Year: 2020

In addition to the several types of therapeutic ketogenic diets mentioned in the previous post, such as the Classic Ketogenic Diet (KD), the Modified  Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) used in the treatment of epilepsy and seizure disorder and as adjunct treatment in glioblastoma, there is another type of therapeutic ketogenic diet used in the treatment of type 2 diabetes and for weight loss which is referred to in the literature as a Very Low Carbohydrate Diet (VLCD). This post outlines two examples of this type of therapeutic ketogenic diet, and how it differs from the popularized “keto diet”.

When compared with a Very Low Carbohydrate Diet (VLCD), the popularized “keto diet” which focuses on high intake of eggs and fatty cuts along with copious amounts of added fat in the form of ‘fat bombs’ and ‘bulletproof coffee’ is like a caricature compared with a portrait.  A portrait seeks to accurately represent physical attributes, and a caricature uses hyperbole to exaggerate some, and over-simplify others. 

This new article picks up from the previous one in outlining another type of therapeutic ketogenic diet used for putting type 2 diabetes into remission as well as for weight loss, and how it is very different from the popularized “keto diet”.

A Therapeutic Ketogenic Diet

A ketogenic diet is one that induces and sustains a state of ketosis which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate. What makes any diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains.

In reference to the treatment of type 2 diabetes and obesity, ketogenic diets are often referred to in the literature as a ”Very Low Carbohydrate Dies (VLCD)“, which is where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake[1]. It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate and at this very low level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis.

Ketosis is where the ketone betahydroxybutyrate (BHB) reaches levels between 0.5 — 3.0 mmol/L (and up to 4.0 mmol/L for therapeutic ketogenic diets  used in the treatment of epilepsy, seizure disorder and glioblastoma). In a Very Low Carbohydrate Diet (VLCD) used in the treatment of type 2 diabetes, BHB levels are usually set between 1.5-3.0 mmol/L, a level described as nutritional ketosis [2].

A drug or diet is said to be therapeutic when it is used in the treatment of a disease or medical condition(s). When implemented by a Dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) [3].

Use of a Very Low Carbohydrate Diet (VLCD) as Medical Nutrition Therapy in the treatment of type 2 diabetes is recognized by numerous organizations around the world, including the European Association for the Study of Diabetes (EASD).

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included both a low carbohydrate (LC) and very low carbohydrate (VLC) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report, and has included both in their 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  This year,  Diabetes Canada released a Position Statement outlining that a low carbohydrate (LC) and very low carbohydrate diet (VLCD) are both safe and effective treatment for non-pregnant or lactating adults with type 2 diabetes.

The American Diabetes Association’s  Consensus Report defines low carbohydrate and very low carbohydrate as follows;

”In this review, a low carbohydrate (LC) eating patterns is defined as reducing carbohydrates to 26-45% of total calories [4].”

and

”In this review a very low carbohydrate (VLC) eating pattern is defined as reducing carbohydrate to <26% of total calories [4].”

Diabetes Canada also defines low carbohydrate and very low carbohydrate diets in terms of the amount of carbohydrate the diet contains. Low carbohydrate diets are defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate,  and very low carbohydrate diets as <50 g of carbohydrate per day [5].

Very Low Carbohydrate Diet (VLCD) for Treatment of Type 2 Diabetes

Back in 2018, the American Diabetes Association cited Virta Health’s one-year study data [6] as evidence for the safety and efficacy of a Very Low Carbohydrate Diet (VLCHD) in lowering blood sugar and diabetes medication usage and the new Diabetes Canada’s recommendations refers to the same study. As a result, Virta Health’s study is a good place for defining what a Very Low Carbohydrate Diet (VLCD) for the treatment of type 2 diabetes looks like.

Note: It should be noted that at the time the ADA’s 2019 Standards of Medical Care in Diabetes was published, Virta Health’s 2-year data had not yet been published, so the ADA and in turn, Diabetes Canada recommendations which were based on it, as well as other international organizations support for low and very low carbohydrate diets were only able to say conclusively that low carbohydrate diets and very low carbohydrate diets were safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months). 

Virta Health’s Approach

As covered in this article about Virta Health’s 2-year update and in this article with their 1-year update , subjects in their studies typically ate;

1. <30 g per day of total dietary carbohydrate
2. daily protein intake was targeted to a level of 1.5 g / kg based on ideal body weight
3. Participants were coached to incorporate dietary fats until they were no longer hungry (i.e. to satiety)

Note (August 31, 2020): To put the protein requirements in perspective, a male whose ideal body weight is 150 pounds (68 kg) would be eating over 100 g of protein per day and a female whose ideal body weight is 135 pounds (61 kg) would be eating 92 g of protein per day.  That is, protein is targeted for its nutrient-density and satiety, and fat is incorporated only until satiety is reached.

Phinney and Volek’s Approach

Dr. Stephen Phinney MD, PhD, a medical doctor and Dr. Jeff Volek, RD, PhD a Registered Dietitian with a PhD have decades of combined scientific and clinic research experience in the area of low carbohydrate diets. In 2011 they published their expert guide titled The Art and Science of Low Carbohydrate Living [7] documenting the clinical benefits of carbohydrate restriction and how it can be used for weight loss.

In Phinney and Volek’s book [7], the Very Low Carbohydrate Diet (VLCD) outlined is one that is higher protein during the weight loss phase than during the weight maintenance stage, with ~30% of caloric intake coming from protein during weight loss, but which decreases to ~21% of caloric intake during weight maintenance. Fat is 60% of calories during the weight loss phase, and is increased to 65-72% during weight maintenance. Carbohydrate intake is kept very low (7.5-10% of calories for men, 2.5-6.5% of calories for women) in order to induce nutritional ketosis.

The reason dietary fat intake is lower during the weight loss phase in Phinney and Volek’s approach is to allow for the using of body fat stores for energy.

In Phinney and Volek’s approach;

1. Carbohydrate intake is 7.5-10% of calories for men, 2.5-6.5% of calories for women
2. Protein intake is up to 30% of calories during weight loss, 21% during weight maintenance
3. Fat is 60% of calories during weight loss, 65-72% of calories during weight maintenance

Note (August 31, 2020): Protein intake for someone eating 2000 kcals per day is 150 g and for someone eating 1700 kcals per day is 141 g per day. Again, protein is targeted for its nutrient-density and satiety, and fat is only 60% of calories during weight loss.  This is very different than the popularized “keto diet”.

Popularized “Keto Diet”

The popularized “keto diet” is usually described as 70 – 80% fat, 15-20% protein* and 5% carbohydrate, with websites and articles promoting it frequently show plates laden with bacon and eggs, large fatty steaks with added butter melting on top, and loads of whipping cream over berries, and lots of avocado.

*while many “keto” proponents still stick with the lower protein intake [8], others have more recently increased the protein macro to 20% of calories, with fat at 70%.

This popularized “keto diet” is not the Very Low Carbohydrate Diet (VLCD) used by either Virta Health for putting type 2 diabetes into remission, or the VLCD approach used by Phinney and Volek for weight loss.

The popularized “keto diet” has ~50% less protein than a Very Low Carbohydrate Diet (VLCD) and ~20% more fat, which has twice the energy density as protein. 

Furthermore, the popularized “keto diet” is a very high fat, very low carbohydrate diet and which is often promoted along with periods of intermittent fasting (IF), as frequent periods of less than 24 hours, or longer fasting periods which may include 5:2 (5 days of normal diet, 2 days restricting total calories to 500 per day), alternate day fasting, 36 hour fasts, or 42 hour fasts. This approach may suit some, but one has to ask if only eating ~1/3 of the time, is any weight loss really due to eating super high fat all the time, or due to the periods of fasting?

Like a caricature, the popularized “keto diet” exaggerates some aspects of a Very Low Carbohydrate Diet (VLCD) and over-simplifies others. It exaggerates the fallacy that one needs to add extra fat into everything in order to lose weight, and it overlooks the satiety of protein.

[Personal note: Approximately 1/3 of clients come to me for support after having followed this popularized “keto diet” without the fasting, and having failed to lose more than a bit of weight initially, or having gained weight.] 

Final Thoughts

There is no one-sized-fits-all low carb or ketogenic diet for weight loss, because each person’s nutrition needs are different. As covered in the preceding article, for those seeking safe and effective weight loss, there are a range of low carbohydrate diets available to choose from, with some that includes periods of ketosis, and others that don’t.

For those seeking to put type 2 diabetes into remission, a well-designed ketogenic diet using the Virta Health approach, or for weight-loss using Phinney and Volek’s approach are both safe and effective, if individualized for each person and done with adequate oversight. 

Remember, if you are taking any medication for type 2 diabetes, please read this article for why it can be dangerous to begin a very low carbohydrate diet (VLCD) / ketogenic diet without the involvement of your diabetes team.

More Info?

If you would like more information about type of low carb or ketogenic diet that might be best suited to you, please send me a note using the Contact Me form on the tab above.

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

References

1. 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
2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
3. U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415
4. 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
5. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
   Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
6. 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
7. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
8. Zoe Harcombe, LCHF and Butter, January 29, 2018, https://www.zoeharcombe.com/2018/01/lchf-and-butter/

Copyright ©2020 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.

There is a common, but mistaken belief that there is such as thing as “the keto diet” (singular) — which is high in fat of all types, including cream, butter, bacon, avocado and fatty cuts of meat. In fact, there are a wide range of “keto diets” (plural) — including several different therapeutic ones, as well as those that have been popularized the last several years for weight loss.  This article will explains the range of ketogenic diets that are available, and what they are used for as well as the unintended consequence of believing that a “keto diet” has to be high in fat.

What is a Ketogenic Diet?

A ketogenic diet is one that induces and sustains a state of ketosis, which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate.

There are a number of different therapeutic ketogenic diets, as well as a number of weight-loss ketogenic diets. 

What makes any diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains.

This bears repeating.

A ketogenic diet is determined solely on the basis of how much carbohydrate it contains, and not on how much fat in contains.

Ketogenic diets, which are also referred to in the literature as “very low carbohydrate diets” are where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake [1].  It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate and at this very low level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis. 

Ketosis is where the ketone betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L — and up to 4.0 mmol/L for therapeutic ketogenic diets used in the treatment of epilepsy, seizure disorder and glioblastoma.

Nutritional ketosis used predominantly for weight loss is usually set with BHB levels between 1.5-3.0 mmol/L [2].

Low carbohydrate diets are those where carbohydrate intake is limited to < 130 g per day or < 26% of total energy intake [1] and moderate carbohydrate diets are where carbohydrate intake is limited to 130—225 g per day or 26—45% of total energy intake [1].

Again, the amount of fat in the diet has nothing to do with a diet being ketogenic — only the amount of carbohydrate it contains.

Therapeutic Ketogenic Diets

First of all, what does “therapeutic” mean?

Something is therapeutic when it is used in the treatment of a disease. This may be a pharmaceutical drug or a diet.  What makes a diet therapeutic is that it is used to treat a medical condition, or conditions.

A therapeutic diet may be prescribed by a physician, and implemented by a Dietitian or the physician themselves.  When implemented by a Dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) [3].

The first therapeutic ketogenic diet was used in the 1920s by Dr. Russell Wilder, for the treatment of diabetes and later, for epilepsy.

Physicians at Harvard Medical School had begun experimenting with periods of extended fasting as a treatment, and discovered that seizures improved after 2-3 days. In 1921 , Dr. Russell Wilder[3] used a very high fat, low carbohydrate, and restricted protein diet in a series of patients with epilepsy, and found that it was as effective as fasting and had the advantage that it could be maintained for much longer a period of time than fasting.

The percentage of carbohydrate, fat and protein in what has since become called the “classic” Ketogenic Diet (KD) was worked out by Dr. M.G. Peterman in 1925 [4] and are the same as used today.  In the classic KD, the total amount of calories are matched to the number of calories the person needs. Protein is usually determined as being 1 g of protein per kg body weight, 10-15 g of carbohydrate per day total, and the remainder of calories provided as fat.  For very young children, the diet may be prescribed based on body weight (e.g. 75-100 calories for each kg (2.2 pounds) of body weight. 

Since the 1920s, several other therapeutic ketogenic for the treatment of epilepsy and seizure disorder have been developed, including the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD). These are all high fat diets, but differ in the amount of protein they contain. They are all very low carbohydrate diets, which is by definition what makes them ketogenic.

The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs. In the classic Ketogenic Diet, 90% of calories come from fat, 6% from protein, and only 4% of calories come from carbohydrate.

The Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein and carbohydrate. In a Modified Ketogenic Diet, 80-90% of calories come from fat, 12-15% of calories come from protein, and 5-6 % calories come from carbohydrate[5].

The Modified Atkins Diet (MAD) has a 2:1 ratio, with 2 parts fat for every 1-part protein and carbohydrate.  In a Modified Atkins Diet, carbohydrates are restricted to <15 g / day for children, <20 g / day for adults. In a Modified Atkins Diet, 60% of calories come from fat, 30% of calories come from protein, and 10% of calories come from carbohydrate[5].

As well as their use in epilepsy and seizure disorder, any of the above therapeutic ketogenic diets may be prescribed for patients as adjunct treatment in glioblastoma, or as adjunct treatment in Alzheimer’s disease.

These high fat diets are not weight loss diets. These are therapeutic ketogenic diets used with the goal of producing high amounts of ketones (> 4.0 mmol/L / 40 mg/dl) for therapeutic reasons.

Other Types of Therapeutic Ketogenic Diets – for treatment of type 2 diabetes and obesity

In addition to the three types of therapeutic ketogenic diets above, ketogenic diets where carbohydrate is restricted to 50g of carbohydrates per day or less are considered Medical Nutrition Therapy (MNT) in the treatment of type 2 diabetes.

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included the use of a very low carbohydrate (ketogenic) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report and both the 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  In addition, Diabetes Canada released a Position Statement in April of this year outlining that a low carb and very low carb / keto (<50 g of carbohydrates per day) are both safe and effective treatment for adults with diabetes. 

According to the American Diabetes Association, what makes a diet low carbohydrate (LC) or very low carbohydrate (VLC) / ketogenic is defined by the amount of carbohydrate contained in the diet, not the amount of fat. The American Diabetes Association’s  Consensus Report defines low carb and very low carb as follows;

“In this review, a low carbohydrate (LC) eating patterns is defined as reducing carbohydrates to 26-45% of total calories [6].”

and

“In this review a very low carbohydrate (VLC) eating pattern is defined as reducing carbohydrate to <26% of total calories [6].”

Diabetes Canada also defines low carbohydrate and very low carbohydrate diets in terms of the amount of carbohydrate the diet contains. Low carbohydrate diets are defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate,  and very low carbohydrate diets as <50 g of carbohydrate per day [7].

[August 8, 2020: You can read more about the use of a Very Low Carbohydrate Diet (VLCD) used as Medical Nutrition Therapy for type 2 diabetes in the following article, posted here.]

Weight-Loss “Keto” Diets

There are a wide range of weight-loss approaches that have a ketogenic (keto) component to them.

The 1997 Protein Power[8] published by Dr. Micheal Eades and his wife Dr. Mary Dan Eades is a low carb, high protein, moderate fat ketogenic diet. In fact, the authors warn in the book that eating a large number of calories as fat would make it impossible to lose weight, so this is not a high fat diet at all.

The New Atkins For a New You [9], was redesigned in 2010 by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, and while considered a low carbohydrate high fat, moderate protein weight loss diet, it has 4 phases, with only the first phase being ketogenic (20-50 g carbs per day), but only for two weeks. This first stage is where the Modified Ketogenic Diet (MKD) used in epilepsy and seizure disorder came from — but as a weight-loss diet, the high fat stage in The New Atkins for a New You is very short lived. In phase two, more carbohydrate is added (nuts & seeds, berries, cherries and melon, cheese,  dairy products, legumes (pulses), tomato juice and vegetable cocktail) and this level is maintained until close to goal weight when higher carbohydrate amounts are added in phase 3, then phase 4. It is only higher fat for the first two weeks.

Then there is the 2013 Real Meal Revolution [10] by Tim Noakes, Sally-Ann Creed, Jonno Proudfoot which is a handbook on the Banting lifestyle (which originated in the late 1800s), with foods broken down into green list, orange list and red list, with varying levels of carbohydrate intake.

Note: there is also the 2014 Bulletproof Diet by former Silicon-Valley biohacker, Dave Asprey but since he doesn’t have a clinical background, I have not included it.  That said, the diet is very high fat and is where “bulletproof coffee” (with added butter and coconut oil) comes from.

In 2016, Dr. Jason Fung, a Toronto nephrologist (kidney specialist) wrote the Obesity Code [11] which promotes a high fat version of a very low carb / keto diet, which is used in conjunction with his 2016 book written with Jimmy Moore titled The Complete Guide to Fasting [12]. In 2020, Fung published Life in the Fasting Lane [13], written with Eve Meyer and Megan Remos which builds on his approach of using a low carb high fat diet along with intermittent fasting.

In 2014, the web site “Diet Doctor” was launched by Dr. Andreas Eenfeld. This was initially mostly with articles translated from his Swedish site and later added content from a variety of other people, including Dr. Jason Fung, Dr. Eric Westman and Dr. Ted Naiman.  In 2017, Eenfeld wrote his own diet book titled Low Carb High Fat Food Revolution [14], which promoted a high fat version of a very low carb / ketogenic weight loss diet.  Later, Dr. Eric Westman went on to found his own Adapt weight loss program which is a very low carb / keto, moderate protein, moderate fat approach and Dr. Ted Naiman went on to write his P:E Diet [15] which promotes a low carb, high protein, low fat approach.

Of ketogenic weight-loss diets outlined above, the two that promote a very high fat intake are Dr. Jason Fung’s approach, and the “Diet Doctor” approach. While both fat and protein result in satiety (not feeling hungry), fat has almost two and a half the caloric density as protein. In addition, fat can trigger the reward system of the brain in the same way carbs do, resulting in many over-eating fat, especially added fat. What many people fail to take into consideration is that both of these approaches also promote periods of intermittent fasting (IF) which as Diet Doctor teaches may be frequent periods of less than 24 hours, to longer fasting periods which may include 5:2 (5 days of normal diet, 2 days restricting total calories to 500 per day) or alternate day fasting, as well as two types of fasts that Dr. Fung promotes, including 36 hour fasts, and 42 hour fasts. If one is only eating ~1/3 of the time, is any weight loss really due to the high fat diet, or the fasting?

“In our clinic, we will often recommend 36-hours fasts 2-3 times per week for type 2 diabetes.” ~Dr. Jason Fung

[ADDED NOTE, August 24, 2020: a well-formulated ketogenic diet such as used by Virta Health (covered here and here) which is high in fat and moderate in protein and that consists of a diet of real, whole food is not the same as popularized “keto diets” high in fat and moderate protein, but that consist of lots of added fat, in both food and beverages. There is more to a well-designed ketogenic diet for remission of type 2 diabetes and obesity than macros, alone.

August 27, 2020: There is a fundamental difference between a well-designed ketogenic diet that is high in fat and that is comprised of real, whole food — and the popularized “keto diet”, which is all about added fat. It’s not about macros, but nutrients.]

Unintended Consequences of Believing That a High Fat Diet is THE “Keto Diet”

Over the last several years, about 1/3 of people that come to me do so after following one of these popular high fat “keto” diets.  Most lost some weight initially and then stalled — and quite a few actually ended up gaining weight.

Whether following Dr. Fung’s approach or the Diet Doctor approach, people reported eating 75% fat, 15% protein and 10% carbohydrate — which is essentially a hybrid between the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) which as mentioned above are NOT weight loss diets — in fact, they were designed to not result in weight loss. These high fat, moderate protein diets are diets are solely intended to produce large amounts of ketones for therapeutic purposes. 

It is no wonder high fat “keto” diets don’t deliver weight loss results. That’s not what they were designed to do! 

Unless these high fat “keto” diets are combined with the frequent periods of <24 hours of fasting, >24 hour periods of fasting several times per week, weight loss is unlikely to occur — unless as byproduct of the higher satiety of the fat, and over all eating less food.

Losing Body Fat is Not About Eating Less Carbs and More Fat!

If we want to lose body fat, then eating food that is very high in dietary fat won’t accomplish that — UNLESS one is only eating every second or third day, which is what high fat “keto” diets promote. If we are eating a high fat diet and regularly fasting for extended periods of time, it is the fasting itself that underlies body fat loss and lower insulin, not all the added dietary fat.

Eating tons of bacon, butter, cream and avocado makes perfect sense in a therapeutic diet for epilepsy, seizure disorder or as an adjunct treatment in glioblastoma or Alzheimer’s disease, because the goal is to produce lots of ketones — but if one wants to lose weight without using frequent periods of fasting, then adding tons of fat to food makes no sense. We want to utilize our fat stores for energy, not burn dietary fat.

One can use any one of a number of low carbohydrate approaches to accomplish weight loss, as well as improve blood sugar — by focusing on eating nutrient dense foods with a high protein-to-energy ratio, and that are rich in micronutrients.  Protein also increases satiety, helps build muscle and is much less calorically dense than fat [16].

Whether starting at a brief ketogenic level and working up (such as the method used by Protein Power, New Meal Revolution or Westman, Phinney and Volek’s approach in the New Atkins, or using an approach I often do which is to start people off at 130 g of carbohydrate per day, and lower carbohydrate as required to achieve clinical outcomes. In either approach, weight loss and lower insulin and glucose can be achieved without extended or frequent periods of fasting.

That doesn’t mean there aren’t benefits to doing short daily periods of fasting, such as from after dinner on one day until the first meal the following day — there are.  It simply isn’t required for weight loss.

Final Thoughts…

There are several therapeutic ketogenic diets that can be used in epilepsy and seizure disorder as well as other conditions, and other types of therapeutic ketogenic diets that are considered Medical Nutrition Therapy (MNT) for the treatment of type 2 diabetes and obesity.

The idea that “a keto diet” has to be high in fat is a fallacy — one that has the unintended consequence of many people failing to lose weight (and often gaining weight) because they don’t realize that it needs to be combined with periods of intermittent fasting. 

A weight-loss “keto diet” that is 75% fat, 15% protein and 10% carbs is only one type of ketogenic diet. It is by no means “THE keto diet!”. A diet that is low in carbohydrate and rich in nutrient-dense lean protein, as well as a wide range of vegetables and fruit is just as much a “keto diet” because it is low in carbohydrate — and one that can be used successfully to achieve weight loss, with no fasting required.

In short, there is no one-size-fits-all-low-carb or keto diet, but rather a range of low carb and keto diets that can be chosen from, based on each person’s personal preference, as well as their specific medical needs.

More Info?

If you would like more information about type of low carb or ketogenic diet that might be best suited to you, please send me a note using the Contact Me form on the tab above.

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

References

1. 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
2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
3. U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415
4. Peterman MG, The Ketogenic Diet, JAMA. 1928;90(18):1427—1429. doi:10.1001/jama.1928.02690450007003
5. Kossoff EH, Doward JL. The Modified Atkins Diet. Epilepsia 2008; 49 (Suppl8): 37-41
6. 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
7. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
   Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
8. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
9. Westman E, Phinney SD, Volek J, (2010) The New Atkins for a New You – the Ultimate Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
10. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
11. Fung J (2016) Obesity Code, Greystone Books, Vancouver
12. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
13. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
14. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
15. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020)
16. Paddon-Jones D, Westman E, Mattes RD et al, Protein, weight management, and satiety, The American Journal of Clinical Nutrition, Volume 87, Issue 5, May 2008, Pages 1558S—1561S, https://doi.org/10.1093/ajcn/87.5.1558S

Copyright ©2020 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.

INTRODUCTION: I’ve heard other Dietitians say that the keto diet is a potentially dangerous and an overall unhealthy diet because it focuses on ‘high intakes of processed meat, butter and cream’. Some have said that harmful effects were seen as much as three years post keto —  with one case involving symptoms of uncontrollable food cravings and “a head rush” after ingesting any carbs, and another three cases of people having developed severe adverse health effects, including one with newly diagnosed diabetes that wasn’t present before the diet, and two others with non-alcoholic fatty liver disease. All of these individuals were said to have gained all the weight back plus more, and the concern was raised as to whether the keto diet can really be called “a key to diabetes reversal or diabetes remission” because we haven’t actually fixed a broken pancreas. This article will address some of these beliefs.

The belief that there is such as thing as “the keto diet” (singular) which is high in processed meat, butter and cream is common, but incorrect. More on that below.

As a Dietitian, I am expected to be well-informed about a wide range of dietary options and to speak and write from an evidenced-based perspective, but the reality is that as Dietitians we can’t be knowledgeable in all available diets. While I am by no means an expert on low carb or ketogenic diets, I have written over 200 articles on the topic (published on my dedicated low-carb practice website), and have been using low carb and ketogenic diets as two of several dietary options in clinical practice for the past 5 years.

Firstly, with regards to the severe adverse health effects that the 3 individuals reportedly developed as a result of following the keto diet, it has been documented that abnormal glucose responses are present as long as 20 years before a diagnosis of Type 2 Diabetes[1] and the American Association of Clinical Endocrinologists (AACE) concluded that both insulin resistance and prediabetes precede a diagnosis of type 2 diabetes[2] — which means that people presenting with type 2 diabetes after following “the keto diet” had been developing the disease for many years prior.

Furthermore, non-alcoholic fatty liver disease (NAFLD) is strongly associated with insulin resistance, which is characterized by excessive hepatic glucose production (high production of glucose by the liver) and compensatory hyperinsulinemia [3-9], which is the response of the liver to produce high amounts of insulin in order to remove the excess glucose. The association of NAFLD with insulin resistance indicates that the fatty liver was developing for years prior to these individuals following “the keto diet”.  Furthermore, it has been documented that a classic ketogenic diet (KD) is an effective treatment for nonalcoholic fatty liver disease [10] and “rapidly reverses NAFLD and insulin resistance despite increasing circulating non-esterified fatty acids, the main substrate for synthesis of intrahepatic triglycerides” [10].

As for “the keto diet” being a key to diabetes reversal or diabetes remission, I’ve addressed this in detail in a previous article.

So, let me address the misconception that there is such a thing as “the keto diet” (singular), which is high in processed meat, butter and cream.

Many Types of Keto Diets

There are a variety of therapeutic ketogenic diets, including the Ketogenic Diet (KD), the Modified Ketogenic Diet and the Modified Atkins Diet, as well as a variety of ketogenic diets that are used both for therapeutic reasons (such as the management of type 2 diabetes), as well as those that are followed for personal choice.

What makes a diet therapeutic is that it is used to treat a medical condition or conditions and is recommended by a Physician, and implemented by a Dietitian, or by the MD themselves. When a doctor sends me a referral to implement a Modified Atkins Diet for one of their patients with seizure disorder, it is a therapeutic diet. So is a referral to implement a very low carbohydrate / ketogenic diet for the treatment of type 2 diabetes or fatty liver disease.

Use of a very low carb / keto diet by Physicians or Dietitians in the management of type 2 diabetes should come as no surprise to anyone given that these dietary patterns are considered Medical Nutrition Therapy (MNT) in the treatment of type 2 diabetes.

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included the use of a very low carb / keto eating pattern for treating type 2 diabetes in their 2019 Consensus Report and and both the 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020) and Diabetes Canada released a Position Statement in April of this year acknowledging that a low carb and very low carb / keto (<50 g of carbohydrates per day) are both safe and effective for adults with diabetes. 

Therapeutic ketogenic diets such as the classic Ketogenic Diet (KD), the Modified Ketogenic Diet and the Modified Atkins Diet are by necessity high fat diets — because the goal is to produce very high levels of ketones in order to improve clinical outcomes in epilepsy and seizure disorder, and as adjunct treatment in glioablastoma ( a type of brain cancer) and in Alzheimer’s disease.  The Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs, the Modified Ketogenic Diet (MKD) has a 3:1 ratio; 3 parts fat for every 1-part protein and carbs, and the Modified Atkins Diet (MAD) has a 2:1 ratio, with 2 parts fat for every 1-part protein and carbs.

What makes a weight loss diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains. Very low carbohydrate / ketogenic diets are diets where carbohydrate is limited to 20-50 g per day or 10% of total energy intake [11]. It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate.  At this level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis. 

Ketosis is where betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L (and up to 4.0 mmol/L for therapeutic ketogenic diets such as those used in the treatment of epilepsy, seizure disorder and gliolblastoma), whereas nutritional ketosis for optimal weight loss is commonly set with BHB levels between 1.5-3.0 mmol/L [12].

There is no one “keto diet” for weight loss but a range of choices, only some of which I will mention here.

I will start by looking at one of the earlier known diets that used a ketogenic level of carbohydrate intake; the 1972 Dr. Atkins’ Diet Revolution[13], by Dr. Robert Atkins. The so-called “Atkins’ Diet” had an introductory phase which limited carbohydrate intake to 20-25 grams of net carbs from nuts, seeds, and low carb vegetables, and this phase resulted in people going into ketosis.  In fact, this first phase of the Atkin’s Diet is what forms the basis for the Modified Atkins Diet, a therapeutic diet used in the treatment of epilepsy and seizure disorder.

The 1997 Protein Power[14] published by Dr. Micheal Eades, and his wife Dr. Mary Dan Eades is a low carb,  high protein, moderate fat ketogenic diet. In fact, the authors warn in the book that eating a large number of calories as fat would make it impossible to lose weight, so this is not a high fat diet at all.

The New Atkins For a New You [15], was redesigned in 2010 by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, and is a low carb high fat, moderate protein weight loss diet that has 4 phases, with the first phase being ketogenic to start with (20-50 g carbs per day), but is only ketogenic for two weeks.  In phase two, more carbohydrate is added as nuts & seeds, berries, cherries and melon, cheese,  dairy products, legumes (pulses), tomato juice and vegetable cocktail and this level is maintained until close to goal weight when phase 3, then phase 4 (both higher carb) are implemented.

The 2011 book by Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, The Art and Science of Low Carbohydrate Living [16] is not a diet book, but elaborates on type 2 diabetes as ‘carbohydrate intolerance’ and on the importance of electrolyte and mineral management to avoid side effects of a ketogenic diet. In this approach, added dietary fat is incorporated after weight loss, for long term weight maintenance, to prevent further weight loss.

Then there is the 2013 Real Meal Revolution [17] by Tim Noakes, Sally-Ann Creed, Jonno Proudfoot which is a handbook on the Banting lifestyle (which originated in the late 1800s), with foods broken down into green list, orange list and red list, with varying levels of carbohydrate intake.

Note: there is also the 2014 Bulletproof Diet by former Silicon-Valley biohacker, Dave Asprey but since he doesn’t have a clinical background, I have not included it.  That said, the diet is very high fat and is where “bulletproof coffee” (with added butter and coconut oil) comes from.

In 2016, Dr. Jason Fung, a Toronto nephrologist (kidney specialist) wrote the Obesity Code [18] which promotes a high fat version of a very low carb / keto diet, which is used in conjunction with his 2016 book written with Jimmy Moore titled The Complete Guide to Fasting [19]. In 2020, Fung published Life in the Fasting Lane [20], written with Eve Meyer and Megan Remos which builds on his approach of using a low carb high fat diet along with intermittent fasting.

In 2014, the web site “Diet Doctor” was launched by Dr. Andreas Eenfeld. This was initially mostly with articles translated from his Swedish site and later added content from a variety of other people, including Dr. Jason Fung, Dr. Eric Westman and Dr. Ted Naiman.  In 2017, Eenfeld wrote his own diet book titled Low Carb High Fat Food Revolution [21], which promoted a high fat version of a very low carb / ketogenic weight loss diet.  Later, Dr. Eric Westman went on to found his own Adapt weight loss program which is a very low carb / keto, moderate protein, moderate fat approach and Dr. Ted Naiman went on to write his P:E Diet [22] which promotes a low carb, high protein, low fat approach.

Of ketogenic weight-loss diets above, the only ones that promote a high fat intake with processed meat (bacon), butter and cream are Dr. Jason Fung’s approach and the “Diet Doctor” approach. These are not THE “keto diet” — but one type of ketogenic approach, amongst many.

Self Administered Diets

If an individual hears about a diet from friends, or reads about it online and implements it, and is unsuccessful at losing weight or at keeping it off, or has adverse side effects, is this a reflection of the diet itself or is it a problem inherent in self-administered diets?

Does it matter if the failed “diet” is a calorie-restricted diet, a ketogenic diet, a grapefruit diet or any other diet?

Self administered diets of any type may or may not be appropriate for an individual, because the person’s individual nutritional needs, risk factors, metabolic conditions, and medications are not factored in. Weight-loss failure is one issue, as are potential adverse side-effects.  For example, if a person decides to follow a very low-calorie diet, experiences hypoglycemia and falls and injures themselves, is this the fault of the diet itself, or their self-administration of a diet?  Likewise, if a person decides to follow a very low carbohydrate / ketogenic diet and has an adverse reaction because of some medications they are taking, is this the fault of the particular version of a ketogenic diet they are following?

All diets have potential benefits and risks and self-administered diets pose additional risks that simply haven’t been factored in — regardless what type of diet is chosen.

Failed Weight Loss

Studies show that the failure rate with weight-loss diets is high — often as much as 80 – 90%, and regain of weight is thought to possibly be higher because follow-up rates are very low, and weights are often self-reported either by phone or mail [23].

The fact that most people will gain most of the weight they lost while dieting back, and sometimes end up weighing more than before dieting is not disputed, and is irrespective of the type of diet followed.

Regardless of the dietary approach chosen, “dieting” is not the answer for sustained weight loss. If someone goes “on” a diet that means that at some point they will go “off” of it.  In my opinion, a lifestyle change is a preferred approach and what will work for one person long-term, may not work for another. That is why I say that there is no one-sized-fits-all diet.

Final Thoughts…

Low carb and very low carb / ketogenic diets are two approaches that can suit some, but not all people.  A Mediterranean Diet or a whole food plant based (vegetarian) diet may be better suited to others. 

The misconception that there is one “keto diet” that is high in fat, especially processed meat, butter and cream is simply incorrect. There are a range of ketogenic (keto) diets and even in a high fat ketogenic diet, the fat can come from avocado, nuts and seeds and olives.

A high fat versions of a keto diet may be appropriate and work well in some individuals when used with periods of intermittent fasting, such as OMAD (one meal a day). In my clinical experience, I have observed that high fat versions of a keto diet often result in weight stalls and even weight gain in peri- or post-menopausal women. Since I don’t recommend extended fasting > 24 hours in older adults due to the muscle-loss which can result from the fasting, combined with the muscle loss that is already associated with aging, I generally recommend a higher protein, lower added fat version in such cases. In any case, there are lots of ways to do a ketogenic weight-loss diet — which is ultimately about the total amount of carbohydrate in the diet, not the amount of fat.

More Info?

If you would like more information about the services I offer, please send me a note using the Contact Me form on the tab above.

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

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. 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
3.  Fabbrini E., et al. , Alterations in adipose tissue and hepatic lipid kinetics in obese men and women with nonalcoholic fatty liver disease. Gastroenterology 134, 424—431 (2008). 
4. Gastaldelli A., et al. , Relationship between hepatic/visceral fat and hepatic insulin resistance in nondiabetic and type 2 diabetic subjects. Gastroenterology 133, 496—506 (2007). 
5. Korenblat K. M., Fabbrini E., Mohammed B. S., Klein S., Liver, muscle, and adipose tissue insulin action is directly related to intrahepatic triglyceride content in obese subjects. Gastroenterology 134, 1369—1375 (2008). 
6. Kotronen A., Juurinen L., Tiikkainen M., Vehkavaara S., Yki-Jí¤rvinen H., Increased liver fat, impaired insulin clearance, and hepatic and adipose tissue insulin resistance in type 2 diabetes. Gastroenterology 135, 122—130 (2008).
7. Bugianesi E., et al. , Insulin resistance in non-diabetic patients with non-alcoholic fatty liver disease: Sites and mechanisms. Diabetologia 48, 634—642 (2005).
8. Seppí¤lí¤-Lindroos A., et al. , Fat accumulation in the liver is associated with defects in insulin suppression of glucose production and serum free fatty acids independent of obesity in normal men. J. Clin. Endocrinol. Metab. 87, 3023—3028 (2002).
9. Ryysy L., et al. , Hepatic fat content and insulin action on free fatty acids and glucose metabolism rather than insulin absorption are associated with insulin requirements during insulin therapy in type 2 diabetic patients. Diabetes 49, 749—758 (2000). 
10. Luukkonen PK, Dufour S, Lyu K, et al. Effect of a ketogenic diet on hepatic steatosis and hepatic mitochondrial metabolism in nonalcoholic fatty liver disease. Proc Natl Acad Sci U S A. 2020;117(13):7347-7354.
11. 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.
12. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
13. Atkins, R. C. (1972). Dr. Atkins’ diet revolution; the high calorie way to stay thin forever. New York: D. McKay Co.
14. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
15. Westman E, Phinney SD, Volek J, (2010) Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
16. Phinney SD, Volek J, (2011), The Art and Science of Low Carbohydrate Living, Beyond Obesity LLC
17. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
18. Fung J (2016) Obesity Code, Greystone Books, Vancouver
19. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
20. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
21. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
22. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020),
23. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233. doi:10.1037/0003-066X.62.3.220

Copyright ©2020 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.

Yesterday, as I was pondering what some Dietitians think with respect to what a ketogenic diet is and isn’t, it occurred to me that many people who follow me on social media and who follow a low carb or keto diet themselves, may not know the answers either. What started off as a single question, morphed into a series of 10 questions asked in Twitter polls which I will give the answers to here.

Please keep in mind, the questions were difficult to clearly formulate due to the limitation on the number of characters in Twitter polls.

Question #1

While there is a common misconception that a ketogenic diet needs to have lots of butter, cream and bacon and/or lots of meat, eggs and cheese, most people got the right answer that for a weight loss diet to be classified as keto, it needs to have carbs < 50 g per day. A keto diet for weight loss is not about the amount of fat it has, but the amount of carbohydrate it has.

As covered in this article titled What Makes a Diet Low Carb or Keto is NOT How Much Fat it Contains, different people define ”low carb” or ”keto” level of carbohydrates in different ways, but Feinman et al [1] defined three categories of reduced-carbohydrate diets as follows;

(a) very low carbohydrate ketogenic: carbs limited to 20—50 g per day or < 10% of total energy intake.

Note: What makes a keto diet ketogenic is that that low carbohydrate intake puts people into a state of ketosis, which is a normal physiological state that people go into after an overnight fast. It is where the body burns stored fat for energy, releasing ketones which can be used by the brain and other tissues.

(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.

Question #2

I found the response to this question very interesting. While only a small number of people believed that protein, fats and carbs are all “essential nutrients” defined as ones the body can’t make but that have to be taken in through the diet, almost as many people only believed that protein and omega 3 fats are essential nutrients, as believed that some amino acids and some fatty acids are essential.

As covered in the article Which Protein Foods are Best for Weight Loss on a Low Carb Diet according the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids, there are two essential fatty acids (linoleic acid, alpha-linolenic acid) and the nine essential amino acids(the building blocks of protein), including histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine that the body can’t manufacture. As covered in How Much Carbohydrate is Essential in the Diet, there is no essential carbohydrate.

Question #3

The answers to this question seemed to capture an underlying belief that a ketogenic diet for weight loss must have a certain amount of fat to be “keto” relative to a therapeutic ketogenic diet for epilepsy or seizure disorder — with 1/3 of people saying a weight-loss keto diet needed to have either a 4:1, 3:1 or 2:1 ratio of fat to (protein plus carbs) or a 3:1 or 2:1 ratio. Another 8% believed a keto diet for weight loss needs to have twice as much fat as protein plus carbs.  Less than 60% got the answer correct, that for a weight loss diet to be keto, it can be any ratio of protein or fat, given carbs are kept below 50g per day. As covered in How Much Carbohydrate is Essential in the Diet, page 275 of the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids states;

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

Question #4

I guessed that very few people realize that the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids actually states that the amount of carbohydrate required in the diet is zero, provided that adequate amounts of protein and fat are consumed.

For those that have never seen it from the source, here it is page 275 of the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids;

Question #5

On page 276 of the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005) it states:

“In the absence of dietary carbohydrate, de novo synthesis of glucose requires amino acids derived from the hydrolysis of endogenous or dietary protein or glycerol derived from fat. Therefore, the marginal amount of carbohydrate required in the diet in an energy-balanced state is conditional and dependent upon the remaining composition of the diet.”

That is, even when minimal amounts of carbohydrate is eaten, the body will synthesize the glucose needed by the brain from the protein taken in through the diet (provided it is in adequate amounts) or from glycerol which is formed when fat is broken down. If the protein in the diet (exogenous protein) is inadequate however, the body’s own protein (endogenous protein) will be used.

Question #6

The answer to this question was also very interesting.  Almost 1/2 (49%) of the 64 people that responded thought for a weight loss diet to be classified as keto, it needed to have either much more fat (22%) or more fat (27%) than protein. 13% thought for a weight loss diet to be keto it needed to have a bit more protein than fat and 40% got the answer correct, that it can have any mixture of protein or fat.  Remember, what makes a weight loss diet ketogenic is how much carbohydrate it has, not how much fat or protein it has (see question #1, above).

Question #7

Of concern, 1/4 of 85 people polled believed that there can never be serious side effects doing a keto diet. I would encourage everyone reading this post to read the article I wrote titled Don’t Try This at Home — the need for medication supervision which outlines the serious side effects that can occur if beginning a very low carb or ketogenic diet if taking

(1) insulin

(2) medication to lower blood glucose such as sodium glucose co-transporter 2 (SGLT2) medication including Invokana, Forxiga, Xigduo, Jardiance, etc. and other types of glucose lowering medication such as Victoza, etc.

(3) medication for blood pressure such as Ramipril, Lasix (furosemide), Lisinopril / ACE inhibitors, Atenolol / β₁ receptor antagonists

(4) mental health medication such as antidepressants, medication for anxiety disorder, and mood stabilizers for bipolar disorder and schizophrenia.

Question #8

Those who saw my talk at the Low Carb and Ketogenic Approach to Health summit last Sunday heard me refer to some discussion that had occurred on Twitter two weeks ago regarding the mistaken belief that ketosis is a pathological state.

Here is my response, with the reference.

Question #9

Since I was limited in the number of characters I could put in the answers, technically both answers would be correct the way it is worded. Yes, ketoacidosis is a physiological state, but a pathological physiological state.

In type 1 diabetes or insulin dependent type 2 diabetes the beta cells don’t produce enough inusulin so glucose can’t be moved into the cells to be used as fuel (needs insulin). The body starts to break down fat stores (triglycerides) for energy at a very fast rate, resulting in a build up of ketones (also called keto acids).  This excess keto acid buildup is called ketoacidosis and is a serious pathological condition that can be fatal.

Ketoacidosis can also occur if starting a very low carb or keto diet while taking certain medications (see question #7 for which medications).

Question #10

The majority of the 108 people answering this question got the answer correct.

Almost all people with type 2 diabetes following a keto diet can experience remission of type 2 diabetes as long as they maintain a very low carbohydrate or ketogenic diet.

”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. There are a few very limited cases  in the literature of this occurring, but for the most part long term remission is usually what is attainable.  This article titled The Difference Between Reversal and Remission of Type 2 Diabetes explains this in detail.

More Info?

If you would like more information about how I can help you follow a low carb or keto diet, please send me a note using the Contact Me form on the tab above.

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

References

1. 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.

Copyright ©2020 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 recommendation to lower the consumption of saturated fat in the diet to reduce the risk of cardiovascular disease (CVD) has been the central theme in both the US and Canadian since 1977, and has been carved into our respective Dietary Guidelines since the 1980s.

A newly published report published by the American College of Cardiology has stated that there is no beneficial effect on either cardiovascular disease (CVD) or death of lowering saturated fatty acid (SFA) intake and that saturated fat intake is actually protective against stroke [1]. This reassessment of dietary saturated fat intake was based on a meta-analysis of randomized control trials (the strongest data available), as well as observational studies.

The newly published report stated;

“Whole-fat dairy, unprocessed meat, eggs and dark chocolate are saturated fatty acid-rich foods with a complex matrix that are not associated with increased risk of cardiovascular disease. The totality of available evidence does not support further limiting the intake of such foods.”[1]

Dietary Recommendations to Lower Saturated Fat

From 1977 onward, based on a belief that saturated fat caused heart disease, both Canada and the US changed their respective dietary recommendations to move the diet away from consuming fat — especially saturated fat, to a diet where more than half the calories (55-60% in Canada, 45-65% in the US) were from carbohydrate. The goal was to lower the risk of cardiovascular disease based on the fact that eating saturated fat raised total LDL (LDL-C), and it was assumed that higher total LDL was tied to increased risk of heart disease. The problem was that it wasn’t known until many years later that there are different types of LDL particles (you can read more about that here) and that it is the small, dense LDL particles that are associated with heart disease, not all LDL particles [2].  

Coinciding with the recommendation for people to eat less saturated fat and more carbohydrate as the main source of calories, we have seen obesity rates go from ~10% of the population in both countries, to 1 in 3 people in the US, and 1 in 4 people in Canada — with another 1/3 of people falling in the overweight category.

What this newly published reassessment of the data indicates is that the American and Canadian diet, which has shunned whole-fat dairy, unprocessed animal meats and eggs for the last 40+ years did so without benefit to cardiovascular disease rates, or rates of death.

Telling people to eat “low fat” everything and to avoid butter, red meat and eggs not only did not do what it was intended to do, it has likely been a significant contributor to the obesity epidemic we now face, along with astronomical rates of type 2 diabetes, hypertension and yes, cardiovascular disease. How ironic.

The report summarized;

“The dietary recommendation to reduce intake of SFAs without considering specific fatty acids and food sources is not aligned with the current evidence base. As such, it may distract from other more effective food-based recommendations, and may also cause a reduction in the intake of nutrient-dense foods (such as eggs, dairy, and unprocessed meat) that may help decrease the risk of CVD, type 2 diabetes, and other non-communicable diseases, but also malnutrition, deficiency diseases and frailty, particularly among ”at-risk” groups. Furthermore, based on several decades of experience, a focus on total SFA has had the unintended effect of misleadingly guiding governments, consumers, and industry toward foods low in SFA but rich in refined starch and sugar.”[1]

Bias Against Saturated Fat

The report concluded;

“The long-standing bias against foods rich in saturated fats should be replaced with a view towards recommending diets consisting of healthy foods. What steps could shift the bias? We suggest the following measures:

1) Enhance the public’s understanding that many foods (e.g., whole-fat dairy) that play an important role in meeting dietary and nutritional recommendations may also be rich in saturated fats.

2) Make the public aware that low-carbohydrate diets high in saturated fat, which are popular for managing body weight, may also improve metabolic disease.”

“There is no robust evidence that current population-wide arbitrary upper limits on saturated fat consumption in the US will prevent CVD or reduce mortality.

Final Thoughts…

I  remember when the 1977 guidelines first came out, and when the 1988 Canada’s Food Guide was new.  I also remember when the majority of people were normal body weight and it was the exception for someone to be overweight or obese. Here it is, more than 40 years later and we now have strong evidence that saturated fat from unprocessed meat, full fat dairy and eggs does NOT contribute to heart disease or death, and is protective against stroke.

Given this evidence, will Health Canada revisit its most recent  Canada Food Guide of January 2019 and adjust it’s recommendation to ”limit the amount of foods containing saturated fat, such as cream, higher fat meats…cheeses and foods containing a lot of cheese”?

More Info?

If you would like more information about restoring your weight and healthy by eating a diet lower in carbohydrate and which includes real, whole food such as unprocessed meat, full-fat dairy and eggs, please send me a note using the Contact Me form on the tab above.

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

Reference

1. Astrup A, Magkos F, Bier, DM, et al, Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art Review, J Am Coll Cardiol. 2020 Jun 17. Epublished DOI:10.1016/j.jacc.2020.05.077
2. Lamarche, B., I. Lemieux, and J.P. Després, The small, dense LDL phenotype and the risk of coronary heart disease: epidemiology, patho-physiology and therapeutic aspects. Diabetes Metab, 1999. 25(3): p. 199-211.

Copyright ©2020 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.

WorkSafeBC has just released what will be required of regulated health professionals such as myself, as a Dietitian to safely run an in-person clinical practice in British Columbia during the ongoing Covid-19 outbreak, and it is much more involved than I imagined when I wrote a recent article. As well, these protocols are in addition to the obligations required prescribed by our professional college, as well as to abide by any relevant orders, notices, or guidance issued by the provincial health officer, and the relevant health authority, in my case Fraser Health.

The WorkSafeBC protocols include sections on Understanding the Risk, Selecting Protocols for the Workplace, as well as detailed Protocols for Health Professionals.

Understanding the Risk

The WorkSafeBC website outlines that the virus that causes COVID-19 is spread in several ways, including through droplets when a person coughs or sneezes, and from touching a contaminated surface before touching the face. It is outlined that risk or person-to-person transmission is increased the closer a healthcare professional comes to other people, the amount of time a healthcare professional spends near them, and the number of people seen by a healthcare professional.  The site emphasizes that “physical distancing measures help mitigate this risk”. The WorkSafeBC website also emphasizes that the risk of surface transmission is increased when many people contact same surface, and when those contacts happen in short intervals of time, therefore “effective cleaning and hygiene practices help mitigate this risk”[1].

Selecting Protocols for the Workplace

The WorkSafeBC website notes that there are different protocols which offer different levels of protection and emphasize that “Wherever possible, use the protocols that offer the highest level of protection and add additional protocols as required”[1].

Engineering controls – second level protection : if it is not always possible to maintain physical distancing, then install barriers such as plexiglass to separate people.

Administrative controls – third level protection – WorkSafeBC encourges the establishing of clinic rules and guidelines, such as cleaning protocols, making sure there is no sharing of equipment, and implementing one-way doors, or walkways, in order to minimize risk.

Personal Protective Equipment (PPEs) – fourth level protection – If the first three levels of protection aren’t enough to control the risk, WorkSafeBC recommends considering the appropriate use of non-medical masks, and to be aware of limitation of non-medical masks to protect the wearer from respiratory droplets.

Protocols for Health Professions

The list of protocols for healthcare professionals is extensive and includes several categories, including those for;

(a) hygiene, cleaning and disinfection – Ensure adequate hand washing facilities are available, and provide approved alcohol-based hand sanitizers,
Encourage staff and clients to practice hand hygiene upon entering and exiting the clinic. Identify all common areas such as clinical space, washrooms, etc. and high contact surfaces such as door handles, stair rails and develop and implement a cleaning and disinfection schedule and associated procedures. Increase cleaning and sanitizing of shared equipment and facilities (e.g. scales, washrooms). Develop and implement protocols for sanitizing treatment areas and equipment to prevent surface transmission between clients. Ensure safe handling and effective application of cleaning products.

(b) modifying staff areas and workflow – Work remotely whenever possible, develop and enforce policy that staff stay home when sick, hold meetings virtually through use of teleconference or online meeting technology and where in-person meetings are required ensure people are positioned at least two metres apart. Consider staggering start times / appointment times to reduce the number of people in the workplace at a given time. Minimize the number of co-workers that staff are interacting with, prioritize the work that needs to occur at the workplace in order to offer services. Minimize the shared use of equipment where possible, consider the requirement for staff to have dedicated work clothes and shoes, provide a place for staff to safety store their street clothes while working and change in/out of clothes to prevent cross-contamination upon entry and exit. Consider adjusting the ventilation such as increasing the amount of outdoor air while maintaining the indoor air temperature and humidity at comfortable levels for building occupants. 

(c) scheduling appointments and communicating with clients – Determine how many clients can be within the clinic at a given time while maintaining at least two metres of physical distance and do not book appoints above this number. In order to accommodate physical distancing, appointment times may need to be staggered. When speaking with clients during scheduling and appointment reminders, ask clients to consider rescheduling if they become sick, are placed on self-isolation, or have travelled out of the country within the last 14 days and attending appointments alone where possible, and not bring friends or children. Consider emailing the client forms that need to be filled out so clients can complete them prior to arriving, and clinics with a website should consider posting information on modifications made to the location and appointment visit procedures.

(d) reception – Post signage at the entrance and within the clinic to assist with communicating expectations, such as hand hygiene, physical distancing, respiratory etiquette, reporting illness or travel history, occupancy limits and no entry if unwell or in self-isolation. Consider placing lines on the floor to mark a two metres distance from the reception desk. Consider use of a transparent barrier such as a plexiglass shield around reception desk, when there is insufficient space to maintain two metre distance between staff and clients. Screen all clients when they check-in for their appointment by asking if they have symptoms associated with COVID-19, have been advised to self-isolate, or have travelled outside of Canada within the last 14 days. Clients that respond in the positive should be asked to leave and reschedule the appointment when deemed clinically appropriate. During transactions, limit the exchange of papers such as receipts if possible and where possible, payments should be accepted through contactless methods.

(e) waiting area – Arrange the waiting area in a way that allows at least two metres of physical distance between each client and consider removing extra chairs and coffee tables from the area to support this. Remove unnecessary items and offerings such as magazines etc. and use disposable cups or single- use items where necessary for beverages. Instruct clients to arrive no more than five minutes before their expected appointment. Where room size or layout presents challenges to physical distancing, consider alternative approaches, such as asking clients not to enter the clinic until they receive a text message or phone call to advise that their appointment can start.

(f) provision of health services – Conduct appointments virtually where clinically appropriate, conduct a point of care assessment for risk of COVID-19 for every client interaction and health services should not be performed on ill or symptomatic clients. Where the client requires timely treatment, ensure PPE is used in accordance with BC-CDC guidance. When possible, the clinical staff should position themselves at least 2 metres from the client and where physical distancing cannot be maintained consider the use of barriers and masks to reduce the risk of transmission. Clients should be required to wear masks for services in order to protect workers and workers should also wear masks to protect clients. Consider treating only one client at a time to minimize risks associated with moving between two or more clients, ensure clients are positioned at least 2 metres apart and shared equipment is cleaned and disinfected between uses by clients. If products / equipment is shared, they must be cleaned and disinfected between uses. Practice effective hand hygiene after each client by washing hands with soap and water or using an alcohol-based hand sanitizer approved by Health Canada. Where feasible, workers should avoid sharing equipment or treatment rooms and treatment rooms should be allocated to a single worker per shift.

(g) preparing for the next appointment and the end of the day – Ensure waiting and treatment areas and equipment are sanitized to prevent surface transmission between clients. Commonly touched surfaces and shared equipment must be cleaned and disinfected after contact between individuals even when not visibly soiled. Towels or any other items contacting a client are to be discarded or laundered between each use. Change into a separate set of street clothes and footwear before leaving work and work clothing should be placed in a bag and laundered after every shift. Shower immediately upon returning home after every shift.

As well, the WorkSafeBC website has protocols for documentation and training of staff, as well as links to the various professional colleges for health professionals to check additional requirements for their profession.

The Effect of these Necessary Protocols

These enhance protocols take time away from healthcare professionals being able to schedule actual clinical appointments. They require PPEs to be available and provided when necessary, as well as require extra time and labour for cleaning and disinfecting waiting areas, office equipment and washrooms, and to dispose of the waste. As much as we would all like things to “return to normal”, there is the need to accept that for now, this is the “new normal”.

For clinical practices that require a clinician to touch a client in the provision of services, such as in dentistry or registered massage therapy or physiotherapy there is no choice, but this is not the case in my practice. Thankfully, we are living in an era where there is secure video conferencing available which is ideal for the services that I provide as a Registered Dietitian, and is recommended by WorkSafeBC as the first approach when possible in the provision of health services.

I have been providing Distance Consultations for over a decade; which are virtual face-to-face’ visits that are functionally indistinguishable from the in-person services I provided prior to Covid-19. They are a very efficient use of my client’s time, as well as my own, and no PPEs are required, no disinfecting or extra hand-washing, or sanitizing of waiting areas, office space and washrooms between each client, and appointments are not spread out through the day due to the need to carry out decontamination tasks between clients.

I use secure HIPAA & PIPEDA compliant telemedicine software – with no download required.

During virtual appointments my clients and I see each other’s faces when we meet, and can comfortably talk, laugh and even sneeze without concern, and weight obtained from people’s own scales is more than adequate for the types of clients I see — and I provide my clients with written instructions for measuring their waist circumference the same way I would do it if they were in my office.

More Info?

If you would like more information about the different type of Dietetic services I provide, please have a look under the Services tab or in the Shop. If you have any 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/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd

References

WorkSafeBC – Health professions: Protocols for returning to operation,  https://www.worksafebc.com/en/about-us/covid-19-updates/covid-19-returning-safe-operation/health-professionals

Copyright ©2020 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.

INTRODUCTION: Governments around the world are beginning to relax lock-down measures put in place due to the Covid-19 pandemic and with that, many people are looking forward to having life ‘get back to normal’. But will it, and how soon?

For the past few months, we’ve stayed at home and sheltered-in-place in order to keep the healthcare system from becoming overwhelmed with too many cases of Covid-19 all at the same time. While there is much debate on social media as to whether things were done soon enough, or whether the measures taken should have been implemented at all, here in British Columbia, we are expecting to see the restoring of some medically-related services under enhanced protocols beginning mid-May[1]. 

What can people expect when it comes to medically-related services such as Dentists, Physiotherapists, Registered Massage Therapists, Chiropractors and Dietitians? Each of these types of professionals require a different amount of physical contact with clients. For example, Dentists and Physiotherapists must be able to touch their clients in order to provide services, therefore the types of personal protective gear and physical distancing barriers they will need to use will be very different than for someone who is a clinical counsellor or for me, as a Dietitian.

In my case, there would be the need to space out in-person appointments so that clients can physically distance from one another as one client is leaving and another arrives. What this would mean is that I would either need to see fewer people in the course of a day to ensure that there was no overlap between clients, or to provide a waiting area with chairs spaced 2 meters apart, which would need to be sanitized after each use.  This extra time would eat into my clinical day and also provide me much less flexibility for me to spend more time with client should it been necessary, since ensuring adequate social distancing between clients would take precedence. In fact, regulations require that before an appointment is even set up, there is the need to screen for risk factors and symptoms of COVID-19.

Basic PPEs

To protect both my clients and myself, there would be the need for use of some basic personal protective equipment (PPEs).

For example, I would need to wear a face mask in order to greet my clients, as well as to invite them into my office and I would be wearing gloves and a mask to weigh them, and take their waist circumference. Then there would be the need to sanitize the equipment after each use.

My clients would also need to wash their hands well when they arrive, as put on a clean mask (as my mask helps protect them and theirs helps to protect me). I would need to have disposable masks on hand in the event a client didn’t bring one of their own.  I would also need a designated place to throw out used disposable gloves and masks — which would need to be treated as a hazardous waste container, since there would be no way of knowing if someone were an asymptomatic carrier of Covid-19. I would also need a place where I could wash my hands well with soap and water between glove changes, or to sanitize my hands with an alcohol based hand-sanitizer.

To protect both my clients and myself during the assessment, my desk would  need to have a clear plexiglass screen that would enable my clients and I to see each other, but that would protect each other should one of us sneeze or cough, not to mention should we laugh, or “speak moistly”.

The washroom available for client use would need to have disposable towels available, as well as a designated bin for them to be disposed of as they too would need to be treated as potentially hazardous waste and the bathroom would need to be sanitized after each use.

These enhance protocols take time away from scheduling actual clinical appointments. They require PPEs to be available and provided when necessary, as well as require extra time and labour for cleaning and disinfecting waiting areas, office equipment and washrooms, and to dispose of the waste. For clinical practices that require a clinician to touch a client in the provision of services such as in dentistry or registered massage therapy or physiotherapy, there is no choice, but in my practice there really is no need. For clinical practices that require a clinician to touch a client in the provision of services such as in dentistry or registered massage therapy or physiotherapy, there is no choice, but in my practice there really is no need.

I have been providing Distance Consultations for over a decade; which are virtual face-to-face’ visits that are functionally indistinguishable from the in-person services I provided prior to Covid-19. Virtual appointments are a very efficient use of my client’s time, as well as my own, and no PPEs are required, no disinfecting or extra hand-washing, or sanitizing of waiting areas, office space and washrooms between each client. I can see many more clients in a day because appointments are not spread out due to the need to carry out decontamination tasks between clients.

During virtual appointments, my clients and I see each other’s faces when we meet, and can comfortably talk, laugh and even sneeze without concern.  Weight from people’s own scales is more than adequate for the types of clients I see, and I provide each of my clients with written instructions for measuring their waist circumference the same way I would do it if they were in my office.

Until When…?

It is apparent that enhanced protocols will need to remain in place in a clinical office setting until there is either a safe and effective vaccine available, or herd-immunity is obtained. Herd immunity is where the spread of the contagious virus within a population is sufficiently low because people had developed antibodies to it from exposure to the virus itself.  The challenge in the Covid-19 pandemic is that a reliable vaccine is estimated to be a year or 18 months away and herd-immunity via exposure to the virus is unlikely given that only those who get very ill with Covid-19 produce antibodies.

As I wrote about in a recent post, an article published April 27, 2020 in the journal The Lancet reported that while ~90% of those who have been hospitalized with severe Covid-19 develop IgG antibodies in the first 2 weeks, in non-hospitalized individuals with milder disease or with no symptoms, under 10% develop specific IgG antibodies to the disease[2]. That means that people that don’t get sick enough to require hospitalization likely don’t produce antibodies to the virus, resulting in very low herd immunity. As a result, in a clinical setting, these enhanced protocols will likely need to be maintained until a safe and effective vaccine is available, which is not going to be anytime soon.

The New Normal

As much as we would all like things to “return to normal”, there is the need to accept that for now, this is the “new normal”.

Thankfully, we are living in an era where there is secure video conferencing available which is ideal for clinical work that does not involve clinicians touching clients such as the ones that I provide as a Registered Dietitian.

More Info?

If you would like more information about the different type of Dietetic services I provide, please have a look under the Services tab or in the Shop. If you have any 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/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Reference

1. Government of British Columbia, BC’s Restart Plan, May 6, 2020,  https://www2.gov.bc.ca/gov/content/safety/emergency-preparedness-response-recovery/covid-19-provincial-support/bc-restart-plan#next-challenge
2. Altmann DM, Douek D, Boyton RJ, What policy makers need to know about COVID-19 protective immunity, The Lancet, April 27, 2020, DOI:https://doi.org/10.1016/S0140-6736(20)30985-5

Copyright ©2020 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.

A new study published this past Friday (May 1, 2020) in the journal Cell Metabolism has reported that people with type 2 diabetes (T2D) are at much greater risk of having a poor outcome in Covid-19 if they have poorly controlled blood glucose.

The study looked at data from 7337 people who were hospitalized with Covid-19 in nineteen different hospitals in Hubei Province in China. Over 950 people had T2D (952) whereas the remaining almost 6385 people did not and among those with type 2 diabetes, 282 had well-controlled blood glucose, whereas the other 528 did not.

Consistent with what I reported in a recent review of a previous study in Covid-19, people admitted to hospital with the virus and who were diagnosed with T2D had poorer outcomes. In the present study, those with T2D required more medical interventions including requiring supplemental oxygen and/or ventilators than those without type 2 diabetes, and had much higher death rates (mortality) than those without T2D.  Mortality in Covid-19 in those with T2D was 7.8%, but in Covid-19 without T2D, mortality was only 2.7%. What was very encouraging was that those with people with T2D who were admitted to the hospital with COVID-19 and who had maintained well-controlled blood glucose ranging between 3.9 to 10.0 mmol/L (70-180 mg/dl) had much lower death rates than those people with poorly controlled blood glucose, with the upper limit of blood sugar readings exceeding 10.0 mmol/L (180 mg/dl).

Almost 99% (98.9%) of those in hospital with Covid-19 and who had type 2 diabetes but well-controlled blood glucose survived Covid-19.

BUT

11% of those in hospital with Covid-19 and who had type 2 diabetes but poorly controlled blood glucose, died.

These findings provide clinical evidence that having better blood sugar control  leads to significantly better outcome in those hospitalized with COVID-19 and who have pre-existing type 2 diabetes.

More Info?

If you would like more information about how I can help you better control your blood sugar levels and aim put your type 2 diabetes into remission, please reach out to me.

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

Reference

Zhu L, She GZ, Cheng X, et al, Association of Blood Glucose Control and Outcomes in Patients with COVID-19 and Pre-existing Type 2 Diabetes. Cell Metabolism, 2020; DOI: 10.1016/j.cmet.2020.04.021

A new large-scale preliminary US study[1] looking at data from more than 4000 Covid-19 patients who sought medical care at Langone Health Hospital in New York City found that outside of older age (> 75 years of age), obesity was the single most significant risk factor that contributed to requiring hospitalization and critical care, such as requiring being on a ventilator. This is a different study than the one that I wrote about yesterday [2] which found that in people under the age of 60, obesity poses a significant risk factor of hospitalization, especially with respect to requiring Acute Care or Intensive Care (click here to read that article).

We Need to “Get” This

Taken together, these two large-sample US studies find that being obese (which is having a Body Mass Index (BMI) of 30 or more) puts those under 60 years of age at significantly greater risk of being hospitalized and requiring critical care than any other factor, including high blood pressure (hypertension), diabetes and cardiovascular disease (CVD) [2], and having a BMI of 40 is the most significant risk factor after older age[1]. Old or young, being obese is a significant risk factor to requiring medical intervention in Covid-19. What many don’t realize is that 2/3 people in the US and Canada are either overweight or obese. 

How Big an Issue is Obesity?

One in three adults in the US are obese and one in four adults in Canada are obese. Not just overweight, but obese.

We have become used to this being common place, so much so that many of us consider “average weight” what is actually overweight (BMI between 25 and 30) and consider someone to be “overweight” when they are actually obese.

As mentioned in an article from earlier this week, recent US data found that 90% of patients hospitalized due to Covid-19 had underlying medical conditions, including hypertension (high blood pressure), obesity, diabetes and cardiovascular disease and as noted in that article, only 12% adults are considered metabolically healthy as defined as having a healthy waist circumference and normal systolic and diastolic blood pressure, blood glucose and HbA1C and cholesterol such as HDL, as well as triglycerides.

Looking at this information together, we need to understand that something as straight-forward as losing weight, particularly the weight that we carry around our middles can significantly improve our outcome should we become infected with Covid-19. 

With many experts suggesting that it is only a matter of time until we are all exposed to Covid-19, it would seem that it ‘s not a matter of “if”, but “when” and while we can’t change our age, but if we are overweight or obese, we can lose weight. If we are carrying excess fat around our abdomen (the risk of having an increased waist circumference) — even at normal body weight, we can lower that. It takes being willing to make dietary and lifestyle changes and it take some time, but in a matter of weeks, someone who is currently in the class I obesity category can be re-categorized as overweight and with persistence can achieve a healthy body weight and waist circumference.   Previous studies that I’ve reviewed indicate that significant risk factors such as high blood pressure and abnormal blood sugar can be normalized in as little as 10 weeks with a well-designed diet of whole, real food and these benefits can be maintained. By making these changes now we can significantly lower our risk in a fairly short amount of time and why would we not want to do so now given there is currently no vaccine for Covid-19 and no consistently effective medication yet?

[Note: If I hadn’t already gone from being obese to a normal body weight a few years ago, I certainly would be very motivated to do it now.]

For the past 5 years I have spent about half my clinical time helping others do just that, while helping them considerably improve their lab markers for several different metabolic conditions. Since we are already eating most of our meals at home, now is an ideal time to make the dietary changes needed to lower our risks of requiring hospitalization should we get Covid-19.

More Info?

If you would like more information about how I can help you lose weight and then keep it off, please reach out to me. All my services are now provided via Distance Consultation but I already have more than a decade of experience providing virtual nutrition support, so this is nothing new for me and I am licensed as a Dietitian in every province in Canada except PEI. I can also provide nutrition education services to those in the US and elsewhere.

You can find more about the details of the different packages I offer by looking under the Services tab or in the Shop. If you have any 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/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

References

As covered in the preceding article, we now know from US data between March 1-30, 2020 that older adults and those with hypertension (high blood pressure), obesity, diabetes and CVD are at an increased risk of requiring hospitalization should they contract Covid-19, but a new study finds that so are young people with obesity.

A study released ahead of publication found that of the more than 3600 people who tested positive for Covid-19 in a large academic hospital in New York City, more than 20% had a BMI of 30-34 (Class I obesity) and more than 15% had a BMI > 35 (Class II obesity or higher). When stratified by age, researchers found significantly higher rates of hospital admission and the requirement for ICU care in patients <60 years of age with obesity.

Compared with patients with a BMI of < 30 (i.e. overweight but not obese), patients under 60 years of age with Class I obesity were;

• 2.0 times more likely to be admitted to Acute Care
• 1.8 times more likely to be admitted to intensive care

Compared with patients under the age of 60 years old with a BMI <30 (not obese), patients with a BMI of 35 and above (Class II obesity and higher) were;

• 2.2 times more likely of being admitted to Acute Care
• 3.6 times more likely to be admitted to intensive care

Among the 3600 patients who were subjects in this study, there was no significant difference in hospitalization rates and intensive care needs by BMI among people 60 years of age and older, which is consistent with findings reported in the preceding article which found that obesity was a significantly higher risk factor of hospitalization in those 18-49 years of age [1].

Note: As covered in the previous article, hypertension (i.e. high blood pressure) is a significant underlying condition to adults ⩾ 65 years of age hospitalized with Covid-19.

Patients with a BMI of ⩾30 in the current study represented 36% of all patients; which is fairly representative of the US population as a whole which is estimated to have an obesity rate of BMI ⩾30 of 40% [3,4]. Given that obesity rates of BMI ⩾30 in Canada [5] is ~ 33%, it is possible that need for hospitalization and acute or intensive care may be somewhat lower here (i.e. more reflective of the slightly lower obesity rates in Canada).

With a vaccine for COVID-19 a year or longer away, current efforts to reduce the risk of contracting the virus necessarily focus on physical and social distancing, personal hygiene including proper hand-washing techniques and avoiding touching one’s face, as well as wearing face coverings in public places. These are all very important, however those under the age of 60 years of can reduce the risk of getting serious complications or dying from complications from the virus by achieving, then maintaining a healthy body weight.

Reversing Obesity – easier said than done?

Most people know that achieving and maintaining a healthy body weight is important to lower the risk of getting type 2 diabetes, hypertension and cardiovascular disease. Since we are already eating most of our meals at home and with a covid-19 vaccine a year or more away, now is an ideal time to make the dietary changes needed to achieve a healthy body weight and lower our risks of requiring hospitalization should we get Covid-19. In fact, most people in the class I obesity (BMI > 30) category can make the dietary changes necessary to achieve a normal body weight within in a few months.

I can help.

More Info?

If you would like more information about how I can help you lose weight and then keep it off, please reach out to me. All my services are now provided via Distance Consultation but I already have more than a decade of experience providing virtual nutrition support, so this is nothing new for me.

You can find more about the details of the different packages I offer by looking under the Services tab or in the Shop. If you have any 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/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

References

1. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1—30, 2020. MMWR Morb Mortal Wkly Rep. ePub: 8 April 2
2. Lighter J, Phillips M, Hochman S et al, Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission, accepted manuscript, Clinical Infectious Diseases. doi: 10.1093/cid/ciaa415,  https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa415/5818333
3. Ogden, C.L., et al., Prevalence of Obesity Among Adults, by Household Income and Education – United States, 2011-2014. MMWR Morb Mortal Wkly Rep, 2017. 66(50):p. 1369-1373
4. State of Obesity, Adult Obesity in the United States, https://stateofobesity.org/adult-obesity/
5. Statistics Canada, Health at a Glance, Adjusting the scales: Obesity in the Canadian population after correcting for respondent bias,  https://www150.statcan.gc.ca/n1/pub/82-624-x/2014001/article/11922-eng.htm

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.

It is well-known that older adults are at greater risk of getting serious complications from COVID-19, but few people realize that the majority of people that require hospitalization in the US [1] (and presumably the data is similar in Canada) have very common underlying medical conditions (known as “comorbid” conditions), including high blood pressure (hypertension), obesity, diabetes and cardiovascular disease and chronic lung disease [1]. With a vaccine for COVID-19 coronovirus more than a year a way, current efforts to reduce the risk of contracting the virus focus on physical and social distancing measures, personal hygiene including proper hand-washing techniques and avoiding touching one’s face, as well as wearing face coverings in public places but there is more we can do to reduce the risk of getting serious complications or dying from complications from the virus — and that is addressing dietary and lifestyle changes that are documented to put comorbid conditions such as high blood pressure, type 2 diabetes and obesity into remission.

Early release of a research study on April 8, 2020 [1] reported that between March 1-30, 2020, hospitalization rate in 99 counties of 14 US states was 4.6 people per 100,000 population, and rates were highest amongst those who were ≥65 years of age and those with underlying medical conditions. Among almost 1500 laboratory-confirmed COVID-19—associated hospitalizations, almost 25% were between the ages of 5—17 years, almost 25% were aged 18—49 years, ~30% were aged 50—64 years and 43% were aged ≥65 years. Among those patients with data on underlying medical conditions, almost 90% had one or more comorbid conditions — with almost 50% of patients having hypertension (high blood pressure) or obesity and almost 30% having diabetes or cardiovascular disease. This is huge.

“These findings suggest that older adults have elevated rates of COVID-19—associated hospitalization and the majority of persons hospitalized with COVID-19 have underlying medical conditions.”[1]

Changing What’s in Our Control to Change

Many of us feel somewhat powerless during this COVID-19 outbreak and while the internet is full of recommendations for dietary supplements, many overlook the most obvious way to lower risk of serious complications by lowering any known comorbid conditions we may have. We can achieve and maintain a normal body weight and waist circumference, normalize blood pressure and blood sugar, and lipid markers such as improving HDL cholesterol and lowering triglycerides.

As covered in an earlier article, a study published in November 2018 reported that 88% of Americans are already metabolically unhealthy[2]; that is, only 12% have metabolic health defined as [2];

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

When considering only waist circumference, blood glucose levels and blood pressure levels, ~50% of Americans were considered metabolically unhealthy [3].  Given the slightly lower rates of obesity in Canada as in the United States, there is likely a slightly lower percentage of Canadians who are metabolically unhealthy, but the similarity of our diets may make that difference insignificant.

While we obviously can’t reduce our age or the presence of chronic lung conditions such as asthma or COPD, we can lower our risk of having severe outcomes should we contract the virus;

• If we are overweight, we can lose weight.
• If we have high blood pressure we can make safe and effective dietary changes to lower that, and by adding other lifestyle changes, achieving normal blood pressure without the need for medication is possible.
• If we have higher than normal blood sugar, we can normalize that through dietary and lifestyle changes. Type 2 diabetes need not be a “chronic progressive disease”! It can be put into remission.
• If we have abnormal lipid panel (cholesterol), we can change the way we eat to lower triglyceride levels, as well as increase HDL (“good”) cholesterol levels.

Final Thoughts…

There is much about the current situation we can’t change. Physical (social) distancing measures will likely be in place for some time. The need for consistent hand hygiene and avoiding touching our face will likely be come second nature for most of us, as may be the wearing of face coverings in public for many.

But with all of us eating at home almost all of time, now is an ideal time to find out how to eat in such a way to improve our metabolic health and lower our risk of serious outcomes should we contract the virus.

More Info?

If you would like more information about how I can help you and your family eat better, or how I can help you lose weight, lower blood pressure or blood sugar or lower cardiovascular risk, please reach out to me. While all my services are now provided via Distance Consultation, I have more than a decade of experience providing virtual nutrition support.

You can find more about the details of the different packages I offer by looking under the Services tab, or in the Shop and if you have any 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/
Instagram: https://www.instagram.com/lchf_rd
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References

1. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1—30, 2020. MMWR Morb Mortal Wkly Rep. ePub: 8 April 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6915e3
2. Araíºjo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009—2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105

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.

Note: This article is a follow-up to two previous articles (this one and this one) about the presence of the COVID-19 coronavirus in the Vancouver area, as well as recommendations from the Federal Chief Medical Officer about preparing for an “outbreak” or “pandemic”.

Yesterday, Monday February 24, 2020, Provincial health officer Dr. Bonnie Henry said a 7th case of COVID-19 has been identified in BC [1] and that this patient is a man in his 40s who is a close contact of B.C.’s 6th case, a woman in her 30s who recently returned from Iran [2,3]. Apparently, the man had symptoms prior to the woman being diagnosed. The Globe and Mail reports that the Provincial Health Authority has been working with the Fraser Health Authority to try to identify anyone who may have been in touch with the two latest cases. This would include the fact that Fraser Health Authority sent a letter to all school districts in its region this past Friday, which includes Burnaby, New Westminster, Maple Ridge, Pitt Meadows and the Tri-Cities — warning them that contacts of the woman with coronavirus ”may have attended schools in the region and are currently isolated” [4].

The 6th case (and perhaps the 7th case too, as the woman was reported to have a travelling companion) also flew from Montreal to Vancouver on Valentine’s Day, February 14th [5,6]. On February 23, 2020, the BC Provincial Health Authority (PHSA) had advised Air Canada that it planned to contact all passengers who flew out of Montreal that day and who were seated within three rows of the woman so that they can monitor their health for a 14-day period and report any symptoms to a health professional [5,6].

In a dramatic shift from earlier indications that the risks in Canada are “low”, this morning’s Ottawa Citizen newspaper reported that Chief Medical Officer of Health Dr. Theresa Tam acknowledged yesterday (Monday, February 24, 2020) that “Canada may no longer be able to contain and limit the virus if it continues to spread around the world” and that she said “governments, businesses and individuals should prepare for an outbreak or pandemic” [7].

The Globe and Mail also reported that Dr. Tam said yesterday, ”The window of opportunity for containment — for stopping the global spread of the virus — is closing”, and ”…that we have to prepare across governments, across communities and as families and individuals, in the event of more widespread transmission in our community” [8].

Further thoughts…

In addition to the original COVID-19 outbreak in Wuhan, China, a growing outbreak of COVID-19 in Iran and South Korea is of particular concern, especially in the Greater Vancouver area which has thriving Chinese, Iranian and South Koreans communities.

With regards to the possibility of others having arrived from Iran with coronovirus prior to it being identified there, Dr. David Fisman, professor of epidemiology at the Dalla Lana School of Public Health at the University of Toronto said in the Globe and Mail report, ”I think it’s highly unlikely that that’s the only individual from a country without [declared] coronavirus disease who has come into Canada [8]”. I think it is likewise reasonable to assume that it is highly unlikely that no one arrived from South Korea before the first cases were identified there, as well.

Practical advice (outside of preparing to have sufficient non-perishable food on hand in case there is a need to self-isolate at home for 14 – 28 days) is to avoid the easiest means of transmission, which is touching someone or something that is contaminated with the virus, and then touching one’s eyes, nose or mouth. Use of alcohol gel is an alternative, when soap and water and a good hand wash for 20 seconds is not possible. Since transmission of COVID-19 can occur from an infected person to others within ~2 meters / 6.5 feet (even if the infected person has no symptoms), avoiding crowded public places such as restaurants, food courts, cashier line-ups and waiting rooms would be prudent. 

With no vaccine against this novel coronavirus or medicine available to treat it, practicing ‘social distancing’ is good advice; which is limiting one’s exposure to places where groups of people gather, decreasing opportunity for the virus to spread. This is where Distance Consultations can help. These have always been very popular with those on the other side of the city and across the country, but with seven local COVID-19 cases, people in the immediate vicinity are glad to have this option especially given me having a decade of experience providing them. You can find out more about Distance Consultations by clicking on the tab above.

More Info?

If you would like more information about the services that I provide, please have a look under the Services tab or in the Shop. 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/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

References

1. The Globe and Mail, Andrea Woo, Feb. 24, 2020, B.C. identifies seventh case of coronavirus, https://www.theglobeandmail.com/canada/british-columbia/article-bc-identifies-seventh-case-of-coronavirus/
2. Montreal Gazette, Susan Schwartz, February 23, 2020, Passenger from Iran on flight from Montreal to Vancouver tests positive for new coronavirus, https://montrealgazette.com/news/local-news/passenger-from-iran-on-flight-from-montreal-to-vancouver-tests-positive-for-new-coronavirus
3. CBC, B.C.’s 6th presumptive COVID-19 case flew from Montreal to Vancouver on Feb. 14, https://www.cbc.ca/news/canada/british-columbia/bc-coronavirus-flight-montreal-vancouver-1.5473283
4. Global News, Sean Boynton, Passenger on Air Canada flight to Vancouver is not a new case of COVID-19: B.C. officials, Feb 23 2020 2:11 pm, updated 5:18 pm), https://globalnews.ca/news/6586274/covid19-air-canada-vancouver-montreal/
5. Montreal Gazette, Susan Schwartz, February 23, 2020, Passenger from Iran on flight from Montreal to Vancouver tests positive for new coronavirus, https://montrealgazette.com/news/local-news/passenger-from-iran-on-flight-from-montreal-to-vancouver-tests-positive-for-new-coronavirus
6. CBC, B.C.’s 6th presumptive COVID-19 case flew from Montreal to Vancouver on Feb. 14, https://www.cbc.ca/news/canada/british-columbia/bc-coronavirus-flight-montreal-vancouver-1.5473283
7. Ottawa Citizen, Elizabeth Payne, Canadians being told to prepare for a possible novel coronavirus pandemic, https://ottawacitizen.com/news/local-news/canadians-being-told-to-prepare-for-a-possible-novel-coronavirus-pandemic
8. The Globe and Mail, Kelly Grant, February 24, 2020, Canada steps up screening efforts as coronavirus inches toward a pandemic, https://www.theglobeandmail.com/canada/article-canada-steps-up-screening-efforts-as-coronavirus-inches-toward-a