Author: BBDN

People on social media argue about which is the “best diet” for humans — vegan or carnivore? Low carb or keto? Vegetarian or vegan? I avoid these “diet wars” largely because I don’t believe there is a “best” diet for everybody. Some diets are preferable over others for a variety of reasons, including religious constraints, ethical reasons and specific health conditions — so the “best diet” is one that meets an individual’s personal health goals and objectives, and that is consistent with their belief system. 

One of my clients recently mentioned that the more they read about different types of diets online, the more confused they became. They wanted to know if I could write an article to explain them simply. That is the purpose of this post.

Macros

Foods are made up of protein, fat and carbohydrate in different ratios, and these together are commonly referred to as “macros”. This term is shortened from “macronutrients”, where macro means “big” in Greek. Micronutrients is the term used for all the vitamins and minerals, where micro means “small” in Greek.

Macros refer to the three categories of nutrients (protein, carbohydrates and fat) that make up the food that people eat, and which together provide them with their source of energy, as calories.

When people are “counting macros” or “calculating their macros”, they are counting the grams of proteins, carbohydrate (carbs) and fat they are eating.

Different Diet Types

This is not an exhaustive list of all the different diet types, but a summary of popular categories.

Standard American Diet

The average American (or Canadian diet) is often referred to as the “SAD Diet” — which is a shortened form of the “Standard American Diet”.

The Standard American Diet is one where the majority of calories come from carbohydrate and fat — mostly vegetable fat, as recommended by both the American and Canadian dietary guidelines. Vegetable fats are also called “seed oils” and include soybean, canola, and corn oil.

Carbohydrate (“carbs”) are most commonly thought of in terms of various types of bread, rolls, pizza, pasta, rice, and potatoes (French fries, mashed, baked potato, boiled potato), but also include fruit (other than berries which are eaten on a low carb diet), as well as fruit juice, and milk (but not cheese or yogurt that are low in carbs). Milk is included as “carbs” because of its high carbohydrate content.

Vegetarians and Vegans

Vegetarians

Vegetarians are those that don’t eat meat, fish or poultry, but do eat eggs and milk.  These are also known as ovo-lacto vegetarians, as they eat eggs (“ovo” meaning eggs) and milk (“lacto” meaning milk).

Pescatarians are vegetarians that eat fish.

People who eat a vegetarian or pescatarian diet can also eat low carb or very low carb (keto). They are not mutually exclusive.

Vegans

Vegans don’t eat any food of animal origin, including eggs, milk, butter or cream (and products made from them) may do so for religious or ethical reasons. Vegans are sometimes considered a subclass of vegetarian, or an entirely different category. 

They often refer to themselves eating an entirely “plant-based” diet.

A vegan diet can be done low carb, but to obtain adequate nutrients takes a great deal of time and knowledge, but it can be done.

“Low Carb” – LCHF

In a research context [1] and in the clinical guidelines of the American Diabetes Association [2] and Diabetes Canada [3], low carbohydrate diets (“low carb”) are those where carbohydrate intake is limited to <130 g per day or < 26% of total energy intake[1].

These are also referred to as low carb high fat diets (LCHF) or low carb healthy fat diets (also LCHF).

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

A “Paleo diet” is modelled after what is understood to have been the diet of our ancient hunter-gatherer ancestors. It varies considerably between individuals, but is essentially a low carbohydrate diet that uses protein and fat sources that have been known to mankind for millennia.

A Keto Diet

A keto diet is a subtype of low carb diet and in a research context [1], and in the clinical guidelines of the American Diabetes Association [2] and Diabetes Canada [3] are referred to as “very low carbohydrate diets”. A “very low carbohydrate diet”, or “keto diet” is one where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake [1,2,3].

They are called “keto” diets because at this very low level of carbohydrate intake, blood ketones (by-products of the body burning fat for energy) increase at or above 0.5 mmol/L, resulting in a state known as “ketosis”.

Keto diets used predominantly for weight loss or improving symptoms of type 2 diabetes are where ketone levels are usually set with betahydroxybutyrate (BHB) levels between 1.5-3.0 mmol/L [4].

There is no one “keto diet” but some versions of the popularized high fat keto diet are associated with Dr. Jason Fung and Diet Doctor.

Therapeutic Ketogenic Diet

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

The percentage of carbohydrate, fat and protein in what has since become called the ”classic” Ketogenic Diet (KD) was worked out by Dr. M.G. Peterman in 1925 [4], and are the same as used today. 

In the classic KD, the total amount of calories are matched to the number of calories the person needs. Protein is usually determined as being 1 g of protein per kg body weight, 10-15 g of carbohydrate per day total, and the remainder of calories provided as fat.  For very young children, the diet may be prescribed based on body weight (e.g. 75-100 calories for each kg (2.2 pounds) of body weight.

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

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

The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs. That is, for every 5 grams of food there are 4 grams of fat and 1 gram of protein and/or carbohydrate. 

In the classic Ketogenic Diet, 80%  (i.e. 4í/5=80%) of calories come from fat and 20% (i.e. 1/·5=20%) from a combination of protein and carbohydrate.

Protein may be set at 15% of calories with a maximum of 5%  of calories coming from carbohydrate, or protein may be set lower at 10%, and carbohydrate as high as 10%.

The Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein and carbohydrate. In a Modified Ketogenic Diet, 75% of calories come from fat and 25% from a combination of protein and carbohydrate. Protein may be set at 15% of calories with a maximum of 10% of calories coming from carbohydrate[5].

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

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

Carnivore

Carnivores are people who eat only protein and fat of animal origin, including any edible part of mammals (including organ meats), birds of many types including poultry such as chicken and turkey as well as their eggs, and fish and seafood. Fats include butter, rendered chicken or duck fat, beef fat (tallow), and lard (rendered pig fat).

Carnivores and vegans are polar opposites — one eating ONLY animal products and the other not eating any animal products.

Protein to Energy (P:E)

Protein to Energy (P:E) is an entirely new class of diet created by Dr. Ted Naiman. It focusses on eating the most amount of protein for the least amount of energy (calories).

It is not a low carbohydrate diet as the P:E calculator recommend carbohydrate intake  >130 g per day, which is the cut-off for low carb in most of the literature.

This article explains how everyone’s protein needs are different, and how protein should be calculated to prevent deficiency, to sustain exercise and to preserve muscle mass in older adults. Each of these calculations are different but at the same time, total protein should not exceed the ability of the kidney to excrete urea. 

There is no “best diet” for everyone. The “best diet” is an individual is one that meets their personal health goals and objectives and that is consistent with their beliefs.

More Info?

If you would like more information about my services, please have a look around my web page and if you have questions, please send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

Please read the terms and conditions (link below) regarding use of images on this web page.

References

1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13
2. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
3. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
   Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
4. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)

Copyright ©2021 BetterByDesign Nutrition Ltd.

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

[NOTE: This is a combination Science Made Simple article and editorial, expressing my opinion.]

This past Wednesday March 24, 2021, Dr. James Muecke, a South Australia ophthalmologist who was the 2020 Australian of the Year, posted on Facebook that Diabetes Australia reworded their webpage from ”Type 2 diabetes is a progressive condition” to ”Type 2 diabetes is often a progressive condition” — wording that Dr. Muecke calls;

“a small, but significant change that will give some degree of hope to the 280 Australians diagnosed [with type 2 diabetes] every day“. 

Diabetes Australia’s change in phraseology occurred shortly after Diabetes Victoria  removed the words ”Type 2 diabetes is a progressive condition” entirely from its Type 2 Diabetes webpage — replacing it with nothing. This, Dr. Muecke said;

“gives tremendous hope to patients that their newly diagnosed condition can potentially be put into remission.”

I was curious what Diabetes Canada’s web site said and was saddened to discover that it stated that “Type 2 diabetes is a progressive, life-long disease“.

We don’t tell people diagnosed with cancer they have “a progressive, lifelong disease” — but speak to them instead about treatment options and the possibility of remission. While some types of cancer are incurable and untreatable, in general people diagnosed with cancer are not told they have a “progressive, lifelong disease”. Why are people with type 2 diabetes told this? 

I think calling type 2 diabetes a progressive, lifelong disease is a vestige from before there was evidence that it could be put into remission. I think we need to change our terminology to reflect that it is now possible.

In February 2018, one year data from Virta Health’s outpatient study using a ketogenic diet intervention demonstrated that reversal of type 2 diabetes symptoms is sustainable over the long term — with HbA1c level at baseline being 7.6% ± 1.5% being reduced by 1.0% and the percentage of individuals with a HvA1C of <6.5% was 56% [1].

Virta Health’s 2-year data indicated that there were improvements in body weight and that improved blood sugar control was also largely sustained, and that significant metabolic markers and health improvements occurred while using a ketogenic approach in an outpatient setting, over the usual care model approach [2]. On average after one year, participants in the intervention (ketogenic) group lowered HbA1c from 7.7% to 6.3% and at two years, HbA1C of participants in the intervention group increased slightly 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.

Even a 2019 study using an calorie-restricted diet found that “remission of type 2 diabetes within 1-year can be achieved at a cost below the annual cost of diabetes, including complications“ [3] .

There is no cure for diabetes — at least not yet, but there are three documented ways to put type 2 diabetes into remission;

1. a ketogenic diet [1,2]
2. a low calorie energy deficit diet [4,5,6]
3. bariatric surgery (especially use of the roux en Y procedure) [7,8]

Since there is evidence that both a well-designed ketogenic diet and a well-designed calorie-restricted diet put type 2 diabetes into remission (i.e. maintaining blood glucose  below the diabetes cut-offs), we need to stop referring to type 2 diabetes as “a progressive, lifelong disease” — as if it is always the case. 

It can be a progressive, lifelong disease for those who would rather not make the significant dietary and lifestyle changes that are required to put it into remission (and as I outline in this article, this is a valid choice, too!)

People can choose to live WITH diabetes or to seek remission FROM it  — but they deserve to know that remission is possible.

More Info?

If you would like more information about how I can support you in aiming to put type 2 diabetes into remission, please let me know.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

1. Hallberg, S.J., McKenzie, A.L., Williams, P.T. 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 9, 583—612 (2018). https://doi.org/10.1007/s13300-018-0373-9
2. Athinarayanan SJ, Adams RN, Hallberg SJ, McKenzie AL, Bhanpuri NH, Campbell WW, Volek JS, Phinney SD, McCarter JP. 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. Front Endocrinol (Lausanne). 2019 Jun 5;10:348. doi: 10.3389/fendo.2019.00348. PMID: 31231311; PMCID: PMC6561315.
3. Xin Y, Davies A, McCombie L, Briggs A, Messow CM, Grieve E, Leslie WS, Taylor R, Lean MEJ. Type 2 diabetes remission: economic evaluation of the DiRECT/Counterweight-Plus weight management programme within a primary care randomized controlled trial. Diabet Med. 2019 Aug;36(8):1003-1012. doi: 10.1111/dme.13981. PMID: 31026353.
4. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia2011;54:2506-14. doi:10.1007/s00125-011-2204-7 pmid:21656330
5. Steven S, Hollingsworth KG, Al-Mrabeh A, et al. Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes Care2016;39:808-15. doi:10.2337/dc15-1942 pmid:27002059
6. Lean ME, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet2018;391:541-51.
7. Cummings DE, Rubino F (2018) Metabolic surgery for the treatment of type 2 diabetes in obese individuals. Diabetologia 61(2):257—264.
8. Madsen, L.R., Baggesen, L.M., Richelsen, B. et al. Effect of Roux-en-Y gastric bypass surgery on diabetes remission and complications in individuals with type 2 diabetes: a Danish population-based matched cohort study, Diabetologia (2019) 62: 611. https://doi.org/10.1007/s00125-019-4816-2

Copyright ©2021 BetterByDesign Nutrition Ltd.

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

In November 2018, the American Association of Clinical Endocrinologists (AACE) released a Position Statement [1] which identified 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, nephropathy and neuropathy

Long before blood sugar becomes abnormal in the stage known as prediabetes, the progression to type 2 diabetes has already begun in the form of insulin resistance — and identifying insulin resistance at this stage (while blood glucose is still normal) enables people to implement dietary changes to avoid the progression to pre-diabetes, and type 2 diabetes.

Discovering insulin resistance in those who lack the more obvious outward signs can be especially helpful — including those who appear slim, but who may have visceral or ectopic fat  (so-called TOFIs, “thin on the outside, fat on the inside”), or those who may have undetected hyperinsulinemia due to their abnormal response to dietary carbohydrate. Some people that fall in this category may include those with a significant family history of type 2 diabetes, or previous gestational diabetes, even though they currently appear healthy.

The Homeostatic Model Assessment (HOMA-IR) is a test that uses a simultaneous fasting blood glucose test and fasting insulin test to accurately estimate the degree of insulin resistance (IR) and β-cell function (the cells of the pancreas that produce insulin). Alternatively, HOMA-IR can also be determined from a simultaneous fasting blood glucose test and a fasting C-peptide test [2]. C-peptide is released in proportion to insulin, so it can be used to estimate insulin.

The Homeostatic Model Assessment (HOMA) equations have been widely used in research to estimate insulin resistance and the two equations which use fasting blood levels of insulin and glucose are as follows, with HOMA-IR used to assess insulin resistance and HOMA-B used to assess pancreatic β—cell  (beta-cell) function [3,9]. 

Individual results are best compared to local population cut off values for HOMA1-IR [3] (1985) or the updated HOMA2-IR* [4] (1998).

HOMA2-IR* is easily and accurately calculated using the online HOMA2 calculator released by the Diabetes Trials Unit, University of Oxford available at http://www.dtu.ox.ac.uk/homacalculator/index.php.

The original HOMA1-IR equation proposed by Matthews in 1985 [3] 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. [5]. The updated HOMA2-IR computer model [6] mentioned above and available from Oxford University has been used since 1998 and corrects for these — and estimates both insulin resistance and β-cell function.

Cut-off for insulin resistance using the original Matthews values (1985) [3] for HOMA-IR = 2.7

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

Cuff-off values for insulin resistance using the HOMA2-IR calculator (1998) [6] is HOMA2-IR = 1.8. Three population based studies found the same or very close cut-offs applied, including a 2009 Brazilian study [6] which found HOMA2-IR =1.8, a 2014 Venezuelan study [7] which found HOMA2-IR= 2.0 and a 2014 Iranian study [8] which found HOMA2-IR =1.8.

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

HOMA-IR has been used to assess Insulin Resistance (IR) and β-cell function as a one-off measures in individuals in >150 epidemiological studies of subjects of various ethnic origins, with varying degrees of glucose tolerance [9].

In the Mexico City Study which used single glucose-insulin pairs (not the mean of three samples at 5-min intervals) [10], β-cell function and insulin resistance were assessed using HOMA-IR in ~1500 Mexicans with normal or impaired glucose tolerance (IGT). 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 in order to 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 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].

Assessing HOMA2-IR is the reason I may request a simultaneous fasting blood glucose and fasting insulin from those that come to me and who have insulin resistance and/or hyperinsulinemia. My goal is to find out even when blood sugar results are still normal in order find out if their pancreas is working too hard in order to keep them that way.

More Info?

If you would like more information about how I can support you in meeting your health and nutrition goals, please have a look around my web page.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

Note: In British Columbia, family MDs may decline to order the fasting insulin test for the investigation of insulin resistance as the BC government does not authorize payment for that use, but many physicians will if they feel it is clinically warranted. Alternatively, a fasting C-peptide test can be ordered without restriction and can be used to determine HOMA2-IR using the Oxford calculator.

References

1. American Association of Clinical Endocrinologists Announces Framework for Dysglycemia-Based Chronic Disease Care Model, November 28, 2018, AACE Online Newsroom, url: https://media.aace.com/press-release/american-association-clinical-endocrinologists-announces-frameworkdysglycemia-based-c
2. Crofts, C., Understanding and Diagnosing Hyperinsulinemia. 2015, AUT University: Auckland, New Zealand. p. 205.
3. 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
4. Levy JC, Matthews DR, Hermans MP. Correct homeostasis model assessment (HOMA) evaluation uses the computer program. Diabetes Care. 1998;21:2191—2192
5. 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
6. 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
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
8. 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
9. 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
10. 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

Copyright ©2021 BetterByDesign Nutrition Ltd.

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

More than half of middle aged people have a hiatal hernia (sometimes referred to as a “hiatus hernia“), but most people are only diagnosed when their symptoms become a problem or when having medical tests for something else.

A hiatal hernia is where part of the stomach bulges up through the space (called a “hiatus”, meaning a “gap”) in the diaphragm/ abdominal wall where the esophagus normally passes. 

There are two types of hiatal hernias; the sliding type and the fixed type.

The sliding type of hiatal hernia is the more common type and occurs intermittently (i.e. from time to time), when the pressure in the abdomen increases.  This increased pressure pushes part of the stomach up through the gap in the diaphragm where only the esophagus is supposed to pass, and the little bulge is caused the hiatal hernia.

The fixed type of hiatal hernia is also called a paraesophageal hiatal hernia and occurs when the opening for the esophagus in the abdominal wall is bigger than usual. The stomach, and sometimes other organs including the small intestine or colon (large intestine) may also bulge into the chest cavity through this paraesophageal hernia. Paraesophageal hernias often get worse over time, in which case surgery is required to treat the problem. 

A strangulated hernia is not a type of hernia, but rather a complication in any one of a number of different types of hernias that can occur in different parts of the body — such as an inguinal hernia which can occur near the pubic bone, an umbilical hernia which occurs near the umbilicus (or “belly button”), or in a hiatal hernia in the upper part of the abdominal wall. A strangulated hernia is a serious condition where the blood supply to the stomach, intestines or other organ is being cut off because of that part of the body being forced into the small hole of the hernia, and requires immediate medical attention.

What Causes Hiatal Hernia?

A common contributing factor to development of a hiatal hernia is obesity — especially when people are carrying their weight around their middles.  The presence of increased fat around their internal organs (called visceral fat), as well as the excess fat under their skin (called sub-cutaneous fat — meaning “under the skin”) contributes to increased abdominal pressure especially when they are sitting, frequently bending, or lifting heavy objects.

Other contributing factors are frequent coughing (sometimes secondary to smoking), straining due to constipation, or it may simply be hereditary.

Symptoms of a Hiatal Hernia

Hiatal hernias are usually diagnosed when people go to their doctors complaining of symptoms such as frequent heartburn, or are having a test such as a barium swallow or endoscopy, for some other reason.

Many people with hiatal hernias have no symptoms — and because of that, they don’t even know they have one! People without symptoms usually don’t require treatment — although they may be advised to lose weight — especially if they are carrying excess weight around their abdomen. If their waist-to- height ratio is greater than 0.50, this means they are carrying more weight around their middle then optimal, so reducing this is a great place to start to prevent symptoms from occurring. Reducing fat around the abdomen may reduce abdominal pressure caused by the excess fat in the belly pushing the stomach up through the hernia.

Symptoms may include heartburn, chest pain or pressure, coughing, or frequent burping and since these symptoms may be caused by other conditions, it is important that people first see their doctor to find out the cause.  In addition, many people with hiatal hernia have also been diagnosed with  GERD (gastroesophageal reflux disease) and by teaching people how to make simple dietary and lifestyle changes often greatly reduces and even eliminates the symptoms of both.

Final Thoughts…

Losing weight, especially around the belly, and simple dietary and lifestyle changes can significantly improve the symptoms that result from hiatal hernia, as well as GERD which often accompany it.

More Info?

I provide nutrition education for reducing the symptoms of hiatal hernia which can be taken as a one-hour stand alone session, or at reduced cost as an add-on option for those taking the Complete Assessment Package. You can read more about that here.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

Ashwell M, Mayhew L, Richardson J, Rickayzen B (2014) Waist-to-Height Ratio Is More Predictive of Years of Life Lost than Body Mass Index. PLoS ONE 9(9)

HealthlinkBC, Hiatal Hernia, https://www.healthlinkbc.ca/health-topics/hw239946

Simic, P. John, Hiatal Hernia, emedicinehealth, March 3, 2020, https://www.emedicinehealth.com/hiatal_hernia/article_em.htm

Copyright ©2021 BetterByDesign Nutrition Ltd.

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

When  people come to me because they think they may be allergic to certain foods, the first thing I ask is if they have an allergy to any trees or grasses. This may seem like a strange question but some people who are allergic to tree or grass pollen may have symptoms when eating certain foods because the pollen of the tree or grass is similar to the pollen that forms the fruit or vegetable and the body recognizes the similarity. This is known as cross-reactivity.

A person who is allergic to a tree or grass pollen reacts to the food — not because they are allergic to the food itself, but because they are allergic to a pollen from a tree or grass that has similar protein sequences. If a person has never been tested for environmental allergies (pollens, for example) or for food allergies, the first place I get started is to recommend that their doctor have them tested by an allergist. 

What is a Food Allergy?

An allergy is an immune-system mediated reaction which results in the body producing specific allergen IgE antibodies to the substance they are allergic to (the allergen). When people are exposed to the substance they are allergic to, the specific IgE antibody binds with their mast cells (a type of white blood cell that is part of the immune system) which result in the release histamine which causes the symptoms of an allergic reaction, which most often are sneezing, itching, difficulty breathing, or other symptoms. A true allergy is always involve IgE antibodies therefore food sensitivity tests based on IgG antibodies commonly performed by naturopaths do not diagnose food allergy.

Each IgE antibody is specific to one type of allergen, but some types of environmental substances (such as pollen or grass) or foods have several components that have protein sequences that can produce allergy. Using a food as an example, a person with a “milk allergy” may produce IgE antibodies to β-Lactoglobulin or α-Lactalbumin — two completely different proteins found in the whey fraction of milk, or they may be allergic to casein, a protein that makes up another fraction of milk.  A person with a milk allergy may produce specific IgE antibodies to α-Lactalbumin but not to β-Lactoglobulin, or to casein but not the others. Or, they may allergic to all three.

Similarly, a person allergic to a tree pollen may produce IgE antibodies to only one protein in that pollen, or to several.

Oral Allergy Syndrome (OAS) – pollen allergy

Most food allergies in adults who never had food allergies as children are the result of cross-reactions between food and inhaled allergens such as pollen[1] that they are allergic to. This is this known as Oral Allergy Syndrome (OAS). 

If a person has seasonal allergies in the early spring, it is most likely caused by allergies to tree pollen [2], and as many as 50%—70% of people who are allergic to birch pollen will have Oral Allergy Syndrome [3,4].

Alder is another common pollen allergen that results in OAS, as is latex found in rubber trees.

OAS reactions are most often thought of involving people’s lips, tongue or the roof of their mouth — where the cross-reacting food comes into contact with their body, but some people can also experience gastro-intestinal symptoms as a result of OAS — particularly related to birch pollen allergy[5].

It can get complicated, too.

An allergy to either birch or alder pollen can cause a Oral Allergy Syndrome to apples — but so can an allergy to apples, themselves.

How do we know if the person is reacting to apple because they are allergic to either birch or alder pollen (or both!), or because they are allergic to apples?

Only an allergist can determine that.

Since an allergist is specialized physician (MD), the costs of allergy tests done by an allergists are covered by provincial health plans

Once I’ve assessed someone, if I think they may be experiencing either food allergy of oral allergy syndrome, I will recommend that they speak to their doctor about being referred to an allergist for testing.

Once a person has been tested, the allergist’s office faxes me their report (with their permission, of course) and then person returns to me for teaching.  If they have tested positive to foods or to pollens, I teach them how to avoid coming into contact with foods they are allergic to, as well as which foods may result in cross-reactions because they are allergic to specific pollens.

If they have tested negative to food or pollen allergies and the person’s symptoms are gastro-intestinal (involving their stomach or intestines), then if they haven’t already been tested, the next thing I usually rule out is celiac disease (gluten intolerance). This is determined with a simple blood test that their family doctor can requisition.

If the person has no food or pollen allergies, doesn’t have celiac disease, and their doctor has ruled out inflammatory conditions such as Crohn’s or colitis, then very often they are diagnosed with Irritable Bowel Syndrome (IBS). Since symptoms of IBS can be significantly minimized with changes in diet, I provide them with this type of teaching.

Final Thoughts…

Spring is almost here, and if you have seasonal allergies and find yourself having more reactions to food, it may be an indication that you have Oral Allergy Syndrome.

More Info?

Under the Services tab, you can find out more information about the Food Sensitivity / Food Allergy Package and the Irritable Bowel Syndrome (IBS) Package and if you have questions, you can send me a note using the Contact Me form on this web page.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

1. Pong AH. Oral allergy syndrome. Vaughan (ON): Allergy/Asthma Information
   Association (AAIA); 2000. Available: www.calgaryallergy.ca /Articles/English
   /Oral_Food_Allergy.htm (accessed 2009 Dec. 3).
2. Sussman G, Sussman A, Sussman D, Oral Allergy Syndrome, CMAJ 2010. DOI:10.1503/cmaj.090314
3. Mogensen JE, Wimmer R, Larsen JN, et al. The major birch allergen, Bet v 1
   shows affinity for a broad spectrum of physiological ligands. J Biol Chem 2002;
   277: 23684-92.
4. 8. Hoffmann-Sommergruber K, O’Riordain G, Ahorn H, et al. Molecular characterization of Dau c 1, the Bet v 1 homologous protein from carrot and its cross-reactivity with Bet and Api g 1. Clin Exp Allergy 1999; 29:840-7.
5. Rentzos G, Lundberg V, Stotzer PO, Pullerits T, Telemo E. Intestinal allergic inflammation in birch pollen allergic patients in relation to pollen season, IgE sensitization profile and gastrointestinal symptoms. Clin Transl Allergy. 2014;4:19. Published 2014 May 30. doi:10.1186/2045-7022-4-19

Copyright ©2021 BetterByDesign Nutrition Ltd.

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

Most people know that prediabetes and diabetes is having “high blood sugar” but just how much sugar is actually in the human body? And how does grazing on food, rather than eating set meals affect this?

An adult has 5 liters of blood circulating in their body at any one time.  A healthy person’s body keeps the range of sugar in the blood (called ‘blood glucose’) tightly-controlled between 3.3-5.5 mmol/L (60-100 mg/dl) — that is, when they eat food with carbohydrate the body breaks it down to sugar,  and insulin takes the extra sugar out of the blood and moves it into cells.

Where does it put it?

First, the body makes sure that glycogen stores are sufficient, which is the body’s “emergency supply of energy”. There’s about a day’s worth of energy (2000 calories) in our muscle and liver glycogen. Once the liver and muscle glycogen is full, the rest of the blood sugar is moved to the liver where it is converted into LDL cholesterol and triglycerides and then the rest stored in fat cells. Fat is where the sugar that we make from the food we’ve eaten goes if it is not needed right away. Fat is storage for later.

So how much sugar is there in the blood of a healthy adult?

Doing the math (see illustration below), there are only 5 grams of sugar in the entire adult human body — which is just over one teaspoon of sugar.

That’s it!

One heaping teaspoon of sugar in the entire adult body!

How Do We Understand Diabetes in Terms of Blood Sugar?

How much sugar does someone with diabetes have in their blood compared to a healthy person?

Someone with a fasting plasma glucose level of 7 mmol/L (126 mg/dL) meets the diagnostic criteria for Diabetes — which is just 6.25 grams of sugar or 1 -1/4 teaspoons. That is, the difference between the amount of sugar in the blood of a healthy person and the amount of sugar in the blood of someone with  Diabetes is just a quarter of a teaspoon of sugar.

That’s it!

A quarter teaspoon of sugar is such a small amount but it makes the difference between someone who is healthy and someone who has Diabetes.

The difference between the amount of sugar in the blood of a healthy person and the amount of sugar in the blood of someone with Diabetes is just a quarter of a teaspoon of sugar.

In a person with type 2 diabetes, the once tightly-controlled system that is supposed to keep the range of sugar in the blood between 3.3-5.5 mmol/L  (60-100 mg/dl) is “broken” — and it may get this way by them “grazing” all day long, or eating more carbohydrate than their body can handle. When someone with diabetes eats food with carbohydrate in it, their insulin is unable to take the sugar out of their blood fast enough, so the sugar stays in their blood longer than it should. Just as with a healthy person, the body of someone with type 2 diabetes takes the sugar that results from the food they’ve eaten and ‘tops up’ their liver and muscle glycogen stores, then the rest is sent to the liver where it is converted into LDL cholesterol and triglycerides, and then the rest is stored in fat cells. But what if the person is grazing all day long? The sugar just keeps on coming!

Some people have the ability to store the excess sugar in the form of fat under the skin (called sub-cutaneous fat). In this way, obesity is a way of protecting the body from this sugar overflow.  Eventually though, if the constant flow of carbohydrate continues, the ability of the body to store the excess as sub-cutaneous fat is limited and then fat around the organs (called visceral fat) increases and this is what ends up contributing to type 2 diabetes and fatty liver disease. It is easy to pack away excess carbohydrate when one is grazing instead of eating, because they don’t eat enough at anyone time to feel satiated (full).

The problem often is that we never get to access our fat stores because we are grazing on food with carbohydrate in it every few hours, storing the excess sugar in our fat stores. According to recent statistics, three-quarters of us lead sedentary (inactive) lives and barely get to make a dent in the energy we take in each day.  We just keep getting fatter and fatter.

We eat breakfast — maybe a bowl of cereal (30 gms of carbs) or two toast (30 gms of carbs) or if we’re in a rush we grab a croissant breakfast sandwich at our favourite drive-through (30 gms of carb). Each of these contains the equivalent of a bit more than 6 teaspoons of sugar. Mid-morning, maybe we eat a fruit – say, an apple (30 gm of carbs) to hold us together until lunch — and take in another 6+ teaspoons of sugar in the process. If we didn’t bring a fruit, maybe we go out for coffee and pick up an oat bar at Starbucks® (43 gms of carbs) — the equivalent of almost 10 teaspoons of sugar. The grazing continues…

At lunchtime, maybe we’ll have a sandwich (30 gm of carbs) or some leftover pasta from the night before (30 gm of carbs) or we’ll go to the food court and have a small stir-fry over rice (30 gm of carbs) — the equivalent of another 6+ teaspoons of sugar. Then, believing grazing is better than eating 3 big meals, maybe we eat another piece of fruit mid-afternoon, this time an orange (30 gms of carb) — and we’ve provided our body with the equivalent of another  6+ teaspoons of sugar.

In the scenario above, by mid afternoon (assuming we didn’t eat any fast-food or convenience foods, but only eating the food from home) we’ve eaten the equivalence of 24 teaspoons of sugar! But isn’t grazing, and eating food we bring from home supposed to be healthier?

What if we go to MacDonald®’s and eat a Big Mac® (20 g of carbs), large fries (66 g of carbs) and a large soft drink (86 g of carbs) – we’ve eaten a total of 172 g of carbs – which is equivalent to 43 teaspoons of sugar in just one meal!

In short, a healthy person will keeps moving the excess carbohydrate they eat off to their liver and will keep making triglyceride and LDL cholesterol out of it and storing the rest as fat and a person who is not insulin resistant or does not have type 2 diabetes will have normal blood sugar level, but their high carbohydrate intake can be reflected in their “cholesterol tests” (called a lipid panel) — where we may see high triglyceride results or high LDL cholesterol results or both.

The body takes the triglycerides into very-low-density lipoprotein (VLDL) cholesterol. Think of these as “taxis” that  move cholesterol, triglycerides and other lipids (fats) around the body. When the VLDL reach fat cells (called ”adipose tissue”), the triglyceride is stripped out and absorbed into fat cells. The VLDLs shrink and becomes a new, smaller, lipoprotein, which is called Low Density Lipoprotein, or LDL — the so-called bad cholesterol’. This is a misnomer, because not all LDL is harmful.  LDL which is normally large and fluffy in texture is  a good cholesterol (pattern A) that can become bad cholesterol (pattern B) when it becomes small and dense.

In a healthy person, LDL is not a problem because they find their way back to the liver after having done their job of delivering the TG to cells needing energy. In a person with insulin resistance however, the LDL linger a little longer than normal, and get smaller and denser, becoming what is known as “small, dense LDL” and these are the ones that put us at a risk for cardiovascular disease.

There are two important points here: (1) the only source of LDL is VLDL not the fat we take in though our diet and (2) only the “small dense LDL are “bad” cholesterol and these occur as a result of insulin resistance.

People often believe that because their blood sugar is ‘normal’ on a lab test, that there isn’t any problem, but as Dr. Joseph Kraft discovered in his 25+ years of research measuring blood glucose and insulin response in some 10,000 people, 75% of people with normal glucose levels are actually insulin resistant and are at different stages of pre-diabetes or “silent Diabetes” (what Dr. Kraft called “Diabetes in situ”).

These people (and maybe their doctors) think they are “fine” because their blood sugar seems normal. Perhaps however, their triglycerides and LDL blood tests come back high. The origin of the problem is not because they are eating too much fat, but grazing on too much carbohydrate.

The body is trying to store the excess sugar somewhere.  First it stores it in glycogen, then the rest is made into triglyceride and LDL and shipped all over the body, with the rest stored as fat.  The fat cells in the body keep filling up — in the muscle, in and around our organs, and some get “fatty liver disease” and some even get fat cells in their bones if their body needs a place to put it.  Bone is not supposed to have fat cells it in, but the body has to store it somewhere, because the carbohydrates just keep arriving every few hours!

Think of grazing it this way;

Imagine you are at home and you hear the doorbell ring. You go to the door and there’s a package and it’s for you.  You take the package, close the door and head to the kitchen table to open it.  Just as you’re about to open it, the door bell rings again.  You go to the door, and there’s another package — and it’s for you, again.  You take the package and head back to the kitchen and set it down beside the first, when (you guessed it) the doorbell rings again. You take that package and the ones that keep arriving, finding places to put them.  When the kitchen table is full, you put the packages on the floor underneath the table, but then you get a delivery of several packages.  You set those down wherever there’s a spot, just in time to answer the door yet again.  Package after package arrives and before you know it, you look like something out of the TV series Hoarders.  You can barely move for all the boxes, and all of them are unopened.

This is what grazing on meals and snacks with carbohydrates in them every few hours is like.

We overwhelm our body’s tightly-regulated system that is supposed to maintain our blood sugar level between 3.3 and 5.5 mmol/L (60-100 mg/dl) by continually requiring it to process the equivalent of anywhere from 6 teaspoons of sugar in a bowl of cereal or two toasts to the equivalent of 43 teaspoons of sugar in a fast-food meal.

This is how the system gets “broken”.

In time, we may get Type 2 Diabetes or fatty liver disease or high triglycerides or high cholesterol or group of symptoms called Metabolic Syndrome. This is the result of the constant strain we put our bodies under by eating a steady diet of foods containing a large percentage of  carbohydrate.

It is easy to see where the high rates of obesity and Diabetes have come from. We have become a nation of “hoarders”.

What’s the solution?

We stop the constant delivery of packages of carbohydrate every few hours.

We feed our body the protein and the nutrients it needs with enough fat to use as fuel (in place of carbs) and allow it to take the extra energy it needs from our “stored fat”.  We finally take the fat out of storage and we do this by following a low carb high fat diet.

Science made simple.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

Michigan State University, How to convert grams of sugars into teaspoons,  http://msue.anr.msu.edu/news/how_to_convert_grams_of_sugars_into_teaspoons

Klí¶ting N, Fasshauer M, Dietrich A et al, Insulin-sensitive obesity, Am J Physiol Endocrinol Metab 299: E506—E515, 2010, http://www.physiology.org/doi/10.1152/ajpendo.00586.2009

Copyright ©2021 BetterByDesign Nutrition Ltd.

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

I often hear the question, “how much protein is best?” but that depends for whom. Different people have a different protein needs. A healthy man or woman seeking to build muscle has a different protein need than an older adult wanting to reduce the risk of sarcopenia (muscle loss) or someone simply wanting to prevent deficiency. The amount of protein someone needs depends on many factors, including whether a person is growing, pregnant or lactating (breastfeeding), or has been sick or just had surgery. Even for those who aren’t in these special circumstances, protein needs may be calculated to prevent deficiency, to sustain exercise or to preserve muscle mass in older adults, and each of these calculations are different.

Protein needs are calculated as grams of protein per kilogram of body weight of the person, and not as a percentage of daily calories (energy). As explained below, 40% of calories as protein may be safe for one person and be in excess for someone else. For this reason, protein must to be calculated as grams of protein per kilogram of body weight.

Basic Needs – the Recommended Daily Allowance (RDA) for Protein

The Recommended Daily Allowance (RDA) for any nutrient is the average  daily dietary intake level that is sufficient to meet the needs of 97-98 % of healthy people. It is important to keep in mind that the RDA is not the optimal requirement, but the absolute minimum to prevent deficiency.

The RDA for protein for healthy adults is calculated at 0.8 g protein / kg of body weight [1]. A sedentary 70 kg / 154 pound man needs a minimum of 56 g of protein and a sedentary 60 kg / 132 pound woman needs a minimum of 48 g protein per day.

Protein Needs for Active Healthy Adults

For those who are physically active, the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] recommend a protein intake of 1.2—2.0 g protein / kg per day to optimize recovery from training, and to promote the growth and maintenance of lean body mass.

Protein Needs for Older Adults

There have been several position statements issued by those that work with an aging population indicating that protein intake between 1.0 and 1.5 g protein / kg per day may best meet the needs of adults during aging [3,4].

For the average, healthy 70 kg / 154 pound sedentary man this would be daily protein intake of 70 -105 g per day and for the average, healthy 60 kg / 132 pound sedentary woman this would be a protein intake of 60-90 g protein per day.

[UPDATE (August 15, 2023): Protein needs for older adults are now established at above 90g per day, with the optimal amount of 30g highly bioavailable protein over each of 3 meals, along with sufficient amounts of the amino acid leucine, which is needed to trigger muscle protein synthesis.  This updated article explains.

Range of Safe Intake

As I wrote about in an earlier article, according to Dr. Donald Layman, PhD, Professor Emeritus, of Nutrition from the University of Illinois, the highest end of the range of safe intake of protein is 2.5 g protein/ kg per day.

For the average 70 kg / 154 pound sedentary man this would be a maximum daily protein intake of 175 g per day and for the average 60 kg / 132 pound sedentary woman, this would be a maximum protein intake of 150 g/ day.

Someone eating on occasion above their safe range is a different scenario than someone eating above or at the very high end of that range on a regular basis. The body has a flexible capacity to tolerate higher protein intake on occasion, but regularly eating too much protein can result in protein toxicity.

Maximum Amount of Protein the Body can Safely Process

[Special thanks to Richard Morris, research biochemist from Canberra, Australian for the information contained in this section.]

When protein is eaten, the body needs to get rid of the ammonia that results and this is done by turning the ammonia into urea and excreting it in the urine.

The disposal rate of ammonia isn’t able to be calculated because ammonia is literally given off by the lungs and skin, and tracer studies suggest that the disposal rate is higher than the rate that urea appears in urine. This means that there are probably several reservoirs for ammonia (such as urea building up in circulation before filtration in the kidneys) and this ‘elastic’ or flexible capacity for ammonia enables us to survive high protein days interspersed with low protein days.

The rate limit for maximal disposal of urea through urine is 0.53 g of N per kilo of 3/4 body weight[4], as a proxy for lean body mass. The ratio of molecular weights between a nitrogen atom and the average molecular weight of amino acids is a factor of 6.05x, so the effective rate limit for maximal disposal of urea through urine is .53 x 6.05 = 3.21 g of protein/kg lean body mass. If someone were to eat above that amount of protein for too long, they will have filled their ‘elastic’ (flexible) reservoirs with urea, and would then be at risk of ammonia intoxication.

This calculation for determining the maximum amount of protein based on urea clearance requires know a person’s energy consumption (in kcals / calories), as well as lean body mass (LBM).  Note that this is lean body mass, not total body weight. Lean body mass is essentially one’s total body weight minus the amount of fat they have.

Lean body mass can be assessed using a DEXA scan, or estimated by using relative fat mass (RFM). The amount of fat someone has can be estimated from total body weight (taken on a scale), minus their estimated RFM as described in this article. 

Once we know a person’s lean body mass, we can use the equation (3.21 g of protein / kg lean body mass) to determine the maximum amount of protein they can eat on an ongoing basis while being able to safely dispose of the ammonia via urea through urine.

Here are some examples of calculations;

A hundred years ago, Dr. Russell M. Wilder and two Dietitians from the Mayo Clinic wrote a 69-page book titled “A Primer for Diabetic Patients – A Brief Outline of The Principles of Diabetic Treatment, Sample Menus and Food Tables[1]” which outlined the dietary treatment for diabetes that was used and which had different levels of a low carbohydrate, as well as short periods of fasting. I read through this book over the weekend and was quite surprised with how similar this approach was to current low carbohydrate diets that are being by those seeking remission from symptoms of the disease using a diet-first approach.

The name Dr. Russell Wilder was familiar to me, but I knew him as the physician who in 1921 proposed use of a very high fat, low carbohydrate diet for the treatment of epilepsy to produce the same benefits as fasting[2]? It was Wilder himself who is credited with coining the term “ketogenic diet” — and his version of the classic 4:1 ketogenic diet (KD) is still used today in the management of epilepsy, as well as in adjunct treatment for glioblastoma (a very aggressive type of brain cancer) — along with chemo and radiation, as well as in some neurological disorders.  But his first work using the diet was in diabetes.

How could it be that Wilder is so famous for being a very early implementer of a ketogenic diet for epilepsy, yet virtually unknown for his earlier use of low carbohydrate and ketogenic diet for the treatment of diabetes? I wondered if it could it be that the discovery of insulin a short time later by Dr. Fredrick Banting and medical student Charles Best[3] and its manufacture by Eli Lilly [3] relegated the use of a low carbohydrate diet in diabetes to the pages of history? I found out, that is exactly what happened!

While it makes total sense to me that use of insulin as treatment of those with type 1 diabetes (where a person’s pancreas produces little or no insulin) took a front and center role to keep them from literally wasting away without it, it is unfathomable to me that Wilder’s dietary recommendations did not continue to be widely used in the management of type 2 diabetes —  an impairment in the way the body uses glucose and which results in too much sugar circulating in the blood. Again I wondered if perhaps it was because type 2 diabetes wasn’t identified as being different than type 1 diabetes until Harold Percival Himsworth differentiated between the two in 1936 — and by then, use of insulin was standard treatment.

Oral diabetes medications such as Metformin and other biguanide derivatives, as well as sulfonylurea such as Carbutamide and Tolbutamide were not developed until 1955-1956,  so prior to 1955 insulin was the only treatment for type 2 diabetes[4].

As it turned out, a paper published in 1958 by Dr. Russell Wilder provides some much needed understanding as how the discovery of insulin and its free provision to those with diabetes by the drug company Eli Lilly ended up shaping the use — and eventual disuse of low carb diets in diabetes treatment.

“Insulin at that time cost five cents a unit in the market. However, the patients in our early cases received theirs gratis (i.e. free) for a period of several years, thanks to the Eli Lilly Company.” (p.247-8 [4])

In Wilder’s 1958 paper, he outlines how the A Primer for Diabetic Patients [1] (the book on which this article is based) went from being a diet-first approach to the treatment of diabetes prior to the discovery of insulin to a diet that was indistinguishable from the carbohydrate and protein rich diet of non-diabetics, as the result of the use of insulin.

“The nine editions of the little book A Primer for Diabetic Patients, the first written in 1921, the last in 1950, provide a panorama of diabetic therapy in that interval. The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. We were then following the generally accepted treatment of that time, which was based on the research of Dr. Frederick M. Allen at the Rockefeller Institute in New York. It involved an initial period of starvation and the effort afterward to maintain control of glycosuria by a very rigidly restricted diet and periodic fast days. The second edition (1923 ) introduced insulin and diets made more liberal in fat. The pre-insulin diets were continued because of the cost of insulin—5 cents a unit then—and because of a disinclination to give more of this new drug than was absolutely necessary, since it was not yet known whether ill effects would result from the continued use of insulin. As the years went by, greater and greater liberality was permitted, until, in the later editions of the book, the diets recommended, although still controlled as to composition, provided almost as much protein and carbohydrate as would be contained in the well-selected diets of normal persons [4].

Perhaps the reason diabetes has been considered a “chronic and progressive disease” is because dietary treatment had been all but forgotten after the discovery of insulin.

In 1921, Wilder understood that;

“Diabetes is a disease which in manifested by excretion of sugar in the urine. This sugar comes from the foods which the patient eats, but which is body, owing to the disease, is unable to utilize.”

and his treatment recommendations (pg.12) were;

“suiting the diet to the condition of the patient and feeding no more sugar-forming foods than the patient’s body is able to use.”

The concept of “eat what you want and cover it with insulin” simply wasn’t an option for those with diabetes, as insulin hadn’t been discovered yet. Diet was the only choice for managing symptoms of the disease — which begs the question, for those with type 2 diabetes who want to get off of diabetes medications now, why isn’t carbohydrate restriction offered as a choice?

No one denies the safety and efficacy of a ketogenic diet for the treatment of epilepsy, yet many deny that a low carb or ketogenic diet appropriate for those with diabetes — when both have been used safely for 100 years! While there is an absolute need to manage the dosage of oral hypoglycemic medications before and during reduction in the amount of carbohydrate in the diet there is no reason that we cannot support a diet-first, not drug-first approach to diabetes treatment and management when people want.

Determining Carbohydrate Tolerance in Diet

Diabetes is at its very essence “carbohydrate intolerance” and Wilder describes ‘tolerance‘ as ‘the amount of sugar-forming foods which a person can eat in twenty-four hours without causing sugar in the urine’.

“The tolerance of a given patient is ascertained by feeding foods of known composition in weighed and gradually increasing amounts.”

“The actual procedure will vary with different patients, but, in general, foods of known composition in weighted amounts are fed, the total intake of carbohydrate, protein and fat being increased very gradually as high as possible without the return of sugar in the urine.”

“Some patients will be found to have low tolerance, others may stand 100 gm. of carbohydrate. Every patient should be treated as an individual case, but for convenience in prescribing diets, the following arbitrary grouping is made:

Group A — tolerance below 40 gm. carbohydrate

Group B — tolerance between 40 and 60 gm. carbohydrate

Group C — tolerance between 60 and 100 gm. carbohydrate

Group D — tolerance above 100 gm. of carbohydrate

Use of Fasting and Protein Sparing Modified Fasts in Diet

Wilder’s approach incorporates short fasts of 12 – 24 hours as part of the management of blood sugar and up to 2-days if spilling sugar in the urine (i.e. exceeding their carbohydrate tolerance).

Those in Group A who have carbohydrate tolerance of less than 40 grams of carbohydrate (ketogenic level for women and men) are instructed to “interrupt their diet by a “fast day” once a week” — but its not a complete fast.  They are told to “take liberally of liquids”, including beef broth and coffee or tea.

Those in Group B who have carbohydrate tolerance between 40 and 60 grams of carbohydrate are instructed to “institute weekly days of half-fasts” on which they restrict their diet to 20 grams of carbohydrate, as well as 12 grams of protein and 12 grams of fat.

“On the appearance of sugar in the urine at any time, the patient, irrespective of his group, must institute a fast day. If the sugar persists, a second fast day should follow the first.

Of interest,  if sugar persists in the urine Wilder’s recommendations are to institute what would be known today as a “protein sparing modified fast“;

“If sugar persists, the patient should return to one-half of his diet, continue on this for a week, and then again try the effect of a fast day. After the urine is again sugar-free, he can return gradually to his previous diet.”

Wilder cautions that “longer fasts should never be attempted outside of an institution”, but it’s important to keep in mind that there was no distinction at this point between type 1 and type 2 diabetes.

There is no fasting protocol for those whose carbohydrate tolerance is between 60 and 100 grams.

Daily Macros

Those in Group A who have a carbohydrate tolerance of less than 40 grams of carbohydrate (ketogenic level for women and men) are instructed to eat breakfast, lunch and dinner such that the value of three such meals has 20 grams of carbohydrate, 70 grams of protein and 100 grams of fat (pg. 30 [1]).

Those in Group B who have carbohydrate tolerance between 40 and 60 grams of carbohydrate are instructed to eat breakfast, lunch and dinner such that the value of three such meals has 40 grams of carbohydrate, 70 grams of protein and 100 grams of fat (pg. 33 [1]).

Those in Group C who have carbohydrate tolerance between 60 and 100 grams of carbohydrate are instructed to eat breakfast, lunch and dinner such that the value of three such meals has 60 grams of carbohydrate, 70 grams of protein and 100 grams of fat (pg. 37 [1]).

Those in Group D who have carbohydrate tolerance above 100 grams of carbohydrate are instructed to eat breakfast, lunch and dinner such that the value of three such meals 100 grams of carbohydrate, 70 grams of protein and 140 grams of fat (pg. 41 [1]).

At 70 grams of protein per day irrespective of a person’s weight or gender, these low carb / ketogenic diets provided plenty of satiety and this amount is above the current DRIs of 46 g protein for the average sedentary woman, and 56g protein per day for the average sedentary man.

Fat sources in the sample menus were butter, cream, cheese and eggs and the fat found in the protein.

Carbohydrate sources in the diets were mainly from recipes for something called “Hepco Cakes” made from eggs, cream, Hepco flour, butter and water or from “Cullu-flour Griddle Cakes” made from eggs, salt, water and cellu-flour. Very low carb meals included low carb vegetables and a little bit of fruit, and the higher carbohydrate meals included low carb vegetables, root vegetables such as onion and beet, as well as a bit of fruit.

Final Thoughts…

Wilder understood that diabetes is a disease of carbohydrate intolerance and that each person with diabetes should be treated as an individual.

He was aware that some people with diabetes will have very low carbohydrate tolerance of less than 40 grams per day requiring a very low level of carbohydrate intake, while others can tolerate up to 100 grams of carbohydrate per day.

Over the last 5 years that I have been helping people with type 2 diabetes to follow a low carbohydrate diet to improve their symptoms, and to seek to put the disease into remission, my understanding turns out to be remarkably similar Wilder’s.  I have found that each person with type 2 diabetes (and even pre-diabetes) has different levels of carbohydrate tolerance and I don’t believe that everyone needs to be on “a keto diet”.

When I first started teaching low carbohydrate diets 5 years ago, unless someone was already on a ketogenic diet, I would start those with type 2 diabetes (who were not on any of the medications previously mentioned) at 130 grams of carbohydrate per day and gradually lower carbohydrates until clinical outcomes were reached. In the past two or three years I came to the realization that none of my clients with type 2 diabetes were tolerating carbohydrate intakes above 100 grams per day — which interestingly is consistent with Wilder’s categories.

People think of a low carb or “keto diet” to treat diabetes as something new — a “fad” even, but this diet has been around for over 100 years and was standard treatment at the Mayo Clinic for those with the disease until the discovery of insulin.  I have heard anecdotal stories of those who were diagnosed before the widespread use of insulin and who used a low carb diet their entire lives, avoiding the unnecessary complications that are thought to be part and parcel of having type 2 diabetes.

For those seeking to take a diet-first approach in managing their symptoms, this diet has stood the test of time in terms of safety and efficacy and very similar approaches have solid studies supporting their use. Is it any wonder that Diabetes Australia, American Diabetes Association and the European  Association for the Study of Diabetes (EASD) and Diabetes Canada accept a low carb and very low carb (keto) diet as medical nutrition therapy for the treatment and and management of diabetes?

More Info?

If you would like more information about how I might be able to support your needs, please have a look under the Services tab or send me a note through the Contact Me form.

People come to me as a Dietitian with different goals with respect to type 2 diabetes. Most people who have been diagnosed with type 2 diabetes come to see me in my low carb division seeking to put their diabetes into remission — that is, to no longer meet the criteria for diagnosis. 

As stated throughout this web site and on my forms, I do not counsel people with type 1 diabetes, or with insulin-dependent type 2 diabetes because I am not a Certified Diabetes Educator (CDE). 

As explained in this earlier article, the American Diabetes Association has defined partial remission, complete remission and prolonged remission from type 2 diabetes, as follows;

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

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

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

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

Complete and prolonged remission can be achieved after bariatric surgery such as the roux-en-y procedure, and partial remission and complete remission have been documented with dietary and lifestyle changes, including a very low calorie diet and a very low-carbohydrate (ketogenic diet). To date, there is limited long-term data of 5 years or more documenting prolonged remission with dietary and lifestyle changes alone, although there are case studies.

I support people with a wide-range of goals when it comes to diabetes through my long-standing general dietetic practice, BetterByDesign Nutrition, and for those seeking remission through either that division or my low carbohydrate focussed practice, The Low Carb Healthy Fat Dietitian.  

• • Some people come to me with a diagnosis of pre-diabetes wanting to implement dietary changes to avoid getting type 2 diabetes.
  • Others come to me once they are diagnosed with type 2 diabetes, wanting to better control their blood sugar level through dietary changes and avoid complications.
  • Those who found me searching for a Dietitian with experience with low carbohydrate- and very low carbohydrate (ketogenic) diets most often are coming to avoid developing diabetes after a pre-diabetes diagnosis, or to have me help them put the disease into remission.

These are each valid goals.

Those who know that remission of type 2 diabetes is entirely possible find it difficult to understand that not everyone with type 2 diabetes wants to put the disease into remission.

Some people simply don’t known that this is even a possibility — believing that the disease is automatically both chronic (long-term) and progressive (getting worse with time). This type of a situation gives me the opportunity to explain to them that type 2 diabetes can be put into remission, and the different ways that I can support them in aiming to achieve that.

Other people may simply want to ‘manage’ their blood sugar levels to keep them from getting higher in order to avoid complications. They don’t want to have normal blood sugar, but want to avoid losing toes or going blind. These people have every right to choose these goals and to be supported by their healthcare team including me, in meeting them. I will make sure that they know that it is possible to achieve remission (because many don’t know), but if they don’t want to make the significant lifestyle changes required, then I will help them manage their diet to keep their blood sugar from getting higher. That said, they before they even begin services with me, they know that the Meal Plan I will design for them will not be “high carb” by any stretch of the imagination. Since type 2 diabetes is, in essence end-stage carbohydrate intolerance, the amount and type of carbohydrate on a Meal Plan that I will design for them will be limited, and specific. 

Note: Those coming to me on SGLT2 medication, such as Jardiance and Victosa or ACE inhibitors for high blood pressure will be asked to first consult with their doctor to have them monitor their dosages, as the carbohydrate content of their diet is gradually reduced.

For those coming to me to avoid having their pre-diabetes progress to type 2 diabetes or seeking to put their type 2 diabetes into remission, I will present to them the various dietary options available and explain how I am best able to support them in each. In my long-standing general dietetic practice I support three main approaches, including a very low calorie diet (including time-restricted eating), a whole-food predominately plant-based (vegetarian) diet, a modified DASH diet, a Mediterranean diet, and a very low carbohydrate / ketogenic diet. Through my low carb division, I offer a low carb and very low carbohydrate / ketogenic diet which can be tailored to someone being a vegetarian, if that is their preference. To those coming to me for support in following a carnivore diet (all meat / animal product consumption) or a vegan diet (one devoid of any animal products), I recommend they seek the support of another Dietitian with expertise in those areas.  I simply don’t feel equipped to ensure a nutritionally-adequate diet following either of those approaches.

The byline of my low carb division (The Low Carb Healthy Fat Dietitian) is “there is no one-sized-fits-all low carb or ketogenic diet” — because there isn’t.  A high-fat moderate protein ketogenic diet may be appropriate in some circumstances, whereas a higher lean protein, moderate fat approach may be better suited in others. Everyone’s medical conditions, risk factors and personal preferences are different, so I go over the different options and make my recommendations while explaining my reasons for them and let the person decide for themselves. Nothing is carved in stone.  Meal Plans can be changed or “tweaked” to best meet the individual’s needs.

The byline of my long-standing general dietetic practice is “Nutrition is BetterByDesign“. This emphasises the same conviction that Meal Plans need to be designed for the individual.  A person who doesn’t eat meat for religious, cultural or ethical considerations, for example needs to have an individual Meal Plan that helps them achieve their health goals — in the same way that someone who eats meat does. Those who choose to live with diabetes have just as much right to dietary support to meet those goals, as someone who desires to seek remission from diabetes. It doesn’t matter that remission is possible if they don’t want to achieve that, or they don’t want to make the lifestyle changes necessary to make that a possibility. They are free to make that decision. As a Dietitian, my responsibility is to support them in meeting their goals, and not to try and convince that other goals are “better”.  As long as they know that the possibility for remission exists and how that can be accomplished, I will whole-heartedly support them in their desire to live better with diabetes.

One of the reasons why I continue to maintain both my long-standing dietetic practice, BetterByDesign Nutrition (BBDNutrition), as well as my low carb division, The Low Carb Healthy Fat Dietitian is to providing people with different dietary approaches to type 2 diabetes. The other reason is that some people come to me seeking support for GI disorders or food allergies / sensitivities, or for nutritional support in pregnancy or for their children, which I do only through BBDNutrition. My two divisions give people options. People who want only low carb and ketogenic dietary support in a practice that does nothing else have that at the Low Carb Healthy Fat Dietitian.

Individuals have different goals and various needs. People are also at different stages of change when it comes to them having type 2 diabetes. Some may start with wanting to manage their symptoms — and only later arrive at a point where they want to seek remission.  If and when they do, I support them in doing that.

This is why I do, what I do, the way I do.

Please let me know if I can help.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
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Copyright ©2021 BetterByDesign Nutrition Ltd.

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

I was excited when I saw a thread on social media over the weekend about Diabetes Canada’s new 7-day Low Carb Meal Plan. After all, last May they released a Position Statement summarizing the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) and very low- carbohydrate diets (<50g carbohydrate/day) in the management of type 1 and type 2 diabetes and I thought “great!” — they are going to be providing support for people with diabetes to be able to choose a low carb or very low carb (keto) diet as one of the available healthy eating patterns.  Not quite.

This was the ad I saw on Facebook;

Clicking on the link associated with the ad, the text reads;

“Current evidence suggests that a low-carbohydrate diet can be safe and effective for people with diabetes. This dietary pattern can help with weight loss and blood sugar management. Keep in mind that a low-carbohydrate diet can also reduce the need for certain diabetes medications. People living with diabetes who want to follow a low-carbohydrate diet should seek professional advice from their healthcare provider to avoid any adverse effects, such as hypoglycemia (low blood sugar) or an increased risk for diabetic ketoacidosis (DKA).

This meal plan features healthy plant-based foods, low glycemic index carbohydrates, and less than 130 grams carbohydrates per day. [1]”

At the bottom of the meal plan it indicates;

While the promotion on Facebook indicated that it features ‘plant-based foods’, it is not a plant-based menu. It includes eggs and yogurt, fish (tuna, fish fillet, salmon),  a (bun-less) cheeseburger, beef or pork meatballs, and chicken breast — along with tofu, legumes such as chick peas and black beans. Not surprisingly given one of the sponsors of the menu, each day includes one or more servings of plant-based beverages and recipes use canola oil.

The Diabetes Canada “low carb” meal plan is like no other I have ever come across, as it includes servings of starches such as bread, potato, rice, pasta and legumes.

Breakfast on day 1, 3 & 5 of the menu features a smoothie made with 200 ml of a sugar-sweetened soy beverage manufactured by one of the menu’s sponsors, along with 65 g of blueberries, 85 g of pomegranate and 2 g of ginger. This is hardly the best way for someone with diabetes (an inability to adequately handle carbohydrate) to begin the day — and that’s all there is for breakfast! One little glass of smoothie totalling almost 30g of carbs and only 9 g of protein.

Lunches and Dinners included either a slice of whole-grain bread, 1 small baked potato, 1/2 cup cooked brown rice, 3/4 cup (150 ml) cooked pasta, 1/2 cup (125 ml) mashed sweet potato or chick peas or black beans. Sure, small amounts of sweet potato can be appropriate as part of a real, whole food low carbohydrate meal plan, and a small amount of chick peas or black beans can be included from time to time, but there is no established “low carb” diet that includes bread, rice and pasta!

Low Carb — and low protein and fat too

I was curious how much food there was at each meal on this plan, as well as  the total amount of carbs and protein per day, so I decided to analyze Day 1, Day 3 and Day 5 to get a rough idea.

Where a recipe was not provided as part of the menu, I looked up the food item in Cronometer and used the nutritional information for the specified quantity.

These meals were <130 g of carbohydrate per day — so technically these are considered “low carb“, but they are also low fat, and low or inadequate in protein.

Day 1

Breakfast on Day 1 had a small glass of the “smoothie” (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it until lunch! Given the high amount of ground-up fruit in it as well as the low amount of fat and protein, the first thing I thought of was how soon an adult with diabetes would be ravenous after drinking this. Then I wondered how high would their blood sugar go?

[Note: February 5, 2021]: In an earlier article, I covered the effect of various types of food processing on blood glucose, including mechanical processing such as the pureeing of the fruit in this smoothie. While 60g of whole apple, 60 g of pureed apple, and 60g of juiced apple have the same amount of carbohydrate and similar Glycemic Index neither of these indicate how blood glucose responds to eating pureed fruit, versus intact fruit.  We know from a 1977 study published in the Lancet (reference below) that when pureed fruit or juiced fruit is consumed, the glucose response 90 minutes later is significantly higher than if the fruit were eaten whole. 

[Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre. Effects on satiety, plasma-glucose, and serum-insulin. Lancet. 1977 Oct 1;2(8040):679-82. doi: 10.1016/s0140-6736(77)90494-9. PMID: 71495]

This is typical of what is seen with any ultra-processed carbohydrate. So, the first problem with someone with diabetes having a fruit smoothie such as this as a meal is that the fruit is ground up, and not whole.  A smoothie will spike blood glucose much more than if the same food was eaten not pureed. 

We also know from a 2015 study on the effect of food order on the response of glucose and insulin, that if carbs are eaten last, the glucose curve will be approximately 74% smaller, with a 49% smaller insulin spike.

[Shukla AP, Iliescu RG, Thomas CE, Aronne LJ. Food Order Has a Significant Impact on Postprandial Glucose and Insulin Levels. Diabetes Care. 2015;38(7):e98-e99. doi:10.2337/dc15-0429]

The second problem with someone with diabetes drinking a fruit smoothie like this for breakfast with no other food is that there is no way of having the carbs last!

Lunch on Day 1 was a small serving of vegetable frittata (3 g carbs, 13.6 g pro, 14.9 g fat), 1 slice whole-grain bread (13.2 g carbs, 4.5 g pro, 1.3 g fat) and 1 cup unsweetened plant based beverage such as Silk plain Oat milk (7.6 g carbs, 0.4 g pro, 0.3 g fat). A slice of frittata, a slice of plain bread and a glass of oat milk and that’s it for lunch. Maybe a nice lunch for child home from school?

Dinner was 1 cup of Indonesian tofu stew with vegetables (8 g carbs, 5 g pro, 8 g fat) and ½ cup (125 mL) cooked brown rice (24.2 g carbs, 2.8 g pro, 1.0 g fat). That’s it. This might be an adequate serving for an older adult with a small appetite.

So what did this day provide in terms of carbohydrate and total protein?

Well, it was low carb (84.4 g) but it was also inadequate in protein — having only 35.2 g PRO. Based on “average” body weight and a minimum 0.36 g of protein per pound of body weight (0.8 g protein per kg), this is less than the 46g protein required for the average sedentary woman, and much less than the 56g of protein required for the average sedentary man.

Day 3

Breakfast was small glass of the same smoothie (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it until lunch!

Lunch was a “cup” of low fat cream of cauliflower soup that was actually only 3/4 cup / 175ml in size ( 10 g carbs, 7g PRO,  2g fat), 3.5 oz / 100 g grilled chicken breast (0 carbs, 41.7 g pro, 6.1 g fat) and a cup of unsweetened plant based beverage (7.6 g carbs, 0.4 g pro, 0.3 g fat). No salad, no side of veggies, that was it.

Dinner was 1 serving (3 oz) of grilled fish fillet (pink salmon – 0 g carbs, 17.4 g pro, 3.7 g fat), ½ cup (125 mL) cooked quinoa (17.1 g carbs, 4.1 g pro, 1.8 g fat) and 1.5 cups green salad with dressing (2.8 g carbs, 0.8 g pro, 2.5 g fat). What adult would find a small piece of fish, a small serving of quinoa and a small salad enough for supper — unless they had a big lunch?

What did this day provide, in terms of carbohydrate and total protein? Well, it was low carb (65.9 g) and adequate (71.4 g) protein, but had very few vegetables, little healthy fat, and very small portions.

Day 5

Breakfast was small glass of the same smoothie (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it.

Lunch was 1 egg on 3/4 cup of Mexican baked black beans (19 g carbs, 12 g pro, 9 g fat) and 1 cup unsweetened plant based beverage (7.6 g carbs, 0.4 g pro, 0.3 g fat). Nothing else. No veggies, no salad, not even a dollop of guacamole!

Dinner was 1 serving (3.5 oz) of beef or pork meatballs without sauce (10.5 g carbs, 19.3 g pro, 16.6 g fat) and ¾ cup (150 mL) of plain cooked pasta (30.5 g carbs, 6.1 g pro, 1.0 g fat). How is this an appropriate “low carb” dinner for someone with diabetes? How is this a complete meal?

It was low carb (96.0 g) and adequate (46.7 g) protein for a sedentary woman but inadequate protein for even a sedentary man. It had few vegetables, very little healthy fat, and very small portions.

Final Thoughts…

There are parts of this menu that are certainly usable, and it can be modified to make it into a lovely low-carb meal plan.

The frittata, for example could be a great start to a low-carb lunch when paired with a nice big salad, with a bit of crumbled cheese, a few pumpkin seeds and a bit of avocado — and skip the bread!

Double the amount of tofu stew and vegetables, and make a nice Asian style cucumber salad on the side and skip the rice!

The cauliflower soup with a splash of cream and the grilled chicken breast would go every well with a nice helping of steamed veggies or mixed greens on the side — and why not? They are low carb, and high in micronutrients. The cooked ones would taste great with a dab of butter and the raw ones, with a squeeze of lemon and some extra virgin olive oil. Now there’s lunch!

And why on earth would a person with diabetes be encouraged to drink that smoothie 3 times per week if not to promote the product of one of the menu’s sponsors?  Why not suggest an omelette made with some leftover cooked veggies from the night before — and they could even add an ounce of sharp cheddar to it, which would easily get them through to lunch. Or, how about a bowl of Greek yogurt with 1/2 cup of blueberries and a tablespoon of hemp heart? That is a high protein breakfast with far fewer carbs than the smoothie and will keep a person going with stable blood sugars until lunch.

Ditch the carbs.  Who needs the bread and pasta and rice — especially on a “low carb” meal plan?

People can get all the B-vitamins they need, including B1 (thiamine), B2 (riboflavin), B3 (niacin) and folate from real, whole food such as chicken liver, sardines, eggs and sunflower seeds. They can plenty of the most bioavailable iron from seafood and meat and get ample magnesium from nut, seeds, dark chocolate and avocados, and selenium from Brazil nuts and eggs.

The American Diabetes Association understands that a low carbohydrate diet ”limits sugar, cereals, pasta, bread, fruit & starchy vegetables” and “consist mostly of protein foods like meat and dairy, fatty foods like oil, nuts, seeds, avocado, and butter, and non-starchy vegetables” [2].

Canadian with diabetes deserve to have a low carb menu based on these same principals, and which provides them with adequate protein, a good source of healthy fats and adequate size servings of food.

We can do better.

Canadians with diabetes deserve better.

If you would like more information about how I can help support your nutrition needs, please click on the Services tab to learn more.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
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Copyright ©2021 BetterByDesign Nutrition Ltd.

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

Reference

1. Diabetes Canada, 7-day low carbohydrate meal plan, https://diabetes.ca/nutrition—fitness/meal-planning/7-day-low-carbohydrate-meal-plan
2. American Diabetes Association, Diabetes Food Hub, Meal Prep: meals for any eating pattern, Low Carb, https://www.diabetesfoodhub.org/articles/meal-prep-meals-for-any-eating-pattern.html

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

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

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

A Therapeutic Ketogenic Diet

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

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

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

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

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

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

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

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

and

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

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

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

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

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

Virta Health’s Approach

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

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

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

Phinney and Volek’s Approach

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

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

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

In Phinney and Volek’s approach;

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

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

Popularized “Keto Diet”

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

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

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

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

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

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

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

Final Thoughts

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

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13
2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
3. U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415
4. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
5. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
   Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
6. Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an  open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583—612
7. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
8. Zoe Harcombe, LCHF and Butter, January 29, 2018, https://www.zoeharcombe.com/2018/01/lchf-and-butter/

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

What is a Ketogenic Diet?

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

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

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

This bears repeating.

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

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

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

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

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

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

Therapeutic Ketogenic Diets

First of all, what does “therapeutic” mean?

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

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

The first therapeutic ketogenic diet was used in the 1920s for the treatment of epilepsy. Physicians at Harvard Medical School had begun experimenting with periods of extended fasting as a treatment, and discovered that seizures improved after 2-3 days. In 1921 , Dr. R.M. Wilder[3] used a very high fat, low carbohydrate, and restricted protein diet in a series of patients with epilepsy, and found that it was as effective as fasting and had the advantage that it could be maintained for much longer a period of time than fasting.

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

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

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

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

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

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

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

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

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

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

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

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

and

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

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

Weight-Loss “Keto” Diets

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

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

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

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

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

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

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

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

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

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

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

The Stereotypical High Fat Keto Diet is Only ONE Type

Over the last several years, about 1/3 of people that come to me do so after following “the keto diets” without realizing that there is not just one.  Most lost some weight initially on this high fat diet, and then stalled — and quite a few actually ended up gaining weight.

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

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

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

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

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

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

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

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

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

Final Thoughts…

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

The idea that there is “THE keto diet” which is high in fat is a fallacy — one that has the unintended consequence of many people failing to lose weight (and often gaining weight) because they don’t realize that it needs to be combined with periods of intermittent fasting.  A weight-loss “keto diet” that is 75% fat, 15% protein and 10% carbs is only ONE type of ketogenic diet. It is by no means “THE keto diet!”.  A diet that is low in carbohydrate and rich in nutrient-dense lean protein, as well as a wide range of vegetables and fruit is just as much a “keto diet” because it is low in carbohydrate — and one that can be used successfully to achieve weight loss, with no fasting required.

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

More Info?

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13
2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
3. U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415
4. Peterman MG, The Ketogenic Diet, JAMA. 1928;90(18):1427—1429. doi:10.1001/jama.1928.02690450007003
5. Kossoff EH, Doward JL. The Modified Atkins Diet. Epilepsia 2008; 49 (Suppl8): 37-41
6. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
7. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
   Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
8. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
9. Westman E, Phinney SD, Volek J, (2010) Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
10. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
11. Fung J (2016) Obesity Code, Greystone Books, Vancouver
12. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
13. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
14. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
15. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020)
16. Paddon-Jones D, Westman E, Mattes RD et al, Protein, weight management, and satiety, The American Journal of Clinical Nutrition, Volume 87, Issue 5, May 2008, Pages 1558S—1561S, https://doi.org/10.1093/ajcn/87.5.1558S

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

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

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

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

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

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

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

Many Types of Keto Diets

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Self Administered Diets

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

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

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

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

Failed Weight Loss

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

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

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

Final Thoughts…

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

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

1. Sagesaka H, S.Y., Someya Y, et al, Type 2 Diabetes: When Does It Start? Journal of the Endocrine Society, 2018. 2(5): p. 476-484.
2. American Association of Clinical Endocrinologists Announces Framework for Dysglycemia-Based Chronic Disease Care Model, November 28, 2018, AACE Online Newsroom, url: https://media.aace.com/press-release/american-association-clinical-endocrinologists-announces-frameworkdysglycemia-based-c
3.  Fabbrini E., et al. , Alterations in adipose tissue and hepatic lipid kinetics in obese men and women with nonalcoholic fatty liver disease. Gastroenterology 134, 424—431 (2008). 
4. Gastaldelli A., et al. , Relationship between hepatic/visceral fat and hepatic insulin resistance in nondiabetic and type 2 diabetic subjects. Gastroenterology 133, 496—506 (2007). 
5. Korenblat K. M., Fabbrini E., Mohammed B. S., Klein S., Liver, muscle, and adipose tissue insulin action is directly related to intrahepatic triglyceride content in obese subjects. Gastroenterology 134, 1369—1375 (2008). 
6. Kotronen A., Juurinen L., Tiikkainen M., Vehkavaara S., Yki-Jí¤rvinen H., Increased liver fat, impaired insulin clearance, and hepatic and adipose tissue insulin resistance in type 2 diabetes. Gastroenterology 135, 122—130 (2008).
7. Bugianesi E., et al. , Insulin resistance in non-diabetic patients with non-alcoholic fatty liver disease: Sites and mechanisms. Diabetologia 48, 634—642 (2005).
8. Seppí¤lí¤-Lindroos A., et al. , Fat accumulation in the liver is associated with defects in insulin suppression of glucose production and serum free fatty acids independent of obesity in normal men. J. Clin. Endocrinol. Metab. 87, 3023—3028 (2002).
9. Ryysy L., et al. , Hepatic fat content and insulin action on free fatty acids and glucose metabolism rather than insulin absorption are associated with insulin requirements during insulin therapy in type 2 diabetic patients. Diabetes 49, 749—758 (2000). 
10. Luukkonen PK, Dufour S, Lyu K, et al. Effect of a ketogenic diet on hepatic steatosis and hepatic mitochondrial metabolism in nonalcoholic fatty liver disease. Proc Natl Acad Sci U S A. 2020;117(13):7347-7354.
11. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13.
12. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
13. Atkins, R. C. (1972). Dr. Atkins’ diet revolution; the high calorie way to stay thin forever. New York: D. McKay Co.
14. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
15. Westman E, Phinney SD, Volek J, (2010) Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
16. Phinney SD, Volek J, (2011), The Art and Science of Low Carbohydrate Living, Beyond Obesity LLC
17. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
18. Fung J (2016) Obesity Code, Greystone Books, Vancouver
19. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
20. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
21. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
22. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020),
23. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233. doi:10.1037/0003-066X.62.3.220

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

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

The newly published report stated;

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

Dietary Recommendations to Lower Saturated Fat

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

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

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

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

The report summarized;

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

Bias Against Saturated Fat

The report concluded;

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

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

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

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

Final Thoughts…

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

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

Understanding the Risk

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

Selecting Protocols for the Workplace

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

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

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

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

Protocols for Health Professions

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

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

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

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

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

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

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

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

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

The Effect of these Necessary Protocols

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

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

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

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

Diabetes Canada has just released a new Position Statement acknowledging that a low carb and very low carb (keto) diet is both safe and effective for adults with diabetes.

Reflecting back on their 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada released in April 2018 and covered in this article from my affiliate practice, Diabetes Canada clarified in this new Position Statement that it was not their intention to restrict the choice of individuals with diabetes to follow dietary patterns with carbohydrate intake that were below the consensus recommendation of 45-60% energy as carbohydrate, nor to discourage health-care practitioners from providing low-carb dietary support to individuals who wanted to follow a low-carb meal pattern. 

In the new Position Statement, Diabetes Canada acknowledged what I’ve written about previously, that Diabetes Australia, Diabetes UK, and the American Diabetes Association (ADA) in conjunction with the European Association for the Study of Diabetes (EASD) have developed position statements and recommendations regarding the use of low carbohydrate and very low carbohydrate (ketogenic) diets for people with diabetes. They state that from these previous international position statements and recommendations, several consistent themes have emerged — specifically that low carbohydrate diets (defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate) and very low carbohydrate diets (defined as <50 g of carbohydrate per day) can be safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months).

Diabetes Canada explained in the publication that they periodically develop position statements in order to address issues that are important for people living with diabetes, as well as their health-care providers and when there is either insufficient data to perform a systematic review, or there is no high level evidence (e.g. double-blind placebo controlled studies).

Diabetes Canada stated that this new position statement was developed in response to emerging evidence. as well as a shift in international consensus regarding lower carbohydrate diets — with the goal of providing important clarification for people living with diabetes, as well as health-care providers. It is their hope that this update will make effective engagement with multi-disciplinary teams easier, as well as avoid inter-professional tensions, as well as clearly identify areas where there are key safety issues and the need for clinical monitoring.

The purpose of the position statement was to summarize the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) or very low- carbohydrate diets (<50g carbohydrate/day) in the management of people diagnosed with type 1 and type 2 diabetes.

Summary of the Evidence – type 2 diabetes

Low Carbohydrate Diets

A review of the evidence found that a low carbohydrate diet (<51-130g carbohydrate/day) may be effective for weight loss, improved blood sugar control including a reduction in need for blood sugar lowering medication (anti-hyperglycemic therapies).

Also noted in the position paper is that while other dietary approaches for managing type 2 diabetes may be effective for weight loss and better blood sugar control, they have not achieved this while also reducing the need for blood-sugar lowering medication. Diabetes Canada calls this a  “meaningful outcome”.

Very Low Carbohydrate Diets

Of significance, this new position statement states that a review of the current literature suggests that very low- carbohydrate diets (<50g carbohydrate/day) may be superior to higher carbohydrate diets for improving blood sugar control and body weight, and that it can reduce the need for blood sugar lowering medications in the short term (up to 12 months).

They state that evidence regarding longer-term benefits is limited.

Summary of the Evidence – type 1 diabetes

The new position paper states that “there is very little reliable data and major evidence gaps which make it difficult to make general  recommendations with any confidence” for those with type 1 diabetes.

That said, the paper does state that for those living with type 1 diabetes, significant improvements in outcomes such as lower HbA1C, reduced insulin requirements, less variability in blood sugar and weight loss have been reported by individuals who have chosen to follow a low carbohydrate or very low carbohydrate diet.

Diabetes Canada concludes that “in the absence of clear trial evidence to support generalized recommendations, as well as the positive results experienced by people following low- and very low- carbohydrate diets;

• health-care providers will need to work as partners with individuals seeking to identify an optimal and sustainable dietary pattern that fits with their individual preferences.
• Health-care providers will need to recognize that diverse approaches are required to address the complex challenges of diabetes and obesity.
• Health-care providers should strive to engage with patients in supportive relationships which respect shared decision making. “[1]

Cautions and Safety

Diabetes Canada advised that insulin and/or sulphonylurea doses may need to be reduced or discontinued to avoid hypoglycemia (low blood sugar) in those following a low carb or very low carb diet, and that SGLT2 inhibitors may increase the risk of diabetic ketoacidosis in individuals following low carbohydrate diets. As well, Diabetes Canada states that some added caution may be needed to ensure detection and treatment of hypoglycemia.

Diabetes Canada’s Five Recommendations

1. Individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences.
2.  Healthy low carb or very-low-carb diets can be considered as one healthy eating pattern for individuals living with type 1 and type 2 diabetes for weight loss, improved blood sugar control and/or to reduce the need for blood sugar lowering medications. Individuals should consult with their health-care provider to define goals and reduce the likelihood of adverse effects.
3. Health-care providers can support people with diabetes who wish to follow a low-carbohydrate diet by recommending better blood glucose monitoring, adjusting medications that may cause low blood sugar or increase risk for diabetic ketoacidosis and to ensure adequate intake of fibre and nutrients.
4. Individuals and their health-care providers should be educated about the risk of diabetic ketoacidosis while using SGLT2 inhibitors along with a low carbohydrate diet, and be educated in lowering this risk.
5. People with diabetes who begin a low carbohydrate diet should seek support from a dietitian who can help create a culturally appropriate, enjoyable and sustainable plan. A dietitian can propose ways to modify carbohydrate intake that best aligns with an individual’s values, preferences, needs and treatment goals as people transition to- or from a low carbohydrate eating pattern.

Healthy Low Carb and Very Low Carb Diets

Finally, Diabetes Canada underscores that Canadians both with- and without diabetes who choose to adopt a low or very low-carbohydrate dietary
pattern “should be encouraged to consume a variety of foods recommended in Canada’s Food Guide”, and that “regular or frequent consumption of high energy foods that have limited nutritional value, and those that are high in sugar, saturated fat or salt, including processed foods and sugary drinks, should be discouraged.”

Final Thoughts…

As a Dietitian who has been helping individuals in Canada safely follow a variety of meal patterns over the past 12 years, as well as a low carbohydrate and very low carbohydrate diets over the past 5 years, I am delighted that Diabetes Canada shares the consensus of other international groups that have determined that these diets are both safe and effective for adults to follow in order to get much better blood sugar control, and for weight loss.

More Info?

If you would like more information about how I can help you get started on a low carbohydrate or very low carbohydrate diet, please reach out to me by sending me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/lBetterByDesignNutrition/

Reference

1. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
   Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

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

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

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

Basic PPEs

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

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

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

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

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

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

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

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

Until When…?

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

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

The New Normal

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

Reference

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

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

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

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

BUT

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

Reference

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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