The most recent data available from 2011 indicates that the cost per person per year of having Type 2 Diabetes in Canada ranges from $1611 (Quebec) to $3427 (New Brunswick) based on an average income of $43,000 per year. Necessary medications, devices and supplies are expensive – costing more than 3% of income. While those with extended health benefits now may not consider this cost now, a change in employment circumstances can affect this overnight.
As Type 2 Diabetes progresses, more medications are often added and the number of times blood sugar needs to be taken each day often increases, as well. Job loss or retirement suddenly results in Canadians being faced with bearing the burden of their disease, along with the chronic, progressive nature of poorly managed blood sugars.
A per-province breakdown using the 2011 figures from the Canadian Diabetes Association appears below;
Cost of Type 2 Diabetes per person per year by province (2011 figures) – from Canadian Diabetes Association
It doesn’t have to be so.
Long term studies that have been published in the last couple of years (reviewed in previous articles on this site) which demonstrate that a well-designed low carbohydrate or ketogenic diet can and does enable a significant improvement in Type 2 Diabetes symptoms.
After as little as 10 weeks, glycosylated Hemoglobin (HbA1C) has been reported to drop a full percentage point; from 7.6% to 6.6%. After a year, the average HbA1C was 6.3%, which is below the diagnostic criteria for Type 2 Diabetes. That is, in just a year of following a well-designed low carbohydrate diet, it has been demonstrated that people can get their average blood glucose in the non-Diabetic range.
Medication use drops substantially when people are able to control their blood sugar by limiting the amount and types of carbohydrates they eat. At the start of the study mentioned above published in Feb of 2018, 87% of people were taking at least one medication for Diabetes and at just 10 weeks, almost 57% had one or more Diabetes medications reduced or eliminated. After one year, Type 2 Diabetes medication prescriptions other than Metformin declined from 57% to below 30%. Insulin injections were reduced or eliminated in 94% of users and sulfonylurea medication was entirely eliminated.
For each one of these individuals, a simple change to a low carbohydrate diet resulted not only in significantly improved health and a reduction in Diabetes symptoms, but in significantly reduced cost, as well.
According to Virta Health who conducted the study referred to above, cost savings are as indicated in this diagram below.
The cost of "Diabetes Reversal" below reflects the estimated cost of an individual being cared for by the Virta Health multi-disciplinary team program, which appears to be an excellent program given the methods used in the studies they have published.
It should be noted that the cost of working one-on-one with me over the course of a year (and as overseen by your GP) is substantially less. In fact, getting started by being assessed and having me design an individual Meal Plan just for you is significantly less than the yearly cost of achieving better blood sugar control in the graphic below.
Average Per Person Per Year Saving Potential (US dollars, 2018) – from Virta Health
Sometimes people are hesitant to invest in the cost of seeing a Registered Dietitian who can help them adopt a low carbohydrate lifestyle that can enable them to achieve significantly improved blood sugar control – even though the yearly costs of Diabetes supplies is far greater than the cost of being assessed and getting a Individualized Meal Plan. Such an estimate is at the level of health they are today, but waiting a few years, with longer Type 2 Diabetes, more medications, possibly including insulin injections, and the cost is closer to $3500 in 2011 Canadian dollars / $4000 in 2018 (US) dollars.
Does this make any sense?
The sooner someone changes their diet and lifestyle upon being diagnosed with Type 2 Diabetes, the more likely it seems they may be able to achieve full remission of symptoms. If you’ve followed my own story on “A Dietitian’s Journey” then you know how much harder it is for me, after being diagnosed 10 years ago.
If you have extended benefit coverage, then now is the time to invest some time in learning how to make lifestyle changes that will benefit your health and your finances for the years to come. Even for those without such coverage, the cost of an assessment package which will provide you with a Meal Plan designed specifically for you is substantially less than you are already paying for your medications, devices and supplies. I provide both in-person services in my Coquitlam, British Columbia office and via Skype Distance Consultations.
If you have questions about this package entails or about the flexible payment options that are available, why not send me a note using the “Contact Me” form located above? I’ll be happy to reply.
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.
As demonstrated in a previous article, a low-carbohydrate or therapeutic ketogenic diet is a viable option for people to reduce their symptoms of Type 2 Diabetes, but does it increase the risk of cardiovascular disease, such as heart attack and stroke?
Results of a New Study
Results of a peer-reviewed study of cardiovascular outcomes of people with type 2 diabetes (T2D) that was published at the beginning of May in the Journal of Cardiovascular Diabetology [1] found that those that followed a ketogenic diet (<30 g carbohydrate per day) significantly improved in 22 of 26 cardiovascular disease risk factors, including biomarkers of cholesterol/lipoproteins, blood pressure, inflammation, and carotid intima media thickness (cIMT).
Previously published results from the same researchers and published in February 2018, demonstrated that significant improvement of T2D symptoms was able to be achieved and sustained long-term using a ketogenic diet [2,3]. A post reviewing that study can be read here.
Simply by decreasing the amount of carbohydrate in the diet over the course of a year, there was not only a significant decrease in blood sugar and weight, but a dramatic improvement in lipid and lipoprotein markers associated with markers of cardiovascular risk.
The results of this most recent study do much to dispel the myth that a therapeutic ketogenic diet puts individuals at increased risk for heart attack and stroke. In fact, it reduces their risk.
Methods
Continuous Care Intervention (CCI) Group Participants
At the beginning of the study, there were 238 participants enrolled in the continuous care intervention (CCI) group, and all had a diagnosis of Type 2 Diabetes (T2D) with an average HbA1c of 7.6% ±1.5%. They ranged in age from 46 — 62 years of age, 67% were women, and 33% were men. The weight of the subjects ranged from 200 pounds to 314 pounds (117±26 kg) with an average weight of 257 pounds (117 kg), and the Average Body Mass Index (BMI) was 41 kg·m-2 (class III obesity) ±9 kg·m-2, with 82% categorized as obese. The majority of participants (87%) were taking at least 1 medication for glycemic control medication.
At the end of a year, 218 participants (83%) remained enrolled in the continuous care intervention (CCI) group.
Intervention and Monitoring of CCI Group
Each participant in the CCI group received an Individualized Meal Plan, which enabled them to attain and maintain nutritional ketosis. They also received behavioural and social support, biomarker tracking tools, and ongoing care from a health coach with medication management by a physician.
Subjects typically required <30 g/day total dietary carbohydrates.
Daily protein intake was targeted to a level of 1.5 g per day based on ideal body weight, and participants were coached to incorporate dietary fats until they were no longer hungry.
Other aspects of the diet were individually tailored to ensure safety, effectiveness and satisfaction, including consumption of 3-5 servings of non-starchy vegetables and sufficient mineral and fluid intake.
Participants’ ability to achieve and maintain nutritional ketosis was determined by subjects monitoring their blood ketone level of β-hydroxybutyrate (BHB) using a portable, handheld device. Blood glucose and β-hydroxybutyrate (BHB) levels were initially tracked daily using a combination blood glucose and ketone meter, and frequency of tracking was modified by the care team based on each individual’s needs and preferences.
Participants with high blood pressure (hypertension) were provided with an automatic home blood pressure machine (sphygmomanometer) and they were instructed to record their readings daily to weekly in the supplied app, depending on recent blood pressure control. Antihypertensive medication prescriptions were adjusted based on home blood pressure readings and reported symptoms.
Downward Adjustment and/or Discontinuation of Medications
As blood pressure came down, diuretic medication was the first antihypertensive medication to be discontinued. This was followed by beta blockers (unless the participant had a history of coronary artery disease).
Angiotensin-converting-enzyme inhibitors (ACE inhibitors) and angiotensin II receptor blockers (ARBs) were generally continued due to their known protective effect on the kidneys in those with Type 2 Diabetes.
Statin medications were adjusted to maintain a goal of LDL-P under 1000 nmol/L (or based on participant preference after full risk/benefit discussion with the physician).
The Usual Care (UC) Group
For comparison purposes, an independent group of patients with Type 2 Diabetes were also recruited for the study and was referred to Registered Dietitians who provided dietary advice according to the American Diabetes Association Guidelines [4].
Laboratory Assessors
Since an abnormal lipid/cholesterol profile (“atherogenic dyslipidemia”) is a known risk factor for CVD [5] and is very common in people with Type 2 Diabetes, some laboratory tests were conducted at the beginning of the study and the end to determine if they improved, stayed the same or got worse.
Most common in people with type 2 diabetes is where there are increased triglycerides (TG), decreased high-density lipoprotein cholesterol concentration (HDL-C) and increased small low-density lipoprotein particle number (small LDL-P).
The authors of this study state that evidence suggests that increased very low-density lipoprotein particle number (VLDL-P) and a large VLDL-P in particular may be one of the key underlying abnormalities in this abnormal lipid/cholesterol profile (“atherogenic dyslipidemia”) associated with T2D.
The authors also outline how higher concentrations of small LDL are often associated with increased total LDL particle number (LDL-P) and increased ApoB, which is the main protein constituent of very low-density lipoprotein (VLDL) and low-density lipoprotein (LDL). The authors provide previous studies that demonstrates that in people with insulin resistance and T2D, increased total LDL particle number (LDL-P) and increased ApoB may exist even with normal to low LDL-C concentrations. For this reason, LDL-C alone was not relied on as a measure of abnormal lipid/cholesterol profile (“atherogenic dyslipidemia”) in this study, as it could miss the impact of increased total LDL particle number (LDL-P) and/or ApoB.
The authors mentioned that in previous studies with carbohydrate restriction of up to 1 year, while triglycerides (TG) usually decrease and HDL-C often increase, LDL-C sometimes increased and other times decreased. The authors note that although higher LDL-C is a known risk factor for CVD, low LDL-C may also reflect higher small, dense LDL, total LDL particle number (LDL-P) or ApoB and thus be a risk factor, as well.
Since inflammation is involved at all stages of the atherosclerotic process, higher high-sensitivity C-reactive protein (CRP) and/or higher white blood cell count (WBC) were assessed as risk factors for CVD.
Finally, since high blood pressure (hypertension) is also an added risk factor for CVD in people with T2D, tighter blood pressure control was deemed to reduce the risk of CVD, stroke and other microvascular events.
Continuous Care Intervention (CCI) Group
Standard laboratory fasting blood draws of the CCI group were obtained at the start of the study (baseline), at 70 days (3 months) and at ~ 1 year follow-up.
Lipid/cholesterol-related tests included ApoB, ApoA1, total cholesterol, triglycerides, direct HDL-C concentrations and LDL was calculated using the Friedewald equation.
The LipoProfile3 algorithm was used to determine relationship of lipid subfractions to cardiovascular (CVD) risk – specifically the number of HDL particles (HDL-P) previously reported to be associated with death, Myocardial Infarction (MI), stroke and hospitalization, HDL-C (HDL cholesterol) which is the amount of cholesterol those particles are carying, which is not associated with these negative outcomes and HDL-P subclasses [6].
Risk was also determined using the lipoprotein insulin resistance score (LP-IR), which was proposed to be associated with the homeostasis model assessment of insulin resistance (HOMA-IR) and glucose disposal rate (GDR) [7].
Finally, risk was also determined using the 10-year atherosclerotic cardiovascular disease (ACSVD) risk score of the American College of Cardiology [8].
Carotid ultrasonography (cIMT) measurement was performed at baseline and 1 year to characterize atherosclerotic risk.
The Usual Care (UC) Group
Body measurements, vital signs and fasting blood draws for the Usual Care (UC) group were obtained at the start of the study (baseline) and at 1 year using the same clinical facilities and laboratory and data collection methods. Carotid ultrasonography (cIMT) measurement was also performed at baseline and 1 year to characterize atherosclerotic risk.
Results
There were no significant differences in the baseline characteristics of the two subgroups of CCI participants (web-based on onsite-based) and no significant difference at 1 year, so for the purpose of analysis, data from both groups were combined.
As well, there were no significant differences in the baseline characteristics of the Usual Care (UC) group (which served as an observational comparison group) and the Continuous Care Intervention Group (CCI), except that mean body weight and BMI were higher in the CCI versus the UC group.
The within-Continuous Care Intervention group changes in the following lipids and lipoproteins were all statistically significant and were as follows;
ApoA1 [a component of high-density lipoprotein (HDL)] increased by 9.8%
ApoB / ApoA1 ratio decreased by 9.5%
Triglycerides (TG) decreased by 24.4%
LDL-C increased by 9.9% but LDL-particle size also increased by 1.1% (that is, large, fluffy LDL increased compared with small, dense LDL)
HDL-C increased by 18.1%
total HDL-P increased by 4.9%
Large HDL-P increased by 23.5%
Triglyceride/ HDL-C ratio decreased by 29.1%
Large VLDL-P decreased by 38.9%
Small LDL-P decreased by 20.8%
There were no significant changes in total LDL-P or ApoB.
These results are impressive!
Simply by decreasing the amount of carbohydrate in the diet over the course of a year, there was a dramatic improvement in lipid and lipoprotein markers associated with markers of cardiovascular risk.
In addition, the Continuous Care Intervention group had a significant reduction in systolic blood pressure, which decreased 4.8%, diastolic blood pressure decreased 4.3% C-Reactive Protein (CRP) decreased almost 40% (i.e. 9.3%), and white blood cell (WBC) count decreased 9.1%
Below are graphs of the changes in biomarkers for the Continuous Care Intervention (CCI) group (Figure 1) and the Usual Care (UC) Group.
FIGURE 1: Changes in biomarkers for the Continuous Care Intervention (CCI) groupFIGURE 2: Changes in biomarkers for the Usual Care (UC) group
Below is a comparative graph of the two groups, the Continuous Care Intervention (CCI) Group and the Usual Care (UG) Group
FIGURE 3: Changes in biomarkers for the Continuous Care Intervention (CCI) group compared to the Usual Care (UC) group
Some Final Thoughts…
This study demonstrates that a therapeutic ketogenic diet followed over the course of one year significantly improved 22 of 26 cardiovascular disease risk markers in those with type 2 diabetes. This is huge!
The size of the study group was large and had an 83% retention rate over the course of the year, which in and of itself demonstrates that the intervention diet was one that people had no difficulty staying with in their day-to-day lives, without the use of meal replacements (shakes or bars).
While not a randomized control trial between CCI and UG groups, this study supports that a ketogenic diet is both safe and effective for periods of up to a year (and in other studies has been documented to be safe and effective for up to two years). Not only can a well-designed ketogenic diet reverse many of the symptoms of Diabetes, but it can also significantly improve risk markers for cardiovascular disease.
Do you have questions about how a well-designed low-carbohydrate or ketogenic diet can help you improve symptoms of Type 2 Diabetes and lower markers of risk factors for cardiovascular disease? Please send me a note using the ”Contact Me” form above to find out more.
References
Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open-label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56) https://pubmed.ncbi.nlm.nih.gov/29712560/
McKenzie AL, Hallberg SJ, Creighton BC, Volk BM, Link TM, Abner MK, Glon RM, McCarter JP, Volek JS, Phinney SD, A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes, JMIR Diabetes 2017;2(1):e5, URL: http://diabetes.jmir.org/2017/1/e5, DOI: 10.2196/diabetes.6981
Hallberg SJ, McKenzie AL, Williams, PT et al. Diabetes Ther (2018). Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study.
Fruchart J-C, Sacks F, Hermans MP, Assmann G, Brown WV, Ceska R, et al. The Residual Risk Reduction Initiative: a call to action to reduce residual vascular risk in patients with dyslipidemia. Am J Cardiol. 2008;102:1K—34K. https://pubmed.ncbi.nlm.nih.gov/19068318/
May HT, Anderson JL, Winegar DA, Utility of high density lipoprotein particle concentration in predicting future major adverse cardiovascular events among patients undergoing angiography, Clinical Biochemistry, 2016;49(15): 1122-1126, https://pubmed.ncbi.nlm.nih.gov/27616009/
Shalaurova I, Connelly MA, Garvey WT, Otvos JD. Lipoprotein insulin resistance index: a lipoprotein particle-derived measure of insulin resistance. Metabol Syndr Relat Disord. 2014;12:422—9. https://pmc.ncbi.nlm.nih.gov/articles/PMC4175429/
Goff DC, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R, et al. ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;2014:S49—73 (tool: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/)
LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only. The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything you have read or heard in our content.
In a recent article about why Waist Circumference and Waist-to-Height Ratio is so important, I explained that a meta-analysis from 2012 which pooled data from 300,000 adults of different races and ages found that the lowest risk of cardiovascular disease and shorter lifespan was associated with a Waist to Height Ratio (WHtR) of 0.5. That is, we are at lowest risk when our waist circumference is less than half our height (even if our BMI is in the normal range). I also explained exactly how to take waist circumference, so that the results are accurate.
There are other measures of cardiovascular risk that I think are worth considering.
A 2015 study of 3200 adults found that Waist-to-Hip Ratio (WHR) is more accurate in predicting 10-year cardiovascular risk than Waist to Height Ratio (WHtR), however whether this relationship would hold up in a sample as large as the meta-analysis above is unknown. I feel it is worth mentioning Waist-to-Hip Ratio (WHR) as an indicator of cardiovascular risk, as it is easy to do.
Another index this 2015 study found to accurately predict 10-year cardiovascular risk was something called Conicity Index which I will touch on even though it is not as easily determined as Waist-to-Hip Ratio (WHR) or Waist to Height Ratio (WHtR).
Determining Waist to Hip Ratio
As mentioned in the previous article, to use these indices requires waist measurements and hip measurements to be done accurately and at a specific place on the body. To make it easier, I will repeat how to measure waist circumference here and below, how to measure hip circumference.
Measuring Waist Circumference
For the purposes of calculating risk associated with increase abdominal girth, waist circumference needs to be measured at the location that is at the midpoint (i.e. half way) between the lowest rib and the top of the hip bone (called the ”iliac crest”). Below is a picture that should help.
Where to measure waist circumference
This measurement should be taken with a flexible seamstress-type tape measure, being sure that the tape measure is at the same height in the front and the back, when looking in front of a mirror. That is, the tape measure should be perpendicular to the floor (not higher in the back or the front).
It’s also important that the person’s abdomen (belly) is completely relaxed when taking the measurement, not sucked in. One way to do that is to taking a deep breath and let it out fully just as the measurement is taken.
If your Waist to Height ratio is greater than 0.5, then you are at increased risk for cardiovascular events and a shortened lifespan. Looking at the graph above, one can see that for every little bit over 0.5, the risk rises steeply.
Measuring Hip Circumference
Hip circumference needs to be measured at the widest portion of the buttocks (butt) and as with waist circumference, the tape measure needs to be parallel to the flood (same height in the front and the back, when looking in front of a mirror).
For both the waist and hip measurement, the tape measure should be snug around the body, but not pulled so tight that it is constricting and it is best if a stretch”resistant but flexible seamstress-type tape measure is used.
Assessing Waist-to-Hip Ratio
If the waist circumference is measured in inches, then the hip circumference needs to be as well – same if the measurement is in centimeters; both need to be in the same units.
To calculate the Waist-to-Hip Ratio take the waist circumference and divide it by the hip circumference.
Waist-to-Hip Ratio and Risk of Cardiovascular Disease
The following ratios are associated with low, moderate and high risk of cardiovascular risk;
Low Risk: For men, if the ratio is 0.95 or less, for women if the ratio is 0.80 or less
Moderate Risk: For men, if the ratio is 0.96 – 1.0, for women if the ratio is 0.81 – 0.85
High Risk: For men, if the ratio is 1.0 or more, for women if the ratio is 0.85 or more.
The Waist-to-Hip Ratio can also be thought of as people being shaped like “apples” or “pears”.
“Apples” versus “Pears”
People who carry most of their excess weight around their middle (“apples”) have more visceral fat and this type of fat is much more dangerous than the fat under our skin (called “sub-cutaneous fat”) because it is found around the heart, liver, pancreas and other organs and increases the risk not only of cardiovascular disease, but also Type 2 Diabetes and hypertension.
People who’s hips are much wider than their waist (so-called “pears”) have less visceral fat and therefore lower risk of these weight-related health problems.
Conicity Index
Conicity Index(CI) is a little more cumbersome a calculation than either Waist-to-Hip (WHR) Ratio or Waist-to-Height (WHtR), but was found in the 2015 study mentioned above with 3200 subjects to be a strong predictor of cardiovascular risk.
Conicity literally means “cone-shaped” and determines how much our body fat distribution like two end-to-end cones.
In the first figure below, body weight is distributed evenly, however when someone has a conical distribution, their weight is more heavily distributed around the abdomen. As a result, it has increased conicity and is more highly correlated to increased cardiovascular disease (as well as Type 2 Diabetes and hypertension).
For those who are interested in calculating Conicity Index (CI), the formula is below along with the formula for Waist-to-Hip (WHR) Ratio, Waist-to-Height (WHtR).
Indices of central adiposity
Final Thoughts…
Given the sample size of the data on which Waist-to-Height (WHtR) is based (300,000 adults) and that it is an easy to determine and robust measure of cardiovascular risk, this is the one I tend to favour. That said, Waist-to-Hip (WHR) Ratio was previously used for years and found to be a simple and accurate predictor of risk. From that point of view, either could be used, but why not both?
In my clinical experience, I have encountered many people with much wider hips than waist (so-called “pears”) but whose Waist-to-Height (WHtR) is considerably greater than 0.5, and for this reason I tend to put more credence on Waist-to-Height (WHtR) than Waist-to-Hip (WHR) Ratio as a measure of visceral fat and increased cardiovascular risk.
Since both Waist-to-Height (WHtR) and Waist-to-Hip (WHR) Ratio are very easy to determine, for those with a family risk of cardiovascular disease, Type 2 Diabetes or hypertension, I think it makes sense to aim for a waist measurement that is within both of these easily obtained measures.
Do you have questions about how I can help you lower your risk of cardiovascular disease, Type 2 Diabetes or hypertension? I provide both in-person and Distance Consultation services via Skype or telephone (and remember, many extended benefits plans will reimburse for visits with a Registered Dietitian).
Please feel free to send me a note using the “Contact Me” form on the tab above to find out more.
To our good health,
Joy
References
Rabiee B, Motamed N, & Perumal D, et al. Conicity index and waist-hip ratio are superior obesity indices in predicting 10-year cardiovascular risk among men and women. Clin. Cardiol. 38, 9, 527—534 (2015)
LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only. The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything you have read or heard in our content.
Note: This article was originally posted on May 22, 2018 and was updated on November 25, 2025.
Most of us get on the scale to determine if we are getting to, or staying at, our “goal weight” — thinking that weight is the best way to assess risk. This article is about a more accurate assessor that can also be done at home.
Assessing BMI
Most people have a general idea of what “obesity” means, and that it involves carrying too much body fat, but knowing when “overweight” becomes “obese” is not always simple. Traditionally, this has been based on Body Mass Index (BMI), which uses a person’s weight in kilograms divided by their height in meters squared [4]. In recent years, BMI cutoffs for Asians and South Asians have been set lower than those of European descent because metabolic risk (diabetes, heart disease) occurs at lower BMIs.
Below are the commonly recommended BMI thresholds for those of European descent and those of Asian or South Asian descent according to the World Health Organization (WHO) [7] and Diabetes Canada [9]:
Category
Standard BMI (kg/m²)
Asian / South Asian BMI (kg/m²)
Underweight
< 18.5
< 18.5
Normal weight
18.5 – 24.9
18.5 – 22.9
Overweight
25 – 29.9
23 – 27.4
Obese Class I
30 – 34.9
27.5 – 32.4
Obese Class II
35 – 39.9
32.5 – 37.4
Obese Class III
≥ 40
≥ 37.5
While BMI categories are still used, they do not always reflect a person’s actual health risk because weight alone does not tell us where fat is stored.
Fat stored deep in the abdomen (visceral fat) is associated with the highest risk [4,5].
Waist-to-Height Ratio
Over the last decade, many studies have shown that Waist-to-Height Ratio (WHtR) is a better way of identifying health risk than BMI [1,2]. WHtR compares your waist to your height, giving a clearer picture of the fat stored in and around your abdominal organs. This “central fat” is closely linked with metabolic illness, including heart disease, high blood pressure, and type 2 diabetes [1,3,4,5].
A large 2012 review of 31 studies found that WHtR was better than BMI at detecting cardiometabolic risks [1].
A 2014 study also showed that WHtR was more predictive of “years of life lost” than BMI [2].
Waist-to-Height Ratio Is More Predictive of Years of Life Lost than Body Mass Index [2]
More recent studies show that people can have a normal BMI yet still be at risk if their waist is too large for their height [1,2,5].
This is why using waist circumference and waist-to-height ratio gives a more meaningful picture of health risk, especially for adults over 30 [1,2,5].
How to Calculate Waist-to-Height Ratio
Measuring WHtR is very easy.
Measure your height (without shoes).
Measure your waist circumference (as described below).
Divide your waist measurement by your height. Use the same units for both [1,2].
A WHtR of 0.50 or less is generally considered lower risk [1,2].
A WHtR above 0.50 suggests a higher risk of metabolic disease [1,2].
For example, a man who is 5′10″ (178 cm) should have a waist around 35″ (89 cm) or less [1,2].
A woman who is 5′6″ (168 cm) should have a waist of 33″ (84 cm) or less [1,2].
Where to Measure Your Waist
Where you measure your waist makes a difference.
For assessing health risk, the recommended place to measure is halfway between your lowest rib and the top of your hip bone (the iliac crest) [6].
Measuring at this midpoint — rather than at the narrowest part of the waist or at the navel (belly button) ensures the reading reflectsvisceral fat (abdominal fat that surrounds the organs), not just subcutaneous fat (fat under the skin) [3,4,5].
Measuring the waist at this precise midpoint is especially important for those from Asian or South Asian backgrounds, because visceral fat accumulates earlier and increases metabolic risk even at lower waist sizes [7,8,9].
How to Measure Your Waist Properly
Use a soft tape measure, like a seamstress (sewing tape)
Stand comfortably and relax your stomach. Do not pull it in.
Ensure you measure exactly halfway between your lowest rib and the top of your hip bone (iliac crest) — see diagram, above.
Make sure the tape is level all the way around.
Measure after a gentle exhale for the most consistent result [6].
How to Measure Your Hips Properly
Waist-to-hip ratio (WHR) is another measurement used to help assess health risk, and while it is not the topic of this article, I do ask my clients to measure their hips so that I can use it in the assessment. This is how hips should be measured.
Stand up straight and breathe out
Using a soft tape measure like a seamstress tape, measure the distance around the widest part of your hips
Make sure the tape is level all the way around.
Why Pay Attention to Waist Circumference?
Anyone can benefit from knowing their waist size, but this becomes even more important after age 30, when body fat often shifts toward the abdomen [5,6].
It is also important for those of Asian and South Asian descent, who often face higher metabolic risk at lower weights [7,8,9].
If you already have high blood pressure, borderline blood sugar, high cholesterol, or a family history of heart disease or diabetes, paying attention to waist size is especially important [5,6].
Putting It All Together
Instead of focusing on weight or BMI, waist circumference and waist-to-height ratio give a clearer idea of health risk, especially for adults over 30 [1,2,5], and those of Asian and South Asian descent [7,8,9].
It is easy to measure and is more strongly linked with metabolic health than weight or BMI [1,2,5].
If your waist is more than half your height, it is an indication that it is time to make dietary and lifestyle changes that reduce abdominal fat, including reducing stress and improving sleep quality and quantity [1,2,5].
A scale alone does not tell the whole story. A tape measure, used in the right place, provides much more useful information [3,4,5].
More Info
If you would like support with achieving and maintaining a healthy waist circumference, I can help. Learn about the different packages available under the Services tab.
Ashwell M, Gunn P, Gibson S. Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis. Obesity Reviews. 2012;13(3):275–286. [https://pubmed.ncbi.nlm.nih.gov/22106927/]
Hsieh SD, Yoshinaga H. Abdominal fat distribution and coronary heart disease risk factors in men—waist/height ratio as a simple and useful predictor. International Journal of Obesity. 1995;19(8):585–589. [https://pubmed.ncbi.nlm.nih.gov/7489031/]
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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.
There are some things that people should not do on their own and one of them is to begin a very low carb (ketogenic) diet without first consulting with their doctor, especially if they take certain types of medication. Medical supervision is necessary before a person substantially decreases their carbohydrate intake if they are taking;
(1) insulin
(2) medication to lower blood glucose such as sodium glucose co-transporter 2 (SGLT2) medication including Invokana, Forxiga, Xigduo, Jardiance, etc.
(3) medication for blood pressure such as Ramipril, Lasix (furosemide), Lisinopril / ACE inhibitors, Atenolol / βeta receptor antagonists, etc.
(4) mental health medication such as antidepressants, medication for anxiety disorder, bipolar disorder (such as Lithium), and schizophrenia.
I don’t provide low carb or ketogenic services those taking insulin (either type 1 diabetes or type 2 diabetes) as I do not have CDE certification. I will provide services if a person is being overseen by their endocrinologist and do require a doctor’s letter. This is very important because clinical studies indicate that injected insulin levels need to be adjusted downward very soon after beginning a low carb or ketogenic diet and this needs be supervised.
Those taking medication for mental health conditions should consult with their psychiatrist and/or family practice physician before adopting a low carb or ketogenic diet as this may have an effect on the dosage of some types of medication, including mood stabilizing medications such as Lithium. (A recent article written by Psychiatrist Georgia Ede, MD related to a ketogenic diet appeared in Psychology Today and appears here.)
I advise people coming to me to implement a low carbohydrate or ketogenic lifestyle and taking medications to control their blood sugar, or blood pressure to first consult with their doctor before changing how they eat because blood sugar levels and blood pressure decreases fairly soon after adopting these diets and can have serious consequences if dosages of these medications are not monitored and adjusted downward (sometimes being discontinued entirely). For example, a sudden drop in blood pressure could result in people becoming dizzy or confused and could even result in injury to themselves or others if they ‘blacked out’ while walking or driving a car.
Some medications which lower blood sugar such as sodium glucose co-transporter 2 (SGLT2) medication including Invokana, Forxiga, Xigduo, Jardiance, etc. might result in life-threatening and even fatal cases of a very serious condition called “diabetic ketoacidosis (DKA)” even with no change in diet, but these risks can be increased for patients on a very low carbohydrate diet as the combination of the medication and diet may increase the amount of ketone production (see Health Canada’s Safety Review here).
Those with significant alcohol consumption who are taking these medications are at risk for DKA, so it is very important that if you drink alcohol on a regular basis and take these medications to tell your doctor. If you are taking any of these medications and come to me, I will ask you about your alcohol consumption because alcohol and these medications together could potentially result in this serious and potentially life-threatening condition.
People taking any of the above medications (or any medications for other conditions) should not adopt a low carb or ketogenic lifestyle on their own without first checking with their doctor.
Another thing that people should never do on their own is adjust the dosage of any of their prescribed medication without first discussing it with their doctor. The consequences of doing so can be very serious, even life-threatening. For example, people taking SGLT2 inhibitors such as Invokana or Jardiance who decrease their insulin dosage suddenly are at increased risk for DKA. This is very serious. Medication dosages and timing must be adjusted by a doctor.
Another condition which is less common than DKA but is very serious is Hyperosmolar Hyperglycemia State (HHS). It is life-threatening and has a much greater death rate than DKA, reaching up to 5-10%. It is most commonly seen in people with Type 2 Diabetes (T2D) that have some illness which results in reduced fluid intake, and them becoming seriously dehydrated. Being sick with an infection is one such situation where it is very important for you to see your doctor if you have T2D, so they can monitor you for HHS. You can read more about HHS here.
If you come to see me to adopt a low carb diet, I will work with you to coordinate dietary and lifestyle changes with your doctor, as they monitor your health and adjust the levels of prescribed medications. In more complex cases, I may ask for written consent to coordinate care with your doctor because depending on those medications, your doctor may need to know in advance what level of carbohydrates you have been advised to eat so that they can monitor your health and make adjustments in your medication dosage.
Your health is important and your diet and the medications need to be coordinated and overseen by your doctor. The potential risks are too great to attempt to do this on your own.
Do you have questions as to how I could work with you and your doctor as they oversee you adopting a low carb lifestyle? Feel free to drop me a note using the Contact Me form on the tab above.
LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only. The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything you have read or heard in our content.
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