Month: July 2018

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Early Warning Signs that May Help Prevent Developing Type 2 Diabetes

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

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

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

The rest of the insulin stored in β-cells is only released when blood sugar rises after the person eats foods containing carbohydrate. This insulin is released in two phases [1]. The first-phase insulin response occurs as soon as the person begins to eat and peaks within 30 minutes and can be seen at 30 minutes on the graph above.

The amount of the first-phase insulin release is based on how much insulin the body is used to needing each time the person eats. Provided the person eats more or less the same amount of carbohydrate-based food at each meal, the amount of insulin in the first-phase insulin response will be enough to move the excess glucose from the food into the cells, returning blood sugar to ~5.5 mmol/L (100 mg/dl). If there is not enough insulin in the first-phase insulin response, the β-cells will release a smaller amount of insulin within an hour to an hour and a half of the person beginning to eat. This is the second-phase insulin response [1] and can be seen at 60 minutes on the graph above.

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

Dysfunctional Insulin Release & Insulin Resistance

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

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

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

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

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

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

The first-phase insulin response won’t produce enough insulin be able to clear the extra blood glucose after a high carbohydrate meal into the cells and even the second-phase insulin response won’t be enough to overcome the insulin resistance of the cells. At this point, the β-cells of the pancreas are unable to make enough insulin to clear the excess glucose from the blood and blood glucose rises above the normal high peak of 7.8 mmol/L (140 mg/dl), to levels of 9.0 mmol/L (160 mg/dl) or higher.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To your good health,

Joy

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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. Del Prato, S., P. Marchetti, and R.C. Bonadonna, Phasic insulin release and metabolic regulation in type 2 diabetes. Diabetes, 2002. 51 Suppl 1: p. S109-16.
  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.
  3. Crofts, C., Understanding and Diagnosing Hyperinsulinemia. 2015, AUT University: Auckland, New Zealand. p. 205.
  4. Halban, P.A., et al., β-cell failure in type 2 diabetes: postulated mechanisms and prospects for prevention and treatment. Diabetes Care, 2014. 37(6): p. 1751-8.
  5. Reaven, G., The metabolic syndrome or the insulin resistance syndrome? Different names, different concepts, and different goals. Endocrinol Metab Clin North Am, 2004. 33(2): p. 283-303.
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Stanford Blood Sugar Study Findings Known for More Than 45 Years

This week Stanford University published a study which substantiates the huge glucose spikes that “healthy” people with normal blood sugar levels experience and that Dr. Joseph Kraft began documenting 45 years ago [2,3,4] — until just before his death in 2017 [5].  To those of us that are familiar with the research of Dr. Kraft, this is a bit like the 1969 Apollo 11 lunar astronauts ‘discovering’ the existence of craters and mountains on the moon that were documented by Galileo in 1609.

Kraft called these abnormal glucose spikes along with the corresponding abnormal spikes of insulin ‘occult diabetes‘ or ‘diabetes in situ‘ [4] and used the term ‘occult diabetes’ to describe it since ‘occult’ in this context means “not accompanied by readily discernible signs or symptoms“.  It is these ‘covert’ glucose spikes that Stanford university researchers reported this week.

The Stanford Study

Stanford researchers gave 57 healthy subjects without prior diagnosis of diabetes continuous glucose monitors (CGM) that recorded their blood sugar fluctuations in their normal environment for two weeks. There were 32 women, 25 men — ranging in age from 25 to 76, with an average age of 51 years [1].

Subject’s Blood Sugar Upon Screening

Upon screening for the study, 5 of the subjects were discovered to have met criteria for having type 2 diabetes, as defined as HbA1c ≥6.5%, fasting blood glucose ≥ 126 mg/dL (7.0 mmol/L), or 2-hour glucose during 75 gram Oral Glucose Tolerance Test (OGTT) ≥ 200 mg/dL (11.1 mmol/L); 14 subjects were found to meet the criteria for prediabetes, defined as HbA1c > 5.7% and < 6.5%, fasting blood glucose 100—125 mg/dL (5.5 mmol/l-6.9 mmol/L) , or 2-hour glucose during OGTT 140—199 mg/dL (7.8-11.0 mmol/L). The remaining 38 subjects had normal blood glucose defined as fasting and 2-hour OGTT plasma glucose and HbA1c below the diagnostic thresholds for prediabetes and diabetes. Average fasting glucose was 93 mg/dL (5.2 mmol/L), 2-hour glucose 125 mg/dL (6.9 mmol/L) and HbA1c 5.4%[1].

Huge Variations in Blood Sugar Response

Researchers found that there was huge inter-individual (between individuals) and intra-individual (in the same individual at different times) variation in blood sugar response — which is exactly what a 2015 study that fitted 800 people with CGMs reported [6]. In light of only the glucose part of Kraft’s findings as well as the data from the Israeli study with a study population more than 10x the size, the Stanford findings are not ‘new’.

Using mathematical techniques including spectral clustering and dynamic time warping, researchers defined 3 clusters of glucose patterns which were said to capture 73% of the variation [1]. Based on the amount of variability in glucose levels in each cluster, researchers classified the 3 patterns as low, moderate and severe variability.

Some People had lots of Abnormal Glucose “Spikes”

The researchers found that each of the 3 patterns showed a progressive increase in both the severity and magnitude of the blood sugar fluctuations. As well, some subjects mainly stayed in the low variability range, whereas others were mostly in the moderate to severe variability range. These are basically rankings of blood sugar “spike” intensity [7].

Of significance, blood sugar in the individuals that were considered healthy fluctuated a lot more than what is normally picked up by standard ‘finger-prick’ methods of blood sugar testing and these fluctuations come in the form of “spikes’; which are rapid increases in the amount of glucose (sugar) in the blood, especially after eating specific foods — most commonly carbohydrate [7].

Dr. Michael Snyder, professor and chair of genetics at Stanford and senior author of the study said;

“There are lots of folks running around with their glucose levels spiking, and they don’t even know it. The covert spikes are a problem because high blood sugar levels, especially when prolonged can contribute to cardiovascular disease risk and a person’s tendencies to develop insulin resistance, which is a common precursor to diabetes.”

“We saw that some folks who think they’re healthy actually are misregulating glucose—sometimes at the same severity of people with diabetes—and they have no idea [7].”
~ Dr. Michael Snyder

Stanford researchers documented that abnormal glucose responses were more common than they previously thought [7], but these results come as no surprise to those of us familiar with Kraft’s research [2-5] and the findings of the 2015 study from Israel [6].

You can read more about the significance of these covert glucose and corresponding insulin spikes in this article titled When Normal Fasting Blood Glucose Results Aren’t Necessarily “Fine”.

Cornflakes For Breakfast?

The Stanford researchers conducted a sub-study in 30 subjects whose prior blood sugar tests indicated that they were “healthy” (i.e. not prediabetic or diabetic). They were fitted with continuous glucose monitors (CGMs) and alternated between 3 breakfasts; (1) a bowl of cornflakes with milk, (2) a peanut butter sandwich and (3) a protein bar.

Significantly, more than half of the “healthy” group had blood sugar spikes at the same high levels as those who were diagnosed as prediabetic or diabetic [1,7].

Dr. Michael Snyder, professor and senior author of the study said;

“We saw that 80% of our participants spiked after eating a bowl of cornflakes and milk. Make of that what you will, but my own personal belief is it’s probably not such a great thing for everyone to be eating[7].”

Ordinary Blood Tests Available to Detect These Abnormal “Spikes”

Different people respond to carbohydrate based foods differently and even the same individual can respond to the same carbohydrate-based food differently — depending on part on the degree of processing it has undergone, or whether it is eaten alone or after eating protein-containing foods (see two articles on the Perils of Food Processing for more information).

As elaborated on in a previous article titled “Are You Pushing Your Pancreas Too Hard, abnormalities in insulin, including insulin resistance and/or hyperinsulinemia begin to occur as much as 20 years before a diagnosis of Type 2 Diabetes [8]; while blood sugar results are still normal and the results of this new Stanford study underscores the need to diagnose these abnormalities by capturing the blood glucose and insulin spikes well in advance of that!

The problem is, if we only monitor people’s fasting blood glucose and glycated hemoglobin (HbA1C) as a screening tool, we can miss that someone’s pancreas is overworking by constantly producing too much insulin.

Even if a standard 2 hour Oral Glucose Tolerance Test (OGTT) is run, if a person’s blood glucose results are normal at fasting and normal at 2 hours (such as was the case in the Stanford study!), we will miss the “spike” that occurs 30 minutes to 1 hour after the glucose is consumed in those with covert glucose spikes. The way to capture those “spikes” is to run a 2 hour Oral Glucose Tolerance Test with simultaneous glucose and insulin and do the two measurements at baseline (fasting), 30 minutes / 1 hour, and at 2 hours. When we detect these “spikes”, we can implement dietary changes to avoid further β-cell damage or β-cell death whose end-result is type 2 diabetes.

The Cost of Documenting These “Spikes” – penny wise and pound foolish

For less than $130 (cost in British Columbia, Canada), a physician can order a 2-hour OGTT with both glucose and insulin measured at (a) fasting, (b) 1 hour and (2) 2 hours which will capture abnormal glucose spikes at 1 hour, as well as the underlying hyperinsulinemia.

When there are clinical reasons to suspect that a person may be insulin resistant and/or hyperinsulinemic, a blood test that assesses simultaneous glucose and insulin response to a glucose challenge can provide sufficient motivation for individuals to implement dietary changes that can prevent progression to Type 2 Diabetes.

is such a test that costs <$130 to the public healthcare system not good value when the cost per person per year of having Type 2 Diabetes in Canada ranges from $1611 to $3427 ( more about that here)?

In British Columbia, the cost of a standard 2 hour Oral Glucose Tolerance Test is $11.82 before tax and $13.36 with HST.

Each additional glucose assessment is $3.48 before tax and $3.93 after tax.

Each insulin assessment costs $32.82 before tax and $37.09 after tax, so a 2 hour Oral Glucose Tolerance Test with additional glucose assessor at 1 hour and 3 insulin assessors at fasting, 1 hour and 2 hour costs as follows;

2 hour Oral Glucose Tolerance (fasting, 2 hours)           = $  13.36  with GST
additional glucose at 1 hour                                                       = $   3.93   with GST
3 insulin assessors at fasting, 1 hour, 2 hours                   = $111.27  with GST
TOTAL                                                                                                   = $128.56 with GST

The reason often given by physicians for NOT requisition the above tests is that it is “saving healthcare system dollars”, but in those with clear risk indicators, how is it wise to ignore what can’t be detected with standard screening tests?

More Info?

If you would like more information about determining how you respond to carbohydrate containing foods and whether you are at risk for prediabetes type 2 diabetes especially if your blood sugar values appear normal on standard screening tests, I can help.

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

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

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
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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. Hall H, Perelman D, Breschi A, et al, 2018, Glucotypes reveal new patterns of glucose dysregulation. PLOS Biology 16(7). https://doi.org/10.1371/journal.pbio.2005143
  2. Kraft JR, Glucose Insulin Tolerance. A routine Clinical Laboratory Tool Enhancing Diabetes Detection. In O.B. Hunter. Jr. (ed): Radio assay: Clinical Concepts. Skokie, IL. Professional Education Dept. G.D. Searie & Co., 1974. Pp 91-106.
  3. Kraft JR, The Glucose Tolerance Examination: An Obsolete Procedure. read at the Symposium on Radioimmunioassay in Diagnostic Medicine.” Annual Convention, American Medical Association, Chicago, IL. June 26, 1974
  4. Kraft JR, Detection of Diabetes Mellitus In Situ (Occult Diabetes), Laboratory Medicine, Volume 6, Issue 2, 1 February 1975, Pages 10—22, https://doi.org/10.1093/labmed/6.2.10
  5. Crofts C, Schofield G, Zinn C, Wheldon M, Kraft J., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.
  6. Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094.
  7. Medical Press, July 24, 2019, Diabetic-level glucose spikes seen in healthy people, study finds, https://medicalxpress.com/news/2018-07-diabetic-level-glucose-spikes-healthy-people
  8. 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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American Diabetes Association (ADA) is Making Sense of Carbs

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

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

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

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

I am in complete agreement.

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

Uelmen explains,

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

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

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

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

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

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

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

This is true and I agree with her recommendation;

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

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

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

Uelmen makes other excellent points;

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

She offers this terrific advice;

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

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

Uelmen advises;

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

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

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

Uelman says;

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

…and this is excellent advice!

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

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

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

Final thoughts…

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

Why is this?

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

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

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

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

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

To our good health,

Joy

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

 

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Dairy Fat Doesn’t Increase the Risk of Cardiovascular Disease

A new study published this week in the American Journal of Clinical Nutrition reports that long-term consumption of the saturated fat found in full-fat dairy products is not associated with an increased risk of cardiovascular disease (atherosclerosis, coronary artery disease, etc.) or other causes of death, and may actually be protective against heart attack and stroke[1].

The study, which took place over almost a quarter of a decade, measured three specific fatty acids found in dairy products in 2,900 older adults, aged 65 years and above— first in 1992, again in 1998, and finally in 2015. The three fatty acids they measured were pentadecanoic, heptadecanoic, and palmitoleic acids.

During the 22 years, 2,428 of the participants died, of which 833 were due to heart disease.  When the data was analyzed, none of the three fats was associated with the risk of total mortality (death) or heart disease — in fact, high levels of heptadecanoic acid were associated with a lower risk of death from heart disease and stroke.

This is significant because while higher amounts of saturated-fat consumption, including the saturated fats in this study, increase blood LDL cholesterol, they also increase HDL cholesterol and decrease triglycerides[2], both of which are protective. Since it was unknown what the ‘net effect’ on total mortality (death) and cause-specific death, this study was done to determine what effect, if any, increased dairy fats had on these outcomes.

The results were clear.

Not only did long-term consumption of these three dairy fats not affect either total death or heart disease, but high levels of one of the fats found in full-fat dairy were actually found to be associated with a lower risk of heart disease and stroke!

The authors of the study conclude;

“For decades dairy fat consumption has been hypothesized to be a risk factor for CVD, as well as potentially diabetes, weight gain, and cancer, little empirical evidence for these effects existed from studies of clinical events. In current years, a growing number of prospective studies have shown generally neutral or protective associations between self-reported dairy foods and dairy fat consumption with the risk of CVD, diabetes, weight gain and cancers, raising questions about this conventional wisdom.”

The results of this long-term study with almost 3,000 older adults demonstrate that the saturated fat found in full-fat dairy is not associated with cardiovascular disease (CVD), diabetes, or cancer and may even be protective against both heart attack and stroke.

Final Thoughts…

With both the American and Canadian Dietary Guidelines currently being revised, and “front of label labeling” in Canada to advise against foods high in saturated fat, it is time for both the US Office of Disease Prevention as well as Health Canada to review their respective recommendations with regard to consumption of low-fat dairy, in light of current research.

Dairy protects play an important role in health and nutrition and are rich sources of calcium, potassium, and phosphorus, and are a ready supply of protein and essential fat, not only to growing children, but to older adults who risk osteoporosis and sarcopenia (muscle wasting). Given the results of this study on the saturated fat in dairy, as well as the results of a recent 158-country study which found that total fat and animal fat consumption were least associated with the risk of cardiovascular disease, it is time to re-evaluate the long-held belief that animal fat (whether in meat or dairy) is somehow ‘dangerous’.

A Few Words “Fat Phobia”

I regularly come across people in my practice who grew up in the last 40 years and who have spent their entire lives avoiding any form of animal fat.  The very idea of eating the yolk in an egg is a source of anxiety — and it need not be so.

I am not suggesting that these folks suddenly start eating copious amounts of eggs, meat, cheese, cream, and butter, but often suggest they start with things such as avocado, olives, nuts, and seeds that are rich in monounsaturated fats that have been less villainized than saturated fat. I encourage them to use a little cream on top of fresh berries or use a bit of butter to cook with. In time, I may show them delightful egg recipes that have other foods they are used to eating and enjoy, such as a spinach-ricotta pie, which makes a lovely summer-time dinner when it’s too hot too cook.

Overcoming “fat phobia” takes time — especially when it has been ingrained in you since you’re young. I understand. When we work together, you set the pace.

People are sometimes concerned that they can’t follow a low-carbohydrate lifestyle because they “can’t eat all that fat”, but the truth is, not all low-carb diets have large amounts of fat. It’s only because fat has 2  1/2 times the calories as both protein and carbs that some types of low-carb diets are still considered “high fat”. There is a whole range of low-carb diets as well as different types of ketogenic diets.

If you want to learn about my services and their costs, please visit the Services tab, above.

To our good health!

Joy

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. Otto MC , Lemaitre, RN, Song, X et al; Serial measures of circulating biomarkers of dairy fat and total and cause-specific mortality in older adults: the Cardiovascular Health Study,The American Journal of Clinical Nutrition, https://doi.org/10.1093/ajcn/nqy117
  2. Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 2003;77(5):1146—55

 

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Symptoms of Type 2 Diabetes ARE reversible – a Dietitian’s Journey

For the last 16-months my goal has been to put my Type 2 Diabetes into remission and to no longer meet the criteria for Metabolic Syndrome. Towards that end, last year on July 11, 2017 I had complete lab work done, including fasting insulin, cholesterol, fasting blood glucose and glycated hemoglobin (HbA1C) and planned to redo the same tests at the same time this July to see how much progress I was making.

The day I had been waiting for arrived!

So, how did I do?

Let’s see where I started from in July 2017;

fasting insulin July 11, 2017

Last year, my fasting insulin was 54 pmol/L which converts to 7.8 μU/ml — well above the ideal insulin sensitive range of 2-6 μU/ml. I was insulin resistant, which was no surprise given I had Type 2 Diabetes for more than 10 years.

What about yesterday – 16 months after starting a low carbohydrate lifestyle?

fasting insulin, July 10, 2018

I went from 54 pmol/L (7.8 μU/ml) to 33 pmol/L (4.8 μU/ml). I no longer have high insulin; in fact, my insulin was now in the ideal range, between 2-6 μU/ml. Very cool!

But then what explains why my fasting blood sugar is still so high?

fasting blood glucose July 11, 2017

I mean, it has dropped a lot from 8.0 mmol/L  (144 mg/dL) last year to 6.9 mmol/L (124 mg/dl) this year, but this was still a huge disappointment.  Yes, many days my fasting blood sugar is in the low 5’s mmol/L (94-95 mg/dl) but not this time. It was at the high end of what it goes to!

Why?

fasting blood glucose July 10, 2018

In the last several months, I’ve been losing a lot of fat from my abdomen (2.5 more inches since the beginning of March, on top of the 8 inches I lost in the first year) and the end result of the action of hormone sensitive lipase on fat cells (adipocytes) is the release of free fatty acids and glycerol. The liver cells (hepatocytes) take the glycerol and turn it into glucose in a process called gluconeogenesis (literally “making new glucose”).  It is this glucose that is produced by my liver from my broken down fat stores that is raising my fasting blood sugar.

The good part is that my fat cells are emptying out.  The bad part is that my liver is making glucose out of it…and what complicates the matter is that I have what’s called “peripheral insulin resistance” from often eating only once a day (time-restricted-eating) and that causes my body to “save” the glucose for necessary processes.  As a result, my body cells don’t take in the excess glucose made by my liver and it hangs around in my blood until I get moving.  Then it will dissipate (provided I eat some breakfast).

What about my glycated hemoglobin (that is effectively the three month average of my blood sugar)?

glycated hemoglobin (HbA1C) July 11, 2017

A year ago, my HbA1C  was 7.5% which is well above the cutoffs of 7% which is set for those with Type 2 Diabetes.

glycated hemoglobin (HbA1C) July 10, 2018

This year it was 6.3% which is below the cutoffs for Type 2 Diabetes of 6.5% and lower than what it was 3 months ago, which was 6.4%. Naturally, it is higher than I would like because it includes all the glucose my liver is making from the fat cells it is breaking down, but sooner or later it is going to run out of that!  Soon my waist circumference WILL be half my height and around that point, my fasting blood glucose should be dropping.  My goal is to see my HbA1C below 5.5 mmol/L (100 mg/dl) and be in full remission from Type 2 Diabetes, not only partial remission which is what I have now.

But celebrating the victory, I am in partial remission of Type 2 Diabetes!!

So how have my lipids changed this last year, with the butter, coconut oil and coconut milk and full fat cream that I have been eating, as well as much more meat than I used to?

Last year, four months into my following a low-carbohydrate diet, this is what they looked like:

Lipid panel, July 11, 2017

 

…and this year?

 

Lipid panel, July 10, 2018

My LDL is down (2.60 to 2.47 mmol/L) , my HDL is up significantly (1.97 to 2.44 mmol/L), my non-HDL cholesterol (chylomicrons and VLDL) is down (2.45 to 2.11 mmol/L) and my already low triglycerides went even LOWER (0.64 to 0.52 mmol/L).

In July 2017 my TG:HDL ratio was 0.35, which is well below 0.87 and this year my TG:HDL ratio was 0.21! This means that of my LDL cholesterol, most are the large fluffy kind (the ‘good’ LDL), and not the small dense kind (the ones that put us at cardiovascular health risk).

I no longer meet the criteria for Metabolic Syndrome which is having 3 or more of the following 5 symptoms:

Criteria for Metabolic Syndrome – from Merck Manual

My waist circumference is significantly <35″

My blood pressure is well below 130/85 (usually around 120/70)

My triglycerides are well below 1.7 mmol/L (150 mg/dl) at 0.52 mmol/L

My HDL is well above 1.29 (it’s 2.44 mmol/L!!)

…but yes, my fasting blood glucose is still > 5.6 mmol/L (100 mg/dl).

So, I’m not “done” yet.

While I didn’t get “perfect” blood work, it’s pretty good for someone that 16 months ago was obese, had been Type 2 Diabetic for 10 years, had been diagnosed 3 years earlier with mast cell disease (which elevates blood sugar and insulin), had extremely high blood pressure and abnormal cholesterol.

Not bad at all.

…and all this by simply reducing my carbohydrate intake and eating whole, real food, including fruit, dairy, meat, lots of veggies and healthy fats from a variety of sources.

Of course, these are only my results. Everyone is different, but at a year, my results closely mirrored the results Virta Health’s study published at one- year study, with 218 subjects that had been eating the same as I have. So, it is certainly not unusual for people following a well-designed low carbohydrate diet to get these kinds of results.

NOTE: There is no “one-size-fits-all” low carbohydrate diet and what works for me may not be what is best for you. Before undertaking a major change in diet, please discuss your plans with your doctor.

Perhaps you wonder what adopting this type of eating style would look like for you, or have questions about how Distance Consultation services work compared with in-person services, and the cost involved. Please send me a note using the ”Contact Me” form above and I’ll reply shortly.

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. Merck Manual – Metabolic Syndrome (Syndrome X; Insulin Resistance Syndrome), https://www.merckmanuals.com/en-ca/professional/nutritional-disorders/obesity-and-the-metabolic-syndrome/metabolic-syndrome

 

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Update on My Own Weight Loss Journey

It’s 16 months since I began my own weight loss journey and I thought it would be a good time to do updated “before” and “now” photos, as well as some measurements.

The photo on the left was me “before”.

Not only was I very overweight, but I had Type 2 Diabetes, high blood pressure and high cholesterol and was in denial about how very metabolically ill I was.

I was in denial partly because I believed that I was eating a healthy diet for someone with Type 2 Diabetes. I dutifully followed the recommended diet from the time I was pre-diabetic until I was diagnosed as having Type 2 Diabetes and continued on it because that is what was recommended to control my blood sugar. I deliberately avoided missing meals or fasting, to keep my blood sugar stable.

As per the recommendations for Diabetics (covered in an article I wrote here), I ate 193 – 259 g of carbs per day, plus sufficient daily protein for my age and a little essential fat.  Keep in mind that only the recommended amount of daily carbs adds up to ~800 – 1000 calories per day — and with sufficient protein for my age was another ~4oo calories, plus another ~150 calories or so in olive oil and a few nuts or seeds on my salad. With intake of 1400 – 1500+ calories per day, how was I supposed to lose weight?

If “eating less” wasn’t an option for me then of course, I was expected to “move more”.  If I didn’t move enough to burn off the excess carbohydrates that I was expected to eat as someone with Type 2 Diabetes, then this was my fault. This is why I was fat, right?

Really?

My diet was “healthy” by most people’s understanding — certainly as defined by the Dietary Guidelines (Canada’s Food Guide) as well as the Clinical Practice Guidelines for Diabetes. My bread was whole grain and so was my pasta and I ate brown or red cargo rice (with the husk). Lunch and dinner and my 2 snacks per day were comprised of lots of fruit and vegetables of all kinds along with some lean protein; 3-4 oz at each meal and an ounce of cheese at snacks.  I barbecued meat, fish and chicken all year round and if I did pan-fry something, I always poured off the ‘excess fat’. The quantities I ate were recommended by the guidelines and as evidenced by the fact that I neither gained, nor lost any weight.

Eating 65 g of carbs at each meal along with protein and 45 g of carbs at each of 2 snacks each day along with a bit of protein however didn’t help me avoid getting Type 2 Diabetes — so what was I expecting to accomplish eating this way after I was diagnosed?* It was supposed to help me manage my blood glucose levels, but unfortunately after a few years of eating that way, I ended up getting high blood pressure and then abnormal cholesterol as well, which is common.

*I believe that some people with Type 2 Diabetes do well eating according to the standard recommendations of the Clinical Practice Guidelines and others by following a whole foods, Mediterranean-style Diet. There is also strong research evidence that still others achieve excellent clinical results following a therapeutic low carb or a well-formulated ketogenic diet for a period of time. There is no one-size-fits-all diet for everybody and it is for this reason that I offer people choices.

When I saw my Endocrinologist 2 1/2 years ago, she said that if I kept eating as I had been, that in 2 years I would be on medication for Diabetes, hypertension and high cholesterol — and within 5 years, I would be on insulin. At that time, I discussed with her my intention to eat a low carb diet and how low in carbohydrate I was willing to go, if I needed to. I was expecting a great deal of resistance from her, given some doctors consider a low carb diet unconventional. Her response surprised me. She told me that me that eating very low carb was the best chance that I had to avoid the scenario she outlined above as well as the complications of Diabetes, including blindness and lost limbs. In fact, she recommended less grams of carbs per day than I was intending.

Unfortunately, it took another 2 years before I became metabolically unwell enough to actually implement the dietary change, but with my Endocrinologist’s approval and encouragement, as well as my GP monitoring my health, March 5, 2017 I began changing how I was eating and I’ve never looked back.

Me – July 2 2018 (16 months later)

The photo on the left is of me on the Canada Day stat (July 2nd), which was Monday.

As of today, 16 months along I’ve lost;

  • 39 pounds (18 kg)
  • 10.5 inches off my waist (27 cm)
  • 2.5 inches off my chest (6.5 cm)
  • 3 inches off my neck (8 cm)
  • 1.5 inches off each arm (4 cm)
  • 1.5 inches off each thigh (4 cm)
  • Both my HbA1C and FBG are in the non-diabetic range
  • My blood pressure is normal for someone without Type 2 Diabetes
  • My lipids (cholesterol and triglycerides) are considered ideal.

I still have an inch and a half to lose off my waist to get to where my waist circumference is half my height and I’m guessing that will take me losing another 18 lbs but who knows? Whatever it is, it is. I had a foot to lose from my waist when I started — so what’s an inch and a half more?

Now, “moving more” is possible! Yesterday, as I do most weekends, I walked for 2 hours and wasn’t tired at all. I work out each week doing slow High Intensity Training and love it and am thinking about joining a dance class in September.  “Moving more” is the result, not the solution.

Keep in mind that my results are only relevant to me, as I am ”a sample-set of one” (n=1). As well, my doctor’s recommendations to me may not be the same as your doctor’s recommendations to you. Everyone’s results following a low carb diet will differ, because each person’s Meal Plan will be based on their own medical history, any metabolic conditions they may have, medications they are taking, their family risk factors, starting weight and lifestyle factors. What my journey and yours will have in common if you’re working with me is that it will begin as a moderately low carb intake, where you’ll be eating whole foods from all food categories, with your doctor monitoring your labs and the dosage of any medication that you may be taking.  I’ll gradually lower the amount of carbohydrate you’re eating only as necessary to achieve the clinical outcome(s) that you’re seeking, and with you doctor monitoring the dosage of any medications you’re taking. This often has to occur quite soon after lowering the amount of carbohydrates and in time they may be discontinued entirely.

Some “low carb diets” available on the internet or in popular books promote unlimited amounts of meat, cream, butter and eggs and others promote (or promise) “rapid weight loss”.  I don’t do either. But if you are looking for a Dietitian to support your desire to eat a low carb diet in order to lose weight and lower metabolic markers of Type 2 Diabetes, high blood pressure or abnormal cholesterol, then I’d be glad to be part of your healthcare team.

I have almost a decade of experience providing services via Distance Consultation (Skype and long telephone) and for those living in the Lower Mainland of British Columbia you can see me in-person in my Coquitlam office.

Perhaps you have questions about how I might be able to help you?

Please send me a note using the ”Contact Me” form above and I will reply shortly.

To your good health,

Joy

Note: I am a "sample-set of 1" - meaning that my results may or may not be like any others who follow a similar lifestyle. If you are considering eating "low carb" and are taking medication to control your blood sugar or blood pressure, please discuss it with your doctor, first.

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.