their 2019 Standards of Medical Care in Diabetes and only 4 months after the ADA released its Consensus Report and this past weekend, thousands of American Certified Diabetes Educators (CDE) gathered at their annual conference znd ~500 learned how to implement a low carbohydrate or ketogenic diet to advance chronic disease prevention and management.

It is my sincere hope that it won’t be much longer before clinicians in Canada are provided with diabetes Standards of Care that support the use of a well-designed low carbohydrate and very low carbohydrate diet as therapeutic options.

More Info?

If you have been diagnosed as being pre-diabetic or as having type 2 diabetes and would like support to put the symptoms into remission by implementing  a low carbohydrate or very low carbohydrate eating pattern, then I can help.
I also don’t believe in a ”one-sized-fits-all” approach and will work with you to design an individual Meal Plan that will meet your needs. You can learn more about my services 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.

 

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
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UPDATE
(August 16 2019):
You can find the second presentation from the American Certified Diabetes Educators conference
here. This is where hundreds of CDEs learned about dietary and medication management of lowcarb and ketogenic diets from a Registered Dietitian and Dr. of Pharmacy with CDE certification.

 

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. American Association of Diabetes Educators, Annual Conference, Houston Texas, Friday August 9 – Monday August 12, 2019, https://www.aademeeting.org/
  2. National Certification Board for Diabetes Educators (NCBDE), What is a CDE, https://www.ncbde.org/certification_info/what-is-a-cde/

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Only Half of People Have Newer Gene that Controls High Blood Sugar

The maintenance of blood sugar is very tightly regulated; with a healthy person’s blood glucose being kept in the range from 3.3-5.5 mmol/L (60-100 mg/dl) between meals, however a new study indicates that it may be newer variant of a gene that determines how well (or not) we are able to maintain these levels.

After eating, the higher levels of blood glucose that comes from the broken-down carbohydrate-based food triggers the release of insulin by the pancreas, which in turn causes the release of a special transporter called GLUT4.  The GLUT4 transporter acts like a taxi to remove excess glucose from the blood, taking it into muscle and fat tissue.

Newer Variant of an Older Gene

Between meals and with the help of a special protein (CHC22) produced by the CLTCL1 gene, the GLUT4 glucose transporter remains inside muscle and fat, so that some blood sugar will continue to circulate.

A newly published study [1] by research specialists in population genetics, evolutionary biology, ancient DNA and cell biology analyzed the human genomes to understand how the gene producing CHC22 has changed over human history [2].

By examining the genomes of 2,504 people from the global 1000 Genomes Project compared to the genomes of ancient humans, researchers found that almost half of the people in various ethnic groups have a variant of CHC22 protein that is produced by a new variant of the CLTCL1 gene that became more common as humans moved away from being hunter-gathers and began farming and raising crops. Researchers postulate that the increased consumption of carbohydrates may have been the selective force driving this genetic adaptation.

Researchers found that the newer CHC22 variant of the gene is less effective at keeping the GLUT4 glucose transporter inside muscle and fat tissue between meals, which means that the transporter can more readily clear glucose out of the blood.*

As a result, people with the newer variant of the gene will have lower blood sugar than those with the older variant of the gene.

“The older version of this genetic variant likely would have been helpful to our ancestors as it would have helped maintain higher levels of blood sugar during periods of fasting, in times when we didn’t have such easy access to carbohydrates, and this would have helped us evolve our large brains”[2] — lead author Dr Matteo Fumagalli

*Note: It’s important to keep in mind that only GLUT4 transporters are insulin dependent. There are other glucose transporters that allow glucose into the cell that don’t involve insulin, such as the GLUT1 transporter that works on a concentration gradient. That is, the effect of this gene is not on all glucose regulation, but only glucose regulation in adipose and muscle cells that use GLUT4 transporters.

The higher carbohydrate diets that came as a result of the advent of agricultural meant that this newer variant of the gene could be advantageous, as it moves the excess blood sugar from the blood into the muscle and fat tissue and having the older variant of the gene may make people more likely to develop Diabetes and may also make worse the insulin resistance that underlies the process of developing Diabetes.

“People with the older variant (of the gene) may need to be more careful of their carb intake, but more research is needed to understand how the genetic variant we found can impact our physiology”[2] — co-author Dr. Frances Brodsky 

Along with the 2015 study from Israel[3] that demonstrated substantial differences in blood glucose response between both healthy individuals and those with Diabetes predictable by their gut microbiome, this new research adds to the knowledge that multiple factors are involved with determining whether people can tolerate specific dietary carbohydrate loads.

Nutritional guidelines for maintaining healthy blood glucose levels are portrayed as universally applicable, however this new study and the 2015 Israeli study demonstrates that blood glucose varies significantly between individuals based on genetics as well as on gut microbiota composition, which necessitates the need for personalized nutrition in managing blood glucose levels.

More Info

If you are interested in a personalized approach aimed at helping you gain control of your blood sugar levels, I can help.

I offer both in-person services in my Coquitlam, British Columbia office as well as remote services via Distance Consultation. You can find more information about my packages under the Services tab or in the Shop and if you would like to learn more about how Distance Consultation services work, you can click here.

Have Questions?

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/lchfRD/
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. Matteo Fumagalli, Stephane M Camus, Yoan Diekmann, Alice Burke, Marine D Camus, Paul J Norman, Agnel Joseph, Laurent Abi-Rached, Andrea Benazzo, Rita Rasteiro, Iain Mathieson, Maya Topf, Peter Parham, Mark G Thomas, Frances M Brodsky. Genetic diversity of CHC22 clathrin impacts its function in glucose metabolism. eLife, 2019; 8 DOI: 10.7554/eLife.41517
  2. University College London. “Gene mutation evolved to cope with modern high-sugar diets.” ScienceDaily. ScienceDaily, 4 June 2019, https://www.sciencedaily.com/releases/2019/06/190604084857.htm
  3.  Zeevi D, et al. Personalized nutrition by prediction of glycemic responses. Cell. 2015;163:1079—1094.
  4. Noecker C, Borenstein E. Getting Personal About Nutrition. Trends Mol Med. 2016;22(2):83—85. doi:10.1016/j.molmed.2015.12.010

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From Injecting Insulin to a Low Carb Diet – the first two weeks

Note: This article is a personal account, and I have written consent from the person whose story this is, to share these details in this article. She hopes it encourages someone. Keep in mind, individual results following a low carb or ketogenic diet vary person-to-person.

At the end of May, a young woman was coming to see me for an assessment appointment, and as I was reviewing her chart in preparation, I noticed that she was taking insulin. It was apparent that she didn’t see the notice on  my web page that I don’t treat Type 1 Diabetics or Type 2 Diabetics on insulin, as I am not a CDE (Certified Diabetes Educator).

Discontinuing Insulin

When she arrived, we discussed some of the options she had, and she decided to go and see her endocrinologist and request that they discontinue her insulin and give her 12 weeks to follow a Meal Plan that I would design for her. She then signed and sent me the Confirmation of Non-Insulin Use Form, indicating that with her doctor’s permission and oversight, that she was no longer taking insulin. To support her in being successful, she decided to book weekly 1/2 hour check ins with me for the following 12 weeks.

Note: If you are taking insulin to manage blood glucose in Type 2 Diabetes or other medications do not attempt to discontinue these on your own, as the results can be very serious. Please read this post titled “Don’t Try This at Home – the need for medical supervision” for more information.

Last Friday was her first follow up appointment and she was very excited to show me her blood sugar results, her first week off insulin.  Here is the graph;

Week 1 - no insulin, low carbAs can be seen, her fasting blood sugar the first morning was 16.8 mmol (303 mg/dl) which went up to 18.7 mmol/L (337 mg/dl) 2 hours after her low carbohydrate breakfast.

The following morning her fasting blood glucose was 12 mmol/L (216 mg/dl) where it stayed more or less for a few days, then dropped to 9.9 mmol/L (178 mg/dl). This was after only one week.

I asked her to speak to her doctor to see if they would be willing to add a dose of Metformin at bedtime, to help control “dawn phenomenon”; the rise in glucose due to gluconeogenesis of the liver.  Her doctor agreed and this week she started that.

This morning was her second follow up appointment and again, she was so excited to show me her blood sugar results.

As can be seen, her fasting blood sugar the first morning of the second week was 10.8 mmol (195 mg/dl) which hardly went up at all to 10.9 mmol/L (196 mg/dl) 2 hours after her low carbohydrate breakfast.

The second morning of the second week, her fasting blood glucose was 9.2 mmol/L (166 mg/dl). The rest of the week, her morning fasting blood sugar ranged from 8.4 mmol/L (151 mg/dl) to 9.6 (173 mg/dl) where it stayed. This was only her second week off insulin.

Moderate Low Carb (not Ketogenic) Diet

Understand, that this young woman (aged 33 years of age) achieved these results eating a moderate low carbohydrate diet of 130 g of carbs per day — which is no where near the level of 25-35 g per day that most women would need to be at in order to be in ketosis, and she has been Type 2 Diabetic since 2017.

2 weeks graph – June 8 – 20, 2019 – moderate low carb diet

Here is the graph of her first two weeks of blood glucose results, tracked at fasting, before a meal, and 2 hours after a meal. The steady, linear drop is quite apparent.

She saw her GP yesterday and he is thrilled with her progress! He agreed to provide her with a requisition to do the fasting insulin that I requested, along with a fasting blood glucose and HbA1C — which we have agreed together to have re-run in 3 months, at the end of the 12 weeks.

For this week, no changes are being made in the number of carbs she is eating, however this may be adjusted in the future in order to achieve clinical outcomes.

These results speak for themselves in terms of the effectiveness of a  moderate-low carbohydrate diet to significantly lower blood sugar, as well as the adjunct treatment with Metformin, largely to control early morning gluconeogenesis.

These results also speak to the incredible benefits of her having the support of a healthcare team; me designing and monitoring her Meal Plan and her GP overseeing her care, along with her Endocrinologist.

In two weeks she will see her Endocrinologist again and she (and I!) are looking forward to hearing their response to her progress at that point in time. Given her results the first two weeks, I am confident that she will have much to be proud of!

When I asked her to send me her written consent to share these details in a blog article, I ask her to say a few words about what it was like for her to go from injecting insulin to control her blood sugar, to eating real, whole food to do it — and achieving these types of results.

This is what she wrote;

“I had done so much research into diet and lifestyle changes for Type 2 diabetes as I did not want to go on insulin. Prior to starting on insulin, I was put on Metformin and given the chance from my endocrinologist to change my diet. There was so much information about a low carb diet and its positive effect on blood sugar, so I gave it a try. It could be that I was overwhelmed, but I followed what I believed to be a low carb diet and did not see any significant changes to my blood sugar levels. They were all over the place with huge spikes, even when I would have zero carbs. Clearly something was not right. It gave me no motivation to continue and really made me feel defeated.

I knew I needed help and the only answer my endocrinologist gave me was a prescription for insulin.

I started insulin and was on it for 2 weeks without seeing any significant changes in my blood sugar levels again. This was not working.

So I decided to look for help on the nutrition side of it. Then I found you, Joy Kiddie. I read a little bit about your journey and it inspired me that you have been in my position and therefore would understand my challenges. Your journey gave me hope that there is still something that can be done. Meeting with you was even more of a motivation because you wanted what I wanted; lower A1C and more importantly, no insulin!

These past two weeks, following your guidance and eating a LCHF diet the right way, has been eye opening. I never thought I would get results like this in such a short time.

I used to hate checking my blood sugar levels and poking my poor fingers just to see a discouraging number. Now, I could check all day long because I see numbers that I never thought I would.

Seeing the levels come down and that linear decline in the graph just encourages me to continue down this path and work with you to create a healthier lifestyle.

I cannot wait to see what next week brings!”

For the last 4 years I have been working with those with Type 2 Diabetes and seen so many significantly improve their blood glucose management, and lose weight. Working with this young woman has inspired me to consider learning about insulin management and writing the CDE (Certified Diabetes Educator) certification exam next year while I will  continue to partner with people’s GPs and Endocrinologists (as is my current practice) to wean them off insulin while using a well-designed low carbohydrate diet to effectively manage their blood sugar. The literature, including the studies from Virta Health demonstrate it can be done safely and effectively and the American Diabetes Association recognize both a low carbohydrate meal pattern, and a very low carbohydrate (ketogenic) meal pattern as Medical Nutrition Therapy in the management of pre-diabetes, as well as Type 1 and Type 2 Diabetes in adults.  For more information on this, please see several articles from April 2019, under the Science Made Simple tab including this one.

My hope is that  in the days ahead, Diabetes Canada will arrive at a similar conclusion as the American Diabetes Association, the EASD, Diabetes Australia and others and recognize a low carbohydrate and ketogenic diet as options for those with Diabetes in Canada. Towards that end, I want to be credentialed as a Certified Diabetes Educator in order to be able to support those using insulin.

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
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.

 

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A New Little Black Dress – a Dietitian’s Journey continues

May 25 2008 and June 15 2019

Yesterday I had an occasion to wear a new little black dress that I had bought, and remembered the last time I wore one. Ironically, it was for my Master’s convocation just over 11 years ago, and the dress was a size 16. My degree was in Human Nutrition, yet I was very overweight and had pre-diabetes.

The degrees on the wall did not help me understand why — despite my best efforts to “exercise more and eat less”, I was still overweight.  Despite my research related to the neurotransmitter dopamine, it was not known at the time how dopamine is involved in the potent joint reward system of eating foods that are a combination of both carbohydrate and fat (you can read more about that here). 

I did not understand why following the advice of my physician didn’t help.  I ate according to the (then) Canadian Diabetes Association (now called Diabetes Canada)’s recommendation to eat 65 g of carbohydrate at each meal and 25-45 g of carbs at each snack — along with lean protein and monounsaturated and polyunsaturated fat and participated in exercise several days each week. I ate “plenty of healthy whole grains” and “lots of fruit and vegetables“, along with low fat dairy,  yet a year later progressed to Type 2 Diabetes; what I was told was a “progressive, chronic disease”.

My studies didn’t help me understand the impact of high levels of circulating insulin on obesity and the effect of the after-meal and after-snack rise in insulin and then it’s drop shortly later on hunger. The reality was, the advice we were taught to “eat less and move more” did nothing to address the underlying issue of being hungry every few hours. In fact, the detrimental effects of high circulating levels of insulin weren’t taught; only the effects of high blood sugar.

My studies didn’t help me understand that “plenty of healthy whole grains” for someone who is already insulin resistant, with high levels of circulating insulin isn’t helpful.  I didn’t understand how eating plenty of fruit was further contributing to my problems;  both because of it’s high carbohydrate load, as well as it being a high source of fructose. I drank 3 glasses of low-fat milk daily, but didn’t understand the effect of all of those extra carbohydrates on my blood sugar, as well as underlying insulin response.  It was not part of what I studied — either in my undergraduate degree or Master’s studies, because it simply was not well known.

It is only recently (April 18, 2019) that the American Diabetes Association (ADA) issued their Consensus Report which indicated that “reducing carbohydrate intake has the most evidence for improving blood sugar” (you can read more about that here). In fact, the ADA now includes both a low carbohydrate eating pattern and a very low carbohydrate (keto) eating pattern as Medical Nutrition Therapy for the treatment of those with pre-diabetes, as well as adults with Type 1 or Type 2 Diabetes.

While these are not currently part of Diabetes Canada‘s options, they are recommendations available to those in the United States.

In fact, the European Association for the Study of Diabetes (EASD) also classifies low carb diets as Medical Nutrition Therapy (see here) and Diabetes Australia released their own updated position paper for people diagnosed with Diabetes who want to adopt a low carbohydrate eating plan. 

Many studies already demonstrate that a well-designed low carbohydrate diet is both safe and effective for the treatment of obesity and Diabetes (you can find a convenient list of studies under the Physician and Allied Health Provider tab), but much of this has only come to light in the years since I graduated with my Master’s degree.

In the last 4+ years since I first learned about the therapeutic use of a low carbohydrate diet, I have read scores of studies in an effort to become well-informed and continue to do so in order to stay current with the emerging evidence. Under the Science Made Simple tab, you can read some of the almost 170 articles I have written so far, many of them fully referenced.

April 2017 – April 2019

On March 5, 2017 I began what I have called “A Dietitian’s Journey” where over the subsequent two years, I put my Type 2 Diabetes into remission, lowered my dangerously high blood pressure and achieved a normal body weight and optimal waist circumference. You can read my story under A Dietitian’s Journey.

I have been in maintenance mode for more than three months and have been able to maintain my weight loss and health gains with little effort. My ongoing personal articles since being in maintenance appear under Making Health a Habit which can be read here.

I continue to maintain my original Dietetic practice that focuses on food allergy and food sensitivity (including Celiac disease, Irritable Bowel Syndrome, Inflammatory Bowel Disease) through BetterByDesign Nutrition, and through continued reading in the scientific literature, I am now able to provide a range of options for weight loss and improvement in many metabolic conditions, including Type 2 Diabetes, hypertension and abnormal cholesterol that I was unable to offer a few years ago.  Through BetterByDesign Nutrition, I offer variety of evidence-based approaches, including a Mediterranean Diet, a plant-based whole foods approach (vegetarian or including meat, fish and poultry), as well as a low carbohydrate approach and through this division, The Low Carb Healthy Fat Dietitian I focus exclusively on using a low carbohydrate or ketogenic approach.

If you would like to learn how I might be able to help you, 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

NOTE: This post is classified under “A Dietitian’s Journey” and is my personal account of my own health and weight loss journey that began on March 5, 2017. Science Made Simple articles are referenced nutrition articles, and can be found here.

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.

 

How Reliable is Glycemic Index for Predicting Blood Sugar Response?

In my last post, I shared some infographics developed by Dr. David Unwin, a UK General Practitioner that help communicate the concept of Glycemic Index (GI) & specifically Glyemic Load (GL) in terms of how they impact blood sugar compared to teaspoons of ordinary table sugar.

Below is one of those infographics;

Infographic for health professionals to show how the glycemic index helps inform dietary choices (from Unwin D, Haslam D, Livesey G. It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance. 2016;1(1))

Glycemic Response Represented as Teaspoons of Sugar

(Reference “from bit.lv.carbs-vs-fat”)

The infographic to the left has been making the rounds recently on social media and is based on the idea that high Glycemic Index (GI) foods can be represented by the effect those foods have on people’s blood sugar, compared to teaspoons of sugar.

It is not dissimilar to the infographic that I designed below for the previous article , based on Dr. Unwin’s work (1).    

The problem is, these tools are only as useful as Glycemic Index is reliable, so the questions is, is GI (and GL which is derived from it) reliable for predicting blood sugar response?

That is, if the Glycemic Index (GI) values (1) change between individuals for the same amount of the same food or (2) if they change value within the same individual when they are assessed at different times, then they cannot be relied on to predict blood sugar response in an individual.

Is Glycemic Index Reliable for Predicting Blood Sugar Response?

A study published in  the American Journal of Clinical Nutrition (2) reported that individual response to individual carbohydrate-containing food vary so much that Glycemic Index values may not be useful in indicating blood sugar response in individuals.

The Study 

Randomized, controlled, repeated tests on 63 healthy adults participated in 6 testing sessions over a twelve week period and fasted and abstained from exercise and alcohol before each session.

During each session participants ate either (1) white bread (test food) or (2) a standardized glucose drink (reference control).

Blood sugar values were measured at several points over the next 5 hours, and Glycemic Index was derived by testing the test food and reference in the same participant according to standard method. This is usual practice to control for the variability between people which may be caused by biological differences.

Results

Out of the 63 participants, in 22 participants blood sugar response was classified as “low”, in 23 participants it was classified as “medium” and in 18 participants it was classified as “high’ for the same amount of bread. That is, white bread fell in all three Glycemic Index categories with different individuals.

In addition, responses within the same individual varied by as much as 60 points between tests.

Interpretation of the Results

The study indicated (as I also covered in a previous two-part post on the effect of food processing on blood sugar response) that blood glucose response is affected by differing physical structure of similar foods, the effect of food processing and preparation methods, as well as meal consumption patterns (single or mixed meals).

The study authors concluded that the high inter- (between people) and intra-individual (within the same person) variation that was observed in the GI value of foods essentially resulted in the results being of no practical value.

“In summary, our data indicate substantial variability in GI value  determinations for white bread despite the use of standardized methodology and multiple testing in a large number of healthy volunteers. The high degree of variability demonstrates that there is potential to misclassify foods into the 3 commonly used GI categories (low, medium, and high), which would result in the inability to distinguish between foods, thus invalidating the practical applicability of the GI value.

 

The authors also indicated that this variability was also partly explained by differences in baseline HbA1c (i.e. glycated hemoglobin) which is an estimate of 3 month average of blood glucose control, as well as the insulin index (the differing insulin response to foods which was covered in this previous article), which both affect the GI value. 

Individual Glycemic Response

It should be noted that inter-individual and intra-individual variation in glycemic response isn’t only to white bread, as in this small study.

A 2015 study from Israel (3) involving 800 people who were monitored with continuous glucose monitors (CGMs) indicates that there isn’t a universal’ blood sugar response to either low Glycemic Index foods or high Glycemic Index foods — that glycemic (blood sugar) response is very individual. 

“We continuously monitored week-long glucose levels in an 800-person cohort, measured responses to 46,898 meals, and found high variability in the response to identical meals, suggesting that universal dietary recommendations may have limited utility.”

Some Final Thoughts…

One cannot reliably predict that a specific amount of carbohydrate-based food will raise a person’s blood sugar the same amount as a certain number of teaspoons of sugar, because each carbohydrate-based food will have different effects on different people, and different effects within the same individual at different points in time.

More Info?

If you would like to know how to determine how you respond to specific carbohydrate based foods and how to know which carbohydrate-based foods spike your blood sugar and which don’t, I can help.

You can learn more about my services including individual hourly appointments and packages 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/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

  1. Unwin D, Haslam D, Livesey G. It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance. 2016;1(1), a8. http://dx.doi.org/10.4102/jir.v1i1.8
  2. Matthan NR, Ausman LM, Meng H, Tighiouart H, Lichtenstein AH. Estimating the reliability of glycemic index values and potential sources of methodological and biological variability. Am J Clin Nutr. 2016;104(4):1004—1013. doi:10.3945/ajcn.116.137208
  3. Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094.

ADA’s New Consensus Report — 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 Consensus Report of April 18, 2019 regarding the use of a low carbohydrate eating pattern of 26-45% of total daily calories as carbohydrate and the use of a very low carbohydrate (ketogenic) eating pattern of 20-50 g carbohydrate per day for the management of pre-diabetes, Type 1 or Type 2 Diabetes in adults [1]. 

This new downloadable printout is available by clicking here.

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

The previous printout from January 2019 (available by clicking here ) was based on two earlier reports;

(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 [2]

and

(2) the ADA’s recently released 2019 Standards of Medical Care in Diabetes – Lifestyle Management [3] which includes the use of low carbohydrate diets as Nutrition Therapy and which reflects the organization’s emphasizes on a patient-centered, individualized approach

If you have been diagnosed as pre-diabetic or as having Type 2 Diabetes (T2D) and would like some professional support to put the symptoms into remission by following a low carbohydrate or very low carbohydrate eating pattern,  I can help.

I can provide Registered Dietitian services to those in any province in Canada (except PEI), and for those in the US, I can provide you with nutrition education to help you know how to eat according to a low carb eating pattern.

You can learn more about my services 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 4 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 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

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. 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
  3. 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.

    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.    

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:

Twitter: https://twitter.com/lchfRD
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.    

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:

â—‹ Improve A1C, blood pressure, and cholesterol levels (goals differ for individuals based on age, duration of diabetes, health history, and other present health conditions. â—‹ Achieve and maintain body weight goals â—‹ 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

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
 

ADA: reducing carbs has most evidence for improving blood sugar

A newly published American Diabetes Association (ADA) consensus report on Diabetes and pre-diabetes that was just published online ahead of print yesterday (April 18, 2019) indicates 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.”

* glycemia is blood glucose, also called “blood sugar”
 
NOTE: This is the first article in a series I will be writing on this new Consensus Report.
 
The report emphasizes that there is no “one-size-fits-all” eating pattern for the prevention or management of diabetes, and that it is an unrealistic expectation that there should be a singular eating pattern given the broad spectrum of people affected by diabetes and pre-diabetes, their cultural backgrounds, personal preferences, co-occurring conditions (i.e. co-morbidities), 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).
 
“The most robust research available related to eating patterns for pre-diabetes or type 2 diabetes prevention are Mediterranean-style, low-fat, or low-carbohydrate eating plans.”
 
According to this new report, low-carbohydrate eating patterns (26-45% of total calories from carbs ) and very low carbohydrate eating patterns, also called “ketogenic” or “keto” diets (20-50 g of non-fiber carbohydrate per day) show the most evidence for blood glucose control
 
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 indicates that for adults 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.”
 
“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.”
 

American Diabetes Association Consensus Recommendations Summary

  • A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes.
  • Until the evidence surrounding comparative benefits of different eating patterns in specific individuals strengthens, health care providers should focus on the key factors that are common among the patterns:

â—‹ Emphasize non-starchy vegetables.
â—‹ Minimize added sugars and refined grains.
â—‹ Choose whole foods over highly processed foods to the extent possible.

  • 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 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.

If you have been recently diagnosed as pre-diabetic or as having Type 2 Diabetes (T2D) and would like to work on reversing the symptoms through a low carbohydrate or very low carbohydrate eating pattern, then 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 the body

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

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

American Diabetes Association: Very Low Carb Diet is the most powerful for treating T2D

Dr. Laura Saslow, PhD serves on the nutrition review committee for the American Diabetes Association (ADA) and spoke on March 15, 2019 at the 42nd annual National Food Policy Conference in Washington, DC . She was on a panel of experts discussing the tremendous cost of diet-related disease and the role of public policy in encouraging healthier eating.

The talk was titled, Let Food Be Thy Medicine and Dr. Saslow said this;

“…The American Diabetes Association (ADA) reviewed all of the clinical trial evidence for the new 2019 ADA clinical guidelines and has noted that a very low carbohydrate diet (VLCD) of 20-35g carbohydrate per day (not low in fat or salt) is the most powerful eating approach for treating type 2 diabetes, leading to a 40-50% remission rate.

Current standard of care leads to less than a 5% remission rate.

VLCD can also be helpful for patients with type 1 diabetes, pre-diabetes, hypertension, nonalcoholic fatty liver disease, polycystic ovarian syndrome and Alzheimer’s disease, and there is now more clinical trial evidence for VLCD than for any other eating pattern…”

In December, the American Diabetes Association (ADA) released its 2019 Standards of Medical Care in Diabetes, including its Lifestyle Management Standards of Care which included use of a low carbohydrate diet (you can read about that here), but that the ADA has now noted that a very low carbohydrate diet of 20-35 g carbohydrate per day is “the most powerful eating approach for treating Type 2 Diabetes, leading to a 40-50% remission rate” compared to the current standard of care which  leads only to “less than a 5% remission rate” is very exciting.

A very low carbohydrate diet listed as Medical Nutrition Therapy in the upcoming 2019 American Diabetes Association Clinical Guidelines will certainly pave the way for organizations such as Diabetes Canada to re-evaluate the strength of the evidence for use of carbohydrate restriction for significantly improving remission rates for those with Type 2 Diabetes in this country.

What an exciting time to be a Dietitian!

NOTE: The video of her speaking had been posted on YouTube at https://www.youtube.com/LEKw1Ri7ryA but has since been deleted as the individual posting it did obtain permission to post it.

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

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

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

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

https://www.instagram.com/lchf_rd

 

Reference

42nd Annual National Food Policy Conference, Renaissance Washington, DC Downtown Hotel, March 14 & 15, 2019, Panel 1: Let Food Be Thy Medicine

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.

Are You Pushing Your Pancreas Too Hard – estimating β-cell function

Most people think of pre-diabetes as ‘warning sign’ that they are at risk for developing type 2 diabetes, but it is actually the final stage before diagnosis. By the time a person is prediabetic their blood glucose results (also called “blood sugar”) are in the abnormal range on routine tests such as a fasting blood glucose test (FBS) and glycated hemoglobin (HbA1C). They also may already have increased high blood pressure, abnormal cholesterol, and be at increased risk of cardiovascular disease, including heart attack and stroke as well as chronic kidney disease. By assessing a person’s fasting blood glucose and fasting insulin at the same time then using a simple calculation we can accurately estimate the degree of a person’s insulin resistance and β-cell function before they become pre-diabetic — enabling them to make dietary interventions to prevent that from occurring, lower the likelihood of them progressing to type 2 diabetes

It is now known that abnormalities with the hormone insulin — including insulin resistance and hyperinsulinemia appear more than 20 years before a diagnosis of Type 2 Diabetes[1], so prevention of type 2 diabetes needs to begin when blood sugar results still appear normal.

Before getting into the technical details of insulin resistance and hyperinsulinemia, I want to explain these concepts in terms that everyone can understand.

Measuring Glucose and Insulin Together

Most people know that a car’s speedometer indicates how fast the car is going. The tachometer indicates how many times per minute the engine is rotating. If a car is doing 180 km / hour (110 miles per hour) on the highway, one would expect the engine to be working hard. But if a car was only doing 70 km / hour (44 miles per hour), one wouldn’t expect the engine to be working that hard, right?

The problem is that blood sugar may be within normal range because the pancreas is overworking to keep it low! The β-cell of the pancreas are being overworked but no one notices because they aren’t looking for it.

Even when people have a 2 hour Oral Glucose Test with added insulin assessors (explained below), blood glucose results may come back normal because the person is healthy. The problem is that blood glucose results may appear normal because the pancreas is working way too hard to keep it that way! That is, using the car example, the tachometer is working very hard, but the car is hardly moving!

Normal blood sugar values with abnormal insulin values = overworked pancreas – original illustration by Joy Y. Kiddie MSc, RD (special thanks to Dr. Eric Sodicoff for the idea)

Let’s look at this scenario in terms of blood test results;

Let’s say we have a person that has fasted overnight and their fasting blood glucose in the morning is normal at 4.9 mmol/L (88 mg/dl), but their fasting insulin is much higher than the ideal 14.0 – 42.0 pmol/L (2-6 uU/ml) — in this case, say it is 132.6 pmol/L (19.1 uU/ml).

This would be like the car being started but in “park” in the driveway and the engine turning at 3,000 RPM!  The pancreas is working  way too hard to maintain blood sugar and the person hasn’t even eaten yet!

Say we now give this person 75 g of pure glucose to drink and check what happens to their blood sugar at 30 minutes and/or one hour afterwards.

What we expect a healthy person’s blood sugar to do is to go up in response to taking in the glucose, for the pancreas to release the appropriate amount of insulin which results in the blood sugar going back down to at- or slightly below where it started from. This is the normal, healthy response.

On a graph it would look like this;

Normal Glucose Response with 75 g of glucose

But in the case of the person whose blood sugar is normal at fasting (i.e. 4.9 mmol/L (88 mg/dl)) but their fasting insulin is much higher than ideal (i.e. 132.6 pmol/L (19.1 uU/ml) instead of 14.0 – 42.0 pmol/L (2-6 uU/ml)), their car is in “park” but the engine is already turning fast!

When this person drinks the 75 g of glucose, their pancreas goes into “high rev” and releases a huge amount of insulin—which not only keeps the blood sugar from going up normally in response to taking in glucose, it may result in the blood sugar actually dropping slightly below the fasting level (from 4.9 mmol/L / 88 mg/dl to 4.8 mmol/L / 86 mg/dl). This is not a healthy response but is characteristic of hyperinsulinemia (too much circulating insulin even when the person is fasting).

This glucose and insulin response would look as follows;

If this person had only had a standard 2 hour Glucose Tolerance Test, they would be told everything is “fine” because their fasting blood glucose was normal at 4.9 mmol/L / 88 mg/dl and at 2 hours their blood glucose came right back down to normal (4.9 mmol/l / 88 mg/dl)!

Using the car analogy, their “tachometer” (pancreas that produces insulin) is working way too hard in order to keep blood sugar low. Burnout of the pancreatic β-cells is what results in type 2 diabetes (T2D) but without assessing simultaneous glucose AND insulin at fasting, either 30 minutes or 1 hour, and at 2 hours, the fact this person’s pancreas is working way too hard to keep glucose low would be totally missed. 

By the time a person is diagnosed with T2D, they have lost approximately half of their β-cell mass, so preventing the β-cell’s of the pancreas from being overworked is how to delay or prevent becoming type 2 diabetic!

Four Stages of Type 2 Diabetes – why assessing β-cell function is important

There are four stages in the progression of type 2 diabetes, with Insulin Resistance (IR) and hyperinsulinemia being the stage BEFORE pre-diabetes [2].

Stage 1: Insulin Resistance (including hyperinsulinemia)
Stage 2: Pre-diabetes
Stage 3: Type 2 Diabetes
Stage 4: Metabolic and Vascular Complications

Four Stages of Type 2 Diabetes – original illustration by Joy Y. Kiddie MSc, RD

Insulin resistance and  hyperinsulinemia together are essentially “pre-pre-diabetes“, therefore stopping progression of the disease at this point reduces the risk associated with high blood pressure, abnormal cholesterol, heart attack and stroke, as well as chronic kidney disease.

Insulin resistance is where the cells of the body ignore signals from the hormone insulin which tell it to move glucose from broken down from digested food — from the blood and into the cells. When someone is insulin resistant, blood glucose stays higher than it should be, for longer than it should be, which is called  hyperglycemia.  When there are insufficient receptors on muscle cells to move glucose out of the blood after eating, this is called insulin resistance. It isn’t known whether insulin resistance comes first or hyperinsulinemia (high circulating levels of insulin) does. It is believed that it may be different depending on the person[3].

Assessing Insulin Resistance and β-cell Function

Homeostatic Model Assessment (HOMA-IR) estimates the degree of insulin resistance (IR), β-cell function (the cells of the pancreas that produce insulin) and insulin sensitivity (%S) and is determined from the results simultaneous fasting blood glucose test and a fasting insulin test.

Alternatively, HOMA-IR can be determined from a fasting blood glucose test and a fasting C-peptide test [3]. C-peptide is released in proportion to insulin, so it can be used to estimate insulin. Individual results are best compared to local population cut off values for HOMA1-IR [4] (1985) or the updated HOMA2-IR [5] (1998) .

HOMA1-IR  is defined as [fasting insulin (µU/mL)í— fasting glucose (mmol/L)]/22.5 [4] and HOMA2-IR is calculated using an online HOMA2 calculator released by the Diabetes Trials Unit, University of Oxford available at http://www.dtu.ox.ac.uk/homacalculator/index.php (updated January 8, 2013).

The original HOMA1-IR equation proposed by Matthews in 1985 [4] was widely used due to its simplicity, however it was not always reliable because it did not consider the variations in the glucose resistance of peripheral tissue and liver, or increases in the insulin secretion curve for blood glucose concentrations above 10 mmol/L (180 mg/dL) or the effect of circulating levels of pro-insulin. [6]. The updated HOMA2-IR computer model [5] has been used since 1998 and corrects for these.

Cut-off for insulin resistance using the original Matthews values (1985) [4] for HOMA-IR ≥ 2.7

Insulin sensitive is considered less than 1.0
Healthy is considered 0.5-1.4
Above 1.8 is early insulin resistance
Above 2.7 is considered significant insulin resistance

Cuff-off values for insulin resistance using the HOMA2-IR calculator (1998) [5] is HOMA2-IR ≥ 1.8. Three population based studies found the same or very close cut-offs applied, including a 2009 Brazilian study [7] which found HOMA2-IR ≥ 1.8, a 2014 Venezuelan study [8] which found HOMA2-IR ≥ 2.0 and a 2014 Iranian study [9] which found HOMA2-IR ≥ 1.8.

Use of HOMA-IR to Assess Insulin Resistance and β-cell Function in the Individual

HOMA-IR has been used to assess Insulin Resistance (IR) and β-cell function as a one-off measures in >150 epidemiological studies of subjects of various ethnic origins, with varying degrees of glucose tolerance [10].

In the Mexico City Study which used single glucose-insulin pairs (not the mean of three samples at 5-min intervals) [11], β-cell function and Insulin Resistance were assessed using HOMA-IR in ~1500 Mexicans with normal or impaired glucose tolerance (IGT) (27). Subjects were followed up for 3.5 years for the incidence of diabetes and to examine any possible relationship with baseline β-cell function and IR. At 3.5 years, ~4.5% of subjects with normal glucose tolerance at baseline and ~23.5% with impaired glucose tolerance at baseline had progressed to type 2 diabetes. That is, the development of diabetes was associated with higher HOMA-IR at baseline. 

The use of HOMA-IR on an individual basis enables clinicians to quantify both the degree of insulin sensitivity and β-cell function on assessment — before the person makes any dietary changes. Once the individual understands the significance of their HOMA-IR results, it can provide significant motivation for them to make dietary changes to slow– or prevent the progression toward abnormal glucose tolerance, or type 2 diabetes. When HOMA-IR is repeated 6 months into dietary changes, it provides significant feedback to the individual regarding the effectiveness of of dietary changes, and the motivation to continue.

“HOMA-IR can be used to track changes in insulin sensitivity and β-cell function longitudinally in individuals. The model can also be used in individuals to indicate whether reduced insulin sensitivity or β-cell failure predominates.[10]

Measuring Hyperinsulemia

Detection of hyperinsulinemia (high circulating levels of insulin) can occur using an Oral Glucose Sensitivity Index (OGIS) where available, or with a 2-hr Oral Glucose Tolerance Test (2-hr OGTT) with simultaneous assessors of insulin.  These are tests where a fasting person drinks a known amount of glucose (usually 75 g or 100 g of glucose) and their blood sugar and insulin values are measured before the test starts (baseline, while fasting) and at 2 hours. An additional assessor of blood glucose and insulin can be requested at 1 hour which is very helpful for detecting abnormalities that would missed if only assessing at 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[3].

Final thoughts…

As mentioned at the start of this article, abnormalities in insulin, including insulin resistance and/or hyperinsulinemia begin to occur as much as 20 years before a diagnosis of type 2 diabetes — while blood sugar results are still normal. That is when we need to diagnose abnormalities!

If we simply monitor fasting blood glucose, we will miss that someone’s pancreas may be overworking.

Even if we monitor fasting blood glucose and glycated hemoglobin (HbA1C), we can miss that someone’s pancreas is overworking by constantly producing too much insulin.

Furthermore, even if a standard 2 hour Glucose Tolerance Test is run and the person’s fasting blood glucose and 2 hour glucose level after a load is measured, we still can miss that someone’s pancreas is being pushed way too hard if those values appear normal at baseline and at the end of the test.

By running a 2 hour Glucose Tolerance Test with simultaneous glucose and insulin at baseline (fasting), 30 minutes or 1 hour, and at 2 hours we can observe the pancreas being pushed way too hard and implement dietary changes to avoid further β-cell damage or β-cell death.

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 HST
additional glucose at 1 hour                                                       = $   3.93   with HST
3 insulin assessors at fasting, 1 hour, 2 hours                   = $111.27  with HST
TOTAL                                                                                                   = $128.56 with HST

When there are clinical reasons to suspect that a person may be insulin resistant and/or hyperinsulinemic and assessment of simultaneous glucose and insulin function can provide sufficient motivation for individuals to implement dietary changes that can prevent progression to type 2 diabetes, is this testing not worth <$130?

NOTE (March 9, 2021): Some family medicine doctors won’t order tests to assess insulin along with glucose in order to “save healthcare system dollars” — but instead will send their patient to an endocrinologist which costs the system ~$300 before any tests are run. Why? In parts of Canada, if audited, family medicine physicians have to re-pay for preventative tests (which are deemed “unnecessary”) . Self-paying for these tests is an option to consider.

If you would like to know about the services that I offer, please click on the Services tab to learn more and if you have questions related to these, please send me a note using the Contact Me form located on the tab above and I will reply as I am able.

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. 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.
  2. Mechanick JI, G.A., Grunberger G, et al, Dysglycemia-Based Chronic Disease: an American Association of Clinical Endocrinologists Position Paper. Endocrine Practice, 2018. 24(11): p. 995-1011.
  3. Crofts, C., Understanding and Diagnosing Hyperinsulinemia. 2015, AUT University: Auckland, New Zealand. p. 205.
  4. Matthews, D. R; Hosker, J. P; Rudenski, A. S; Naylor, B. A; Treacher, D. F; Turner, R. C; “•Homeostasis model assessment: insulin resistance and β-cell function from fasting plasma glucose and insulin concentrations in man”–; Diabetologia; July, 1985; Volume 28, Number 7: Pp 412-419
  5. Levy JC, Matthews DR, Hermans MP. Correct homeostasis model assessment (HOMA) evaluation uses the computer program. Diabetes Care. 1998;21:2191—2192
  6. Song YS, Hwang Y-C, Ahn H-Y, Comparison of the Usefulness of the Updated Homeostasis Model Assessment (HOMA2) with the Original HOMA1 in the Prediction of Type 2 Diabetes Mellitus in Koreans, Diabetes Metab J. 2016 Aug; 40(4): 318—325
  7. Geloneze B, Vasques AC, Stabe CF et al, HOMA1-IR and HOMA2-IR indexes in identifying insulin resistance and metabolic syndrome: Brazilian Metabolic Syndrome Study (BRAMS), Arq Bras Endocrinol Metabol. 2009 Mar;53(2):281-7
  8. Bermíºdez V, Rojas J, Martí­nez MS et al, Epidemiologic Behavior and Estimation of an Optimal Cut-Off Point for Homeostasis Model Assessment-2 Insulin Resistance: A Report from a Venezuelan Population, Int Sch Res Notices. 2014 Oct 29;2014:616271
  9. Tohidi M, Ghasemi A, Hadaegh F, Age- and sex-specific reference values for fasting serum insulin levels and insulin resistance/sensitivity indices in healthy Iranian adults: Tehran Lipid and Glucose Study, Clin Biochem. 2014 Apr;47(6):432-8
  10. Wallace TM, Levy JC, Matthews DR, Use and Abuse of HOMA Modeling, Diabetes Care 2004 Jun; 27(6): 1487-1495. https://doi.org/10.2337/diacare.27.6.1487
  11. Haffner SM, Kennedy E, Gonzalez C, Stern MP, Miettinen H: A prospective analysis of the HOMA model: the Mexico City Diabetes Study. Diabetes Care 19:1138—1141, 1996

 

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.

UPDATE (April 18, 2019) – There is now an updated one page downloadable printout that summarizes the American Diabetes Association’s new Consensus Report of April 18, 2019 regarding the use of a low carbohydrate eating pattern of 26-45% of total daily calories as carbohydrate and the use of a very low carbohydrate (ketogenic) eating pattern of 20-50 g carbohydrate per day for the management of pre-diabetes, Type 1 or Type 2 Diabetes in adults. It is available by clicking here.

You can follow me at:

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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. 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

 

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:

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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. 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

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

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

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

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

To our good health!

Joy

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

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

References

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

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.*

* some studies such s those from Virta Health define partial remission as a HbA1C < 6.5% and fasting blood glucose ≤ 5.5 (100 mg/dl) while taking  no medication, or only generic Metformin.

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

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

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

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

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

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

Some final thoughts…

I think it’s important what terms we use.

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

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

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

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

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

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

To yours and my good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

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          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. 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. Laferrí¨re 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

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:

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

The Three Stages of Carbohydrate Intolerance – before type 2 diabetes

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).

A normal blood glucose curve represents Carbohydrate Tolerance, and there are 3 Stages of Carbohydrate Intolerance — early, advanced, and severe, with the final stage being a 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 Carbohydrate Tolerance curve (i.e. normal glucose curve). The solid black line is unlabeled 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.

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.
In 990 people with normal glucose tolerance and normal insulin tolerance (i.e. with curves like the one above), mean fasting insulin = 48.6 pmol/L, which is equivalent to 7 uU/ml / 7 mU/L [SD = 5 mU/L]. Therefore the normal range for fasting insulin 2-12 uU/ml.

Early Carbohydrate Intolerance

Below is the Early Carbohydrate Intolerance curve 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 when their body is unable to tolerate it. 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 abnormalities [2].

NOTE (March 9, 2021): Some family medicine doctors won’t order tests to assess insulin along with glucose in order to “save healthcare system dollars” — but instead will send their patient to an endocrinologist which costs the system ~$300 before any tests are run. Why? In parts of Canada, if audited, family medicine physicians have to re-pay for preventative tests (which are deemed “unnecessary”) . Self-paying for these tests is an option to consider.

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.

To your good health!

Joy

You can follow me at:

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

 

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

 

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