Author: BBDN

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

We Need to “Get” This

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

How Big an Issue is Obesity?

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

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

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

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

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

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

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

More Info?

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

You can find more about the details of the different packages I offer by looking under the Services tab or in the Shop. If you have any service-related questions please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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

References

1. Christopher M. Petrilli, Simon A. Jones, Jie Yang, Harish Rajagopalan, Luke F. O’Donnell, Yelena Chernyak, Katie Tobin, Robert J. Cerfolio, Fritz Francois, Leora I. Horwitz,  medRxiv 2020.04.08.20057794; doi: https://doi.org/10.1101/2020.04.08.20057794
2. Lighter J, Phillips M, Hochman S et al, Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission, accepted manuscript, Clinical Infectious Diseases. doi: 10.1093/cid/ciaa415,  https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa415/5818333
3. Araíºjo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009—2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105

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

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

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

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

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

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

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

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

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

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

Weight Loss – easier said than done?

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

I can help.

More Info?

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

You can find more about the details of the different packages I offer by looking under the Services tab or in the Shop. If you have any service-related questions please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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

References

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

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

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

Changing What’s in Our Control to Change

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

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

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

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

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

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

Final Thoughts…

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

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

More Info?

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

You can find more about the details of the different packages I offer by looking under the Services tab, or in the Shop and if you have any service-related questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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

References

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

 

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

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

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

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

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

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

Further thoughts…

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

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

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

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

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.

References

References

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

Note: This article is a follow-up to an earlier article about COVID-19 coronavirus in the Vancouver area that was posted on February 6th, 2020. Please note this article was updated twice on February 23rd, with the updates posted below.

Provincial health officer Bonnie Henry announced Thursday, February 20th that a woman in her 30s who just returned from Iran this week is British Columbia’s sixth case of the novel COVID-19 coronavirus.  The woman was assessed at a hospital and is now in self-isolation at home in the Fraser Health region. Health officials won’t say which area she is in, but only that the Fraser Health region spans from Burnaby to Hope[1].

Note: The north shore (North Vancouver) is well known for its vibrant Iranian community, but so is Coquitlam, which is part of the Fraser Health region.

Health officials are now investigating details of the woman’s travel and working to determine whether other passengers on her flight home will need to be notified and tested.

This case is unusual in that the travel was to Iran, and not China or Singapore. Dr. Henry said that this is what is called a “sentinel event”, which is “a marker that something may be going on broader than what we expect[1].”

Earlier this week, on February 16th two Canadians returned to British Columbia from having been on the Westerdam cruise, and were asked by officials to put on protective face masks at Vancouver International Airport as an American woman who was on the cruise with them has tested positive for the COVID-19 coronovirus, and both she and her husband have been hospitalized with pneumonia [2,3]. The Global News headline for the story read “COVID-19 fears spike after woman let off cruise ship in Cambodia tests positive“.  The story’s opening paragraph reads, “The feel-good story of how Cambodia allowed a cruise ship to dock after it was turned away elsewhere in Asia for fear of spreading the deadly virus that began in China has taken an unfortunate turn after a passenger released from the ship tested positive for the virus [3].”

A week ago, a 5th case of COVID-19 had been identified in British Columbia in a woman in her 30s who travelled to the Shanghai area of China. “She was not in Hubei province and was not in an area where travel was restricted,” said Dr. Bonnie Henry, B.C.’s Chief Medical Health Officer. ”She came home from Shanghai through YVR (the Vancouver International Airport) and then travelled by private vehicle to her home in the interior,” said Henry. The woman was tested on February 11th, and the lab returned a positive result on Thursday February 13th [4]. Global News reported that they think that the woman’s symptoms started around her time of arrival. Henry said, ”We’re still working out the seating and looking at the flights“.  Global News also reported that “health officials are still working to contact everyone who sat within three rows of the woman to discuss what to do if they show symptoms”. Officials are not saying what flight the woman was on, or where she lives in the interior because “because they don’t want to unnecessarily alarm people“, Henry said [4].

It is also known that 5 million people left Wuhan before quarantine was set up in that city in preparation for the lunar New Year[5]. Where did they go? We know for sure that two people from Wuhan came to Vancouver during that time and that a woman in her 50s with whom they were staying contracted COVID-19 from them [6,7]. Since incubation period for the illness is believed to be up to 14 days and these individuals they were without symptoms while touring Vancouver sites, it is unknown how many individuals in the greater Vancouver area may have also been exposed to the coronavirus over the last few weeks by being in close contact with these three individuals. It is also unknown how many other people from the outbreak area may have come to Canada before the quarantine was in place. 

Some thoughts…

Medical officials are continuing to assure the public that the risks of getting COVID-19 are “low”, but “low” is a relative term.

Risk would certainly be “low” when compared to Wuhan where the coronavirus originated from (based on the sheer number of individuals infected there) and would also be “low” compared to those who were quarantined on the Diamond Princess off of the coast of Japan, but people in the Greater Vancouver area are very much on edge knowing that being within 2 meters (6.5 feet)  for any length of time of those who are contagious may put them at risk. Two meters is the distance between tables in  a restaurant, the distance between people in front and behind in a long line up at a checkout line, or at popular locations including the airport. Given that people can have no symptoms whatsoever and be contagious for 14 days has many people concerned.

In addition to a growing outbreak of COVID-19 in Iran, also of concern is the recent emergence of hundreds of cases of COVID-19 in Seoul, South Korea — as both of these countries have strong ties to local communities, and neither country is currently restricting travel.

Distance Consultations

Over the past decade that I have provided services via Distance Consultation, they had become increasingly popular with local-area clients as it saved them travelling booking time off work, or arranging childcare. As events related to coronavirus have unfolded, many local clients are glad to have the ability to consult with me remotely, especially given my experience in doing so. 

You can find out more about Distance Consultations by clicking on the tab above.

More Info?

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

To your good health!

Joy

You can follow me on:

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

Update: February 23, 2020: Several media outlets [8,9] are reporting that the woman that tested positive for the new coronavirus and had recently flown from Iran, also flew from Montreal to Vancouver on Valentine’s Day, February 14th. The BC Provincial Health Authority (PHSA) advised Air Canada that it plans to contact all passengers who flew out of Montreal that day and who were seated within three rows of the woman so that they can monitor their health for a 14-day period and report any symptoms to a health professional [8.9].

Global News reported later this afternoon that the Fraser Health Authority sent a letter to all school districts in its region on Friday, which includes Burnaby, New Westminster, Maple Ridge, Pitt Meadows and the Tri-Cities — warning them that contacts of the woman with coronavirus ”may have attended schools in the region and are currently isolated.”  Fraser Health’s medical health officer Ingrid Tyler wrote in the letter that ”these contacts were not showing any signs or symptoms of illness while attending school, and remain well” and the health authority has assured that “there is no public health risk at schools in the region” and “no evidence that novel coronavirus is circulating in the community” [10].

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.

References

1. Globe and Mail, Andrea Woo, B.C. hit with sixth case of coronavirus after woman returns from Iran, https://www.theglobeandmail.com/canada/british-columbia/article-bc-hit-with-sixth-case-of-coronavirus-after-woman-returns-from-iran/
2. CBC News, Austin Grabish, As Canadians return home from Westerdam cruise, health officials urge them to self-isolate, February 16, 2020 https://www.cbc.ca/news/canada/british-columbia/westerdam-cruise-canadians-return-home-1.5466131
3. Global News, Sopheng Cheang, Eileen Ng, Grant Peck (Associated Press), COVID-19 fears spike after woman let off cruise ship in Cambodia tests positive, February 17, 2020, https://globalnews.ca/news/6559821/cambodia-cruise-ship-coronavirus-positive/
4. GlobalNews, Stuart Little, B.C. identifies 5th presumptive case of COVID-19, woman who travelled near Shanghai, https://globalnews.ca/news/6552744/british-columbia-covid-19-update/
5. CTVNews, Erika Kinetz, Where did they go? Millions left Wuhan before quarantine. February 9, 2010, https://www.ctvnews.ca/health/where-did-they-go-millions-left-wuhan-before-quarantine-1
6. CityNews 1130, Paul James and Kathryn Tindale, Health officials track coronavirus in Metro Vancouver, risk remains low, posted Feb 5, 2020 11:31 am PST, last Updated Feb 5, 2020 at 11:32 am PST,  https://www.citynews1130.com/2020/02/05/virus-expert-tracking-infected/
7. National Post, Richard Warnica, Fifth suspected coronavirus case in Canada is B.C. woman who had ‘close contact’ with Wuhan visitors, Posted February 4, 2020 and 11:33 PM EST, https://nationalpost.com/news/canada/fifth-suspected-coronavirus-case-in-canada-is-b-c-woman-who-had-close-contact-with-wuhan-visitors
8. Montreal Gazette, Susan Schwartz, February 23, 2020, Passenger from Iran on flight from Montreal to Vancouver tests positive for new coronavirus, https://montrealgazette.com/news/local-news/passenger-from-iran-on-flight-from-montreal-to-vancouver-tests-positive-for-new-coronavirus
9. CBC, B.C.’s 6th presumptive COVID-19 case flew from Montreal to Vancouver on Feb. 14, https://www.cbc.ca/news/canada/british-columbia/bc-coronavirus-flight-montreal-vancouver-1.5473283
10. Global News, Sean Boynton, Passenger on Air Canada flight to Vancouver is not a new case of COVID-19: B.C. officials, Feb 23 2020 2:11 pm, updated 5:18 pm), https://globalnews.ca/news/6586274/covid19-air-canada-vancouver-montreal/

The American Diabetes Association (ADA) has just released its new Standards of Medical Care in Diabetes (2020) [1] which begins the section on Medical Nutrition Therapy by referring to the ADA’s April 2019 Consensus Report[2] which emphasized that there is no ”one-size-fits-all” eating pattern for the prevention or management of diabetes (more in this article).

In the section on Medical Nutrition Therapy (MNT), the new Standards of Medical Care 2020 underscores that for many people with diabetes, the most challenging part about treatment is determining what to eat — and for this reason the ADA emphasizes that meal planning needs to be individualized.

The ADA also states that all people diagnosed with diabetes should be referred to an a Registered Dietitian (RD/RDN) who is “knowledgeable and skilled in providing diabetes-specific MNT at diagnosis and as needed throughout the life span”[1] and that research indicates that edical Nutrition
Therapy delivered by an RD/RDN is associated with decrease in HbA1C of between 0.3 and 2.0% for people with type 2 diabetes [3].

In the section on Eating Patterns, Macronutrient Distribution and Meal Planning, the new Standards of Medical Care in Diabetes re-iterated what the Consensus Report stated, that evidence suggests that;

“there is not an ideal percentage of calories from carbohydrate, protein, and fat for people with diabetes. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals.”

As well, the new Standards of Medical Care re-iterates that a low carbohydrate eating pattern is an example of one that is both healthful and helpful in controlling blood glucose;

“The Mediterranean-style ([4-5], low-carbohydrate* [6-8] and vegetarian or plant-based [9-10] eating patterns are all examples of healthful eating patterns that have shown positive results in research, but individualized meal planning should focus on personal preferences, needs, and goals. “

*In the  Consensus Report referred to in this section, a low carbohydrate eating pattern was defined as 26-45% of total calories from carbohydrate and a very low carbohydrate eating pattern (ketogenic) was defined as 20-50 g of non-fiber carbohydrate per day.

The new Standards of Medical Care encourages healthcare practitioners to not only consider a person’s metabolic goals, but also their personal preferences, including tradition, culture, religion, health beliefs, goals, and economic situation in helping them choose a suitable eating patterns.

It encourages each member of the healthcare team;

“to be knowledgeable about nutrition therapy principles for people with all types of diabetes and be supportive of their implementation.”

Given that a low carbohydrate diet is one of the eating patterns that the ADA considers both healthful and helpful in the management of diabetes, healthcare professionals ought to be prepared to be supportive of a person seeking to implement this approach.

The Standards of Medical Care states that until there is stronger evidence surrounding comparative benefits of different eating patterns in specific individuals, “healthcare providers should focus on the key factors that are common among the patterns:

1) emphasize non-starchy vegetables
2) minimize added sugars and refined grains
and
3) choose whole foods over highly processed foods to the extent possible”[2].

Similar to what was stated in the Consensus Report, the Standards of Medical Care reiterates that “research studies on some low-carbohydrate eating plans generally indicate challenges with long-term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach”. Given the wide range of “low carbohydrate” diets people may be following, it makes good sense to ensure a person is following one that is evidence-based and appropriate for them.

The Standards of Medical Care restates that  at this time a low carbohydrate eating pattern is not recommended for women who are pregnant or lactating, people with or at risk for disordered eating, or people who have renal disease, and should be used with caution in patients taking sodium—glucose cotransporter 2 inhibitors due to the potential risk of ketoacidosis [11-12]. (Note: This caution regarding those taking certain medication is covered in this previous article).

Carbohydrates

The section of the Standards of Medical Care in Diabetes on Carbohydrates re-emphasizes the benefits to blood sugar (glycemic) control of a low carbohydrate eating patterns that was previously outlined in the Consensus Report, namely;

“For people with type 2 diabetes or prediabetes, low-carbohydrate eating plans show potential to improve glycemia and lipid outcomes for up to 1 year [6, 8, 13, 14-17]

The new Standards re-iterates that “part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan [8, 18]”.

Final Thoughts…

There is nothing really “new” in the section on Medical Nutrition Therapy in the new Standards of Medical Care as it pertains to the safety and efficacy of low carbohydrate eating patterns, or in their ability to help improve blood sugar control. This, in and by itself is very encouraging because it means that the ADA has considers a well-designed low carbohydrate diet to be both healthful and helpful in the management of diabetes for the second year in a row.

When will Diabetes Canada complete their review of the current literature,  including that cited by the ADA in the Consensus Report and their new Standards of Medical Care in Diabetes 2020 and update their position on the use of low carbohydrate diets in those with diabetes in Canada?

More Info

If you would like more information about the services I provide and how I can design a Meal Plan for you based on your needs, please have a look under the Services tab, or in the Shop. If you have questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
   American, Diabetes Care Jan 2020, 43 (Supplement 1) S48-S65; DOI: 10.2337/dc20-S005
2. Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care 2019;42:731—754
3. Franz MJ, MacLeod J, Evert A, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet 2017;117:1659—167
4. Esposito K, Maiorino MI, Ciotola M, et al. Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial. Ann Intern Med 2009;151:306—314
5. Boucher JL. Mediterranean eating pattern. Diabetes Spectr 2017;30:72—76
6. Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239—252
7. van Zuuren EJ, Fedorowicz Z, Kuijpers T, Pijl H. Effects of low-carbohydrate- compared with low-fat-diet interventions on metabolic control in people with type 2 diabetes: a systematic review including GRADE assessments. Am J Clin Nutr 2018;108:300—331
8. Snorgaard O, Poulsen GM, Andersen HK, Astrup A. Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes. BMJ Open Diabetes Res Care 2017;5:e000354
9. Rinaldi S, Campbell EE, Fournier J, O’Connor C, Madill J. A comprehensive review of the literature supporting recommendations from the Canadian Diabetes Association for the use of a plant-based diet for management of
10. Pawlak R. Vegetarian diets in the prevention and management of diabetes and its complications. Diabetes Spectr 2017;30:82—88
11. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. Accessed 1 November 2019. Available from http://www.fda.gov/Drugs/DrugSafety/ucm475463.htm
12. Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: analysis of FAERS data. Diabetes Metab Res Rev 2017;33:e2924
13. Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes 2017;7:304
14. 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
15. van Wyk HJ, Davis RE, Davies JS. A critical review of low-carbohydrate diets in people with type 2 diabetes. Diabet Med 2016;33:148—157
16. Meng Y, Bai H, Wang S, Li Z, Wang Q, Chen L. Efficacy of low carbohydrate diet for type 2 diabetes mellitus management: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2017;131:124—131
17. Tay J, Luscombe-Marsh ND, Thompson CH, et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. Am J Clin Nutr 2015;102:780—790
18. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev 2009;1:CD006296

Many people say they plan to lose weight, lower their blood sugar, pressure or cholesterol in the New Year, but the difference between a “wish” and a “resolution” is having a plan in place to actually do it.

Wish or Resolution?

A “wish” is really just a hope that something will occur — an “it would be nice” type of thought, whereas a “resolution” is a firm decision to do something and is associated with specific qualities that will make it a reality.  A resolution is a SMART goal; one which is specific,  measurable,  achievable, realistic and timely.

A goal to lose weight or eat healthier isn’t specific — it’s just a wish. A resolution to stop eating foods with added sugar is specific, so is a goal to eat whole, real foods that are low in refined carbohydrate.  These are specific.

A resolution isl measurable. It decides what success looks like. For someone to say they want to lose 25 pounds is very different than to say they plan to lose a pound a week so that in 6 months they’ve lost 25 pounds.

But is that goal achievable?  If someone is significantly overweight, it is achievable to set a goal of losing 25 pounds in 6 months. 

What if someone wants to incorporate long periods of intermittent fasting into their lifestyle, but also eat all of their meals with their family? This isn’t realistic —  but they can choose to have shorter ‘eating windows’ (such as 18:6), intermittently fast each day and still eat dinner each night with their family. That’s entirely realistic. 

For a goal to be timely (or time-bound) means that it will also be achieved in a specific amount of time. So, for example, the resolution to lose 25 pounds in 6 months, is time-bound.

So, while there are lots of people saying they’d like to lose weight, eat healthier, exercise more or have better blood sugar, blood pressure or cholesterol in the New Year, to be successful one needs a go about putting a SMART plan in place now in order to achieve it.

Without such a plan, January will arrive and a week into the New Year, 50% of people will have already given up on their goal [1] and by the end of the month, 83% will have quit [1].  Those are pretty discouraging statistics!

Why is that?

Because it takes ~66 days (more than 2 months) for a habit to become ingrained [2], so having professional support during that critical time is important!

I can help you get off to a good start in achieving your New Year’s resolution, but the best time to put a plan in place is now — before all the festivities begin.

Why not make this the year you actually achieve your health and weight-loss goals?

If you would like more information about the services I provide and how I can design a Meal Plan for you based on your needs, please have a look under the Services tab, or in the Shop. If you have questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Norcross, JC et al, Auld lang syne: success predictors, change processes, and self-reported outcomes of New Year’s resolvers and nonresolvers. J Clin Psychol. 2002 Apr;58(4):397-405
2. Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W. and Wardle, J. (2010), How are habits formed: Modelling habit formation in the real world. Eur. J. Soc. Psychol., 40: 998—1009.

The whole matter of ‘when we eat’ meals and ‘when we don’t eat’ was historically a non-issue; we ate when it was daylight and we had food available, and we didn’t eat when it was dark or had no food. With the creation of indoor lighting and electricity, “day” lasted as long as we keep the lights on and for most of us, food is available in our fridges around the clock. Before elaborating on the current science surrounding when to eat meals and to not eat, let’s look at a short history of the origins of eating 3 meals per day, and when the idea of ‘snacks’ became prominent.

Timing of Meals

According to food historian Ivan Day[1], during the Middle Ages, availability of daylight shaped meal times, as there was no electricity. People got up and began to work in the fields at first daylight and by mid-day they were hungry after working for 6 hours or so and lunch was the first and main meal of the day. As there was no artificial lighting, cooking large meals in the evening simply wasn’t possible, so dinner was really a smaller meal, such as bread and cheese.

Breakfast became popular during the mid-19th century when labourers needed an early meal to sustain them at work. It became widely popularized in the early 20th century when John Harvey Kellogg invented the first breakfast cereal. Dinner became the main meal of the day with the creation of artificial (gas) lighting, and by the early 1900s, people were eating 3 meals per day, with the last meal occurring after work. Gas lighting was expensive to run, so after dinner was eaten and cleaned up from, bedtime was shortly after.

Snacks

“Snacks” were frowned upon by the middle class during Victorian era because they did not require use of “proper” utensils (cutlery, plates), were seen as unhygienic and were associated with the lower class [2].

Snacks as we know them took root in the 1950s due to the manufacturing industry’s drive to sell new products in a growing economy after the end of WWII, along with an ability to create inexpensive disposable packaging and unique labelling to market these products. Sale of snack foods escalated in the late 1970s [2], and between 1977 and 2006, Americans were eating approximately 570 calories more per day, much of it as snacks rather than during meals [3].

Historic Dietary Treatment of Diabetes

Before the discovery of insulin, successful management of diabetes involved restricting carbohydrates eaten at meals.

In his text book titled “The Principles and Practice of Medicine” (1892), Dr. William Osler recommended a diet of 65% fat, 32% protein, and 3% carbohydrate, as well as abstaining from ”all fruits and garden stuff.” [4] — not dissimilar to some of the high-fat “keto” diets available today. 

In the early 1900s, Bernard Naunyn encouraged a strict carbohydrate-free diet [5], with energy being provided as fat and protein.

In 1914, Dr. Frederick M. Allen treated people for several days with a period of fasting to clear the excess blood sugar via the urine, and then followed that with a diet that was mostly fat and protein, with a small amount of carbohydrates, mostly as vegetables ⁠[6].

Dr. Elliot P. Joslin was the first doctor in the United States to specialize in treating diabetes, and in 1916 adopted the same low-carbohydrate approach as Fredrick Allen [7].

Medications as Treatment in Diabetes

Type 1 Diabetes

The discovery of insulin by Dr. Fredrick Banting and Dr. Charles Best in 1921 provided life-saving therapy for those with type 1 diabetes (which results from failure of the insulin-producing  β-cells of the pancreas). The insulin was initially isolated from the pancreases of beef and pigs, but “human insulin” became possible in the 1980s due to recombinant DNA technology which enabled the development of both basal insulin, as well as rapid acting insulin. This was life-changing and life-saving to those with type 1 diabetes.

Type 2 Diabetes

Metformin initially became available as a first-line treatment for type 2 diabetes in the late 1990s, and enabled those with type 2 to better control their blood sugar levels along with dietary changes — but when people were unable, or unwilling to adequately limit carbohydrate intake, insulin was prescribed.

Insulin went from being a life-saving therapy for those with type 1 diabetes to  also being a ‘treatment’ for people with type 2 diabetes who ate what they wanted at meals and snacks and “covered it with insulin“. The problem is that this type of “liberalization” of the diet creates a “vicious cycle” for those with type 2 diabetes, described as follows in a new study published ahead of print in September 2019, and to appear in the December 2019 journal, Diabetes Care[8];

“Dietary intervention is usually accompanied by sequential addition of several anti-hyperglycemic agents, including glucagon-like peptide 1 (GLP-1) analogs and sodium—glucose cotransporter 2 (SGLT2) inhibitors. Despite this medical treatment, many patients require insulin therapy, which is gradually augmented according to the glucose target-driven strategy. However, this progressive increase in insulin dose often leads to weight gain, which may increase insulin resistance, leading to a vicious cycle further increasing insulin doses, continued weight gain, decreased likelihood of achieving glycemic targets, a high risk for diabetes complications and increased insulin dose-dependent cardiovascular risk and mortality. It is, therefore, important to prevent the weight gain when insulin treatment is required.”

Of course, medications such as biguanides, sulfonylureas, SLP-1 analogues and SGLT2 inhibitors are very important tools for doctors to add in helpong manage blood sugar levels, but too often they are used instead of / in the absence of carbohydrate reducing dietary changes and this results diabetes becomes “a chronic, progressive disease“. It need not be so if people are willing to reduce their carbohydrate intake and time when they do eat some carbohydrate-containing food, in accordance with when their body handles them best.

Dietary Recommendations – meals and snacks

Since 2009, people with type 2 diabetes have been advised to eat 3 meals per day plus several snacks per day ⁠— with carbohydrates evenly distributed across the meals and snacks, in order to achieve the best weight management and blood sugar control [9-11].  They’ve been told to aim for between 45-60 grams of carbohydrate at each meal, and 15-20 grams of carbohydrate for each of 3 daily snacks (between breakfast and lunch, between lunch and dinner, and before bed). Surprisingly, the new study referred to above that will appear in the December 2019 issue of Diabetes Care states that there were no research studies to support these practices [8].

The 45-60 g of carbs for each of 3 meals per day and 15-20 g per snack distribution is still being recommended as goals to those with type 2 diabetes — resulting in between 190 -240 g of carbohydrate being eaten each day. That is a lot of carbohydrate for people who’s bodies can no longer handle that much. Presumably the snacks are to lower the risk of hypoglycemia (low blood sugar) that can result from the anti-hyperglycemic medications that have become necessary to prescribe because these people do not restrict carbohydrate and as a result have blood sugar levels that are too high.

Most concerning is that recent studies have found that snacks consumed later in the day have been associated with an increased risk of obesity and type 2 diabetes, with higher overall blood sugar and higher glycated hemoglobin (HbA1C) [12-13]. These are some of the “costs” of people being told to eat an afternoon and evening snack in order to avoid low blood sugar that can result from taking medication to lower blood glucose, and in an absence of being willing to reduce carbohydrate intake.

Would it not make far more sense to encourage people with type 2 diabetes to eat less carbs and eat less often — along with doctors de-prescribing anti-hyperglycemic medication, including insulin? That way, no snacks are needed to keep them from having low blood sugar and their average blood sugar levels can fall.

In fact, a soon-to-be-published pilot study [8] found that those with type 2 diabetes who ate the same calories each day as 3-meals per day, rather than as 6 meals per day [i.e. 3 meals and 3 snacks] reduced body weight, blood glucose, and insulin doses! Without even changing how many carbs they ate or how many calories they ate, in just 12 weeks, the subjects in the 3 meal per day group, lost on average 12 pounds (5.4 kg) more than those in the 6 meal per day group, had 1.2% lower HbA1C than the 6 meal per day group and their total daily insulin dose was reduced by 26 units ± 7 (with no reduction in the 6 meal per day group). On top of this, this study found that “there was a significant decrease in hunger and cravings only in the 3 meal per day group“. This makes sense of course, because they were able to lower their injected insulin, which drives hunger and fat storage, leading to weight gain. The mechanism was thought to be an up-regulation in the clock genes of those that ate 3 meals per day, which contributed to the improved glucose metabolism.

Note: it’s important to keep in mind that it is the eating of carbohydrate-containing food that triggers the release of insulin from our pancreas, so even in healthy people i.e. those who are not diabetic, eating the same amount of food as 3 meals per day with no snacks (versus 3 meals plus 3 snacks) will result in less insulin being released. Less insulin means less hunger and less fat storage — whether it is the natural insulin from our own pancreas or it is injected insulin. If our goal is weight management, eating the same amount of food as 3 meals, rather than as meals and snacks makes sense.

This study verified that when we eat and when we don’t eat matters a great deal because our body has evolved over hundreds of thousands of years to function in response to light and day cycles, called circadian rhythms.

When We Eat – especially which meals to eat carbs

Chronobiology is the study of the effect of time of day on living systems and is emerging as an important player in human health.

We now know that the body’s processes involved in the maintaining of blood sugar control such as β-cell function, glucose uptake by the muscles, and glucose production by the liver, are all under the control of circadian rhythms. The body’s “master clock” which controls these circadian rhythms is found in a part of the hypothalamus of our brain, called the suprachiasmatic nucleus (SCN) and is “set” by exposure to light.

Note: Historically, the only light that set the SCN was sunlight, but our increasing exposure to bright lights emanating from office- and store- lights, TVs, computers and smart phones has disrupted this once tightly regulated system. 

Similar “peripheral clocks” are found in our body’s tissues, including muscle cells, liver cells, β-cells of our pancreas which produce and release insulin, and fat cells (adipose), and these are controlled by the “master clock” in our SCN, and by when we eat [14,15]. 

As it turns out, our circadian rhythms are optimized for us to eat during periods of light (daytime), and to fast and sleep in periods of dark (night time) [16,17] — so fasting after supper and overnight is consistent with our body’s built-in circadian rhythms.

In addition, blood sugar control is not the same at all times of the day, but fluctuates according to our body’s circadian rhythms. It has been shown in both healthy individuals and those with type 2 diabetes that identical foods eaten in the afternoon and evening cause much higher elevations in blood sugar, compared with the same foods eaten in the morning [18-20] . Based on this, it makes the most sense for any major carbohydrate sources (milk, fruit, root vegetables etc.) that are going to be eaten during the day to be consumed at breakfast, rather than evenly distributed across the whole day and evening.

When We Don’t Eat – intermittent fasting

It has been shown for those with type 2 diabetes that fasting until noon time actually results in much higher after-meal blood sugar levels (postprandial hyperglycemia), as well as an impaired insulin response after lunch and dinner [21], so while it is currently popular for people to chose their “eating windows” based on a wide range of popular protocols, it seems to me that choosing them in a way that is consistent with our circadian rhythms makes the most sense — especially if the goal is weight loss, appetite control and blood sugar regulation.

More Info

If you would like more information about having me design a Meal Plan for you that arranges your eating times and non-eating times around your schedule and in accordance with your natural circadian rhythms, please have a look under the Services tab or in the Shop. If you have service-related questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 division of BetterByDesign Nutrition Ltd.

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

References

1. BBD News Magazine, Winterman, Denise, Breakfast, lunch and dinner; Have we always eaten them? Nov 15 2012, https://www.bbc.com/news/magazine-20243692
2. Carroll, Abigail (30 August 2013). “How Snacking Became Respectable”. Wall Street Journal. August 30, 2013, https://www.wsj.com/articles/how-snacking-became-respectable-1377906874
3. Duffey KJ, Popkin BM, Energy Density, Portion Size, and Eating Occasions: Contributions to Increased Energy Intake in the United States, 1977—2006, June 28, 2011, https://doi.org/10.1371/journal.pmed.100105
4. Osler W. The Principles and Practice of Medicine. New York, D. Appleton and Company, 1892
5. Woodyatt RT, Bernhard Naunyn. Diabetes 1952;1:240—241, pmid:1493683
6. Allen FM, Studies concerning diabetes. JAMA 1914;63:939—94
7. Joslin EP, Treatment of Diabetes Mellitus. 2nd ed. Philadelphia, Lea & Febiger, 1917, p. 409
8. Jakubowicz D, Landau Z, Tsameret S et al, Reduction in Glycated Hemoglobin and Daily Insulin Dose Alongside Circadian Clock Upregulation in Patients With Type 2 Diabetes Consuming a Three-Meal Diet: A Randomized Clinical Trial, Diabetes Care 2019 Dec; 42(12): 2171-180.https://doi.org/10.2337/dc19-1142
9. Seagle HM, Strain GW, Makris A, Reeves RS; American Dietetic Association. Position of the American Dietetic Association: weight management. J Am Diet Assoc 2009;109:330—346
10. Beyond the Basics: Meal Planning for Healthy Eating, Diabetes Prevention and Management. Canadian Diabetes Association, 2014.
11. Arnold L,MannJI, Ball MJ. Metabolic effects of alterations in meal frequency in type 2 diabetes. Diabetes Care 1997;20:1651—1654
12. Mekary RA, Giovannucci E, Willett WC, van Dam RM, Hu FB. Eating patterns and type 2 diabetes risk in men: breakfast omission, eating frequency, and snacking. Am J Clin Nutr 2012;95:1182—1189
13. Gouda M, Matsukawa M, Iijima H. Associations between eating habits and glycemic control and obesity in Japanese workers with type 2 diabetes mellitus. Diabetes Metab Syndr Obes 2018;11:647—658
14. Dyar KA, Ciciliot S, Wright LE, et al. Muscle insulin sensitivity and glucose metabolism are controlled by the intrinsic muscle clock. Mol Metab 2013;3:29—41
15. Sadacca LA, Lamia KA, deLemos AS, Blum B, Weitz CJ. An intrinsic circadian clock of the pancreas is required for normal insulin release and glucose homeostasis in mice. Diabetologia 2011;54:120—124
16. Poggiogalle E, Jamshed H, Peterson CM. Circadian regulation of glucose, lipid, and energy metabolisminhumans. Metabolism2018;84:11—27
17. Saad A, Dalla Man C, Nandy DK, et al. Diurnal pattern to insulin secretion and insulin action in healthy individuals. Diabetes 2012;61:2691—2700
18. Bo S, Fadda M, Castiglione A, et al. Is the timing of caloric intake associated with variation in diet-induced thermogenesis and in the metabolic
    pattern? A randomized cross-over study. Int J Obes 2015;39:1689—1695
19. Jakubowicz D, BarneaM, Wainstein J, Froy O. High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity (Silver Spring) 2013; 21:2504—2512
20. Morgan LM, Shi JW, Hampton SM, Frost G. Effect of meal timing and glycaemic index on glucose control and insulin secretion in healthy volunteers. Br J Nutr 2012;108:1286—1291
21. Jakubowicz D, Wainstein J, Ahren B, Landau Z, Bar-Dayan Y, Froy O. Fasting until noon triggers increased postprandial hyperglycemia and impaired
    insulin response after lunch and dinner in  individuals with type 2 diabetes: a randomized clinical trial. Diabetes Care 2015;38:1820—1826

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DISCLAIMER: This article does NOT recommend not getting a flu shot, nor does it recommend taking Vitamin D instead of getting a flu shot. 

This article is about the use of Vitamin D supplementation to help protect against the flu.

---

Studies Showing that Vitamin D Attenuates the Flu

There are two large-scale meta-analyses — one from 2013 and the other from 2017 that indicate that Vitamin D supplementation can reduce the risk of getting an upper respiratory infection (URI) including influenza (“the flu”).

The first study by Bergman et al [4] analyzed data from 11 placebo controlled trials that involved more than 5,600 subjects and found that those taking a daily dose of Vitamin D had half the risk of developing an upper respiratory infection (URI), including influenza (‘the flu”). This held true even though many of the studies used very low dose of supplementation.

The second of the two large-scale meta-analysis by Martineau et al [5] analyzed the data from 25 randomized controlled trials and involved more than 11,300 subjects. This study found that Vitamin D supplementation reduced the risk of developing an upper respiratory infection (URI), including the flu and those who were the most deficient experienced the most benefit. Even those subjects with very low Vitamin D status had 1/3 the risk when supplementing with Vitamin D, compared to those who did not take any.

Both meta-analysis found that daily dosing with Vitamin D was more effective than taking larger (bolus) doses once a week, or once a month.

There are numerous studies which indicate that people with lower levels of Vitamin D are more likely to get the flu and a 2010 study with healthy adults found that people with lower levels of were twice as likely to get the flu than people with high levels of Vitamin D [6].

Supplementing with Vitamin D

Health Canada’s recommended daily intake (RDAs) for Vitamin D (updated in 2011) are 600 International Units (IUs) for everyone aged one year old to 70 years old and 800 IU for adults over 70 years of age. Health Canada’s safe upper limit (UL) is listed as 4,000 IU per day, however recent scientific publications indicate that there was an error in the calculations used to determine them.

Two researchers from the School of Public Health at the University of Alberta published a paper in October 2014 which indicates that the Institute of Medicine (IOM) that develops the Recommended Dietary Allowances (RDAs) used by both Canadians and Americans made a serious error in their calculations in determining the RDAs for Vitamin D [7] and that rather than 600 IUs being needed to prevent deficiency in 97.5% of individuals, the actual amount is estimated to be 8895 IU of Vitamin D per day — which is above the Health Canada’s tolerable upper intake of 4000 IU per day.

On top of that, researchers from the University of California at San Diego and Creighton University in Omaha, Nebraska published a letter in the same online journal in March 2015 which said that they have confirmed the Institute of Medicine’s miscalculation that was noted by the Canadian investigators [8].

A press release published in Science News on March 17, 2015 indicated that;

“The recommended intake of vitamin D specified by the IOM is 600 IU/day through age 70 years, and 800 IU/day for older ages. Calculations by us and other researchers have shown that these doses are only about one-tenth those needed to cut incidence of diseases related to vitamin D deficiency.“

How much Vitamin D should we supplement?

The Vitamin D Council (a US-based group) recommends adults take 5,000 to 10,000 IU/day, depending on body weight and recommend people have their levels checked to make sure it is > 40 ng/ml (100 nmol/l) and to maintain serum levels at 50 ng/ml (125 nmol/L). Since Vitamin D toxicity manifests as high levels of calcium in the blood and urine, the Vitamin D Council recommends monitoring via blood tests that serum levels don’t exceed 150 ng/ml (374 mmol/L).

Since Health Canada’s current upper limit is 4,000 IUs per day (which may be based on an error in calculation, as noted above), a prudence dosage for supplementation for a healthy adult would not exceed 4,000 IUs per day.

Note: I also recommend people take 100 mcg of Vitamin K2 (menaquinone-4, or menaquinone-7) as Vitamin K2 plays a synergistic role with Vitamin D which regulates blood levels of calcium. Vitamin K prevents calcium from accumulating in soft tissues, such as the blood vessels (contributing to Coronary Artery Calcification)[10].  Put simply, Vitamin K helps ensure that calcium ends up in bone, not arteries.

NOTE: People taking Warfarin (Coumadin) or other anticoagulant medication should not supplement with Vitamin K2 except under the advice of the physician prescribing Warfarin.

Keep in mind that food also provides Vitamin D with natural sources being salmon (447 IU per 3 ounces), tuna (154 IU per 3 ounces), eggs (41 IU per yolk) and cheese (14 IU per 2 ounces of cheddar) and milk and non-dairy beverages made as ‘milk replacements’ are fortified, with 100 IU per cup (250 ml).

If you are a healthy adult under 50 years old with no family risk of cancer* or osteoporosis, 1000 IU Vitamin D3 per day (plus 100 mcg of Vitamin K2) is probably sufficient. Be sure to choose the D3 form (not D2) as it is more efficient at raising serum levels. For adults under 50 with a family history of cancer or who are at risk for osteoporosis, a dosage of 2000 IU Vitamin D3 per day (plus 100 mcg of Vitamin K2) may be more appropriate.

Healthy adults over the age of 50 can safely double the amounts above ⁠— so 2,000 IUs Vitamin D3 per day (plus 100 mcg of Vitamin K2) and for those with a family history of cancer to take 3,000 IUs Vitamin D3 per day (plus 100 mcg of Vitamin K2).

Remember though that Vitamin D is a fat soluble vitamin, so be sure to have your serum levels checked periodically as your body is able to stores for long periods of time. The best indicator of Vitamin D status is a routine blood test called 25-hydroxy vitamin D.

Final thoughts…

There is good evidence that adding Vitamin D3 supplementation to your daily routine may boost your ability to fight of upper respiratory infections, including the flu.

…and if you supplement with Vitamin D, don’t forget to add the Vitamin K2 to help keep the calcium where it ought to be.

More Info

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 division of BetterByDesign Nutrition Ltd.

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

References

1. CTV News, Canadian warns against vaccine apathy after flu sends him to hospital for two months, https://www.ctvnews.ca/health/canadian-warns-against-vaccine-apathy-after-flu-sends-him-to-hospital-for-two-months
2. Dairy Nutrition, Vitamin D status of Canadians — Results from the Canadian Health Measures Survey, https://www.dairynutrition.ca/nutrients-in-milk-products/vitamin-d/vitamin-d-status-of-canadians-results-from-the-canadian-health-measures-survey
3. Vitamin D Council, Dr. John Cannell, MD, Influenza, https://www.vitamindcouncil.org/health-conditions/influenza/
4. Bergman P, Lindh AU, Bjí¶rkhem-Bergman L et al, Vitamin D and Respiratory Tract Infections: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, PLoS One. 2013 Jun 19;8(6):e65835.
5. Martineau AR, Jolliffe DA, Hooper RL, Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data, BMJ. 2017 Feb 15;356:i6583
6. Sabetta, J.R., DePetrillo, P., Cipriani, R.J., et al., Serum 25-hydroxyvitamin d and the incidence of acute viral respiratory tract infections in healthy adults. PLoS One, 2010. 5(6): p. e11088.
7. Veugelers PJ, Ekwaru JP. A statistical error in the estimation of the recommended dietary allowance for vitamin D. Nutrients. 2014;6(10):4472—4475. Published 2014 Oct 20. doi:10.3390/nu6104472
8. Heaney R, Garland C, Baggerly C, French C, Gorham E. Letter to Veugelers, P.J. and Ekwaru, J.P., A statistical error in the estimation of the recommended dietary allowance for vitamin D. Nutrients 2014, 6, 4472-4475; doi:10.3390/nu6104472. Nutrients. 2015;7(3):1688—1690. Published 2015 Mar 10. doi:10.3390/nu7031688
9. Science News, Recommendation for vitamin D intake was miscalculated, is far too low, experts say, https://www.sciencedaily.com/releases/2015/03/150317122458.htm
10. Theuwissen E, Smit E, Vermeer C, The role of vitamin K in soft-tissue calcification, Adv Nutr. 2012 Mar 1;3(2):166-73.

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⁠—

There is much “push back” when it comes to the standard advice to “eat less and exercise more” as a means of losing weight, and for good reason. For one, metabolism will slow as a result of caloric restriction — making it that much more difficult to lose weight when deliberately cutting calories. Another reason is that it is exceedingly difficult for an obese person to exercise. For many, just getting around is a chore. It is for this reason that I focus on helping people be less hungry by eating a different mix of protein, fat and carbohydrate — because a natural byproduct of being less hungry, is eating less. Being active is possible once a person is losing weight and not feeling hungry all the time.  Yes, they are still “eating less and moving more” — but as a result, not as the focus.

Addendum (Sept 10 2019) — Weight loss is not only about what we eat.  It’s also about when we don’t eat; whether it’s having times between meals where we don’t eat, or not eating from the end of supper until the first meal of the following day (whenever that is). Thanks Dr. Andy Phung for the reminder!

A new study published yesterday (September 9, 2019) in the journal Nature Medicine[1] has found that “eating less and exercising more” may actually be good advice as we age — because it turns out that we have decreased fat turnover as we age. If we eat the same amount as we always have and don’t increase the amount we exercise,  we will end up gaining approximately 20% over a 10-15 year period [3].

Until recently little was known about fat turnover [2] — which is the storage and removal of fat from adipocytes (fat cells). A 2011 study showed that  during the average ten-year lifespan of human fat cells, the fat in them (triglycerides) turns over six times, in both men and women [2], and that when people are obese, the fat removal rate decreases and the amount of fat as triglyceride stored each year increases [2]. What we didn’t know until now is  what happened to fat turnover as we age.  This follow-up study headed by the same lead researcher as the 2011 study explored this issue, as well as differences in fat turnover after people have bariatric surgery which helps explain why some people regain their weight after weight loss, where as others don’t.

Eating Less Matters as We Age

Fat turnover is a difference between the rate of fat uptake into fat cells and the fat removal rate. High fat storage but low fat removal is what results in the accumulation of fat and in obesity. The “bad news” of this new study is that fat accumulation due to decreased fat turnover is what happens as we age, leading to accumulation of fat. That is, even if we don’t eat more or exercise less than previously, we will store more fat — which can result in as much as a 20% increase in body weight over 13 years [3].

“Those who didn’t compensate for that (i.e. decrease fat turnover) by eating less calories gained weight by an average of 20 percent”[3].

Researchers from the University of Uppsala in Sweden and the University of Lyon in France studied the fat cells of 54 men and women over an average 13 year period [3] and regardless of whether the subjects gained weight or lost weight, they had a decreased fat turnover. 

Since fat turnover is decreased as we age, to prevent weight gain we need to take in less calories than we used to, even if we are just as active.

Why We Regain Weight After Weight Loss

The study also looked at fat turnover in 41 women who underwent bariatric surgery. Results showed that only those who had a low lipid turnover rate before the surgery were able to increase their lipid turnover after surgery and maintain their weight loss 4-7 years after surgery [1]. Researchers think that if people had a high lipid turnover rate before surgery, there is less ‘room’ for them to increase their lipid turnover rate after surgery, which is why they regain the weight. This could explain why so many people who lose incredible amounts of weight following any one of a number of “diets” regain it (and then some) afterwards.

Exercise and Lipid Turnover

Previous studies have reported that fat turnover increases as we exercise [2], so based on this new study, the idea of ‘eating less and exercising more’ actually matters as we age. We can either decrease our intake as we age and/or be a little more active and avoid gaining weight — which is easy enough to do for those who are slim, if they know.

But what about those who are already overweight or obese and now find out they are more prone to storing fat now that they’re older, even though they eat the exact same way and haven’t changed their activity level?

I believe the solution is the same regardless of a person’s age — focusing on the person eating in such a way as to be less hungry, so that in the end they end up eating less. As they lose weight because they’re not hungry all the time, being more active is easier to implement.  The difference between it being “doable” depends on what we focus on. As covered in a previous article, we understand why a person who eats foods that are a combination of fat and carbs together eat more, but my approach is to gradually adjust the amount of carbohydrate in the diet, so that people can eat more protein and healthy fat, and end up feeling less hungry. When they aren’t being driven by the reward system of their brain (see linked article) to want more and more foods with carbs and fat together, it is much easier for them to eat when they are actually hungry. As they do, their weight drops as a result.

In light of this new study, what is important is that as people age there is a natural tendency to put on weight, even if they eat the same and don’t change their activity level. This means older people need to modify the amount of calories they take in and/or expend more energy, the question is how.

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 The Low Carb Healthy Fat Dietitian (a division of BetterByDesign Nutrition Ltd.)

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

References

1. Arner P, Bernard S, Appelsved K-Y et al. (2019). “Adipose lipid turnover and long-term changes in body weight.” Nature Medicine 25(9): 1385-1389.
2. Arner, P. et al. Dynamics of human adipose lipid turnover in health and metabolic disease. Nature 478, 110—113 (2011).
3. Karolinska Institutet, New study shows why people gain weight as they get older, Published: 2019-09-09 18:35, https://news.ki.se/new-study-shows-why-people-gain-weight-as-they-get-older

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In the first article in this series about Small Intestinal Bacterial Overgrowth (SIBO) I covered what SIBO is, how common it is, as well as its symptoms. In the second article, I outlined different tests used to diagnose SIBO, some of the challenges with those, the difference between hydrogen-dominant and methane-dominant SIBO, and why Irritable Bowel Syndrome (IBS) that does not improve despite adopting appropriate dietary changes may be SIBO.  In this article (which is part 3 in the series), I outline the main dietary approaches used in treating SIBO along with antibiotic and evidence-based herbal antimicrobial therapy, and elaborate as to whether dietary changes should come before- or after antimicrobial treatment.

In discussing the treatment of Small Intestinal Bacterial Overgrowth, it’s important to keep in mind that SIBO is the presence of types of bacteria in the small intestine that are not supposed to be there.  While dietary changes can help by improving the symptoms, in and by themselves they will not result in the elimination of the bacteria that are contributing to the symptoms. The bacteria that are foreign to the small intestine need to be eradicated and the underlying cause of the SIBO needs to be addressed. As outlined in the first article, Small Intestinal Bacterial Overgrowth may be caused by a number of conditions, including low stomach acid (achlorhydria), pancreatic insufficiency, anatomical abnormalities such as small intestinal obstruction, diverticula, or fistula (which are abnormal connections between an organ and the intestine), as well as slowing of intestinal movements (motility disorders) that are common in those with diabetes mellitus, as well as due to alcohol consumption and a number of other factors. Addressing those underlying causes is needed, along with correcting intestinal flora imbalance.

NOTE: As a Dietitian, my role is to support treatment of a diagnosed condition from a dietary perspective, but not to diagnose. Diagnosis is the realm of medicine, and diagnosis of SIBO is for a gastroenterologist or Functional Medicine MD to make, using established medical testing protocols. It is also the role of MDs to prescribe antimicrobials.  I provide dietary support during the three phases of treatment with the goal of reducing the person’s symptoms, increasing the likelihood of eradication during antimicrobial treatment, and reducing the likelihood of recurrence of SIBO after eradication.

There are two important factors to keep in mind when it comes to Small Bacterial Overgrowth treatment; (1) despite antibiotic treatment, an older (2008) study found that recurrence of SIBO as diagnosed by glucose breath tests occurs in almost half of all people within a year of treatment [1], however individuals in this study that relapsed were older aged (which is associated with decreased stomach acid), and had a history chronic use of proton-pump inhibitor medication (which also results in lower stomach acid), (2) addressing the underlying cause of SIBO is necessary, otherwise recurrence is likely.

Three Phases of Dietary Treatment for SIBO

Some clinicians take a single dietary approach with SIBO and prescribe one of several low fermentable carbohydrate diets; either a low-FODMAP diet or the Specific Carbohydrate Diet (SCD), or some combination or variation of these. These diets limit the food sources for bacterial that live in the gut (both small and large intestine), thereby reducing symptoms and at first glance, this may seem like an effective approach, except it has two drawbacks;

• following a diet low in fermentable carbohydrate for periods of longer than a month has been shown to also reduce beneficial bacteria in the gut, such as bifidobacteria [2].
• Some researchers such as Dr. Mark Pimentel’s group at the Gastrointestinal Motility Program at Cedars-Sinai Medical Center suggest that some fermentable carbohydrates remain in the diet while treating with antimicrobials based on the concept that bacterial are easier to eradicate when they’re active. Antimicrobials act on the replicating cell wall of bacteria, so when bacteria are being starved, they aren’t replicating.

A 2010 study found that treatment of SIBO with the first-line antibiotic Rifaximin alone was only 62% effective, however when Rifaximin was combined with a specific fermentable carbohydrate called partially hydrolyzed guar gum (PHGG), eradication rate was 85% [3]. In addition, the addition of PHGG during the antibiotic treatment phase also prevented the eradication of both of the beneficial bacteria lactobacilli and bifidobacteria from the large intestine.

I take a 3-phase approach to dietary support treatment of SIBO.

Phase I

A first phase of dietary treatment includes the use of a low fermentable carbohydrate diet for 4-6 weeks which enables people to begin to feel better. This is of huge importance to quality of life, after so long of feeling quite unwell! By also including the addition of partially hydrolyzed guar gum (PHGG) in the diet, it allows for the small amount of bacterial growth needed so that once the person is treated with antimicrobials, it is likely to be more successful.

Use of PHGG is also well-known to reduce the symptoms of IBS in both the constipation and diarrhea subtypes [4,5] and since most people with SIBO experience one of these symptoms, or both alternating, addition of PHGG is also beneficial for helping people feel much better, while preparing for the antimicrobial treatment phase.

Phase II

The second phase of dietary treatment coincides with the 4-week period of antimicrobial treatment prescribed by the gastroenterologist or Functional Medicine MD. During this phase, the low fermentable carbohydrate diet is maintained along with the PHGG intake, but begins to include some additional fermentable carbohydrate food, as tolerated. This helps feed the bacteria just enough so that the antimicrobials are more likely to be effective, but without making the person feel unwell.

As mentioned above, studies have shown that the antimicrobials along with PHGG may result in up to 85% eradication[3], a study from 2009 found that eradication rates with Rifaximin alone is only about 50% [6]. It is thought that this may be due to a failure to distinguish between hydrogen-positive and methane-positive types of SIBO.  In methane-positive SIBO, eradication has been found to be as high as 85% when Rifamixin is combined with another antibiotic, Neomycin [7]. In methane-positive SIBO, Dr. Pimentel and his group recommend 550 mg Rifaximin three times per day in combination with neomycin 500 mg twice a day for 14 days, or Rifaximin 550 milligrams three times per day with Metronidazole 250 milligrams three times per day for 14 days [8].

Antimicrobials prescribed by some MDs may include herbal antimicrobials. Herbal antimicrobials (FC Cidal® with Dysbiocide® or Candibactin-AR® with Candibactin-BR®) were shown in a 2014 study to be even more effective in eradication of SIBO bacteria as Rifaximin [8]. Of those treated with one of the herbal therapy combinations, 46% of subjects had a negative result upon re-testing, whereas only 34% of those using Rifaximin had a negative result upon re-testing. Furthermore, approximately 57% of those who failed to achieve eradication on Rifaximin as measured by repeat breath testing, achieved eradication on one of the two herbal antimicrobial regimens [8]. Also of significance, in 2014 when the study was conducted, standard treatment with a 4-week supply of Rifaximin (two 200 mg Rifaximin tablets 3x daily) cost $1247.39, whereas the cost for the herbal therapy (2 capsules twice daily of either treatment) was no more than $120 for a one-month supply [9]. The high treatment response rate of the herbal formulations, reduced cost of treatment and long term Generally Recognized As Safe (GRAS) safety record of specific herbs used in the formulations [8], and the fact that these supplements can be purchased by the general public without a prescription provides individuals and their practitioners with several treatment options.

Phase III

The last phase of dietary treatment is the gradual liberalization of the low-fermentable carbohydrate diet. After antimicrobial treatment, once the gut microbiome has been restored, a person should be able to tolerate a healthy, whole food diet. That said, it may be advantageous for a person who has had SIBO previously to continue to avoid unnecessary additions to the diet such as sugar alcohols (xylitol, erythritol, etc.) or gums such as carrageenan, xanthan gum and guar gum (not to be confused with hydrolyzed guar gum!), as well as to limit high fructose and lactose intake.

However, if a person begins to have symptoms again, then having a new hydrogen breath run to ensure there is no recurrence of SIBO makes sense. If the breath test is negative, then further medical investigation for other underlying causes of causes, including low stomach acid, pancreatic insufficiency or intestinal motility disorders may be next. Given that no other underlying cause is identified, food intolerances , including histamine intolerance, A1 beta-casein intolerance might be worth evaluating.

Final Thoughts

SIBO, like IBS is not easy-to-diagnose. More clear-cut diagnoses such as IBD, celiac disease, food allergies etc. need to be ruled out first and while IBS has now gained acceptance as a “real” diagnosis, SIBO is still one of those in which there is much debate.

I have more confidence in the jejeunal aspirate method of diagnosis and wonder if the breath tests really measure what they purport to measure. That said, when people previously diagnosed and unsuccessfully treated for IBS are treated with diet plus antimicrobials, many get better. Are IBS and SIBO really two diagnoses or one?

A low fermentable carbohydrate diet has long been used in the treatment of IBS and the use of partially hydrolyzed guar gum has a successfully and safe long-term history in the treatment of IBS), so continuing to use these in the treatment of SIBO, along with evidence-based antimicrobial treatment prescribed by an MD is a sensible and safe approach.

The Gut Microbiome – so much to learn

There is so much we are discovering about the gut microbiome (the bacteria in our intestines that we live in symbiosis with) and the relationship between alterations in the gut microbiome and chronic disease.

For example, a study published on June 19, 2019 in the journal Pain [10] found a correlation between fibromyalgia (another one of those diseases that medical professionals debate the legitimacy of) and abnormalities in the gut microbiome. In this study conducted in Montreal, approximately  20 different species of bacteria were found to be abnormally high, or abnormally low in the microbiomes of subjects suffering from the disease, compared with healthy controls. It was found that “fibromyalgia and the symptoms of fibromyalgia — pain, fatigue and cognitive difficulties – contribute more than any of the other factors to the variations we see in the microbiomes of those with the disease” [11].

There is much we don’t know in terms of IBS and SIBO but at the end of the day, there are people suffering with these conditions whose quality of life is greatly affected. If the best we have to offer people diagnosed with SIBO at this time is the use of a low fermentable carbohydrate diet along with the addition of well-studied PHGG used in conjunction with antimicrobial agents prescribed by a physician — and this helps people feel significantly better, then this is the most evidence-based approach we have at this time.

More Info?

If you would like to know more about the hourly consultations and packages I provide, including SIBO support, then please click on the Services tab or have a look in the Shop. If you would like additional information, please send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Lauritano EC, Gabrielli M, Scarpellini E, Small intestinal bacterial overgrowth recurrence after antibiotic therapy. Am J Gastroenterol. 2008 Aug;103(8):2031-5.
2. Staudacher HM, Lomer MCE, Anderson JL, Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome, The Journal of Nutrition, Volume 142, Issue 8, August 2012, Pages 1510—18, https://doi.org/10.3945/jn.112.159285
3. Furnari M, Parodi A, Gemignani L, Clinical trial: the combination of rifaximin with partially hydrolysed guar gum is more effective than rifaximin alone in eradicating small intestinal bacterial overgrowth, Alimentary Pharacology and Therapeutics, Volume 32(8) August 2010, page 1000—1006 https://doi.org/10.1111/j.1365-2036.2010.04436.x
4. Quartarone G, Role of PHGG as a dietary fiber: a review article, Minerva Gastroenterol Dietol. 2013 Dec;59(4):329-40, https://www.ncbi.nlm.nih.gov/pubmed/24212352
5. Russo L, Andreozzi P, Zito FP, Vozzella L, Partially hydrolyzed guar gum in the treatment of irritable bowel syndrome with constipation: effects of gender, age, and body mass index, Saudi J Gastroenterol. 2015 Mar-Apr;21(2):104-10. doi: 10.4103/1319-3767.153835.
6. Peralta S, Cottone C, Doveri T, Almasio PL, Craxi A. Small intestine bacterial overgrowth and irritable bowel syndrome-related symptoms: experience with Rifaximin. World J Gastroenterol. 2009;15(21):2628—2631. doi:10.3748/wjg.15.2628
7. Low K, Hwang L, Hua, J.,A Combination of Rifaximin and Neomycin Is Most Effective in Treating Irritable Bowel Syndrome Patients With Methane on Lactulose Breath Test, Journal of Clinical Gastroenterology: September 2010 – Volume 44 – Issue 8 – p 547-550, doi: 10.1097/MCG.0b013e3181c64c90
8. Scarlata K, Small Intestinal Bacterial Overgrowth (SIBO), For a Digestive Peace of Mind blog, https://blog.katescarlata.com/2014/01/22/small-intestinal-bacterial-overgrowth/
9. Chedid V, Dhalla S, Clarke JO, et al. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014;3(3):16—24. doi:10.7453/gahmj.2014.019
10. Minerbi A, Gonzalez E, Brereton NJB,   et al (2019). Altered microbiome composition in individuals with fibromyalgia. PAIN, Articles in Press. https://doi.org/10.1097/j.pain.0000000000001640
11. McGill University Health Centre Press Room, Gut bacteria associated with chronic widespread pain for first time, June 19th, 2019, https://muhc.ca/news-and-patient-stories/press-releases/gut-bacteria-associated-chronic-widespread-pain-first-time

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In the first article of this series about Small Intestinal Bacterial Overgrowth (posted here), I covered what SIBO is and how common it is, as well as its symptoms. If you haven’t yet, I’d encourage you to read that article first as it will serve as a good introduction. In this second article, I cover the different tests used in diagnosing SIBO, as well as some of the advantages and drawbacks of each. In the next article will cover various treatment options for SIBO, including dietary protocols combined with antibiotic or herbal therapies (which interestingly have been found in research studies to be equally effective as the first-line antibiotic). 

Diagnosing SIBO

One of the first challenges in diagnosing SIBO is finding a physician that is knowledgeable about the condition and current in its treatment. In the past only gastroenterologists diagnosed and treated SIBO and only after very invasive and expensive surgical tests were performed.

Before the invention of endoscopy, diagnosing SIBO required an invasive surgical procedure where a gastroenterologist would take a small amount of liquid from the jejeunum of the small intestine, and that fluid would be cultured to see what types of bacteria grew, and in what quantities.  A positive diagnosis of SIBO would occur when  >  10⁴ colony-forming units of bacteria grew per milliliter of jejunal liquid [1]. The problem with this type of testing was that it was very invasive and expensive.

The medical invention of the endoscope in the mid-1980s enabled gastroenterologists to obtain fluid from the duodenum of the small intestine using a much less invasive procedure. In endoscopy, a long, flexible tube (endoscope) is passed into the throat of a sedated patient, then into the esophagus, past the stomach and into the duodenum, where a fluid sample is collected for culturing.  One drawback to this test was that the sample was easily contaminated as it was withdrawn and the procedure was still quite invasive and expensive [1]. A second drawback is that only 30% of gut bacteria taken from the small intestine in this procedure and the one above are able to be cultured [3].  This surgical test is still invasive and expensive and as such is not widely used, although it is still considered the “gold standard” for diagnosing SIBO [2].

A brilliantly simple solution to testing for SIBO came as the result of the discovery that certain gases such as hydrogen or methane are only produced in the small intestine as the by-product of unabsorbed or incompletely absorbed carbohydrate in the diet. Simple breath tests to detect the presence of either gas provides not only the evidence of carbohydrate malabsorption (such as lactose and fructose malabsorption [3]), but the specific gas produced indicates the types of bacteria that are fermenting them (more on that below). The two breath tests for diagnosing SIBO that have become the most widely used are the glucose breath test and the lactulose breath test.

Glucose Breath Test or Lactulose Breath Test?

Either lactulose or glucose are used as substrates in hydrogen and methane breath testing for diagnosing SIBO, with some believing that glucose provides greater test accuracy [2] because glucose is absorbed completely in the upper small intestine [3], but may not be able to detect SIBO in the ileum, the far part of the small intestine, that connects to the large intestine [3]. Lactulose may be able to detect small-bowel bacterial overgrowth in the ileum [2,3].

Depending on which clinician one goes to, they  likely will have a preference for using either glucose or lactulose breath test for diagnosing SIBO, whereas some gastroenterologists prefer to use jejeunal sampling via endoscopy.

How Does a Breath Test Work?

Hydrogen or methane exhaled in the breath following consumption of either glucose or lactulose is estimated using a gas chromatograph.

Normally, a small amount of hydrogen is produced from the limited amounts of unabsorbed carbohydrate that reaches the large intestine, however large amounts may be produced if there is malaborption of carbohydrate (such as fructose or lactose) in the small intestine, or if there are the wrong types of bacteria in the small intestine.  

The hydrogen (or methane) is produced by the bacteria in the intestine, absorbed through the wall of the small-intestine, large-intestine or both, and the the hydrogen (or methane) containing blood travels up to the lungs. During a breath test, the hydrogen (or methane) is exhaled in the breath, and measured by the gas chromograph.

It is estimated that about 15%-30% of people have gut bacteria that contain Methanobrevibacter smithii, a methane-producing bacteria that recycles hydrogen by combining it with carbon dioxide, to produce methane. This bacteria converts 4 atoms of hydrogen into 1 molecule of methane [4], so people with this intestinal bacteria won’t exhale much hydrogen during the breath test (even if they have carbohydrate malabsorption or SIBO) because the hydrogen that they produce is converted into methane [3].

How the Breath Test is Performed

The person having the breath test first needs to fast overnight and have to brush their teeth and rinse their mouth with mouthwash to make sure oral bacteria don’t affect the test. At baseline, fasting breath hydrogen is estimated 3 – 4 times and averaged as basal breath hydrogen. If the person is found to have high breath hydrogen before they eat the sugar, then it may be attributed to SIBO. Then the person eats a specific amount of the test sugar; either 10 g lactulose or 100 g glucose, and the person’s breath is analyzed for hydrogen and methane every 15 minutes for 2 to 4 hours [3].  Diagnosing SIBO on the basis of a glucose breath test requires a rise in breath hydrogen by 12 ppm above baseline [3].

Based on a study published in 2000, Dr. Mark Pimentel, a key researcher in the area of SIBO from Cedar-Sinai Medical Center believes that a rise in breath hydrogen 20 ppm above basal levels within 90 minutes in a lactulose breath test should be considered a positive diagnosis of SIBO [5]. Some researchers maintain [3] that lactulose should not be used at all for diagnosing SIBO because it assumes that the time from when the lactulose is eaten until it reaches the junction of the small and large intestine (the cecum) is always greater than 90 minutes, whereas other studies indicate that it can range from 40 to 110 minutes [6]. As well, use of lactulose may only be able to diagnose 1/3 of people with SIBO [3].

A recent consensus paper from 2017 [7] published by 10 medical doctors involved in The North American Consensus group on hydrogen and methane-based breath testing concluded that both glucose breath testing and lactulose breath testing were reliable and were considered the least invasive tests for diagnosing SIBO [7]. The consensus group considered a rise in hydrogen of ≥20 ppm by 90 minutes* during glucose or lactulose breath test  for SIBO to be positive for SIBO, and methane levels ≥10 ppm was considered methane positive.

*It should be noted that some clinicians such as Dr. Mark Pimentel consider a positive hydrogen test to be anything >20 ppm, and not necessarily a 20 ppm rise above baseline. In addition, Dr. Pimentel considers a positive methane test to be a reading of >3 PPM within 90 minutes (which is significantly lower than the levels set by the consensus group, of which he was a part [8]). Since different clinicians use different cutoff points to indicate a positive test for SIBO, this leads to what some consider to be a tendency to “overdiagnose” the condition [3].

As mentioned above, since a hydrogen breath test using glucose may miss SIBO in the far part of the small intestine (ileum), and a hydrogen breath test using lactulose may only be able to diagnose 1/3 of people with SIBO, some practitioners take the approach to treat patients “as if” positive for SIBO, in the absence of a positive breath test. If the person gets better on antimicrobial therapy along with appropriate dietary support, then it is deemed that the end goal for the person to feel better has been reached. There are two challenges that come to mind with respect to this approach; first of all, often more than one round of antibiotics or herbal antimicrobials are needed to completely eradicate the bacteria population in the small intestine that are responsible for the symptoms of SIBO.  Does one do one round of treatment and hope for the best, or two rounds as that is the most likely to be effective? While Generally Recognized As Safe, even herbal treatments are not without risks, so treating “as if” is not a preferred option. The second drawback (that I will cover just below) is that the treatment for methane-dominant bacteria is different than the treatment for hydrogen-dominant bacteria. One could treat with herbal antimicrobials based on symptoms (i.e. the presence of constipation), but having a positive methane breath test (perhaps at the level of positive indicated by the consensus report, above) would enable an evidence-based treatment decision. While not without drawbacks, it is my opinion that breath testing should at least be tried unless doing so could cause a person severe gastro-intestinal discomfort.

UPDATE (Sept 5 2019): It should be noted that a recent (2018) study found that a glucose-based hydrogen and methane breath test does not detect bacterial overgrowth in the jejunum, but that a positive breath test may indicate altered jejunal function and microbial dysbiosis. This calls into question the validity of using breath tests in diagnosing SIBO. (Sundin OH, Medoza-Ladd A, Morales E et al, Does a glucose”based hydrogen and methane breath test detect bacterial overgrowth in the jejunum, Neurogastroenterology & Motility 30 (11), https://doi.org/10.1111/nmo.13350).

Positive Breath Test for Methane

As mentioned above, whether a breath test is positive for hydrogen or methane indicates something about the types of bacteria involved in SIBO. In several studies, positive methane results on breath tests have been associated with symptoms of constipation [9-12] and are 5 times more likely to have constipation than those with hydrogen dominant overgrowth [12] and the severity of constipation was found to be directly related to the level of methane [9]. Identifying whether SIBO is methane-predominant is important because the methane-producing bacteria Methanobrevibacter smithii is resistant to many antibiotics [7].

Distinguishing SIBO from IBS

As mentioned in the first article in this series on SIBO (available here) many of the symptoms of Irritable Bowel Syndrome (IBS) and SIBO are similar, including abdominal pain, bloating, gas, bouts of diarrhea or constipation or alternating diarrhea and constipation.

To make matters more confusing, Pimentel et al found that almost 80% (78%) of subjects in their study that had an abnormal lactulose breath test which suggested they had SIBO also met the Rome I criteria for IBS [5]. This begs the question how many of those who have been diagnosed with IBS based on the current Rome IV criteria [13] might actually meet the criteria for SIBO?

It is my opinion that someone who has been unsuccessful at resolving their symptoms of IBS using appropriate dietary treatment with the help of a knowledgeable Dietitian would benefit by undergoing glucose or lactulose breath testing to determine if their symptoms may be caused by SIBO.

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In the next article, I will cover the main dietary approaches that are used in SIBO treatment, along with antibiotic or studied herbal antimicrobials.  I will also cover why some clinicians do NOT change the person’s diet until after antimicrobial treatment has been completed.

More Info?

You can find out more about the hourly consultations and packages I offer by visiting the Services tab or the Shop, and if you would like additional information please send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Quigley EMM. The Spectrum of Small Intestinal Bacterial Overgrowth (SIBO), Current Gastroenterology Reports, (2019) 21:3, https://doi.org/10.1007/s11894-019-0671-z
2. Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol (N Y). 2007;3(2):112—122.
3. Ghoshal UC How to interpret hydrogen breath tests. J Neurogastroenterol Motil. 2011; 17: 312—317
4. Levitt MD, Furne JK, Kuskowski M, Ruddy J. Stability of human methanogenic flora over 35 years and a review of insights obtained from breath methane measurements. Clin Gastroenterol Hepatol. 2006;4:123—129.
5. Pimentel M, Chow EJ, Lin HC, Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome.
   Am J Gastroenterol. 2000 Dec; 95(12):3503-6
6. Ghoshal UC, Ghoshal U, Ayyagari A, et al. Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time. J Gastroenterol Hepatol. 2003;18:540—547
7. Rezaie A, Buresi M, Lembo A et al, Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus, Am J Gastroenterol 2017; 112:775—784; doi: 10.1038/ajg.2017.46
8. Scarlata K, Small Intestinal Bacterial Overgrowth (SIBO) blog article, January 22, 2014, https://blog.katescarlata.com/2014/01/22/small-intestinal-bacterial-overgrowth/
9. Chatterjee S , Park S , Low K et al. Th e degree of breath methane production in IBS correlates with the severity of constipation . Am J Gastroenterol 2007 ; 102 : 837 — 41.
10.  Attaluri A , Jackson M , Valestin J et al. Methanogenic fl ora is associated with
    altered colonic transit but not stool characteristics in constipation without
    IBS . Am J Gastroenterol 2010 ; 105 : 1407 — 11.
11. Hwang L , Low K , Khoshini R et al. Evaluating breath methane as a diagnostic
    test for constipation-predominant IBS . Dig Dis Sci 2010 ; 55 : 398 — 403.
12. Kunkel D , Basseri RJ , Makhani MD et al. Methane on breath testing is
    associated with constipation: a systematic review and meta-analysis .
    Dig Dis Sci 2011 ; 56 : 1612 — 8.
13. Schmulson MJ, Drossman DA. What Is New in Rome IV. J Neurogastroenterol Motil. 2017;23(2):151—163. doi:10.5056/jnm16214

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I used to believe that SIBO was a condition that only alternative medicine practitioners such as naturopaths identified & ‘treated’, and it wasn’t a real diagnosis at all and it seems I was not alone in this belief.

This is the first article about SIBO which will outline what it is, it’s symptoms and risk factors and a subsequent article will outline how SIBO is diagnosed and some of the treatment options.

Last week I asked on Twitter “Do you believe that SIBO is a credible diagnosis?” and of the sixty one people that responded, here’s what people thought;

Fifteen percent of people thought SIBO wasn’t a legitimate medical diagnosis, while the remainder thought that either it was a credible diagnosis that not all doctors know about (62%), or that only Functional Medicine MDs diagnose and treat it (18%), or only naturopaths (5%) do.

My interest in searching the scientific literature about SIBO came when a rheumatologist suggested that it may be SIBO that was underlying the increase in joint pain that I was experiencing. While I had been diagnosed with osteoarthritis many years ago — which is a degenerative joint disease and not a normal part of aging (more in this article), the pain in my fingers had become excessive, even though there had not been any additional deterioration or deformation in those joints. If it wasn’t a rheumatologist that was suggesting SIBO as a possible cause, I would have discounted it without a thought but because the possibility was raised by a credible clinician, I decided to search the scientific literature to see what I could find.  To be honest, I was quite surprised to find that it was not only well-researched, but that there were academics at well-known universities that have been studying it!

What is SIBO?

Small Intestinal Bacterial Overgrowth (SIBO) is an increase in the type of bacteria present in the small intestine that are normally found in the large intestine (also called the colon) [1].

The small intestine consists of three parts; the duodenum connects to the stomach, the middle part is the jejunum and the last part called the ileum, attaches to the colon. It is called the small intestine because its diameter is smaller than the large intestine, although it is actually longer in length than the large intestine [2].

Normally, the small intestine contains very few bacteria and when it does, the type of bacteria found in the duodenum and jejunum are usually a specific type (i.e. lactobacilli and enterococci, gram-positive aerobes or facultative anaerobes) and are found in small amounts (< 10⁴ organisms per mL)[1] and research indicates that samples taken from the jejunum of healthy volunteers found no bacteria present at all. When the bacteria that normally populate the large intestine spills over into the small intestine, it is called Small Intestinal Bacterial Overgrowth or “SIBO”.

The body has several built-in defense mechanisms for normally preventing bacterial overgrowth of the small intestine. The major defense against small intestine bacterial overgrowth is (1) the very high acid environment of the stomach (gastric acid) which kills most bacteria, as well as (2) a normally intact ileocaecal valve which is the sphincter muscle that separates the small intestine from the large intestine. In addition, there are additional defense mechanisms such as immunoglobulins in the secretions of the small intestine, as well as  secretions from the pancreas and bile-related secretions that keep bacteria from reproducing [1].

SIBO can occur for different reasons, including low stomach acid (achlorhydria), pancreatic insufficiency, as well as anatomical abnormalities including small intestinal obstruction, diverticula (more about this in this article), fistula (which is abnormal connection between an organ and the intestine which can be created after some infections), as well as slowing of intestinal movements (motility disorders) that are common in those with diabetes mellitus, and other conditions. It has been known for many years that those that consume significant amounts of alcohol are known to be at risk for SIBO [3] but a more recent study found an association between moderate alcohol consumption and SIBO [4], which was defined as up to one drink per day for women and two drinks per day for men. It is thought that alcohol consumption may cause injury to the mucosal cells of the small intestine which contributes to a slowing of intestinal contractions (i.e. motility disorder), which is associated with SIBO. In some people, a combination of the above factors may be involved.

[Note: in my case, an underlying diagnosis of SIBO was certainly possible as I had been on a long-term, high dose of H2 antihistamines due to having Mast Cell Activation Disorder (MCAD) — medications which are known to also significantly reduce stomach acid, and I had also been diagnosed with type 2 diabetes 8 years before going into remission 2 1/2 years ago.

How Common is SIBO?

The prevalence of SIBO in young and middle-aged adults appear to be between 6 and 15% , but higher in the older adults (14.5—15.6%) [5]. Perhaps this is due to decreasing amounts of stomach acid associated with aging, as well as increase prevalence of diverticulosis and type 2 diabetes, all of which are associated with SIBO risk.

What are the Symptoms of SIBO?

Many of the symptoms of SIBO are similar to those of Irritable Bowel Syndrome (you can read more about that here), including abdominal pain, bloating, gas, bouts of diarrhea or constipation or alternating diarrhea and constipation. As mentioned above, there are other lesser known symptoms of SIBO, including joint pain.

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Update (September 4, 2019): In the second article (posted here), I outlined different tests used to diagnose SIBO, the difference between hydrogen-dominant SIBO and methane-dominant SIBO and why Irritable Bowel Syndrome (IBS) that does not improve despite adopting appropriate dietary changes may be SIBO.

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More Info?

You can find out more about the hourly consultations and packages I offer by visiting the Services tab or the Shop, and if you would like additional information please send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Bures J, Cyrany J, Kohoutova D, et al. Small intestinal bacterial overgrowth syndrome. World J Gastroenterol. 2010;16(24):2978—2990. doi:10.3748/wjg.v16.i24.2978
2. Medscape, Small Intestine Anatomy, Dec 8 2017, https://emedicine.medscape.com/article/1948951-overview
3. Hauge T, Persson J, Danielsson D: Mucosal Bacterial Growth in the Upper Gastrointestinal Tract in Alcoholics (Heavy Drinkers). Digestion 1997;58:591-595. doi: 10.1159/000201507
4. Gabbard SL, Lacy BE, Levine GM et al, The Impact of Alcohol Consumption and Cholecystectomy on Small Intestinal Bacterial Overgrowth, Digestive Diseases and Sciences, 2014, Volume 59, Number 3, P. 638
5. Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol (N Y). 2007;3(2):112—122.

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Note: This article is not one of my usual Science Made Simple posts, but a comment about something that occurred on social media yesterday.

Yesterday, I posted a photo on Instagram, Facebook and Twitter of some fresh chicken that I had bought and that I had cut up into legs and breasts. Real food is perfectly normal for a Dietitian to write about, right?

The photo I posted is above.

The caption under the photo indicated that this shouldn’t look foreign and that real chicken comes with a head, feet and bones (in contrast to chicken we buy in a supermarket that usually comes boneless or pre-cut, in Styrofoam trays, and covered in plastic wrap).

Presumably, someone found this  photo of chicken before and after cutting as being offensive and reported it to Instagram.  I was not notified that the photo had been censored, and it looks the same from my end, but several people that follow me told me that my photo was deemed to contain “sensitive content”.

To anyone viewing the post now, it now looks like this:

A physician posted the following comment about the censoring;

“I cannot believe a photo of food is blurred as “sensitive content”. It is absolutely mind boggling. But it’s totally fine to be constantly inundated with ads for crap that make us feel bad about ourselves, making us buy junk we don’t need.“

This physician is right! There’s a huge difference between real food and the processed food-like substances (“crap”) that we are encouraged to buy and eat. You can read more about telling the difference between these in this previous article.

The two photos of chicken that I posted before and after being cut up has been blurred on Instagram because “some might find offensive or disturbing“.

Do you know what I consider offensive and disturbing?

I find people having to have toes amputated because of uncontrolled diabetes offensive.

I find obese people trying desperately to lose weight, yet finding themselves unable to curb an insatiable craving for processed food that was deliberately created by its producers, disturbing.

I find the fact that many young children in Canada and the US (and likely in many other countries) think of chicken as something that comes boneless, deep fried in batter and packaged in small individual packages with various flavours of sweetened sauce to dip it in, disturbing.

I find pea protein isolate, industrial seed oil, methyl cellulose and a host of other processed ingredients masquerading in the meat counter, offensive.  But please don’t misunderstand…

I have absolutely no problem with vegetarians and vegans having a wide variety of plant-based food available to eat as alternatives to animal-based foods, but it should not be marketed to consumers as “meat”, but ‘better’.

It may be “better” or “ultra” or “beyond” for those who choose a plant-based lifestyle, but an ultra-processed mixture of pea protein isolate, canola oil, refined coconut oil, cellulose from bamboo, methylcellulose, potato starch, maltodextrin, yeast extract, sunflower oil, vegetable glycerin, dried yeast, gum arabic along with seasoning and flavourings is not ‘better’ or preferable to whole, real food with a single ingredient, “beef”.

These are choices…

…and people have the right to choose what they want to eat, without condemnation and judgement.

There is no one-sized-fits-all-diet and individuals who choose to eat meat, fish or poultry should not be vilified or censored for doing so.

To your good health,

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

 

 

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A migraine is more than just a really bad headache. While migraine is characterized by intense, debilitating headache, it also may include nausea, vomiting, difficulty speaking, sensitivity to light and sound, and may- or may not be preceded by an aura (sensory, motor, visual or speech symptoms that act like a warning signal that a migraine is about to begin). People with a reduced ability to clear the amino acid tyramine (which is called tyramine intolerance) often experience migraine, along with other symptoms including heart palpitations and GI issues, including nausea and vomiting.

In those who have insufficient amounts of an enzyme called monoamine oxidase (MAO), levels of tyramine can build up, and this is called tyramine intolerance.  A tyramine intolerance diet can be helpful in helping reduce people’s symptoms.

Tyrosine combines with other amino acids to form proteins, and just like the amino acid histadine breaks down to histamine (see this previous article on histamine intolerance), tyrosine breaks down to form tyramine. Normally, the excess tyramine is broken down by the enzyme monoamine oxidases (MAO) — in the same way that excess histamine is broken down by the enzyme diamine oxidase (DAO).  In individuals that take certain types of medications such as MAO inhibitors (used in treating some types of depression) and certain medications used for treating Parkinson’s disease, levels of tyramine will build up in the body because the enzyme that breaks it down is inhibited.

In those who have insufficient amounts of the enzyme monoamine oxidase, levels of tyramine can also build up and this is called tyramine intolerance [1].

Symptoms of Tyramine Intolerance

The body naturally responds to the presence of tyramine by making catecholamines such as epinephrine and norepinephrine which are neurotransmitters involved in the “fight or flight” response. If tyramine accumulates, too much of these chemicals are released, which leads to an increase in blood pressure and heart rate [2]. If these chemicals go high enough (such as is the case with those taking certain medications) this can lead to a very rapid and dangerous increase in blood pressure called a ‘hypertensive emergency’ which can result in bleeding in the brain (hemorrhagic stroke)[3] and rarely, even death.  At very least, the very high blood pressure can cause damage the body’s tissues and organs.

Those with a reduced ability to clear tyramine due to tyramine intolerance may experience migraine, heart palpitations or GI issues, including nausea and vomiting [2].

Tyramine Intolerance Diet

In those taking MAO Inhibitor medication or specific medications for treating Parkinson’s disease,  a tyramine-free diet is prescribed. Since the adverse effects of eating tyramine-containing foods can be so serious, strict adherence is needed.

For those with diagnosed tyramine intolerance, a low tyramine diet will be recommended, and for those with suspected tyramine intolerance a low tyramine diet may be trialed to see if symptoms improve. This is especially the case in people who experience migraine— as it has long been thought that tyramine may underlie the constriction of blood vessels that increases blood pressure associated with migraine[4].

Low Tyramine Diet — not as easy as following a ‘list’

Tyramine naturally occurs in small amounts in protein-containing foods, but as foods age, mature or ripen, tyramine levels increase.

Avoiding strong or aged cheeses, cured, smoked or processed meats, pickled, cultured or fermented foods (including many Asian condiments), nuts and nut butters and some seeds and seed butters, aged spreads such as Marmite and Vegemite, and alcoholic beverages [3,5] is a good place to ‘start’, however reducing tyramine in the diet isn’t as straight forward as simply following a “list’.

Knowing which cheeses, for instance have high levels of tyramine and which have moderate levels can be looked up, but some tyramine-containing foods may act as a trigger to migraine in one person, but not in another — so it is often unnecessary to restrict all tyramine-containing foods. Sometimes by me helping people systematically eliminate the most common tyramine triggers is sufficient to provide them significant relief — without them having to eliminate all tyramine-containing foods.  That’s where experience helps!

More Info?

If you have been diagnosed with tyramine intolerance or suspect you may be sensitive to tyramine, I can help.

You can learn more about the Histamine / Tyramine Intolerance Specialty Hourly Service here  and I also offer a migraine add-on option to the Complete Assessment Package which you can learn about here. If you would like information as to which is a better fit for your needs, please send me a note using the Contact Me form above.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Joneja, J. Histamine and tyramine sensitivity — how closely are they linked? Food Matters, October 2017, https://www.histamine-sensitivity.com/histamine-tyramine-similaraties-10-12.html
2. Van Eaton J. Tyramine-Free Diets. Healthline, Feb 1, 2019, https://www.healthline.com/health/tyramine-free-diets
3. Hall-Flavin D. Mayo Clinic, MAOIs and diet: Is it necessary to restrict tyramine? https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/maois/faq-20058035
4. Costa MR, Glória MBA. Migraine and Diet, Encyclopedia of Food Sciences and Nutrition (Second Edition), 2003, https://www.sciencedirect.com/science/article/pii/B012227055X007835
5. Skypala IJ, Williams M, Reeves L, Meyer R, Venter C. Sensitivity to food additives, vaso-active amines and salicylates: a review of the evidence. Clin Transl Allergy. 2015;5:34. Published 2015 Oct 13. doi:10.1186/s13601-015-0078-3

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Why do so many post menopausal women and older men have low iron stores or iron-deficient anemia — especially given that the women are no longer menstruating, and men never had this regular blood loss? 

It should be noted that in this article, I am only discussing low iron stores and iron-deficient anemia and not anemia of other types, such as accompanies low vitamin B12 status or a problem with intrinsic factor that helps absorb it; both of which are common as people age, nor they type that is the result of low folate intake.  This is a different type of anemia, called macrocytic anemia, where the blood cells are fewer, but larger than normal (macro means larger).

Microcytic anemia is where there are fewer red blood cells and they are smaller than normal (micro means small) and this is caused by conditions that keep the body from making enough hemoglobin, the oxygen carrying part of the blood. Low levels of hemoglobin in red blood cells results in the red blood cells appearing paler in colour and this is called hypochromic (hypo means low, chromic means colour). Iron deficient anemia is the most common type of hypochromic microcytic anemia.

Low iron stores or iron deficient anemia

May be caused by;

1. 1. inadequate dietary intake such as is common in those who are vegetarian (eat no meat from animals) or vegan (eat no animal products, including no eggs or cheese).
   2. decreased absorption which is common in conditions such as Celiac disease or in those that have h. pylori; a type of bacteria that causes stomach ulcers (or may be without symptoms at all
   3. chronic blood loss, such as is common in women with heavy menstrual periods or in those with inflammatory gastrointestinal (GI) diseases and experience internal bleeding, such as those Crohn’s Disease or Ulcerative Colitis.
   4. pregnancy due to increased blood needs of the fetus.

Post-menopausal women are past the age where they can either be pregnant or have periods, so low iron stores or iron-deficient anemia in older women are for reasons similar to older men; either due to decreased iron absorption or chronic blood loss.

In older adults with low iron stores or iron deficient anemia, the first thing I rule out is Celiac Disease because it is as simple as a routine blood test, and a fair number of people with the disease (immune reaction to gluten) have no symptoms whatsoever. The second thing I rule out is any history of- or symptoms of stomach ulcers, which is caused by the heliobacter pylori (h. pylori) bacteria. This bacteria takes up iron and can contribute to iron status in its host. Ruling this out can be done by a breath test looking for urea given off by the bacteria.

Assuming an older adult tests negative for both Celiac disease and h. pylori and does not have any chronic disease that may be causing the anemia  — then what can be contributing to them having lower than normal iron stores or iron deficiency?

Iron deficient anemia (IDA) occurs in ~2%-5% of adult men and postmenopausal women; with blood loss from chronic blood loss from gastrointestinal bleeding being the most common cause [1,2] and malabsorption being the second most common 2,3].  Goddard et al [2] found that 5-10% of of iron deficient anemia is due to malabsorption mainly from Celiac disease, but since there was very little research assessing iron deficient anemia in post menopausal women, a 2015 study from Pakistan sought to do that [4]. 

Chronic blood loss is not only caused by inflammatory bowel diseases such as Crohn’s and Colitis, but with long term used of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) such as Advil® (ibuprofen) and Naproxen®. For years, doctors often recommend that older adults take a “baby aspirin” (low dose ASA, 81 mg) to lower their risk of heart disease, but long term use of even the small dose has been associated with GI bleeding. A study published in October 2018 in the New England Journal of Medicine found that for every 1,000 people taking low dose ASA, 11 avoided a serious cardiovascular event (heart attack, stroke) but 9 experienced GI bleeding serious enough to result in hospitalization or even death [5]. As a result, physicians are re-thinking the previous recommendation for people without a previous heart attack or stroke to take low dose aspirin [6]. Older adults who have been taking NSAIDs for pain or a low dose ASA to protect against heart attack and stroke may have low iron stores or even iron-deficiency as a result.

A major contributor to iron deficiency caused by malabsorption other than Celiac Disease in older adults is the use of Histamine-2 Receptor Antagonists (H2 antihistamines) such as Ranitidine which is the active ingredient in over-the-counter stomach acid reducer, Zantac®, as well as the commonly prescribed Proton Pump Inhibitors (PPIs). Gastric acid inhibitor use of either H2 antihistamines or PPIs for ~2 years is known to be associated with an increased risk of iron deficiency [7], so those with Gastroesophageal Reflux (GERD), chronic heartburn or indigestion or Histamine Intolerance taking these medications are at risk.  

Reduced iron status in older adults taking NSAIDs, including low dose aspirin or gastric acid reducers such as Zantac® or PPIs is quite common, so finding ways to decrease dependence on NSAIDS for pain reduction strategies by exploring dietary strategies including an Anti-Inflammatory Diet can be very helpful.

In addition, weight loss especially reduction of weight carried around the abdomen can result in a reduction of- and often a discontinuation of the need for gastric acid inhibitors.

Finally, a major challenge in determining the cause of lower iron stores or iron deficient anemia in older adults is that chronic diseases such as diabetes and chronic kidney disease can cause the anemia of chronic disease (ACD) also called anemia of inflammation, which is very similar to iron deficient anemia (IDA). It is important to distinguish the two.  The 2015 study from Pakistan had a rather simple, but ingenious way of doing so. Subjects who were deficient were given iron supplementation and most improved indicating that there was no malabsorption, but low intake. However, if there was no change in serum iron when serum iron was re-tested, these individuals were concluded to be iron deficient due to malabsorption In those with malabsorption due to Celiac disease for example or the use of gastric acid inhibitors that can’t be reduced, recommendation is for intravenous iron administration, as oral iron administration is not effective.

More Info?

If you are an older adult and have lower than optimal iron stores or have been diagnosed with iron deficiency, working with your doctor I can help rule out whether it may be a result of asymptomatic Celiac Disease, over the counter or prescribed medications that you’ve been taking, inadequate dietary intake or malabsorption that has contributed to the problem.

You can find out more about the packages and hourly consultations I offer by clicking here and if you would like additional information, please send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood. 2004;104:2263—2268
2. Goddard AF, James MW, McIntyre AS, Scott BB. Guidelines for the management of iron deficiency anaemia. Gut. 2011;60:1309—1316
3. Amy Z, Kaneshiro M, Kaunitz JD. Evaluation and
   treatment of iron deficiency anemia: a gastroenterological
   perspective. Dig Dis Sci. 2010;55(3):548-559.
4. Qamar K, Saboor M, Qudsia F, Khosa SM, Moinuddin, Usman M. Malabsorption of iron as a cause of iron deficiency anemia in postmenopausal women. Pak J Med Sci. 2015;31(2):304—308.
5. The ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med 2018; 379:1529-1539
6. Harvard Health Publishing, Rethinking low-dose aspirin, https://www.health.harvard.edu/heart-health/rethinking-low-dose-aspirin
7. Lam JR, Schneider JL, Quesenberry CP, Proton Pump Inhibitor and Histamine-2 Receptor Antagonist Use and Iron Deficiency. Gastroenterology. 2017 Mar;152(4):821-829.

 

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INTRODUCTION: In the previous article about milk intolerance related to a novel beta casein protein found in commercial cow’s milk, I mentioned both histamine intolerance and Mast Cell Activation Disorder (MCAD) — which is also called MCAS (Mast Cell Activation Syndrome).  Quite a few people with these disorders reached out to me on social media, looking for articles I may have written about them and as I hadn’t yet, I decided to write this one.

Adverse reactions to food or components of food can be divided into food allergy and food intolerance.

A food allergy is an IgE antibody-mediated immune reaction and can range from mild skin itching or hives, to full-blown anaphylactic attack where a person is unable to breathe. Specific IgE-mediated antibodies can be assessed and quantified by a blood test for an allergen, or assessed via skin scratch test with a small amount of the allergen.

A food intolerance is a non-immune reaction to a food or food component that can result in a disturbance of enzymes of the gastrointestinal (GI) tract. Lactose intolerance is probably the best known food intolerance, where people have a disturbance of the enzyme lactase in the GI tract, which makes them unable to properly digest the sugar in milk.

Histamine intolerance, like tyramine intolerance is a food intolerance and while rarely life-threatening, it can makes people’s lives quite miserable.

What are Histamines

Most people know that term ‘antihistamine‘ as medications that people take when they have seasonal allergies, such as trees and grasses or ragweed (“hay fever”), but what are histamines?

Histamine is a chemical that performs many helpful functions in the body such as stimulating the production of stomach acid (via the H2 receptors), but in this context, the interest is in histamine’s role in the immune system.

As it is intended to, histamine is released in response to exposure to an allergen, in the body’s attempt to protect you against something that it perceives as a threat. If you have breathed in some pollen that you you are allergic to for example, a signal is sent to your mast cells to release histamine in the body.  These histamines result in inflammation; a condition which signals the immune system to respond. That response could make you sneeze or make your nose run in order to help get rid of the offending allergen — or in cases with people with IgE mediated allergies it can be a very serious reaction that causes your blood pressure to suddenly drop very low, and you find it very difficult to breathe (anaphylaxis).

In histamine intolerance or mast cell activation disorder, histamine is either not broken down properly so it builds up in the body or is released by the mast cells inappropriately, such as when there is no allergen present. In these people, histamine becomes like gluten to a celiac, or regular milk to someone with lactase deficiency — only worse.

Some foods are high in an amino acid called histidine; which converts to histamine during digestion (via a carboxylation reaction mediated L-histidine decarboxylase).

Foods high in histamine include aged and fermented foods such as cheese, yogurt, pickled foods such as kimchi or saurkraut, and smoked fish. Other foods include dried fruit, specific vegetables, some nuts, well as alcohol.

There are also foods that are histamine-liberators, such as chocolate, milk and tomatoes (just to name a few) that need to be considered to minimize the symptoms of histamine intolerance, as well as certain food additives [1].

Finally, foods high in histidine, which is converted to histamine upon digestion, aslo need to be factored in to the diet of someone with histamine intolerance or mast cell activation disorder.

People with mastocytosis, mast cell activation disorder (MCAD) or histamine intolerance react to foods high in histadine / histamine as well as to foods that liberate histamine from mast cells. While these are separate disorders, they all involve problems with histamine.

Mastocytosis is condition where there are too many mast cells. This can be limited to just the skin or can be systemic (all over the body) and occurs due to a mutation in a specific gene.

Mast Cell Activation Disorder (MCAD) – sometimes called Mast Cell Activation Syndrome (MCAS) is where the mast cells ‘degranulate’ (spill their contents, including histamine) at an inappropriate time.  That is, they release histamine when there is no allergen present.

Histamine Intolerance is where the rate of histamine accumulation in the body is greater than the rate at which histamine degrades. The analogy of histamine intolerance is that of an overflowing “bucket”.

Histamine Intolerance

Normally, histamine is stored in the mast cells, or is rapidly degraded by one of two enzymes; either by diamine oxidase (DAO) or histamine-N-methyltransferase (HNMT) upon release, so it doesn’t accumulate.  Disfunction in these enzymes can

DAO primarily functions in the small intestine, ascending colon (a section of the large intestine), as well as kidney [1]. The primary function of DAO is the elimination of excess histamine, as well as controlling the amount of histamine in the body, coming from the digestive tract [1].

HNMT is primarily functions at the level of the histamine receptors themselves, where it deactivates histamine. This enzyme is active in a wide range of body tissues; but greatest in the kidney and liver, followed by the spleen, colon (large intestine), reproductive organs (prostate, ovary), spinal cord cells and parts of the lungs (bronchi, trachea).

Histamine Receptors

There are 4 types of histamine receptors that bind histamine and cause mast cells to release histamine. The binding of histamine with these receptors result in different types of allergic reactions.

H1 Receptors

H1 receptors are primarily involved in allergic rhinitis symptoms (sneezing, blowing ones nose), broncho-constriction such as what occurs in allergy-induced asthma, as well as systemic vasodilation (enlarging of the blood vessels)[2].

H2 Receptors

H2 receptors stimulate the stomach to release HCL acid, and inhibit the body from making antibodies, as well as activate the immune system response, including T-cell proliferation and the production of cytokines[2].

H3 Receptors

H3 receptors change neurotransmitter release in the central nervous system, including serotonin and norepinephrine (noradrenaline)[2].

H4 Receptors

H4 receptors are found mostly in bone marrow and white blood cells and are also expressed in the colon (large intestine), small intestine, spleen, tonsils and trachea (wind-pipe)[2].

Symptoms of Histamine Intolerance

People with histamine intolerance display a wide variety of symptoms, affecting different parts of the body.  Some people have many symptoms in different parts of the body, whereas others have a few symptoms clustered in specific parts.  Those with histamine intolerance may have chronic reactions and others may have them seemingly ‘randomly’.

That said, the most frequently observed symptoms are acute (sudden) or chronic (long term) gasto-intestinal GI symptoms [2] and can easily  be mistaken for ‘food poisoning’ (acute symptoms) or irritable bowel syndrome (chronic symptoms). That said, there are individuals with MCAD that have anaphylactic-type reactions. 

Gastro-intestinal symptoms often take place several hours after ingestion of the offending food or food component, because the food itself has to be digested (which takes time) for its histamine to be liberated and bind with the histamine receptors.

In other cases, the reaction is faster; especially when eating aged or leftover food or other foods with high histamine content. These foods may trigger abdominal cramps or diarrhea within 15-30 minutes[2].

Other non-GI related symptoms common with histamine intolerance and mast cell activation disorder (MCAD) are skin rashes, hives (with or without itchiness), facial and chest flushing (getting red and ‘hot’ feeling), faster or slower heartbeat (arrhythmia) or low blood pressure or extreme fatigue. Some people also experience mood changes, including inattentiveness or something described as a ‘brain fog’, as well as sleep disturbances [3,4].

Getting Diagnosed

Histamine intolerance and mast cell activation disorder are difficult to diagnose, firstly because people themselves don’t think wide range of symptoms are related, so they often don’t seek medical help. Another challenge is that the very fact that the symptoms are diverse may result in them be discounted by some physicians as being related to stress/anxiety or depression.

Mast cell activation disorder (MCAD) takes on average 14 years to be diagnosed [4] and often only occurs once the person finally gets a referral to an immunologist or allergist knowledgeable in the condition. I can assist in helping people get that referral, as well as provide support once they know they have either MCAD or histamine intolerance.

You may be interested in this article about similar condition called tyramine intolerance, especially if you suffer from migraine headaches.

More Info?

If you have been diagnosed with histamine-intolerance or mast cell activation disorder (MCAD) or suspect you may have one of these, I can help by providing you with nutrition education to make the needed dietary changes to help minimize symptoms.

You can find out more about the packages and hourly consultations I offer by clicking here and if you would like additional information, please send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd

Copyright ©2019 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. Baily N, Histamine Intolerance, Igennus Healthcare Nutrition, https://www.slideshare.net/igennus/managing-histamine-intolerance-80982438
2. Jernigan D, Histamine Intolerance Syndrome, Hansa Center for Optimal Health, Bimed Network, https://www.marioninstitute.org/histamine-intolerance-syndrome/
3. Molderings GJ, Brettner S, Homann J et al, 2011, Mast cell activation disease: a concise practical guide for diagnostic workup and therapeutic options, J of Hemat and Onc 4 (10)
4. Hamilton MJ et al, 2011, Mast cell activation syndrome: A newly recognized disorder with systemic clinical manifestations. J of Allergy and Clin Immunology Vol 28 (1), p. 147-153

 

Digestive issues that result from milk consumption are often attributed to lactose intolerance, but research indicates that it may be the result of an intolerance to a specific type of protein found in some types of cow’s milk; specifically A1 beta-casein.

Casein and whey are the two primary proteins found in milk, with casein accounting for ~ 80 % of the protein in milk. Approximately 30% of the protein in milk is beta-casein.

There are two variants of beta-casein; A1 and A2, however before cows were domesticated, they only produced milk that only contained the A2 form of beta-casein[1,2]. Older breeds of cows such as most Jerseys, Guernseys, Brown Swiss, Normandes, as well as most of the cows in Asia, Africa and southern Europe[2] produce milk with the A2 variant of beta-casein, as do goats, sheep, donkeys, yaks, camel and buffalo [2]. In addition, human milk contains A2 beta-casein.

It is thought that ~8,000 years ago, a single-gene mutation occurred in Holsteins which resulted in the production of the A1 beta-casein protein in this breed. This novel gene variant was passed on to other northern European breeds of cows, including Friesian, Ayrshire and British Shorthorn since Holsteins were bred with them to improve milk production[2]. 

Today’s Holstein breed is the most common dairy cow in the US, Canada, Australia and northern Europe and carries both A1 and A2 forms of beta casein in approximately equal amounts[2].

Milk intolerance may not always be due to lactose intolerance, but due to intolerance to milk containing A1 beta-casein.

Note: Primary lactose intolerance is a result of a lack of the enzyme lactase, which is genetic in origin. This is a permanent condition. Secondary lactose intolerance is temporary and the result of being sick with something that causes diarrhea which sloughs off the lactase from the wall of the intestine. Genuine lactose intolerance can be tested with a hydrogen breath test.

Research suggests that A1 beta-casein protein may be at the root of stomach pain and other gastrointestinal (GI) symptoms associated with consumption of milk from A1 cows and which closely resemble lactose intolerance. These symptoms are not present when consuming milk from cows that only produce A2 beta-casein. Food-derived peptides such as β-casomorphins and others are known to have different effects on the intestines, including the secretions of the stomach and pancreas, as well as gut motility [3]. Studies have found that a peptide called β-(beta) casomorphin (BCM-7) may be behind stomach pain and other symptoms associated with milk containing A1 beta-casein.

The Difference Between A1 and A2 Beta-Casein

If one thinks of proteins as chains of amino acids strung together like train-cars in a train, each one of the ‘cars’ represents a different amino acid.  In the older A2 beta-casein variant, the ‘car’ which occupies the 67th position is an amino acid called proline, but in the newer A1 beta-casein variant, the amino acid in the 67th position is histidine. When milk with A1 beta-casein is digested, the histidine bond breaks, resulting is a peptide made up of 7 amino acids, called β-(beta) casomorphin-7 (BCM-7).

β-(beta) casomorphin-7 (BCM-7) is a naturally occurring opioid peptide, with a structure similar to morphine and is known to bind to opioid receptors [3]. What effect does BCM-7 have on the body as a result of binding with these opioid receptors?

A 2015 review paper cites research demonstrating that milk containing A1 beta-casein increases GI transit time (the amount of time that it takes for food to go through the GI tract) which means in slows it down, and in animal studies, increases inflammatory markers significantly more than A2 beta-casein containing milk[5]. In a small, double-blinded, randomized crossover study from 2014 with 41 subjects, it was found that participants consuming A1 beta-casein cow’s milk had significantly softer stools, more bloating and more abdominal pain than those drinking A2 beta-casein milk [6]. In another unrelated double-blind, randomized, crossover trial from 2016 with 45 Chinese participants with self-reported intolerance to cow’s milk drank  250 mL of either A1/A2 or A2 milk following each of two meals over a 14-day period. When drinking the A1 beta-casein milk, there was an increase in transit time and in GI inflammation, and a worsening of digestive discomfort [7] as well as an increase in inflammatory markers such as IgG, IgE, and IgG1. These were significantly lower in those that drank A2 milk [7].

Addendum (July 22, 2019): *there has been some anecdotal evidence that people with arthritis do considerably better when they do not consume casein (see Arthritis Foundation website).

In a large scale 2017 randomized cross-over design follow-up study, 600 adult who reported lactose intolerance and digestive discomfort following milk consumption were assigned over a 7-day period to consume either 300 mL of conventional milk containing both A1 and A2 beta casein, or only A2 milk. Results indicated digestive symptoms were markedly reduced after consuming A2 milk versus conventional milk [8].

Healthcare professionals have often assumed (without giving people hydrogen breath tests to confirm it) that people with GI symptoms related to consuming dairy products have lactose intolerance, when it is possible that the symptoms could be related to intolerance of A1 beta-casein.

Concerning to those with histamine-intolerance, including those with Mast Cell Activation Disorder (MCAD) who need to lower their intake of histadine-containing foods and histamine-liberators [9] may unknowingly be adversely affected by milk commonly available in the US, Canada, Australia and northern Europe that contains A1 beta-casein, as when it is digested it produces betacasomorphin-7 (BCM-7), a potent histamine liberator. The most well-known Histamine Intolerance Food Compatibility List from the Swiss Histamine Intolerance Group (SIGHI) lists milk as producing a low reaction — perhaps because the milk available in Central Europe, as in southern Europe, contains A2 beta casein, and not A1 beta-casein as in North America, Australia and northern Europe [10]. Those with histamine-intolerance in the US and Canada, for example and other countries with A1 beta-casein in dairy need to be aware that the milk and the hard cheeses listed as being “well-tolerated, no symptoms expected at usual intake” does not apply to the milk and cheese available to them.

Final Thoughts…

While much research has yet to be done to determine the extent that A1 beta-casein proteins impact human health, those with suspected lactose intolerance who continue to have symptoms while consuming lactose-free milk and low-lactose products such as yogurt and hard cheese, should try eliminating milk produced at ordinary large-scale dairies that have milk containing both A1 and A2 beta-casein to see if their symptoms improve.  As a substitute, they could use goat milk or buffalo milk, or find small, local dairies that use “heritage herd” cows, such as specific species of Jerseys, Guernseys, Brown Swiss, and Normandes that only produce milk with A2 beta-casein.

Note: My tried and true recipe for making homemade goat or A2 yogurt in an oven or crock-pot using a temperature controller, as well as turning it into thick Greek yogurt is posted here.

Those with histamine-intolerance in the US, Canada and Australia might feel better avoiding milk, cheese, and yogurt from conventional dairies, as these contain A1 beta-casein, which are high histamine liberators. After a period of dairy avoidance to enable mast cells to calm, dairy products from “heritage herd” cows can then be trialed.

NOTE: Butter and full-fat (whipping) cream are entirely fat, and as such do not contain either A1 or A2 beta-casein proteins. These would be fine to consume regardless of which dairy they were from.

More Info?

If you have food allergies or food intolerances, including what you thought was lactose intolerance, or have been diagnosed with histamine-intolerance or Mast-Cell Activation Disorder (MCAD), I can help.

You can find out more about the packages and hourly consultations I offer under the Services tab or by clicking here. If you would like further information, please send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Ware M, Metropulos M, Medical News Today, A2 milk: What you need to know, July 25, 2017, https://www.medicalnewstoday.com/articles/318577.php
2. Pasin G. A2 milk facts. California Dairy Research Foundation website. http://cdrf.org/2017/02/09/a2-milk-facts/. Published February 9, 2017.
3.  European Food Safety Authority. Review of the potential health impact of β-casomorphins and related peptides. EFSA J. 2009;7(2):1-107.
4. Kurek M, Przybilla B, Hermann K, A naturally occurring opioid peptide from cow’s milk, beta-casomorphine-7, is a direct histamine releaser in man, Int Arch Allergy Immunol. 1992;97(2):115-20.
5. Pal S, Woodford K, Kukuljan S, Ho S. Milk intolerance, beta-casein and lactose. Nutrients. 2015;7(9):7285-7297.
6.  Ho S, Woodford K, Kukuljan S, Pal S. Comparative effects of A1 versus A2 beta-casein on gastrointestinal measures: a blinded randomised cross-over pilot study. Eur J Clin Nutr. 2014;68(9):994-1000.
7. Jianqin S, Leiming X, Lu X, Yelland GW, Ni J, Clarke AJ. Effects of milk containing only A2 beta casein versus milk containing both A1 and A2 beta casein proteins on gastrointestinal physiology, symptoms of discomfort, and cognitive behavior of people with self-reported intolerance to traditional cows’ milk. Nutr J. 2016;15:35
8. He M, Sun J, Jiang ZQ et al, Effects of cow’s milk beta-casein variants on symptoms of milk intolerance in Chinese adults: a multicentre, randomised controlled study. Nutr J. 2017 Oct 25;16(1):72.
9. Molderings GJ, Brettner S, Homann J, Afrin LB. Mast cell activation disease: a concise practical guide for diagnostic workup and therapeutic options. J Hematol Oncol. 2011;4:10. Published 2011 Mar 22. doi:10.1186/1756-8722-4-10
10. Lamprecht H, Swiss Interest Group Histamine Intolerance (SIGHI), Histamine Intolerance Food Compatibility List, wwww.mastzellaktivierung.info & www.histaminintoleranz.ch

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This article is based in part on material by Judith C. Thalheimer, RD, LDN, Is A2 Milk the Game-Changer for Dairy Intolerance?Today’s Dietitian, Vol. 19, No. 10, P. 26

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Many people mistakenly believe that arthritis is a normal part of the aging process, but many older adults never get it and most of the people that are diagnosed with it are under the age of 65 years old. In fact,  2/3 of those diagnosed are not seniors, and some include children.

US statistics report that almost 1/4 ( 22.7%) adults have doctor-diagnosed arthritis — with significantly higher age-adjusted prevalence in women (23.5%) than in men (18.1%). While arthritis is not a normal part of aging, the likelihood of getting a diagnosis increases with age[1]. Only 7.3% of adults aged 18 to 44 years have been diagnosed arthritis, almost 50% (49.7%) of adults aged 65 years of age have been diagnosed[1].

There are different types of arthritis, including osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis, gout, and juvenile arthritis. More on each of these, below.

Osteoarthritis (OA)

Osteoarthritis (OA) is the most common form of arthritis and is a degenerative joint disease that results from a breakdown of the cartilage within a joint. This breakdown results in the bone actually changing, or remodeling in order to try and accommodate the lack of cartilage. The bone does this by producing bone overgrowth called osteophytes, or ‘bone spurs’. An osteophyte is a smooth, bony deposit that grows slowly over time, and often has no symptoms but can be painful if they impinge on nerves or affect the movement of the joint. It most commonly occurs in the hands, hips, and knees and changes usually develop slowly, and get worse over time. OA can cause stiffness, swelling and pain and in some cases it results in some people are no longer able to do daily tasks.

Rheumatoid Arthritis (RA)

Rheumatoid arthritis (RA) an autoimmune and inflammatory disease where the body’s immune system attacks healthy cells in the body, resulting in inflammation and painful swelling. It mainly attacks the joints in the hands, wrists, and knees, and often many joints at once. In a joint with RA, the lining of the joint becomes inflamed, causing damage to joint tissue and this damage is what results in chronic pain, difficulty with mobility and joint deformity.

Ankylosing Spondylitis (AS)

Ankylosing spondylitis (AS) is the most common form of a group of inflammatory arthritis called spondyloarthritis and is an autoimmune disease, which means it is caused by the body’s immune system attacking healthy tissue. AS leads to rigidity of the spine, and the sacroiliac (SI) joints which attach the pelvis (hips) to the base of the spine. Ankylosing’ means “fusing” and spondylitis’ means “inflammation of the spine”. AS 

Gout

Gout is a form of inflammatory arthritis that usually affects one joint at a time, (often the big toe joint. In this form, symptoms wax and wane, with times where there are symptoms being known as ‘flares’. Gout is associated with high levels of uric acid, which can also contribute to kidney stones, so controlling the level of uric acid through diet may be part of treatment.  This includes keeping levels of purine-containing foods constant (not eliminating them). Repeated bouts of gout can lead to ‘gouty arthritis’; a worsening form of arthritis.

Juvenile (childhood) Arthritis

The most common type of childhood arthritis is ‘juvenile idiopathic arthritis’  (JIA), which is also known as juvenile rheumatoid arthritis (J-RA) which can cause permanent physical damage to joints and make it hard for the child to do everyday tasks such as walking, or even getting dressed by themselves.

Arthritis, Other Conditions and Quality of Life

Arthritis in adults is more common in people with other chronic health conditions, including;

– 31% of those with arthritis are obese
– 47% of those with arthritis have diabetes
and
– 49% have heart disease [1].

This isn’t all that surprising given that all of these conditions are linked to different types of systemic inflammation.

Having any of these other chronic conditions ⁠— along with arthritis makes it all the more difficult for people to enjoy life. The pain associated with arthritis may be a barrier to physical activity for those with heart disease[1] and those who are overweight or obese already struggle with having little energy to be active and the pain of arthritis only makes that more difficult [2]. 

That said, physical activity ⁠— whether it is simple aerobic activity like walking or swimming or strength / resistance training can benefit all of those conditions, so reducing the pain in arthritis is an important key to being able to be active, and have a much improved quality of life.

Reducing Inflammation – the role of an Anti-inflammatory Protocol

Many people when they get diagnosed with arthritis want to know if there is an “arthritis diet”.  There is no diet specific to people diagnosed with arthritis, except perhaps a diet that lowers uric acid in those with gout, however eating in such a way as to lower inflammation can help a great deal!

I have offered an Anti-Inflammatory Protocol Package for close to ten years and recently completely updated the materials that I used to teach it, as well as the 27 pages of handouts I provide, in light of the most current research.

The goal of the Anti-Inflammatory Protocol is simple; to reduce stiffness and pain by lowering inflammation. It is divided into 3 sessions of an hour each and covers everything from the components of foods that contribute to inflammation; from grains and seed oils, to otherwise ‘healthy’ foods and even that may make symptoms worse and why, as well as those that are fine to use. I provide teaching on “nightshades” and the reasons why these should be limited and provide a list of fruits, vegetables and spices are in this family. I teach about the effect of alcohol and sugar alcohols used as sugar-substitutes and their effect on inflammation, as well as different gums and thickeners that are commonly used in many food products and that can contribute to inflammation.

My purpose in offering this package is to help those diagnosed with arthritis (and other inflammatory conditions) to improve their quality of life.

As well, I understand what it’s like to live with osteoarthritis (which I was diagnosed with in my 20’s) and the need to reduce symptoms, through diet whenever possible.

More Info?

You can find out more about the Anti-Inflammatory Protocol Package that I offer by clicking here and if you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Barbour KE, Helmick CG, Boring MA, Brady TJ. Vital signs: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2013—2015. Morb Mortal Wkly Rep. 2017;66:246—253. DOI: http://dx.doi.org/10.15585/mmwr.mm6609e1External.
2. Hootman JM, Murphy LB, Helmick CG, Barbour KE. Arthritis as a potential barrier to physical activity among adults with obesity—United States, 2007 and 2009. Morb Mortal Wkly Rep. 2011;60(19):614—618. PubMed PMID: 21597454

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According to the scientific literature to date, there are three ways of putting type 2 diabetes into remission, but an article that was widely circulated on social media earlier this week implied that a ketogenic diet ‘cures’ type 2 diabetes.

The article was titled “What If They Cured Diabetes and No One Noticed?”[1] and said;

“So you’d think that if someone figured out a way to reverse this horrible disease, there would be big bold headlines in 72-point type. You’d think the medical community, politicians and popular press would be shouting it from the rooftops.

Guess what? Someone did. Yet it appears no one noticed.

The cure was simple — so simple, in fact, that it involved no medication, no expensive surgery and no weird alternative supplements or treatments.

What was this miracle intervention? Diet. Specifically, the ketogenic diet.”

The author is entitled to hold the above opinion and to express it, however in my opinion, a ketogenic diet does not “reverse diabetes” — it does not “cure” it. It is one of three scientifically documented ways to put the disease into remission. More on that below.

The distinction between “reversing diabetes” and “reversing the symptoms of diabetes” is very important, and more than a matter of semantics. In an article I posted last year titled The Difference Between Reversal and Remission of Type 2 Diabetes, I wrote that;

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

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

I believe that claiming that a keto diet ‘cures diabetes’ or ‘reverses the disease’ does the public a disservice:

• Firstly, it implies that there is simple, free ‘cure’ that will work for everybody.  As I outline below; some people are able to achieve partial or complete remission of their symptoms following a keto diet, and others are not.

• Secondly, it implies that there is a simple, free ‘cure’ available, but that it is being ‘withheld’ for some reason — either because doctors don’t know about or are afraid what colleagues might think, or because the agricultural and pharmaceutical industries have ‘big bucks to lose’ by people limiting their intake of bread, pasta and insulin.

There is no question that physicians (and all clinicians) need to be selective about recommending a keto diet for their patients / clients and to be able to document from the literature that it is safe, effective and best clinical practice for the condition for which it is recommended, and appropriate for the individual.

While falling markets for specific types of food products and drugs certainly have an impact on the economics of both the agricultural industry and pharmaceutic industry, it comes across like a ‘conspiracy theory’ to imply there is a ‘cure’ available out there, but that the public is being ‘denied’ access to it by “big food” and “big pharma”.

• Finally, it implies that if people are unable to ‘reverse their diabetes’ and get ‘cured’ following a keto diet, that it is their fault; they mustn’t have done it properly.  Even if we substitute the terms and say instead “put their diabetes into remission” or “reverse the symptoms of diabetes”, it is unreasonable and unfair to assume that everyone will be successful in doing so, and if they aren’t, the responsibility falls on them.

There is no “one-sized-fits-all-diet” that is good for everybody, nor is there a “better” dietary means to achieve remission of type 2 diabetes. As I will elaborate on below, there are 3 ways to put the symptoms of type 2 diabetes into remission, with two of them being dietary,  and some might prefer one over the other for a variety of reasons. The one that they want to adopt and ‘stick with’ will be the one that will work best for them.

Virta Health Data

The on-going study from the Virta Health has had over 200 adults ranging in age from 46-62 years of age in the intervention group following a ketogenic diet for the last two years, so far. At the one year mark, participants in the ketogenic diet group lowered their glycated hemoglobin (HbA1c) to 6.3% (from 7.7% at the beginning of the study) —  with 60% of them putting their type 2 diabetes into remission based on HbA1C levels >=6.5% (American Diabetes Association and Diabetes Canada guidelines).  HbA1C rose slightly to 6.7% at two years. The keto group did considerably better than the ‘usual care group’ whose average HbA1C actually rose to 7.6% at one-year (from 7.5% at the beginning of the study), and rose again to 7.9% at two years [3]. 

Fasting blood glucose of the intervention group following a keto diet increased slightly from  127 mg/dl (7.0 mmol/L) at one year to 134 mg/dl (7.4 mmol/l) at two years, which was considerably better than the usual care group, whose fasting blood glucose was 160 mg/dl (8.9 mmol/L) at one-year and 172 mg/dl (9.5 mmol/L) at two years [3].

The data so far demonstrates that a well-designed keto diet can be a very effective means of reversing the symptoms of type 2 diabetes, and that it is more effective than what was ‘standard care’ (prior to the new ADA guidelines), but it is by no means a ‘cure’.

Dr. Stephen Phinney and the research team at Virta Health have written on the Virta Health website [3];

“A well-formulated ketogenic diet can not only prevent and slow down progression of type-2 diabetes, it can actually resolve all the signs and symptoms in many patients, in effect reversing the disease as long as the carbohydrate restriction is maintained.” [2]

That is, the Virta researchers state that a well-designed keto diet can resolve the signs and symptoms of the disease in many people, which “in effect” (i.e. ‘is like’) reversing the disease —  as long as the carbohydrate restriction is maintained. They don’t promote the diet as a ‘cure’, but as an effective treatment, which it is.

There is no question that Virta’s results are impressive — so much so that their studies have been included in the reference list of the American Diabetes Association’s (ADA) new Consensus Report of April 18, 2019, where the ADA included adopted the use of both a low carb and very low carb (ketogenic) diet (20-50 g of carbs per day) as one of the management methods for both type 1 and type 2 diabetes in adults. You can read more about that here.

In fact, the ADA said in that report that;

”Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia*’

* blood sugar

…but a keto diet is not a ‘cure’ for type 2 diabetes.

At this present time, there is no cure for diabetes. There are, however three documented ways to put type 2 diabetes into remission;

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

Final Thoughts…

I believe that based on what has been published to date, it is fair to say that a well-designed ketogenic diet can;

• prevent progression to type 2 diabetes, when adopted early in pre-diabetes
• slow down progression of type 2 diabetes
• resolve the signs and symptoms of the type 2 diabetes
• serve in effect like reversing the disease, provided carbohydrate restriction is maintained

…but to claim that a keto diet ‘cures’ type 2 diabetes is simply incorrect.

A ketogenic diet is a safe and effective option for those wanting to put the symptoms of type 2 diabetes into remission. So is a calorie restricted diet. The primary difference is in a calorie restricted diet, calories are drastically reduced in order to lose weight and feeling hungry is simply a side-effect that people come to expect.  In a low carb or ketogenic diet, calories end up being substantially reduced as an inadvertent result of targeting protein and vegetables and adding sufficient healthy fat that comes along with that protein, or that are added to the vegetables to make them more interesting, while limiting carbohydrates.  One isn’t better than the other; it is what is better suited to each individual.

More Info?

If you would like more information on using diet to seek to put the symptoms of type 2 diabetes into remission or for weight loss, I’d be glad to help.

You can learn more about my services under the Services tab or in the Shop.

If you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Steel, P, “What If They Cured Diabetes and No One Noticed? – if the ketogenic diet can reverse diabetes, why isn’t your doctor recommending it?”, The Startup, July 13 2019, https://medium.com/swlh/what-if-they-cured-diabetes-and-no-one-noticed-keto-diet-ketogenic-virta-study-d49c195bf8f5
2. Phinney S and the Virta Team, Can a ketogenic diet reverse type 2 diabetes? https://blog.virtahealth.com/ketogenic-diet-reverse-type-2-diabetes/
3. Athinarayanan SJ, Adams RN, Hallberg SJ et al, Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 2-year Non-randomized Clinical Trial.  preprint first posted online Nov. 28, 2018;doi: http://dx.doi.org/10.1101/476275.
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

Constipation is one of the most common problems that people face, with between 2 and 28% of the population in Western countries reporting having this [1-3]. In 2007 in the United States, 19.4% of people reported problems with chronic constipation[4] and in Canada between 15% and 27% of people reported having sought health care support for chronic constipation in 2001 [5].

Defining Constipation

The term “constipation” means different things to different people. For some it simply means they don’t pass their stools (feces) often enough, and for others it means that when they do, their stools are hard, difficult to pass, may cause lower abdominal discomfort, or feel like they “still have to go” afterwards (incomplete evacuation).

What is considered a ‘normal range’ in the number of bowel movements per week varies considerably; from anywhere from 3 – 21 times per week, provided the stools are soft and easy to pass, but not loose or unformed.

For some people, having bowel movements 3 times per week may be normal, as long as their stools aren’t hard, dry or compact and there is no abdominal discomfort. For others, 3 times per day (21 times per week) may also be considered fine, provided the stools aren’t unusually loose. There are many factors that can contribute to chronic constipation; including some medications that people take, inadequate fiber or the wrong kind of fiber, insufficient hydration (not drinking enough water, especially when its hotter out, or exercising), high levels of estrogen and progesterone when a woman is pregnant, or disorders such as Irritable Bowel Syndrome (IBS) and diverticulosis.

The Causes of Chronic Constipation

People often think (or are told) that if they are constipated, they just need to eat more fiber, but in some cases increasing fiber from certain sources such as grains may make the problem worse. For example, some people are wheat sensitive, but not gluten-intolerant (i.e. not Celiac). That is, they are sensitive to wheat only, but not rye or barley (which also contain gluten).  Others have something called non-celiac gluten sensitivity which resolves when gluten is eliminated from the diet, yet don’t test positive for Celiac disease. These people feel better when they avoid grain-based carbs, and may opt instead for eating nutritiously-dense starchy vegetables, such as winter squash or yam, for instance. Since a low-carb diet is non-grain-based, people who experience chronic constipation due to wheat intolerance or non-celiac gluten sensitivity will start to feel considerably better eating this way.  The problem may be that for those with non-celiac gluten sensitivity, other sources of gluten, such as those found in malt vinegar or low carb beer may continue to cause them symptoms.

Many people who try a “low-carb” or “keto” diet on their own often complain of being constipated and this may be for a number of other reasons.  They may be taking a medication that causes constipation as a side-effect, they may not don’t drink enough water, or it may be the result of something else.

Inadequate Hydration

I would estimate that ~80% of the people that I assess in my office have observable signs that they are aren’t drinking enough water, so this is something I would recommend most people to consider as a possible contributor to chronic constipation.

The idea that everybody needs to drink “8 glass of water per day” is a fallacy; everyone’s need for water is different. A good rule of thumb to know if you are dehydrated is just to look in the mirror. If your lips are dry and wrinkled, then you probably should aim to increase your water intake. When your lips are plump and without deep lines, you’ve probably had sufficient amount. Water is best, as coffee and tea act as a mild diuretic. They won’t dehydrate you, but you will pass the water contained in them more rapidly.

If you don’t really like plain water, a Sodastream® that enables you to make carbonated water at home may be the answer. My clients know that there is always a bottle of it on my desk, as that is how I make sure to drink enough water. A twist of lime or lemon makes a nice treat too!

What about Getting Enough Fiber?

In Canada, dietary recommendations  for dietary fiber intake varies with age and gender. Men under the age of 50 years are recommended to take in 38 gm / day of dietary fiber, and men over 50 years to take in 30 gm / day. Women under 50 years old are recommended to take in 25 gm of fiber per day and over 50 years, 21 gm per day [6].

In the US, fiber intake recommendations from the Institute of Medicine range from 19 grams to 38 grams per day, depending on gender and age [7].

While people generally think of “healthy whole grains” as good sources of fiber, many are not. For example, medium grain brown rice only has 3.4 g of fiber per 100 g, whereas wild rice (which is actually a grass and not a grain) has 6.2 g of fiber per 100 g [8]. Many vegetables and fruit such as avocado and berries are excellent sources. More on that below.

Two Kinds of Fiber — soluble and insoluble

There are two kinds of fiber; insoluble and soluble.

Insoluble fiber is what most people think about when they think of ”roughage” needed to form stool and prevent constipation. It helps form the bulk of the stool. Insoluble fiber is naturally present in the outside of grains, such as whole grain wheat and the outside of oats and is also found in fruit, legumes (or pulses) such as dried beans, lentils, or peas, some vegetables, and in nuts and seeds. Many of these are eaten on a low carb diet and can provide the recommended amount of fiber (more on that below).

Soluble fiber forms a gel’ in the intestine and binds with fatty acids. It slows stomach emptying and helps to make people feel fuller for longer, as well as slow the rate that blood sugar rises, after eating. Soluble fiber absorbs water in the gut, and helps to form a pliable stool. Soluble fiber is found on the inside of certain grains, such as oats, chia seeds or psyillium, as well as the inside of certain kinds of fruit such as apple and pear.

For those eating a low carb diet, getting enough fiber is not that difficult. Here are a few examples of the fiber content of foods that can be eaten;

• Avocado — Surprisingly, avocado which is an excellent source of vegetable fat, is also high in fiber, having more than 10 gm fiber per cup (250 ml). Avocado grown in Florida which are the bright green, smooth-skinned variety have more insoluble fiber than California avocado, which are the smaller, darker green, dimpled variety.
• Berries — Berries such as blackberries and raspberries are an excellent source of antioxidants, but also have 8 gm fiber per cup (250 ml).
• Coconut — Fresh coconut meat has 6 gm of net carbs per 100 grams of coconut, but also packs a whopping 9 gms of fiber and is a very rich source of fat (33 gms per 100 gm coconut). It can be purchased peeled, grated and sold frozen in many ethnic stores or in the ethnic section of regular grocery stores.
• Artichoke — Artichoke is a low-carbohydrate vegetable that is delicious boiled and it’s leaves dipped in seasoned butter. Surprisingly, one medium artichoke has over 10 gm of fiber.
• Okra — Okra, or lady fingers’ is a staple vegetable in the South Asian diet and is commonly eaten in the Southern US. Just one cup of okra contains more than 8 gm of fiber.
• Brussels Sprouts — These low-carb cruciferous vegetables are not just for Thanksgiving and Christmas dinner.  Split and grilled on the BBQ with garlic, they are a sweet, nutty addition to any meal, packing almost 8 gm of fiber per cup.
• Turnip — Turnip, the small white vegetable with a hint of purple is not to be confused with the pale beige, larger rutabaga. Turnip contains almost 10 gm of fiber per cup. It is delicious pickled with salt and one beet and is commonly eaten with Middle Eastern food.

Irritable Bowel Syndrome (IBS) and Diverticulosis

Unfortunately, in addition to the fact that 20-30% of people in the US and Canada experience chronic constipation, approximately 10-15% of the population have Irritable Bowel Syndrome (IBS) [9].

IBS is a functional disorder of the gastrointestinal (GI) tract  â — which means there is no structural or biological abnormality that can be measured on routine diagnostic tests. These people often experience chronic constipation, sometimes alternating with bouts of diarrhea, as often experience abdominal pain and bloating, as well. You can read more about IBS here. As mentioned in the linked article, many people with IBS feel considerably better when they adopt a low-carb diet because they are no longer eating many of the foods that underlie their symptoms such as grains, milk and fruit, other than berries. Unfortunately, even after adopting a low carb diet about 15- 20% of those diagnosed with IBS still have residual symptoms. I have years of experiencing working with those with IBS and offer a package as well as a one-hour teaching session that can help.

Another common problem is diverticulosis, which an estimated 50% of those over 50 years of age have. Diverticulosis is where your colon (large intestine) has small ”pockets” in it called diverticula, which can cause a number of symptoms including chronic constipation. Like those with IBS, many people with diverticulosis feel much better when they adopt a low-carb diet because they are no longer eating foods such as wheat, dairy products with lactose or high fructose fruit that used to contribute to their symptoms. The problem is that many of the low carb vegetables that are low in carbs and may be rich in fiber also may be contributing to their symptoms. So many of my clients have recently been diagnosed with diverticulosis, that I have recently added a one-hour teaching session that can be added to the end of a Complete Assessment Package, or taken as a stand-alone session to help.

Final Thoughts

In trouble-shooting constipation, I recommend that people ensure they are adequately hydrated, and that they remember to drink extra water when it’s hot out or when they’ve been ill.

Eating wide variety of low-carb veggies, including those listed above that are known to be high in fiber is also good. For those on a moderate low-carb diet (not a ketogenic diet), small amounts of yam or winter squash are other ways to get added nutrients and fiber.

Berries are a wonderful source of nutrients and anti-oxidants, can be enjoyed by those on a low-carb diet and are a wonderful source of fiber! Strawberries have 3g of fiber per cup and blackberries and raspberries have a whopping 8 g of fiber per cup, with blueberries paling in comparison with a mere 2.4 g of fiber (and are higher in carbs, too).

Of course, exercise as simple as a daily walk can often help people move their bowels and many people swear by their morning cup of coffee!

For those doing all of the things above and still experiencing chronic constipation, it may be time to rule out other possible causes such as Celiac disease, or non-celiac gluten sensitivity, IBS, or diverticulosis.

I can help.

More Info?

If you would like more information about how I can help in this regard, you can find the various services I offer related to Food Sensitivities / Food Allergies, Celiac Disease, IBS and Diverticulosis under the Services tab, and in the Shop.

If you have questions please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

1. Higgins PDR, Johanson JF, Epidemiology of constipation in North America: a systematic review, The American Journal of Gastroenterology 99(4); 750—759, 2004.
2. Corazziari E, Definition and epidemiology of functional gastrointestinal disorders, Best Practice and Research: Clinical Gastroenterology, 18 (4); 613—631, 2004. 
3. Harris LA, Prevalence and ramifications of chronic constipation, Managed Care Interface, 18 (8); 23—30, 2005.
4. Johanson JF,  Kralstein J, Chronic constipation: a survey of the patient perspective, Alimentary Pharmacology and Therapeutics, 25(5); 599—608, 2007. 
5. Pare P, Ferrazzi S, Thompson WG et al, An epidemiological survey of constipation in Canada: definitions, rates, demographics, and predictors of health care seeking, The American Journal of Gastroenterology, 96(11); 3130—3137, 2001.
6. Health Canada, Fiber, https://www.canada.ca/en/health-canada/ services/ nutrients/fibre.html
7. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Energy, Carbohydrates, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington, DC: National Academies Press; 2005
8. Source: US Department of Agriculture, Agricultural Research Service. 2014. USDA National Nutrient Database for Standard Reference, Release 27. Nutrient Data Laboratory Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl.
9. Foundation for Gastrointestinal Disorders (IFFGD),  https://www.aboutibs.org/facts-about-ibs/statistics.html

 

Quite a few physicians that I know that recommend a low-carb diet to their patients have mentioned to me that those who had previously been diagnosed with Irritable Bowel Syndrome (IBS) and who suffered for years reported significant improvements within a short time of adopting the dietary changes and have asked me why. That is the topic of this article.

Prior to expanding my Dietetic practice to include this low carb division a little over 4 years ago, my main focus was on helping people who were dealing with food allergies and food sensitivities; including Celiac disease, Mast Cell activation disorder (MCAD) / histamine intolerance, fructose intolerance and Irritable Bowel Syndrome  For many of my clients, it was the gastrointestinal (GI) symptoms that caused them to seek out my help in the first place.

What is IBS?

I have often thought of Irritable Bowel Syndrome (IBS) as the diagnosis that people receive when all the other possible options have been ruled out. For the most part, by the time people are told that they have IBS, they already know for sure that they don’t have Celiac disease or inflammatory Bowel Disease (IBD) such as Ulcerative Colitis or Crohn’s, and they don’t have diverticulosis ⁠—as each of those diagnoses are confirmed after a colonoscopy and/or a biopsy, and are often supported with underlying blood test results.

What makes IBS different is that it is a functional GI disorder ⁠— which means there is no structural or biological abnormality that can be measured on routine diagnostic tests.

Of course a person experiencing  a bout of diarrhea or constipation, or abdominal pain does not mean that person has a GI disorder or disease. Those symptoms could be the result of a virus, bacteria, food-borne illness (“food poisoning”) or food sensitivities. Once these have been ruled out, if the symptoms recur over and over again over time, then investigation as to what else it could be is often begun.

How is IBS Diagnosed?

While many of the symptoms of IBS and Celiac disease can be quite similar, including diarrhea and abdominal pain and bloating, there are very specific indicators that a person may have Celiac disease that clinicians such as myself notice as evidence to request further testing. The first stage in ruling out Celiac disease is an ordinary blood test looking for an antibody to gluten. If that comes back positive, then the person is referred to a Gastroenterologist for an endoscopy. If the blood test is negative, the next step may be for the person to be scheduled for a colonoscopy.

A colonoscopy which is where the inside of the large intestine (colon) is examined using a flexible probe about 1/2″ in diameter that’s fitted with a light and telescopic camera at one end and endoscopy is where a fine, flexible probe fitted with a light and telescopic camera is inserted via the mouth to view the esophagus, stomach and the upper part of the small intestine.

Celiac disease will be ruled out or confirmed using endoscopy, as the upper small intestine is where the damage to the villi (little hair-like projections on the wall that increase the surface area in order to help absorb nutrients from food) will be visible, or not.

A colonoscopy enables the Gastroenterologist to see what the lining of walls of the colon look like and to look for physiological signs of diverticulosis (little bulges or “pouches” in the colon) or signs of inflammation and damage consistent with Inflammatory Bowel Disease (IBD), such as Ulcerative Colitis or Crohn’s and to rule out colon cancer.

If the endoscopy and colonscopy come back normal, the person is often told that their symptoms of diarrhea or constipation (or both alternating), flatulence (“gas”), bloating, abdominal pain or cramping, mucous in the stool is Irritable Bowel Syndrome (IBS).

Prevalence of IBS

According to the International Foundation for Gastrointestinal Disorders (IFFGD), approximately 10-15% of the population have IBS; with 40% having a mild form, 35% having a moderate form, and 25% having severe IBS. While many people think of IBS as being a woman’s health issue, 35% to 40%  of people with IBS are men and 60-65% are women [1].

IBS is so common, that it is estimated that 12% of all visits to primary care providers (family doctors) is related to symptoms of IBS [1].

Physicians will sometimes suggest their patients try following a “low-FODMAP diet” but since IBS is so common, there are many different diets called by this name that differ significantly. Even if the doctor provides guidance as to which low-FODMAP diet they should follow, people often eliminate a whole host of foods and wind up eating a very limited diet, with no way of knowing which food they stopped eating actually helped.

Why Eating a Low-Carbohydrate Diet often Improves IBS Symptoms?

A low-FODMAP diet eliminates sources of very specific carbohydrates that are fermented by the gut bacteria and that result in the increased gas production that underlies the classic IBS symptoms of abdominal pain and bloating, and the water flooding into the intestine in response to these fermented carbohydrate is what causes the very common symptom of diarrhea. The constipation results when the contractions of the colon are impaired, resulting in the stool sitting longer in the colon resulting in more and more of the water being re-absorbed.

When people eat a low-carb diet, they either eliminate or greatly reduce sources of fructose (the sugar found in fruit and many processed foods, especially processed condiments like ketchup) and significantly reduce one of the key sources of fructans (inulin) found in wheat; which is a highly fermentable carbohydrate. Galactans, another fermentable carbohydrate found in beans, lentils and legumes such as soy is also eliminated or greatly reduced — which is why people with IBS feel so much better after beginning eating a low-carb diet!

Before I taught a low-carbohydrate approach, I used to have people take the IBS Package before the Complete Assessment Package, so we could find out what foods underlie their unpleasant symptoms and eliminate them before I designed their Meal Plan. Now, if they are planning to adopt a lower carb lifestyle anyway, then I recommend they don’t take the IBS Package, as it may not be necessary.  I recommend focus on them adopting a diet that greatly reduces the sources of the fermentable carbohydrates mentioned above, plus a few more that I tell them about and see how they feel. If their symptoms are gone, then there is no reason for them to take the IBS Package!  If however, they are feeling quite a bit better, but still have residual symptoms, then I suggest they take the IBS Package so that we can systematically determine what other non-FODMAP foods are contributing to them feeling unwell.

More Info?

If you would like more information about the IBS Package, you can find that under Services tab of my affiliate website, BetterByDesign Nutrition Ltd. and if you’re interested in the low-FODMAP teaching, you can find that in the Shop on that site.

Of course, if you have questions please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

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

References

Foundation for Gastrointestinal Disorders (IFFGD),  https://www.aboutibs.org/facts-about-ibs/statistics.html