Tag: T2D

February 22, 2019April 1, 2021

Reference

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

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

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

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

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

Measuring Glucose and Insulin Together

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

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

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

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

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

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

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

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

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

On a graph it would look like this;

Normal Glucose Response with 75 g of glucose

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

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

This glucose and insulin response would look as follows;

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

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

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

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

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

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

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

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

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

Assessing Insulin Resistance and β-cell Function

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

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

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

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

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

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

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

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

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

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

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

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

Measuring Hyperinsulemia

Detection of hyperinsulinemia (high circulating levels of insulin) can occur using an Oral Glucose Sensitivity Index (OGIS) where available, or with a 2-hr Oral Glucose Tolerance Test (2-hr OGTT) with simultaneous assessors of insulin. These are tests where a fasting person drinks a known amount of glucose (usually 75 g or 100 g of glucose) and their blood sugar and insulin values are measured before the test starts (baseline, while fasting) and at 2 hours. An additional assessor of blood glucose and insulin can be requested at 1 hour which is very helpful for detecting abnormalities that would missed if only assessing at fasting and at 2 hours. In the OGIS, both blood glucose and blood insulin levels are measured at baseline (fasting), at 120 minutes and at 180 minutes[3].

Final thoughts…

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

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

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

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

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

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

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

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

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

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

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

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

To your good health!

Joy

You can follow me at:

https://twitter.com/lchfRD
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References

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

December 19, 2018July 9, 2019

American Diabetes Association Low Carb Recommendations – one page printout

and

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

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

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

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

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

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

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

You can follow me at:

December 18, 2018July 9, 2019

References

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

Low Carb Diet in 2019 American Diabetes Association Standards of Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Low Carbohydrate Diets for Weight Loss

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

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

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

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

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

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

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

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

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

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

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

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

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

In this section on Carbohydrates, it was emphasized that;

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

and

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

Protein

With respect to protein intake, it was emphasized that;

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

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

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

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

Fats

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

Other Points of Interest

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

Conclusion

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

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

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

To your good health!

Joy

You can follow me at:

December 16, 2018July 9, 2019

References

American Diabetes Association, Lifestyle Management Standards of Medical Care in Diabetes – 2019. Available at: http://care.diabetesjournals.org/content/42/Supplement_1. Accessed: Dec. 17, 2018.
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
Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes 2017;7:304
Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239—252

Long-Term Benefits of a Ketogenic Diet – 2 year update

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

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

Baseline Details

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

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

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

Intervention

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

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

Participants

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

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

Medication Use

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

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

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

Glycosylated Hemoglobin (HbA1C)

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

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

Fasting Blood Glucose

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

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

Fasting Insulin

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

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

Weight Loss

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

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

Cholesterol and Triglycerides

LDL-cholesterol

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

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

HDL-cholesterol

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

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

Triglycerides

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

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

Summary of Results and Significance

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Personal Reflections

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

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

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

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

Some Final Thoughts…

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

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

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

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

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

To our good health!

Joy

You can follow me at:

December 14, 2018December 27, 2019

References

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

The Difference Between Reversal and Remission of Type 2 Diabetes

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

What is meant by Type 2 Diabetes “reversal”

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

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

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

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

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

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

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

What is meant by Type 2 Diabetes “remission”

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

Type 2 Diabetes “reversal” defined

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

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

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

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

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

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

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

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

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

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

Some final thoughts…

I think it’s important what terms we use.

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

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

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

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

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

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

To yours and my good health!

Joy

You can follow me at:

November 30, 2018April 1, 2021

References

Xiong, S. W., Cao, J., Liu, X. M., Deng, X. M., Liu, Z., & Zhang, F. T. (2015). Effect of Modified Roux-en-Y Gastric Bypass Surgery on GLP-1, GIP in Patients with Type 2 Diabetes Mellitus. Gastroenterology research and practice, 2015, 625196.
Schauer P. R., Kashyap S. R., Wolski K., et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. The New England Journal of Medicine. 2012;366(17):1567—1576
Lee W. J., Chong K., Ser K. H., et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Archives of Surgery. 2011;146(2):143—148.
Laferrí¨re B., Heshka S., Wang K., et al. Incretin levels and effect are markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese patients with type 2 diabetes. Diabetes Care. 2007;30(7):1709—1716
Taylor R. Banting Memorial lecture 2012: reversing the twin cycles of type 2 diabetes. Diabet Med. 2013;30:267-275
Watson J., Can Diet Reverse Type 2 Diabetes? December 12, 2018 https://www.medscape.com/viewarticles/905409_print

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

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

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

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

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

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

This Position Statement also recognizes;

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

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

What is the importance of these two early stages?

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

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

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

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

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

To your good health!

Joy

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

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

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Reference

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
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.

November 29, 2018April 1, 2021

The Three Stages of Carbohydrate Intolerance – before type 2 diabetes

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

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

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

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

A normal blood glucose curve represents Carbohydrate Tolerance, and there are 3 Stages of Carbohydrate Intolerance — early, advanced, and severe, with the final stage being a diagnosis of type 2 diabetes (T2D).

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

Insulin Resistance

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

Normal Insulin Response

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

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

Carbohydrate Tolerance based on [1] Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.

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

Early Carbohydrate Intolerance

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

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

Early Carbohydrate Intolerance – based on [1] Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.

Advanced Carbohydrate Intolerance

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

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

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

Advanced Carbohydrate Intolerance – based on [1] Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.

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

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

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

Severe Carbohydrate Intolerance

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

Type 2 Diabetes

Type 2 Diabetes (T2D) is the final stage of Carbohydrate Intolerance and is the natural outcome of a person continuing to eat a diet high in carbohydrate-containing foods when their body is unable to tolerate it. Too often this is the natural outcome of people following Dietary Guidelines (US or Canadian) which are designed for a healthy population, not people who are metabolically unwell. The problem is most people think they are healthy because they have normal blood glucose tests, and their metabolic dysfunction is never diagnosed. No one is looking for it.

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

Some Final Thoughts…

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

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

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

In fact, it is long overdue.

If you would like my help in lowering your risk to developing type 2 diabetes and the chronic disease risks associated with hyperinsulinemia, or reversing their symptoms, then please send me a note using the Contact Me form, on the tab above.

To your good health!

Joy

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References

Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.
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.

October 11, 2018July 9, 2019

ADA Deems Low Carb Diet Medical Nutrition Therapy for T2D

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

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

What is Medical Nutrition Therapy?

Medical Nutrition Therapy (MNT) is defined as;

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

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

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

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

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

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

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

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

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

This move has far-reaching significance!

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

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

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

Some final thoughts…

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

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

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

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

To your good health!

Joy

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October 7, 2018July 9, 2019

References

Davies M.J., D’Alessio D.A., Fradkin J., et al, Management of Hyperglycemia
in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), Diabetes Care, October 2018, https://doi.org/10.2337/dci18-0033
Click here for pdf of the full article.
Diabetes Australia, Low Carbohydrate Eating for People with Diabetes — Position Statement, August 2018, https://www.diabetesqld.org.au/media-centre/2018/august/low-carb-position-statement.aspx and https://www.diabetesqld.org.au/media/583017/da-low-carb-statement-21-august-2018.pdf
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

American Diabetes Association & European Association Approve Low Carb Diets

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

This is huge!

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

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

A Full Range of Therapeutic Options

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

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

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

Diet Quality and Eating Patterns

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

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

but

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

Included in this category are;

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

The joint position paper noted that;

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

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

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

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

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

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

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

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

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

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

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

To your good health!

Joy

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

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