Is the Glycemic Index Reliable for Predicting Blood Sugar Response?

The infographic below has been making the rounds recently on social media and is based on the idea that high Glycemic Index (GI) foods can be represented by the effect those foods have on people’s blood sugar, compared to teaspoons of sugar.

(Reference “from bit.lv.carbs-vs-fat”)

The infographic below is one that I designed to explain the work of Dr.  David Unwin who communicates the concept of Glycemic Index (GI) & specifically Glyemic Load (GL) in terms of how they impact blood sugar compared to teaspoons of ordinary table sugar, as outline in this post on my affiliate web site.

Here is one of Dr. Unwin’s infographics which describes the effect each food has on blood glucose based on Glycemic Index (1). 

Infographic for health professionals to show how the glycemic index helps inform dietary choices (from Unwin D, Haslam D, Livesey G. It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance. 2016;1(1))

The problem is, these tools are only as useful as Glycemic Index is reliable, so the question is, is GI (and GL which is derived from it) reliable for predicting blood sugar response?

If the Glycemic Index (GI) values (1) change between individuals for the same amount of the same food or (2) if they change value within the same individual when they are assessed at different times, then they cannot be relied on to predict blood sugar response in an individual.

Is Glycemic Index Reliable for Predicting Blood Sugar Response?

A study published in  the American Journal of Clinical Nutrition (2) reported that individual response to individual carbohydrate-containing food vary so much that Glycemic Index values may not be useful in indicating blood sugar response in individuals.

The Study

Randomized, controlled, repeated tests on 63 healthy adults participated in 6 testing sessions over a twelve week period and fasted and abstained from exercise and alcohol before each session.

During each session participants ate either (1) white bread (test food) or (2) a standardized glucose drink (reference control).

Blood sugar values were measured at several points over the next 5 hours, and Glycemic Index was derived by testing the test food and reference in the same participant according to standard method. This is usual practice to control for the variability between people which may be caused by biological differences.

Results

Out of the 63 participants, in 22 participants blood sugar response was classified as “low”, in 23 participants it was classified as “medium” and in 18 participants it was classified as “high’ for the same amount of bread.

That is, white bread fell in all three Glycemic Index categories with different individuals. In addition, responses within the same individual varied by as much as 60 points between tests.

Interpretation of the Results

The study indicated that blood glucose response is affected by differing physical structure of similar foods, the effect of food processing and preparation methods, as well as meal consumption patterns (single or mixed meals).

The study authors concluded that the high inter- (between people) and intra-individual (within the same person) variation that was observed in the GI value of foods essentially resulted in the results being of no practical value.

“In summary, our data indicate substantial variability in GI value  determinations for white bread despite the use of standardized methodology and multiple testing in a large number of healthy volunteers. The high degree of variability demonstrates that there is potential to misclassify foods into the 3 commonly used GI categories (low, medium, and high), which would result in the inability to distinguish between foods, thus invalidating the practical applicability of the GI value.

 

The authors also indicated that this variability was also partly explained by differences in baseline HbA1c (i.e. glycated hemoglobin) which is an estimate of 3 month average of blood glucose control, as well as the insulin index (the differing insulin response to foods) both affect the GI value.

Individual Glycemic Response

It should be noted that inter-individual and intra-individual variation in glycemic response isn’t only to white bread, as in the above small study.

A 2015 study from Israel(3) involving 800 people who were monitored with continuous glucose monitors (CGMs) indicates that there isn’t a ‘universal’ blood sugar response to either low Glycemic Index foods or high Glycemic Index foods, and that glycemic (blood sugar) response is very individual.

“We continuously monitored week-long glucose levels in an 800-person cohort, measured responses to 46,898 meals, and found high variability in the response to identical meals, suggesting that universal dietary recommendations may have limited utility”.

Some Final Thoughts…

One cannot reliably predict that a specific amount of carbohydrate-based food will raise a person’s blood sugar the same amount as a certain number of teaspoons of sugar, because each carbohydrate based food will have different effects on different people, and different effects within the same individual, at different points in time.

More Info?

If you would like to know how to determine how you respond to specific carbohydrate-based foods and how to know which carbohydrate-based foods spike your blood sugar and which don’t, I can help.

You can learn more about my services including individual appointments and packages above under the Services tab or in the Shop.

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

Reference

  1. Unwin D, Haslam D, Livesey G. It is the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited. Journal of Insulin Resistance. 2016;1(1), a8. http://dx.doi.org/10.4102/jir.v1i1.8
  2. Matthan NR, Ausman LM, Meng H, Tighiouart H, Lichtenstein AH. Estimating the reliability of glycemic index values and potential sources of methodological and biological variability. Am J Clin Nutr. 2016;104(4):1004–1013. doi:10.3945/ajcn.116.137208
  3. Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094.
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Cancer Cases Related to Excess Weight Will Triple Over Next 20 Years

A new study published today in Preventive Medicine estimates that excess body weight, including overweight and obesity is expected to become the second leading cause of preventable cancer in Canada, after tobacco over the next 20 years.

Cancer Rates Expected to Triple

The results of the new ComPARe study (Canadian Population Attributable Risk of Cancer) stemming from research conducted by the Canadian Cancer Society and a Canadian team of experts in epidemiology, biostatistics, cancer risk factors, and cancer prevention provides estimates of the number and percentage of more than 30 cancer types in Canada. 

It found that if current trends continues, it is expected that new cancer cases related to overweight or obesity will triple over the next 20 years, from the current 7,200 cases per year to 21,200 cases per year. These figures are due to overweight and obesity alone and do not include the increase number of cancer cases that are expected due to smoking, physical inactivity / sitting too much or alcohol consumption.

Excess body weight increases the risk of esophageal and endometrial cancer by about 50% and increases the risk of kidney, gallbladder, stomach and liver cancers by 20-30%.  Achieving and maintaining a healthy body weight can substantially lower the risk of these, and other cancers. The study estimates that if Canadians maintained a healthy body weight (BMI ⩽  25), that approximately 110,600 cancer cases could be prevented by the year 2042.

UPDATED (May 8, 2019 5:00 PM): It is not body weight per se that increases the risk of cancer. There are several proposed mechanisms where excess body weight may increase cancer risk, including alterations in the levels of hormones and growth factors, chronic inflammation, excess insulin and leptin. It is thought that excess insulin may help promote cancer cell growth and cause insulin resistance, which
increases the risk of colon, endometrial and kidney cancers in particular.

If you’d like to know how I can help you with symptoms of overweight or obesity (or some of the metabolic disorders that often accompany them), please let me know.

You can learn more about my services and their costs above under the Services tab or in the Shop and if you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To our good health!

Joy

You can follow me on:

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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.

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ADA: Brain’s Need for Glucose can be Fulfilled by the Body

In its recently published Consensus Report (April 18, 2019), the American Diabetes Association confirmed something that I have written about in several previous articles, including most recently in Part III of Carbohydrates are Not Evil and that is that it isn’t biologically essential to eat carbohydrate containing foods in the diet. From the top of page 4 of the Consensus Report:

“The amount of carbohydrate intake required for optimal health in humans is unknown. Although the recommended dietary allowance for carbohydrate for adults without diabetes (19 years and older) is 130 g/day and is determined in part by the brain’s requirement for glucose, this energy requirement can be fulfilled by the body’s metabolic processes, which include glycogenolysis, gluconeogenesis (via metabolism of the glycerol component of fat or gluconeogenic amino acids in protein), and/or ketogenesis in the setting of very low dietary carbohydrate intake.”

Body can make all the glucose it needs for the brain

That is, the body can make all the glucose the brain needs from the glycogenolysis (which is the breakdown of glycogen to glucose), via  gluconeogenesis (which is the generation of glucose from glycerol or glucogenic amino acids) and via ketogenesis(which is from ketones generated in a very low dietary carbohydrate [ketogenic] diet). In short, dietary intake of carbohydrate is not essential. While there is no biological need to eat carbohydrate-based food, one certainly can and there are many good reasons to include some types of carbohydrate-containing food in the diet.

Because there is no essential need to eat carbohydrate because the body can make all the glucose it needs itself, the American Diabetes Association includes among its eating patterns both a low carbohydrate pattern (26-45% daily calories as carbohydrate) and a very low carbohydrate (ketogenic) eating pattern (20-50 g carbohydrate / day). How much carbohydrate is a major consideration for those who are pre-diabetic or Diabetic because as the ADA stated in this new consensus report;

“Carbohydrate is a readily used source of energy and the primary dietary influence on postprandial blood glucose.

That is, it is the carbohydrate in a meal that is the biggest predictor of how high blood sugar will rise after a meal, and how quickly. For those who want to improve their blood sugar levels (glycemia) the same report also makes it clear that;

Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia* and may be applied in a variety of eating patterns that meet individual needs and preferences.”

For those adults with Type 2 Diabetes who are not meeting their blood sugar targets or who need to, or want to have their physician reduce their need for Diabetes medications, a low carbohydrate or very low carbohydrate (keto) eating pattern is a viable option;

“For select adults with type 2 diabetes not meeting glycemic targets or where reducing anti-glycemic medications is a priority, reducing overall carbohydrate intake with low or very low- carbohydrate eating plans is a viable approach.”

Remember, carbohydrate-based foods are not necessary for your brain because your body can make all the glucose it needs from the metabolic processes listed above. That’s not to say one has to avoid carbohydrate-based foods, but how much and how often can and is best determined based on people’s individual needs and glycemic response to carb-based foods.  I recently outlined in another article based on the American Diabetes Association’s Consensus Report and which was posted on my affiliated low carbohydrate-focused website, that in the US a well-designed low carb or ketogenic diet to lower blood sugar need not have all the same foods or food groups as a diet based on The Dietary Guidelines for Americans because it is used as Medical Nutrition Therapy (i.e. is a therapeutic diet).

While these are the guidelines in the US, in Canada individuals have the right to choose a low carbohydrate lifestyle if that is their personal preference.

If you would like some professional support to begin eating this way or to continue eating this way,  I can help. I provide Registered Dietitian services to those in any province in Canada (except PEI), and for those in the US, I can provide nutrition education to help you know how to eat according to a low carb eating pattern.

You can learn more about my services including individual hourly appointments and sessions as well as packages above under the Services tab or in the Shop and if you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

Here are the links to other articles that I wrote about the new ADA Consensus Report:

April 24, 2019 – ADA Eating Patterns Differ from The Dietary Guidelines for Americans April 23, 2019 –  ADA includes use of a Very Low Carb (Keto) Eating Pattern in New Report

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Reference

Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014 Copyright

©2019 The LCHF-Dietitian (a division of BetterByDesign Nutrition Ltd.)

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

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ADA includes use of a Very Low Carb (Keto) Eating Pattern in New Report

On April 18, 2019, the American Diabetes Association published a new Consensus Report which not only includes the use of a low carbohydrate eating pattern of 26-45% of total daily calories as carbohydrate, but in this report also includes the use of a very low carbohydrate (ketogenic) eating pattern of 20-50 g carbs per day. The report is clear that there is no “one-size-fits-all” eating pattern for the prevention or management of diabetes, and that it unrealistic to expect that there should be just one eating pattern for everyone; especially given the wide variety of people affected by diabetes and pre-diabetes, including their varied cultural backgrounds, personal preferences, co-occurring conditions and the variety of socio-economic backgrounds from which they come.

The new report underlines several eating patterns that are effective to varying degrees for achieving different goals, with potential benefits including HbA1C reduction, weight loss, lowered blood pressure, improved lipids (higher HDL-c, lower LDL-c), lower triglycerides (TG), but says clearly that low carb eating patterns show the most evidence for blood glucose control;
 

“Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia (blood sugar) and may be applied in a variety of eating patterns that meet individual needs and preferences.”

The new Consensus Report includes low carb eating patterns and very low carb (keto) eating patterns among the choices of eating patterns for those with pre-diabetes as well as adults with Type 1 or Type 2 Diabetes.
 
The various eating patterns with their different potential benefits are summarized in Table 3, below;
 
Table 3 – Eating Patterns reviewed for this report
 
The report also indicates that for adults with Type 2 Diabetes not meeting their blood sugar targets, or where there is a need to lower anti-glycemic medications that lower blood sugar, that
 
reducing overall carbohydrate intake with low- or very low- carbohydrate eating plans is a viable approach.”
 
If you have been recently diagnosed as pre-diabetic or as having Type 2 Diabetes (T2D) and would like support to reverse the symptoms through a low carbohydrate or very low carbohydrate eating pattern, then I can help.  I also don’t believe there is a “one-sized-fits-all” approach to either of these and will work within you needs to design an individual plan just for you. 
 
You can learn more about my services including individual hourly appointments and sessions as well as packages above under the Services tab or in the Shop.
 
If you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.
To your good health!
 
Joy
 
You can follow me on: Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd

Copyright ©2019 BetterByDesign Nutrition Ltd.)

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

Reference

Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
 
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Eating one slice of bacon per day does NOT increase your colon cancer risk

Yesterday, the headlines screamed out from around the world that a new study from Oxford University found that there is a 20% higher chance of developing colorectal cancer from eating as little as one strip of bacon per day. This sounds terrible, but is it true? To understand what this study is reporting, it is important to understand the difference between relative risk and absolute risk.

Absolute Risk

It was known before this study, that regardless what people eat, there is approximately a 5% chance of developing colorectal cancer in a person’s lifetime (whether they eat bacon every day or not). This is known as the absolute risk.

A 5% likelihood means that for every 100 people, 5 will get colorectal cancer regardless what they eat.

Illustrated, this looks as follows;

Absolute Risk: 5% = 5 per every 100 people

Relative Risk

The study reported that there is a 20% higher chance of developing colorectal cancer by eating as little as one strip of bacon per day.

This means that compared to not eating bacon daily, eating it daily results in one more person per 100 people developing colorectal cancer in their lifetime.

This is known as relative risk and illustrated that looks as follows:

20 % increase in relative risk

Headlines as click-bate

“People who ate 76 grams of red and processed meat per day — that’s in line with current guidelines and roughly the same as a quarter-pound beef burger — had a 20% higher chance of developing colorectal cancer compared to others, who ate about 21 grams a day” – https://www.cnn.com/2019/04/17/health/colorectal-cancer-risk-red-processed-meat-study-intl/index.html

It wasn’t only the American media that reported this, Canadian new outlet CTV did also.

Scientists found that colorectal cancer risk rose 20 per cent with every 25 grams of processed meat people ate per day, equivalent to a strip of bacon or slice of ham. (https://www.ctvnews.ca/health/just-a-strip-of-bacon-a-day-increases-cancer-risk-u-k-study-finds-1.4383867)

Each individual person’s increased risk of getting colorectal cancer by eating as little as 1 strip of bacon per day is NOT 20%! Their increased absolute risk of getting colorectal cancer (*based on this study) is 0.08%.

*this study was an epidemiological study, not a clinical study and can only show if there is an association between two factors and cannot make any conclusions about cause. The difference is explained below.

The study found that for every 10,000 people who ate 21g a day of red and processed meat, 40 were diagnosed with colorectal (bowel) cancer, and a single slice (or rasher) of bacon is ~23g.

i.e. 40 / 10,000 = 0.4%

The study also found that for every 10,000 people who ate 76g a day of red and processed meat, 48 were diagnosed with colorectal (bowel) cancer.

i.e. 48/10,000 = 0.48%

The actual chance of a person getting colorectal cancer (i.e. absolute risk) from eating bacon daily is the difference between these two numbers; i.e. 0.4% – 0.48% = 0.08%

Association is not Causation

This was an epidemiological study based on population data, and was not a clinical study.

Epidemiological studies are the study of diseases in populations and are helpful for researchers to know which areas warrant clinical studies.

It is important to know that epidemiological studies cannot attribute “cause” of disease or death. When an epidemiological study finds an “association” between two factors  such as bacon and higher colon cancer rates — this does NOT mean that eating bacon ’causes’  heart disease.

Based on this study, all that can be said is that there was an increase in the association between eating bacon and absolute rates of colon cancer of 0.08%.

Not so impressive now, is it?

If you are having trouble sifting through all the information you read and in knowing if it is accurate, or even says what it seems to be saying, I can help. Sometimes people start by booking an appointment just to ask me those types of questions, because they want credible answers.

You can learn more about my services including individual hourly appointments and sessions as well as packages above under the Services tab or in the Shop.

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

Reference

Kathryn E Bradbury, Neil Murphy, Timothy J Key, Diet and colorectal cancer in UK Biobank: a prospective study, International Journal of Epidemiology, , dyz064, https://doi.org/10.1093/ije/dyz064

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Is Walking ‘Real’ Exercise?

I often get asked if walking is “real” exercise, so this morning I decided to respond to that question in this short (< 5 minute) video.

In it I share some of the reasons I choose to walk and when, along with other options that may work better for you. I also talk about some of walking’s health benefits when it comes to those who are Type 2 Diabetic or in remission from it.

Please keep in mind that the information contained in this video is of a general nature and may be able to be applied to almost anyone, provided it is adapted for each person’s specific clinical needs.

If you’d like to know how I can help you to get started eating healthier or being more active, please let me know.

You can learn more about my services and their costs above under the Services tab or in the Shop and if you have questions, please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To our good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD (low carb focused)
Facebook: https://www.facebook.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.

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New Study: Vitamin and Mineral Supplements Won’t Help You Live Longer

A newly published large-scale epidemiological study has reported that taking vitamin and mineral supplements does not reduce the risk of cardiovascular disease such as heart attack and stroke, cancer rates or other causes of health-related death. The study published Tuesday, April 9, 2019 in the Annals of Internal Medicine analyzed US nutritional data from 30, 899 adults over the age of twenty from the NHANES survey between 1999 to 2010 and linked it to mortality data from the National Death Index [1]. During the six year follow-up period there were 3613 deaths; of which 945 were cardiovascular-related and 805 were from cancer.

Vitamin and Mineral Supplement versus Nutrient Intake from Food

The study found that use of vitamin and mineral supplements was not related to improved outcomes in rates of death from cardiovascular disease, cancer or all-cause health related death. Adequate intake of vitamin A, vitamin K, magnesium, zinc and copper was associated with reduced rates of cardiovascular disease and death from all health-related causes, but these improved associations only applied to those who obtained these nutrients from food.

Calcium Supplements – too much of a ‘good’ thing

So many adults take calcium supplements, however  calcium intake from supplements of ≥ 1000 mg/day (which many adults take!) was associated with increased risk of death from cancer.

Want to Live Longer? Eat Whole, Real Food

Based on this large-scale epidemiological study, eating foods rich in vitamin A, vitamin K, magnesium, zinc and copper was associated with reduced rates of cardiovascular (CVD) disease and death from all health-related causes. Good news! All of these nutrients are widely available in whole, real foods that also happen to be low in carbohydrate.

Zinc and Copper

Meat and seafood are some of the richest sources of zinc and copper.

Vitamin K

Dark, leafy greens  are excellent sources of vitamin K. Vitamin K is needed to help the body absorb vitamin D and to help with proper calcium utilization.

Magnesium

Nuts and seeds, including cocoa beans (think ‘dark chocolate’!)  are very good sources of magnesium, as are avocados

Vitamin A

…and yellow and orange vegetables are excellent sources of vitamin A.

Final thoughts…

Epidemiological studies (which are the study of diseases in populations) are helpful to know what areas warrant good quality clinical trials, but aren’t useful for attributing “cause” of disease or death. When an epidemiological study finds an “association” between two factors, this does NOT mean that one causes the other.  For that, clinical trials are necessary. That said, eating whole, real foods that also happen to be low in carbohydrate are an excellent way to get all of the nutrients that this study found are associated with lower rates of cardiovascular disease and death from all health related causes and it is pretty difficult to eat too much of any nutrient when eating whole, real food. Since taking vitamin and mineral supplements is not associated with lower rates of disease or death, and in the cases of calcium supplements may even be associated with negative health outcomes, eating a whole-food diet rich in the above foods is the safest way to ensure adequate intake of these nutrients. If you would like more information about how much of these foods you should be eating, I’d be glad to help. Please have a look at the Services tab or the Shop for more information. To your good health! Joy You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd. LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Reference

  1. Chen F, Du M, Blumberg JB, Ho Chui KK, Ruan M, Rogers G, et al. Association Among Dietary Supplement Use, Nutrient Intake, and Mortality Among U.S. AdultsA Cohort Study. Ann Intern Med. [Epub ahead of print ] doi: 10.7326/M18-2478
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Complex Carbohydrates as Long Chains of Sugar Molecules

An analogy is a comparison between similar ideas to help illustrate one of them. The featured photo for this post are sugar crystals on a string and the reason for this will become clear. The idea for this article came when someone I follow on social media (Dr. RD Dikeman*) posted the graphic below, which shows complex carbohydrates as long strings of glucose, which starches are. But there are also other types of complex carbohydrates that are long strings of different sugar molecules that can impact blood glucose differently. I thought a simple explanation of what “complex carbohydrates” are, how they are digested and how these can affect blood sugar differently might be helpful, so that is what this article is about.

graphic from RD Dikeman, Typeonegrit

*Dr. RD Dikeman holds a PhD in Theoretic and Mathematical Physics and has become very knowledgeable in carbohydrate metabolism as a result of his son having been diagnosed in 2013 with Type 1 Diabetes. His son was eating 40-60 g of carbohydrate per meal and was experiencing a “roller-coaster ride” of high and low blood sugars, including an incidence of “ketoacidosis”; which is a life-threatening condition when the body produces high levels of ketones due to an insufficiency of insulin. This should not be confused with “ketosis” where the body switches to using fat stores for energy, such as after an overnight fast. Five years ago, Dr. Dikeman’s son began to follow the low carbohydrate protocol of Dr. Richard Bernstein MD (outlined in his book “Diabetes Solution”) and since that time has been able to maintain normal normal blood sugar levels with the minimum required doses of insulin. 

I liked the analogy of Dr. Dikeman’s graphic and wanted to use it as a ‘jumping off point’ for this article.

Glucose Explain Simply

Glucose (also called dextrose) is the type of sugar found in the blood which is why the common term “blood sugar” and the more clinical term “blood glucose” refer to the same thing. Glucose is one of the two sources of energy (along with ketones) that are used to fuel the body’s cells. Even people that don’t eat “low carb” will make ketones after a night’s sleep, so the body of healthy people runs on both glucose and ketones. The carb-containing foods that we eat are broken down into glucose for energy or the body makes the glucose it needs for the brain and red blood cells from other substances in a process called gluconeogenesis.

The Glucose-Complex Carb Analogy

In the graphic above, Dr. Dikeman questions whether people such as Diabetics that have trouble metabolizing glucose should be eating complex carbohydrates which are essentially just long strings of glucose molecules strung together like beads on a chain. As in Dr. Dikeman’s illustration, some complex carbohydrates such as starch are just long chains of glucose molecules,  however other complex carbohydrates are made up of other sugars such as galactose and fructose, along with glucose. Because of that I wanted to expand on Dr. Dikeman’s illustration.

Simple and Complex Carbs

One way that carbs are sometimes classified is as “simple” or “complex”; with starch and fiber being categorized as complex carbs and all sugars being categorized as simple carbs.

Simple Sugars

There are two types of simple sugars; monosaccharides and disaccharides. Mono means “one” and saccharides means “sugar” so a monosaccharide is just a single sugar molecule. Di means “two”, so a disaccharide is two sugar molecules joined together.

Monosaccharides

As mentioned above, monosaccharides are made up of only a single sugar molecule and examples of these are glucose, fructose and galactose. All three monosaccharides have 6 carbons and the same chemical formula but look entirely different from each other. For example, glucose and galactose are 6-ring sugars and fructose is a 5-ring sugar. Glucose is usually found in food bound either to other glucose molecules, as in Dr. Dikeman’s illustration above, or may be bound to other types of sugar molecules in a disaccharide (2 sugar molecules) or a starch or fiber (long chain of sugar molecules). Fructose is the sugar found in fruit and since it is a 5-ring sugar, it can’t simply be broken down into glucose, which is a 6 ring sugar. Galactose is a six ring sugar that rarely exists on its own in food but that can be broken down in the body through digestion. It is usually found bound to glucose to form lactose, the sugar found in milk and dairy products.

Disaccharides

Disaccharides are two monosaccharide sugar molecules bound together. Sucrose is ordinary table sugar and made up of glucose-fructose. Lactose is the sugar in milk and milk products and is glucuse-galactose Maltose which rarely occurs naturally in foods, is glucose-glucose. Maltose is used in food processing such as the shiny glaze on Chinese roast duck.

complex carbohydrates

Complex carbohydrates are made up of more than two monosaccharides (sugar molecules). Oligosaccharides (where oligo means “scant” or “few”) are made up of 3-10 sugar molecules, whereas polysaccharides are made up of hundred or even thousands of monosaccharides (sugar molecules).

Oligosaccharides

Oligosaccharides are made up of 3-10 sugar molecules and the two most common are some of the complex carbohydrates found in dried beans, peas and lentils[1]. Raffinose is an oligosaccharide made from 3 sugar molecules: galactose-glucose-fructose and stachyose is an oligosaccharide made from 4 sugar molecules: galactose-galactose-glucose-fructose. The body can’t break down either raffinose or stachyose, but this is done by the bacteria in the intestine.

Polysaccharides

Polysaccharides are made up of hundreds or thousands of sugar molecules linked together. When those sugar molecules are only glucose, the polysaccharide is called “starch”. Some polysaccharides form long straight chains while others are branched like a tree. These structural difference affect how these carbohydrates behave when they’re heated or put in water. The way the monosaccharides are linked together makes the polysaccharides either digestible as in starch, or indigestible as in fiber. Polysaccharides found in plant foods such as fiber, cellulose, hemicellulose, gums and mucilages (such as psyllium) are indigestible by the body so won’t be covered in this article, but it should be noted that they can slow down the absorption of digestible carbohydrate.

Starch

Starches are long chains of glucose molecules strung together like beads on a string and are the ones illustrated in Dr. Dikeman’s illustration, above. Starches are found in grains such as wheat, corn, rice, oats, millet and barley as well as in legumes such as peas, beans and lentils* and tubers such as potatoes, yams and cassava.

*Recall as mentioned above that peas, beans and lentils also have the complex carbohydrates called oligosaccharides which are not broken down by the body, but by the bacteria of the gut.

There are two types of starches; the long unbranched chains called amylose and the long branched chain ones call amylopectin. What is important in this context is that the long branched chain starches called amylopectin are more easily digested. The body digests most starches very easily, although those with a high percentage of amylopectin (such as cornstarch) are digested much more easily than those with a high amount of amylose, such as wheat starch [1]. Since starches are just glucose molecules linked together and they are easily broken down to individual glucose molecules, starches can quickly affect the blood sugar of those who are pre-diabetic or have Diabetes. That is the “point” behind Dr. Dikeman’s illustration, above which I have modified slightly, below.

adapted from graphic by RD Dikeman by Joy Y. Kiddie, MSc, RD

Those who are Diabetic (or pre-diabetic) already have challenges with their blood glucose, so does eating foods such as starches that are nothing more than long strings of glucose really make sense?

Note: While the fiber content of whole grain pasta will slow down its digestion compared to refined pasta, it is still long strings of glucose molecules. Think of whole wheat pasta as a string of pearls with in addition to the pearls, in this case fiber.

Digestion of Carbohydrates

Carbohydrate digestion begins in the mouth where an enzyme in saliva called amylase breaks starch down into shorter polysaccharides and maltose. The acidity of the stomach temporarily stops the effect of the salivary amylase, but the digestion of carbohydrate starts up again in the small intestine where most carbohydrate digestion takes place.

Digestion of carbohydrates begins again when the pancreas secretes pancreatic amylase into the small intestine. In the small intestine, starch is broken down in to many, many individual units of the disaccharide maltose, which are simply two glucose molecules linked together.

Then, enzymes located to the brush border of the small intestine break the alpha bond which holds the two glucose molecules together. It’s easy to understand how starch, which is simply long chains of glucose molecules strung together are so easily broken down when digestion already starts in the mouth and is completed in the small intestine where the disaccharide (maltose) is broken down into 2 glucose molecules.

In the small intestine, other enzymes split other disaccharides into monosaccharides; so for example, the enzyme sucrase splits the disaccharide sucrose into glucose and fructose and the enzyme lactase splits the disaccharide lactose into glucose and galactose.  Note that these other disaccharides are only 1/2 glucose.

Absorption of Carbohydrates

Monosaccharides are absorbed into the mucosal cells of the small intestine and travel to the liver, where galactose and fructose are converted to glucose and the glucose is stored in the liver as glycogen. Glycogen is long, highly branched chains of glucose molecules (similar to amylopectin, but much more highly branched).

When needed, the liver can break down glycogen into glucose at a rate of 100 mg to 150 mg of glucose per minute for up to 12 hours [2]. When glycogen stores of the liver are already full, the glucose from the broken down carbohydrate with the help of the hormone insulin converts the excess glucose into fat and sends to other parts of the body to be stored in adipose tissue.

Carbohydrate-based Foods in the Diet

As covered in previous articles including this one , there is NO requirement for people to eat carbohydrate-based food” provided that adequate amounts of protein and fat are consumed”[3] which are used to provide essential glucose for the brain via gluconeogenesis. This does not mean that I recommend people don’t eat any carbohydrate-based food!

Which carbohydrate-based food people are able to eat and in what quantity without it affecting their blood sugar to any large degree varies considerably from person to person[4], whether or not they are Diabetic.  For those who already have Type 2 Diabetes or are pre-diabetic, a personalized nutrition approach is needed.  This is often called “eating to your meter“; testing a specific quantity of a food by itself, to see how your blood sugar responds. 

Based on research, some people with Type 2 Diabetes can do well eating certain types of legumes (pulses) including black beans, white navy beans, pinto beans, red and white kidney beans, chickpeas and fava beans [5] which is helpful for those who follow a plant-based vegetarian diet. Once people have lowered their HbA1C and fasting blood glucose levels and achieved remission of Type 2 Diabetes symptoms, I work can work with them in determining which foods they can re-introduce into their diet and in what quantities and how often, so as not to adversely impact their blood sugar. Some do better than others.

Over the last 4 years of my clinical practice, I have found that many people with pre-diabetes or Type 2 Diabetes can often manage their blood glucose well while including small servings (1/2 cup / 125 ml) of whole-food starchy vegetables such as winter squash (butternut, acorn, kobacha, etc.), as well as small servings of other starchy whole-food vegetables such as orange or purple yam, or peas. For those eating a moderately-low level of carbs (non-ketogenic) or want to keep eating these foods, I encourage them to choose these more often over starch-based foods such as pasta, rice and bread.

That doesn’t mean that people with Type 2 Diabetes shouldn’t ever eat whole, unmilled brown rice or quinoa but that avoiding refined starches such as white bread, pasta and rice is best preferable. I hope that you found this article helpful to understand what complex carbohydrates are, and why certain types of complex carbs are more of a challenge to those with Type 2 Diabetes or pre-diabetes.

If you have questions about how I can help you eat in a way to lower your blood sugar levels, please send me a note through the Contact Me form above and for information about the types of services I offer, please have a look under the Services tab or in the Shop.

To your good health,

Joy

You can follow me on: Twitter: https://twitter.com/lchfRD Facebook: https://www.facebook.com/BetterByDesignNutrition/ Instagram: https://www.instagram.com/lchf_rd

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. Chapter 4, Carbohydrates: Simple sugars and Complex Chains, http://samples.jbpub.com/9781284064650/9781284086379_CH04_Disco.pdf
  2. Rappaport B, Metabolic factors limiting performance in marathon runners. PLoS Comput Biol. 2010; 6(10). doi: 10.1371/journal.pebi.1000960
  3. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005), Chapter 6 Dietary Carbohydrates: Sugars and Starches”, pages 265-275
  4. Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094.
  5. Sievenpiper, J.L., Kendall, C.W.C., Esfahani, A. et al. Effect of non-oil-seed pulses on glycaemic control: a systematic review and meta-analysis of randomised controlled experimental trials in people with and without diabetes. Diabetologia (2009) 52: 1479.
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New Study: Dietary Saturated Fat is Not Associated with Increased Risk of CVD

A recently published meta-analysis of 43 cohort or nested case-control studies up until July 1, 2018 [1] did not find that higher saturated fat intake is associated with higher risk of cardiovascular disease (CVD) events. This is the first study to examine the effect of total dietary fat intake and the intake of specific fatty acids on CVDs risk based on dose-response meta-analysis of prospective cohort studies. It has been proposed that saturated fat (SFA) and trans fatty acids (TFA) contribute to CVD via inflammatory mechanisms and oxidative stress, mediated through the production of reactive oxygen species (ROS) [2,3]. With respect to trans fatty acids, this new study found that dietary TFA intake had a dose-response association with CVDs risk; specifically a 16% increased risk of CVD with an increased TFA intake of 2% of energy per day, however no association was observed between total fat or dietary saturated fatty acid (SFA) intake and the risk of CVDs [1]. In addition, this meta-analysis found no protective effect from the consumption of either monounsaturated fatty acids (MUFA), or polyunsaturated fatty acids (PUFA) and risk of CVDs, except PUFAs showed a protective effect in sub-group analysis followed up for more than 10 years [1]. These findings do not support 2010 recommendations of the WHO / FAO [4] which continue to influence national dietary guidelines around the world to recommend reducing intake of saturated fat in order to lower the rates of CVD. As well, these new findings call into question the findings of the PREDIMED study [5] and the Lipid Research Clinics Prevalence Follow-up Study [6] that indicate that diets high in polyunsaturated fatty acid (PUFA) and monounsaturated fatty acid (MUFA) and low in saturated fatty acid (SFA) and trans fatty acids (TFA) are associated with reduced CVDs events. The authors caution that;
it is possible that the role of dietary fat played in the development of CVDs might be confounded by the fat sources. For instance, vegetables and fruits play protective roles in the development of CVDs. However, we could not investigate the different effects of fat from animal, vegetables and fruit separately in this current meta-analysis.” [1]

Some thoughts…

For almost 50 years it has been believed that dietary saturated fat intake was a risk factor for CVDs based on the assumption that dietary fat can increase low density lipoprotein (LDL) cholesterol and blood pressure and in turn, increase CVDs risk, however this meta-analysis of 43 cohort studies did not find a positive association between total dietary fat intake or saturated fat intake and CVDs risk. The 2017 Prospective Urban Rural Epidemiological (PURE) study (covered in this earlier article) is the only prospective study to date which covered multiple world regions and which found that total dietary fat and types of dietary fat were not associated with cardiovascular disease or mortality and further, that dietary saturated fat had an inverse association with stroke and a risk of all-cause mortality with higher intake (up to ~14% of energy intake). That is, dietary saturated fat intake was protective. The findings of the current meta-analysis study, combined with the findings of the 2017 PURE study call into question current dietary recommendations which continue to recommend that people limit dietary saturated fat in order to reduce cardiovascular risk. Such recommendations are included in the most recent Canada’s Food Guide which encourages Canadians to “choose foods with healthy fats instead of saturated fat” and to “prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat” (see this article for details) .

Post publication note (April 7, 2019): As I’ve stated in previous articles, I am not opposed to Canada’s new Food Guide. It is a huge improvement over it’s predecessor for many reasons already discussed. My two concerns that I’ve expressed previously remain; (a) that the recommendations for the general population to continue to limit saturated fat because it contributes to CVD has not been conclusively demonstrated. The only thing that has been shown is that saturated fat can raise LDL, but which LDL; the large fluffy sub-fraction, or the small dense sub-fraction? Please see article linked to above for an elaboration. My second concern is that; (b) the amount of carbohydrate in the diet is too high for the large percentage of the population that are metabolically unhealthy. Please see this article for an elaboration.

Author’s Conclusions

The study’s authors concluded that;

This current meta-analysis of cohort studies suggested that total fat, SFA, MUFA, and PUFA intake were not associated with the risk of cardiovascular disease. However, we found that higher TFA intake is associated with greater risk of CVDs in a dose-response fashion. Furthermore, the subgroup analysis found a cardio-protective effect of PUFA in studies followed up for more than 10 years. Dietary guidelines taking these findings into consideration might be more credible.” [1]

If you would like to learn about the types of fats in your diet and how they may impact your health or those of your family, please send me a note through the Contact Me form on the tab above. You can learn more about the services I provide by clicking on the Services tab or having a look in the Shop. To your good health, Joy You can follow me on: Twitter: https://twitter.com/lchfRD Facebook: https://www.facebook.com/BetterByDesignNutrition/ Instagram: https://www.instagram.com/lchf_rd

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. Zhu Y, Bo Y, Liu Y, Dietary total fat, fatty acids intake, and risk of cardiovascular disease: a dose-response meta-analysis of cohort studies, Lipids in Health and Disease (2019) 18:91, https://doi.org/10.1186/s12944-019-1035-2
  2. Sverdlov AL, Elezaby A, Qin F, Behring JB, Luptak I, Calamaras TD, Siwik DA, Miller EJ, Liesa M, Shirihai OS, et al. Mitochondrial reactive oxygen species mediate cardiac structural, functional, and mitochondrial consequences of diet-induced metabolic heart disease. J Am Heart Assoc. 2016;5:e002555.
  3. Ruparelia N, Chai JT, Fisher EA, Choudhury RP. Inflammatory processes in cardiovascular disease: a route to targeted therapies. Nat Rev Cardiol. 2017;14:133–44.
  4. Nations FaAOotU. Summary of conclusions and dietary recommendations on total fat and fatty acids in fats and fatty acids in human nutrition—report of an expert consultation. Geneva: FAO/WHO; 2010.
  5. Estruch R, Ros E, Salas-Salvado J, Covas MI, Corella D, Aros F, Gomez- Gracia E, Ruiz-Gutierrez V, Fiol M, Lapetra J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368:1279–90.
  6. Guasch-Ferre M, Babio N, Martinez-Gonzalez MA, Corella D, Ros E, Martin-Pelaez S, Estruch R, Aros F, Gomez-Gracia E, Fiol M, et al. Dietary fat intake and risk of cardiovascular disease and all-cause mortality in a population at high risk of cardiovascular disease. Am J Clin Nutr. 2015;102:1563–73.
  7. Dehghan M, Mente A, Zhang X, Swaminathan S, Li W, Mohan V, Iqbal R, Kumar R, Wentzel-Viljoen E, Rosengren A, et al. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017;390:2050–62.
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Green Tea Should not be like Buckley’s®

Recently, I came across a social media post about someone that wanted to drink green tea for it’s health benefits, but just couldn’t get over it’s “bad taste”.  I followed the origin of the thread to Reddit, where people guessed whether green tea’s “off taste” for that person may be genetic, like the taste of cilantro. While that can be the case (i.e. genetic sensitivity to a compound called 6-n-propylthiouracil which is found in some flavonoids), others touched on whether it was because the person was making tea using supermarket green tea bags rather than loose tea, whereas a few people hit on the complexity of the issue.  In this post I will discuss some of the factors that affects whether your green tea has a pleasant or “off taste”,  because after all green tea should be something you actually enjoy and not only drink for it’s health benefits.

NOTE: The first part of this article are some personal details of my experience learning to prepare multi-ethnic food and beverages and the second part of the article is specifically about the preparation of green tea and its health benefits.


Once a Foodie, Always a Foodie

I have been adventurous in trying different kinds of food and beverages since I’m little and I remember my parents taking me to an authentic Japanese restaurant even as a kid.  As a teen, I enjoyed cooking multi-ethnic food and learned authentic Cantonese cooking in the 1970s when my mom took a course in Chinatown. In the 1980’s, I learned authentic Thai cooking from the friend of a family business associate who was from Thailand and in those days one couldn’t buy pre-made Thai curry pastes that are available everywhere now, so I sourced the raw ingredients in Lao-Thai groceries and hand-pounded them myself in a mortar and pestle (that I still own and use!). I still have the recipe books sent to me from Thailand.

It didn’t matter whether it was Asian, Middle Eastern or Jamaican, I was a bit of a purist; wanting the ingredients and cooking method to be as authentic as possible. For me, the best way to find out how to make something was to ask someone from that culture that loved to cook.

What was true about food was also true for beverages.

I couldn’t just enjoy a cup of coffee or glass of wine without knowing more. Whether it was the origin of the coffee beans, the length of time the beans were roasted, or how long the water is in contact with the beans — I needed to know, and I was interested in such things when it was not popular either.

Before “West Coast coffee” was a thing and before there ever was Starbucks® or Peet’s, there was a place called La Vieille Europe on St. Laurent Blvd in Montreal which was where I got my single origin, whole bean coffee. As I found out years later, the son of the roaster that owned that store taught the original roaster from Peet’s in the US how to roast beans. Small world.

When I lived in wine country (Sonoma county) of California for a few years in the early 2000s, I was determined to educate my palate to distinguish between different types of wine, which I did. I knew what I liked — which turned out to be an expensive habit when I returned to Canada after 9/11.  At the beginning I explored the wines of Australia and found some I really liked, but missed the delicious and inexpensive  wines of Sonoma and Napa.

Once again, my palate returned to coffee, but finding a decently roasted coffee in Vancouver BC was harder than I thought. Given that this was the “West Coast”, I was discouraged how difficult it was to find good quality Arabica beans that weren’t over roasted. I stumbled across a few small roasters that did an excellent job, but in time they modified their roasts for “local tastes”, so once again, I was back looking for a new roaster. On a few occasions, I ordered from La Vieille Europe in Montreal because in the 40 or 50 years they have been in business, they never lost their passion for properly roasted, single origin coffee.

Over the 20 years I have lived in Vancouver, I discovered the world of quality tea that is largely unknown to most non-Asian born Chinese. There was one excellent tea importer in the Chinatown that I knew of and one that is still in the Richmond Public market that have single origin estate teas that rival the diversity of the best coffee roaster. Over the past 20 years, I’ve explored different types of tea from China and  have come to like a few; my favourite of which is a fermented tea known as Pu-ehr.

A number of years ago, I stumbled across matcha tea in a specialty Japanese store before it was a “thing”.  Knowing nothing about it, I have since found out that I had been using ‘culinary matcha‘ (designed for making Japanese sweets) for drinking.  No wonder it tasted bitter and I needed to blend it with other ingredients to make it palatable. Thankfully, when fresh it had the same health benefits, which I wrote about in 2013 in this article about the Role of Green Tea Powder (Matcha) in Weight and Abdominal Fat Loss. As you’ll read below, I have since learned about making and enjoying real ceremonial-grade matcha, which is intended for drinking from large matcha bowls.

Learning about Japanese Green Tea

At the beginning of this year, I began to explore green teas from Japan when I discovered Hibiki-An, an online tea importer from Uji region of Kyoto. My culinary world expanded once again.

Unable to decide between the many different types and grades of tea that they carry, I order a sampler of 3 types of green teas (Sencha, Gyokuro Superior and Sencha Fukamushi).  They came in 4 oz individual bags — the quantity that can be reasonably be used up within 3 months, when it is fresh.  All 3 teas were all of “superior” grade, which is not the best quality (as my palate is not developed yet) but is a high grade tea.

When the tea arrived, it came with very specific brewing instructions (a summary of the much more detailed instructions on their web page). I’ve since learned that different types of green tea require different water temperatures and different lengths of brewing time.

Wow, who knew?

For the purpose of “cooling” the water to just the right temperature, there is a yuzamashi — which is a small ceramic cup with a spout that the boiled water gets poured into to cool momentarily before being poured into the kyuzu; a special tea pot with a single handle, built in mesh filter and large opening for the water (see photo, above).

You don’t need the get fancy, though.  I had these things for years from my days exploring different regional teas, but one can use an ordinary bowl to cool the water and any plain ceramic tea pot to brew the tea in!

Tea to Water Ratio, Water Temperature and Steeping Time

Each type of green tea has a very specific ratio of green tea leaves to water, and very specific water temperatures and steeping time.

For example, of the three teas in my sample set, Sencha is brewed at 80° Celsius (176 ° Fahrenheit) for one minute, Gyokuro is brewed at 60-70 ° Celicus (140-158° Fahrenheit) for 1 -1/2 to 2 minutes and Sencha Fukamushi is brewed at the same temperature as regular Sencha, but for only 40-45 seconds.

I’ve discovered that following these guidelines using good quality, fresh tea leaves makes a cup of tea that is like nothing I’ve tasted anywhere before. It is not simply snobbery, but the science of what makes for a good cup of tea.

Note: I downloaded several studies that have researched the difference in brewing time, water to tea leaf ratio and water temperature but have decided against boring anyone with the details.

Recently, I became ready to move onto “realmatcha tea and ordered some from the same supplier in Japan.

It came in tiny cans (quantities that should be used up in a 3 week period).

The colour was a bright jade green and the taste had no hint of bitterness whatsoever!

It tastes amazing!

My teas ordered from Japan are my “weekend teas” and during the week I used run-of-the-mill Sencha purchased locally at a Japanese store.

I drink them because I like them and for the health benefits.

Health Benefits of Green Tea

The health benefits of green tea are many. Several large-scale population studies have linked increased green tea consumption with significant reductions in the symptoms of metabolic syndrome; a cluster of clinical symptoms which include insulin resistance and hyperinsulinemia (high levels of circulating insulin), Type 2 Diabetes, high blood pressure, and cardiovascular disease including coronary heart disease and atherosclerosis.

Catechins make up ~ 30% of green tea’s dry weight, of which 60–80% are catechins. Oolong and black tea which are produced from partially fermented or completely fermented tea leaves contains approximately half the catechin content of green tea

It is believed that epigallocatechin gallate (EGCG) which is the most abundant catechin in green tea actually mimics the action of insulin, which has positive health effects for people with insulin resistance or Type 2 Diabetes [Kao et al].

EGCG also lowers blood pressure almost as effectively as the ACE-inhibitor drug, Enalapril, having significant implications for people with hypertension (high blood pressure) and cardiovascular disease [Kim et al].

Green tea catechins also have benefit for weight loss. A 2009 meta-analysis of 11 green tea catechin studies found that subjects consuming between 270 to 1200 mg green tea catechins / day (1 – 4 tsp of matcha powder per day) lost an average of 1.31 kg (~ 3 lbs) over 12 weeks with no other dietary or activity changes [Hursel].

Drinking 8-10 cups of green tea per day is enough to increase blood levels of EGCG into a measurably significant range [Kim et al], but matcha contains  137 times greater concentration of EGCG compared to green tip tea [Weiss et al].

WARNING TO PREGNANT WOMEN While EGCG has also been found to be similar in its effect to etoposide anddoxorubicin, a potent anti-cancer drug used in chemotherapy [Bandele et al], high intake of polyphenolic compounds during pregnancy is suspected to increase risk of neonatal leukemia. Bioflavonoid supplements (including green tea catechins) should not be used by pregnant women [Paolini et al].

Green Tea Shouldn’t Taste Bad!

The reason someone would find green tea has an “off flavor” was because the tea was either not fresh, not of a half-decent quality, was brewed at the wrong temperature or for the wrong length of time. Think about it this way; it all a person ever drank was cheap pre-ground coffee, they might think coffee tasted bad, too.

The fact is, one doesn’t need to order tea from Japan to enjoy a decent cup of green tea! I found the green teas below at a local Japanese grocery store and when brewed properly they are great as everyday tea.

If you aren’t adventurous to explore ethnic markets or time is limited, I can highly recommend the online supplier I mentioned above as having excellent price for the quality of green tea, very good explanations on their web page and quick delivery.

For everyday use, I have a little water cooler (yuzamashi) bowl and small single handed tea pot (kyuzu) so brewing a decent quality sencha green tea (my daily tea of choice) has become second nature, but as I mentioned above, one doesn’t need special equipment to make a decent cup of green tea!  All you need is the  right amount of fresh, good quality tea leaves steeped for the right length of time in hot water that’s at the right temperature. The only thing to keep in mind is that once the package of tea is opened, it needs to be stored in a sealed, airtight, light-proof container and used up within 3 months or sooner.

Making a good cup of green tea is not really much different than brewing a good cup of coffee. To make a good cup of coffee, one needs to consider the country / countries of origin of the beans, the bean roasting time and temperature, the brewing method involved (drip, espresso, French press, etc), the required water temperatures needed for that method, and the different grind of beans and a specific water-to-ground-bean ratio required for that brewing method. It sound’s complicated, but if you a few types of coffee regularly, it’s not hard.

It’s the same with green tea.

In one sense, there is a lot to learn at first to make a good cup of green tea but on the other hand, once you know a few basics and find a green tea or two you really enjoy, the rest is easy!

Tea has amazing health benefits, but unlike the cough medicine Buckley’s®, there is no need to drink tea that “tastes terrible, but it works”!

If you would like to know more about what I do as a Dietitian and how I can help you with weight loss or to seek to reverse the symptoms of metabolic syndrome, including Type 2 Diabetes, high blood pressure and other related markers, please send me a note using the Contact Me form on this web page.

If you would like to learn more about the services I offer and their costs, please click on the Service tab or have a look in the Shop.

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

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https://www.instagram.com/lchf_rd

 

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

Gayathri Devi A, Henderson SA, Drewnowski A. Sensory acceptance of Japanese green tea and soy products is linked to genetic sensitivity to 6-n-propylthiouracil. Nutr Cancer. 1997;29(2):146-51

Hursel R, Viechtbauer W, Westerterp-Plantenga MS. The effects of green tea on weight loss and weight maintenance: a meta-analysis. Int J Obes (Lond) 2009;33:956–61.

Paolini, M, Sapone, A, Valgimigli, L, “Avoidance of bioflavonoid supplements during pregnancy: a pathway to infant leukemia?”. Mutat Res 527 (1–2): 99–101. (Jun 2003)

Kao YH, Chang MJ, Chen CL, Tea, Obesity, and Diabetes, Molecular Nutrition & Food Research, 50 (2): 188–210, February 2006

Kim JA, Formoso G, Li Y, Potenza MA, Marasciulo FL, Montagnani M, Quon MJ., Epigallocatechin gallate, a green tea polyphenol, mediates NO-dependent vasodilation using signaling pathways in vascular endothelium requiring reactive oxygen species and Fyn, J Biol Chem. 2007 May 4;282(18):13736-45. Epub 2007 Mar 15.

Weiss, DJ, Anderton CR, Determination of catechins in matcha green tea by micellar electrokinetic chromatography, Journal of Chromatography A, Vol 1011(1–2):173-180, September 2003

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The Connection Between Sugar and Cancer

I’ve heard that some types of cancer feed on glucose (the sugar in our blood) and I know of a few people that started a ketogenic diet as adjunct therapy to be used along side surgery and chemotherapy in the treatment of glioblastoma (a form of aggressive brain cancer), but just came across an article that explains why limiting sugar intake can lower one’s risk of cancer. In this article, I explain one biological link between cancer and sugar.


A “Master Switch for Cancer”

In the 1980’s, Dr. Lewis Cantley was a Professor at Tufts University School of Medicine in Boston when he identified a previously unknown enzyme known as phosphoinositide-3-kinase, or PI3K which turned out to a type of ‘master switch for cancer’.

PI3K’s normal function is to alert cells to the presence of the hormone insulin; resulting in the cells pumping in glucose to be used as metabolic fuel for the cell. Signals from PI3K are necessary for normal cell growth, survival and reproduction, however when this enzyme is hijacked by cancer cells, it provides tumors with an over-abundant supply of glucose, which results in their rapid proliferation.

The gene that codes for PI3K is now thought to be the most frequently mutated cancer-promoting gene in humans and is believed to be associated with 80% of cancers, including those of the breast, brain and bladder.

In 2012, Dr. Cantley became the Director of the Sandra and Edward Meyer Cancer Center at Weill Cornell Medicine, which is the biomedical research unit and medical school of Cornell University, where he is Professor of Cancer Biology. In his work at Weill Cornell, Dr. Cantley has continued to investigate the role of PI3K.

Challenges with some anti-cancer drugs that have been developed that block the PI3K enzyme is that these PI3K-inhibitor drugs are designed to starve the cancer cell of glucose, but also signal the person’s liver that their body is starving for glucose, too.  As a result, the liver would break down glycogen (a storage form of glucose) and send large amounts of glucose into the person’s blood, resulting in their blood sugar spiking and triggering their pancreas to release lots of insulin, as a result. The presence of all of this glucose from the liver and insulin from the pancreas resulted in these patient’s tumors continuing to grow.

Dr. Cantley and his colleagues wondered whether the spike in insulin from the breakdown of glycogen might be countering the effect of the PI3K-inhibiting drugs by reactivating the PI3K pathway in the cancer cells.  Studies first tried giving these patients Diabetes medications to lower their blood sugar and insulin levels, but this didn’t work nearly as well as what they tried next.

The researchers came up with a theory that a ketogenic diet (a diet that is very low in carbohydrate)   could prevent the spikes caused in blood sugar by the  PI3K-inhibiting drugs and might help the drug starve the tumor, while the patient’s blood sugar remained normal because the body would be fueled by breaking down fat and protein for ketones.

They tested the theory using genetically engineered mice that developed pancreatic, bladder, endometrial and breast cancers and treated the mice with a new PI3K inhibitor drug. The study demonstrated that spikes of insulin did indeed reactivate the pathway in tumors, countering the anti-cancer effect of the drug. However, when the researchers put the mice on a ketogenic diet, in addition to the medication, the tumors shrank. The results were published in the journal Nature in July 2018.

Dr. Cantley explains the biological connection between cancer and sugar this way;

“Our pre-clinical research suggests that if somewhere in your body you have one of these PI3K mutations and you eat a lot of rapid-release carbohydrates, every time your insulin goes up, it will drive the growth of a tumor. The evidence really suggests that if you have cancer, the sugar you’re eating may be making it grow faster.”

Some Final Thoughts…

A normal cell function requires the enzyme PI3K that results in the cell pumping in glucose to fuel growth and reproduction and a cancer cell that has a defect in the gene that codes for PI3K may do the same thing. Sugar, in and by itself does not cause cancer, but in those that have a few abnormal cells, sugar can drive the process of tumor development.

According to the World Health Organization, the average American consumes 126 grams of sugar a day, more than people in any other country and the average Canadian eats almost 90 grams (89.1) of sugar per day. Sugar is not required in the diet; in fact, there is no essential need to eat carbohydrate at all, if people eat adequate amounts of healthy fats and protein.

Given that as many as 88% of Americans are already metabolically unhealthy — with likely a smaller percentage of Canadians following suit (due to slightly lower obesity statistics), there is no valid reason* for the average American or Canadian to be eating foods with added sugar. As I’ve written about in many previous articles, high blood sugar and high insulin levels already predispose people to Type 2 Diabetes and obesity and as outlined in this article, are involved in the proliferation of some types of cancer cells.

*(update April 29, 2019): While I say above that there is “no valid reason” for those who may already be metabolically unwell to eat foods with added sugar – in retrospect, this is not well worded.  I think there are lots of valid reasons for people to eat foods with added sugar, but believe that it may be preferable for those who are already metabolically unwell to limited added sugars.

It would seem to me that a prudent approach for metabolically healthy people (12% of Americans, and perhaps an estimated 25% of Canadians) is to stay healthy by avoiding processed foods that are high in refined carbs and sugar, as well as foods high in “natural sugar” such as 100% fruit juice  in order to reduce the risk of becoming metabolically unwell or inadvertently feeding malignant cells that feed on glucose.

For the large majority of those that are already metabolically unhealthy, a well-designed low carbohydrate diet can help you reverse the symptoms of Type 2 Diabetes, putting the disease into remission, as well as achieve and maintain a healthy body weight.  Not inadvertently feeding tumor proliferation seems like a nice ‘side benefit’, too.

If you would like to know more about how I can help you achieve and maintain a healthy body weight or halt the progression of Type 2 Diabetes and other related metabolic disorders, please send me a note using the Contact Me form on this web page.  If you would like to learn more about the services I offer and their costs, please click on the Service tab or have a look in the Shop.

To your good health!

Joy

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Reference

Crawford A, Increasing evidence of a strong connection between sugar and cancer, MedicalXPress, March 20, 2019,  https://medicalxpress.com/news/2019-03-evidence-strong-sugar-cancer.html

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

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Now Licensed for Virtual Dietetic Practice Across Canada

If you live almost anywhere in Canada and are looking for a Registered Dietitian with experience in food allergy or sensitivity, including celiac disease and IBS as well as the specific of providing low carbohydrate or ketogenic diet support, I can help.

Whether you live in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia, Newfoundland or Labrador, I am now licensed to provide you with services.

I currently can’t provide Dietitian services to Prince Edward Island (PEI) but if I have enough demand, that may change.

Registered in British Columbia since 2002

I have been registered with the College of Dietitians of British Columbia since 2002 as an RD(t) and since 2008 as a full registrant. This registration enables me to provide services to people across Canada, with the exception of  Alberta and PEI but since I’ve had several physicians in Alberta who have asked to refer patients to me as well as individuals from Alberta requesting services, I recently applied to- and was accepted into the College of Dietitians of Alberta.

Provincial Registration Requirements for Virtual Dietetic Practice

As can be seen from the table below, Registered Dietitian such as myself that provide virtual Dietetic practice services (Distance Consultation) to other provinces are required to meet very specific registration requirements, as well as observe other regulatory regulations.

Virtual Dietetic Practice (Telepractice) – from the Alliance of Dietetic Regulatory Bodies. August, 2017

In the US or overseas?

I am a member of the College of Dietitians of British Columbia as well as the College of Dietitians of Alberta and am licensed to provide Registered Dietitian services in most provinces in Canada (except PEI), but if you live in the USA or elsewhere, I can provide you with nutrition education services that would not be considered medical nutrition therapy (MNT) and that would be provided for information purposes only.

More Info

If you would like more information, you can find out more under the Services tab or by looking in the Shop. If you have specific questions, please send me a note using the Contact Me form on the tab above and I’d be glad to reply as I am able.

To your good health!

Joy

You can follow me at:

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American Heart Association: Some Kids & Teens at Risk for Premature CVD

INTRODUCTION: It is well known that adults are at risk of cardiovascular disease (CVD) due to having obesity and Type 2 Diabetes, but it is now known that children and adolescents are also at risk of premature coronary artery disease and stroke for the same reasons.


According to a new scientific statement from the American Heart Association (AHA) published in the Association’s journal Circulation this past Monday (February 25, 2019) [1], obesity and severe obesity in childhood and adolescence have been added to the list of conditions that put kids and teenagers at increased risk for premature heart disease, including coronary artery disease (CAD) and stroke and are considered at high risk of cardiovascular disease simply by having Type  2 Diabetes, whether or not they are overweight.

Childhood overweight is defined as a Body Mass Index (BMI) between the 85th to 94th percentile for age and sex, and childhood obesity is defined as having a Body Mass Index (BMI) ≥ 95th percentile for age and sex.

Youth with obesity are now considered at-risk of heart disease and stroke
and those with severe obesity are now considered at moderate risk of heart disease and stroke based on a large-scale study from 2016 that followed 2.3 million people for over 40 years and found the risk of dying from a cardiovascular disease were 2-3 times higher if people’s body weight as adolescents had been in the overweight or obese category, compared to youth with normal weight [2].

Obesity,  specifically the ectopic fat  (fat in the organs) is considered an independent risk factor for cardiovascular disease (CVD) and is associated with other CVD risk factors such as high triglycerides, low levels of HDL cholesterol, high blood pressure,  high blood sugar (hyperglycemia),  insulin resistance, inflammation and oxidative stress.

It Is estimated that in 2014 ~6% of all youth 2 to 19 years old in the United States were severely obese [3] and 2015 Canadian data indicates that obesity in children aged 5-17 years of age averaged around 12% (14.5% for boys and ~9.5% in girls) [4].

Given these children are 2-3 times more likely to have premature cardiovascular disease as adults, the time to successfully address their overweight and obesity is when they are still young.

Cardiovascular Disease -a leading cause of death

Cardiovascular disease is the leading cause of death for people of all ages and both genders in the United States [5] and the second leading cause of death in Canada [6] and a large percentage of these deaths are entirely preventable with appropriate dietary and lifestyle habit changes whether they are implemented as children, youth or adults.

Proposed Mechanism – inflammation

The American Heart Association scientific statement states that the exact mechanism by which these contribute to cardiovascular disease remains to be fully understood and explained, they believe that the cardiovascular risk is brought about by a combination of insulin resistance and oxidative stress (free radical damage), but that inflammation comes first.

“Insulin resistance, oxidative stress, and
inflammation are linked multidirectionally, but emerging
evidence supports a mechanism by which inflammation
comes first.”

SIDE-NOTE: This idea that inflammation precedes insulin resistance is something I’ve been coming across recently. Some propose that insulin resistance itself may be a protective mechanism against high levels of circulating glucose (sugar) in the blood [a], in much the same way as the ability to produced more and more subcutanous fat (the fat directly under the skin) may be protective against the accumulation of fat around the organs (called visceral fat) or fat in the organs or even the bone (called ectopic fat). That is, excess energy (calories) seen as high levels of glucose in the blood may be the result of storage problems in fat cells (the body’s inability to make new subcutaneous fat cells), and the subsequent overflow of fat may drive excess high glucose production in the liver. a. Nolan CJ, Prentki M, insulin resistance and insulin hypersecretion in the metabolic syndrome and type 2 diabetes: Time for a conceptual framework shift, Diabetes and Vascular Disease Research, Feb 15, 2019

The American Heart Association (AHA) suggests that inflammation may increase cardiovascular risk through a combination of these three factors;

(1) high triglycerides (TG)
(2) low high-density lipoprotein cholesterol (HDL)
(3) high small low-density lipoprotein (LDL) particles (LDL-s)

NOTE: Studies on LDL-particle size indicate that people whose LDL is mostly the small, dense sub-particles have a 3x greater risk of coronary heart disease than those with mostly the large, fluffy sub-particle type, which is thought to be protective.”

The American Heart Association suggests that it’s the inflammatory process itself that triggers insulin resistance as a mechanism to keep blood sugar high in order to meet the needs of an  immune system that has become activated, as would occur when the body is fighting a significant infection.

They propose that this process of inflammation leads to;
(1) defective activity of an enzyme that is responsible for breaking down triglycerides (i.e. lipoprotein lipase) which would normally be used by the body as energy or stored in fatty tissue for later use
(2) blocking of normal fat cell creation (adipogenesis)
(3) an increase in triglycerides in order to deal with infectious toxins and
(4) an overproduction of smaller LDL particles* and HDL particles

*The ADA suggests that the formation of small LDL particles may perform some important function in this situation of high inflammation, as small LDL particles can easily penetrate the blood vessels to deliver cholesterol to damaged tissue and that oxidation of these small LDL particles make athlerosclerosis even worse.

The decrease in HDL cholesterol which is frequently seen on a standard cholesterol test (lipid panel) in the context of inflammation is thought to be associated with a decrease in reverse cholesterol transport which promotes the building up of cholesterol in the tissues, where it is used for the synthesis of cortisol for the cell membranes that have become damaged by what the body sees as an ‘infection’.

Recommended Dietary Changes

The AHA recommends different dietary and lifestyle changes for each of the risk factors

High Triglycerides(TG)

The AHA recommends a diet low in simple carbohydrates and added sugars, high in dietary fiber from fruits* and vegetables**, moderate amounts of complex carbohydrates, and high in polyunsaturated*** and  monounsaturated fats, without specific restriction of saturated fats.

NOTES: * fructose, the sugar in fruit is a simple carbohydrate and can be a major contributor to high TG.  ** there is no distinction between starchy vegetables such as potato and sweet potato (which accounts for a large percentage of overweight children and adult’s ‘vegetable’ servings) and non-starchy vegetables such as leafy greens and cruciferous vegetables, such as broccoli and cauliflower, as well as a whole host of other low carbohydrate non-starchy vegetables. *** it is well established that omega 6 polyunsaturated fats contribute to the inflammation process yet the recommendation doesn’t indicate that there should be a decrease in omega 6 polyunsaturated fats such as from soybean oil, canola oil, etc. and an increase in anti-inflammatory omega 3 fats from fatty fish such as tuna, salmon, sardines, etc even though the paper itself proposes inflammation at the heart of the issue. This makes no sense to me.

Total LDL Cholesterol

Diet high in fiber from fruits* and vegetables**, whole grains, high in polyunsaturated*** and monounsaturated fats, low in saturated
fat and devoid of trans fats.

See Notes above for * , ** and ***.

NOTE: The body of the AHA paper elaborates on the detrimental effect of the small LDL subparticle (LDL-s), yet no such differentiation from total LDL cholesterol (LDL-c) is made in the Dietary Recommendations. Why is that? Particle size of LDL can be established by testing, using Apo B:Apo A ratio (Apo B is a component of lipoproteins involved in atherosclerosis and cardiovascular disease) and by proxy using a TG:HDL ratio. It makes no sense to me that the dietary recommendations focus on total LDL cholesterol when the paper makes it clear that it is the small LDL subparticle that is the risk factor.

Blood glucose (without diagnosis of
Type 1 or Type 2 diabetes)

Low glycemic diet limiting intake of added sugar to ≤5% of total
calories, high in fruits* and vegetables**, encouraging intake of
polyunsaturated*** and monounsaturated fats, and without specific limitation to dietary saturated fats.

See Notes above for * , ** and ***.

Some final thoughts…

The dietary recommendations in this paper that focus on lowering simple carbohydrate and added sugars are very sound, as are recommending moderate amounts of complex carbohydrate and high in monounsaturated fat. However, to me it makes no sense for the AHA to recommend a diet high in fruit when fruit is the primary source of the simple sugar fructose and it also makes no sense to me for the dietary recommendations not to differentiate between starchy vegetables like potatoes, sweet potatoes and corn (which is actually a grain that is counted as a vegetable) that raise blood sugar and the non-starchy vegetables such as salad greens,  broccoli and cauliflower and the abundance of other low carbohydrate vegetables.

Furthermore, given that the AHA proposes an inflammatory mechanism at the root of the cardiovascular disease process, it makes no sense to me for the dietary recommendations to fail to differentiate between pro-inflammatory omega 6 polyunsaturated fatty acids (such as those found in soybean and canola oil) and anti-inflammatory omega 3 polyunsaturated fatty acids, such as those found in fatty fish.

Finally, when the body of the paper makes it very clear that it is the small LDL cholesterol subparticle that contributes to athlersclerosis and that oxidization of it in particular is an additional risk factor, why do the dietary recommendations not focus on lowering the small LDL subparticle, rather than total LDL cholesterol?

Eating a lower carbohydrate intake will both reduce triglycerides (TG) and increase high density lipoproteins (HDL), resulting in an improved TG:HDL ratio, which would indicate a reduction in the small, dense LDL subfraction, and reduced risk of cardiovascular disease.   Recommending a reduction in saturated fat intake will likely reduce any increase in HDL cholesterol with no consistent evidence that lower total LDL cholesterol will result in lower cardiovascular rates.

On one hand, the paper provides a good explanation about the risks of the small, dense LDL subparticle yet recommends lowering dietary intake of saturated fat, in order to lower total LDL cholesterol.

Why the avoidance of consistent dietary changes that would reduce the small, dense LDL subparticle and increase protective HDL?

If you would like to know about the services that I offer for lowering body weight in adults as well as youth as well as bringing high blood sugars under control, then please click on the Services tab to learn more. If you have questions related to my services then please send me a note using the Contact Me form located on the tab above and I will reply as I am able.

To your good health!

Joy

You can follow me at:

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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. American Heart Association, Cardiovascular Risk Reduction in High-Risk Pediatric Patients – a scientific statement from the American Heart Association, Circulation. 2019;139:00-00
  2. Twig G, Tirosh A, Leiba A, Levine H, Ben-Ami Shor D, Derazne E, Haklai
    Z, Goldberger N, Kasher-Meron M, Yifrach D, Gerstein HC, Kark JD.
    BMI at age 17 years and diabetes mortality in midlife: a nationwide cohort
    of 2.3 million adolescents. Diabetes Care. 2016;39:1996–2003.
  3. Skinner AC, Perrin EM, Skelton JA. Prevalence of obesity and severe obesity
    in US children, 1999–2014. Obesity (Silver Spring). 2016;24:1116–
    1123. doi: 10.1002/oby.21497
  4. Statistics Canada. 2015 Canadian Community Health Survey, Measured children and youth body mass index (BMI) (World Health Organization classification), by age group and sex, Canada and provinces, Canadian Community Health Survey.
  5. Benjamin EJ, Virani SS, Callaway CW et al (on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee). Heart disease and stroke statistics—2018 update: a report from the American Heart Association [published correction appears in Circulation. 2018;137:e493]. Circulation. 2018;137:e67–e492
  6. Statistics Canada, Leading causes of death, total population, by age group, https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039401
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Are You Pushing Your Pancreas Too Hard?

Most people think of pre-diabetes as ‘warning sign’ that they are at risk for developing Type 2 Diabetes, but it is actually the final stage before diagnosis. By the time a person is prediabetic their blood glucose results (also called “blood sugar”) are in the abnormal range on routine tests such as a fasting blood glucose test (FBS) and glycated hemoglobin (HbA1C). They also already have increased rates of high blood pressure, abnormal cholesterol, cardiovascular disease, including heart attack and stroke as well as chronic kidney disease.

It is now known that abnormalities with the hormone insulin — including insulin resistance and hyperinsulinemia appear more than 20 years before a diagnosis of Type 2 Diabetes[1], so prevention of Type 2 Diabetes needs to begin when blood sugar results still appear normal.

Before getting into the technical details of insulin resistance and hyperinsulinemia, I want to explain these concepts in terms that everyone can understand.

Most people know that a car’s speedometer indicates how fast the car is going. The tachometer indicates how many times per minute the engine is rotating.

If a car is doing 180 km / hour (110 miles per hour) on the highway, one would expect the engine to be working hard. But if a car was only doing 70 km / hour (44 miles per hour), one wouldn’t expect the engine to be working that hard, right?

***The problem is blood sugar may be within normal range because the pancreas is overworking to keep it low!***

When people have a 2 hour Oral Glucose Test with added insulin assessors (explained below), blood glucose results may come back normal because the person is healthy.

The problem is that blood glucose results may appear normal because the pancreas is working way too hard to keep it that way! That is, using the car example, the tachometer is working very hard, but the car is hardly moving!

Normal blood sugar values with abnormal insulin values = overworked pancreas – original illustration by Joy Y. Kiddie MSc, RD (special thanks to Dr. Eric Sodicoff for the idea)

Let’s look at this scenario in terms of blood test results;

Let’s say we have a person that has fasted overnight and their fasting blood glucose in the morning is normal at 4.9 mmol/L (88 mg/dl), but their fasting insulin is much higher than the ideal 14.0 – 42.0 pmol/L (2-6 uU/ml) — in this case, say it is 132.6 pmol/L (19.1 uU/ml).

This would be like the car being started but in “park” in the driveway and the engine turning at 3,000 RPM!  The pancreas is working  way too hard to maintain blood sugar and the person hasn’t even eaten yet!

Say we now give this person 75 g of pure glucose to drink and check what happens to their blood sugar at 30 minutes and/or one hour afterwards.

What we expect a healthy person’s blood sugar to do is to go up in response to taking in the glucose, for the pancreas to release the appropriate amount of insulin which results in the blood sugar going back down to at- or slightly below where it started from. This is the normal, healthy response.

On a graph it would look like this;

Normal Glucose Response with 75 g of glucose

But in the case of the person whose blood sugar is normal at fasting (i.e. 4.9 mmol/L (88 mg/dl)) but their fasting insulin is much higher than ideal (i.e. 132.6 pmol/L (19.1 uU/ml) instead of 14.0 – 42.0 pmol/L (2-6 uU/ml)), their car is in “park” but the engine is already turning fast!

Image result for oral glucose tolerance testWhen this person drinks the 75 g of glucose, their pancreas goes into “high rev” and releases a huge amount of insulin—which not only keeps the blood sugar from going up normally in response to taking in glucose, it may result in the blood sugar actually dropping slightly below the fasting level (from 4.9 mmol/L / 88 mg/dl to 4.8 mmol/L / 86 mg/dl). This is not a healthy response but is characteristic of both hyperinsulinemia (too much circulating insulin even when the person is fasting) as well as insulin resistance (cells not responding to insulin’s signal to take up glucose from the blood).

This glucose and insulin response would look as follows;

If this person had only had a standard 2 hour Glucose Tolerance Test, they would be told everything is “fine” because their fasting blood glucose was normal at 4.9 mmol/L / 88 mg/dl and at 2 hours their blood glucose came right back down to normal (4.9 mmol/l / 88 mg/dl)!

Using the car analogy, their “tachometer” (pancreas that produces insulin) is working way too hard in order to keep blood sugar low and without assessing simultaneous glucose AND insulin at fasting, 30 minutes or 1 hour and at 2 hours, the fact this person’s pancreas is working way too hard to keep glucose low would be totally missed. Burnout of the pancreatic β-cells is what results in Type 2 Diabetes (T2D).

By the time a person is diagnosed with T2D, they have lost approximately half of their β-cell mass, so preventing the β-cell’s of the pancreas from being overworked is how to delay or prevent becoming Type 2 Diabetic!

Four Stages of Type 2 Diabetes

There are four stages in the progression of Type 2 Diabetes, with Insulin Resistance and Hyperinsulinemia being the stage BEFORE pre-diabetes [2].

Stage 1: Insulin Resistance (including hyperinsulinemia)
Stage 2: Pre-diabetes
Stage 3: Type 2 Diabetes
Stage 4: Metabolic and Vascular Complications

Four Stages of Type 2 Diabetes – original illustration by Joy Y. Kiddie MSc, RD

Insulin resistance and  hyperinsulinemia together are essentially “pre-pre-diabetes”, therefore stopping progression of the disease at this point reduces the risk associated with high blood pressure, abnormal cholesterol, heart attack and stroke, as well as chronic kidney disease.

What is Insulin Resistance and Hyperinsulinemia?

Insulin resistance is where the cells of the body ignore signals from the hormone insulin which tell it to move glucose from broken down from digested food — from the blood and into the cells. When someone is insulin resistant, blood glucose stays higher than it should be, for longer than it should be, which is called  hyperglycemia.  When there are insufficient receptors on muscle cells to move glucose out of the blood after eating, this is called insulin resistance. It isn’t known whether insulin resistance comes first or hyperinsulinemia (high circulating levels of insulin) does. It is believed that it may be different depending on the person[3].

What Can Cause Insulin Resistance & Hyperinsulinemia?

It is known that excessive carbohydrate intake can trigger both high blood sugar levels (hyperglycemia), as well as too much insulin release (hyperinsulinemia).  Eating lots of fruit, for example or foods that contain fructose (fruit sugar) will cause the body to first move the fructose into the body in order to get it to the liver, before it deals with glucose. Since many processed foods contain “high fructose corn syrup” (HFCS), eating these foods contribute to problems with both high blood sugar and high levels of circulating insulin. Eating lots of fruit or drinking fruit juice or smoothies made with lots of fruit can contribute to the same problem. There are other things that can also trigger high blood sugar and high insulin levels besides too much carbohydrate intake, including certain medications like corticosteroids and anti-psychotic medications, and even stress.  Stress causes the hormone cortisol to rise, which is a natural corticosteroid. It is thought that long-term stress may lead to hyperinsulinemia, which increases appetite by affecting something called neuropeptide Y. This may explain why people tend to eat more when they’re stressed and are very often drawn to carbohydrate-based foods that are quickly broken down for energy.

Measuring Insulin Resistance

Homeostatic Model Assessment (HOMA-IR) estimates the degree of insulin resistance (IR), β-cell function (the cells of the pancreas that produce insulin) and insulin sensitivity (%S) and is determined from the results simultaneous fasting blood glucose test and a fasting insulin test.

Alternatively, HOMA-IR can be determined from a fasting blood glucose test and a fasting C-peptide test [3]. C-peptide is released in proportion to insulin, so it can be used to estimate insulin. Individual results are best compared to local population cut off values for HOMA1-IR [4] (1985) or the updated HOMA2-IR [5] (1998) .

HOMA1-IR  is defined as [fasting insulin (µU/mL)× fasting glucose (mmol/L)]/22.5 [4] and HOMA2-IR is calculated using an online HOMA2 calculator released by the Diabetes Trials Unit, University of Oxford available at http://www.dtu.ox.ac.uk/homacalculator/index.php (updated January 8, 2013).

The original HOMA1-IR equation proposed by Matthews in 1985 [4] was widely used due to its simplicity, however it was not always reliable because it did not consider the variations in the glucose resistance of peripheral tissue and liver, or increases in the insulin secretion curve for blood glucose concentrations above 10 mmol/L (180 mg/dL) or the effect of circulating levels of pro-insulin. [6]. The updated HOMA2-IR computer model [5] has been used since 1998 and corrects for these.

Cutoff for insulin resistance using the original Matthews values (1985) [4] for HOMA-IR ≥ 2.7

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

Cuffoff values for insulin resistance using the HOMA2-IR calculator (1998) [5] is HOMA2-IR ≥ 1.8. Three population based studies found the same or very close cutoffs applied, including a 2009 Brazilian study [7] which found HOMA2-IR ≥ 1.8, a 2014 Venezuelan study [8] which found HOMA2-IR ≥ 2.0 and a 2014 Iranian study [9] which found HOMA2-IR ≥ 1.8.

Measuring Hyperinsulemia

Detection of hyperinsulinemia (high circulating levels of insulin) can occur using an Oral Glucose Sensitivity Index (OGIS) where available, or with a 2-hr Oral Glucose Tolerance Test (2-hr OGTT) with simultaneous assessors of insulin.  These are tests where a fasting person drinks a known amount of glucose (usually 75 g or 100 g of glucose) and their blood sugar and insulin values are measured before the test starts (baseline, while fasting) and at 2 hours. An additional assessor of blood glucose and insulin can be requested at 1 hour which is very helpful for detecting abnormalities that would missed if only assessing at fasting and at 2 hours. In the OGIS, both blood glucose and blood insulin levels are measured at baseline (fasting), at 120 minutes and at 180 minutes[3].

Final thoughts…

As mentioned at the start of this article, abnormalities in insulin, including insulin resistance and/or hyperinsulinemia begin to occur as much as 20 years before a diagnosis of Type 2 Diabetes — while blood sugar results are still normal. That is when we need to diagnose abnormalities!

If we simply monitor fasting blood glucose, we will miss that someone’s pancreas may be overworking.

Even if we monitor fasting blood glucose and glycated hemoglobin (HbA1C), we can miss that someone’s pancreas is overworking by constantly producing too much insulin.

Furthermore, even if a standard 2 hour Glucose Tolerance Test is run and the person’s fasting blood glucose and 2 hour glucose level after a load is measured, we still can miss that someone’s pancreas is being pushed way too hard if those values appear normal at baseline and at the end of the test.

By running a 2 hour Glucose Tolerance Test with simultaneous glucose and insulin at baseline (fasting), 30 minutes or 1 hour, and at 2 hours we can observe the pancreas being pushed way too hard and implement dietary changes to avoid further β-cell damage or β-cell death.

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 HST
additional glucose at 1 hour                                                       = $   3.93   with HST
3 insulin assessors at fasting, 1 hour, 2 hours                   = $111.27  with HST
TOTAL                                                                                                   = $128.56 with HST

When there are clinical reasons to suspect that a person may be insulin resistant and/or hyperinsulinemic and assessment of simultaneous glucose and insulin function can provide sufficient motivation for individuals to implement dietary changes that can prevent progression to Type 2 Diabetes, is this testing not worth <$130?

If you would like to know about the services that I offer, please click on the Services tab to learn more and if you have questions related to these, please send me a note using the Contact Me form located on the tab above and I will reply as I am able.

To your good health!

Joy

You can follow me at:

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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. Sagesaka H, S.Y., Someya Y, et al, Type 2 Diabetes: When Does It Start? Journal of the Endocrine Society, 2018. 2(5): p. 476-484.
  2. Mechanick JI, G.A., Grunberger G, et al, Dysglycemia-Based Chronic Disease: an American Association of Clinical Endocrinologists Position Paper. Endocrine Practice, 2018. 24(11): p. 995-1011.
  3. Crofts, C., Understanding and Diagnosing Hyperinsulinemia. 2015, AUT University: Auckland, New Zealand. p. 205.
  4. Matthews, D. R; Hosker, J. P; Rudenski, A. S; Naylor, B. A; Treacher, D. F; Turner, R. C; ―Homeostasis model assessment: insulin resistance and β-cell function from fasting plasma glucose and insulin concentrations in man‖; Diabetologia; July, 1985; Volume 28, Number 7: Pp 412-419
  5. Levy JC, Matthews DR, Hermans MP. Correct homeostasis model assessment (HOMA) evaluation uses the computer program. Diabetes Care. 1998;21:2191–2192
  6. Song YS, Hwang Y-C, Ahn H-Y, Comparison of the Usefulness of the Updated Homeostasis Model Assessment (HOMA2) with the Original HOMA1 in the Prediction of Type 2 Diabetes Mellitus in Koreans, Diabetes Metab J. 2016 Aug; 40(4): 318–325
  7. Geloneze B, Vasques AC, Stabe CF et al, HOMA1-IR and HOMA2-IR indexes in identifying insulin resistance and metabolic syndrome: Brazilian Metabolic Syndrome Study (BRAMS), Arq Bras Endocrinol Metabol. 2009 Mar;53(2):281-7
  8. Bermúdez V, Rojas J, Martínez MS et al, Epidemiologic Behavior and Estimation of an Optimal Cut-Off Point for Homeostasis Model Assessment-2 Insulin Resistance: A Report from a Venezuelan Population, Int Sch Res Notices. 2014 Oct 29;2014:616271
  9. Tohidi M, Ghasemi A, Hadaegh F, Age- and sex-specific reference values for fasting serum insulin levels and insulin resistance/sensitivity indices in healthy Iranian adults: Tehran Lipid and Glucose Study, Clin Biochem. 2014 Apr;47(6):432-8

 

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McGill Professor: Risks and Benefits of Low-Carb Keto Diets

INTRODUCTION: Last Friday, February 8, 2019, the Montreal Gazette published a special article with accompanying video by Dr. Joe Schwarcz, Professor of Chemistry from McGill University titled “Keto Diets Work, but is There a Catch?” and this morning the follow-up was published titled “The Known Benefits of Low-Carb Keto Diets”. This post contains a summary of both.


PART I – “Keto Diets Work, but is There a Catch?”

Dr. Joe Schwarcz, The Montreal Gazette, February 8, 2019 (reference below)

This article began;

“There is little doubt that cutting way back on carbs results in weight loss. But how does all that fat impact cardiovascular risk factors?”

This is a very good question, however it is incorrectly based on the assumption that a “keto diet” is necessarily very high in fat, especially saturated fat, something which is not necessarily the case.

Dr. Schwarcz stated in the article in the Montreal Gazette that on a “keto diet” there is no bread, pasta, cereal, potatoes, carrots, rice, fruit or beer but that one can;

“gorge on fish, butter, eggs, high-fat cheese, whipped cream, coconut oil and meat to your heart’s delight.”

As mentioned in an earlier article that I wrote on a site dedicated to low carbohydrate diets;

“There is no one “keto diet“, but many variations of ketogenic diets that are used for different therapeutic purposes.

Some therapeutic ketogenic diets are used in the treatment of epilepsy and seizure disorder and are extremely high in fat. Other types of therapeutic ketogenic diets are used in the treatment of various forms of cancer (those that feed on glucose), such as brain cancer. There are ketogenic diets that are used in the treatment of Polycystic Ovarian Syndrome  (PCOS), as well as for weight loss and for increasing insulin sensitivity in those with Type 2 Diabetes and insulin resistance.

Even among those using a nutritional ketogenic diet for weight loss and to increase insulin sensitivity, there is no one “keto diet”.

There are ketogenic diets with a higher percentage of fat than protein, with a higher percentage of protein than fat and mixed approaches which may have different ratios of protein to fat – depending on whether the individual is in a weight loss phase or a weight maintenance phase.

There are as many permutations and combinations as there are people following a keto diet for these reasons.

What makes a diet ketogenic (or keto) is that the amount of carbohydrate relative to the amount of protein and fat results in the utilization of fat as a primary fuel source rather than carbohydrate. “

Assuming that the specific type of “keto diet” that Dr. Schwarcz is referring to is one where one that (1) avoids bread, pasta, cereal, potatoes, carrots, rice, fruit* or beer and (2) indulges in foods high in fat, such as fish, butter, eggs, high-fat cheese, whipped cream, coconut oil and meat, it is a very appropriate question to ask as to what effect does this type of keto diet have on cardiovascular risk factors.

Note: Most keto diets used for weight loss allow fruit as berries, such as raspberries, strawberries, blueberries, blackberries as well as those fruit that we often think of as vegetables, including tomato, avocado, cucumbers, lemon and lime.  Dr. Schwarcz raised a concern in the video that not eating fruit limits one’s access to the important antioxidants in fruit, which for the most part is incorrect.

The article states that;

“There is little doubt that cutting way back on carbs results in weight loss. The question is, why?

The body’s main source of energy is glucose, generally supplied by starches and sugars [i.e. carbs] in the diet. If consumption of these carbohydrates is drastically reduced, below about 50 grams a day, energy has to be derived from an alternate source. At first, the 65 or so grams of glucose the body needs per day are produced from amino acids, sourced from proteins. But this process itself has a high energy requirement, and furthermore, the body is not keen on using up proteins that are needed to maintain muscle integrity. Fortunately, there is a backup system that can swing into action.

The liver begins to convert fats into “ketone bodies,” namely beta-hydroxybutyrate, acetoacetate and acetone. These are then shuttled into the mitochondria, the cells’ little energy factories, where they are used as fuel. At this point the body is said to be in “ketosis,” with excess ketones being excreted in the urine.”

Great explanation!

The article raises a few excellent points;

The article states that the “usual argument” for the more efficient weight loss associated with extremely low carb diets as compared to low fat diets is that (1) low carb diets produce a metabolic advantage because a lot of calories are needed to convert proteins to glucose.  The article adds that not everyone agrees with this premise and states that others suggest that (2) ketone bodies have either a direct appetite suppressant effect or that they (3) alter levels of the respective appetite stimulating and inhibiting hormones, ghrelin and leptin. Lastly, the article states that some argue that (4) ketogenic diets lead to a lower calorie intake which the article’s author believes is “due to the greater satiety effect of protein”.

“No long-term studies of keto diets”

The article correctly states that;

“There are numerous studies published over the last 20 years that have compared low-fat diets to low-carb diets with the overall conclusion that the low-carb diets are more effective in terms of weight loss, at least in the short term.

…but incorrectly adds;

“Unfortunately, there are no long-term studies of keto diets.”

While there have been 3 long-term clinical trials (2 years) published over the past 10 years involving low carb diets, unfortunately as documented in and earlier article none of these involved research groups that actually ate a low carbohydrate diet. There is, however the recent two-year data from the Virta Health’s study that was published this past December 2018 which demonstrated the long term safety of a ketogenic diet and that participants on average;

(1) lost 12.4 kg (28 pounds) in two years; most of which was achieved in the first year maintained with only a slight increase of 2.3 kg (5 pounds) in the second year.

In addition to the weight loss, participants in the Virta Health study;

(2) significantly lowered medication use for Type 2 Diabetes (read more here)

(3) lowered glycated hemoglobin (HbA1C) by a full percentage point at two years (7.7% to 6.7%)

(4) lowered fasting blood glucose from 9.1 mmol/L (164 mg/dl) at the start of the study to 7.4 mmol/l (134 mg/dl ) at two years.

High Fat Keto Diet and Cardiovascular Risk Factors

The article concludes with the initial question as to how a diet “high in fat, such as fish, butter, eggs, high-fat cheese, whipped cream, coconut oil and meat” impacts markers of cardiovascular risk.

“As one would expect, LDL, the “bad cholesterol,” does go up, although the increase is mostly in the “large particle” sub fraction that is deemed to be less risky.

Triglycerides, a significant risk factor, actually decrease on a very-low-carbohydrate diet, as does the body’s own production of cholesterol.

Levels of HDL, the “good cholesterol,” increase.

That is, over the short term, markers of cardiovascular risk doesn’t change to any degree.

What about over the long term?

Unfortunately, the article concludes with;

“the problem is that there are no studies of people who have followed a keto diet long enough to note whatever effect such a diet may have on heart disease.”

…but as mentioned above, we do have the two-year data from the Virta Health’s study that was published this past December 2018 and which demonstrates that;

(1)  LDL cholesterol of the intervention group at the start of the study averaged 2.68 mmol/L (103.5 mg/dl) and at two years was slightly higher as expected, to 2.96 mmol/L (114.5 mg/dl), however this level after 2 years was almost identical to what it was at 1 year; 2.95 mmol/L(114 mg/dl). That is, LDL (mostly the large particle sub-fraction) increased as expected the first year but didn’t continue to rise.

(2) At baseline, HDL cholesterol (“good cholesterol”) of the intervention group averaged 1.11 mmol/L (41.8 mg/dl) and after two years was stable at the same level it had risen to at 1 year, namely 1.28 mmol/L (49.5 mg/dl).

(3) At baseline, triglycerides of the intervention group averaged 2.23 mmol/L (197.2 mg/dl) and at two years was down to 1.73 mmol/L (153.3 mg/dl ), only up slightly for the one year average of 1.68 mmol/L (148.9 mg/dl).

Final Thoughts…

While Dr. Schwarcz seemed to be unaware of the publication of the two-year Virta Health study data in December 2018 that demonstrates both long-term safety and efficacy of a ketogenic diet for weight loss and improvement in metabolic health (including markers of cardiovascular risk), the Montreal Gazette article and accompanying video does indicate that a very high fat ketogenic diet does not adversely impact markers of cardiovascular risk.

Reference
  1. Dr. Joe Schwarcz, “The Right Chemistry: Keto diets work, but is there a catch?” Montreal Gazette, February 8, 2019, https://montrealgazette.com/opinion/columnists/the-right-chemistry-keto-diets-work-but-is-there-a-catch

PART II – “The Known Benefits of Low-Carb Keto Diets”

Dr. Joe Schwarcz, The Montreal Gazette, February 15, 2019 (reference below)

This morning, Dr. Joe Schwarcz, Professor of Chemistry from McGill University and popular radio show host released a follow-up to last week’s opinion article and video that was published in the Montreal Gazette on the cardiovascular risks of a keto diet; this one on the known benefits of low-carb keto diets.

Schwarcz begins by fondly reminiscing about going to the circus with his mother when he was about 7 or 8 years old and the memories of the snack that she packed for him of crusty Hungarian bread, slathered with butter and topped with green bell pepper. He said that he’s loved it ever since, but “now we question such snacks. Why? Because of the carbohydrate content of the bread”.

“I’ve been looking into this for quite a while. There is really a plethora of papers and information that floods us about the keto diets; the very low carbohydrate diets”.

To his credit, Dr. Schwarcz acknowledged (possibly as a result of my written response to his article of last week in the Montreal Gazette) that there isn’t just one “keto diet” (singular) but several very low carbohydrate diets (plural) .

Schwarcz reiterates;

“I would have thought that by having all of that fat in the diet that risk levels for certain cardiovascular factors would go up, but really there isn’t really that much alteration in these factors”.

Low-Carb “Keto” Diets and Diabetes

Transitioning from the lack of cardiovascular risks associated with low-carb keto diets, Schwarcz adds;

“When it comes to Diabetes the information is really overwhelming to the benefit of these low carb diets. There are people — Type 2 Diabetes sufferers, who have been able to give up their medication by following a stringent, low carbohydrate diet.”

Schwarcz dismisses anecdotal reports of people’s “brain fog” resolving and possible benefits for cancer, Parkinson’s disease and Alzheimer’s disease as not being scientifically based but is unequivocal about the known benefits;

“What we do know is that weight loss can be very significant on a low carbohydrate diet and as I said — surprisingly, without any significant risk factors.”

Schwarcz continues;

“On the other hand, the longest terms studies that I’ve seen which were really properly controlled have only been about six months, and that really isn’t long enough.”

NOTE: In this case, Dr. Schwarcz is referring only to randomized, controlled double blind studies — excluding the data from long term studies of other types.

“We also know from dietary studies that after about a year, it doesn’t much matter what diet you’re on when it comes to weight loss — whether it’s low fat, whether it’s low carb, the results tend to be the same as long as you’re cutting out some calories.”

NOTE: While this may be true, what Schwarcz neglects to mention is that the major difference is that in a calorie-restricted low-fat diet, people are deliberately restricting food intake, often feeling hungry — whereas in a low carbohydrate diet, people naturally feel less hungry due to the satiety (hunger-reducing effect of protein and fat) which results in them eating less. In one case people are purposely restricting calories in the the other case, they don’t feel as hungry so they naturally eat less.

Schwarcz reiterates;

“However, for people who are afflicted with Diabetes, I think there is no question that the very low carb diets are worth trying.”

Towards the end of the video Dr. Schwarcz reflects on his childhood snack of crusty Hungarian bread, slathered with butter and topped with a quarter of a green bell pepper and admits that he looks askew at this snack.

“I admit that I’ve been eating less bread — I haven’t cut it out because I don’t think I need to do that, but I’m eating less.”

Schwarcz adds that for those who are gravitating towards a low carbohydrate diet, they can opt instead to eat bell pepper with a dollop of hummus with tahini (ground sesame seeds) or raw broccoli dipped in a bit of hummus.

“It tastes good! I think it is possible to cut down on the bread!”

Since Dr. Schwarcz is presumably not Diabetic and has all the nostalgia of memories of the circus as a child, he concludes the video by happily biting into a slice of crusty Hungarian bread that’s been slathered with butter and topped with a quarter of a green bell pepper…for nostalgia reasons, of course!

Bon appetit, Dr. Schwarcz!

If you would like to know more about the services I offer (including low carbohydrate and ketogenic diets) please click on the Services tab, and if you have questions about those please feel free to send me a note using the Contact Me form located on the tab above.

To your good health!

Joy

You can follow me at:

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Reference

Montreal Gazette, February 15, 2019, Dr. Joe Schwarcz, Known Benefits of Low Carb “Keto” Diets” https://montrealgazette.com/category/opinion

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

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Why I Posted My “Before” Pictures When I was Still Obese

INTRODUCTION: It is not uncommon for people to post their “before” pictures after they’ve reached their goal weight to show how much they’ve accomplished, but why on earth did I post pictures of myself when I was still obese and metabolically unwell? That’s a good question.

There’s a saying that “it is not the healthy who need a physician, but the sick” and while people will consult with Dietitian for many different reasons, those who are significantly overweight find it very difficult to take that first step when it is weight loss they’re seeking. Why?

People feel ashamed of being overweight or obese.

Oftentimes, overweight people feel that they are assumed to be undisciplined or lazy — that their condition is their own fault. They have heard over and over again that;

“If only they would eat less and move more they wouldn’t be so fat!”

or

“If only they ate ‘real food’ instead of ‘junk food’ they would be so much slimmer!”

Really?

If it were that simple, why would 1 in 4 Canadians (and 1 in 3 Americans) be obese?

Because it’s not that simple.

It’s been my experience that many overweight people and obese people often eat what has traditionally been thought of as a “healthy diet”; plenty of fruit and vegetables, low fat dairy products and only brown bread, rice and pasta and they feel frustrated and ashamed of being what is perceived as “a failure”.

Some have told me that sometimes their own healthcare providers have given them the impression that they must be being untruthful about what they’ve been eating because surely if they were eating the way they say, they would have been losing weight. In other words, they are not believed, or in stronger words, they are thought to be lying or at least incapable of accurately assessing how much they are ‘really’ eating.

Why would an overweight or obese person seek help in losing weight from a healthcare professional that views them as undisciplined, lazy or unrealistic about what they are eating?

They don’t.

Often people will try various diets that they read about online because no one will see them try and more importantly no one will see when they give up, feeling once again that they are ‘failures’.

I don’t think that overweight and obese people are failures. I believe many are doing what they’ve been told is the “right thing” but for different reasons. it is not working for them.  My role as a Dietitian is to help people understand what isn’t working and to enable them to be successful — without judgement.

It is for just such people that I posted my “fat” pictures before I ever started to lose weight!

I wanted people to see me as no different and certainly no better than they are, because I’m not. Sure, I have an undergraduate and graduate degree in nutrition, but I don’t get any “free passes” when it comes to losing weight and turning around my own metabolic health. I needed to do it just like everybody else.

I’ve lived each step of my weight loss and metabolic health recovery journey in public because I wanted people to experience in “real time” my frustrations and my victories. I wanted people to see that the path is not linear; that there are twists and turns and stalls, but yes it is possible to be successful. It just takes time and some dedicated work to get well and achieve a healthy body weight.

I look at it this way;

If it took me 20 years to become metabolically unhealthy and obese, what’s a couple of years to become metabolically healthy and normal weight?

Everyone’s weight loss and health restoration journey will be different.

There are no “magic bullets” or “super diets”— but there are different dietary and lifestyle options that can be pursued for success.

I can help.

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

To our good health!

Joy

You can follow me at:

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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

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Middle-Eastern Style Lentil Soup – whole food plant based

The new Canada Food Guide encourages a whole food plant-based diet which is a good option for those who are metabolically healthy — especially those who are insulin sensitive. The challenge is that I was diagnosed with Type 2 Diabetes 10 years ago and while I am in partial remission now as a result of dietary changes I implemented 23 months ago, on a cold winter day like yesterday I really wanted a bowl of my favourite homemade lentil soup.

I knew from testing my blood sugar in response to different foods that I was beginning to tolerate a small amount of whole, unground legumes such as chickpeas that had been soaked from the dried ones, then cooked. I also knew that leaving the lentils whole rather than pureeing them would reduce the blood sugar response and by adding additional non-starchy vegetables such as spinach and fresh green herbs would also help lower the glycemic response, so in the interest of science (of course) I decided to make the lentil soup and test my response two hours afterwards and the next morning.

The only significant source of carbohydrates that I ate yesterday was the soup which was ~20 g of carbs per bowl.  I was pleased and encouraged that after 23 months of changing how I ate that my blood glucose two hours after eating it was only 5.5 mmol/L (100 mg/dl), which was normal. This morning my fasting blood glucose was 6.3 mmol/L (114 mg/dl) which was significantly higher than what it has been the last few months eating a low carbohydrate diet, but considering the amount of slowly digestible carbohydrate in the soup, it was somewhat understandable.  To more accurately assess my glycemic response to the soup, I should have tested my blood sugar before I ate it, after 30 minutes, 60 minutes and 2 hours after eating it, as I did with my chickpea “experiment” as the 2 hour snapshot after 2 hours doesn’t provide any information as to what was happening to my blood glucose at 30 minutes and 60 minutes, which may have included a spike.

The soup was a nice treat and it was encouraging to me to continue to discover that as time goes on, I can reintroduce small amounts of whole-food carbohydrate sources without unduly impacting my blood sugars. Of course, being in remission from Type 2 Diabetes is not Diabetes  reversal, so I am by no means “cured”, but I am doing much better than 23 months ago.

As I know from several studies, including a 2015 study from Israel (Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094), everyone’s glucose response to individual foods is different and the only way to know how each person will respond (whether Diabetic or non-diabetic / insulin resistant) is to test individual response to a specific amount of the food, which is what I did. While legumes are not something I would eat on a regular basis as it would negatively impact my glycated hemoglobin (HbA1C) level, it is certainly nice to be able to have it sometimes.

Of course, for those who are insulin sensitive, this is a delicious whole-food, largely plant based meal.

Below is the recipe for the soup. I included a piece of beef shank, but it can as easily be made without any meat for those that don’t eat it.

NOTE: This recipe is posted as a courtesy for those following a variety of different types of eating styles and not necessarily as part of a Meal Plan designed by me. This recipe may or may not be appropriate for you.

Middle Eastern Lentil Soup

Ingredients

1 medium yellow onion, chopped finely
1 medium carrot, diced
4 cloves fresh garlic, minced finely
2 tbsp olive oil
1 slice of beef shank, optional
2 cups small brown lentils, rinsed well
2 tsp coriander powder
1 tsp cumin powder
1/2 tsp freshly ground black pepper
kosher salt, to taste
1 cup fresh cilantro leaves (coriander greens), chopped
1 cup fresh parsley (flat leaf or curly), chopped
2 300 g packages of frozen chopped spinach, defrosted and squeezed dry
4 liters cold water

Herb Topping (optional)

3 green onions, minced finely
2 cloves fresh garlic, minced finely
1/2 cup fresh parsley, minced finely
1/2 cup fresh cilantro, minced finely
1 tbsp olive oil

Saute the green onions in the olive oil over a medium heat until wilted, but not browned, add the garlic and saute a minute or two then add the chopped parsley and cilantro and continue sauteing until the greens are slightly cooked.  Set aside to top each bowl of soup with, just before serving.

Method

  1. Saute the chopped onion in the olive oil until lightly browned
  2. Add the chopped carrot and saute until partially cooked
  3. Add the beef shank, if using and brown on both sides
  4. Add the minced garlic and saute (being careful not to let it brown as it would become bitter)
  5. Add the coriander and cumin powder, and keep stirring
  6. Toss in the rinsed brown lentils
  7. Season with salt and freshly ground black pepper
  8. Add cold water and stir to dislodge anything that may have stuck to the bottom
  9. Over a medium-low heat, bring to a simmer, skimming off any foam that accumulates from the meat protein
  10. Cook at medium-low for several hours, until the lentils are cooked but not too soft
  11. Twenty minutes before serving, add in the well-squeezed spinach, fresh parsley and fresh cilantro (coriander greens)
  12. Prepare the herb topping and set aside to top individual bowls of soupd when serving
  13. Enjoy!

Middle Eastern Style Lentil Soup

You can follow me at:

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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

 

 

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Reflections of a Nutritional Centrist

INTRODUCTION: In a recent article titled Carbohydrates are not Evil I referred to myself as a “nutritional centrist” and in this post I’ll elaborate on what I mean by this. This post is more of an editorial than a standard ‘Science Made Simple’ article. References can be found in the previous articles by using the search feature.


Much of the discussion about nutrition these days on social media seems to take an “all-or-nothing” stance.

As in politics, there are those that tend towards a “left-wing” (liberal) position and others who tend towards a “right-wing” (conservative) position; some who are libertarian (let people decide for themselves) and others who are very authoritarian (dictate what they believe is best).

When it comes to nutrition, I am a centrist.

Defining a Nutrition Centrist

In this article, I am using the term “centrism” to include a very wide range of nutritional positions apart from any at extreme ends of the spectrum. I believe that a wide range of nutritional centrists positions are supported by current, evidence-based science.

Veganism and Carnivory – two ends of the spectrum

In the food world there are vegans on one hand and carnivores on the other.  One eats only plant-based food with nothing coming from animals (no eggs, milk or cheese) and the other eats only animal flesh food (no fruit, vegetables or dairy). In my understanding, these nutritional positions are the corresponding equivalent to left wing/liberals and right wing/conservative political positions and while I respect people’s individual right to choose veganism or carnivory as a lifestyle choice, for health reasons or on the basis of ethical or religious beliefs, in my understanding there are significant nutritional challenges to both ends of the spectrum.

Nutritional centrists – vegetarians, pescatarians and omnivores

Somewhere between veganism and carnivory are vegetarians
(who eat mostly plant-based foods but will also eat eggs, milk and cheese because no animal is killed or harmed in the making of these) and those who are omnivores (that will eat food from a wide variety of plant and animal sources). Somewhere in the middle of these two are pescatarians who are like vegetarians but who will also eat fish (perhaps because they are not mammals, and sometimes only when they are wild species i.e. not man raised).

From my perspective, people who chose any of these lifestyles fall somewhere in the “nutritional centrist” position. I find it easy to support people following any of these lifestyle or ethical choices because it is possible to design a diet that ensures adequate nutritional intake of a wide range of macro- and micro-nutrients from the foods they choose to eat.

Whole-food-plant-based

Those who follow a “whole-food plant-based diet” can be either vegan or vegetarian so in my understanding, whole-food plant-based vegetarians fall somewhere in the “nutritional centrist” position, whereas whole-food plant-based  vegans are vegans with an approach that falls at one end of the spectrum.

Low Carb High Fat and Ketogenic diets – a centrist approach

As I’ve mentioned in numerous previous articles, there are several different types of “low carb” and “ketogenic” diets.

For example, if a client comes to me with a dietary prescription from a physician for a specific type of ketogenic diet to support a specific medical or metabolic condition that is a very different scenario than someone who wants me to help them with “quick weight loss” using a “keto diet”.

As a “nutritional centrist” my approach to supporting people in following a low carbohydrate lifestyle for weight loss is to start at a moderately-low level of carbohydrates (130 g carbohydrate per day) and lower the amount of carbohydrate as needed to achieve clinical outcomes. If individuals are insulin sensitive, this level of carbohydrate intake often works very well, especially at first when people were formerly eating ~300+ g of carbohydrate per day. For those who are insulin resistant or have Type 2 Diabetes, I start at a moderately-low level of carbohydrate intake and with self-monitoring of blood sugar and follow-up and oversight from their doctor with respect to any medications taken, will gradually lower carbohydrate intake as needed to achieve the desired clinical outcome(s).

It is not a “one-sized-fits-all” approach. As documented in several previous articles, people’s glycemic (blood sugar) response to carbohydrate varies significantly, even among those who are insulin sensitive and also in those with Type 2 Diabetes, so determining individual blood sugar response to carbohydrate is the best way to determine which types and amounts of carbohydrate people respond best to. I don’t believe it is appropriate or necessary for everyone to follow a “keto diet”.

Nutritional Centrism with respect to added fat

Amongst those that teach and support a “low carb” lifestyle, there are those that promote lots of added fat from a wide variety of sources.  These are people that believe in adding coconut oil and butter to beverages, butter to top meat and vegetables and using whipping cream copiously. From the beginning this is not an approach I have taken. In light of the recent scientific evidence (such as the large-scale PURE epidemiological study and others), I do not believe that moderate saturated fat intake is harmful to cardiovascular health. At the same time, I see no reason that if added fat is helpful in a particular person’s diet, that fats such as cold-expressed olive and avocado oil as well as nut and seed oils such as macadamia, walnut and almond oil aren’t suitable options.

I don’t see the need for extremes with regards to added fat. I encourage people for whom the recommendation is appropriate to add enough good quality healthy fat to make the vegetables or salad taste interesting enough that they will want to eat a fair amount of them and enjoy them. After all, eating isn’t only about getting enough nutrients, but enjoying the foods that are eaten.

Fat that comes with protein

Unless there is a medical or metabolic condition involved which precludes it, I encourage people to eat the fat that comes naturally with their protein source if they enjoy doing so.

I encourage folks to trim excess external fat off a fatty cut of steak, but if they enjoy chewing on the bone on a rib steak to ‘go for it’. The yolk in an egg or the fat in cheese is not harmful when eaten in moderate amounts so unless there are strong risk factors, I don’t believe people need to avoid or limit these foods.

While the new Canada Food guide recommends limiting foods with saturated fat based on the fact that dietary saturated fat raises total-LDL cholesterol, as I’ve documented in several previous articles I don’t believe when considering all the recent evidence that there is compelling reason to advise all people to limit foods containing cheese or to select plant-based foods over foods that contain saturated fat.

As mentioned in a few recent articles, Canada Food Guide is directed towards a healthy population in order to help them stay metabolically well and I believe that the whole-food approach of the new Guide which avoids refined grains, fruit juice and processed foods is a good evidence-based approach to accomplishing this, and one I support in my practice.

My concern as covered recently is that as many as 88% of Americans are already metabolically unwell (with presumably a slightly lower percentage in Canada due to our slightly lower obesity statistics) so in those that already have indications of insulin resistance (which is a large percentage of my client base), I do recommend a whole-foods approach but with a lower percentage of carbohydrate intake.  In my understanding, this is a “nutritional centrist” approach which is supported by the American Diabetes Association and the European Association for the Study of Diabetes who both support the use of a low carbohydrate diet as Medical Nutrition Therapy in the management of Type 2 Diabetes and for weight loss.

Supporting lifestyle choices

Veganism, like carnivory is a lifestyle choice that is sometimes made for religious or ethical reasons and sometimes for health reasons.  Regardless of the reason for the choice, these are lifestyles that need to be respected and supported by healthcare professionals who are qualified to do so.

As a “nutritional centrist” I can help healthy individuals follow the new Canada Food Guide and provide meals for their family along those lines if they so choose, as well as to support those who are already metabolically unhealthy using everything from a Mediterranean diet, a whole-food plant-based approach or a low carbohydrate or ketogenic diet. There is no “one-sized-fits-all” diet for any of these approaches and each should be tailored to individual needs.

No Conspiracy Theories

Conspiracy theories abound in many areas from religion to politics and there are plenty in the nutrition arena, as well. As a “nutritional centrist”, I don’t believe that “big-pharma” and “big-food” are behind everything, but at the same time I am also not naive enough to think that industries and special interests groups don’t attempt to influence the marketplace or government funding or policies by the types of research they fund, or by other means. I give scientists and researchers the benefit of the doubt that their intentions are in the interest of good science and the public interest, even though on occasion it is found out otherwise.

No Conspiracy Theories

My writing about topics such the funding of the Harvard studies by the sugar industry does not mean that I believe the scientists involved deliberately wrote biased reports. The articles were written to document the fact that researchers were funded by the sugar industry to write articles about why saturated fat was the underlying issue with respect to cardiovascular disease. Likewise, the recently translated French language newspaper report that shed light on why the government (e.g. Agriculture Canada or a political party’s leadership) may have been motivated to encourage the highlighting of legumes does not mean anything inappropriate occurred.  In my understanding, conspiracy theories are not compatible with a “nutritional centrist” position.

I would encourage my readers to give scientists and researchers the benefit of the doubt when it comes to their intentions; unless there is very credible and verifiable reasons to believe otherwise.

Libertarian versus Authoritarian Approach – a centrist approach

A libertarian approach to dietary choice supports each person’s individual’s right to choose the most suitable dietary approach for themselves whereas an authoritarian approach essentially tells a person what is best for them.

As a “nutritional centrist”, I am frequently in the scientific literature, reading and reviewing the latest studies and evaluating these in light of what is already known about nutrition. My motivation in writing articles that put these studies into “plain English” is that so ordinary people can evaluate these in light of what they know and choose what they feel is best for them. From my perspective, the current available quality research on the subject is the “authority” but by no means should this be used in an authoritarian way to tell a person what is best for them. My position as a “nutritional centrist” is that people should be presented with the range of available evidenced-based options and the supporting science behind those options, but in accordance with a libertarian approach, the choice is theirs to make.

I hope that as a result of reading this article, you have a fuller understanding of what I believe and why and that I support a range of evidence-based dietary approaches including those who want to follow the Canada Food Guide, a Mediterranean approach, a whole-food vegetarian plant-based approach or a low carbohydrate approach and that include moderate amounts of healthy fats of all types. There certainly isn’t a “one-sized-fits-all” dietary approach suitable for everyone so from my perspective, the issue is which one may be best suited to help you achieve your health and nutrition goals, within your personal food preferences.

If you would like to know more about the services I offer, please click on the Services tab and if you have questions related to those, please feel free to send me a note using the Contact Me form located on the tab above.

To your good health!

Joy

Feedback and question from Dr. Andrew Samis, MD, PhD – shared with prior permission

UPDATE: February 1, 2019 13:20

Dr. Andrew Samis, MD, PhD, a surgeon and critical care specialist from Kingston, Ontario asked a very interesting question on Twitter, in response to this article;

“Could the same eating strategy be healthy for one person, and make a second metabolically unhealthy?”

This was my response;

Yes, I believe there is ample evidence that the same eating strategy could be healthy for one person and make a second person metabolically unhealthy. Monitoring metabolic markers enables us to catch this early and make adjustments, as necessary.”


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Carbohydrates are Not Evil

Much of the discussion about nutrition these days on social media seems to take an “all-or-nothing” stance on carbohydrates.  On one hand there are those who promote a plant-based diet that necessarily comes with a large amount of carbohydrate as grains, legumes (pulses) such as beans and lentils as well as carbohydrate-containing vegetables and fruit, and on the other hand there are those who eschew anything with the remotest amount of carbohydrate.

In politics, there are left-leaning ‘liberals’ and right-leaning ‘conservatives’, as well as those that hold a moderate position called “centrists”.

I am a centrist when it comes to my position regarding carbohydrates. In this article, I will elaborate on the following;

  1. Carbs are not evil or single-handedly responsible for the obesity epidemic or metabolic diseases. If that were the case, then the traditional diets of much of Asia and West Africa would have resulted in obesity and diabetes and they did not. It is the degree of processing of the carbohydrate-based foods that impacts the blood glucose and blood insulin response of carbohydrate-containing foods.
  2. Carbohydrate-based foods combined with fat in the same food ‘hijack’ the reward center of our brains (striatum), resulting in over-consumption.
  3. Carbohydrates are not essential macronutrients.

Part 1 – Degree of Processing of Carbohydrate-based Foods Impacts Blood Glucose and Insulin Response

Processing carbohydrate even in simple ways such as cooking or grinding means that more of the carbohydrate is available to the body to be digested. As pointed out in an earlier article which I will refer to throughout this section, when grains are cooked they become much more digestible – meaning that more of the nutrients in the grain is available to be absorbed. In the case of potatoes, there is double or triple the amount of energy (calories) available to the body when they are cooked versus when they are raw.

Mechanical processing, such pounding, grinding or pureeing are also forms of food processing which have an effect on how many nutrients are available to be digested. The nutrients available to the body when food is eaten raw and whole versus raw and pounded is significant.

Glucose Response – based on the amount of food processing

Mechanical processing of a food doesn’t change the amount of carbohydrate that is in it. That is, when 60 g of whole apple are compared with 60 g of pureed apple or 60 g of juiced apple, there are the same amount of carbohydrates in each and the Glycemic Index of these are similar, however when these foods are eaten the blood glucose response 90 minutes later is significantly different. As outlined in the earlier article, in healthy individuals, blood glucose level goes very high with the juiced apple and in response to the release of insulin, blood glucose then goes very low, below baseline. The response that we see with the juiced apple in healthy individuals is typical of what is seen with other forms of ultra-processed carbohydrates.

This is why it is preferable for metabolically healthy people to eat carbohydrate-based foods as whole, unprocessed foods with a minimum of disruption to the cell structure.

Insulin Response with Mechanical Processing

When healthy individuals eat grain-based meals, the plasma insulin response is inversely related to the particle size of the grain. That is whole, unprocessed grain releases less insulin than the same amount of cracked grain, which is still less than the same amount of course flour. The highest amount of insulin is released in response to eating the same amount of fine flour.

This increased insulin response of eating grains that are highly processed can drive chronic hyperinsulinemia, which underlies the metabolic dysfunction of insulin resistance.

It is for this reason that for metabolically healthy individuals, eating whole, unrefined grains is recommended.

Effect or Lack of Effect of Fiber

It is the lack of disruption to the cell structure of the grain that limits the insulin response and not the fiber content.

There isn’t a big difference between the insulin response of brown rice versus white rice. That is, the amount of fiber in the rice does not change the insulin response so eating brown rice instead of white rice won’t change the amount of insulin that is released, Insulin is the hormone that signals the body to store energy (calories), and chronically high levels of insulin called hyperinsulinemia is what eventually results in insulin resistance; the beginning of the metabolic disease process.

As mentioned in the earlier article (link above), studies have been done with bread where the fiber was added back in (such as in so-called “whole wheat bread”) and the insulin response was the same as with white bread, so it is not the amount of fiber in the grain that makes the difference, but the lack of disruption to the grain structure itself.

The disruption of the structure of the grain also has an adverse effect on GIP response (an incretin hormone released from the K-cells high up in the intestine that triggers the release of insulin). Bread made with flour (as opposed to whole, intact grains) results in a much larger and earlier plasma GIP response, which in turn results in a higher and earlier insulin response, than bread made with whole kernel grains, such as artisanal rye or wheat breads.

In metabolically healthy individuals, the eating of whole, intact minimally processed carbohydrate-containing food is preferable, as opposed to eating processed carbohydrate-containing foods (be it grains or fruit) with significant disruption to the cell structure.

Part II – Carbohydrate and Fat Combined

In nature, there are very few foods in the human diet that contain a combination of both carbohydrate and fat in substantial quantities. Human breast milk is one of those few natural foods, along with some nuts and seeds. When humans began drinking the milk of other mammals such as goats, sheep and cows, milk became one of those foods.

Also as outlined in a previous article foods with both fat and carbs together result in much more dopamine being released from the reward-center of our brain, called the striatum. Dopamine is the same neurotransmitter that is released during sex and that is involved in the addictive “runner’s high” familiar to athletes so this is a very powerful neurotransmitter.

It is believed that there are separate areas of the brain that evaluate carb-based foods and fat-based foods but when carbs and fat appear in the same food together, this results in what the researchers called a “supra-additive effect“. That is, both areas of the brain get activated at the same time, resulting in much more dopamine being released from the striatum and a much bigger feeling of “reward” being produced. This combination of carbs and fat in the same food is why we find foods such as French fries, donuts and potato chips irresistible and this powerful reward-system is why we’ll  choose French fries over baked potato and why we have no difficulty wolfing back a few donuts, even when we’ve just eaten a meal.

This “supra-additive effect” on the pleasure center of our brain along with the fact that more insulin is released when both carbs and fat are eaten together helps explain the roots of the current obesity epidemic and the metabolic diseases such as Type 2 Diabetes that go along with it. The high rates of obesity seen more recently in places like China (as covered in this article) are due to the adoption of Western eating habits (refined, processed foods) that are notoriously high in both carbohydrates and fat.

When foods that are rich sources of carbohydrate are eaten it is best that foods that are also rich sources of fat are not eaten at the same time in order to avoid this supra-additive effect.

I do not believe that carbohydrate-based foods in and by themselves in metabolically healthy individuals are the underlying cause of obesity and metabolic disease. I believe that it is the (1) consumption of carbohydrate-based foods that have undergone some kind of food processing (grinding, milling, pureeing, etc) that has disrupted their cell structure and (2) the consumption of foods that combine both carbohydrate and fat in the same food that have driven both.

Part III – Carbohydrates are Not Essential Macronutrients

With all the arguing about eating more carbs or less carbs, it needs to be emphasized that carbohydrates are not essential nutrients. Yes, the body needs a certain amount of glucose for the brain, but the body can make this glucose from protein and fat through a process called gluconeogenesis.

This is not simply my opinion, but is stated by the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005) on page 275;

The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed. 

That is, there is no essential need for dietary carbohydrate provided there are adequate amounts of protein and fat provided in the diet.

The Recommended Dietary Allowance (RDA) for carbohydrate is set at 130 g / carbohydrate per day based on the average minimum amount of glucose utilized by the brain— however the body can manufacture this glucose from protein or fat. A well-designed low carbohydrate diet provides sufficient amounts of fat and  protein such that the body can manufacture the glucose it needs.

Carbohydrate – to eat or not to eat

For Healthy Individuals

For those who are healthy and metabolically flexible, consumption of whole, unprocessed carbohydrate-containing foods such as whole grains, tubers, starchy vegetables such as peas, squash and corn and whole fruit are of no concern. Due to the ‘supra-additive’ effect of fats with carbohydrate, I recommend that when eating carbohydrate-based foods, to avoid foods that are a rich source of fat.

For Metabolically Unhealthy Individuals

As mentioned in the two previous articles related to the new Canada Food Guide (here and here), 88% of Americans are already metabolically unwell, with presumably a large percentage of Canadians as well.

That is, only 12% have metabolic health defined as;

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

For the large majority who are metabolically unhealthy, knowing which carbohydrate-based food raise one’s blood glucose levels is important. Even if lab tests show one’s fasting blood glucose is still normal, blood glucose levels after eating carbohydrate may be quite abnormal, and even more significantly insulin levels may be as well. You can read more about that here. As mentioned previously in this article, these high insulin levels are what drives metabolic disease by driving insulin resistance.

Eating a low carbohydrate diet can be very helpful to lower blood glucose response and lower chronically high levels of insulin. Which carbohydrates can be tolerated and in what quantities varies considerably between people, but is easy to determine and I help people do this.

For those that already have Type 2 Diabetes, reducing carbohydrate intake for a considerable length of time will enable them to reduce their overall blood glucose and insulin response, which will help them reverse the symptoms of Diabetes as well as other metabolic diseases that often go along with it, such as high blood pressure and high triglycerides. In time, some carbohydrates may be able to be eaten again however the amount and type will vary between individuals.

Final Thoughts…

Carbohydrates aren’t “evil”.  In and by themselves, they don’t result in obesity or metabolic disease. It is the amount of food processing that carbohydrate-containing foods have undergone that results in cell-wall disruption that will determine how much of a glucose- or insulin-response they will cause. In metabolically healthy people, eating minimally processed whole grains, starchy vegetables and fruit without a source of fat is fine.

For those who are metabolically unhealthy, especially those who have a measurably abnormal glucose- or insulin-response, the amount of carbohydrate that can be tolerated is individual and will need to be determined.

For those who have Type 2 Diabetes and follow a low carbohydrate diet to reduce the symptoms of high blood sugar or metabolic diseases that often go along with it, eating the amount of tolerated carbohydrates as minimally processed ones, without a source of fat is also best.

There is no “one size fits all” diet that is suitable for everyone.

For metabolically healthy individuals, following the new Canada Food Guide and selecting carbohydrate sources using the above principles can provide people with a healthy diet. For those that are already metabolically unhealthy, I can help design a Meal Plan that will meet your energy and nutrient needs and that provides the amount of carbohydrate that you can tolerate. If you would like more information, please send me a note using the Contact Me form, above and I’ll be happy to reply soon.

To your good health!

Joy

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New Canada Food Guide – carbohydrate estimate of the sample plate

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

Actual Number, Standard Cup Measure and Scale of Reference

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

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

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

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

Carbohydrate Content of the Protein Group

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

Carbohydrate content of the protein group on the sample plate

Carbohydrate Content of the Whole Grains Group

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

Carbohydrate content of the whole grains group on the sample plate

Carbohydrate Content of the Vegetable and Fruit Group

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

Carbohydrate content of the vegetable and fruit group on the sample plate

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

And this is just for 3  MEALS.

What about snacks?

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

Recommendations for meals and snacks

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

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

Real Life Meals

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

If a person ate twice that amount of pasta (instead of also eating some wild rice or rice or bread, for example), this is what the size of that portion would look like (of course it would be “whole grain”!);

1 cup of cooked pasta – size of a tennis ball

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

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

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

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

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

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

The problem is, most adults are not metabolically healthy.

Majority of Adults Metabolically Unhealthy

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

Metabolic Health is defined as [1];

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

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

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

Carbohydrate Intolerance

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

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

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

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

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

Final Thoughts…

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

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

To your good health!

Joy

You can follow me at:

 https://twitter.com/lchfRD

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

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

References

  1. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  2. Crofts, C., et al., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.
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The New Canada Food Guide at a Glance

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

The suite of Food Guide resources includes:

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

Canada Food Guide “plate”

Canada Food Guide – directed towards healthy Canadians

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

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

The New Canada Food Guide – no more rainbow

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

“Protein Foods”

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

Protein Foods Group

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

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

Whole Grains

Whole Grains Food Group

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

  • Whole grain foods are good for you
  • Whole grain foods have important nutrients such as: fibre, vitamins and minerals
  • Whole grain foods are a healthier choice than refined grains because whole grain foods include all parts of the grain. Refined grains have some parts of the grain removed during processing.
  • Whole grain foods have more fibre than refined grains. Eating foods higher in fibre can help lower your risk of stroke, colon cancer, heart disease and type 2 diabetes
  • Make sure your choices are actually whole grain. Whole wheat and multi-grain foods may not be whole grain. Some foods may look like they are whole grain because of their colour, but they may not be. Read the ingredient list and choose foods that have the word “whole grain” followed by the name of the grain as one of the first ingredients like; whole grain oats, whole grain wheat. Whole wheat foods are not whole grain, but can still be a healthy choice as they contain fibre.
  • Use the nutrition facts table to compare the amount of fibre between products. Look at the % daily value to choose those with more fibre.

Vegetables and Fruit

Vegetable and Fruit Food Group

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

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

Beverage of Choice – water

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

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

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

Healthy Food Choices

The link for “healthy food choices” indicates;

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

* the limited of saturated fat is addressed below,

Eating Habits

The link for “healthy eating habits” indicates;

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

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

First Impressions of the New Canada Food Guide

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

I have two main concerns with respect to the Guide;

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

Percentage of Carbohydrate in the Diet

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

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

Metabolic Health is defined as [1];

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

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

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

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

Saturated Fat

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

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

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

What do recent studies show?

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

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

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

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

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

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

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

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

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

Limit foods that contain saturated fat

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

cream

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

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

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

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

from Reference #17

Final thoughts…

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

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

To our good health!

Joy

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

You can follow me at:

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https://www.instagram.com/lchf_rd

 

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  2. Tribble DL, Holl LG, Wood PD, et al. Variations in oxidative susceptibility among six low density lipoprotein subfractions of differing density and particle size. Atherosclerosis 1992;93:189–99
  3. Gardner CD, Fortmann SP, Krauss RM, Association of Small Low-Density Lipoprotein Particles With the Incidence of Coronary Artery Disease in Men and Women, JAMA. 1996;276(11):875-881
  4. Lamarche B, Tchernof A, Moorjani S, et al, Small, Dense Low-Density Lipoprotein Particles as a Predictor of the Risk of Ischemic Heart Disease in Men, 
  5. Packard C, Caslake M, Shepherd J. The role of small, dense low density lipoprotein (LDL): a new look, Int J of Cardiology,  Volume 74, Supplement 1, 30 June 2000, Pages S17-S22
  6. Genest JJ, Blijlevens E, McNamara JR, Low density lipoprotein particle size and coronary artery disease, Arteriosclerosis, Thrombosis, and Vascular Biology. 1992;12:187-195
  7. Siri-Tarino PW, Sun Q, Hu FB, Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease, The American Journal of Clinical Nutrition, Volume 91, Issue 3, 1 March 2010, Pages 502–509
  8. Skeaff CM, PhD, Professor, Dept. of Human Nutrition, the University of Otago, Miller J. Dietary Fat and Coronary Heart Disease: Summary of Evidence From Prospective Cohort and Randomised Controlled Trials, Annals of Nutrition and Metabolism, 2009;55(1-3):173-201
  9. Hooper L, Summerbell CD, Thompson R, Reduced or modified dietary fat for preventing cardiovascular disease, 2012 Cochrane Database Syst Rev. 2012 May 16;(5)
  10. Chowdhury R, Warnakula S, Kunutsor S et al, Association of Dietary, Circulating, and Supplement Fatty Acids with Coronary Risk: A Systematic Review and Meta-analysis, Ann Intern Med. 2014 Mar 18;160(6):398-406
  11. Schwingshackl L, Hoffmann G Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and meta-regression BMJ Open 2014;4
  12. Hooper L, Martin N, Abdelhamid A et al, Reduction in saturated fat intake for cardiovascular disease, Cochrane Database Syst Rev. 2015 Jun 10;(6)
  13. Harcombe Z, Baker JS, Davies B, Evidence from prospective cohort studies does not support current dietary fat guidelines: a systematic review and meta-analysis, Br J Sports Med. 2017 Dec;51(24):1743-1749
  14. Ramsden CE, Zamora D, Majchrzak-Hong S, et al, Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73), BMJ 2016; 353
  15. Hamley S, The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials, Nutrition Journal 2017 16:30
  16. Dehghan M, Mente A, Zhang X et al, The PURE Study – Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062
  17. Harcombe  Z, Saturated Fat,  http://www.zoeharcombe.com/2018/01/saturated-fat/
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EAT-Lancet Diet – inadequate protein for older adults

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

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

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

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

Protein Requirement in Older Adults

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

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

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

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

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

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

The Eat-Lancet Diet

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

The Eat-Lancet Diet recommends only;

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

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

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

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

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

Final Thoughts…

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

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

To your good health!

Joy

You can follow me at:

       https://twitter.com/lchfRD

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

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

https://www.instagram.com/lchf_rd

 

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

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

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

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

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

The Planetary Health Diet

The Planetary Health Diet – aka the EAT-Lancet Diet [4]
Here is the food per day that can be eaten per adult on the “Planetary Health Diet”;

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

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

Vast Majority (88%) of Americans are Metabolically Unhealthy

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

Metabolic Health is defined as [3];

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

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

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

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

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

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

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

Table 1 – Healthy reference diet, with possible ranges, for an intake of 2500 kcal/day (from Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems)

Nutritional Deficiency of the Eat-Lancet Diet

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

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

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

High Carbohydrate Content

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

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

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

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

Final Thoughts…

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

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

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

To your good health!

Joy

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

You can follow me at:

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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. The EAT-Lancet Commission on Food, Planet and Health,  https://eatforum.org/eat-lancet-commission/
  2. The EAT-Lancet Commission on Food, Planet and Health – EAT-Lancet Commission Brief for Healthcare Professionals,  https://eatforum.org/lancet-commission/healthcare-professionals/
  3. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  4. BBC News, A bit of Meat, a lot of veg – the flexitarian diet to feed 10 billion, James Gallagher, 17 January 2019, https://www.bbc.com/news/health-46865204
  5. State of Obesity, Adult Obesity in the United States, https://stateofobesity.org/adult-obesity/
  6. Statistics Canada, Health at a Glance, Adjusting the scales: Obesity in the Canadian population after correcting for respondent bias,  https://www150.statcan.gc.ca/n1/pub/82-624-x/2014001/article/11922-eng.htm
  7. Willet W, Rockstrom J, Loken B, et al, Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems, The Lancet Commissions, http://dx.doi.org/10.1016/ S0140-6736(18)31788-4
  8. Harcombe Z, The EAT Lancet diet is Nutritionally Deficient,  http://www.zoeharcombe.com/2019/01/the-eat-lancet-diet-is-nutritionally-deficient/
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Background to the New Canada Food Guide Draft

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

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

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

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

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

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

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

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

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

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

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

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

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

Key dates

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

In early 2019, we will release:

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

Later in 2019, we will release:

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

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

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

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

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

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

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

Audiences for Phase 2 included:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Regarding these “justifications”;

“the placement of the justification seemed to be pertinent.

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

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

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

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


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

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

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

“At-a-glance” Visual Concept A

“At-a-glance” Visual Concept B

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

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

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

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

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

Some final (personal) thoughts…

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

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

To your good health!

Joy

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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.

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New Canada Food Guide Drops Meat and Milk Groups

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

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

According to the article;

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

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

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

from “Healthy Eating Strategy – Dietary Guidance Transformation – Focus Groups on Healthy Eating Messages, Visuals and Brands Research Report, Earnscliffe Strategy Group

from “Healthy Eating Strategy – Dietary Guidance Transformation – Focus Groups on Healthy Eating Messages, Visuals and Brands Research Report, Earnscliffe Strategy Group

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

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

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

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

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

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

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

and added that

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To your good health!

Joy

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

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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

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