Another Therapeutic Ketogenic Diet and How it Differs from “the Keto Diet”

In addition to the several types of therapeutic ketogenic diets mentioned in the previous post, such as the Classic Ketogenic Diet (KD), the Modified  Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) used in the treatment of epilepsy and seizure disorder and as adjunct treatment in glioblastoma, there is another type of therapeutic ketogenic diet used in the treatment of type 2 diabetes and for weight loss which is referred to in the literature as a Very Low Carbohydrate Diet (VLCD). This post outlines two examples of this type of therapeutic ketogenic diet, and how it differs considerably from the popularized “keto diet”.

When compared with a Very Low Carbohydrate Diet (VLCD), the popularized “keto diet” which focuses on high intake of eggs and fatty cuts along with copious amounts of added fat in the form of ‘fat bombs’ and ‘bulletproof coffee’ is like a caricature compared with a portrait.  A portrait seeks to accurately represent physical attributes, and a caricature uses hyperbole to exaggerate some, and over-simplify others. 

This new article picks up from the previous one in outlining another type of therapeutic ketogenic diet used for putting type 2 diabetes into remission as well as for weight loss, and how it is very different from the popularized “keto diet”.


A Therapeutic Ketogenic Diet

A ketogenic diet is one that induces and sustains a state of ketosis which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate. What makes any diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains.

In reference to the treatment of type 2 diabetes and obesity, ketogenic diets are often referred to in the literature as a “Very Low Carbohydrate Dies (VLCD)”, which is where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake[1]. It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate and at this very low level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis.

Ketosis is where the ketone betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L (and up to 4.0 mmol/L for therapeutic ketogenic diets  used in the treatment of epilepsy, seizure disorder and glioblastoma). In a Very Low Carbohydrate Diet (VLCD) used in the treatment of type 2 diabetes, BHB levels are usually set between 1.5-3.0 mmol/L, a level described as nutritional ketosis [2].

A drug or diet is said to be therapeutic when it is used in the treatment of a disease or medical condition(s). When implemented by a Dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) [3].

Use of a Very Low Carbohydrate Diet (VLCD) as Medical Nutrition Therapy in the treatment of type 2 diabetes is recognized by numerous organizations around the world, including the European Association for the Study of Diabetes (EASD).

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included both a low carbohydrate (LC) and very low carbohydrate (VLC) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report, and has included both in their 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  This year,  Diabetes Canada released a Position Statement outlining that a low carbohydrate (LC) and very low carbohydrate diet (VLCD) are both safe and effective treatment for non-pregnant or lactating adults with type 2 diabetes.

The American Diabetes Association’s  Consensus Report defines low carbohydrate and very low carbohydrate as follows;

“In this review, a low carbohydrate (LC) eating patterns is defined as reducing carbohydrates to 26-45% of total calories [4].”

and

“In this review a very low carbohydrate (VLC) eating pattern is defined as reducing carbohydrate to <26% of total calories [4].”

Diabetes Canada also defines low carbohydrate and very low carbohydrate diets in terms of the amount of carbohydrate the diet contains. Low carbohydrate diets are defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate,  and very low carbohydrate diets as <50 g of carbohydrate per day [5].

Very Low Carbohydrate Diet (VLCD) for Treatment of Type 2 Diabetes

Back in 2018, the American Diabetes Association cited Virta Health’s one-year study data [6] as evidence for the safety and efficacy of a Very Low Carbohydrate Diet (VLCHD) in lowering blood sugar and diabetes medication usage and the new Diabetes Canada’s recommendations refers to the same study. As a result, Virta Health’s study is a good place for defining what a Very Low Carbohydrate Diet (VLCD) for the treatment of type 2 diabetes looks like.

Note: It should be noted that at the time the ADA’s 2019 Standards of Medical Care in Diabetes was published, Virta Health’s 2-year data had not yet been published, so the ADA and in turn, Diabetes Canada recommendations which were based on it, as well as other international organizations support for low and very low carbohydrate diets were only able to say conclusively that low carbohydrate diets and very low carbohydrate diets were safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months). 

Virta Health’s Approach

As covered in this article on my affiliate site about Virta Health’s 2-year update and in this article with their 1-year update , subjects in their studies typically ate;

  1. <30 g per day of total dietary carbohydrate
  2. daily protein intake was targeted to a level of 1.5 g / kg based on ideal body weight
  3. Participants were coached to incorporate dietary fats until they were no longer hungry (i.e. to satiety)

Note (August 31, 2020): To put the protein requirements in perspective, a male whose ideal body weight is 150 pounds (68 kg) would be eating over 100 g of protein per day and a female whose ideal body weight is 135 pounds (61 kg) would be eating 92 g of protein per day.  That is, protein is targeted for its nutrient-density and satiety, and fat is incorporated only until satiety is reached.

Phinney and Volek’s Approach

Dr. Stephen Phinney MD, PhD, a medical doctor and Dr. Jeff Volek, RD, PhD a Registered Dietitian with a PhD have decades of combined scientific and clinic research experience in the area of low carbohydrate diets. In 2011 they published their expert guide titled The Art and Science of Low Carbohydrate Living [7] documenting the clinical benefits of carbohydrate restriction and how it can be used for weight loss.

In Phinney and Volek’s book [7], the Very Low Carbohydrate Diet (VLCD) outlined is one that is higher protein during the weight loss phase than during the weight maintenance stage, with ~30% of caloric intake coming from protein during weight loss, but which decreases to ~21% of caloric intake during weight maintenance. Fat is 60% of calories during the weight loss phase, and is increased to 65-72% during weight maintenance. Carbohydrate intake is kept very low (7.5-10% of calories for men, 2.5-6.5% of calories for women) in order to induce nutritional ketosis.

The reason dietary fat intake is lower during the weight loss phase in Phinney and Volek’s approach is to allow for the using of body fat stores for energy.

In Phinney and Volek’s approach;

  1. Carbohydrate intake is 7.5-10% of calories for men, 2.5-6.5% of calories for women
  2. Protein intake is up to 30% of calories during weight loss, 21% during weight maintenance
  3. Fat is 60% of calories during weight loss, 65-72% of calories during weight maintenance

Note (August 31, 2020): Protein intake for someone eating 2000 kcals per day is 150 g and for someone eating 1700 kcals per day is 141 g per day. Again, protein is targeted for its nutrient-density and satiety, and fat is only 60% of calories during weight loss.  This is very different than the popularized “keto diet”.

Popularized “Keto Diet”

The popularized “keto diet” is described as 70 – 80% fat, 15-20% protein* and 5% carbohydrate, with websites and articles promoting it frequently show plates laden with bacon and eggs, large fatty steaks with added butter melting on top, and loads of whipping cream over berries, and lots of avocado.

*while many “keto” proponents still stick with the lower protein intake [8], others have more recently increased the protein macro to 20% of calories, with fat at 70%.

This popularized “keto diet” is not the Very Low Carbohydrate Diet (VLCD) used by either Virta Health for putting type 2 diabetes into remission, or the VLCD approach used by Phinney and Volek for weight loss.

The popularized “keto diet” has ~50% less protein than a Very Low Carbohydrate Diet (VLCD) and ~20% more fat which has twice the energy density as protein.

Furthermore, the popularized “keto diet” is a very high fat, very low carbohydrate diet and is often promoted along with periods of intermittent fasting (IF), as frequent periods of less than 24 hours, or longer fasting periods which may include 5:2 (5 days of normal diet, 2 days restricting total calories to 500 per day), alternate day fasting, 36 hour fasts, or 42 hour fasts. This approach may suit some, but one has to ask if only eating ~1/3 of the time, is any weight loss really due to eating super high fat all the time, or due to the periods of fasting?

Like a caricature, the “keto diet” exaggerates some aspects of a Very Low Carbohydrate Diet (VLCD) and over-simplifies others. It exaggerates the fallacy that one needs to add extra fat into everything in order to lose weight, and overlooks the satiety of protein.

[Personal note: Approximately 1/3 of clients come to me for support after having followed this popularized “keto diet” without the fasting, and having failed to lose more than a bit of weight initially, or having gained weight.] 

Final Thoughts

There is no one-sized-fits-all low carb or ketogenic diet for weight loss, because each person’s nutrition needs are different. As covered in the preceding article, for those seeking safe and effective weight loss, there are a range of low carbohydrate diets available to choose from, with some that includes periods of ketosis, and others that don’t.

For those seeking to put type 2 diabetes into remission, a well-designed ketogenic diet using the Virta Health approach, or for weight-loss using Phinney and Volek’s approach are both safe and effective, if individualized for each person and done with adequate oversight. 

Remember, if you are taking any medication for type 2 diabetes, please read this article for why it can be dangerous to begin a very low carbohydrate diet (VLCD) / ketogenic diet without the involvement of your diabetes team.

More Info?

If you would like more information about type of low carb or ketogenic diet that might be best suited to you, please send me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

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

References

  1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13
  2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
  3. U.S. Department of Health and Human ServicesFinal MNT regulationsCMS-1169-FCFederal Register1 November 200142 CFR Parts 405, 410, 411, 414, and 415
  4. 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
  5. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
    Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
  6. Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an  open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583–612
  7. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
  8. Zoe Harcombe, LCHF and Butter, January 29, 2018, https://www.zoeharcombe.com/2018/01/lchf-and-butter/

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

 

The Stereotypical High Fat Keto Diet is Only ONE Type

There is a common, but mistaken belief that there is such as thing as “THE keto diet” (singular) — which is high in fat of all types, including cream, butter, bacon, avocado and fatty cuts of meat. In fact, there are a wide range of “keto diets” (plural) — including several different therapeutic ones, as well as those that have been popularized the last several years for weight loss.  This article will explains the range of ketogenic diets that are available, and what they are used for as well as the unintended consequence of believing that a “keto diet” has to be high in fat.

What is a Ketogenic Diet?

A ketogenic diet is one that induces and sustains a state of ketosis, which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate.

There are a number of different therapeutic ketogenic diets, as well as a number of weight-loss ketogenic diets

What makes any diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains.

This bears repeating.

A ketogenic diet is determined solely on the basis of how much carbohydrate it contains, and not on how much fat in contains.

Ketogenic diets, which are also referred to in the literature as “very low carbohydrate diets” are where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake [1].  It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate and at this very low level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis. 

Ketosis is where the ketone betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L — and up to 4.0 mmol/L for therapeutic ketogenic diets used in the treatment of epilepsy, seizure disorder and glioblastoma.

Nutritional ketosis used predominantly for weight loss is usually set with BHB levels between 1.5-3.0 mmol/L [2].

Low carbohydrate diets are those where carbohydrate intake is limited to < 130 g per day or < 26% of total energy intake [1] and moderate carbohydrate diets are where carbohydrate intake is limited to 130–225 g per day or 26–45% of total energy intake [1].

Again, the amount of fat in the diet has nothing to do with a diet being ketogenic only the amount of carbohydrate it contains.

Therapeutic Ketogenic Diets

First of all, what does “therapeutic” mean?

Something is therapeutic when it is used in the treatment of a disease. This may be a pharmaceutical drug or a diet.  What makes a diet therapeutic is that it is used to treat a medical condition, or conditions.

A therapeutic diet may be prescribed by a Physician, and implemented by a Dietitian or the Physician themselves.  When implemented by a Dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) [3].

The first therapeutic ketogenic diet was used in the 1920s for the treatment of epilepsy. Physicians at Harvard Medical School had begun experimenting with periods of extended fasting as a treatment, and discovered that seizures improved after 2-3 days. In 1921 , Dr. R.M. Wilder[3] used a very high fat, low carbohydrate, and restricted protein diet in a series of patients with epilepsy, and found that it was as effective as fasting and had the advantage that it could be maintained for much longer a period of time than fasting.

The percentage of carbohydrate, fat and protein in what has since become called the “classicKetogenic Diet (KD) was worked out by Dr. M.G. Peterman in 1925 [4] and are the same as used today.  In the classic KD, the total amount of calories are matched to the number of calories the person needs. Protein is usually determined as being 1 g of protein per kg body weight, 10-15 g of carbohydrate per day total, and the remainder of calories provided as fat.  For very young children, the diet may be prescribed based on body weight (e.g. 75-100 calories for each kg (2.2 pounds) of body weight. 

Since the 1920s, several other therapeutic ketogenic for the treatment of epilepsy and seizure disorder have been developed, including the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD). These are all high fat diets, but differ in the amount of protein they contain. They are all very low carbohydrate diets, which is by definition what makes them ketogenic.

The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs. In the classic Ketogenic Diet, 90% of calories come from fat, 6% from protein, and only 4% of calories come from carbohydrate.

The Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein and carbohydrate. In a Modified Ketogenic Diet, 80-90% of calories come from fat, 12-15% of calories come from protein, and 5-6 % calories come from carbohydrate[5].

The Modified Atkins Diet (MAD) has a 2:1 ratio, with 2 parts fat for every 1-part protein and carbohydrate.  In a Modified Atkins Diet, carbohydrates are restricted to <15 g / day for children, <20 g / day for adults. In a Modified Atkins Diet, 60% of calories come from fat, 30% of calories come from protein, and 10% of calories come from carbohydrate[5].

As well as their use in epilepsy and seizure disorder, any of the above therapeutic ketogenic diets may be prescribed for patients as adjunct treatment in glioblastoma, or as adjunct treatment in Alzheimer’s disease.

These high fat diets are not weight loss diets. These are therapeutic ketogenic diets used with the goal of producing high amounts of ketones (> 4.0 mmol/L / 40 mg/dl) for therapeutic reasons.

Other Types of Therapeutic Ketogenic Diets – for treatment of type 2 diabetes and obesity

In addition to the three types of therapeutic ketogenic diets above, ketogenic diets where carbohydrate is restricted to 50g of carbohydrates per day or less are considered Medical Nutrition Therapy (MNT) in the treatment of type 2 diabetes.

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included the use of a very low carbohydrate (ketogenic) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report and both the 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  In addition, Diabetes Canada released a Position Statement in April of this year outlining that a low carb and very low carb / keto (<50 g of carbohydrates per day) are both safe and effective treatment for adults with diabetes. 

According to the American Diabetes Association, what makes a diet low carbohydrate (LC) or very low carbohydrate (VLC) / ketogenic is defined by the amount of carbohydrate contained in the diet, not the amount of fat. The American Diabetes Association’s  Consensus Report defines low carb and very low carb as follows;

“In this review, a low carbohydrate (LC) eating patterns is defined as reducing carbohydrates to 26-45% of total calories [6].”

and

“In this review a very low carbohydrate (VLC) eating pattern is defined as reducing carbohydrate to <26% of total calories [6].”

Diabetes Canada also defines low carbohydrate and very low carbohydrate diets in terms of the amount of carbohydrate the diet contains. Low carbohydrate diets are defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate,  and very low carbohydrate diets as <50 g of carbohydrate per day [7].

Weight-Loss “Keto” Diets

There are a wide range of weight-loss approaches that have a ketogenic (keto) component to them.

The 1997 Protein Power[8] published by Dr. Micheal Eades and his wife Dr. Mary Dan Eades is a low carb, high protein, moderate fat ketogenic diet. In fact, the authors warn in the book that eating a large number of calories as fat would make it impossible to lose weight, so this is not a high fat diet at all.

The New Atkins For a New You [9], was redesigned in 2010 by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, and while considered a low carbohydrate high fat, moderate protein weight loss diet, it has 4 phases, with only the first phase being ketogenic (20-50 g carbs per day), but only for two weeks. This first stage is where the Modified Ketogenic Diet (MKD) used in epilepsy and seizure disorder came from — but as a weight-loss diet, the high fat stage in The New Atkins for a New You is very short lived. In phase two, more carbohydrate is added (nuts & seeds, berries, cherries and melon, cheese,  dairy products, legumes (pulses), tomato juice and vegetable cocktail) and this level is maintained until close to goal weight when higher carbohydrate amounts are added in phase 3, then phase 4. It is only higher fat for the first two weeks. 

Then there is the 2013 Real Meal Revolution [10] by Tim Noakes, Sally-Ann Creed, Jonno Proudfoot which is a handbook on the Banting lifestyle (which originated in the late 1800s), with foods broken down into green list, orange list and red list, with varying levels of carbohydrate intake.

Note: there is also the 2014 Bulletproof Diet by former Silicon-Valley biohacker, Dave Asprey but since he doesn’t have a clinical background, I have not included it.  That said, the diet is very high fat and is where “bulletproof coffee” (with added butter and coconut oil) comes from.

In 2016, Dr. Jason Fung, a Toronto nephrologist (kidney specialist) wrote the Obesity Code [11] which promotes a high fat version of a very low carb / keto diet, which is used in conjunction with his 2016 book written with Jimmy Moore titled The Complete Guide to Fasting [12]. In 2020, Fung published Life in the Fasting Lane [13], written with Eve Meyer and Megan Remos which builds on his approach of using a low carb high fat diet along with intermittent fasting.

In 2014, the web site “Diet Doctor” was launched by Dr. Andreas Eenfeld. This was initially mostly with articles translated from his Swedish site and later added content from a variety of other people, including Dr. Jason Fung, Dr. Eric Westman and Dr. Ted Naiman.  In 2017, Eenfeld wrote his own diet book titled Low Carb High Fat Food Revolution [14], which promoted a high fat version of a very low carb / ketogenic weight loss diet.  Later, Dr. Eric Westman went on to found his own Adapt weight loss program which is a very low carb / keto, moderate protein, moderate fat approach and Dr. Ted Naiman went on to write his P:E Diet [15] which promotes a low carb, high protein, low fat approach.

Of ketogenic weight-loss diets outlined above, the two that promote a very high fat intake are Dr. Jason Fung’s approach, and the “Diet Doctor” approach. While both fat and protein result in satiety (not feeling hungry), fat has almost two and a half the caloric density as protein. In addition, fat can trigger the reward system of the brain in the same way carbs do, resulting in many over-eating fat, especially added fat. What many people fail to take into consideration is that both of these approaches also promote periods of intermittent fasting (IF) which as Diet Doctor teaches may be frequent periods of less than 24 hours, to longer fasting periods which may include 5:2 (5 days of normal diet, 2 days restricting total calories to 500 per day) or alternate day fasting, as well as two types of fasts that Dr. Fung promotes, including 36 hour fasts, and 42 hour fasts. If one is only eating ~1/3 of the time, is any weight loss really due to the high fat diet, or the fasting?

“In our clinic, we will often recommend 36-hours fasts 2-3 times per week for type 2 diabetes.” ~Dr. Jason Fung

[ADDED NOTE, August 24, 2020: a well-formulated ketogenic diet such as used by Virta Health (covered here and here) which is high in fat and moderate in protein but that consists of a diet of real, whole food is not the same as popularized “keto diets” high in fat and moderate protein, but that consist of lots of added fat in both food and beverages. There is more to a well-designed ketogenic diet for remission of type 2 diabetes and obesity than macros, alone.

August 27, 2020: There is a fundamental difference between a well-designed ketogenic diet that is high in fat and that is comprised of real, whole food — and the popularized “keto diet”, which is all about added fat. It’s not about macros, but nutrients.]

The Stereotypical High Fat Keto Diet is Only ONE Type

Over the last several years, about 1/3 of people that come to me do so after following “the keto diets” without realizing that there is not just one.  Most lost some weight initially on this high fat diet, and then stalled and quite a few actually ended up gaining weight.

Whether following Dr. Fung’s approach or the Diet Doctor approach, people reported eating 75% fat, 15% protein and 10% carbohydrate — which is essentially a hybrid between the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) which as mentioned above are NOT weight loss diets — in fact, they were designed to not result in weight loss. These high fat, moderate protein diets are diets are solely intended to produce large amounts of ketones for therapeutic purposes. 

It is no wonder high fat “keto” diets don’t deliver weight loss results. That’s not what they were designed to do! 

Unless these high fat “keto” diets are combined with the frequent periods of <24 hours of fasting, >24 hour periods of fasting several times per week, weight loss is unlikely to occur unless as byproduct of the higher satiety of the fat, and over all eating less food.

Losing Body Fat is Not About Eating Less Carbs and More Fat!

If we want to lose body fat, then eating food that is very high in dietary fat won’t accomplish that UNLESS one is only eating every second or third day, which is what the stereotypical high fat “keto” diets promote. If we are eating a high fat diet and regularly fasting for extended periods of time, it is the fasting itself that underlies body fat loss and lower insulin, not all the added dietary fat.

Eating tons of bacon, butter, cream and avocado makes perfect sense in a therapeutic diet for epilepsy, seizure disorder or as an adjunct treatment in glioblastoma or Alzheimer’s disease, because the goal is to produce lots of ketones but if one wants to lose weight without using frequent periods of fasting, then adding tons of fat to food makes no sense. We want to utilize our fat stores for energy, not burn dietary fat.

One can use any one of a number of low carbohydrate approaches to accomplish weight loss, as well as improve blood sugar — by focusing on eating nutrient dense foods with a high protein-to-energy ratio, and that are rich in micronutrients.  Protein also increases satiety, helps build muscle and is much less calorically dense than fat [16].

Whether starting at a brief ketogenic level and working up (such as the method used by Protein Power, New Meal Revolution or Westman, Phinney and Volek’s approach in the New Atkins, or using an approach I often do which is to start people off at 130 g of carbohydrate per day, and lower carbohydrate as required to achieve clinical outcomes. In either approach, weight loss and lower insulin and glucose can be achieved without extended or frequent periods of fasting.

That doesn’t mean there aren’t benefits to doing short daily periods of fasting, such as from after dinner on one day until the first meal the following day — there are.  It simply isn’t required for weight loss.

Final Thoughts…

There are several therapeutic ketogenic diets that can be used in epilepsy and seizure disorder as well as other conditions, and other types of therapeutic ketogenic diets that are considered Medical Nutrition Therapy (MNT) for the treatment of type 2 diabetes and obesity.

The idea that there is “THE keto diet” which is high in fat is a fallacy — one that has the unintended consequence of many people failing to lose weight (and often gaining weight) because they don’t realize that it needs to be combined with periods of intermittent fasting.  A weight-loss “keto diet” that is 75% fat, 15% protein and 10% carbs is only ONE type of ketogenic diet. It is by no means “THE keto diet!”A diet that is low in carbohydrate and rich in nutrient-dense lean protein, as well as a wide range of vegetables and fruit is just as much a “keto diet” because it is low in carbohydrate — and one that can be used successfully to achieve weight loss, with no fasting required.

In short, there is no one-size-fits-all-low-carb or keto diet, but rather a range of low carb and keto diets that can be chosen from, based on each person’s personal preference, as well as their specific medical needs.

More Info?

If you would like more information about type of low carb or ketogenic diet that might be best suited to you, please send me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

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

References

  1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13
  2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
  3. U.S. Department of Health and Human ServicesFinal MNT regulationsCMS-1169-FCFederal Register1 November 200142 CFR Parts 405, 410, 411, 414, and 415
  4. Peterman MG, The Ketogenic Diet, JAMA. 1928;90(18):1427–1429. doi:10.1001/jama.1928.02690450007003
  5. Kossoff EH, Doward JL. The Modified Atkins Diet. Epilepsia 2008; 49 (Suppl8): 37-41
  6. 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
  7. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
    Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
  8. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
  9. Westman E, Phinney SD, Volek J, (2010) Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
  10. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
  11. Fung J (2016) Obesity Code, Greystone Books, Vancouver
  12. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
  13. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
  14. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
  15. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020)
  16. Paddon-Jones D, Westman E, Mattes RD et al, Protein, weight management, and satiety, The American Journal of Clinical Nutrition, Volume 87, Issue 5, May 2008, Pages 1558S–1561S, https://doi.org/10.1093/ajcn/87.5.1558S

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

 

The Keto Diet — a potentially dangerous and an unhealthy diet

INTRODUCTION: I’ve heard other Dietitians say that the keto diet is a potentially dangerous and an overall unhealthy diet because it focuses on ‘high intakes of processed meat, butter and cream’. Some have said that harmful effects were seen as much as three years post keto —  with one case involving symptoms of uncontrollable food cravings and “a head rush” after ingesting any carbs, and another three cases of people having developed severe adverse health effects, including one with newly diagnosed diabetes that wasn’t present before the diet, and two others with non-alcoholic fatty liver disease. All of these individuals were said to have gained all the weight back plus more, and the concern was raised as to whether the keto diet can really be called “a key to diabetes reversal or diabetes remission” because we haven’t actually fixed a broken pancreas. This article will address some of these beliefs.


The belief that there is such as thing as “the keto diet” (singular) which is high in processed meat, butter and cream is common, but incorrect. More on that below.

As a Dietitian, I am expected to be well-informed about a wide range of dietary options and to speak and write from an evidenced-based perspective, but the reality is that as Dietitians we can’t be knowledgeable in all available diets. While I am by no means an expert on low carb or ketogenic diets, I have written over 200 articles on the topic (published on my dedicated low-carb practice website), and have been using low carb and ketogenic diets as two of several dietary options in clinical practice for the past 5 years.

Firstly, with regards to the severe adverse health effects that the 3 individuals reportedly developed as a result of following the keto diet, it has been documented that abnormal glucose responses are present as long as 20 years before a diagnosis of Type 2 Diabetes[1] and the American Association of Clinical Endocrinologists (AACE) concluded that both insulin resistance and prediabetes precede a diagnosis of type 2 diabetes[2] — which means that people presenting with type 2 diabetes after following “the keto diet” had been developing the disease for many years prior.

Furthermore, non-alcoholic fatty liver disease (NAFLD) is strongly associated with insulin resistance, which is characterized by excessive hepatic glucose production (high production of glucose by the liver) and compensatory hyperinsulinemia [3-9], which is the response of the liver to produce high amounts of insulin in order to remove the excess glucose. The association of NAFLD with insulin resistance indicates that the fatty liver was developing for years prior to these individuals following “the keto diet”.  Furthermore, it has been documented that a classic ketogenic diet (KD) is an effective treatment for nonalcoholic fatty liver disease [10] and “rapidly reverses NAFLD and insulin resistance despite increasing circulating non-esterified fatty acids, the main substrate for synthesis of intrahepatic triglycerides” [10].

As for “the keto diet” being a key to diabetes reversal or diabetes remission, I’ve addressed this in detail in a previous article.

So, let me address the misconception that there is such a thing as “the keto diet” (singular), which is high in processed meat, butter and cream.

Many Types of Keto Diets

There are a variety of therapeutic ketogenic diets, including the Ketogenic Diet (KD), the Modified Ketogenic Diet and the Modified Atkins Diet, as well as a variety of ketogenic diets that are used both for therapeutic reasons (such as the management of type 2 diabetes), as well as those that are followed for personal choice.

What makes a diet therapeutic is that it is used to treat a medical condition or conditions and is recommended by a Physician, and implemented by a Dietitian, or by the MD themselves. When a doctor sends me a referral to implement a Modified Atkins Diet for one of their patients with seizure disorder, it is a therapeutic diet. So is a referral to implement a very low carbohydrate / ketogenic diet for the treatment of type 2 diabetes or fatty liver disease.

Use of a very low carb / keto diet by Physicians or Dietitians in the management of type 2 diabetes should come as no surprise to anyone given that these dietary patterns are considered Medical Nutrition Therapy (MNT) in the treatment of type 2 diabetes.

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included the use of a very low carbohydrate (ketogenic) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report and both the 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  In addition, Diabetes Canada released a Position Statement in April of this year outlining that a low carb and very low carb / keto (<50 g of carbohydrates per day) are both safe and effective treatment for adults with diabetes. 

Therapeutic ketogenic diets such as the classic Ketogenic Diet (KD), the Modified Ketogenic Diet and the Modified Atkins Diet are by necessity high fat diets — because the goal is to produce very high levels of ketones in order to improve clinical outcomes in epilepsy and seizure disorder, and as adjunct treatment in glioablastoma ( a type of brain cancer) and in Alzheimer’s disease.  The Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs, the Modified Ketogenic Diet (MKD) has a 3:1 ratio; 3 parts fat for every 1-part protein and carbs, and the Modified Atkins Diet (MAD) has a 2:1 ratio, with 2 parts fat for every 1-part protein and carbs.

What makes a weight loss diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains. Very low carbohydrate / ketogenic diets are diets where carbohydrate is limited to 20-50 g per day or 10% of total energy intake [11]. It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate.  At this level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis. 

Ketosis is where betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L (and up to 4.0 mmol/L for therapeutic ketogenic diets such as those used in the treatment of epilepsy, seizure disorder and glialblastoma), whereas nutritional ketosis for optimal weight loss is commonly set with BHB levels between 1.5-3.0 mmol/L [12].

There is no one “keto diet” for weight loss but a range of choices, only some of which I will mention here.

I will start by looking at one of the earlier known diets that used a ketogenic level of carbohydrate intake; the 1972 Dr. Atkins’ Diet Revolution[13], by Dr. Robert Atkins. The so-called “Atkins’ Diet” had an introductory phase which limited carbohydrate intake to 20-25 grams of net carbs from nuts, seeds, and low carb vegetables, and this phase resulted in people going into ketosis.  In fact, this first phase of the Atkin’s Diet is what forms the basis for the Modified Atkins Diet, a therapeutic diet used in the treatment of epilepsy and seizure disorder.

The 1997 Protein Power[14] published by Dr. Micheal Eades, and his wife Dr. Mary Dan Eades is a low carb,  high protein, moderate fat ketogenic diet. In fact, the authors warn in the book that eating a large number of calories as fat would make it impossible to lose weight, so this is not a high fat diet at all.

The New Atkins For a New You [15], was redesigned in 2010 by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, and is a low carb high fat, moderate protein weight loss diet that has 4 phases, with the first phase being ketogenic to start with (20-50 g carbs per day), but is only ketogenic for two weeks.  In phase two, more carbohydrate is added as nuts & seeds, berries, cherries and melon, cheese,  dairy products, legumes (pulses), tomato juice and vegetable cocktail and this level is maintained until close to goal weight when phase 3, then phase 4 (both higher carb) are implemented.

The 2011 book by Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, The Art and Science of Low Carbohydrate Living [16] is not a diet book, but elaborates on type 2 diabetes as ‘carbohydrate intolerance’ and on the importance of electrolyte and mineral management to avoid side effects of a ketogenic diet. In this approach, added dietary fat is incorporated after weight loss, for long term weight maintenance, to prevent further weight loss.

Then there is the 2013 Real Meal Revolution [17] by Tim Noakes, Sally-Ann Creed, Jonno Proudfoot which is a handbook on the Banting lifestyle (which originated in the late 1800s), with foods broken down into green list, orange list and red list, with varying levels of carbohydrate intake.

In 2016, Dr. Jason Fung, a Toronto nephrologist (kidney specialist) wrote the Obesity Code [18] which promotes a high fat version of a very low carb / keto diet, which is used in conjunction with his 2016 book written with Jimmy Moore titled The Complete Guide to Fasting [19]. In 2020, Fung published Life in the Fasting Lane [20], written with Eve Meyer and Megan Remos which builds on his approach of using a low carb high fat diet along with intermittent fasting.

In 2014, the web site “Diet Doctor” was launched by Dr. Andreas Eenfeld. This was initially mostly with articles translated from his Swedish site and later added content from a variety of other people, including Dr. Jason Fung, Dr. Eric Westman and Dr. Ted Naiman.  In 2017, Eenfeld wrote his own diet book titled Low Carb High Fat Food Revolution [21], which promoted a high fat version of a very low carb / ketogenic weight loss diet.  Later, Dr. Eric Westman went on to found his own Adapt weight loss program which is a very low carb / keto, moderate protein, moderate fat approach and Dr. Ted Naiman went on to write his P:E Diet [22] which promotes a low carb, high protein, low fat approach.

Of ketogenic weight-loss diets above, the only ones that promote a high fat intake with processed meat (bacon), butter and cream are Dr. Jason Fung’s approach and the “Diet Doctor” approach. These are not THE “keto diet” — but one type of ketogenic approach, amongst many.

Self Administered Diets

If an individual hears about a diet from friends, or reads about it online and implements it, and is unsuccessful at losing weight or at keeping it off, or has adverse side effects, is this a reflection of the diet itself or is it a problem inherent in self-administered diets?

Does it matter if the failed “diet” is a calorie-restricted diet, a ketogenic diet, a grapefruit diet or any other diet?

Self administered diets of any type may or may not be appropriate for an individual, because the person’s individual nutritional needs, risk factors, metabolic conditions, and medications are not factored in. Weight-loss failure is one issue, as are potential adverse side-effects.  For example, if a person decides to follow a very low-calorie diet, experiences hypoglycemia and falls and injures themselves, is this the fault of the diet itself, or their self-administration of a diet?  Likewise, if a person decides to follow a very low carbohydrate / ketogenic diet and has an adverse reaction because of some medications they are taking, is this the fault of the particular version of a ketogenic diet they are following?

All diets have potential benefits and risks and self-administered diets pose additional risks that simply haven’t been factored in — regardless what type of diet is chosen.

Failed Weight Loss

Studies show that the failure rate with weight-loss diets is high — often as much as 80 – 90%, and regain of weight is thought to possibly be higher because follow-up rates are very low, and weights are often self-reported either by phone or mail [23].

The fact that most people will gain most of the weight they lost while dieting back, and sometimes end up weighing more than before dieting is not disputed, and is irrespective of the type of diet followed.

Regardless of the dietary approach chosen, “dieting” is not the answer for sustained weight loss. If someone goes “on” a diet that means that at some point they will go “off” of it.  In my opinion, a lifestyle change is a preferred approach and what will work for one person long-term, may not work for another. That is why I say that there is no one-sized-fits-all diet.

Final Thoughts…

Low carb and very low carb / ketogenic diets are two approaches that can suit some, but not all people.  A Mediterranean Diet or a whole food plant based (vegetarian) diet may be better suited to others. 

The misconception that there is one “keto diet” that is high in fat, especially processed meat, butter and cream is simply incorrect. There are a range of ketogenic (keto) diets and even in a high fat ketogenic diet, the fat can come from avocado, nuts and seeds and olives.

A high fat versions of a keto diet may be appropriate and work well in some individuals when used with periods of intermittent fasting, such as OMAD (one meal a day). In my clinical experience, I have observed that high fat versions of a keto diet often result in weight stalls and even weight gain in peri- or post-menopausal women. Since I don’t recommend extended fasting > 24 hours in older adults due to the muscle-loss which can result from the fasting, combined with the muscle loss that is already associated with aging, I generally recommend a higher protein, lower added fat version in such cases. In any case, there are lots of ways to do a ketogenic weight-loss diet — which is ultimately about the total amount of carbohydrate in the diet, not the amount of fat.

More Info?

If you would like more information about the services I offer, please send me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

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

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. American Association of Clinical Endocrinologists Announces Framework for Dysglycemia-Based Chronic Disease Care Model, November 28, 2018, AACE Online Newsroom, url: https://media.aace.com/press-release/american-association-clinical-endocrinologists-announces-frameworkdysglycemia-based-c
  3.  Fabbrini E., et al. , Alterations in adipose tissue and hepatic lipid kinetics in obese men and women with nonalcoholic fatty liver diseaseGastroenterology 134, 424–431 (2008). 
  4. Gastaldelli A., et al. , Relationship between hepatic/visceral fat and hepatic insulin resistance in nondiabetic and type 2 diabetic subjectsGastroenterology 133, 496–506 (2007). 
  5. Korenblat K. M., Fabbrini E., Mohammed B. S., Klein S., Liver, muscle, and adipose tissue insulin action is directly related to intrahepatic triglyceride content in obese subjectsGastroenterology 134, 1369–1375 (2008). 
  6. Kotronen A., Juurinen L., Tiikkainen M., Vehkavaara S., Yki-Järvinen H., Increased liver fat, impaired insulin clearance, and hepatic and adipose tissue insulin resistance in type 2 diabetesGastroenterology 135, 122–130 (2008).
  7. Bugianesi E., et al. , Insulin resistance in non-diabetic patients with non-alcoholic fatty liver disease: Sites and mechanismsDiabetologia 48, 634–642 (2005).
  8. Seppälä-Lindroos A., et al. , Fat accumulation in the liver is associated with defects in insulin suppression of glucose production and serum free fatty acids independent of obesity in normal menJ. Clin. Endocrinol. Metab. 87, 3023–3028 (2002).
  9. Ryysy L., et al. , Hepatic fat content and insulin action on free fatty acids and glucose metabolism rather than insulin absorption are associated with insulin requirements during insulin therapy in type 2 diabetic patientsDiabetes 49, 749–758 (2000). 
  10. Luukkonen PK, Dufour S, Lyu K, et al. Effect of a ketogenic diet on hepatic steatosis and hepatic mitochondrial metabolism in nonalcoholic fatty liver disease. Proc Natl Acad Sci U S A. 2020;117(13):7347-7354.
  11. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13.
  12. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
  13. Atkins, R. C. (1972). Dr. Atkins’ diet revolution; the high calorie way to stay thin forever. New York: D. McKay Co.
  14. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
  15. Westman E, Phinney SD, Volek J, (2010) Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
  16. Phinney SD, Volek J, (2011), The Art and Science of Low Carbohydrate Living, Beyond Obesity LLC
  17. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
  18. Fung J (2016) Obesity Code, Greystone Books, Vancouver
  19. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
  20. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
  21. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
  22. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020),
  23. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233. doi:10.1037/0003-066X.62.3.220

 

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

 

American College of Cardiology: No Benefit to Lower Saturated Fat Intake

The recommendation to lower the consumption of saturated fat in the diet to reduce the risk of cardiovascular disease (CVD) has been the central theme in both the US and Canadian since 1977, and has been carved into our respective Dietary Guidelines since the 1980s.

A newly published study published by the American College of Cardiology has found no beneficial effect on either cardiovascular disease (CVD) or death of lowering saturated fatty acid (SFA) intake and that saturated fat intake is actually protective against stroke [1]. This reassessment of dietary saturated fat intake was based on a meta-analysis of randomized control trials (the strongest data available), as well as observational studies.

The newly published report stated;

Whole-fat dairy, unprocessed meat, eggs and dark chocolate are SFA-rich foods with a complex matrix that are not associated with increased risk of CVD. The totality of available evidence does not support further limiting the intake of such foods.”[1]

The Significance of These Findings

From 1977 onward, based on a belief that saturated fat caused heart disease, both Canada and the US changed their respective dietary recommendations to move the diet away from consuming fat — especially saturated fat, to a diet where more than half the calories (55-60% in Canada, 45-65% in the US) were from carbohydrate. The goal was to lower the risk of cardiovascular disease based on the fact that eating saturated fat raised total LDL (LDL-C), and it was assumed that higher total LDL was tied to increased risk of heart disease. The problem was that it wasn’t known until many years later that there are different types of LDL particles (you can read more about that here) and that it is the small, dense LDL particles that are associated with heart disease, not all LDL particles [2].  

Coinciding with the recommendation for people to eat less saturated fat and more carbohydrate as the main source of calories, we have seen obesity rates go from ~10% of the population in both countries, to 1 in 3 people in the US, and 1 in 4 people in Canada — with another 1/3 of people falling in the overweight category.

What this newly published reassessment of the data indicates is that the American and Canadian diet, which has shunned whole-fat dairy, unprocessed animal meats and eggs for the last 40+ years did so without benefit to cardiovascular disease rates, or rates of death.

Telling people to eat “low fat” everything and to avoid butter, red meat and eggs not only did not do what it was intended to do, it has likely been a significant contributor to the obesity epidemic we now face, along with astronomical rates of type 2 diabetes, hypertension and yes, cardiovascular disease. How ironic.

The report summarized;

“The dietary recommendation to reduce intake of SFAs without considering specific fatty acids and food sources is not aligned with the current evidence base. As such, it may distract from other more effective food-based recommendations, and may also cause a reduction in the intake of nutrient-dense foods (such as eggs, dairy, and unprocessed meat) that may help decrease the risk of CVD, type 2 diabetes, and other non-communicable diseases, but also malnutrition, deficiency diseases and frailty, particularly among “at-risk” groups. Furthermore, based on several decades of experience, a focus on total SFA has had the unintended effect of
misleadingly guiding governments, consumers, and industry toward foods low in SFA but rich in refined starch and sugar.“[1]

The Study’s Conclusion

The report concluded;

The long-standing bias against foods rich in saturated fats should be replaced with a view towards recommending diets consisting of healthy foods. What steps could shift the bias? We suggest the following measures:

1) Enhance the public’s understanding that many foods (e.g., whole-fat dairy) that play an important role in meeting dietary and nutritional recommendations may also be rich in saturated fats.

2) Make the public aware that low-carbohydrate diets high in saturated fat, which are popular for managing body weight, may also improve metabolic disease.”

“There is no robust evidence that current population-wide arbitrary upper limits on saturated fat consumption in the US will prevent CVD or reduce mortality.”

Final Thoughts…

I  remember when the 1977 guidelines first came out, and when the 1988 Canada’s Food Guide was new.  I also remember when the majority of people were normal body weight and it was the exception for someone to be overweight or obese. Here it is, more than 40 years later and we now have strong evidence that saturated fat from unprocessed meat, full fat dairy and eggs does NOT contribute to heart disease or death, and is protective against stroke.

Given this evidence, will Health Canada revisit its most recent Canada Food Guide of January 2019 and adjust it’s recommendation to “limit the amount of foods containing saturated fat, such as cream, higher fat meats…cheeses and foods containing a lot of cheese“?

More Info?

If you would like more information about restoring your weight and healthy by eating a diet lower in carbohydrate and which includes real, whole food such as unprocessed meat, full-fat dairy and eggs, please send me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

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

References

  1. Astrup A, Magkos F, Bier, DM, et al, Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art Review, J Am Coll Cardiol. 2020 Jun 17. Epublished DOI:10.1016/j.jacc.2020.05.077
  2. Lamarche, B., I. Lemieux, and J.P. Després, The small, dense LDL phenotype and the risk of coronary heart disease: epidemiology, patho-physiology and therapeutic aspects. Diabetes Metab, 1999. 25(3): p. 199-211.

 

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

New Protocols for In-Person Clinical Operation for Health Professionals

WorkSafeBC has just released what will be required of regulated health professionals such as myself, as a Dietitian to safely run an in-person clinical practice in British Columbia during the ongoing Covid-19 outbreak, and it is much more involved than I imagined when I wrote a recent article. As well, these protocols are in addition to the obligations required prescribed by our professional college, as well as to abide by any relevant orders, notices, or guidance issued by the provincial health officer, and the relevant health authority, in my case Fraser Health.

The WorkSafeBC protocols include sections on Understanding the Risk, Selecting Protocols for the Workplace, as well as detailed Protocols for Health Professionals.

Understanding the Risk

The WorkSafeBC website outlines that the virus that causes COVID-19 is spread in several ways, including through droplets when a person coughs or sneezes, and from touching a contaminated surface before touching the face. It is outlined that risk or person-to-person transmission is increased the closer a healthcare professional comes to other people, the amount of time a healthcare professional spends near them, and the number of people seen by a healthcare professional.  The site emphasizes that “physical distancing measures help mitigate this risk”. The WorkSafeBC website also emphasizes that the risk of surface transmission is increased when many people contact same surface, and when those contacts happen in short intervals of time, therefore “effective cleaning and hygiene practices help mitigate this risk”[1].

Selecting Protocols for the Workplace

The WorkSafeBC website notes that there are different protocols which offer different levels of protection and emphasize that “Wherever possible, use the protocols that offer the highest level of protection and add additional protocols as required”[1].

WorkSafeBC Covid-19 Hierarchy of Controls [1]
Elimination first level protection –  Limit the number of people in the workplace  by implementing work-from-home arrangements where possible, limiting occupancy, rescheduling work tasks, or by other means. Rearrange work spaces to ensure that health professionals are at least 2 m (6 ft) from co-workers, customers, and other members of the public.

Engineering controls second level protection : if it is not always possible to maintain physical distancing, then install barriers such as plexiglass to separate people.

Administrative controlsthird level protection – WorkSafeBC encourges the establishing of clinic rules and guidelines, such as cleaning protocols, making sure there is no sharing of equipment, and implementing one-way doors, or walkways, in order to minimize risk.

Personal Protective Equipment (PPEs) – fourth level protection – If the first three levels of protection aren’t enough to control the risk, WorkSafeBC recommends considering the appropriate use of non-medical masks, and to be aware of limitation of non-medical masks to protect the wearer from respiratory droplets.

Protocols for Health Professions

The list of protocols for healthcare professionals is extensive and includes several categories, including those for;

(a) hygiene, cleaning and disinfection – Ensure adequate hand washing facilities are available, and provide approved alcohol-based hand sanitizers,
Encourage staff and clients to practice hand hygiene upon entering and exiting the clinic. Identify all common areas such as clinical space, washrooms, etc. and high contact surfaces such as door handles, stair rails and develop and implement a cleaning and disinfection schedule and associated procedures. Increase cleaning and sanitizing of shared equipment and facilities (e.g. scales, washrooms). Develop and implement protocols for sanitizing treatment areas and equipment to prevent surface transmission between clients. Ensure safe handling and effective application of cleaning products.

(b) modifying staff areas and workflow – Work remotely whenever possible, develop and enforce policy that staff stay home when sick, hold meetings virtually through use of teleconference or online meeting technology and where in-person meetings are required ensure people are positioned at least two metres apart. Consider staggering start times / appointment times to reduce the number of people in the workplace at a given time. Minimize the number of co-workers that staff are interacting with, prioritize the work that needs to occur at the workplace in order to offer services. Minimize the shared use of equipment where possible, consider the requirement for staff to have dedicated work clothes and shoes, provide a place for staff to safety store their street clothes while working and change in/out of clothes to prevent cross-contamination upon entry and exit. Consider adjusting the ventilation such as increasing the amount of outdoor air while maintaining the indoor air temperature and humidity at comfortable levels for building occupants. 

(c) scheduling appointments and communicating with clients – Determine how many clients can be within the clinic at a given time while maintaining at least two metres of physical distance and do not book appoints above this number. In order to accommodate physical distancing, appointment times may need to be staggered. When speaking with clients during scheduling and appointment reminders, ask clients to consider rescheduling if they become sick, are placed on self-isolation, or have travelled out of the country within the last 14 days and attending appointments alone where possible, and not bring friends or children. Consider emailing the client forms that need to be filled out so clients can complete them prior to arriving, and clinics with a website should consider posting information on modifications made to the location and appointment visit procedures.

(d) reception – Post signage at the entrance and within the clinic to assist with communicating expectations, such as hand hygiene, physical distancing, respiratory etiquette, reporting illness or travel history, occupancy limits and no entry if unwell or in self-isolation. Consider placing lines on the floor to mark a two metres distance from the reception desk. Consider use of a transparent barrier such as a plexiglass shield around reception desk, when there is insufficient space to maintain two metre distance between staff and clients. Screen all clients when they check-in for their appointment by asking if they have symptoms associated with COVID-19, have been advised to self-isolate, or have travelled outside of Canada within the last 14 days. Clients that respond in the positive should be asked to leave and reschedule the appointment when deemed clinically appropriate. During transactions, limit the exchange of papers such as receipts if possible and where possible, payments should be accepted through contactless methods.

(e) waiting area – Arrange the waiting area in a way that allows at least two metres of physical distance between each client and consider removing extra chairs and coffee tables from the area to support this. Remove unnecessary items and offerings such as magazines etc. and use disposable cups or single- use items where necessary for beverages. Instruct clients to arrive no more than five minutes before their expected appointment. Where room size or layout presents challenges to physical distancing, consider alternative approaches, such as asking clients not to enter the clinic until they receive a text message or phone call to advise that their appointment can start.

(f) provision of health servicesConduct appointments virtually where clinically appropriate, conduct a point of care assessment for risk of COVID-19 for every client interaction and health services should not be performed on ill or symptomatic clients. Where the client requires timely treatment, ensure PPE is used in accordance with BC-CDC guidance. When possible, the clinical staff should position themselves at least 2 metres from the client and where physical distancing cannot be maintained consider the use of barriers and masks to reduce the risk of transmission. Clients should be required to wear masks for services in order to protect workers and workers should also wear masks to protect clients. Consider treating only one client at a time to minimize risks associated with moving between two or more clients, ensure clients are positioned at least 2 metres apart and shared equipment is cleaned and disinfected between uses by clients. If products / equipment is shared, they must be cleaned and disinfected between uses. Practice effective hand hygiene after each client by washing hands with soap and water or using an alcohol-based hand sanitizer approved by Health Canada. Where feasible, workers should avoid sharing equipment or treatment rooms and treatment rooms should be allocated to a single worker per shift.

(g) preparing for the next appointment and the end of the day – Ensure waiting and treatment areas and equipment are sanitized to prevent surface transmission between clients. Commonly touched surfaces and shared equipment must be cleaned and disinfected after contact between individuals even when not visibly soiled. Towels or any other items contacting a client are to be discarded or laundered between each use. Change into a separate set of street clothes and footwear before leaving work and work clothing should be placed in a bag and laundered after every shift. Shower immediately upon returning home after every shift.

As well, the WorkSafeBC website has protocols for documentation and training of staff, as well as links to the various professional colleges for health professionals to check additional requirements for their profession.

The Effect of these Necessary Protocols

These enhance protocols take time away from healthcare professionals being able to schedule actual clinical appointments. They require PPEs to be available and provided when necessary, as well as require extra time and labour for cleaning and disinfecting waiting areas, office equipment and washrooms, and to dispose of the waste. As much as we would all like things to “return to normal”, there is the need to accept that for now, this is the “new normal”.

For clinical practices that require a clinician to touch a client in the provision of services, such as in dentistry or registered massage therapy or physiotherapy there is no choice, but this is not the case in my practice. Thankfully, we are living in an era where there is secure video conferencing available which is ideal for the services that I provide as a Registered Dietitian, and is recommended by WorkSafeBC as the first approach when possible in the provision of health services.

Use of professional HIPAA and PIPEDA compliant telemedicine software

I have been providing Distance Consultations for over a decade; which are virtual ‘face-to-face’ visits that are functionally indistinguishable from the in-person services I provided prior to Covid-19. They are a very efficient use of my client’s time, as well as my own, and no PPEs are required, no disinfecting or extra hand-washing, or sanitizing of waiting areas, office space and washrooms between each client, and appointments are not spread out through the day due to the need to carry out decontamination tasks between clients.

I use secure HIPAA & PIPEDA compliant telemedicine software – with no download required.

During virtual appointments my clients and I see each other’s faces when we meet, and can comfortably talk, laugh and even sneeze without concern, and weight obtained from people’s own scales is more than adequate for the types of clients I see — and I provide my clients with written instructions for measuring their waist circumference the same way I would do it if they were in my office.

More Info?

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

To your good health!

Joy

You can follow me on:

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

References

WorkSafeBC – Health professions: Protocols for returning to operation,  https://www.worksafebc.com/en/about-us/covid-19-updates/covid-19-returning-safe-operation/health-professionals

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

Diabetes Canada Deems Low Carb and Very Low Carb Diet Safe and Effective

Diabetes Canada has just released a new Position Statement acknowledging that a low carb and very low carb (keto) diet is both safe and effective for adults with diabetes.

Reflecting back on their 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada released in April 2018 and covered in this article from my affiliate practice, Diabetes Canada clarified in this new Position Statement that it was not their intention to restrict the choice of individuals with diabetes to follow dietary patterns with carbohydrate intake that were below the consensus recommendation of 45-60% energy as carbohydrate, nor to discourage health-care practitioners from providing low-carb dietary support to individuals who wanted to follow a low-carb meal pattern. 

In the new Position Statement, Diabetes Canada acknowledged what I’ve written about previously, that Diabetes Australia, Diabetes UK, and the American Diabetes Association (ADA) in conjunction with the European Association for the Study of Diabetes (EASD) have developed position statements and recommendations regarding the use of low carbohydrate and very low carbohydrate (ketogenic) diets for people with diabetes. They state that from these previous international position statements and recommendations, several consistent themes have emerged — specifically that low carbohydrate diets (defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate) and very low carbohydrate diets (defined as <50 g of carbohydrate per day) can be safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months).

Diabetes Canada explained in the publication that they periodically develop position statements in order to address issues that are important for people living with diabetes, as well as their health-care providers and when there is either insufficient data to perform a systematic review, or there is no high level evidence (e.g. double-blind placebo controlled studies).

Diabetes Canada stated that this new position statement was developed in response to emerging evidence. as well as a shift in international consensus regarding lower carbohydrate diets — with the goal of providing important clarification for people living with diabetes, as well as health-care providers. It is their hope that this update will make effective engagement with multi-disciplinary teams easier, as well as avoid inter-professional tensions, as well as clearly identify areas where there are key safety issues and the need for clinical monitoring.

The purpose of the position statement was to summarize the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) or very low- carbohydrate diets (<50g carbohydrate/day) in the management of people diagnosed with type 1 and type 2 diabetes.

Summary of the Evidence – type 2 diabetes

Low Carbohydrate Diets

A review of the evidence found that a low carbohydrate diet (<51-130g carbohydrate/day) may be effective for weight loss, improved blood sugar control including a reduction in need for blood sugar lowering medication (anti-hyperglycemic therapies).

Also noted in the position paper is that while other dietary approaches for managing type 2 diabetes may be effective for weight loss and better blood sugar control, they have not achieved this while also reducing the need for blood-sugar lowering medication. Diabetes Canada calls this a  “meaningful outcome”.

Very Low Carbohydrate Diets

Of significance, this new position statement states that a review of the current literature suggests that very low- carbohydrate diets (<50g carbohydrate/day) may be superior to higher carbohydrate diets for improving blood sugar control and body weight, and that it can reduce the need for blood sugar lowering medications in the short term (up to 12 months).

They state that evidence regarding longer-term benefits is limited.

Summary of the Evidence – type 1 diabetes

The new position paper states that “there is very little reliable data and major evidence gaps which make it difficult to make general  recommendations with any confidence” for those with type 1 diabetes.

That said, the paper does state that for those living with type 1 diabetes, significant improvements in outcomes such as lower HbA1C, reduced insulin requirements, less variability in blood sugar and weight loss have been reported by individuals who have chosen to follow a low carbohydrate or very low carbohydrate diet.

Diabetes Canada concludes that “in the absence of clear trial evidence to support generalized recommendations, as well as the positive results experienced by people following low- and very low- carbohydrate diets;

  • health-care providers will need to work as partners with individuals seeking to identify an optimal and sustainable dietary pattern that fits with their individual preferences.
  • Health-care providers will need to recognize that diverse approaches are required to address the complex challenges of diabetes and obesity.
  • Health-care providers should strive to engage with patients in supportive relationships which respect shared decision making. “[1]

Cautions and Safety

Diabetes Canada advised that insulin and/or sulphonylurea doses may need to be reduced or discontinued to avoid hypoglycemia (low blood sugar) in those following a low carb or very low carb diet, and that SGLT2 inhibitors may increase the risk of diabetic ketoacidosis in individuals following low carbohydrate diets. As well, Diabetes Canada states that some added caution may be needed to ensure detection and treatment of hypoglycemia.

Diabetes Canada’s Five Recommendations

  1. Individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences.
  2.  Healthy low carb or very-low-carb diets can be considered as one healthy eating pattern for individuals living with type 1 and type 2 diabetes for weight loss, improved blood sugar control and/or to reduce the need for blood sugar lowering medications. Individuals should consult with their health-care provider to define goals and reduce the likelihood of adverse effects.
  3. Health-care providers can support people with diabetes who wish to follow a low-carbohydrate diet by recommending better blood glucose monitoring, adjusting medications that may cause low blood sugar or increase risk for diabetic ketoacidosis and to ensure adequate intake of fibre and nutrients.
  4. Individuals and their health-care providers should be educated about the risk of diabetic ketoacidosis while using SGLT2 inhibitors along with a low carbohydrate diet, and be educated in lowering this risk.
  5. People with diabetes who begin a low carbohydrate diet should seek support from a dietitian who can help create a culturally appropriate, enjoyable and sustainable plan. A dietitian can propose ways to modify carbohydrate intake that best aligns with an individual’s values, preferences, needs and treatment goals as people transition to- or from a low carbohydrate eating pattern.

Healthy Low Carb and Very Low Carb Diets

Finally, Diabetes Canada underscores that Canadians both with- and without diabetes who choose to adopt a low or very low-carbohydrate dietary
pattern “should be encouraged to consume a variety of foods recommended in Canada’s Food Guide”, and that “regular or frequent consumption of high energy foods that have limited nutritional value, and those that are high in sugar, saturated fat or salt, including processed foods and sugary drinks, should be discouraged.”

Final Thoughts…

As a Dietitian who has been helping individuals in Canada safely follow a variety of meal patterns over the past 12 years, as well as a low carbohydrate and very low carbohydrate diets over the past 5 years, I am delighted that Diabetes Canada shares the consensus of other international groups that have determined that these diets are both safe and effective for adults to follow in order to get much better blood sugar control, and for weight loss.

More Info?

If you would like more information about how I can help you get started on a low carbohydrate or very low carbohydrate diet, please reach out to me by sending me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

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

Reference

  1. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
    Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

Now That Things Are Getting Back to Normal – clinical appointments

INTRODUCTION: Governments around the world are beginning to relax lock-down measures put in place due to the Covid-19 pandemic and with that, many people are looking forward to having life ‘get back to normal’. But will it, and how soon?

For the past few months, we’ve stayed at home and sheltered-in-place in order to keep the healthcare system from becoming overwhelmed with too many cases of Covid-19 all at the same time. While there is much debate on social media as to whether things were done soon enough, or whether the measures taken should have been implemented at all, here in British Columbia, we are expecting to see the restoring of some medically-related services under enhanced protocols beginning mid-May[1]. 

What can people expect when it comes to medically-related services such as Dentists, Physiotherapists, Registered Massage Therapists, Chiropractors and Dietitians? Each of these types of professionals require a different amount of physical contact with clients. For example, Dentists and Physiotherapists must be able to touch their clients in order to provide services, therefore the types of personal protective gear and physical distancing barriers they will need to use will be very different than for someone who is a clinical counsellor or for me, as a Dietitian.

In my case, there would be the need to space out in-person appointments so that clients can physically distance from one another as one client is leaving and another arrives. What this would mean is that I would either need to see fewer people in the course of a day to ensure that there was no overlap between clients, or to provide a waiting area with chairs spaced 2 meters apart, which would need to be sanitized after each use.  This extra time would eat into my clinical day and also provide me much less flexibility for me to spend more time with client should it been necessary, since ensuring adequate social distancing between clients would take precedence. In fact, regulations require that before an appointment is even set up, there is the need to screen for risk factors and symptoms of COVID-19.

Basic PPEs

To protect both my clients and myself, there would be the need for use of some basic personal protective equipment (PPEs).

For example, I would need to wear a face mask in order to greet my clients, as well as to invite them into my office and I would be wearing gloves and a mask to weigh them, and take their waist circumference. Then there would be the need to sanitize the equipment after each use.

My clients would also need to wash their hands well when they arrive, as put on a clean mask (as my mask helps protect them and theirs helps to protect me). I would need to have disposable masks on hand in the event a client didn’t bring one of their own.  I would also need a designated place to throw out used disposable gloves and masks — which would need to be treated as a hazardous waste container, since there would be no way of knowing if someone were an asymptomatic carrier of Covid-19. I would also need a place where I could wash my hands well with soap and water between glove changes, or to sanitize my hands with an alcohol based hand-sanitizer.

To protect both my clients and myself during the assessment, my desk would  need to have a clear plexiglass screen that would enable my clients and I to see each other, but that would protect each other should one of us sneeze or cough, not to mention should we laugh, or “speak moistly”.

illustration of a plexiglass protective barrier around my desk.

The washroom available for client use would need to have disposable towels available, as well as a designated bin for them to be disposed of as they too would need to be treated as potentially hazardous waste and the bathroom would need to be sanitized after each use.

These enhance protocols take time away from scheduling actual clinical appointments. They require PPEs to be available and provided when necessary, as well as require extra time and labour for cleaning and disinfecting waiting areas, office equipment and washrooms, and to dispose of the waste. For clinical practices that require a clinician to touch a client in the provision of services such as in dentistry or registered massage therapy or physiotherapy, there is no choice, but in my practice there really is no need.

I have been providing Distance Consultations for over a decade; which are virtual ‘face-to-face’ visits that are functionally indistinguishable from the in-person services I provided prior to Covid-19. Virtual appointments are a very efficient use of my client’s time, as well as my own, and no PPEs are required, no disinfecting or extra hand-washing, or sanitizing of waiting areas, office space and washrooms between each client. I can see many more clients in a day because appointments are not spread out due to the need to carry out decontamination tasks between clients.

During virtual appointments my clients and I see each other’s faces when we meet, and can comfortably talk, laugh and even sneeze without concern.  Weight from people’s own scales is more than adequate for the types of clients I see, and I provide each of my clients with written instructions for measuring their waist circumference the same way I would do it if they were in my office.

Until When…?

It is apparent that enhanced protocols will need to remain in place in a clinical office setting until there is either a safe and effective vaccine available, or herd-immunity is obtained. Herd immunity is where the spread of the contagious virus within a population is sufficiently low because people had developed antibodies to it from exposure to the virus itself.  The challenge in the Covid-19 pandemic is that a reliable vaccine is estimated to be a year or 18 months away and herd-immunity via exposure to the virus is unlikely given that only those who get very ill with Covid-19 produce antibodies.

As I wrote about in a recent post, an article published April 27, 2020 in the journal The Lancet reported that while ~90% of those who have been hospitalized with severe Covid-19 develop IgG antibodies in the first 2 weeks, in non-hospitalized individuals with milder disease or with no symptoms, under 10% develop specific IgG antibodies to the disease[2]. That means that people that don’t get sick enough to require hospitalization likely don’t produce antibodies to the virus, resulting in very low herd immunity. As a result, in a clinical setting, these enhanced protocols will likely need to be maintained until a safe and effective vaccine is available, which is not going to be anytime soon.

The New Normal

As much as we would all like things to “return to normal”, there is the need to accept that for now, this is the “new normal”.

Thankfully, we are living in an era where there is secure video conferencing available which is ideal for clinical work that does not involve clinicians touching clients such as the ones that I provide as a Registered Dietitian.

More Info?

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

To your good health!

Joy

You can follow me on:

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

Reference

  1. Government of British Columbia, BC’s Restart Plan, May 6, 2020,  https://www2.gov.bc.ca/gov/content/safety/emergency-preparedness-response-recovery/covid-19-provincial-support/bc-restart-plan#next-challenge
  2. Altmann DM, Douek D, Boyton RJ, What policy makers need to know about COVID-19 protective immunity, The Lancet, April 27, 2020, DOI:https://doi.org/10.1016/S0140-6736(20)30985-5

 

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

 

 

Better Outcome in Covid-19 and T2D with Well-Controlled Blood Sugars

A new study published this past Friday (May 1, 2020) in the journal Cell Metabolism has reported that people with type 2 diabetes (T2D) are at much greater risk of having a poor outcome in Covid-19 if they have poorly controlled blood glucose.

The study looked at data from 7337 people who were hospitalized with Covid-19 in nineteen different hospitals in Hubei Province in China. Over 950 people had T2D (952) whereas the remaining almost 6385 people did not and among those with type 2 diabetes, 282 had well-controlled blood glucose, whereas the other 528 did not.

Consistent with what I reported in a recent review of a previous study in Covid-19, people admitted to hospital with the virus and who were diagnosed with T2D had poorer outcomes. In the present study, those with T2D required more medical interventions including requiring supplemental oxygen and/or ventilators than those without type 2 diabetes, and had much higher death rates (mortality) than those without T2D.  Mortality in Covid-19 in those with T2D was 7.8%, but in Covid-19 without T2D, mortality was only 2.7%. What was very encouraging was that those with people with T2D who were admitted to the hospital with COVID-19 and who had maintained well-controlled blood glucose ranging between 3.9 to 10.0 mmol/L (70-180 mg/dl) had much lower death rates than those people with poorly controlled blood glucose, with the upper limit of blood sugar readings exceeding 10.0 mmol/L (180 mg/dl).

Graphical illustration of survival rate in well-controlled T2D vs poorly-controlled blood glucose [1].
The findings were very sobering!

Almost 99% (98.9%) of those in hospital with Covid-19 and who had type 2 diabetes but well-controlled blood glucose survived Covid-19.

BUT

11% of those in hospital with Covid-19 and who had type 2 diabetes but poorly controlled blood glucose, died.

These findings provide clinical evidence that having better blood sugar control  leads to significantly better outcome in those hospitalized with COVID-19 and who have pre-existing type 2 diabetes.

More Info?

If you would like more information about how I can help you better control your blood sugar levels and aim put your type 2 diabetes into remission, please reach out to me.

To your good health!

Joy

You can follow me on:

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

Reference

Zhu L, She GZ, Cheng X, et al, Association of Blood Glucose Control and Outcomes in Patients with COVID-19 and Pre-existing Type 2 Diabetes. Cell Metabolism, 2020; DOI: 10.1016/j.cmet.2020.04.021

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

Too Much and Too Little is Killing Us – reducing comorbidities

I just got “the call” that my mother who lives on the other side of the country, has tested positive for Covid-19. She has all of the major comorbidities, so prognosis is not good. Following the news, most of us know that age, obesity, hypertension and diabetes are known to significantly increase the risk of requiring hospitalization and death from Covid-19 (you can read more about that here, here and here), yet all but one of these comorbidities can be put into remission.  We can’t change our age, but we CAN reduce our weight, lower our blood pressure and normalize our blood sugar. To improve our quality of life outside of the pandemic, and to have the best chance of fighting it off if (or more likely when) we get it, we need to put our energy into achieving a normal body weight (and waist circumference), blood pressure and blood sugar now.

I am from a family of people that always ‘battled with their weight’.

My dad was tall and very fit when he was younger, a boxer and a ski-jumper but as he aged he accumulated excess weight around his middle. He then developed type 2 diabetes, high blood pressure and heart issues and eventually was diagnosed with Alzheimer’s disease, which is sometimes referred to as ‘type 3 diabetes’ by some clinicians. I wrote this article about that when he was first diagnosed.

My dad died just a few weeks shy of his 91st birthday, which is a ‘ripe old age’ of course, but for the last 40 years of his life, he was not in good health. He took several medications due to multiple metabolic conditions related to his diet and lifestyle. Except for his age, many of these conditions could have been put into remission — or at very least, been much better controlled with a change in diet and lifestyle.

My mom will be turning 85 this fall, and has been overweight since I was little. She too has type 2 diabetes and takes multiple medications for various conditions, many related to diet and lifestyle; conditions which could have been greatly improved, if not put into remission with a change in diet and lifestyle. It wasn’t for lack of trying “diets”. When I was young, she weighed her food, counted points and went to “groups” and at times she lost weight, only to put it all back, and then some. Eventually, she stopped trying. I can’t say that I blame her, given what I now know about the drivers to hunger.

Shared comorbidities

When I became overweight and then obese, and developed type 2 diabetes and high blood pressure, I justified that I was at high risk since both of my parents had the same.  I realize now that the “high risk” was our shared diet and lifestyle, more than genetics. Our shared comorbidities were adopted.

I grew up loving to eat good food and unfortunately considered food as both a reward, and a comfort. When someone was happy, we celebrated with good food. When someone was sad, we consoled with “comfort food”.  Food was “medicine”, but not in a good way. It didn’t heal, but contributed to the underlying hyperinsulinemia that drove the disease process. (I’ve written several articles about this topic, but if you only want to read one, I’d recommend this one.)

Those who have followed me for some time know that 3 years ago I began what I call my “journey”.  It took almost two years to do, but I lost ~60 pounds and a foot off my waist and I put my dangerously high blood pressure and uncontrolled type 2 diabetes into remission, as a result.  I recently posted a summary here, to mark my three year health recovery anniversary; two years of active weight loss and a year of maintenance.

Left: April 2017, Middle: April 2019, Right: April 2020

So why am I writing this post?

Like many people, I am upset by this whole “Covid thing” — not just because of my mom being diagnosed. I’ve been following the news, and realize that the hope for a vaccine any time soon is dim, and effective treatments are still lacking. An article published in the journal The Lancet the other day reported that while ~90% of those who have been hospitalized with severe Covid-19 develop IgG antibodies in the first 2 weeks, in non-hospitalized individuals with milder disease or with no symptoms, under 10% develop specific IgG antibodies to the disease.  That means that except for the sickest people who actually survive being hospitalized for several weeks with Covid-19, more than 90% of people who get Covid-19 and recover outside of hospital don’t develop antibodies to this virus [1]. Since the whole purpose to develop a vaccine is to challenge the body to develop antibodies to the virus — the very fact that most of the time people who don’t get that sick don’t develop antibodies, means that the likelihood of most people developing antibodies to a vaccine may be minimal.  As well, in light of this data herd immunity is also a dim prospect because most people that get this disease don’t produce antibodies, which means they aren’t immune and can probably get this virus again.

With little immediate hope of an effective vaccine or of herd immunity, what CAN we do to lower our risk?

I think that we first need to realize that many experts believe it is simply a matter of time until we are all exposed to the SARS-CoV2 virus and develop Covid-19, so we must look at lowering our risk of having a poor outcome. We can’t change our age, which is the biggest risk factor but we CAN do something to change the high risk comorbidities such as obesity, high blood pressure and diabetes.

Too Much and Too Little is Killing Us

For many of us, having both too much and too little is killing us.

We have diets with way too much refined carbohydrate, usually combined with large amounts of refined fat, and our usual diet is full of these in the form of pizza, pastries, take out foods and snack foods.  We now know from a study that was published almost 2 years ago[2] that this combination of both refined carbs and fat results in huge amounts of the neurotransmitter dopamine being released from the reward centre of our brain — way more than when we eat foods with only carbohydrate, or only fat separately. This huge amount of released dopamine results in us wanting to eat these foods, and craving these foods, and being willing to pay more for these foods than foods with only carbs or only fat [2]. Dopamine makes us feel good, and is the same neurotransmitter that is released during sex and that is involved in the addictive “runner’s high” familiar to athletes. This is one powerful neurotransmitter! It is this dopamine that is driving why so many people on “lock-down” have turned to baking bread and pastries for comfort, and buying snack foods with this same combination once they finally get through a long line to get into a grocery store! 

Too much of these refined “foods” is contributing to 1/3 of Americans and 1/4 of Canadians being obese, and another 1/3 in both countries being overweight. These foods are driving the hyperinsulinemia that underlies many metabolic conditions, including type 2 diabetes and hypertension.  These diseases were killing a great many of us before Covid-19, but knowing that these comorbidities increase our risk of hospitalization and death when we get the virus, why don’t we consider limiting these? I think it is because eating these foods make us feel good and so we self-medicate our stressful lives with something that is socially acceptable. High carbohydrate and fat foods are much more socially acceptable but what will it take for us to see that this for what it is and to consider that we need to change how we eat. If we aren’t willing to admit that our obesity, high blood sugar and high blood pressure are a problem, then maybe we are simply in denial. I certainly was, and wrote about this in “A Dietitian’s Journey”, the account of my own health recovery.

No, I am NOT saying that “all carbs are evil” and I’ve written about this previously, but we need to differentiate between what most of us eat as “carbs” and whole, real food that have carbs in them. I believe we need to eat significantly less of the refined foods that are contributing to our collective weight problem and metabolic health issues, and eat more of the real, whole foods that have gone by the wayside in our diet. I’ve written about the science behind this type of dietary change in many previous articles, and that eating this way is both safe and effective. What I can’t do is motivate people to want to change.

It is my hope that by presenting the evidence, as I have in several recent articles posted on this website that comorbidities such as obesity, hypertension and diabetes are significant risk factors to requiring hospitalization or of dying of Covid-19, that it may motivate some people to consider making some changes. If not now, when — especially given that the hope of a vaccine and/or herd immunity is likely a long way off.

I wish each of you good health and a long life.

If I can help, please let me know.

Joy

You can follow me on:

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

Reference

  1. Altmann DM, Douek D, Boyton RJ, What policy makers need to know about COVID-19 protective immunity, The Lancet, April 27, 2020, DOI:https://doi.org/10.1016/S0140-6736(20)30985-5
  2. Di Feliceantonio et al., 2018, Supra-Additive Effects of Combining
    Fat and Carbohydrate on Food Reward, Cell Metabolism 28, 1–12

 

 

My Three Year Health Recovery Anniversary – a Dietitian’s Journey

I delayed posting this update to due to the current Covid 19 pandemic, but thought by now we could all use with a little distraction. I hope that this post about my health and weight recovery serves as encouragement as to what is possible simply by eating real, whole food, and sticking with it.

Me – April 2017, 2019 and 2020

Three years ago, on March 5th, 2017 I was sitting at my desk in my office and I didn’t feel well. I didn’t even know what kind of “unwell” I felt.  I decided to take my blood pressure to see if that would give me a clue.  I was alarmed with the results and decided to lie down and take it again. That didn’t help. Not only was my blood pressure high, it dangerously high.  I was having what is known as a “hypertensive emergency”.  While I hadn’t done so in way too long, I also decided to take my blood sugar. The result was 13.2 mmol/L (238 mg/dl) only a half an hour after I ate, which was way too high — even for someone who had been diagnosed with type 2 diabetes five years earlier.  Here I was, an obese Dietitian with a body mass index (BMI) well over 30, dangerously high blood pressure and blood sugar that clearly showed my type 2 diabetes was not well controlled and I knew that all of these factors put me at significant risk of having a stroke or heart attack. I was scared. Actually I was terrified.

As I’ve said on every podcast I’ve been a guest on, and have written about many times, what I should have done at that point was to have gone straight to my doctor’s office;  even knowing that he would have sent me directly to the hospital by ambulance or taxi due to my dangerously high blood pressure.  I should have gone, let them treat me to get my blood pressure down, including taking the medications they prescribed. Then, with my doctor’s oversight I could have begun a well-designed therapeutic diet to lower all of these significant metabolic markers and in time had my doctor gradually de-prescribed the various medications I would have been given, as my weight, blood pressure and blood sugars normalized.

I didn’t. It was foolish. What I did instead was to immediately change my diet and lifestyle and while I fully acknowledge that this was not a wise choice, that’s what I did.

I was so scared.

In the preceding 6 months, I had two girlfriends die within 3 months of each other; one of a massive heart attack, and the other of a stroke. Both worked in healthcare their entire lives and both had become overweight and had developed some of the same metabolic issues I had. I was terrified because I realized that if I didn’t change, I could be next.

April 2017

That day, I printed off my last set of blood test results, and took all my body measurements as if I were a client. I then designed a Meal Plan for myself as I do for others and from that day on, implemented it “as if my life depended on it”, because quite literally, it did.

There’s been no looking back! March 5, 2017 was the beginning of my health and weight recovery journey; A Dietitian’s Journey.

April 2018

In the first year, I lost 32 pounds and 8 inches off my waist, and my glycated hemoglobin (HbA1C) no longer met the criteria for Type 2 Diabetes (i.e. was ≤ 6.0 %), and my blood pressure ranged between normal and pre-hypertension. Updated lab work indicated that my triglycerides and cholesterol levels were optimal, however my updated measurements showed that my waist circumference was still not half my height, which is what it needed to be (you can read more about the reason for that here). In addition, my fasting blood sugar remained higher than it should be. I still had work to do. I was in recovery, but not recovered yet.

After consulting with two physician colleagues, I made the decision to lower my carbohydrate intake, and continued to monitor my blood pressure daily and blood sugar several times per day.  I also began doing some resistance training exercises with equipment I had on hand (and that had been collecting dust for years).

April 2017 & April 2019 (same outfit)

After 2 years on my recovery journey, I had lost a total of 55 pounds and 12 inches off my waist but since my blood pressure remained between the pre-hypertensive and hypertensive range, and in discussion with my doctor’s colleague, I decided to go on a “baby dose” of Ramipril to protect my kidney function. Even though my blood sugar was good and my HbA1C was below the cut-off for type 2 diabetes, my endocrinologist started me on Metformin as a result of my father’s recent diagnosis of Alzheimer’s disease.

I didn’t look at starting on either of those medications as “failure”, as I probably would have been prescribed those at much higher doses from the beginning had I gone to see my doctor March 5, 2017. It was part of my recovery process. My goal however was to make changes so that blood pressure medication would no longer be necessary, but I didn’t know what other changes I could make to have it to come down to a normal level, and for my fasting blood glucose to continue improve as well. After much reading in the scientific literature about circadian rhythms , I realized that to be successful I needed to change when I ate (and didn’t eat) as well as when I was exposed to bright light in order to get my body working according to its natural circadian (24-hour) cycles. I made the changes documented in the literature and began to sleep much better (falling asleep and staying asleep, when I had previously had poor sleep for years). A few months of home monitoring indicated my blood pressure was normal or slightly below and I was getting fasting blood glucose numbers I hadn’t seen before (4.7mmol/L – 5-2 mmol/L). I hadn’t “arrived” but my recovery phase was definitely approaching the end.

A visit to my doctor’s office just before Covid 19 began indicated I had blood pressure that was just below the normal cutoff of 120/70 for someone who is not diabetic, so my doctor de-prescribed the blood pressure medication and recent lab test results indicated that I have completely normal fasting blood sugar [5.2 mmol/L (94 mg/dl)]. Over the past year without trying, I lost another 5 pounds and a little less than an inch off my waist and I am guessing this was probably the result of continued loss of fat balanced by increased weight from added muscle I gained as a result of the intermittent resistance training I was doing.

April 2020

I am now a normal body weight. I have an optimal waist circumference (slightly less than half my height). I am in remission of type two diabetes; both as assessed by fasting blood glucose and HbA1C, and my high blood pressure is in remission. I went from taking 12 different medications three years ago, to leaving my doctor’s office a few weeks ago with one prescription for something non-metabolically related, and a prescription for glucose test strips.

I feel good about myself, about my health and how I look — so much so that in September of this past year I decided to stop straightening my hair and now wear it the way it grows out of my head.  I am “comfortable in my own skin” (and hair) for the first time in almost 3 decades. I didn’t lose weight quickly but it took me many years to become THAT metabolically unhealthy that I gave myself the time I needed to get well and am staying well, without any added effort. The process wasn’t at all difficult to accomplish, or difficult to maintain. All it took was eating real, whole food and reducing the amount of carbohydrate-based foods I ate.  What is nice is that after 3 years on a therapeutic diet, I am now able to add in small amounts of higher carbohydrate-based whole foods into my diet, and tolerate them very well.

While there are many studies showing many others have accomplished similar clinical results as I have eating the same way, doing it myself enables me to encourage my clients because I have “been” there, and I came back!

More Info?

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

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

 

Obesity Most Significant Risk Factor to Covid-19 Hospitalization after Age

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

We Need to “Get” This

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

How Big an Issue is Obesity?

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

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

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

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

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

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

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

More Info?

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

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

To your good health!

Joy

You can follow me on:

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

References

  1. Christopher M. PetrilliSimon A. JonesJie YangHarish RajagopalanLuke F. O’DonnellYelena ChernyakKatie TobinRobert J. CerfolioFritz FrancoisLeora I. Horwitz, 
  2. Lighter J, Phillips M, Hochman S et al, Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission, accepted manuscript, Clinical Infectious Diseases. doi: 10.1093/cid/ciaa415,  https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa415/5818333
  3. 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

Obesity Poses Significant Risk to People less than 60 years with Covid-19

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

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

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

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

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

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

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

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

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

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

Weight Loss – easier said than done?

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

I can help.

More Info?

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

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

To your good health!

Joy

You can follow me on:

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

References

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

Why Underlying or Comorbid Conditions are Very Important in COVID-19

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

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

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

Underlying comorbid conditions among US adults with COVID-19

Changing What’s in Our Control to Change

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

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

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

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

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

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

Final Thoughts…

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

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

More Info?

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

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

To your good health!

Joy

You can follow me on:

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

References

  1. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. ePub: 8 April 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6915e3
  2. 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

 

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

Canada Told to Prepare for Possible Pandemic Amidst 7th Case in BC

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

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

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

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

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

Further thoughts…

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

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

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

References

References

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

(UPDATED Feb 23) Sixth Case of COVID-19 Coronavirus in Vancouver called a Sentinel Event

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

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

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

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

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

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

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

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

Some thoughts…

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

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

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

Distance Consultations

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

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

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

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

Copyright ©2020 BetterByDesign Nutrition Ltd.

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

References

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

Five Pounds or Fifty Pounds of Fat – in very real terms

Whether one loses 5 pounds of fat or 50 pounds of fat, I think it is very helpful to visualize just how much that is. Yes, five pounds of fat is much larger than most people realize!

This past week, I purchased a life-sized model of 5 pounds of fat from a well-known nutrition supplier; the same supplier I have purchased life-sized food models from, which I used to use a lot in my practice.  When I received it, I was quite surprised how much room it took up and just how heavy it was.

Here is a photo of the life-sized model 5 pounds of fat on a scale, with my left hand for a size reference:

5 pounds of fat on a scale, with adult hand as reference – © BBDNutrition

Here is a photo of it on an ordinary steno chair:

5 pounds of fat on a steno chair – © BBDNutrition

…and here is 5 pounds of fat being held in my hand:

5 pounds of fat in adult hand – © BBDNutrition

Finally, here is 5 pounds of fat being carried as one would carry an infant:

holding 5 pound of fat – © BBDNutrition

Five pounds of fat is a lot! Sure there is the initial water-loss at the beginning of weight loss, but here I’m talking about fat.

Fat takes up a fair amount of room around one’s waist, or worse inside one’s abdomen or organs. If someone has 20 pounds of fat to lose, that is four of those fat models distributed over their body; legs, belly, arms, neck, back and face and perhaps some in their liver.

I had 55 pounds of excess fat before beginning my journey.

Comparing these two full length photos, it is easy to see how I had the equivalent of one of those fat models over the length of each leg, one distributed between each arm, one distributed over my neck and face and 2 spread out around my waist and hips and some no doubt, in my liver and pancreas. But still, I can’t actually imagine where I was carrying 11 of those, all told!

The fat in my abdomen must have been more than I imagined, as it was wreaking metabolic havoc on my body.  I had very high blood pressure and had type 2 diabetes for 8 years.  You can read the entire story (including lab test results) under “A Dietitian’s Journey” on my affiliate low carb web site by clicking here. Keep in mind that I chose to follow a therapeutic low carbohydrate diet, but there is no one-sized-fits-all diet that is right for everyone.  

Whether you have 5 or 10 pounds of fat to lose, or like me ⁠— a whole lot more, it is really only done a pound or so at a time.  If you have significant amount of weight to lose,  I can not only help you do that, but since I’ve been through it myself, I can encourage you and coach you through it. I provide services across Canada (except PEI) via HIPAA-compliant video conferencing, and most extended benefits providers reimburse for licensed Dietitian services.

More Info?

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2020  BetterByDesign Nutrition Ltd.

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

New ADA Standards of Medical Care Includes Low Carbohydrate Diet

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

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

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

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

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

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

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

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

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

It encourages each member of the healthcare team;

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

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

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

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

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

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

Carbohydrates

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

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

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

Final Thoughts…

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

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

More Info

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
    American,
  2. Evert ABDennison MGardner CDet alNutrition therapy for adults with diabetes or prediabetes: a consensus reportDiabetes Care 2019;42:731754
  3. Franz MJ, MacLeod J, Evert A, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet 2017;117:1659–167
  4. Esposito K, Maiorino MI, Ciotola M, et al. Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial. Ann Intern Med 2009;151:306–314
  5. Boucher JL. Mediterranean eating pattern. Diabetes Spectr 2017;30:72–76
  6. Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239–252
  7. van Zuuren EJ, Fedorowicz Z, Kuijpers T, Pijl H. Effects of low-carbohydrate- compared with low-fat-diet interventions on metabolic control in people with type 2 diabetes: a systematic review including GRADE assessments. Am J Clin Nutr 2018;108:300–331
  8. Snorgaard O, Poulsen GM, Andersen HK, Astrup A. Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes. BMJ Open Diabetes Res Care 2017;5:e000354
  9. Rinaldi S, Campbell EE, Fournier J, O’Connor C, Madill J. A comprehensive review of the literature supporting recommendations from the Canadian Diabetes Association for the use of a plant-based diet for management of
  10. Pawlak R. Vegetarian diets in the prevention and management of diabetes and its complications. Diabetes Spectr 2017;30:82–88
  11. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. Accessed 1 November 2019. Available from http://www.fda.gov/Drugs/DrugSafety/ucm475463.htm
  12. Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: analysis of FAERS data. Diabetes Metab Res Rev 2017;33:e2924
  13. Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes 2017;7:304
  14. Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583–612
  15. van Wyk HJ, Davis RE, Davies JS. A critical review of low-carbohydrate diets in people with type 2 diabetes. Diabet Med 2016;33:148–157
  16. Meng Y, Bai H, Wang S, Li Z, Wang Q, Chen L. Efficacy of low carbohydrate diet for type 2 diabetes mellitus management: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2017;131:124–131
  17. Tay J, Luscombe-Marsh ND, Thompson CH, et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. Am J Clin Nutr 2015;102:780–790
  18. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev 2009;1:CD006296

Is Your New Year’s Resolution to Lose Weight or Improve Your Health?

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

Wish or Resolution?

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

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

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

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

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

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

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

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

Why is that?

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

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

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

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

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

When to Eat and Not Eat, How Many Meals and Snacks

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

Timing of Meals

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

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

Snacks

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

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

Historic Dietary Treatment of Diabetes

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

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

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

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

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

Medications as Treatment in Diabetes

Type 1 Diabetes

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

Type 2 Diabetes

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

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

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

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

Dietary Recommendations – meals and snacks

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

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

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

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

In fact, a soon-to-be-published pilot study [8] found that those with type 2 diabetes who ate the same calories each day as 3-meals per day, rather than as 6 meals per day [i.e. 3 meals and 3 snacks] reduced body weight, blood glucose, and insulin dosesWithout even changing how many carbs they ate or how many calories they ate, in just 12 weeks, the subjects in the 3 meal per day group, lost on average 12 pounds (5.4 kg) more than those in the 6 meal per day group, had 1.2% lower HbA1C than the 6 meal per day group and their total daily insulin dose was reduced by 26 units ± 7 (with no reduction in the 6 meal per day group). On top of this, this study found that “there was a significant decrease in hunger and cravings only in the 3 meal per day group“. This makes sense of course, because they were able to lower their injected insulin, which drives hunger and fat storage, leading to weight gain. The mechanism was thought to be an up-regulation in the clock genes of those that ate 3 meals per day, which contributed to the improved glucose metabolism.

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

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

When We Eat – especially which meals to eat carbs

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

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

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

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

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

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

When We Don’t Eat – intermittent fasting

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

More Info

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 division of BetterByDesign Nutrition Ltd.

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

References

  1. BBD News Magazine, Winterman, Denise, Breakfast, lunch and dinner; Have we always eaten them? Nov 15 2012, https://www.bbc.com/news/magazine-20243692
  2. Carroll, Abigail (30 August 2013). “How Snacking Became Respectable”. Wall Street Journal. August 30, 2013, https://www.wsj.com/articles/how-snacking-became-respectable-1377906874
  3. Duffey KJ, Popkin BM, Energy Density, Portion Size, and Eating Occasions: Contributions to Increased Energy Intake in the United States, 1977–2006, June 28, 2011, https://doi.org/10.1371/journal.pmed.100105
  4. Osler W. The Principles and Practice of Medicine. New York, D. Appleton and Company, 1892
  5. Woodyatt RT, Bernhard NaunynDiabetes 1952;1:240241, pmid:1493683
  6. Allen FM, Studies concerning diabetesJAMA 1914;63:93994
  7. Joslin EP, Treatment of Diabetes Mellitus2nd ed. PhiladelphiaLea & Febiger1917, p. 409
  8. Jakubowicz D, Landau Z, Tsameret S et al, 
  9. Seagle HM, Strain GW, Makris A, Reeves RS; American Dietetic Association. Position of the American Dietetic Association: weight management. J Am Diet Assoc 2009;109:330–346
  10. Beyond the Basics: Meal Planning for Healthy Eating, Diabetes Prevention and Management. Canadian Diabetes Association, 2014.
  11. Arnold L,MannJI, Ball MJ. Metabolic effects of alterations in meal frequency in type 2 diabetes. Diabetes Care 1997;20:1651–1654
  12. Mekary RA, Giovannucci E, Willett WC, van Dam RM, Hu FB. Eating patterns and type 2 diabetes risk in men: breakfast omission, eating frequency, and snacking. Am J Clin Nutr 2012;95:1182–1189
  13. Gouda M, Matsukawa M, Iijima H. Associations between eating habits and glycemic control and obesity in Japanese workers with type 2 diabetes mellitus. Diabetes Metab Syndr Obes 2018;11:647–658
  14. Dyar KA, Ciciliot S, Wright LE, et al. Muscle insulin sensitivity and glucose metabolism are controlled by the intrinsic muscle clock. Mol Metab 2013;3:29–41
  15. Sadacca LA, Lamia KA, deLemos AS, Blum B, Weitz CJ. An intrinsic circadian clock of the pancreas is required for normal insulin release and glucose homeostasis in mice. Diabetologia 2011;54:120–124
  16. Poggiogalle E, Jamshed H, Peterson CM. Circadian regulation of glucose, lipid, and energy metabolisminhumans. Metabolism2018;84:11–27
  17. Saad A, Dalla Man C, Nandy DK, et al. Diurnal pattern to insulin secretion and insulin action in healthy individuals. Diabetes 2012;61:2691–2700
  18. Bo S, Fadda M, Castiglione A, et al. Is the timing of caloric intake associated with variation in diet-induced thermogenesis and in the metabolic
    pattern? A randomized cross-over study. Int J Obes 2015;39:1689–1695
  19. Jakubowicz D, BarneaM, Wainstein J, Froy O. High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity (Silver Spring) 2013; 21:2504–2512
  20. Morgan LM, Shi JW, Hampton SM, Frost G. Effect of meal timing and glycaemic index on glucose control and insulin secretion in healthy volunteers. Br J Nutr 2012;108:1286–1291
  21. Jakubowicz D, Wainstein J, Ahren B, Landau Z, Bar-Dayan Y, Froy O. Fasting until noon triggers increased postprandial hyperglycemia and impaired
    insulin response after lunch and dinner in  individuals with type 2 diabetes: a randomized clinical trial. Diabetes Care 2015;38:1820–1826

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Vitamin D Supplementation Can Help Protect Against the Flu

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

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


Studies Showing that Vitamin D Attenuates the Flu

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

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

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

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

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

Supplementing with Vitamin D

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

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

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

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

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

How much Vitamin D should we supplement?

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

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

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

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

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

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

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

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

Final thoughts…

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

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

More Info

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 division of BetterByDesign Nutrition Ltd.

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

References

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

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⁠—

Why Eating Less and Exercising More DOES Matter As We Age

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

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

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

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

Eating Less Matters as We Age

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

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

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

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

Why We Regain Weight After Weight Loss

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

Exercise and Lipid Turnover

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

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

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

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

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

To your good health!

Joy

You can follow me on:

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

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

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

References

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

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Treating Small Intestinal Bacterial Overgrowth (SIBO)

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

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

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

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

Three Phases of Dietary Treatment for SIBO

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

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

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

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

Phase I

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

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

Phase II

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

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

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

Phase III

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

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

Final Thoughts

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

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

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

The Gut Microbiome – so much to learn

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

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

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

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Diagnosing Small Intestinal Bacterial Overgrowth (SIBO)

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

Diagnosing SIBO

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

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

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

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

Glucose Breath Test or Lactulose Breath Test?

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

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

How Does a Breath Test Work?

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

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

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

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

How the Breath Test is Performed

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

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

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

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

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

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

Positive Breath Test for Methane

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

Distinguishing SIBO from IBS

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

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

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


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

More Info?

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. Quigley EMM. The Spectrum of Small Intestinal Bacterial Overgrowth (SIBO), Current Gastroenterology Reports, (2019) 21:3, https://doi.org/10.1007/s11894-019-0671-z
  2. Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol (N Y). 2007;3(2):112–122.
  3. Ghoshal UC How to interpret hydrogen breath tests. J Neurogastroenterol Motil201117312–317
  4. Levitt MD, Furne JK, Kuskowski M, Ruddy J. Stability of human methanogenic flora over 35 years and a review of insights obtained from breath methane measurements. Clin Gastroenterol Hepatol. 2006;4:123–129.
  5. Pimentel M, Chow EJ, Lin HC, Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome.
    Am J Gastroenterol. 2000 Dec; 95(12):3503-6
  6. Ghoshal UC, Ghoshal U, Ayyagari A, et al. Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time. J Gastroenterol Hepatol. 2003;18:540–547
  7. Rezaie A, Buresi M, Lembo A et al, Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus, Am J Gastroenterol 2017; 112:775–784; doi: 10.1038/ajg.2017.46
  8. Scarlata K, Small Intestinal Bacterial Overgrowth (SIBO) blog article, January 22, 2014, https://blog.katescarlata.com/2014/01/22/small-intestinal-bacterial-overgrowth/
  9. Chatterjee S , Park S , Low K et al. Th e degree of breath methane production in IBS correlates with the severity of constipation . Am J Gastroenterol 2007 ; 102 : 837 – 41.
  10.  Attaluri A , Jackson M , Valestin J et al. Methanogenic fl ora is associated with
    altered colonic transit but not stool characteristics in constipation without
    IBS . Am J Gastroenterol 2010 ; 105 : 1407 – 11.
  11. Hwang L , Low K , Khoshini R et al. Evaluating breath methane as a diagnostic
    test for constipation-predominant IBS . Dig Dis Sci 2010 ; 55 : 398 – 403.
  12. Kunkel D , Basseri RJ , Makhani MD et al. Methane on breath testing is
    associated with constipation: a systematic review and meta-analysis .
    Dig Dis Sci 2011 ; 56 : 1612 – 8.
  13. Schmulson MJ, Drossman DA. What Is New in Rome IV. J Neurogastroenterol Motil. 2017;23(2):151–163. doi:10.5056/jnm16214

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What is Small Intestinal Bacterial Overgrowth (SIBO)?

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

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

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

“Do you believe that SIBO is a credible diagnosis?”

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

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

What is SIBO?

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

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

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

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

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

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

How Common is SIBO?

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

What are the Symptoms of SIBO?

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


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


More Info?

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

To your good health!

Joy

You can follow me on:

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

Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

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

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When Real Food is Deemed Offensive and Disturbing, not Processed Food

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

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

The photo I posted is above.

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

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

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

This photo contains sensitive content which some people may find offensive or disturbing.

A physician posted the following comment about the censoring;

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

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

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

Do you know what I consider offensive and disturbing?

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

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

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

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

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

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

These are choices…

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

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

To your good health,

Joy

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