There has been some discussion on Twitter that the macronutrient estimated in the previous article of an average ~325-350 g of carbohydrate per day based on a 2000 kcal per day diet for the new Canada Food Guide was “too high”, so in the interest of determining whether it was accurate, I’ve evaluated the carbohydrate content of the illustrated plate.

Actual Number, Standard Cup Measure and Scale of Reference

Since no portion sizes are provided with the new guide, both scale of reference or when available, the actual number of items was used.

The actual number of chickpeas, kidney beans, nuts and seeds were used and determine in terms of the portions of a standard cup measure.

For items such as vegetables and fruit, actual portions were measured using a standard set of stainless steel measuring cups.

For any remaining quantities, since a quarter of an egg is featured on the illustration of a healthy plate and a large sized egg is the standard on which nutrient analysis is based and this is of a known size, I used the 1/4 of a large egg as the scale of reference for other items,when the actual number was not available.

Carbohydrate Content of the Protein Group

The protein group contributed~37 g of carbohydrate to the sample plate.

Carbohydrate Content of the Whole Grains Group

The whole grains group contributed more than~58 g of carbohydrate to the sample plate.

Carbohydrate Content of the Vegetable and Fruit Group

The vegetable and fruit group contributed more than~53 g of carbohydrate to the sample plate.

The sample plate used as an illustration for the new Canada Food Guide has close to 150 g of carbohydrate on it— and this is for only one meal. The carbohydrate content of lunch and dinner (the two generally mixed meals of the day) already totals as much as 300 g of carbohydrate — and there’s still breakfast to add! Whether it’s a couple of whole grain toast (30 g carbs), 2 tbsp unsweetened nut butter (6 g carbs) or some whole grain cereal (30 g carbs) and 1/2 cup of low fat unsweetened yogurt (6 gm carbs), there’s another 42 g of carbs (plus the carbs for the milk or nut or soy milk to pour on the cereal); bringing the average for the three meals alone to 337+ g of carbs which is exactly what it was estimated as in the previous article — as between 325 – 350 g carbohydrate per day.

And this is just for 3  MEALS.

What about snacks?

Yes, snacks are mentioned TWICE on the first page under the link for “eating habits” in the section on “how to make a meal plan and stick to it”;

Assuming a person eats a “healthy whole grain” muffin without any dried fruit in it for coffee break in the morning (~50 g of carbs) and a single piece of fruit like an apple or orange mid-afternoon (15 g of carbs), these add another 65 g of carbohydrate to this day, bringing the average total to over 400 g of carbohydrate for one day.

UPDATE (January 26, 2019) Given the sample plate is there to demonstrate proportions, not portions — looking at the grain group alone, the proportion of grain is 1/4 of the dietary intake. Based on a 2000 kcal/day diet, that’s 500 calories per day / ~125 g of carbohydrate from the grain group alone. Add in the carbohydrate from the largely plant-based protein group, that’s another ~100 g carbohydrate per day, on average. Since half the plate should be vegetables and fruit and both starchy vegetables such as squash, yam, potato, peas and corn contain 15 g of carbohydrate per half cup, as does the same amount as fruit, it is reasonable to assume that on average, half of the vegetable servings will be comprised of a mixture of starchy vegetables — along with the fruit servings and the other quarter of the plate of non-starchy vegetables. That is, 1/4 of the vegetable and fruit side of the plate will be carbohydrate-containing, adding another ~125 g of carbohydrate per day to the diet. Of course, there will be days where people will eat lower carbohydrate grains like quinoa and lower carbohydrate plant-based protein such as tofu, but equally there will be days where vegetable servings are starchy ones such as peas and corn along with plant-based proteins that are higher in carbohydrate, such as legumes like kidney beans. So, the numbers above are averages.  Whether one uses the portions on sample plate as a basis for estimating the carbohydrate content or uses the proportion of the diet that is carbohydrate, the results fall in the same range of an average of 325 – 350 g carbohydrate per day, based on only 3 meals (without snacks).

Real Life Meals

Despite there being no “portion sizes” in the new Canada Food Guide, some insist that a “serving of pasta is 1/2 cup” because that is what is illustrated on the sample plate. Okay, let’s go with that for the sake of argument.

I’ve been in private practice a long time and in my experience only children and women who are portion restricting eat pasta in amount the size of a tennis ball.  More than 90% of my clients report eating servings of pasta that are significantly larger than that. In fact, the usual ‘smaller-sized’ servings are about a cup and a half when eaten along with salad or a cooked vegetable (bigger if eaten alone). What does a cup and a half of pasta look like? It looks like this;

1 1/2 cups of whole grain pasta…and this amount of pasta without sauce has 45 g of carbohydrate in it — which is still less than the 53 g of carbs illustrated in the Canada Food Guide sample plate. Naturally, no one is expected to eat exactly like the “sample meal”, but whether one eats their “whole grains” as all brown rice, wild rice, Bulgar wheat or something else, 1/4 of the plate all have the same amount of carbohydrate per 1/2 cup serving as pasta.

Add to the pasta the vegetables and fruits above on the sample plate (or corresponding assortment of a mix of starchy, non-starchy vegetables and fruit) and that adds up to 100 g of carbohydrate …and we still haven’t added any protein into the meal, yet.

Add another 37 g of carbohydrate for an assortment of legumes, nuts and seeds as well as a bit of meat and “low fat” cheese for the pasta sauce (because after all, we are encouraged to eat animal protein “less often”) and that totals more than 135 g of carbs for just this one “real life” meal. Eat a meal like the one in the sample illustrations, it adds up to 150 g of carbs!

The question I’ve been asked is if it is “healthy whole grain”, then what’s the concern?

For metabolically healthy adults, none. For metabolically healthy adults, the new Canada Food Guide is a huge improvement from it’s predecessor! It eliminates refined carbs, sugary drinks including fruit juice and encourages eating whole foods, cooked at home as much as possible.

The problem is, most adults are not metabolically healthy.

Majority of Adults Metabolically Unhealthy

As mentioned in the previous article research indicates that as many as 88% of Americans[1] are already metabolically unwell, with presumably a large percentage of Canadians as well. That is, only 12% of the adult population would be considered metabolically healthy [1]”.

Metabolic Health is defined as [1];

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

Given the slightly lower rates of obesity in Canada (1 in 4) as in the United States (1 in 3), presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy. For the sake of argument, let’s assume that there are TWICE as many metabolically healthy adults in Canada, which would mean that only slightly over 75% of adults are metabolically unhealthy.  Since Canada’s Food Guide is intended for a healthy population in order to reduce the risk of overweight and obesity as well as chronic diseases manifest as the markers above, that means that the new Canada Food Guide — as beautiful as it is, is only appropriate for ~1/4 of the adult population.

For the other 75% of adults that are presumably metabolically unwell, a diet that provides 342 g of carbohydrate per day for meals alone (based on a 2000 kcal per day diet) and as much as 400 g of carbohydrate per day with 2 “healthy” snacks is not going to address the large percentage of adults who are already demonstrating symptoms of being carbohydrate intolerant.

Carbohydrate Intolerance

As outlined in detail in a previous article, based on a large-scale 2016 study that looked at the blood glucose response and circulating insulin responses from 7800 adults during a 5-hour Oral Glucose Tolerance Test, 53% had normal glucose tolerance at 2 hours but of these people, 75% had  abnormal blood sugar results between 30 minutes and 60 minutes  demonstrating that they were already hyperinsulinemic, although it went undetected on standard assessors that only look at glucose and insulin responses at baseline (fasting) and at 2 hours.

These people are already exhibiting symptoms of not tolerating a normal carbohydrate load of 100 g.

How does it make sense to encourage adults that already have abnormal glucose response to eat 150 g of carbohydrate per meal when these people already have an impaired first-phase insulin response? How will eating “whole grains” and the “added fiber from plant-based proteins” improve their first-phase insulin response (which likely results from dysfunction in the release of the incretin hormone GIP (Glucose-dependent Insulinotropic Polypeptide) from the K-cells?

For these people, continuing to eat a diet high in carbohydrate, irrespective of the amount of fiber or the glycemic load will not restore their insulin response, and in time is likely to make it worse. This is my concern.

Canada Food Guide is for a healthy population to avoid the risk of chronic disease and based on these statistics most adults are not metabolically healthy.

Final Thoughts…

For the ~1/4 of adults that are metabolically healthy, I think the new Canada Food Guide is beautiful and focuses on real, whole food, preparing food at home, avoiding refined grains and avoiding high sugar beverages such as fruit juice (formerly seen as “healthy”).  For the high percentage of adults that are already metabolically unwell and who already demonstrate abnormal glucose responses, I don’t see that advising them to eat a diet that is between 325-350 g of carbohydrate per day (meals without snacks) helps them to avoid the progression to Type 2 Diabetes.

If you are part of the majority of Canadians that are already struggling with overweight and/or being metabolically unwell and would like to know more about how I may be able to help you achieve a healthy body weight and restore metabolic markers then please send me a note using the Contact Me form, on the tab above.

To your good health!

Joy

You can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/BetterByDesignNutrition/

 https://plus.google.com/+JoyYKiddieMScRD

References

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

This morning at 10 AM EST, the new Canada Food Guide was officially released in Montreal.

The suite of Food Guide resources includes:

• Canada’s Dietary Guidelines for Health Professionals and Policy Makers
• Food Guide Snapshot
• Resources such as actionable advice, videos and recipes
• Evidence including the Evidence Review for Dietary Guidance 2015 and the Food, Nutrients and Health: Interim Evidence Update 2018

Canada Food Guide – directed towards healthy Canadians

According to Eating Well with Canada’s Food Guide – A Resource for Educators and Communicators the goal of Canada’s Food Guide is to ‘define and promote healthy eating for Canadians’ and to ‘translate the science of nutrition and health into a healthy eating pattern’. By definition, Canada’s Food Guide is directed towards a healthy Canadian population so they can meet their nutrient needs and reduce their risk of obesity and chronic diseases.

“By following Canada’s Food Guide, Canadians will be able to meet their nutrient needs and reduce their risk of obesity and chronic diseases such as type 2 diabetes, heart disease, certain types of cancer and osteoporosis.”

The New Canada Food Guide – no more rainbow

The familiar “rainbow” has been replaced with clear, simple photography illustrating food choices. In response to feedback from focus groups that the draft of the Guide focused too much on “how to eat” but didn’t provide adequate direction on “what to eat”, the final version clearly illustrates the proportion of vegetables and fruit, grains and protein foods to eat on a plate.

“Protein Foods”

As anticipated in the draft, the new Canada Food Guide dropped the Meat and Milk groups replacing it with an all-inclusive “Protein Foods” group which includes approximately equal amounts of animal-based and plant-based proteins.

Animal-based proteins included beef, poultry, fish, egg and yogurt. Noticeably absent from the animal-based proteins was cheese.

Plant-based proteins included legumes and pulses (beans and lentils), nuts and seeds and tofu.

Whole Grains

The Whole Grain group is visually exemplified by whole grain bread, pasta, rice, wild rice and quinoa and the link that relates to “whole grain foods” contains the following information;

Vegetables and Fruit

The new Guide illustrated that 1/2 the plate should be comprised of vegetables and fruit and the plate showed mostly non-starchy vegetables as broccoli, carrot, shredded peppers, cabbage, spinach and tomato, with a small amount of starchy vegetables as potato, yam and peas.

Fruit as blueberries, strawberry and apple was illustrated as a small proportion of the overall Vegetable and Fruit group.

Beverage of Choice – water

The place setting showed a glass of water with the words “make water your drink of choice”; which indicates that fruit juice and pop (soft drinks) are not included as part of a recommended diet.

It is good that water is promoted as the beverage of choice, but why does the Guide doesn’t also illustrate a small glass of milk? The absence of milk in the new Guide seems odd.

Note: with both cheese and milk being limited in this new food guide, adequate calcium intake may be of concern; especially since vegetables that are high in calcium will have that calcium made unavailable to the body due to the high amounts of phytates, oxylates and lectins that are contained in the grains, nuts and seeds that are also in the diet.

Healthy Food Choices

The link for “healthy food choices” indicates;

• Make it a habit to eat a variety of healthy foods each day.
• Eat plenty of vegetables and fruits, whole grain foods and protein foods. Choose protein foods that come from plants more often.
• Choose foods with healthy fats instead of saturated fat*
  Limit highly processed foods. If you choose these foods, eat them less often and in small amounts.
• Prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat*
• Choose healthier menu options when eating out
• Make water your drink of choice
• Replace sugary drinks with water
• Use food labels
• Be aware that food marketing can influence your choices

* the limited of saturated fat is addressed below,

Eating Habits

The link for “healthy eating habits” indicates;

• Healthy eating is more than the foods you eat. It is also about where, when, why and how you eat
• Be mindful of your eating habits
• Take time to eat
• Notice when you are hungry and when you are full
• Cook more often
• Plan what you eat
• Involve others in planning and preparing meals
• Enjoy your food
• Culture and food tradition can be a part of healthy eating
• Eat meal with others

Additional links on the web page include, Recipes, Tips and Resources.

First Impressions of the New Canada Food Guide

Overall, I think the new Canada Food Guide is visually clear, well illustrated and in terms of a communication tool is a huge improvement over its predecessor. It promotes a whole food diet with minimum processing, advises people to limit refined carbohydrates and sugary beverages as well as encourages people to cook their own food. It is neat, clean and appealing to look at and use.

I have two main concerns with respect to the Guide;

(1) the percentage of carbohydrate in the diet given the number of adult Canadians who are already metabolically unwell
(2) the focus on avoiding saturated fat

Percentage of Carbohydrate in the Diet

At first glance, it would appear that the overall macronutrient distribution of the new Guide is ~10-15% of calories as protein, 15-20% as fat, leaving the remaining 65-75% of calories as carbohydrate (based on estimates by Dr. Dave Harper, visiting scientist at BC Cancer Research Institute, social media post). While no portions are set out in this new Guide, based on the carbohydrate (and protein) content of the legumes and pulses (beans, lentils) and nuts and seeds contained in the Protein food group, as well as their proportion of the food group, and the fact that they are encouraged to be eaten ‘more often’ than meat, the protein estimate seems accurate. As well, the carbohydrate content seems accurate based on the proportion of the Whole Grain group and carbohydrate-containing other foods relative to the proportion of other foods.

While this diet may be fine for those who are metabolically healthy, research indicates that as many as 88% of Americans [1] are already metabolically unwell, with presumably a large percentage of Canadians as well. That is, only 12% have metabolic health defined as have levels of metabolic markers “consistent with a high level of health and low risk of impending cardiometabolic disease“.

Metabolic Health is defined as [1];

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 looking at only 3 of the above 7 factors (waist circumference, blood glucose levels and blood pressure) more than 50% in this study were considered metabolically unhealthy [1]. Given the slightly lower rates of obesity in Canada (1 in 4) as in the United States (1 in 3), presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy, but the similarity of our diets may make that difference insignificant.

This would indicate that for a large percentage of Canadians that are  metabolically unwell, a diet that provides provides 325-375 g of carbohydrate per day (based on a 2000 kcal per day diet) is not going to adequately address the underlying cause. While there is evidence that a high complex carbohydrate diet with very low fat and moderately-low protein intake (called a “whole food plant based” / WFPB diet) will improve weight and some markers of metabolic health, there is also evidence that a WFPB diet doesn’t work as well at improvements in body weight and metabolic markers as a low carbohydrate higher protein and fat (LCHF) diet. This will be addressed in a future article.

The purpose Canada’s Food Guide is to provide guidance for healthy Canadians so in actuality, this diet may only be appropriate for ~15% of adults.

Saturated Fat

The indication to “choose foods with healthy fats instead of saturated fat” and to “prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat” sends the message that saturated fat is unhealthy. 

It is well-known that saturated fat raises LDL-cholesterol however it must be specified which type of LDL-cholesterol increases. There are small, dense LDL cholesterol which easily penetrates the artery wall and which are associated with heart disease [2,3,4,5] and large, fluffy LDL cholesterol      which are not [6,7].

The long-standing and apparently ongoing recommendation to limit saturated fat is based on it resulting in an increase in overall LDL-cholesterol and not on evidence that increased saturated fat in the diet results in heart disease.

What do recent studies show?

Eight recent meta-analysis and systemic reviews which reviewed evidence from randomized control trials (RCT) that had been conducted between 2009-2017 did not find an association between saturated fat intake and the risk of heart disease [8-15] and the results of the largest and most global epidemiological study published in December 2017 in The Lancet [16] found that those who ate the largest amount of saturated fats had significantly reduced rates of mortality and that low consumption (6-7% of calories) of saturated fat was associated with increased risk of stroke.

UPDATE: There are 44 randomized controlled trials (RCTs) of drug or dietary interventions to lower total LDL-cholesterol that showed no benefit on death rates. (Reference:  DuBroff R. Cholesterol paradox: a correlate does not a surrogate make. Evid Based Med 2017;22(1):15—9.

Canadians are being encouraged to limit foods that are sources of saturated fat. In fact, cheese and milk aren’t even illustrated as foods to regularly include.

Where is the evidence that eating foods with saturated fat is dangerous to health — not simply that it raises overall LDL-cholesterol? I believe that for Canadians to be advised to limit cheese and milk which are excellent sources of protein and dietary calcium and to limit other foods high in saturated fat necessitates more than proxy measurements of higher total LDL-cholesterol.

Dr. Zoe Harcombe a UK based nutrition with a PhD in public health nutrition wrote an article this time last year about saturated fat [17] which is helpful to refer to here.

People have the idea that meat has saturated fat and foods like nuts and olives have unsaturated fats, but Dr. Harcombe points out that;

“All foods that contain fat contain all three fats — saturated, monounsaturated and polyunsaturated — there are no exceptions.”

This article explains may explain why cheese was not included as part of the visual representation of animal-based Protein Foods in the new Guide and why milk was not visually represented because “the only food group that contains more saturated than unsaturated fat is dairy“.

A link off the main page of the new Canada Food Guide explains how to “limit the amount of foods containing saturated fat” such as;

Limit foods that contain saturated fat

Limit the amount of foods containing saturated fat, such as:

cream

higher fat meats
.
.
.
cheeses and foods containing a lot of cheese“

Are Canadians being encouraged to avoid dairy products because they are high in saturated fat? Where is the evidence that saturated fat causes heart disease?

There is proxy data that saturated fat raises total LDL-cholesterol, but not that saturated fat causes heart disease.  In fact, a review of the recently literature finds that it does not (see above).

If saturated fat actually puts one’s health at risk, then Canadians should be warned that olive oil has 7 times the amount of saturated fat as the sirloin steak illustrated below and the mackerel has 1- 1/2 times the saturated fat as the sirloin steak [16] yet the new Guide recommends that Canadian’s choose foods with “healthy fats” such as fatty fish including mackerel and to use “healthy fats” such as olive oil.

Final thoughts…

In generations past, Canada food Guide helped Canadians make food choices in order to achieve adequate nutrition for themselves and their families, especially in the early years after WWII.  With current rates of overweight, obesity, Type 2 Diabetes and other forms of metabolic dysregulation, I wonder how few this beautiful new Guide is appropriate for.

If you would like to learn more about how I can help you or a family member achieve and maintain a healthy body weight and to achieve metabolic health, please send me a note using the Contact Me form located on the tab above.

To our good health!

Joy

In the following post, I validate the average amount of carbohydrate in this new Canada Food Guide.

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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

1. 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
2. Tribble DL, Holl LG, Wood PD, et al. Variations in oxidative susceptibility among six low density lipoprotein subfractions of differing density and particle size. Atherosclerosis 1992;93:189—99
3. Gardner CD, Fortmann SP, Krauss RM, Association of Small Low-Density Lipoprotein Particles With the Incidence of Coronary Artery Disease in Men and Women, JAMA. 1996;276(11):875-881
4. Lamarche B, Tchernof A, Moorjani S, et al, Small, Dense Low-Density Lipoprotein Particles as a Predictor of the Risk of Ischemic Heart Disease in Men, Circulation. 1997;95:69-75
5. Packard C, Caslake M, Shepherd J. The role of small, dense low density lipoprotein (LDL): a new look, Int J of Cardiology,  Volume 74, Supplement 1, 30 June 2000, Pages S17-S22
6. Genest JJ, Blijlevens E, McNamara JR, Low density lipoprotein particle size and coronary artery disease, Arteriosclerosis, Thrombosis, and Vascular Biology. 1992;12:187-195
7. Siri-Tarino PW, Sun Q, Hu FB, Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease, The American Journal of Clinical Nutrition, Volume 91, Issue 3, 1 March 2010, Pages 502—509
8. Skeaff CM, PhD, Professor, Dept. of Human Nutrition, the University of Otago, Miller J. Dietary Fat and Coronary Heart Disease: Summary of Evidence From Prospective Cohort and Randomised Controlled Trials, Annals of Nutrition and Metabolism, 2009;55(1-3):173-201
9. Hooper L, Summerbell CD, Thompson R, Reduced or modified dietary fat for preventing cardiovascular disease, 2012 Cochrane Database Syst Rev. 2012 May 16;(5)
10. Chowdhury R, Warnakula S, Kunutsor S et al, Association of Dietary, Circulating, and Supplement Fatty Acids with Coronary Risk: A Systematic Review and Meta-analysis, Ann Intern Med. 2014 Mar 18;160(6):398-406
11. Schwingshackl L, Hoffmann G Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and meta-regression BMJ Open 2014;4
12. Hooper L, Martin N, Abdelhamid A et al, Reduction in saturated fat intake for cardiovascular disease, Cochrane Database Syst Rev. 2015 Jun 10;(6)
13. Harcombe Z, Baker JS, Davies B, Evidence from prospective cohort studies does not support current dietary fat guidelines: a systematic review and meta-analysis, Br J Sports Med. 2017 Dec;51(24):1743-1749
14. Ramsden CE, Zamora D, Majchrzak-Hong S, et al, Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73), BMJ 2016; 353
15. Hamley S, The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials, Nutrition Journal 2017 16:30
16. Dehghan M, Mente A, Zhang X et al, The PURE Study — Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062
17. Harcombe  Z, Saturated Fat,  http://www.zoeharcombe.com/2018/01/saturated-fat/

We’ve come to expect that as people age they will gain more fat, loose bone mass and have decreased muscle strength which in time leads to difficulty in them getting around on their own, a greater risk of falls and eventually to physical disability. We commonly see older people with spindly little legs and bony arms and we think of this as normal’. It is common in the United States and Canada, but this is not ‘normal’.

Sarcopenia is the visible loss of muscle mass and strength that has become associated with aging here, but what we see as ‘common’ here in North America is not ‘normal’ in other parts of the world where seniors in many parts of Asia and Africa are often active well into their older years and don’t have the spindly legs and bony arms of those here.

 

Here in North America, we celebrate ‘active’ seniors by posting photos of them in the media sitting in chairs and lifting light weights — when people their age in other parts of the world continue to raise crops, tend their grandchildren and cook meals for their extended family, even gathering fuel and water to do so.

The physical deterioration that we associate with aging here doesn’t  develop suddenly, but takes place over an extended period of time and is brought on by poor dietary and lifestyle practices in early middle age —  including less than optimal protein intake and insufficient weight bearing activity from being inactive.

Protein Requirement in Older Adults

The Recommended Dietary Allowance (RDA) for protein is set at 0.8 g protein/kg per day is not the ideal amount that people should take in, but the minimum quantity of protein that needs to be eaten each day to prevent deficiency. Protein researchers propose that while sufficient to prevent deficiency, this amount is insufficient to promote optimal health as people age[1].

There have been several position statements issued by those that work with an aging population indicating that protein intake between 1.0 and 1.5 g protein / kg per day may provide optimal health benefits during aging [2,3]. For an normal-sized older woman of my size, that requires ~65-95 g of high quality bioavailable protein per day and for a lean older man of ~185 lbs (85 kg) that would require between 85 – 125 g of high quality bio-available protein per day

High bioavailability proteins are optimal to preserve the lean muscle tissue and function in aging adults and animal-based proteins such as meat and poultry are not biologically equivalent to plant-based proteins such as beans and lentils in terms of the essential amino acids they provide.

Animal-based protein have high bioavailability and are unequaled by any plant-based proteins. Bioavailability has to do with how much of the nutrients in a given food are available for usage by the human body and in the case of protein, bioavailability  has to do with the type and relative amounts of amino acids present in a protein. Animal proteins (1) contain all of the essential amino acids in sufficient quantities.

Anti-nutrients such as phytates, oxylates and lectins are present in plant-based protein sources and interfere with the bioavailability of various micronutrients.

The recommendations above for older adults to eat 1.0 — 1.5 g protein / kg per day distributed evening over three meals would be on average ~30-40g of animal-based protein at each meal to provide for optimal muscle protein synthesis to prevent sarcopenia as people age.  In an aging population, this maintenance of muscle mass as people age is critical to consider.

The Eat-Lancet Diet

Dr. Zoe Harcombe, a UK based nutrition with a PhD in public health nutrition analyzed the “Healthy Reference Diet” from Table 1 of the Eat-Lancet report using the USDA (United States Department of Agriculture) all-food database and found that in terms of macronutrients, it had only 90g  Protein per day (14% of daily calories) which is below the 100g – 120 g per day that is consider optimal for older adults to maintain their lean muscle mass and as importantly, most of that protein is as low bioavailable plant-based proteins.

The Eat-Lancet Diet recommends only;

• 1 egg per week
• 1/2 an ounce of meat per day (equivalent to a thin slice of shaved meat)
• an ounce of fish or chicken per day (equivalent to 1 sardine)
• and 1 glass of milk

This is not an optimal diet to prevent sarcopenia in adults as they age.

A diet that puts seniors at significant risk of muscle wasting contributes to the loss of quality of life, significant costs to the healthcare system, as well significant cost and stress to individual families that need to care for immobile seniors.

This diet may be beneficial for those living with consistent under-nutrition (malnutrition) but this diet is anything but optimal for healthy, independent aging for the seniors of the US and Canada.

As mentioned in the previous article, the EAT-Lancet Diet also provides way too much carbohydrate intake for the 88% of Americans (and presumably a similar percentage of Canadians) who are metabolically unwell.

Final Thoughts…

For reasons mentioned above, the EAT-Lancet diet is not optimal for health for mature adults or older adults and as mentioned in the previous article, has way too high a carbohydrate intake for the vast majority of people who are already metabolically unwell.

If you would like to learn more about eating an optimal diet to support an active, healthy older age, please send me a note using the Contact Me form, above.

To your good health!

Joy

You can follow me at:

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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. Volpi E, Campbell WW, Dwyer JT, et al. Is the optimal level of protein intake for older adults greater than the recommended dietary allowance? J Gerontol A Biol Sci Med Sci. 2013 Jun;68(6):677-81
2. Fielding RA, Vellas B, Evans WJ, Bhasin S, et al, Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249-56
3. Bauer J1, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
4. Harcombe Z, The EAT Lancet diet is Nutritionally Deficient,  http://www.zoeharcombe.com/2019/01/the-eat-lancet-diet-is-nutritionally-deficient/

A new report released on January 16, 2019 by the EAT-Lancet Commission on Food, Planet and Health sets out what it calls a “healthy and sustainable diet” [1] for the whole world.

The EAT-Lancet report proposes what it calls the “Planetary Health Diet”; a largely plant-based diet which aims to address the simultaneous global problems of malnutrition (under-nutrition) and over-nutrition; specifically that “over 820 million people continue to go hungry every day, 150 million children suffer from long-term hunger that impairs their growth and development, and 50 million children are acutely hungry due to insufficient access to food” and that at the same time “over 2 billion adults are overweight and obese”[2].

The “Planetary Health Diet” intends address both under-nutrition and over-nutrition simultaneously by promoting a 2500 kcal per day diet that focuses on high consumption of carbohydrate-based grains, vegetables, fruit, legumes (pulses and lentils) — while significantly limiting meat and dairy. This sounds a lot like the proposed draft of the new Canada Food Guide (which you can read more about here).

The Planetary Health Diet

Here is the food per day that can be eaten per adult on the “Planetary Health Diet”;

1. Nuts: 50 g (1 -3/4 ounces) /day
2. Legumes (pulses, lentils, beans): 75 g (2-1/2 oz) /day
3. Fish: 28 g (less than an ounce) / day
4. Eggs: 13 g / day (~ 1 egg per week)
5. Meat: 14 g (1/2 an ounce) / day / Chicken: 29 g (1 ounce) / day
6. Carbohydrate: whole grain bread and rice, 232 g carbohydrate per day and 50 g / day of starchy vegetables like potato and yam
7. Dairy: 250 g (the equivalent of one 8 oz. glass of milk)
8. Vegetables: 300 g (10.5 ounces) of non-starchy vegetables and 200 g (almost 1/2 a pound) of fruit per day
9. Other: 31 g of sugar (1 ounce), ~50 g cooking oil

On this diet, you can have twice the amount of sugar as meat or egg, and the same amount of sugar as poultry and fish.

While is is understandable how the above diet may address the problems of under-nutrition in much of the world’s population, what about the effect of such a diet on the average American or Canadian — when 1 in 3 Americans[5] and 1 in 4 Canadians is overweight or obese[6]?

Vast Majority (88%) of Americans are Metabolically Unhealthy

A study published in November 2018 in Metabolic Syndrome and Related Disorders reported that 88% of Americans are already metabolically unhealthy[3]. That is, only 12% have metabolic health defined as have levels of metabolic markers “consistent with a high level of health and low risk of impending cardiometabolic disease“.

Metabolic Health is defined as [3];

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 looking at only 3 of the above 7 factors (waist circumference, blood glucose levels and blood pressure) more than <50% of Americans were considered metabolically unhealthy [3].

Given the slightly lower rates of obesity in Canada[6] as in the United States[5], presumably there is a slightly lower percentage of Canadians who are metabolically unhealthy, but the similarity of our diets may make that difference insignificant. As well, it was not only those who were overweight or obese who were metabolically unhealthy;

“Even when WC (waist circumference) was excluded from the definition, only one-third of the normal weight adults enjoyed optimal metabolic health.”

For the 12% of people who are metabolically healthy, a plant-based low glycemic index diet is not problematic, but it’s a concern to recommend to the other 88% to eat that way — especially if they are insulin resistant or have Type 2 Diabetes.

Is the “Planetary Health Diet” an advisable diet for the average American or Canadian adult who is already metabolically unhealthy? To answer this question, let’s look closer at the macronutrient and micronutrient content of this diet.

Below is the “healthy reference diet” from page 5 of the report [7], which is based on an average intake of 2500 kcal per day;

Nutritional Deficiency of the Eat-Lancet Diet

Dr. Zoe Harcombe a UK based nutrition with a PhD in public health nutrition analyzed the above “Healthy Reference Diet” from Table 1 of the Eat-Lancet report using the USDA (United States Department of Agriculture) all-food database and found that in terms of macronutrients, it had [8];

Protein: 90 g (14% of daily calories)
Fat: 100 g (35% of daily calories)
Carbohydrate: 329 g (51% of daily calories)

Dr. Harcombe also reported that in terms of micronutrients, the diet was deficient in retinol (providing only 17% of the recommended amount), Vitamin D (providing only 5% of the recommended amount), Sodium (providing only 22% of the recommended amount), Potassium (providing only 67% of the recommended amount), Calcium (providing only 55% of the recommended amount), Iron  (providing only 88% of the recommended amount, but mostly as much lower bio-available non-heme iron, from plant-based sources), as well as inadequate amounts of Vitamin K (as the most bio-available comes from animal-based sources).

High Carbohydrate Content

The “Planetary Health Diet” contains on average approximately 329 g of carbohydrate per day which is of significant concern — especially in light of the extremely high rates of overweight and obesity in both the United States and Canada, as well as the metabolic diseases that go along with those, including Type 2 Diabetes (T2D), cardiovascular disease, hypertension, and abnormal triglycerides.

Since 1977, Canada Food Guide has recommended that Canadians consume 55-60% of daily calories as carbohydrate and the Dietary Goals for the United States recommending that carbohydrates are 55-60% of daily calories and in 2015, Canada Food Guide increased the amount of daily carbohydrate intake to 45-65% of daily calories as carbohydrate.

What has happened to the rates of overweight and obesity, as well as diabetes from 1977 until the present?

In the early 1970s, only ~8% of men and ~12% of women in Canada were obese and now almost 22% of men and 19% of women are obese. As mentioned above, 1 in 4 in Canada is obese and 1 in 3 in the US is and with those, Type 2 Diabetes as well as the metabolic diseases mentioned above.

Final Thoughts…

The Dietary Guidelines of both Canada and the US have spent the last 40 years promoting a high carbohydrate diet that has provided adults with between 300 g and 400 g of carbohydrate per day (based on a 2500 kcal / day diet).

EAT-Lancet’s “Planetary Health Diet” may seem to be good for the planet, and for those facing under-nutrition in many parts of the world, but with 88% of Americans already metabolically unhealthy (and presumably the majority of Canadians as well), this diet which provides 300 g of carbohydrate per day is going to do nothing to address the high rates of overweight and obesity and metabolic disease that is rampant in North America.

If you would like to learn more about eating a lower carbohydrate diet for weight loss or for putting the symptoms of Type 2 Diabetes and associated metabolic diseases into remission, please send me a note using the Contact Me form.

To your good health!

Joy

PS If you would like to learn why this diet provides inadequate protein for older adults and seniors, please click here.

You can follow me at:

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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. The EAT-Lancet Commission on Food, Planet and Health,  https://eatforum.org/eat-lancet-commission/
2. The EAT-Lancet Commission on Food, Planet and Health – EAT-Lancet Commission Brief for Healthcare Professionals,  https://eatforum.org/lancet-commission/healthcare-professionals/
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
4. BBC News, A bit of Meat, a lot of veg – the flexitarian diet to feed 10 billion, James Gallagher, 17 January 2019, https://www.bbc.com/news/health-46865204
5. State of Obesity, Adult Obesity in the United States, https://stateofobesity.org/adult-obesity/
6. 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
7. Willet W, Rockstrom J, Loken B, et al, Food in the Anthropocene: the EAT—Lancet Commission on healthy diets from sustainable food systems, The Lancet Commissions, http://dx.doi.org/10.1016/ S0140-6736(18)31788-4
8. Harcombe Z, The EAT Lancet diet is Nutritionally Deficient,  http://www.zoeharcombe.com/2019/01/the-eat-lancet-diet-is-nutritionally-deficient/

This article is to provide background information to the article posted yesterday (available here) about the proposed changes to the new Canada’s Food Guide.

As I thought yesterday, I can confirm now that the source of the draft version of the new Canada’s Food Guide was from the Earnscliffe Strategy Group’s report titled “Healthy Eating Strategy – Dietary Guidance Transformation — Focus Groups on Healthy Eating Messages, Visuals and Brands Research Report which was released on October 31 2018.

Health Canada has confirmed that the draft of the new food guide is not the final version.

Media stories about the new guide first began last week (January 4, 2019) after a draft of the new food guide was referred to by the French media outlet LaPresse in their article titled “Les produits laitiers largement écartés du nouveau Guide alimentaire” (translation: “Milk products are largely removed from the new Food Guide”).

English language media stories cited in the article I posted yesterday also relied on the Earncliffe report.

According to this report, Health Canada is planning to release a Canada’s Food Guide (CFG) “suite of products” to meet the needs of a variety of audiences.  The “look and feel” of the final concept will be applied across the suite of products (pg. 1 Healthy Eating Strategy — Dietary Guidance Transformation — Focus Groups on Healthy Eating Messages, Visuals and Brands — Final Report).

This past June, Ann Ellis who is Manager of Dietary Guidance Manager at Health Canada spoke at the Dietitians of Canada conference on Vancouver Island and shared the specific “suite of products” that will be rolled out.

For the general public the focus of the new guide will be on “how to eat” (eating with others, taking meals to school or work, food shopping) rather than on “what to eat“. Guidance with regards to the types of foods and number of servings will be provided to healthcare professionals such as Dietitians rather than to the general public.

The first set of resources that were supposed to be released this past fall but will probably be release in early 2019 will be;

1. Canada’s Dietary Guidelines for Health Professionals and Policy Makers: A report providing Health Canada’s policy on healthy eating. This report will form the foundation for Canada’s Food Guide tools and resources
2. Canada’s Food Guide Healthy Eating Principles: Communicating Canada’s Dietary Guidelines in plain language
3. Canada’s Food Guide Graphic: Expressing the Healthy Eating Principles through visuals and words
4. Canada’s Food Guide Interactive Tool:  An interactive online tool providing custom information for different life stages, in different settings
5. Canada’s Food Guide Web Resources: Mobile-responsive healthy eating information (fact sheets, videos, recipes) to help Canadians apply Canada’s Dietary Guidelines

The second set of resources that were to be released in the spring of 2019 but will probably be pushed back to the summer are;

1. Canada’s Healthy Eating Pattern for Health Professionals and Policy Makers:  A report providing guidance on amounts and types of foods as well as life stage guidance
2. Enhancements to Canada’s Food Guide: Interactive Tool and Canada’s Food Guide (Web Resources): Enhancements and additional content to Canada’s web application on an ongoing basis

As far as “timelines” for release of the new Canada Food Guide, the following was available from the Health Canada website;

Key dates

The revision of Canada’s food guide will be completed in phases.

In early 2019, we will release:

• Part 1 of the new dietary guidance policy report for health professionals and policy makers, which will consist of general healthy eating recommendations
• supporting key messages and resources for Canadians

Later in 2019, we will release:

• Part 2 of the new dietary guidance policy report, which will consist of healthy eating patterns (recommended amounts and types of foods)
• additional resources for Canadians

It is very good news that healthy eating patterns with recommended amounts and types of foods will be released to health care professionals, but why not to the general public?

Phase 1 of market research was targeted to five different audiences and focused on a variety of healthy eating topics. The five different audiences included;

1. adults experienced in food preparation
2. adults with minimal experience in food preparation
3. seniors responsible for food preparation
4. parents of children who are responsible for grocery shopping and food preparation
5. youth aged 16 to 18

Market research included a series of 10 focus groups that were held in English in Ottawa (March 20 and 21) and in French in Quebec City (March 21 and 22).

Phase 2 of market research was to test the visual elements for the new Canada’s Food Guide to assess:

• effective use of text and graphics/images
• credibility, relevancy and perceived value to the audience
• acceptance
• appeal, usefulness and appropriateness
• relevance and engagement
• memorability (eye-catching and general visual appeal)

Audiences for Phase 2 included:

• those at risk of marginal health literacy
• those with adequate health literacy
• primary level teachers
• community level educators
• registered dietitians working in public health or community nutrition
• registered dietitians working in clinical/private practice/media/bloggers
• registered nurses working in public or community health.

In addition, 10 focus groups were conducted with members of the general public in five Canadian cities:

• Toronto, ON (June 5, 2018)
• Quebec City, QC (June 6, 2018, in French)
• Calgary, AB (June 7, 2018)
• Whitehorse, YK (June 11, 2018)
• St. John’s, NL (June 14, 2018).

Fifteen (15) mini-groups were conducted with health professionals and educators in 3 Canadian cities:

• Toronto, ON (June 4, 2018)
• Calgary, AB (June 6, 2018)
• Quebec City, QC (June 18, 2018, in French)

The following note appeared in the introduction to the Earnscliffe report;

“It is important to note that qualitative research is a form of scientific, social, policy and public opinion research. Focus group research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic. Because of the small numbers involved the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn and findings cannot reliably be generalized beyond their number.”

The following topics on “how to eat” were explored for each of the following audiences during Phase 1:

Adults experienced in food preparation
 Healthy eating at work
 Grocery shopping
 Eating on the go

Adults with minimal experience in food preparation
 Healthy eating at home
 Beginner cook
 Celebrations

Seniors responsible for food preparation
 Building healthy meals & snacks
 Eating on a budget
 Healthy eating for seniors

Youth
 Eating on the go
 Building healthy meals & snacks
 Eating out

Parents responsible for food preparation
 Planning & preparing healthy food with the family
 Packing healthy lunches
 Eating out

It does not appear that any of the focus groups were consulted about the decision to eliminate the Meat and Alternatives and Milk and Alternatives food groups. The senior’s focus group was consulted about the “justification” for particular messages related to these. “Non-meat protein options” and “healthy fats” were considered “new information for which they would like to understand the justification” therefore “providing a rationale was felt to be useful”.

Regarding these “justifications”;

“the placement of the justification seemed to be pertinent.

For example, participants reacted favourably to the statement, ”Eggs are a very convenient and versatile protein food. Prepare them poached, scrambled or made into an omelette with your favourite chopped vegetables.” because the justification (that eggs are convenient and versatile) was provided at the outset.

By way of contrast, reactions to ”Eat meatless meals more often! Instead of meat have baked beans, lentil chilli or an egg sandwich. They cost less!” were less favourable because the justification was provided at the end (they cost less).

Some argued that as a result, this statement came across more as a directive to avoid something they enjoy (eating meat).

(pg. 18 Healthy Eating Strategy — Dietary Guidance Transformation — Focus Groups on Healthy Eating Messages, Visuals and Brands — Final Report).

---

Topics that were explored for each audience (teachers, dietitians, nurses and people with literacy issues) during Phase 2 included:

• reactions to the draft look-and-feel elements
• reactions to the draft visual elements

Two drafts of the new Canada’s Food Guide appeared in the report under the section of “visual elements”;

”At-a-glance” Visual Concept A

”At-a-glance” Visual Concept B

Participant’s feedback on these visual elements are worth noting;

When asked, some could delineate that because vegetables/fruits occupied a larger space visually, or in the example of Visual Concept B that vegetables/fruits were displayed at the top, that most of the food they should consume should come from this category. Others (but not many) inferred from the messaging, ”plenty of vegetables and fruit”, that much of what they eat in a day should be vegetables/fruit.

However, all of this was not obvious and most indicated that they would have preferred a more direct reference to either specific proportions or, at a minimum, an image of a plate or a pyramid, in which the appropriate proportions of vegetables/fruits, grains, and protein were illustrated.

(pg. 34 Healthy Eating Strategy — Dietary Guidance Transformation — Focus Groups on Healthy Eating Messages, Visuals and Brands — Final Report).

It would seem that the draft guide’s focus on “how to eat” left focus group participants wanting more direction on “what to eat” which is primarily what Canadian’s look to the Canada Food Guide for. They wanted to know specific proportions of vegetables and fruit, grains and protein to eat and as a bare minimum wanted an image of a plate or a pyramid in which the appropriate proportions were illustrated.

Some final (personal) thoughts…

As mentioned yesterday, I believe that the role of a national food guide is to enable a country’s population to eat as optimally as possible and without providing guidance as to how much food and how often it should be eaten, the public will be left wanting.

It is clear from the reaction of the senior’s group that they wanted to know why they should eat less meat and less saturated fat and as I expressed yesterday, I believe that before Canadians are discouraged from eating meat and milk that the government should provide current, scientific evidence that eating saturated fat contributes to cardiovascular disease. The public doesn’t need nicer worded “justifications”, but the evidence related to limit saturated fat and to what degree.

To your good health!

Joy

You can follow me at:

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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.

According to an article published in the Globe and Mail yesterday, the new Canada’s Food Guide will have only 3 Food Groups; (1) Vegetables and Fruit (2) Whole Grains and (3) Protein Foods — and will have dropped the Meat and Alternatives and Milk and Alternatives food groups, along with dropping the recommendation for adults and children to consume 2-3 servings of meat and alternatives and milk and alternatives daily[1].

This draft of the new Food Guide does not recommend a specific amount of protein foods be consumed each day.

According to the article;

The proposed changes are consistent with Health Canada’s previous statements on its intentions; ”the majority of Canadians don’t eat enough vegetables, fruits and whole grains.”[1]

The draft of the new Canada Food Guide shows the 3 new food groups and under the heading Protein Foods are images of tofu, red beans & chickpeas, peanut butter, milk, fish and a pork chop, under Whole Grains are images of rice, bread, quinoa and pasta and under Vegetables and Fruit which is the largest of the 3 food groups are a variety of fresh, frozen and canned produce.

The articles published in both the Globe and Mail[1] and on the Canadian Broadcasting Corporation (CBC)’s website[2] state the same things, as do other media outlets and may have been based on the Earnscliffe Strategy Groups report titled “Healthy Eating Strategy – Dietary Guidance Transformation — Focus Groups on Healthy Eating Messages, Visuals and Brands Research Report, Prepared for: Health Canada” which contained the following images:

The proposed new Canada Food Guide should come as no surprise given that the Government of Canada has had posted on its website since 2017 Health Canada’s ‘Guiding Principles, Recommendations and Considerations’ which include Guiding Principle 1;

Regular intake of vegetables, fruit, whole grains, and protein-rich foods* — especially plant-based sources of protein

Inclusion of foods that contain mostly unsaturated fat, instead of foods that contain mostly of saturated fat

*Protein-rich foods include: legumes (such as beans), nuts and seeds, soy products (including fortified soy beverage), eggs, fish and other seafood, poultry, lean red meats (including game meats such as moose, deer and caribou), lower fat milk and yogurt, cheeses lower in sodium and fat.

Nutritious foods that contain fat such as homogenized (3.25% M.F.) milk should not be restricted for young children.

The CBC article stated that Dr. Jennifer Taylor, Professor of Foods and Nutrition at the University of Prince Edward Island (UPEI) and who is one of the experts that was consulted on the new guide said;

 “The new guidelines are evidence-based and relevant.”

and added that

“Any government in any developed country has a responsibility to have some good advice for their citizens.”

The question is, is the de-emphasis on the consumption of meat and milk in order to limit saturated fat based on current evidence? More on this below.

Meat and dairy products have been a major part of the diet of populations around the world for millennia and these are high quality proteins which have high bioavailability to the human body and are unequaled in plant-based proteins. Of course, individuals who choose to be vegetarian or vegan for religious or ethical reasons should be free to choose non-animal based protein foods consistent with their beliefs, however it is my opinion that the role of a country’s food guide is to encourage optimal dietary intake in all of its population.

“Bioavailability” has to do with how much of the nutrients in a given food are available for usage by the human body.  In the case of protein, bioavailability  has to do with the type and relative amounts of amino acids present in a protein*. Anti-nutrients such as phytates, oxylates and lectins which are present in plant-based protein sources interfere with the availability of nutrients in those foods. *Animal proteins (1) contain all of the essential amino acids in sufficient quantities and (2) do not contain anti-nutrients (as plant-based proteins do).

High bioavailability proteins are optimal for the body’s of growing children and youth and to preserve the lean muscle tissue and function in aging adults and a pork chop and red beans or chickpeas are not biologically equivalent in terms of the essential amino acids they provide. I believe, that as in the past the Canadian population should be encouraged to consume both Meats and Alternatives whenever possible.

Professor Taylor said that “not everyone follows the Food Guide strictly” however hospitals, long term care facilities, daycare centers, some  schools, as well as prisons are required by their provincial licenses to provide food that meets Canada’s Food Guide. Will there be a different food guide for institutions with a requirement to provide a specific amount of high bioavailable protein daily? I certainly hope so as the young, the infirm, the institutionalized and the aged are amongst the most vulnerable in our society.

In light of this draft of the new food guide, here are some questions that I believe we, as a society must address;

Do we really NOT want to encourage parents to provide children and youth to be with a specific amount of high bioavailable protein daily?

Do we NOT want to encourage pre-teens and teenagers to eat the most bioavailable protein available to support optimal growth?

Do we NOT want to encourage seniors to consume a specific amount of high quality, bioavailable protein every day to reduce their risk for sarcopenia (muscle wasting)?

The new Canada Food Guide’s shift away from regular consumption of meat and dairy is based a perceived need to avoid foods that contain saturated fat — seeing it as a negative component of the diet. Yes, saturated fat is known to raise LDL-cholesterol however such a finding is meaningless unless it is specified which type of LDL-cholesterol goes up. There are small, dense LDL cholesterol which easily penetrates the artery wall and which are associated with heart disease [4,5,6,7] and large, fluffy LDL cholesterol which are not [8,9].

Eight recent meta-analysis and systemic reviews which reviewed evidence from randomized control trials (RCT) that had been conducted between 2009-2017 did not find an association between saturated fat intake and the risk of heart disease [10-17] and the results of the largest and most global epidemiological study published in December 2017 in The Lancet [18] found that those who ate the largest amount of saturated fats had significantly reduced rates of mortality and that low consumption (6-7% of calories) of saturated fat was associated with increased risk of stroke.

As Canadians we must ask where is the current evidence that eating foods with saturated fat is dangerous to health?

I believe that Health Canada needs to provide this evidence — evidence which is not based on proxy measurements that saturated fat raises total LDL cholesterol. There needs to be a clear differentiation between small, dense LDL cholesterol (which are associated with cardiovascular risk) and large, fluffy LDL cholesterol (which are not).

I believe that it is inadequate for Canadians to not be encouraged to eat meat and milk without the government providing current, scientific evidence that eating saturated fat raises small, dense LDL and/or leads to cardiovascular disease. Where is this evidence?

Finally, Canada is in the midst of an obesity and diabetes epidemic. According to Statistics Canada, one in four Canadian adults were overweight or obese in 2011-2012 [19]. That’s about 6.3 million people and that number is continuing to increase. In 1980, only 15% of Canadian school-aged children were overweight or obese. This number has more than doubled to 31% in 2011 [20] and 12% met the criteria for obesity [21,22,23].

How will Canada’s overweight and obesity crisis be addressed by a new Canada Food Guide that de-emphasizes regular consumption of milk and animal proteins which increase satiety (feeling of fullness) while encouraging Canadian children, youth and adults to eat more vegetables, fruit and whole grains?

I believe Canadians deserve these answers before Canada’s Food Guide is changed.

The Office of Nutrition Policy and Promotion is the federal department that is responsible for developing and promoting dietary guidance, including Canada’s Food Guide. If you have concerns about the proposed changes to Canada Food Guide, they can be reached by email at [email protected].

To your good health!

Joy

UPDATE (January 10, 2019) This new article summarizes the report on which the media stories about the new Canada Food Guide draft are based and includes very interesting focus group reactions.

You can follow me at:

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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. The Globe and Mail, Ann Hui, Canada’s Food Guide poised to shift focus from meat, dairy to vegetables, protein, published January 8, 2019, https://www.theglobeandmail.com/canada/article-new-draft-of-canadian-nutrition-guide-drops-to-three-food-groups/
2. CBC News,  New food guide will shift recommended diet from meat, dairy to fruits, veggies says expert, published January 8, 2019, https://www.cbc.ca/news/canada/prince-edward-island/pei-canada-food-guide-jennifer-taylor-1.4970072
3. Government of Canada, Guiding Principles, Recommendations and Considerations, https://www.foodguideconsultation.ca/guiding-principles-detailed
4. Tribble DL, Holl LG, Wood PD, et al. Variations in oxidative susceptibility among six low density lipoprotein subfractions of differing density and particle size. Atherosclerosis 1992;93:189—99
5. Gardner CD, Fortmann SP, Krauss RM, Association of Small Low-Density Lipoprotein Particles With the Incidence of Coronary Artery Disease in Men and Women, JAMA. 1996;276(11):875-881
6. Lamarche B, Tchernof A, Moorjani S, et al, Small, Dense Low-Density Lipoprotein Particles as a Predictor of the Risk of Ischemic Heart Disease in Men, Circulation. 1997;95:69-75
7. Packard C, Caslake M, Shepherd J. The role of small, dense low density lipoprotein (LDL): a new look, Int J of Cardiology,  Volume 74, Supplement 1, 30 June 2000, Pages S17-S22
8. Genest JJ, Blijlevens E, McNamara JR, Low density lipoprotein particle size and coronary artery disease, Arteriosclerosis, Thrombosis, and Vascular Biology. 1992;12:187-195
9. Siri-Tarino PW, Sun Q, Hu FB, Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease, The American Journal of Clinical Nutrition, Volume 91, Issue 3, 1 March 2010, Pages 502—509
10. Skeaff CM, PhD, Professor, Dept. of Human Nutrition, the University of Otago, Miller J. Dietary Fat and Coronary Heart Disease: Summary of Evidence From Prospective Cohort and Randomised Controlled Trials, Annals of Nutrition and Metabolism, 2009;55(1-3):173-201
11. Hooper L, Summerbell CD, Thompson R, Reduced or modified dietary fat for preventing cardiovascular disease, 2012 Cochrane Database Syst Rev. 2012 May 16;(5)
12. Chowdhury R, Warnakula S, Kunutsor S et al, Association of Dietary, Circulating, and Supplement Fatty Acids with Coronary Risk: A Systematic Review and Meta-analysis, Ann Intern Med. 2014 Mar 18;160(6):398-406
13. Schwingshackl L, Hoffmann G Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and meta-regression BMJ Open 2014;4
14. Hooper L, Martin N, Abdelhamid A et al, Reduction in saturated fat intake for cardiovascular disease, Cochrane Database Syst Rev. 2015 Jun 10;(6)
15. Harcombe Z, Baker JS, Davies B, Evidence from prospective cohort studies does not support current dietary fat guidelines: a systematic review and meta-analysis, Br J Sports Med. 2017 Dec;51(24):1743-1749
16. Ramsden CE, Zamora D, Majchrzak-Hong S, et al, Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73), BMJ 2016; 353
17. Hamley S, The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials, Nutrition Journal 2017 16:30
18. Dehghan M, Mente A, Zhang X et al, The PURE Study — Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062
19. Statistic Canada, Adjusting the scales: Obesity in the Canadian population after correcting for respondent bias, Statistics Canada Catalogue no. 82-624. https://www150.statcan.gc.ca/n1/pub/82-624-x/2014001/article/11922-eng.htm
20. Overweight and obesity in children and adolescents: Results from the 2009 to 2011, Canadian Health Measures Survey [homepage on the Internet]. [Cited 2016 Nov 28]. Available from: http://www.statcan.gc.ca/pub/82-003-x/2012003/article/11706-eng.htm
21. Twells, LK, Midodzi W, et al. Current and predicted prevalence of obesity in Canada: a trend analysis. CMAJ Open. Mar 3, 2014. Vol 2 (1), E18-E26.
22. Diabetes: Canada at The Tipping Point [homepage on the Internet]. [Cited 2016 Nov 28]. Available from: https://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/canada-at-the-tipping-point-english.pdf
23. Janseen, Ian. The public health burden of obesity in Canada. Canadian Journal of Diabetes. Apr 2013. Vol 37 (2), 90-96.

Most people have heard that a “Mediterranean Diet” is healthy, but what is it?

According to the 2018 Clinical Practice Guidelines from Diabetes Canada;

A ”Mediterranean diet” primarily refers to a plant-based diet first described in the 1960s. General features include a high consumption of fruits, vegetables, legumes, nuts, seeds, cereals and whole grains; moderate-to-high consumption of olive oil (as the principal source of fat); low to moderate consumption of dairy products, fish and poultry; and low consumption of red meat, as well as low to moderate consumption of wine, mainly during meals.”

There are many countries that border on the Mediterranean Sea and the traditional diets of these regions vary considerably! Countries such as Greece and Turkey have a long-standing tradition of a meat-rich diet, and countries such as France and Spain are known for their high saturated fat intake, which begs the question “what is the Mediterranean Diet” and “which country in the Mediterranean is it from” and “what time period is it from”?

Countries of the Mediterranean

Mediterranean countries include Albania, Algeria, Bosnia and Herzegovina, Croatia, Cyprus, Egypt, France, Greece, Italy, Israel, Lebanon, Libya, Malta, Morocco, Monaco, Montenegro, Slovenia, Spain, Syria, Tunisia and Turkey and each country traditionally had it’s own diet. That is, there isn’t a single “Mediterranean Diet” but Mediterranean Diets.

The “Mediterranean Diet” referred to in the literature and in common speech refers to what was eaten in Southern Italy in the 1960s when Ancel Keys conducted his Six Country Study (1953) and later his Seven Countries Study (1970). These studies allegedly demonstrated that there was an association between dietary fat as a percentage of daily calories and death from degenerative heart disease but as will be elaborated on below, this is largely because some of the data available at the time was ignored by Ancel Keys’.

The definition of a “Mediterranean Diet” according to the Clinical Practice Guidelines is tied to Keys’ definition;

“Ecologic evidence suggesting beneficial health effects of the Mediterranean diet has emerged from the classic studies of
Keys.” [2]

The Data Ancel Keys Ignored

In 1953, Ancel Keys published the results of his ”Six Countries Study”[3], where he said that he demonstrated that there was a direct association between dietary fat as a percentage of daily calories and death from degenerative heart disease (see figure below).

Looking at the diagram from Keys’ study above, it looks like a clear linear relationship however, four years later in 1957 Yerushalamy et al published a paper with data from 22 countries[4], which showed a much weaker relationship between dietary fat and death by coronary heart disease than Keys’s Six Countries Study data [3].

As can be seen from this diagram from the Yerushalamy et al study, no clear linear relationship exists. Data points are quite a bit more scattered;

In spite of the publication of Yerushalamy et al’s data in 1957,  in 1970 Keys went on to conduct his Seven Countries Study which he concluded showed an associative relationship between increased dietary saturated fat and coronary heart disease but he failed to include data from countries such as France, in which the relationship did not hold. 

In Keys’ paper published in 1989[5] he found that the average consumption of animal foods (with the exception of fish) was positively associated with 25 year coronary heart disease deaths rates and the average intake of saturated fat was supposedly strongly related to 10 and 25 year coronary heart disease (CHD) mortality rates.

The problem is that Keys published his Seven Country Study 32 years after Yerushalamy et al’s 1957 paper which showed a significantly weaker relationship but Key’s (1) failed to mention the Yerushalamy study and  (2) failed to study countries such as France and Spain that had known high intakes of saturated fat, yet low coronary heart disease rates.

The “French Paradox” Ignored

France is known for the “French paradox” (a term which came about in the 1980s) because of the country’s relatively low incidence of coronary heart disease (CHD) while having a diet relatively rich in saturated fat. According to a 2004 paper about the French Paradox [6], there was diet and disease data available from the French population that was carried out in 1986—87 and which demonstrated that the saturated fat intake of the French was 15% of the total energy intake, yet such a high consumption of saturated fatty acids was not associated with high coronary heart disease incidence[6]. According to the same paper about the French Paradox, high saturated fat intake combined with low coronary heart disease rates were also observed in other Mediterranean countries such as Spain [6].  Nevertheless, Keys published his 1989 study[5] ignoring the French dietary and disease data that was available 2-3 years earlier (from 1986-1987) [6], as well as ignoring Yerushalamy et al’s data from 1957. Was this deliberate oversight on Ancel Keys’ part or simply poor research practices?

As a result of Keys omission and the wide publication of his Seven Country Study results, the so-called “Mediterranean Diet” has become synonymous with the diet of Southern Italy in the 1960’s; a diet that is no longer eaten by children and youth there, according to the World Health Organization (WHO):

“In Cyprus, a phenomenal 43% of boys and girls aged nine are either overweight or obese. Greece, Spain and Italy also have rates of over 40%. The Mediterranean countries which gave their name to the famous diet that is supposed to be the healthiest in the world have children with Europe’s biggest weight problem.[7]”

Some Final Thoughts…

There never really was a “Mediterranean Diet” and the diets of Mediterranean countries in the 1960s varied considerably when it came to intake of red meat, cheese and saturated fat. The so-called “Mediterranean diet” is simply what people in Southern Italy ate in the 1960’s.

That said, for those who are metabolically healthy (that is, not having insulin resistance or Type 2 Diabetes, high blood pressure or high cholesterol) eating what has become known as “the Mediterranean Diet” of whole, plant-based foods including vegetables, legumes, nuts, seeds, modest amounts of whole grains and fruit and moderate-to-high consumption of olive oil, as well as the inclusion of full-fat cheese and meat, fish and poultry is certainly a healthy choice and offers lots of variety!

Even for those that are metabolically compromised (already insulin resistance or have Type 2 Diabetes) the same style of eating can be adapted to limit quickly metabolized carbohydrate, while still enjoying all the other foods that comprise a traditional “Mediterranean Diet”.

Would you like to know more?

Please send me a note using the Contact Me form above and I’ll be happy to reply.

To your good health!

Joy

You can follow me at:

https://twitter.com/lchfRD

https://www.facebook.com/BetterByDesignNutrition/

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. Sievenpiper JL, Chan CB, Dwortatzek PD, Freeze C et al, Nutrition Therapy — 2018 Clinical Practice Guidelines, Canadian Journal of Diabetes 42 (2018) S64—S79 http://guidelines.diabetes.ca/docs/CPG-2018-full-EN.pdf
2. Trichopoulou A, Costacou T, Bamia C et al, Adherence to a Mediterranean Diet and Survival in a Greek Population, N Engl J Med 2003;348:2599-608.
3. Keys, A. Atherosclerosis: a problem in newer public health. J. Mt. Sinai Hosp. N. Y.20, 118—139 (1953).
4. Yerushalmy J, Hilleboe HE. Fat in the diet and mortality from heart disease. A methodologic note. NY State J Med 1957;57:2343—54
5. Kromhout D, Keys A, Aravanis C, Buzina R et al, Food consumption patterns in the 1960s in seven countries. Am J Clin Nutr. 1989 May; 49(5):889-94.
6. Ferrií¨res J. The French paradox: lessons for other countries. Heart. 2004;90(1):107-111.
7. Boseley, Sarah, The Guardian, Thur May 24, 2018, ‘The Mediterranean diet is gone’: regions children are fattest in Europe.  https://www.theguardian.com/society/2018/may/24/the-mediterranean-diet-is-gone-regions-children-are-fattest-in-europe

It is said that the definition of “insanity” is doing the same thing over and over again expecting different results, yet with the best of intentions many of us make a New Year’s Resolution each January 1st saying “this will be the year“!  The problem is, that by the end of the first week in January 50% of us will have already given up on our resolution to lose weight, exercise more or eat healthier[1]. By the end of the month, 83% have given up[1].  In fact, a study on New Year’s Resolutions found that only 8% of those that make these types of health-related commitments will actually achieve them[1], which are  pretty discouraging statistics.

If we want to lose weight, get in shape and start eating healthier the way NOT to do it is by making a New Year’s Resolution.

We need a plan; a plan that is specific, with outcomes that are measurable and achievable and that are relevant to our overall life goals and realistic, and we need them to be accomplished in a timely manner. These are the essence of SMART goals! You can read more about those here.

New Year’s Resolutions; a desire without a commitment

Saying “I’m going to lose weight this year” says nothing about how much weight, in what period of time, by what means, nor what “success looks like”.  It’s not a goal, but a wish. It’s expressing a desire without a commitment. This also applies to exercising more or eating healthier.

How convincing would it be to us if someone said “I want to spend the rest of my life with you” but made no commitment to a relationship, or to live in the same city as us or to spending time with us?  Why should we put confidence in our ourselves when we also express desires without commitment?

We may WANT to lose weight, we may WANT to exercise more and WANT to eat healthier but all the “wanting” in the world won’t move us closer to any of those goals because a goal without a plan is just a wish.

…and a goal without a plan is a New Year’s resolution.

If you want to lose weight, exercise more and eat healthier this year, then what I’d recommend is rather than making a New Year’s resolution this year, make a commitment to yourself to take the month of January to design an implementable plan built on SMART goals.

If you do this, by the end of the month when 83% of people that have made New Year’s Resolutions have already given up, you will be ready to begin implement a well thought out plan!  When most people have forgotten their wish, you will have what you need to be successful.

If you would like help setting SMART health and nutrition goals for yourself, I offer a one-hour session that is especially for this purpose that is available via Skype or telephone. I’ll help you set goals for yourself that are specific, measurable,  achievable,  relevant /realistic and timely. These will be your goals and success will look like however you decide to measure it.  I will assist as a coach helping you set goals for yourself that are achievable, relevant and that can be achieved in a realistic amount of time.

If you would like to know more, please click here or if you have questions, please send me a note using the Contact Me form located on the tab above.

Wishing you and yours the very best for a healthy and happy New Year!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/BetterByDesignNutrition/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 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

 

Why on earth would a Dietitian suggest to avoid making New Year’s resolutions to lose weight, exercise more or eat healthier? The reason is that research indicates that half of those that make these types of health-related  New Year’s Resolutions give up just a week into the new year [1] and by the end of January, 83% will have given up [1]. A New Year’s resolution will see only 8% of people reach their goal, with 92% failing[1]. I want people succeed and since it takes approximately 66 days (that’s more than 2 months!) to create a new habit[2] having my support during the critical planning and implementing stage can make a huge difference!

Rather than making a New Year’s resolution, I recommend that people set SMART goals. Ideally if they want to lose weight during the new year, they will have done this in November and begun to implement their plan in December but it’s not too late!  Setting SMART goals in January and beginning to implement them in February works great!

What are “SMART” goals?

SMART is an acronym for goals that are specific, measurable, achievable, relevant and time-bound.

Goals that are Specific

When setting a goal, it needs to be specific.

If your goal is weight loss, then think about exactly what you are trying to accomplish in terms of how much weight in what amount of time.

If your goal is to exercise more, than decide how often you will exercise, for how long at each session , and what types of exercise you will do (weights, resistance, cardio, etc).

If your goal is to eat healthier, then define what that means to you.  Is it “clean eating”; then what is that, exactly?  If you want to eat to lower your blood sugar or cholesterol or blood pressure or to reduce your risk to specific diseases that run in your family, then you need to define it that way.

Goals that are measurable

When setting a goal it is necessary to define what is going to be used to measure whether the goal will have been met.  If the goal is weight loss, then it can be measured by a certain number of pounds or kilos lost or by a specific waist to height ratio.

If the goal is to exercise more, then it can be measured in times per week at the gym, the number of hours spent exercising each week or how many fitness classes you attend each month.

If the goal is to eat healthier, then how are you going to measure that?  It could be measured in how many times you eat fatty fish (like salmon or mackerel) in a week, or how many grams of carbohydrate you eat per day or how many servings of leafy green vegetables you eat per day.  How will you measure it?

What does success look like?

Goals that are achievable

For goals to be be successfully accomplished, they need to be realistically achievable from the beginning, otherwise people get discouraged and give up.

When it comes to setting weight loss goals, it is not uncommon for people to decide they want to lose 20 pounds in a month before a special social function, but is it achievable?

When it comes to exercising more, is it achievable to set a goal of working out an hour a day, 7 days per week or is there a different goal that is more likely to be achievable, but will still keep you progressing?

It’s the same with eating healthier; the goal needs to be achievable.  When I started my personal weight loss and health-recovery journey in March 2017, one of the goals I set was to put my Type 2 Diabetes into remission by a year. Based on the research and how I decided to eat, that was achievable. It actuality it took me 13 months to accomplish, but I was not discouraged that I didn’t actually achieve it in the time frame I planned because the goal was achievable. I was close at a year, just not “there” yet.

Goals that are relevant or realistic

For a goal to be relevant it needs to fit within a person’s broader goals.

If I have a goal to lose weight but I have a larger goal to eat with my kids, then I need to plan to make food for myself that is the same as what I make for them, with some modifications for my weight loss goals

If one of my goals is to spend more time with my kids in the evening then planning to go running each evening as a way of exercising more does not fit within my broader goals. If my goal is to buy only locally-sourced food and I want to eat mangoes as part of my plan to eat healthier, I will face challenges if I live in the northern US or Canada and it’s wintertime. We need to know our broader goals and set our individual ones in that context.

For a goal to be realistic it needs to be achievable and for this step, it is often best to consult someone that would know.

Goals that are time-bound

Setting a goal to “lose weight” is one thing.  That’s pretty generic.  Setting a goal to lose a given amount of weight in a specific amount of time means that a lot of planning and implementing needs to occur for that goal to be successfully realized.  It is the planning and implementing to achieve a specific, measurable, achievable and realistic goal in a specific time-frame that makes it successful.

A Dietitian’s Journey – SMART Goals

Back in March 2017 when I set out to restore my own health and lose weight, these were the goals that I set;

(1) blood sugar in the non-diabetic range

(2) normal blood pressure

(3) normal / ideal cholesterol levels

(4) a waist circumference in the ”at or below” recommended values of the Heart and Stroke Foundation

While they don’t appear as SMART goals, as a Dietitian I knew what the “normal range” for these was and the time-frame I set was one year.

At the one year mark, my progress report as posted on Diet Doctor on March 14, 2018:

I did reach my goal of having my waist circumference at or below the recommended values of the Heart and Stroke Foundation, but still had a way to go to get it in a healthier range based on waist to height ratio;

I have not yet reached a low-risk waist circumference (one where my waist circumference is half my height).  I still have to lose another 3 inches to lose (having already lost 8 inches!), so however many pounds I need to lose to get there, is how much longer I have to go.

I am guessing that will be in about 20-25 pounds which may take another 6 months or so, but I’m not really concerned about the time because this ”journey” is about me getting healthy and lowering my risk factors for heart attack and stroke, and any amount of time it takes is what it will take.

It took years to make myself that metabolically unhealthy and it will take time for me to get to a healthy body weight and become as metabolically well’ as possible.

(from “A Dietitian’s Journey”)

As it turned out, it was only a week ago last Monday that I finally got to a place where my waist circumference was half my height; 8 months after my first year update. That was 2 months more than I thought it would take, but only 20 pounds more that I needed to lose to accomplish it, so I was close.

Was I discouraged at 6 months when I hadn’t “arrived”?

No, because  from the beginning my goals were SMART which made them rooted in what was possible.

I was very specific as to what I wanted to accomplish, how I was going to measure success, that the goals were achievable based on the available research, were relevant to my larger life goals and were time-bound. That said, just because reaching my goals was possible did not guarantee that I would achieve all of them in the time I planned. I achieved most of them within a year, and achieved the rest with a little more patience and time.

Some final thoughts…

Instead of setting a New Year’s resolution to lose weight, exercise more or eat healthier, perhaps spend the month of January setting very specific SMART goals. At the end of January, when 83% of the people have already given up on their New Year’s resolutions to improve their health, you will about to implement your well-thought out, realistic plan and may have already engaged me, as a Dietitian or a personalized trainer to help you implement it. Now THAT is a whole lot more than wishful thinking!

1. “What specifically do I want to accomplish”
2. “How will I measure success?”
3. Is this achievable? Do I know? Where can I find out?
4. Is this goal relevant to my larger life goals?
5. What time-frame do I want to accomplish this by?

Write out what you can about each of your goal(s) and then if achieving your goal will take more than a few months or a year or more to achieve, then I’d recommend engaging a professional to support you.

When it comes to weight loss and eating healthier I can certainly help, and if your goal is to lower risk to specific types of diseases I can certainly share with you the information I have gleaned as to which types of exercise are the most helpful in that regard.

If you want to consult with me to help you set SMART goals, please click here to learn more or send me a note using the Contact Me form located on the tab above. I provide in-person services in my Coquitlam (British Columbia) office or via Distance Consultation (Skype, phone) so whether you live close or far away, I’m happy to help.

If you would like more information about my hourly services or the packages I offer, please click on the Services tab above and if you have questions about those, please send me a note using the Contact Me form and I’ll reply when I am able.

Wishing you the very best for a  healthy and happy New Year!

Joy

You can follow me at:

       https://twitter.com/lchfRD

         https://www.facebook.com/BetterByDesignNutrition/

          https://plus.google.com/+JoyYKiddieMScRD

https://www.instagram.com/lchf_rd

 

Copyright ©2018 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Low Carbohydrate Diets for Weight Loss

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

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

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

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

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

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

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

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

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

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

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

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

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

In this section on Carbohydrates, it was emphasized that;

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

and

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

Protein

With respect to protein intake, it was emphasized that;

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

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

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

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

Fats

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

Other Points of Interest

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

Conclusion

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

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

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

You can find out more about the hourly consultations and packages I offer by clicking on the Services tab above and if you have questions, feel free to send me a note using the Contact Me form, and I will reply as soon as I am able.

To your good health!

Joy

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Copyright ©2018 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, Lifestyle Management Standards of Medical Care in Diabetes – 2019. Available at: http://care.diabetesjournals.org/content/42/Supplement_1. Accessed: Dec. 17, 2018.
2. 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
3. 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
4. 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

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

What is meant by Type 2 Diabetes “reversal”

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

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

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

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

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

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

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

What is meant by Type 2 Diabetes “remission”

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

Type 2 Diabetes “reversal” defined

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

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

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

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

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

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

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

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

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

Some final thoughts…

I think it’s important what terms we use.

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

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

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

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

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

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

To yours and my good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

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https://www.instagram.com/lchf_rd

 

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

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

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

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

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

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

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

Insulin Resistance

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

Normal Insulin Response

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

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

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

Early Carbohydrate Intolerance

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

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

Advanced Carbohydrate Intolerance

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

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

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

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

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

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

 Severe Carbohydrate Intolerance

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

Type 2 Diabetes

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

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

Some Final Thoughts…

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

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

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

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

In fact, it is long overdue.

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

To your good health!

Joy

You can follow me at:

https://twitter.com/lchfRD

https://www.facebook.com/BetterByDesignNutrition/

 

References

1. Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.
2. Sagesaka H, S.Y., Someya Y, et al, Type 2 Diabetes: When Does It Start? Journal of the Endocrine Society, 2018. 2(5): p. 476-484.

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Copyright ©2018 BetterByDesign Nutrition Ltd.

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

 

INTRODUCTION: When people have a fasting blood glucose test and the results come back normal they’re told (or assume) that everything’s fine. But is it? Certainly, a fasting blood glucose test is the least expensive test to find out if someone is already pre-diabetic, but for those wanting to avoid becoming diabetic and to lower their risk of the other chronic disease associated with type 2 diabetes and high levels of circulating insulin (called hyperinsulinemia) noticing abnormalities in how we process carbohydrates is essential and these changes are estimated to take place a decade before our fasting blood sugar begins to become abnormal.

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Our bodies have to maintain the glucose (sugar) in our blood at or below 5.5 mmol/L (100 mg/dl) but each time we eat or drink something other than water or clear tea or coffee, our blood sugar rises as our body breaks down the carbohydrate in the food from starch and complex sugars to glucose, a simple sugar.  Eating causes hormones in our gut, called incretin hormones to send a signal to our pancreas to release insulin, which moves the excess glucose out of our blood and into our cells. When everything is working properly, our blood sugar falls back down to a normal level within 2 hours after we eat.

If we’re healthy and don’t snack after supper, our blood sugar falls to a lower level overnight but that too is maintained in a tightly regulated range between 3.3 mmol/l (60 mg/dl) and 5.5 mmol/l (100 mg/dl). During the night and as we approach morning, our body will break down our stored fat for energy and convert it to glucose in a process called gluconeogenesis.

When we have a fasting blood glucose test, it measures our blood sugar after we’ve fasted overnight and when we’re healthy, the results will be between 3.3-5.5 mmol/L (60-100 mg/dl). If it is higher than 5.5 mmol/l (100 mg/dl) but less than 6.9 mmol/L (125 mg/dl) we are diagnosed with impaired fasting glucose, but what if it’s normal? Is a normal fasting blood glucose test result enough to say that we’re not at risk for Type 2 Diabetes? No, because a fasting blood glucose doesn’t tell us anything about how our body responds when we eat!

A 2 hour Oral Glucose Tolerance Test (2 hr-OGTT) may be requested for people whose fasting blood glucose is impaired (higher than 5.5 mmol/L) in order to see if it returns to normal after they consume a specific amount of glucose (sugar).

If their blood sugar returns to normal (less than 5.5 mmol/L) 2 hours after drinking a beverage containing 75 g of glucose (100 g if they’re pregnant) then the diagnoses remains impaired fasting glucose because it is only abnormal when fasting. However, if the results are greater than 7.8 mmol/L (140 mg/dl) but below 11.0 mmol/L (200 mg/dl), then they are diagnosed with impaired glucose tolerance which is called “pre-diabetes”.

If the 2 hour results are greater than 11.0 mmol/L (200 mg/dl), then a diagnosis of Type 2 Diabetes is made because their fasting blood glucose is > 7.0 mmol/L (126 mg/dl) and their 2 hour blood glucose is > 11.0 mmol/L (200 mg/dl).

But what if someone’s fasting blood glucose is normal? Does this mean that everything’s fine? Not necessarily, unless we know what happens to their blood sugar after a carbohydrate load, especially after 30 minutes or 60 minutes.

A 2016 study looking at blood sugar response (and insulin response) from almost 4000 men aged 20 years or older and 3800 women aged 45 years or older who had a 5 hour Oral Glucose Tolerance Test using 100 g of glucose. The study found that 53% had normal glucose tolerance; that is, they had normal fasting blood sugar and did not have impaired glucose tolerance (IGT) 2 hours after the glucose load. Of these people with normal glucose tolerance, 75% had abnormal blood sugar results between 30 minutes and 1 hour.

Normal Blood Glucose Pattern

Based on the above study, a little less than 1000 people (990) out of the total with normal glucose tolerance (4030) had a normal glucose pattern after having 100 g of glucose (see graph below). See how the blood sugar rises to a moderate peak and then decreases steadily until it’s back to where it started from at 2 hours. This is what blood sugar is supposed to do.

Abnormal Glucose Patterns

Almost the same number of people (961) as had normal glucose curves showed early signs of carbohydrate intolerance which can be seen most noticeably between 30 and 60 minutes. These folks had normal fasting blood glucose and but after 2 hours, blood glucose did not return to baseline, but did not meet the criteria for impaired glucose tolerance. Unless someone was looking between 30 and 60 minutes, one would not know it was not normal in between. Keep in mind, this graph represents the average blood sugar response of these individuals. Rather than blood glucose going up to a moderate peak and then falling gradually, a two-stage rise in glucose can be clearly seen between 30 minutes and 60 minutes before beginning to drop. These people had normal fasting blood sugar and while their blood sugar at 2 hours was below the cutoff for impaired glucose tolerance, it was higher than at baseline.

A little more than 1200 people (1208) had the follow abnormal glucose response between 30 and 60 minutes where blood sugar actually went slightly higher at 60 minutes than at 30 minutes before beginning to fall. While these people had normal fasting blood glucose their blood glucose did not fall to baseline at 2 hours but was below the cutoffs for impaired glucose tolerance.

Slightly more than 800 people (807) had an abnormal glucose response curve shaped as follows, with normal fasting blood glucose and  2-hour postprandial blood glucose results that were higher than at baseline, but did not meet the criteria for impaired glucose tolerance. What was significant is that blood sugar was significantly higher at 60 minutes than at 30 minutes.

The Significance of These Curves

The results of this study shows that even if fasting blood glucose is totally normal AND 2 hour postprandial blood glucose does not meet the criteria for impaired glucose tolerance, it often does not return to baseline and  the blood sugar response between fasting and 2 hours is very abnormal. What can’t be seen from these graphs is what happens to the hormone insulin at the same time. This will be covered in a future article, but suffice to say that in the normal glucose response pattern, blood sugar response mirrors what is happening with insulin but in the abnormal blood glucose response insulin secretion is both much higher and lasts much longer. This is called hyperinsulinemia (high blood insulin) and contributes to many of the same health risks as Type 2 Diabetes, including cardiovascular risks (heart attack and stroke), abnormal cholesterol levels and hypertension (high blood pressure).  This is like having “silent Diabetes”.

A “Waste of Healthcare Dollars”

When a person’s clinical symptoms and risk factors warrant it, I’ll request a 2 hour Oral Glucose Tolerance Test with an extra assessor at 30 minutes (and sometimes at 60 minutes) to determine how their glucose response compares to the above curves. Since these people have normal fasting blood glucose test results, a request for an Oral Glucose Tolerance Test (with or without the extra glucose assessor) is often declined as a “waste of healthcare dollars”.

What About Glycated Hemoglobin (HbA1C)?

A glycated hemoglobin test (HbA1C) measures a form of hemoglobin that binds glucose (the sugar in the blood) and is used to identify the person’s three-month average glucose concentration because blood cells turnover (get replaced) on average every 3 months.

While having a glycated hemoglobin test and a fasting blood glucose test is better than only having fasting blood glucose, it will still miss a significant percentage of people who are able to control their sugars between meals and overnight but who have significant spikes after eating food, between 30 minutes and 60 minutes, but that return to normal by 2 hours. Since most physicians will not even requisition a HbA1C test if a person’s fasting blood glucose is normal, and even if they do that test can miss the glucose spoke that occurs between 30 minutes and 60 minutes after eating, this is the reason I sometimes resort to using a Glucose Response Simulation.

Glucose Response Simulation

A simple, if somewhat crude means of assessing glucose response under a load can be done at home using an ordinary glucometer (a meter for measuring blood sugar) such as would be used by people with Diabetes, and either a 100 g of dextrose (glucose) tablets (available at most pharmacies) or the equivalent. As part of the services I provide to my clients, I work with those that want to do this type of estimate so that they can understand whether they fall into the 75% of people that have normal fasting blood sugar and do not have impaired glucose tolerance at 2 hour postprandial, but do have an abnormal glucose response, as well as hyperinsulinemia. I explain how to prepare for the test, step by step instruction for conducting the test and then I graph and analyze the data then teach them what the results mean.

Basis for Individualizing Carbohydrate Intake

These results are very helpful as firstly they help people understand the reason for reducing their carbohydrate intake over an extended period of time, in order to restore insulin sensitivity and insulin secretion. These results also enable me in time to individualize their carbohydrate intake once they have reversed some of their metabolic response, based on their own blood sugar response to a specific carbohydrate load.  In time, some of these individuals may want to add some carbohydrate back into their diet in small quantities, so with this information, I can guide them to test a standard size serving of rice, pasta or potato compared to their own blood glucose response to 100 g of glucose.

Below are three curves that I’ve plotted from people that all used the same type of glucometer (Contour Next One) which was rated as the best in a 2017 survey (see earlier post) and a standard 100 g glucose load as dextrose tablets or equivalent to 100 g of glucose [2]. I provided each one with identical instructions on how to run this simulation and to collect the results and ensured they understood.

Example 1: The person below had a single glucose peak (similar to the early carbohydrate intolerance of the first abnormal curve, above) but blood glucose did not come back down to the fasting level even after 3 hours.

Example 2: The person below had a single glucose peak  that reached abnormally high levels and that didn’t fall continuously downward but slowed, then dipped below baseline at 2 hours and that gradually came back to baseline over the following couple of hours.

Example 3: This person had a similar initial rise as the person above, but no dip below baseline. In fact, this person’s glucose didn’t fall to baseline until almost 5 hours.

Some Final Thoughts…

An abnormal fasting blood glucose test may warrant further testing, however a normal result is frequently dismissed as being a sign that “everything’s fine”. Data from this study indicates that as many as 75% of people with normal fasting blood sugar may have abnormal glucose responses and associated hyperinsulimia and some of the same risks as someone who has already been diagnosed with Type 2 Diabetes, but they simply don’t know it.

With reliable and relatively inexpensive glucometers, as well as continuous glucose monitors (CGM) people don’t need to wonder whether they are in the minority with a normal glucose response.

Not knowing one is at risk does nothing to provide motivation to make dietary and lifestyle changes, but knowing one has an abnormal response to carbohydrate not only enables them to want to make changes, it enables them  to find out in time which carbohydrates might be able to be added back into their diet, and in what quantities.

If you have questions as to how I can help you get started in knowing your own glucose response and to lower risk factors, please send me a note using the Contact Me form located on the tab, above.

To your good health!

Joy

References

1. Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.
2. Lamar, ME et al, Jelly beans as an alternative to a fifty-gram glucose beverage for gestational diabetes screening, Am J Obstet Gynacol, 1999 Nov 18 (5 Pt 1): 1154-7

You can follow me at:

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Copyright ©2018 BetterByDesign Nutrition Ltd.

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

 

 

 

The new joint American Diabetes Association (ADA) / European Association for the Study of Diabetes (EASD) position paper [1] published online ahead of print on October 4th now classifies a low carbohydrate diet as Medical Nutrition Therapy. in the treatment of Type 2 Diabetes in adults. What this means is these two organizations which are responsible for educating over 30 million Americans and 60 million Europeans diagnosed with Diabetes consider a low carbohydrate not only safe, but effective therapeutic treatment. This recognition comes on the heels of Diabetes Australia having just released in late August their own updated position paper designed to provide practical advice and information for people diagnosed with Diabetes who are considering adopting a low carbohydrate eating plan [2].

What is Medical Nutrition Therapy?

Medical Nutrition Therapy (MNT) is defined as;

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

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

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

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

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

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

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

This move has far-reaching significance!

Publication of this paper indicates that the current scientific literature supports that a low carbohydrate is not only safe for use in adults, but is also effective in lowering metabolic markers of Type 2 Diabetes, as well as  delaying or eliminating the need for blood-glucose lowering medications for up to 4 years [1].

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

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

Some final thoughts…

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

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

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

To your good health!

Joy

you can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/BetterByDesignNutrition/

Copyright ©2018 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. Davies M.J., D’Alessio D.A., Fradkin J., et al, Management of Hyperglycemia
   in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), Diabetes Care, October 2018,  https://doi.org/10.2337/dci18-0033. Click here for pdf of the full article (on affiliate web page).
2. Diabetes Australia, Low Carbohydrate Eating for People with Diabetes — Position Statement, August 2018,  https://www.diabetesqld.org.au/media-centre/2018/august/low-carb-position-statement.aspx and https://www.diabetesqld.org.au/media/583017/da-low-carb-statement-21-august-2018.pdf
3. U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415

 

 

I was asked an interesting question recently which was “have you found the silver bullet for reducing carb cravings“? This was an interesting way to phrase something I have been asked in many different ways the last few years.

Some people have been told that it really doesn’t matter what or how much they eat as long as they only eat “real” food. Others have heard that they need to eat plenty of fat each day, and that this will keep them full and reduce cravings for carb-based foods. Some have read that what they need to do is eat mostly protein with some fat or only eat during a very small ‘eating window’.

So what is the answer?

There really isn’t a ‘silver bullet’ as much as there is the need for a well-designed low carbohydrate diet that is specific to each person’s physiological needs.

Every person has different nutrient needs based on their age, stage of life, gender and activity level. As well, each individual has different degrees of insulin resistance and hyperinsulinemia and each person’s blood sugar responds differently to a carbohydrate load (called glycemic response). Much of these depends on their specific family history, their medical history and the type of foods they normally eat. [You can read more about all three of these here.]

There isn’t a ”once-size-fits-all low carb diet”.  Based on all of the above factors, some people will do better with a higher ratio of protein to fat, whereas others need plenty of natural, healthy fats and average amount of protein. The amount and type of carbohydrate each person can tolerate will also be different. Since everyone’s needs are different, in designing a Meal Plan for someone, I start by conducting a complete nutritional assessment (personal medical history, family medical history, review of recent lab tests, dietary and lifestyle review, etc.) so that the Meal Plan that I design is tailored to their individual needs.

If there was a ‘silver bullet’ to eliminate carb cravings it would be to understand what causes them. Carb cravings are driven by several different hormones that the body produces in response to the way each person eats, as well as how much and how well they sleep, how they manage stress (or don’t), as well as any conditions or diseases that they have and any medications that they take.  All of these affect the various hormones that impact cravings for carbohydrate-based food. When I design people’s Meal Plans, I take all of these into account.

A well-designed low carbohydrate diet designed specifically for each person and taking into account the various factors that are driving their specific carbohydrate cravings is the most effective means to addressing them.

A person’s Meal Plan is not carved in stone. If a person has a fair amount of weight to lose, their Meal Plan will change once they’ve lost a significant amount of weight or if they’ve hit a plateau where they haven’t lost either weight or inches in a while.  Achieving optimal body weight is a dynamic process not a static one — as people’s needs change, so should their diet.  It’s not that a person’s Meal Plan needs to be re-designed, as much as ‘tweaked’ or ‘adjusted’ to keep them moving towards achieving their goals. This is where follow-up can be helpful.

If you have questions as to how I can help you achieve your health and nutrition goals — either by taking service in-person in my office or via Distance Consultation please send me a note using the Contact Me form above and I will be happy to reply as soon as I am able.

To your good health!

Joy

you can follow me at:

 https://twitter.com/lchfRD

  https://www.facebook.com/BetterByDesignNutrition/

Copyright ©2018 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.