Stanford Blood Sugar Study Findings Known for More Than 45 Years

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

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

The Stanford Study

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

Subject’s Blood Sugar Upon Screening

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

Huge Variations in Blood Sugar Response

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

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

Some People had lots of Abnormal Glucose “Spikes”

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

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

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

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

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

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

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

Cornflakes For Breakfast?

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

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

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

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

Ordinary Blood Tests Available to Detect These Abnormal “Spikes”

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

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

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

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

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

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

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

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

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

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

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

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

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

More Info?

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

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

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

To your good health!

Joy

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Copyright ©2019 BetterByDesign Nutrition Ltd.

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

References

  1. Hall H, Perelman D, Breschi A, et al, 2018, Glucotypes reveal new patterns of glucose dysregulation. PLOS Biology 16(7). https://doi.org/10.1371/journal.pbio.2005143
  2. Kraft JR, Glucose Insulin Tolerance. A routine Clinical Laboratory Tool Enhancing Diabetes Detection. In O.B. Hunter. Jr. (ed): Radio assay: Clinical Concepts. Skokie, IL. Professional Education Dept. G.D. Searie & Co., 1974. Pp 91-106.
  3. Kraft JR, The Glucose Tolerance Examination: An Obsolete Procedure. read at the Symposium on Radioimmunioassay in Diagnostic Medicine.” Annual Convention, American Medical Association, Chicago, IL. June 26, 1974
  4. Kraft JR, Detection of Diabetes Mellitus In Situ (Occult Diabetes), Laboratory Medicine, Volume 6, Issue 2, 1 February 1975, Pages 10–22, https://doi.org/10.1093/labmed/6.2.10
  5. Crofts C, Schofield G, Zinn C, Wheldon M, Kraft J., Identifying hyperinsulinaemia in the absence of impaired glucose tolerance: An examination of the Kraft database. Diabetes Res Clin Pract, 2016. 118: p. 50-7.
  6. Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094.
  7. Medical Press, July 24, 2019, Diabetic-level glucose spikes seen in healthy people, study finds, https://medicalxpress.com/news/2018-07-diabetic-level-glucose-spikes-healthy-people
  8. Sagesaka H, S.Y., Someya Y, et al, Type 2 Diabetes: When Does It Start? Journal of the Endocrine Society, 2018. 2(5): p. 476-484.

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Two People, Two Options: living healthy or dying prematurely

This weekend has been a challenging one, as I received two pieces of news. The first was of one client’s incredible success following the low carb high healthy fat diet and the shocked reaction of his doctor, and the other was of the death of a friend who had Diabetes, high blood pressure and high cholesterol. In this blog, I will share how these two events embody the two options each of us have; (1) living a healthy life to the fullest or (2) living with diet-related disease and dying prematurely of ‘natural causes’.

“JP” – a Picture of Success

Last fall, I had a reasonably fit 35-year-old client contact me wanting to lose 15 pounds. He went to the gym twice a week for an hour, and ran 10 km per week, but had put on some pounds and wanted to lose them.

As I always do, I asked for a copy of recent blood test, assessing his fasting blood glucose, HbA1C (3 month average of blood glucose), cholesterol (lipid panel) and requesting his doctor-assessed blood pressure. (Sometimes people insist that I counsel them without seeing blood work, but I explain that they ran out of crystal balls when I was graduating, so I have no choice but to get labs.)  I gave my new client a Lab Test Request form to bring his doctor.  The GP scoffed at the Lab Test Request Form asking him to requisition a lipid panel for a young, fit 35 year old whose parents are both living. That changed when the tests came back, and this man’s triglyceride level was higher than I had ever seen anyone’s, ever. His non-HDL cholesterol was very high and his HDL was very low. LDL wasn’t even available because his triglycerides levels were through the roof. His ferritin was astronomically high – not a sign of excess iron, but likely inflammation.

His doctor called him into the office immediately and wanted to put him on statin medication right away and referred him to the Lipid Clinic at a major local hospital.

My client told his doctor he wanted to wait 3 months and first follow my dietary recommendations and see what would happen to his lipids, and was advised against it by his doctor. My client was insistent, so the doctor told him that his recommendations were for him to eat “decrease saturated fat and carbohydrates, increase fruit and vegetables, increase insoluble fiber and fish, make his plate 1/2 vegetables, 1/4 protein, 1/4 starch“.

After seeing me, he agreed to limit fruit to max 1 / day, preferably a few berries on top of 2 or 3 huge salads with plenty of good quality olive oil and to have most of his carbs as vegetables. He learned that “not all vegetables are created equal” and I taught him to differentiate between those he could eat as much as he wanted at each meal and those he should limit or avoid. We talked about milk consumption, and the health benefits of eating plenty of fatty fish, such as salmon, mackerel and fresh sardine. And we talked about carbs. We talked a lot about carbs. Carbs in fruit, carbs in milk, carbs in bread, pasta and rice, and carbs in vegetables.

I designed an Individual Meal Plan for him, making sure he obtained sufficient macronutrients (protein, fat and carbs) as well as micronutrients (especially potassium, magnesium, sodium, vitamin C and calcium, vitamin D and vitamin K) – and factoring in his desired weight loss. I explained that if he followed his Meal Plan, it is perfectly reasonable for his triglyceride levels to be <2.00 mmol/L in 2 more months.

Three weeks later, his doctor ran his labs again.  His triglyceride level was almost a third what it was! His non-HDL was down substantially and his HDL was rising nicely. When he was seen at the Lipid Clinic, they were willing to give him 2 more months to get his lipids in the normal range before starting him on medication.

Friday, he wrote me telling me that his triglycerides we down well below 2.00 mmol/L and added;

“this amazed the doctor!”

My client left his doctor’s office without a medication prescription and with only the recommendation to keep eating the way I taught him. My client added that he was already within 2 – 3kg of his goal weight.

It’s not magic.

The doctor should not have been amazed that diet alone can be this effective – even for someone for whom high cholesterol has a genetic component. The literature documents the role of a low carb high fat diet.

But it is easier to write a prescription than educate a patient.

My High School Friend – preventable premature death

Last night I learned that my friend since high school, died from natural causes. She had Type 2 Diabetes, high blood pressure and high cholesterol. She and I were the same age.

Three years ago, when my friend was first diagnosed as having Diabetes, she asked my opinion about having received Diabetes counselling in her province to eat 45 gm of carbohydrates at each meal and at least 15 gm of carbohydrates at each of 3 snacks – that’s 180 gm of carbohydrates per day.  A mutual friend of ours from the same province, who had also been recently diagnosed with Diabetes confirmed that she too was advised to eat 45 gm of carbohydrates at each meal and at least 15 gm of carbohydrates at snacks. At that time, I had explained to my friend what I had been learning about the role of excess carbs in Diabetes, hypertension (high blood pressure) and high cholesterol. While I provide distance consultations in my practice (using a combination of phone, email and fax), as Dietitians we are advised specifically not to provide dietary counselling to family members or friends. With my ability to help directly being very limited, I recommended that she find a Dietitian near her who could teach her about managing this triad (called “metabolic syndrome”) using a low carb high fat diet. She followed the standard dietary recommendations to the letter and took her multiple medications as prescribed. Her blood sugar levels came down using medication (but that was effectively treating the symptom of high blood sugar, not the cause which is the underlying insulin resistance). Her blood pressure kept going higher and higher despite medication, so more medication was added.  She then developed high       cholesterol.

Today, my friend is dead, in what could have been an entirely preventable, premature death.

So I am left asking myself ‘could following the standard recommendations of eating 180 gm of carbohydrate per day with Type 2 Diabetes, high blood pressure and high cholesterol — without treating the underlying cause (insulin resistance) have contributed to her death’?

The literature is certainly full of studies documenting the beneficial effects of a low carb high fat diet on metabolic syndrome – but she was never given that as an option.  She was prescribed medication for lowering blood sugar and blood pressure, but nothing was done to lower her insulin resistance.

A lifetime of work by the late Dr. Joseph Kraft with almost 300,000 people documents that it is the insulin resistance that underlies cardiovascular disease – not the high blood sugar. Furthermore, 65-75% of people with normal blood sugar levels still have insulin resistance – and the same elevated risk of having a heart attack.

We keep treating the symptoms and people keep dying anyways – and those without any symptoms are walking around with elevated risk of dying from cardiovascular disease, and don’t even know it.

We are told;

“Diabetes is a chronic, progressive disease”

which means that once diagnosed with Diabetes, you’ll have it forever – and that eventually it will get worse, requiring medication, then more medication and finally insulin.

When people have bariatric surgery (“stomach stapling”), their blood sugars come back to normal within weeks and at the end of a year, they no longer have any of the clinical symptoms of Diabetes.  Their fasting blood glucose levels are normal and their HbA1C levels are normal. They are essentially as if they don’t have Diabetes. Their Diabetes is in remission.

So is Diabetes REALLY a “chronic, progressive disease”? No, it can be stopped.

If the reason people became Diabetic was because of how they were eating, why is it SO hard to grasp the concept that they could get well, but changing how they are eating?

At the end of the day, we have a choice.

We can do as my client above did and put everything we have into changing how we eat based on good, sound scientific studies and with medical supervision, or we can keep doing what we’ve been doing, expecting different results.

I made my choice a month ago tomorrow, and will write an update in the blog titled “A Dietitian’s Journey” tomorrow, for week four  (see Food for Thought tab, above).  Here’s a teaser; two days ago my blood sugar levels were several times at normal levels – and were overall much lower than a month ago. Last night (twice) and once this morning, my blood pressure was in the normal range.  One month!

I ask myself, what will my labs look like in 3 months or 6 months of addressing the underlying insulin resistance (instead of the symptom of high blood sugar?) What will be life be like, when I have normal blood sugar levels and normal blood pressure and normal cholesterol levels?

It will look better than the alternative.

Rest in peace, dear friend.

Copyright ©2017 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 regular monitoring by a Registered Dietitian and with the knowledge of 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 something you have read in our content. 


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Canadian study reports that cardiovascular risk is higher among certain ethnic groups

A study published in May 2010 in the Canadian Medical Association Journal and based on data conducted over an 11 year period was the first to compare cardiovascular risk factors and associated heart disease and stroke prevalence across the four major racial-ethnic groups living in the same geographic area, with a similar living environment and similar access to health care.  The report found that Whites (Caucasian), South Asians, Blacks and Chinese had striking differences in cardiovascular risk profiles.

THE STUDY

The study entitled “Comparison of Cardiovascular Risk Profiles Among Ethnic Groups” was based on population health surveys between 1996 and 2007 and was conducted by the Toronto-based Institute for Clinical Evaluative Sciences.  It compared data from 154,653 Caucasians (Whites), 3,038 Chinese, 3,364 South Asians and 2,742 blacks who participated in Statistics Canada’s cross-sectional national population health survey between 1996 and 2007.

RISK FACTORS

Risk factors for cardiovascular disease include smoking, diabetes, obesity, hypertension (high blood pressure) as well as psychological or social stress.

FAVORABLE DIFFERENCES IN RISK BETWEEN ETHNIC GROUPS

The study reported that Chinese had the most favorable cardiovascular risk factor profile with only 4.3% of the population reporting two or more major cardiovascular risk factors, such as smoking, diabetes, obesity and hypertension (high blood pressure).

South Asians had the next most favorable cardiovascular risk profile (7.9%), followed by Whites (10.1%) and Blacks (11.1%).

PREVALENCE OF RISK FACTORS BY RACE

The study also found that smoking, obesity and stress were significantly more common in Whites, while diabetes and hypertension were much more prevalent among Blacks and South Asians.

WHAT COULD THE STUDY MEAN FOR YOU?

Risk factors such as smoking, diabetes, obesity and hypertension (high blood pressure) are considered to be related to 90% of risk factors for cardiovascular diseases, so being aware of these ethnic differences can help you, your doctor and your dietitian make lifestyle changes specific to your ethnicity, including;

  • diabetes and hypertension lifestyle intervention targeted to high-risk South Asians and Blacks
  • obesity-prevention programs for Black women and White men and women
  • encouraging physical activity among South Asian and Chinese populations

CONSULTING OUR REGISTERED DIETITIAN

If you have any of the risk factors known to be prevalent for your ethnic background, consider consulting with our Registered Dietitian.  She is a food and nutrition expert and is knowledgeable and experienced to help you make the lifestyle changes needed to lower your risk of cardiovascular disease.