T2D Archives - Page 2 of 2 - The Low Carb Healthy Fat Dietitian

August 22, 2018July 9, 2019

Low Carbohydrate Eating for People with Diabetes – new position statement

INTRODUCTION: In response to numerous inquiries from individuals, healthcare professionals and the general public, Diabetes Australia has just released a new Position Statement titled Low Carbohydrate Eating for People with Diabetes[1] said to be based on the latest evidence on the subject. Diabetes Australia is the national body responsible for making treatment and dietary recommendations for the 1.7 million people in that country living with Diabetes. The publication is designed to provide practical advice and information for people diagnosed with Diabetes who are considering adopting a low carbohydrate eating plan. Since I don’t provide dietary to support to those with Type 1 Diabetes (but defer instead to someone with CDE credentials), I have limited my discussion to recommendations pertaining only to Type 2 Diabetes.

Diabetes Australia defines low carbohydrate (“low carb”) eating patterns as those that restrict carbohydrate intake — especially processed and packaged foods and beverages including cakes, candies, chocolate, chips, ice cream and sugary drinks as well as breads, cereals, grains, potatoes, fruit and sugar. They elaborate that when people are limiting carbohydrates they eat a higher proportion of protein and fats such as those found in meat, chicken, eggs, oily fish, avocados, nuts, oils and butter and eat plenty of low carb vegetables, such as cauliflower and zucchini. In this publication, they specify that a low carbohydrate diet provides “less than 130g of carbohydrate daily/ less than 26% of total daily energy intake”[1].

“When it comes to low carb eating, there is no particular diet or standard approach.”

Diabetes Australia reinforces that the (Australian) “Dietary Guidelines provide general healthy eating advice and are a good starting point for people wanting to improve their eating habits”, but that

“there is no one-size-fits-all approach to living well with Diabetes. Everybody is different.”

The publication makes clear that Diabetes Australia “does not promote or encourage any single diet or eating plan or any particular ‘diabetes diet'” and that “every person with Diabetes needs a personalized approach and support to have the healthiest eating plan and this may change over their lifetime with Diabetes“. They mention that in recent years, low carb eating has gained popularity with the general population and has also gained interest for people with Diabetes as “an option to help lose weight and to assist in managing blood glucose levels” — because “low carb diets are relatively easy to follow”.

In formulating their Position Statement, the organization states that they rely on “strong scientific evidence before making specific health and nutrition recommendations for people with diabetes or those at risk” and that “evidence is usually based on the National Health and Medical Research Council (NHMRC) hierarchy of evidence”[2] whose components are; 1. The evidence base, in terms of the number of studies, level of evidence and quality of studies (risk of bias), 2. The consistency of the study results, 3. The potential clinical impact of the proposed recommendation, 4. The generalisability of the body of evidence to the target population for the guideline, and 5. The applicability of the body of evidence to the Australian healthcare context. This hierarchy of evidence is said to also need to take into account “the quality of the study and the likelihood that the results have been affected by bias during its conduct; the consistency of its findings to those from other studies; the clinical impact of its results; the generalisability of the results to the population for whom the guideline is intended; and the applicability of the results to the Australian (and/or local) health care setting”.

The position statement stresses that Diabetes Australia believes that

“People with Diabetes should make their own, informed choices about their Diabetes management (including eating plans) in consultation with their diabetes healthcare team”.

They recognize that “long-term studies can take years to be designed, conducted and published” and underscore that they will continue to review and update their advice in relation to low carb eating for people with Diabetes based on new evidence as it becomes available.

Key Points

[1] Based on two studies [3,4] the report states that “recent evidence has shown that in the short term (up to 6 months), lower carb eating can help with the management of Type 2 Diabetes but that this benefit is no longer evident after 12 months”.

NOTE:
(a) Both of the studies quoted [3,4] were not low carb studies but moderate carb studies of <45% (225g carbohydrate) per day. Low carbohydrate diets as defined by this paper are diets which provide “less than 130 g of carbohydrate daily/ less than 26% of total daily energy intake” and the paper defines a moderate carbohydrate diet as one that provides “130g—225g of carbohydrate daily/ 26%—45% of total daily energy intake”. The two quoted studies provided dietary intake of carbohydrate that were moderate carbohydrate. Neither was a low carbohydrate study.
(b) Interestingly, despite neither study being a low carb study, one of the quoted studies [3] found “greater weight loss at 12 months on moderate carb diets than high carb diets” — which contradicts that there was no benefit after 6 months. Even a moderate-high carb diet had benefit beyond 6 months when compared with a high carb diet!
(c) In addition, the position statement did not consider the recent publication of the 1-year study results from Virta Health [5] outlined in detail in this article.

[2] In addition to promoting weight-loss, reducing carbohydrate intake can provide health benefits that include lowered average blood glucose levels and reduced risk of heart disease such as raised cholesterol and raised blood pressure and that some benefits can be achieved independent of the amount of weight-loss achieved.

[3] All people with Diabetes who wish to follow a low carb diet should
do so in consultation with their Diabetes healthcare team.

[4] People with Diabetes who begin low carb eating should monitor their
blood glucose levels and, if necessary, talk to their doctor about the need to
adjust their Diabetes medication to reduce the risk of hypoglycaemia (low
blood glucose).

[5] People with Diabetes considering low carb eating are encouraged to seek
personalized advice from an Dietitian experienced in Diabetes management as there are some practical considerations that need to be taken into account to ensure the eating plan is safe and enjoyable, provides adequate nutrition for general health, is culturally appropriate and fits into the person’s lifestyle.

[6] People with Diabetes considering low carb eating should be aware of
possible side effects (such as tiredness, headaches and nausea) and seek
advice from their health care team if concerned.

[NOTE: I’ve never heard or read about people experiencing nausea following low carb eating, and even at the beginning of following a low carb style of eating symptoms such as tiredness and headache are easily addressed with adequate fluid and electrolytes.]

[7] Low carb eating may not be safe and is not recommended for children,
pregnant or breastfeeding women, people at risk of malnutrition, people
with kidney or liver failure, or those with a history of disordered eating or some rare metabolic conditions.

[8] All people who choose to follow a low carb eating plan should be encouraged to eat foods proven to be beneficial to good health, including whole fruit and vegetables, whole-grains*, dairy foods, nuts, legumes*, seafood, fresh meat and eggs.

[*NOTE: Depending on the amount of insulin resistance and hyperinsulinemia that someone with Type 2 Diabetes has they may or may not be able to maintain glycemic (blood sugar) control eating whole-grains and legumes. In their minimally processed forms, these may be able to be re-introduced in small quantities on an individual basis after reversal of Type 2 Diabetes symptoms and lower circulating insulin levels / reduced insulin resistance.]

[9] All people should be encouraged to limit their intake of foods that are high in energy*, carbohydrate or salt*, including processed foods such as sugary drinks, chips, cakes, biscuits, pastries and candies.

[NOTE: Unfortunately, foods that are ‘high in energy’ or ‘high in salt’ are inadequately defined in this publication. “High in energy” would be better framed as “low nutrient density foods” — which are foods high in energy relative to the amount of nutrients they contain. Cheese for example may be energy-dense per 100 g but is also very nutrient-dense. What does “high in salt” means — high in salt for whom?

Perhaps you have questions as to how I could help you get started on eating low carb to lower your blood sugars, reverse symptoms of Type 2 Diabetes, reduce your risk of heart disease including raised cholesterol and blood pressure and lose weight?

Since I provide services both in-person in my Coquitlam (British Columbia) office as well as via Distance Consultation (Skype or phone), I am available to help.

Please send me a note using the Contact Me form above and I will reply as soon as I am able.

To our good health!

Joy

you can follow me at:

https://twitter.com/lchfRD

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

References

Diabetes Australia, Low Carbohydrate Eating for People with Diabetes – Position Statement, August 2018, https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/ee67e929-5ffc-411f-b286-1ca69e181d1a.pdf
National Health and Medical Research Council (2009), NHMRC additional levels of evidence and grades for recommendations for developers of guidelines, https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf
Sainsbury E et al. Effect of dietary carbohydrate restriction
on glycaemic control in adults with diabetes: a systematic
review and meta-analysis. Diabetes Research and Clinical
Practice, 2018; 139: 239-252.
Snorgaard O et al. Systematic review and meta-analysis
of dietary carbohydrate restriction in patients with type 2
diabetes. BMJ Open Diabetes Research & Care, 2017;
5(1).
Hallberg, S.J., McKenzie, A.L., Williams, P.T. et al. Diabetes Ther (2018). Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. https://doi.org/10.1007/s13300-018-0373-9

July 30, 2018July 9, 2019

Important Warning Signs of Developing Type 2 Diabetes

INTRODUCTION: To avoid ignoring important warning signs that our body is not working as it should, we first need to understand how it is supposed to work and what begins to go wrong — long before we receive a diagnosis of Type 2 Diabetes. That way we can make the necessary dietary and lifestyle changes to prevent it from ever progressing further. Type 2 Diabetes can be prevented and this article explains what to look for.

When the human body is healthy, it maintains blood sugar between 3.3-5.5 mmol/L (60-100 mg/dl). The beta (β) cells of the pancreas produce the hormone insulin, store it and release it into the blood in the correct amount and at the right time. The β-cells of healthy people are constantly making insulin and storing most of it within the cell until it receives a signal that food with carbohydrate has been eaten. β-cells constantly release a little bit of insulin all the time in very small pulses called basal insulin. This basal insulin allows the body to use blood sugar even when the person hasn’t eaten for several hours or even longer.

Normal insulin and glucose curves (adapted from Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.)

The rest of the insulin stored in β-cells is only released when blood sugar rises after the person eats foods containing carbohydrate. This insulin is released in two phases [1]. 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 above.

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 the person eats more or less the same amount of carbohydrate-based food at each meal, 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 ~5.5 mmol/L (100 mg/dl). 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 of the person beginning to eat. This is the second-phase insulin response [1] and can be seen at 60 minutes on the graph above.

In healthy people, the combination of the larger first-phase insulin response and the smaller second-phase insulin response is sufficient to keep blood sugar level from rising above 7.8 mmol/L (140 mg/dl), even after the person has eaten a lot of carbohydrate. In healthy people whose β-cells are working properly and receiving the correct signals from their small intestines, blood sugar levels will return to their normal fasting level between 4.6-5.5 mmol/L (83-100 mg/dl range) by 2 hours.

Dysfunctional Insulin Release & Insulin Resistance

In the early stages when people are becoming insulin resistant, receptors in the liver and muscle cells begin to stop responding properly to insulin’s signal. To compensate, the β-cells of the pancreas begin producing and releasing more insulin (hyperinsulinemia). This can be seen on the graph below (in black), which is superimposed over the normal glucose and insulin curve (light grey).

As a result of the insulin resistance of the liver and muscle cells, it takes more insulin to move the same amount of glucose into the cells.

Beginning of insulin resistance and hyperinsulinemia (adapted from 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.)

At this point, only 3% of people will meet the criteria for diagnosis with Type 2 Diabetes [2].

Insulin resistance doesn’t come by itself but is accompanied by hyperinsulinemia — too much insulin in the blood. Hyperinsulinemia is the result of the body trying to compensate for insulin resistance by making more and more insulin to try to keep blood sugar levels normal. With ongoing high intake of carbohydrate, especially refined carbohydrate the amount of insulin that has to be released from the β-cells is enormous (see the dashed black line on the graph below compared to the dashed grey line of a healthy person).

Advancing insulin resistance and hyperinsulemia (adapted from Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.)

The first-phase insulin response won’t produce enough insulin be able to clear the extra blood glucose after a high carbohydrate meal into the cells 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 above the normal high peak of 7.8 mmol/L (140 mg/dl), to levels of 9.0 mmol/L (160 mg/dl) or higher.

In this case, since blood glucose is able to be returned to baseline after 2 hours, only 7% of people will be diagnosed with Type 2 Diabetes (T2D) [2] but clearly these people’s insulin response and blood glucose response (in black) is very dysfunctional compared to that of a healthy person (in grey). In fact, almost 30% of people will have normal blood glucose, but they already have hyperinsulinemia and insulin resistance.

If the body is forced to continue to process a high refined-carbohydrate diet, it will make more and more insulin but not without a cost to the β-cells of the pancreas. β-cell failure will begin to occur as a result of this high demand [3].

Since most physicians only monitor fasting blood glucose (FBG) to detect whether their patients are becoming insulin resistant or Diabetic, they and their patients have no idea that between ½ and 1 hour after beginning a meal, the person’s blood sugar had reached levels well in excess of the normal high peak of 140 mg/dl (7.8 mmol/L). Blood sugar in these individuals often goes as high as 9.0 mmol/L (160 mg/dl ) and even higher but no one knows because no one is checking for it.

A standard fasting blood glucose test won’t pick this up and even if a doctor requisitions a two-hour oral glucose tolerance test (OGTT) where the person is required to fast and then drink a standard amount of glucose and have their blood sugar checked, glucose levels are only measured at baseline when the person is fasting (FBG) and after 2 hours, by which time blood sugar has returned to normal, so this huge peak in blood sugar won’t be seen.

People with these abnormal insulin-glucose responses are at significantly increased risk for developing Type 2 Diabetes and the cardiovascular disease (heart attack and stroke) that often accompanies it, but if no one checks, no one knows.

We can only obtain the right answers if we ask the right question, but often we are asking the wrong questions.

Severe insulin and glucose dysfunction (adapted from 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.)

By the time people’s insulin and glucose curves look like above in black, ~75% of people will already meet the diagnostic criteria Type 2 Diabetes [2].

When people’s fasting blood sugar and glycated hemoglobin (HbA1C) falls in the normal range, it can’t simply be assumed that “everything’s fine” if these same individuals also have other symptoms that are known to be associated with hyperinsulinemia, including high blood pressure (hypertension), high triglycerides (TG) and/or low HDL cholesterol [4]. If fasting blood glucose and/or HbA1C lab test results comes back within normal range and the person has some of these other symptoms and/or a family history of them, then requisitioning a fasting insulin test along with a fasting blood glucose test will enable some calculations to be done to estimate insulin resistance using the homeostasis model assessment (HOMA-IR) described in previous articles, but assessing hyperinsulinemia is a more involved process as it requires assessing both insulin response and glucose response simultaneously over several hours. The problem is that hyperinsulinemia is mechanistically linked to Metabolic Syndrome (described below), Type 2 Diabetes and as a result, cardiovascular disease (atherosclerosis, thrombosis) and other diseases associated with Metabolic Syndrome. Hyperinsulinemia is also an independent risk factor for specific cancers (including breast and colon/rectum, Alzheimer’s disease and other forms of dementia and non-alcoholic liver disease [3]. Hyperinsulinemia is a silent disease, with no overt symptoms. Clinical tools such as assessing insulin and glucose at the same time in response to a glucose load (called a ‘Kraft Assay’) may be useful to predict those who are at risk. In order to be able to prevent people from receiving this diagnosis, clinicians must ask the right questions.

If a doctor is willing to requisition a 2-hour glucose tolerance test, then something as simple as having blood glucose checked at baseline, 1/2 an hour, 1 hour and 2 hours — and not just at baseline and at 2 hours will “catch” abnormal spikes after a carbohydrate load. While it is not as involved as a Kraft Assay which assesses insulin levels simultaneously with glucose levels over several hours, it can provide some useful information. Such a simple addition is not very expensive and can go a very long way to enabling a person to make dietary and lifestyle changes to reverse hyperinsulinemia and as a result, decrease insulin resistance and avoid a diagnosis of Type 2 Diabetes. Certainly, left on its own, there is a good chance these individuals will be diagnosed even though their blood sugar didn’t reflect the risk far enough in advance.

Someone taking their own blood sugar reading at 1/2 hour and an hour after eating a high carbohydrate meal can provide them with sufficient early warning to look further. I have loaned glucometers to my clients for just this purpose. It doesn’t need to be complicated. We simply need to ask the right questions.

If people already have some form of cardiovascular disease (CVD), essential hypertension (high blood pressure that has no identifiable cause), Polycystic Ovarian Syndrome (PCOS) or non-alcoholic fatty liver disease (NAFLD) we need to consider that insulin resistance and hyperinsulinemia are very often associated [4].

We need to look past the what appears on the surface to be ‘normal’, because we may be overlooking early warning signs because we didn’t ask the right questions.

Perhaps you have questions about whether you may be insulin resistant or have hyperinsulinemia even though your blood sugar is normal or are concerned that your family history puts you at increased risk of developing Type 2 Diabetes and you want to make some simple dietary and lifestyle changes to avoid what seems as “inevitable”. Please send me a note using the Contact Me form on the tab above and I’d be pleased to reply as soon as I can.

I provide services by Distance Consultation (Skype, long distance telephone) as well as in person in my Coquitlam office. Detailed information can be found on the Services tab, as well as in the Shop. You can download the Intake and Service Option Form under the package of your choice if you would like to get started and please let me know if you need more information.

To your good health,

Joy

If you would like to read well-researched, credible ”Science Made Simple” articles on the use of a low carb or ketogenic diet for weight loss, as well as to significantly improve and even reverse the symptoms of Type 2 Diabetes, high cholesterol and other metabolic-related symptoms, please click here.

You can follow me at:

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References

Del Prato, S., P. Marchetti, and R.C. Bonadonna, Phasic insulin release and metabolic regulation in type 2 diabetes. Diabetes, 2002. 51 Suppl 1: p. S109-16.
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.
Crofts, C., Understanding and Diagnosing Hyperinsulinemia. 2015, AUT University: Auckland, New Zealand. p. 205.
Halban, P.A., et al., β-cell failure in type 2 diabetes: postulated mechanisms and prospects for prevention and treatment. Diabetes Care, 2014. 37(6): p. 1751-8.
Reaven, G., The metabolic syndrome or the insulin resistance syndrome? Different names, different concepts, and different goals. Endocrinol Metab Clin North Am, 2004. 33(2): p. 283-303.

July 26, 2018July 9, 2019

American Diabetes Association (ADA) Makes Sense of Carbs

A June 2018 article written by Sacha Uelmen, RDN, CDE, Director of Nutrition at the American Diabetes Association (ADA) sheds much light on the expanded role for low carb diets in the treatment and management of Type 2 Diabetes [1].

In answering the question “should people with Diabetes cut back on carbs?”, Uelmen says;

“It’s true that foods high in carbohydrate have the biggest impact on blood glucose compared with foods high in protein and fat. Carbohydrates break down into glucose after they are digested, so it makes sense to think that cutting carbs would lead to lower blood glucose levels and better diabetes management. “

Without going into the fact that our body can make glucose from fat and protein, Uelmen says that while our brain needs glucose “there’s a lot of debate around what is the ideal mix of carbohydrate, protein, and fat needed by people with Diabetes” and adds “we don’t have any evidence that one specific proportion will be right for everyone.”

I am in complete agreement.

Uelmen makes the same point that I did in part 3 of my 4-part series titled Some Carbs Are Better Than Others that “what kind of carb is just as important as how much”. This is something that I explain in detail to each one of my clients when I am teaching them their Meal Plan. I agree with her when she says that “some carbs are better for you than others”.

Uelmen explains,

”Refined” carbs refer to foods made with white flour and sugar, such as pretzels, cookies, cakes, and white breads. These foods raise your blood glucose levels quickly, and do not provide much nutritional value. On the other hand, carbs found in vegetables, beans, lentils, fruit, and whole grains break down slower and are packed with fiber, vitamins, and minerals that provide many health benefits.

Unfortunately, what she didn’t explain was the role of food processing in how foods such as legumes (beans and lentils) and grains will raise blood sugar. As I covered in part 1 of my article on The Perils of Food Processing, there are a number of factors other than how many grams of carbohydrate are in a food that will affect how much a food will raise blood sugar. These factors include the amount and types of food processing, including simple grinding, pressing or pureeing, as well as how the food is cooked and for how long. From that article;

Mechanical processing of a food doesn’t change the amount of carbohydrate that is in it. That is, when we compare 60g of whole apple with 60 g of pureed apple or 60g of juiced apple, there is the same amount of carbohydrate each. When we compare the Glycemic Index of these three, the results are very similar so this isn’t very helpful to tell us about the blood glucose response to actually eating these different foods. When these foods are eaten, the blood glucose response 90 minutes later is significantly different.

In the ADA article, Uelmen explains that legumes and whole grains “break down slower” than “refined carbs” such as those made with white flour, but fails to mention that ground beans and lentils or grains will result in a much higher release of glucose and much quicker than legumes or grains that are whole and intact. As well, how they are cooked and for how long will also affect how quickly they release blood sugar. You can read more about that in this article. In short this means that hummus will not have the same effect on blood sugar as the same amount of whole chickpeas. As well, what most people consider “whole grain bread” (i.e. whole wheat bread) has the same Glycemic Index (GI) and Glycemic Load (GL) as white bread. That is, they will both raise blood sugar just as quickly.

“Whole wheat bread” is what most people think of when they hear “whole grain bread” and whole wheat bread has a Glycemic Index of 74 ± 2 and white bread isn’t much worse at 75 ± 2. Compare these to the GI of whole grain rye bread which is 53 [2]. One slice of white bread has a Glycemic Load of 10 and so does one slice of whole wheat bread, but the GL of a real whole grain rye bread is much lower at 7 [2]. Breads made with the whole intact grain or grain that is only coarsely cracked, such as German-style pumpernickel are very different than the “whole grain” bread available in most supermarkets and affect blood sugar much less.

Uelmen makes another point which is correct, but also neglects to mention information that is important. She says;

“The timing and amount of carbs you eat are also important. Eating a lot of carbs in one meal, even if they are high quality carbs, can cause a spike in your blood sugar.”

This is true and I agree with her recommendation;

“Try to spread them [the amount of carbs] across your meals and snacks throughout the day based on your personal carb goal”.

…but there are two things that she fails to mention.

The first omission is that when carb-based foods are eaten at a mixed meal along with fat, they will raise blood sugar significantly more than at meals where carb-based foods are eaten without fat. This is due to the combined effect of carbs and fat on the incretin hormone GIP, from the K-cells. As well, carbohydrate-based foods will spike blood sugar much less if they are eaten at the end of the meal, after protein and fat foods. Secondly, Uelman omits to mention that eating snacks (which are really just smaller meals) frequently results in an overall greater amount of insulin being released than if one eats larger meals less often. When one is trying to lower insulin resistance, eating snacks between meals makes things worse than eating the same amount of food over three (or two) meals. You can read more about both of these in part 2 of The Perils of Food Processing.

Uelmen makes other excellent points;

“Remember, there are many other factors that can affect your blood glucose. Things like changes in activity or sleep, timing and dose of diabetes medicine, and stress can all have an impact on your blood glucose. It’s not always just about food!”

She offers this terrific advice;

“When deciding how much carb is best for you, start by looking at what you are eating on a regular basis. How many grams of carbohydrate are you eating in each of your meals and snacks?”

If people are normally eating 200-300 g of carbohydrate per day, starting a “low carb diet” at 130 g per day will provide significantly better blood sugar control, if the carbs that are selected have a minimum of food processing (grinding) and cooking. Then, carbohydrate amount can be lowered as needed to help achieve clinical and metabolic outcomes.

Uelmen advises;

“If you are considering a low carb eating pattern, be sure to think about how much time you are willing to devote to meal planning. Strict low carb eating patterns, such as the ketogenic (keto) diet, require careful planning and regular visits to your doctor to ensure you are getting all of the vitamins and minerals you need to stay healthy.”

I’m not sure where she arrived at the idea that eating low carb requires people to devote more time to meal planning. When meals center around a protein food and low-carb veggies — with a few nuts or seeds or cheese thrown in, they are super easy and fast to cook.

I agree with Uelmen that for people following a “strict low carb eating pattern, such as the ketogenic (keto) diet” require regular visits to their doctor, but not for the reasons she lists. Yes, a doctor can run tests to check for vitamin or mineral deficiency, however when a Meal Plan is done by a Dietitian that knows how to design a well-formulated ketogenic diet, it takes into consideration adequate intake of vitamins and minerals. Low nutrient intake is likely going to be less of an issue than when the person was eating a Standard American Diet. That said, people following a low carb or ketogenic diet do require regular visits to their doctor IF they are taking any medications that lower blood glucose or blood pressure. Please read this article if you fall in this category.

Uelman says;

“What can we all agree on when it comes to carbohydrates? Whether you follow a Mediterranean, vegan, keto, low carb, or any other eating pattern, one thing is for sure: Eat plenty of colorful non-starchy vegetables. They are full of vitamins, minerals, dietary fiber, and antioxidants to name just a few.”

…and this is excellent advice!

She concludes her article with two excellent suggestions that I long to hear reflected by Diabetes Canada in the days ahead. The first one is;

“How many carbohydrates should you eat each day? Well, that choice is yours. With careful review of your blood glucose trends and your usual eating patterns, you can often find the right balance that meets your daily nutrition needs and health goals as well as satisfying your appetite. Remember, the best meal plan for YOU is the one that you can stick with while meeting your health goals and feeling good!“

Her second recommendation is that if people need more help following a low carb or ketogenic diet that they should find a Registered Dietitian with RD or RDN credentials to help them.

Final thoughts…

At present, Diabetes Canada 2018 Clinical Practice Guidelines continue to recommend that those with Diabetes still eat ~half or more (45% to 65%) of their daily calories as carbohydrate and limit dietary fat regardless of its source to 20% to 35% of daily calories.

Why is this?

Both Americans and Canadians based their dietary recommendation on the exact same Dietary Reference Intakes (DRIs) yet the American Diabetes Association does not hold rigidly to the Acceptable Macronutrient Distribution Ranges (AMDRs) for macronutrients as a percentage of total energy for Diabetics; which are 45% to 65% of energy as carbohydrate, 10% to 35% of energy as protein and 20% to 35% of energy as fat.

What I don’t understand is why Diabetes Canada continues to recommend that Diabetics keep following the same macronutrient distribution (percent of carbs, protein and fat) as the general population when the American Diabetes Association now supports both low carb and ketogenic (keto) diets for Diabetics?

Both Diabetes Canada and the ADA freely admit that carbohydrate-containing foods have the biggest impact on blood glucose compared with foods high in protein and fat, so why are American Diabetics supported in their desire to follow a ketogenic diet, but not Canadian Diabetics?

Or is it just that the Canadian recommendations haven’t yet caught up with the American recommendations?

If you have questions as to how I can help support your preference to follow a low carb lifestyle, please send me a note using the “Contact Me” form on this web page and I’ll reply as soon as possible.

To our good health,

Joy

You can follow me at:

https://twitter.com/lchfRD

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

References

Uelmen S, American Diabetes Association, Diabetes Food Hub, June 2018, Ask the Experts: All About Carbs
Glycemic Index Foundation, https://www.gisymbol.com/product/burgen-rye-bread/

May 31, 2018July 9, 2019

How Much Does Your Type 2 Diabetes Cost per Year?

The most recent data available from 2011 indicates that the cost per person per year of having Type 2 Diabetes in Canada ranges from $1611 (Quebec) to $3427 (New Brunswick) based on an average income of $43,000 per year. Necessary medications, devices and supplies are expensive – costing more than 3% of income. While those with extended health benefits may not consider this cost now, a change in employment circumstances can affect this overnight.

As Type 2 Diabetes progresses, more medications are often added and the number of times blood sugar needs to be taken each day often increases, as well. Job loss or retirement suddenly results in Canadians being faced with bearing the burden of their disease, along with the chronic, progressive nature of poorly managed blood sugars.

A per-province breakdown using the 2011 figures from the Canadian Diabetes Association appears below;

Cost of Type 2 Diabetes per person per year by province (2011 figures) – from Canadian Diabetes Association

It doesn’t have to be so.

Long term studies that have been published in the last couple of years (reviewed in previous articles on this site) which demonstrate that a well-designed low carbohydrate or ketogenic diet can and does enable a significant improvement in Type 2 Diabetes symptoms.

After as little as 10 weeks, glycosylated Hemoglobin (HbA1C) has been reported to drop a full percentage point; from 7.6% to 6.6%. After a year, the average HbA1C was 6.3%, which is below the diagnostic criteria for Type 2 Diabetes. That is, in just a year of following a well-designed low carbohydrate diet, it has been demonstrated that people can get their average blood glucose in the non-Diabetic range.

Medication use drops substantially when people are able to control their blood sugar by limiting the amount and types of carbohydrates they eat. At the start of the study mentioned above published in Feb of 2018, 87% of people were taking at least one medication for Diabetes and at just 10 weeks, almost 57% had one or more Diabetes medications reduced or eliminated. After one year, Type 2 Diabetes medication prescriptions other than Metformin declined from 57% to below 30%. Insulin injections were reduced or eliminated in 94% of users and sulfonylurea medication was entirely eliminated.

For each one of these individuals, a simple change to a low carbohydrate diet resulted not only in significantly improved health and a reduction in Diabetes symptoms, but in significantly reduced cost, as well.

According to Virta Health who conducted the study referred to above, cost savings are as indicated in this diagram below.

The cost of “Diabetes Reversal” below reflects the estimated cost of an individual being cared for by the Virta Health multi-disciplinary team program, which appears to be an excellent program given the methods used in the studies they have published. It should be noted that the cost of working one-on-one with me over the course of a year (and as overseen by your GP) is substantially less. In fact, getting started by being assessed and having me design an individual Meal Plan just for you is significantly less than the yearly cost of achieving better blood sugar control in the graphic below.

Sometimes people are hesitant to invest in the cost of seeing a Registered Dietitian who can help them adopt a low carbohydrate lifestyle that can enable them to achieve significantly improved blood sugar control – even though the yearly costs of Diabetes supplies is far greater than the cost of being assessed and getting a Individualized Meal Plan. Such an estimate is at the level of health they are today, but waiting a few years, with longer Type 2 Diabetes, more medications, possibly including insulin injections, and the cost is closer to $3500 in 2011 Canadian dollars / $4000 in 2018 (US) dollars.

Does this make any sense?

The sooner someone changes their diet and lifestyle upon being diagnosed with Type 2 Diabetes, the more likely it seems they may be able to achieve full remission of symptoms. If you’ve followed my own story on “A Dietitian’s Journey” then you know how much harder it is for me, after being diagnosed 10 years ago.

If you have extended benefit coverage, then now is the time to invest some time in learning how to make lifestyle changes that will benefit your health and your finances for the years to come. Even for those without such coverage, the cost of an assessment package which will provide you with a Meal Plan designed specifically for you is substantially less than you are already paying for your medications, devices and supplies. I provide both in-person services in my Coquitlam, British Columbia office and via Skype Distance Consultations.

If you have questions about this package entails or about the flexible payment options that are available, why not send me a note using the “Contact Me” form located above? I’ll be happy to reply.

To your good health,

Joy

You can follow me at:

https://twitter.com/lchfRD

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

References

Canadian Diabetes Association, The Burden of Out of Pocket Costs for Canadians with Diabetes, 2011, http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/burden-of-out-of-pocket-costs-for-canadians-with-diabetes.pdf

April 11, 2018July 8, 2019

Diabetes Canada 2018 Clinical Practice Guidelines – option of a low carb diet

Diabetes Canada has released their long-awaited 2018 Clinical Practice Guidelines [1] which affirms that nutrition therapy is an integral part of people’s self-management of their Diabetes, as well as part of the treatment for the disease. One of the main goals of nutrition therapy is to maintain or improve the quality of life and nutritional and physical health of those with the disease, while preventing the need to treat both sudden (acute) and long term complications. Effective nutrition therapy can improve blood sugar control, including reducing three-month average blood glucose (i.e. HbA1C, glycated hemoglobin) by 1.0% to 2.0%.

Diabetes Canada 2018 Clinical Practice Guidelines

The new Guidelines mention that since Canada has wide ethnic and cultural diversity, with each group having their distinct foods, preparation methods, and dietary patterns and lifestyles. Effective nutritional therapy needs to take these cultural variations into account and needs to be individualized; specific to the individual, their age, the duration they’ve had type 2 diabetes, their goals, personal values and preferences, along with their individual need, lifestyle and economic situation. They recognize that nutrition therapy for those with Diabetes is not “one-size-fits-all”.

“Nutrition therapy should be individualized, regularly evaluated, reinforced in an intensive manner and should incorporate self-management education. A registered dietitian (RD) should be involved in the delivery of care wherever possible.”

The Nutrition Therapy Guidelines recommend that those with Diabetes follow the recommendations of Eating Well with Canada’s Food Guide;

“The starting point of nutrition therapy is to follow the healthy
diet recommended for the general population based on Eating Well With Canada’s Food Guide.”

They recommend that those with Diabetes continue to eat 45% to 65% of their daily calories as carbohydrate, 10% to 35% of their daily calories as protein and only 20% to 35% of their daily calories as fat, yet at the same time say that “the ideal macronutrient distribution for the management of diabetes can be individualized”;

“The ideal macronutrient distribution for the management of diabetes can be individualized. Based on evidence for chronic disease prevention and adequacy of essential nutrients, the DRIs (Dietary Reference Intakes) recommend acceptable macronutrient distribution ranges (AMDRs) for macronutrients as a percentage of total energy. These include 45% to 65% energy for CHO, 10% to 35% energy for protein and 20% to 35% energy for fat.”

They recommend that those with Diabetes continue to follow the same macronutrient distribution (percent of carbs, protein and fat) as the general population because it

“may help a person attain and maintain a healthy body weight while ensuring an adequate intake of carbohydrate (CHO), fibre, fat, protein, vitamins and minerals.”

What is encouraging is that they also have said that there is evidence to support a number of other macronutrient-, food- and dietary pattern-based approaches and advise against any rigid adherence to any one approach;

“There is evidence to support a number of other macronutrient-, food- and dietary pattern-based approaches. As evidence is limited for the rigid adherence to any single dietary approach, nutrition therapy and meal planning should be individualized.”

These Guidelines leave it open to individuals to choose other dietary approaches and outline a number of those approaches in the body of the text and in a summary table (Table 1). Figure 1 and Figures 2 and Table 1 in the Clinical Practice Guidelines (below) present an algorithm that summarizes the approach to nutrition therapy for diabetes which includes;

“allowing for the individualization of therapy in an evidence-based framework”.

Figure 1 – Clinical Assessment – Diabetes Canada 2018 Clinical Practice Guidelines

Figure 2 – Stage Targeted Nutrition Flowchart – Diabetes Canada 2018 Clinical Practice Guidelines

Table 1:

The new Diabetes Canada guidelines recognize that the ideal macronutrient distribution (the ratio of carbs, protein and fat) may vary and depend on, amongst other things, the individual’s values and preferences;

“The ideal macronutrient distribution for the management of diabetes may vary, depending on the quality of the various macronutrients, the goals of the dietary treatment regimen and the individual’s values and preferences.”

That is, they recognize that a person’s individual preference for the amount and type of protein (animal-based, plant-based, both), fat (from animal or plant based sources), as well as the amount and type of carbohydrate in their diet factors into their personal decision for how they choose to manage their diabetes.

The Clinical Practice Guidelines for Nutrition Therapy mentions that based on the 3 systematic and meta-analysis of controlled trials of carbohydrate restricted diets that they looked at (mean carbohydrate intake from 4% to 45% of total daily energy) that consistent improvements in HbA1C, lipids and blood pressure weren’t shown.

“As for weight loss, low-carbohydrate diets for people with type 2 diabetes have not shown significant advantages for weight loss over the short term. There also do not appear to be any longer-term advantages.”

So while they do not believe based on the few studies that they examined that there is any advantage to someone following a low carbohydrate diet, there are no clear disadvantages. It comes down to individual preference.

The Guidelines also highlight that there may be a benefit of substituting monounsaturated fat (MUFAs) such as is found in olive oil for carbohydrate (something I regularly do when I design Meal Plans) and that systematic review and meta-analysis of randomized controlled trials found that monounsaturated fat substituted calorie for calorie for carbohydrate did not reduce HbA1C, but did improve fasting blood glucose, body weight, systolic BP, triglycerides and HDL (so-called “good cholesterol”) in people with type 2 diabetes over an average follow up of 19 weeks.

Another finding they reported is that replacement of refined high glycemic index carbohydrates with monounsaturated fat (up to 14.5% total energy) or nuts (up to 5% total energy) has been shown to improve HbA1C and lipids in people with type 2 diabetes over a 3 month period.

Together, these findings provide support to those who prefer to replace high glycemic carbs in their diet (such as white bread, pasta and rice) with monounsaturated fat sources such as olives, avocado as well as some nuts.

The new Clinical Practice Guidelines outline several popular weight-loss diets highlighting that there are a “range of macronutrient profiles are available to people with diabetes”;

“Numerous popular weight-loss diets providing a range of macronutrient profiles are available to people with diabetes. Several of these diets, including the Atkins™, Zone™, Ornish™, Weight Watchers™ and Protein Power Lifeplan™ diets, have been subjected to investigation in longer-term, randomized controlled trials in participants with overweight or obesity that included some people with diabetes, although no available trials have been conducted exclusively in people with diabetes.

They say that a systematic review and meta-analysis of four trials of the Atkins™ diet and 1 trial of the Protein Power Lifeplan™ diet showed that these diets were no more effective than conventional energy-restricted, low-fat diets in inducing weight loss, or with improvements in triglycerides and HDL for up to one year and have been reported to increase total cholesterol and LDL. As mentioned in an earlier article, without differentiating between particle size of LDL (small, dense versus large, fluffy), LDL and total cholesterol going up has not real meaning.

The Guidelines also mentioned that “The Dietary Intervention Randomized Controlled Trial (DIRECT) showed that the Atkins™ diet produced weight loss and improvements in the lipid profile compared with a calorie-restricted, low-fat conventional diet; however, its effects were not different from that of a calorie-restricted Mediterranean-style diet at two years.”

They add that “another trial comparing the Atkins™, Ornish™, Weight Watchers™ and Zone™ diets showed similar weight loss and improvements in the LDL:HDL ratio without effects on fasting blood sugar at one year in participants with overweight or obesity, of whom 28% had diabetes.

So again, it comes down to a matter of choice as to whether someone would prefer to do a calorie-restricted weight loss diet or a well-designed low carb one.

At the end of the paper, the authors make their final recommendations, some of which include that;

“People with diabetes should receive nutrition counselling by a registered dietitian to lower A1C levels and to reduce hospitalization rates”.

“Individuals with diabetes should be encouraged to follow Eating Well with Canada’s Food Guide in order to meet their nutritional needs.”

“In people with overweight or obesity with diabetes, a nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight”.

“An intensive healthy behaviour intervention program, combining dietary modification and increased physical activity, may be used to achieve weight loss, improve glycemic control and reduce CV risk.”

“In adults with diabetes, the macronutrient distribution as a percentage of total energy can range from 45% to 60% carbohydrate, 15% to 20% protein and 20% to 35% fat to allow for individualization of nutrition therapy based on preferences and treatment goals.”

“People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control.”

“To reduce the risk of cardiovascular disease, adults with diabetes should avoid trans fatty acids and consume less than 9% of total daily energy from saturated fatty acids, replacing these fatty acids with polyunsaturated fatty acids, particularly mixed n-3 / n-6 sources, monounsaturated fatty acids from plant sources, whole grains or low glycemic index carbohydrates”

“Adults with diabetes should select carbohydrate food sources with a low-GI to help optimize glycemic control to improve LDL and to decrease cardiovacular risk.”

“The following dietary patterns may be considered in people with type 2 diabetes, incorporating patient preferences, including:

(a) Mediterranean-style dietary pattern to reduce major cardiovascular events and improve glycemic control.

(b) Vegan or vegetarian dietary pattern to improve glycemic control and reduce myocardial infarction risk.

(c) DASH dietary pattern to improve glycemic control and reduce major cardiovascular events.

(d) Dietary patterns emphasizing dietary pulses (e.g. beans, peas, chickpeas, lentils) to improve glycemic control, systolic BP and body weight.

(e) Dietary patterns emphasizing fruit and vegetables to improve glycemic control and reduce CV mortality.

(f) Dietary patterns emphasizing nuts to improve glycemic control and LDL cholesterol.

Funding sources for the three authors of the Nutrition Therapy guidelines were as follows; Dr. John L. Sievenpiper, MD, PhD; Canadian Institutes of Health Research (CIHR), Calorie Control Council, INC International Nut and Dried Fruit Council Foundation, The Tate and Lyle Nutritional Research Fund at the University of Toronto, The Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers), PSI Graham Farquharson Knowledge Translation Fellowship, Diabetes Canada Clinician Scientist Award, Banting & Best Diabetes Centre Sun Life Financial New Investigator Award, and CIHR INMD/CNS New Investigator Partnership Prize; grants and non-financial support from American Society for Nutrition (ASN), and Diabetes Canada; personal fees from mdBriefCase, Dairy Farmers of Canada, Canadian Society for Endocrinology and Metabolism (CSEM), GI Foundation, Pulse Canada, and Perkins Coie LLP; personal fees and non-financial support from Alberta Milk, PepsiCo, FoodMinds LLC, Memac Ogilvy & Mather LLC, Sprim Brasil, European Fruit Juice Association, The Ginger Network LLC, International Sweeteners Association, Nestlé Nutrition Institute, Mott’s LLP, Canadian Nutrition Society (CNS), Winston & Strawn LLP, Tate & Lyle, White Wave Foods, and Rippe Lifestyle, outside the submitted work; membership in the International Carbohydrate Quality Consortium (ICQC) and on the Clinical Practice Guidelines Expert Committees of Diabetes Canada, European Association for the study of Diabetes (EASD), Canadian S74 J.L. Sievenpiper et al. / Can J Diabetes 42 (2018) S64—S79 Cardiovascular Society (CCS), and Canadian Obesity Network; appointments as an Executive Board Member of the Diabetes and Nutrition Study Group (DNSG) of the EASD, Director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation; unpaid scientific advisor for the Food, Nutrition, and Safety Program (FNSP) and the Technical Committee on Carbohydrates of the International Life Science Institute (ILSI) North America; and spousal relationship with an employee of Unilever Canada. Dr. Chan reports grants from Danone Institute, Canadian Foundation for Dietetic Research, Alberta Livestock and Meat Agency, Dairy Farmers of Canada, Alberta Pulse Growers, and Western Canada Grain Growers. Dr. Catherine B Chan has a patent No. 14/833,355 pending to the United States. Dr. Catherine Freeze, MEd, RD reports personal fees from Dietitians of Canada and Government of Prince Edward Island.

Some Final Thoughts…

Much of the same wording regarding supporting individual preference was previously embodied in the 2013 Clinical Practice Guidelines of the Canadian Diabetes Association. While not “recommended”, there was previously the same option for individuals to choose to follow a low carb lifestyle, based on personal preference.

As a Dietitian, I keep reading and reviewing the literature in order to provide the most current, evidence-based low carbohydrate diet to support those that choose to follow a low carb lifestyle — or who’s doctors recommend that they do, and in this way allow for the individualization of nutrition therapy in an evidence-based framework.

Do you have questions as to how I can help support your preference to follow a low carb lifestyle? Please send me a note using the “Contact Me” form on this web page and I’ll reply as soon as possible.

To our good health,

Joy

You can follow me at:

https://twitter.com/lchfRD

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

References

Sievenpiper JL, Chan CB, Dwortatzek PD, Freeze C et al, Nutrition Therapy – 2018 Clinical Practice Guidelines, Canadian Journal of Diabetes 42 (2018) S64—S79 http://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf

February 7, 2018July 8, 2019

New Study: Reversal in T2D Symptoms can be Sustained Long Term

In June of 2017 results of a 10-week outpatient study using a ketogenic diet intervention were published and demonstrated significant improvements in subject’s body weight, glycated hemoglobin (HbA1C) and medication usage. One year follow-up data has just been published demonstrating that reversal of Type 2 Diabetes symptoms is sustainable over the long term, as participants continue to eat a ketogenic diet.

Participants

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 control medication at the beginning of the study.

At the end of a year, 218 participants (83%) remained enrolled in the continuous care intervention group.

Intervention

Each participant received an Individualized Meal Plan for nutritional ketosis, behavioral and social support, biomarker tracking tools, and ongoing care from a health coach with medication management by a physician.

Subjects typically required <30 g·dayâˆ’1 total dietary carbohydrates. Daily protein intake was targeted to a level of 1.5 g·kgâˆ’1 based on ideal body weight and participants were coached to incorporate dietary fats until they were no longer hungry. 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. The blood ketone level of β-hydroxybutyrate was monitored using a portable, handheld device.

Ten Week and One Year Outcomes

Medication Use

At baseline, 87% of participants were taking at least one medication for Diabetes and at 10 weeks, almost 57% had one or more Diabetes medications reduced or eliminated.

After one year, Type 2 Diabetes medication prescriptions other than metformin declined from 57% to just below 30%.

Insulin therapy was reduced or eliminated in 94% of users and sulfonylurea medication was entirely eliminated in the continuous care intervention group.

Glycosylated Hemoglobin (HbA1C)

At baseline, the average HbA1c level was 7.6% ±1.5%, with less than 20% of participants having a HbA1c level of <6.5% (with medication usage).

After 10 weeks, HbA1c level was reduced by 1.0% and the percentage of individuals with an HbA1c level of <6.5% was 56%.

Average HbA1C Reduction after One Year [from 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.]

On average after 1 year, participants in the intervention group lowered HbA1c from 7.6% to 6.3% – which is in the sub-Diabetes range.

Weight Loss

At 10 weeks, mean body mass reduction was 7.2% from a baseline average of 117 kg (257.4 pounds) ±26 kg / 57 lbs.

At one year, mean body mass reduction of participants was 12% of their initial body weight.

Other Metabolic Markers

At 10 months, participants experienced a 20% reduction in triglycerides and after one year, reduction in triglycerides was at 24%. After one year, LDL increased on average by 10% however HDL increased on average by 18%. Serum creatinine and liver enzymes (ALT, AST, and ALP) also declined.

Conclusion

This intervention study demonstrated that individualized nutrition care plans that encourage nutritional ketosis can significantly resukt in reduced weight, HbA1c and medication use within 10 weeks, and that these outcomes can be sustained, or even improved on over the long term, as participants continue to eat a ketogenic diet.

Do you have questions about how a carefully-designed low carbohydrate or ketogenic diet can help you improve symptoms of Type 2 Diabetes?

Please send me a note using the ”Contact Me” form above to find out more about how I can provide you with in-person or Distance Consultation services (via Skype or long distance telephone).

To our good health,

Joy

You can follow me at:

https://twitter.com/lchfRD

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

References

McKenzie AL, Hallberg SJ, Creighton BC, Volk BM, Link TM, Abner MK, Glon RM, McCarter JP, Volek JS, Phinney SD, A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes, JMIR Diabetes 2017;2(1):e5, URL: http://diabetes.jmir.org/2017/1/e5, DOI: 10.2196/diabetes.6981

Hallberg, S.J., McKenzie, A.L., Williams, P.T. et al. Diabetes Ther (2018). Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. https://doi.org/10.1007/s13300-018-0373-9

October 25, 2017July 8, 2019

Evidence for Remission of Type 2 Diabetes Symptoms using LCHF

INTRODUCTION: A low carbohydrate, high fat diet is not new, in fact eating this way was the standard recommendation for treating Diabetes prior to the discovery of insulin.

More than 150 years ago, the first weight-loss diet book, written by William Banting, ironically a distant relative of Sir Frederick Banting, the co-discoverer of insulin focused on the limiting the intake of carbohydrates, especially those of a starchy or sugary nature. The book was titled Letter on Corpulence — Addressed to the Public (1864) and summarized the advice of the author’s physician, Dr. William Harvey that had enabled Banting to shed his ‘portly stature’.

In clinical practice, a ketogenic diet (very low carbohydrate, high fat, adequate protein) was successfully used in the Mayo Clinic nearly 100 years ago by Dr. R. Wilder as a treatment for epilepsy and continues to be used at Johns Hopkins University and other centers for this purpose.

In 1963, Dr. Robert Atkins in his own search for a weight loss plan came across an article in the Journal of the American Medical Association titled A New Concept in the Treatment of Obesity [1]. After he successfully lost weight by following its recommendations, he decided to enroll 20 overweight business executives in a 20 week trial. All lost weight and follow up records indicated that they continued to keep it off for at least a year. After establishing his medical practice in New York City, Dr. Atkins made some adjustments to the plan and incorporated it into his practice, helping his own patients successfully lose weight. In 1972, Atkins published his book Diet Revolution which was immediately successful but very controversial. Criticism of Atkins and his diet continues to this day.

Anecdotal evidence which relies on personal testimony is fine as encouragement (hence my blog A Dietitian’s Journey) and the clinical experience of physicians such as Dr. Jason Fung, a nephrologist from Toronto is excellent, but clinical use of a low carbohydrate diet to target the reversal of symptoms of Type 2 Diabetes requires scientific studies.

Enter Phinney and Volek.

Stephen Phinney, MD, PhD is a medical doctor and scientist with 40 years experience and is Professor of Medicine Emeritus at University of California, Davis. Dr. Phinney is an internationally recognized expert on obesity, carbohydrate-restricted diets, diet and performance and essential fatty acid metabolism and has held clinical faculty appointments at MIT, the Universities of Vermont, Minnesota and California at Davis. He has designed, conducted and published data from more than 20 clinical protocols involving diets, exercise, oxidative stress and inflammation and his design of clinical nutrition trials has led to more than 87 peer-reviewed papers and book chapters on clinical nutrition and biochemistry.

Jeff Volek, PhD, RD is a Registered Dietitian with a Doctorate degree and is professor in the Department of Human Sciences at The Ohio State University. Dr. Volek’s work has contributed to the existing science of ketones and ketogenic diets, their use as a therapeutic tool to manage insulin resistance. For the past 20 years, Dr. Volek has researched how humans adapt to diets restricted in carbohydrates, with a focus on both the clinical and performance application of nutritional ketosis. He has published more than 300 peer-reviewed scientific manuscripts and five books.

In 2011, Phinney and Volek published their fully referenced expert guide titled The Art and Science of Low Carbohydrate Living documenting the clinical benefits of carbohydrate restriction and its practicality as both a sustainable and enjoyable lifestyle. While primarily a book directed towards healthcare professionals and those with a science background, it provides ample scientific evidence behind the use of a low carbohydrate diet to target the reversal of symptoms of Type 2 Diabetes.

In the January-June issue of JMIR Diabetes, Phinney and Volek along with a host of other physicians, Registered Dietitians and nurses published initial 10 week results of a nonrandomized, parallel arm, outpatient intervention using a very low carb diet which induced nutritional ketosis*. Each participant was provided with intensive nutrition and behavioral counseling, digital coaching and education platform and physician-guided medication management.

Nutritional ketosis was defined as a dietary regimen resulting in serum ketone levels of β-hydroxybutyrate between 0.5 and 3.0 mmol·Lâˆ’1

There were 238 participants in the intervention, all participants had a diagnosis of Type 2 Diabetes (T2D), mean age was 54 years old (with participants ranging in age from 46 – 62 years). The majority were women 67% with 33% men. Average weight was 257 pounds (117 kg) with participants ranging from 200 pounds to 314 pounds (117±26 kg). Average Body Mass Index (BMI) was 41 kg·m-2 (class III obesity) ±9 kg·m-2. Average HbA1c was 7.6% ±1.5%. The majority of participants (89%) were taking at least 1 glycemic control medication.

Ten Week Outcomes

Medication Use

At baseline, 89% of participants were taking at least one medication for Diabetes.

At 10 weeks almost 57% had one or more Diabetes medications reduced or eliminated.

64% of insulin, sulfonylurea, SGLT-2 inhibitor, DPP-4 inhibitor and thiazolidinedione prescriptions were eliminated in 10 weeks.

Glycosylated Hemoglobin (HbA1C)

At baseline, the average HbA1c level was 7.6% ±1.5%, with less than 20% having a HbA1c level of <6.5% (with medication usage).

After 10 weeks, HbA1c level was reduced by 1.0% and the percentage of individuals with an HbA1c level of <6.5% increased to more than 56%.

Note: 48% achieved this level while taking only Metformin (n=86) or no Diabetes medications (n=39). That is, >15% achieved this level by diet alone.

Weight Loss

Mean body mass reduction was 7.2% from a baseline average of 117 kg (257.4 pounds) ±26 kg / 57 lbs.

Six month outcomes

After 6 months, 89% of participants were still enrolled in the study. Results indicate that nutritional ketosis was quite effective in improving blood sugar control and weight loss in adults with Type 2 Diabetes, while significantly decreasing medication use.

Glycosylated hemoglobin (HbA1C)

At 6 months, HbA1C was reduced to 6.1% ±0.7% from 7.5% ±1.3% in a sample of 108 participants who elected to test HbA1c at 6 months.

Twenty-two of the 108 started with a HbA1c <6.5%, and at 6 months, 76% reduced their HbA1c below the threshold for diabetes diagnosis (6.5%).

Weight Loss

Patients lost 11.5% (±8.8%) of their body weight with 81% having attained a clinically signiï¬cant weight loss (more than 5% of their body weight).

Medication Reduction

Most medication eliminations were maintained through 6 months along with reduced HbA1c and weight.

Participants also experienced a 20% reduction in triglycerides with an average value at follow-up in the healthy range below 1.69 mmol/L (150 mg/dL) [3].

Discussion

Improvements in blood sugar control in adults with Type 2 Diabetes (T2D) have been associated with weight loss of greater than 5% [4], which is why a weight loss component is part of many treatment plans.

As noted by the researchers, it is often assumed that it is the weight loss that leads to the improvements in blood sugar control, but it is possible that improvements in blood sugar control occur simultaneously with- or before signiï¬cant weight loss is achieved.

In their 10-week outcomes, weight and HbA1c reduction seemed to occur simultaneously, but the researchers noted that there were signiï¬cant reductions in HbA1c occurring even before the full life cycle of red blood cells (approximately 100 days), in which HbA1C is measured.

The researchers referred to other research which demonstrated that improvements in blood sugar control occur prior to signiï¬cant weight loss [5]. In that study, patients with Type 2 Diabetes who consumed a very low carbohydrate (ketogenic) diet of 21g of carbohydrate per day had signiï¬cantly improved insulin sensitivity concurrent with signiï¬cantly lower plasma glucose and HbA1c, but had only a 5 lb (2kg) weight loss after two weeks ( 1.8%) [5]. This suggests that it is not only the weight loss that was resulting in better insulin sensitivity.

The researchers also referred to other studies which reported that early improvement in blood sugar control is also highlighted by how quickly insulin and some oral anti-diabetic medications must be reduced or eliminated when a very low carbohydrate diet is begun, with most reductions and eliminations occurring in the ï¬rst 3 weeks [5,6] when there is only a modest reduction in weight.

The researchers noted;

“this suggests that weight loss may not be the driver of improved blood sugar control, but may be a positive side eï¬€ect that is achieved concurrently with a well-formulated, very low carbohydrate diet.”

Medical Involvement

People with Type 2 Diabetes who take medication to lower blood sugar require the involvement of their physician as they follow a low carb- or ketogenic diet, as an adjustment in medication is often needed soon after beginning, due to blood sugar levels coming down. I would consider it prudent that regular daily glucose monitoring take place for (a) fasting blood sugar, at least once (b) just before a meal, and at least once (c) 2 hrs after a meal and again (d) at bedtime.

For those taking medication to lower blood pressure, the involvement of one’s physician is also needed, as blood pressure often drops with– or soon after blood sugar levels come down. The doctor may need to adjust medication dosages several times before attempting to trial eliminating them.

If you are taking medications to lower blood sugar or blood pressure, please speak to your doctor before beginning to eat low carb.

For those with Type 2 Diabetes but not taking any medication to lower blood sugar, regular daily glucose monitoring is still necessary, with (a) daily fasting blood sugar and (b) at bedtime and a few times per week (c) just before a meal, and (d) 2 hrs after a meal. This is to be sure that blood sugar levels do not drop too low.

For those whose clinical condition requires use of a very low carbohydrate diet / use of nutritional ketosis, monitoring of ketone levels using urine sticks at first and then blood levels of β-hydroxybutyrate occurs is highly recommended to make sure that steady levels are maintained.

Note: It is not recommended for people with any health or medical conditions to seek to achieve the levels of nutritional ketosis described in the above study, with levels of β-hydroxybutyrate between 0.5 and 3.0 mmol·Lâˆ’1 without regular medical supervision.

Some final thoughts…

As demonstrated by this intervention study, it is entirely possible for the symptoms of Type 2 Diabetes to go into remission by following a low-carbohydrate lifestyle. After 6 months, >75% of people had HbA1c that was no longer in the Diabetic range (6.5%). This does not mean, however that their Diabetes was “cured”. If those people revert back to eating a high carb intake, they will experience the return of high blood sugar, blood pressure and abnormal lipid profile.

For those wanting to manage and aim to achieve remission of Type 2 Diabetes symptoms, I recommend that people first speak with their doctor about following a low carbohydrate diet with the support of an Registered Dietitian who is experienced using a wide range of low carb diets.

Have questions?

Why not send me a note using the Contact Me form located on the tab above?

You can follow me at:

https://twitter.com/lchfRD

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

References

1. Gordon ES, Goldberg M, Chosy GJ. A New Concept in the Treatment of Obesity, JAMA. 1963;186(1):50—60. doi:10.1001/jama.1963.63710010013014

2. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011

3. McKenzie AL, Hallberg SJ, Creighton BC, Volk BM, Link TM, Abner MK, Glon RM, McCarter JP, Volek JS, Phinney SD
A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes, JMIR Diabetes 2017;2(1):e5
URL: http://diabetes.jmir.org/2017/1/e5
DOI: 10.2196/diabetes.6981

4. Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lifestyle Weight-Loss Intervention Outcomes in Overweight and Obese Adults with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Journal of the Academy of Nutrition and Dietetics. 2015;115(9). doi:10.1016/

5. Boden G, Sargrad K, Homko C, Mozzoli M, Stein PT. Eï¬€ect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. 2005;142(6): 403-411.

6. Bistrian BR, Blackburn GL, Flatt JP, Sizer J, Scrimshaw NS, Sherman M. Nitrogen metabolism and insulin requirements in obese diabetic adults on a protein-sparing modiï¬ed fast. 1976;25(6):494-504.

Note: Everyone's results following a LCHF lifestyle will differ as there is no one-size-fits-all approach and everybody's nutritional needs and health status is different. If you want to adopt this kind of lifestyle, please discuss it with your doctor, first.

October 19, 2017July 8, 2019

American Diabetes Association Approves Low Carb Diets for Weight Loss

In December 2008, the American Diabetes Association (ADA) issued its Clinical Practice Recommendations which included the option for Diabetics to follow low-carbohydrate diets as a weight-loss option. While this is obviously not ‘news’, it is important to note that the Canadian Diabetes Association – now called Diabetes Canada, does not as yet make the same recommendation.

Why is that?

Is there something inherently different about Diabetics in Canada than Diabetics in the United States?

For the last 9 years the American Diabetes Association has given people the option of following what they call a “moderate” carbohydrate diet by (a) omitting some of the carb-containing foods on their standard meal plan or (b) substituting them for much lower carb alternatives. They also (c) provide Americans with the option of following a low carb diet for weight loss.

Let’s take a look at the American dietary recommendations compared with the Canadian ones.

Dietary Recommendations of the American Diabetes Association

On their web page, the American Diabetes Association states that their standard Meal Plans that are “moderate” in carbohydrates provide ~45% of calories from carbs, but they add;

Your healthcare provider may ask you to limit carbohydrate more than our meal plan suggests. This means you should cut back on the carbohydrate foods that you eat throughout the day. To keep your calorie intake about the same, substitute sources of lean protein or healthy fats for those higher carbohydrate foods.

Then they give some examples of how people can lower carbohydrate intake by making some adjustments to the posted meal plan, such as;

omitting the slice of whole wheat toast at breakfast
replacing the whole wheat wrap for a lettuce wrap at lunch
skipping the serving of brown rice at dinner and adding another non-starchy vegetable instead.

For the last 9 years (2008), Diabetics in the US have also been given the option by the American Diabetes Association to follow a low carb diet in order to lose weight. The 2008 Summary of Revisions for the Clinical Practice Recommendations was changed to include the following;

The ”Medical Nutrition Therapy” section has been revised; updates to this section include the following revised recommendations for weight loss:

For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short-term (up to 1 year).

For patients on low-carbohydrate diets, monitor lipid profiles, renal function and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed.

What the last sentence means is that doctors should monitor the cholesterol and triglyceride levels of their patients on low-carb diets and adjust the dosage of the medication prescribed to control blood sugar levels.

As has been the experience of physicians that prescribe a low carb high fat diet to their patients, as blood sugar levels drop – they need to reduce their patient’s medications dosages and in time, these medications are often discontinued entirely.

What are the dietary recommendations given to Diabetics in Canada?

Dietary Recommendations of Diabetes Canada

Diabetes Canada basic meal planning information advises people to;

“Choose starchy foods such as whole grain breads and cereals, rice, noodles, or potatoes at every meal. Starchy foods are broken down into glucose, which your body needs for energy.”

The sample meal plan for small appetites on the Diabetes Canada website recommends that people consume 193 g of carbohydrates per day which is approximately 13 servings* of carb-containing food per day (* based on the Diabetic exchanges, where 1 serving is 15 g of carbohydrate).

Diabetic Sample Meal Plan (for small appetites) from Diabetes Canada

The Diabetic Sample Meal Plan for larger appetites is the same as above, but also includes an afternoon snack with a medium apple or small banana (+ 25 g carbohydrates), plus a medium pear at supper (+29 g carbohydrates) and another glass of milk with the above evening snack (+12 g carbohydrates), amounting to 259 g of carbohydrates per day, which is almost 17 servings* of carb containing foods.

Diabetics in Canada are advised to eat 45 — 60 g of carbs at each of 3 meals, plus 15 — 30 grams of carbs at each of 1-2 snacks.

This is a lot of carbohydrate for someone whose body isn’t handling carbohydrates well.

The Diabetes Canada webpage, under Healthy Living Resources, there is a section titled Diet and Nutrition. Under this are the organizations recommendations concerning Carbohydrates. They encourage carbohydrate counting which “focuses on foods that contain carbohydrate as these raise your blood glucose (sugar) the most.”

They encourage Canadian Diabetics to “follow these steps to count carbohydrates and help manage your blood glucose levels”.

What are those steps?

Step 1: Make healthy food choices
Step 2: Focus on carbohydrate
Step 3: Set carbohydrate goals
Step 4: Determine carbohydrate content
Step 5: Monitor effect on blood glucose level

Diabetes Canada recommends that Diabetics eat ~ 1/2 of their calories as carbohydrate while at the same time advising people that “foods that contain carbohydrate … raise your blood glucose (sugar) the most”.

So, when Diabetics eat the large percentage of their diet as carbs and their blood sugar is raised, what should they do?

Well, the Diabetes Canada webpage goes onto explain under Step 5 that they should “monitor the effect (of carbohydrates) on blood glucose level and

Work with your healthcare team to correct blood glucose levels that are too high or too low.

I had to read this several times to make sure I wasn’t misreading it.

Diabetics in Canada are being told;

carbs raise their blood sugar the most
that they are to take in ~1/2 of their calories as carbs
when their blood sugars get too high, they need to have their medication adjusted to handle the load.

Could this be why Diabetes is said to be “a chronic, progressive disease”?

Change in the American Diabetes Association Postion

In 2007, a year before the revised recommendations came out approving either a low-carb diet or a low calorie restricted diet, the American Diabetes Association recommendations stated that ‘low carb diets were not recommended for the treatment of overweight or obesity—even in the short term, because their long-term effects were unknown and they did not seem to provide better maintenance of weight loss than low-fat diets over the long term’.

However, in a press release with the release of the 2008 recommendations the American Diabetes Association reversed its position saying;

”there is now evidence that the most important determinant of weight loss is not the composition of the diet, but whether the person can stick with it, and that some individuals are more likely to adhere to a low carbohydrate diet while others may find a low fat calorie-restricted diet easier to follow.”

Furthermore, in the same press release, the American Diabetes Association President of Health Care & Education at the time, Registered Dietitian Ann Albright, PhD, RD, said;

”We’re not endorsing either of these weight-loss plans over any other method of losing weight.”

Albright added that it was ‘more important that people with Diabetes choose a weight-loss plan that works for them and that their healthcare team supports their efforts and monitors their health accordingly‘.

Canadian Recommendations

The Canadian Clinical Practice Guidelines recommends that people with Diabetes receive nutrition counselling from a Registered Dietitian. They recommend that those who are overweight or obese reduce caloric intake to achieve and maintain a healthier body weight and state that it is consistency in carbohydrate intake and in spacing and eating regular meals that may help control blood glucose levels and weight.

From the 2017 Guidelines:

People with diabetes should receive nutrition counselling by a registered dietitian.

Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal for people with diabetes who are overweight or obese.

The macronutrient distribution is flexible within recommended ranges and will depend on individual treatment goals and preferences.

Replacing high glycemic index carbohydrates with low glycemic index carbohydrates in mixed meals has a clinically significant benefit for glycemic control in people with type 1 and type 2 diabetes.

Intensive lifestyle interventions in people with type 2 diabetes can produce improvements in weight management, fitness, glycemic control and cardiovascular risk factors.

A variety of dietary patterns and specific foods have been shown to be of benefit in people with type 2 diabetes.

Consistency in carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight.

Final Thoughts…

Why are Diabetics in the US recommended to lose weight by following either a low-carb diet or a low calorie restricted diet, yet Diabetics in Canada are recommended to eat 13-17 servings of carb-containing foods per day, with 45 — 60 g of carbs at each of 3 meals, plus 15 — 30 grams of carbs at each of 1-2 snacks? That’s a good question.

Many physicians report that Diabetics following LCHF diets have their medications reduced and in many cases discontinued entirely. As a Dietitian this seems preferable as a first approach, than recommending that Diabetics eat half of their calories as carbs, which would necessitate having their medication adjusted upwards when their blood sugars get too high, and having people’s Diabetes continue to worsen in time.

Why should Canadians with Diabetes not be provided with choice?

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References

American Diabetes Association, Adjusting the Meal Plan, http://www.diabetes.org/mfa-recipes/2017-07-adjusting-the-meal-plan.html

Dairman T., Diabetes Self-Management, ADA’s New Guidelines OK Low-Carb Diets for Weight Loss, 2008 Jan 7, www.diabetesselfmanagement.com/blog/adas-new-guidelines-ok-low-carb-diets-for-weight-loss/

Dworatzek PD, Arcudi K, Gougeon R, Husein N, Sievenpiper JL, Williams SL. Nutrition Therapy, Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, http://guidelines.diabetes.ca/browse/chapter11

Summary of Revisions for the 2008 Clinical Practice Recommendations, Diabetes Care 2008 Jan; 31(Supplement 1): S3-S4.