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A Nutritional Strategy
for Treating Insulin
Resistance Lori Cheverie, M.D
May 12th 2017
Conflicts of Interest
None to Declare
Objectives
Obesity
Throwing out “eat less/move more”
Hormonal Theory of Obesity
The role of Insulin Resistance
Metabolic Syndrome
Why it’s important
Diabetes (T2)
Focusing on cause rather than effect
Dietary interventions to reverse DM
Obesity
“…chronic and often progressive condition, similar
to diabetes or high blood pressure. Obesity is
characterized by excess body fat that can
threaten or affect your health. Many
organizations…now consider obesity to be a
chronic disease.”
Canadian Obesity Network
Measuring Obesity
Canadian Obesity Network
Edmonton Obesity Staging System
Obesity/Metabolic Syndrome
Negative Outcomes
Inc. all cause mortality
Diabetes
(micro/macrovascular
complications)
CAD
Stroke
NAFLD
Chronic pain (+/- joint
replacements)
Psychological impact
Cancers (breast, colon…)
PCOS/Infertility
Dementia
OSA
Fatigue
Skin/limb infections
“Obesity in Canada”. PHAC
“Weight and Cancer”. World Cancer Research Fund
Obesity Treatment
5-10% decrease in weight causes significant health improvements
Dec. SBP 5-10%
Inc. HDL 1.7
Dec. TG 6.6
Dec. LDL 3.9
Dec. A1C 0.6-1%
Imagine if we had a single drug that could do all of these things?!?!
Metabolic Syndrome and Chronic Disease. PHAC
Calories In = Calories Out?
“Eat Less Move More”
1lb fat = 3500cal, so…If I dec. daily intake by 500 Cal/d, I would be <
100lb in 1yr?
Prolonged Dec. energy in/ Inc. energy out
Dec. BMR = plateau, poor energy…rapid regain
Minnesota Starvation Experiment
Exercise: only minor KCal burn, inc. intake after
Biggest Loser Analogy
Season 2 Contestant Suzanne: never a reunion show because “We’re
all fat again”.
Women’s Health Initiative
Almost 50,000 women, RCT
Dietary group: low-fat, low calorie
Intensive counseling
Reduced daily caloric intake by 342 Kcal, increased
exercise by 10%.
Expected result = weight loss 32lb over a single year
Thereby validate conventional nutritional advice
Final results (1997, 7yr) = virtually no weight loss
Despite good compliance
1st Dietary Guidelines promoted a decrease in fat intake
• As a result, carbohydrate intake went up
Hormonal Theory of Obesity
Why are we obese?
“Humans overeat not because it is a “personal choice” but because “it is a hormonally driven behaviour – a natural consequence of increased hunger hormones”.
Insulin = the Fat Storing Hormone
Insulin rises in response to glucose load (carbohydrate)
Insulin Inc. Ghrelin + Dec. PPY
Hyperinsulinemia Insulin Resistance
= A Potpourri of Problems
Metabolic Syndrome
What’s the ROOT
problem? ? Others
- endothelial
dysfunction
- increased
inflammation
- increased sympathetic
tone
- Increased coagulation
Image Credit, Dr. S. Hallberg
Insulin Resistance METABOLIC SYNDROME
Hyperinsulinemia Insulin Resistance Hyperinsulinemia
J. Fung, the Obesity Code
J. Fung, the Obesity Code
Carbs: A Vicious Cycle
Elevated Insulin
Insulin Resistance
The Stats
PEI = #2 self reported obesity in Canada
2016: 31.7% of Islanders have DM or Pre-DM
Expected to inc. 41% by 2026
This does not account for
A) Pts. not yet Dx
B) Pts. w/ IR but still normal blood glucs
Treatment Options
How to treat hyperinsulinemia
A. Bariatric surgery
B. Very low calorie diet
C. Very low fat diet (evidence w/ entirely plant
based diet, <10% fat)
D. Reduced carbohydrate diet
E. Intermittent fasting
Carbohydrate Restriction
Many Different Levels
Liberal: 100-150g/d
Moderate: 50 – 100g/d
Strict/Ketogenic: <50g/d
Inc. mobilization of fats from adipose tissue
Liver produces ketone bodies (Acetoacetate and 3-hydroxybutyrate)
Ketones replace most of the glucose required by the brain
Tissues that do require some use of carbohydrate (e.g. Red blood cells) supplied
via gluconeogenesis
Dec. Carbohydrate
intake
Dec. Circulating
Insulin
Dec. Insulin
Resistance
End Result = Improved Metabolic Health
Lifestyle intervention for DM
Theory of dietary treatment
1. DM = state of insulin resistance (with early
hyperinsulinemia)
2. Focus treatment on underlying cause (IR) rather than
symptom (hyperglycemia)
Underlying problem is TOO MUCH insulin, therefore avoid
exogenous insulin administration
Changing the Tx focus
Focus on Tx of disease (I.R.) rather than Sx (Hyperglycemia)
Focusing on Sx treatment continual progression of dz.
Pt.’s need more and more medication, they get sicker and sicker
Controlling BG’s likely isn’t enough
No conclusive evidence tight glycemic control improves
macrovascular complications (unless implemented early in disease)
Insulin moves glucose into cells, but doesn’t actually eliminate it
Obesity Tx – A Look Back
William Banting (1796-1878)- “Letter on Corpulence
Addressed to the Public”
• Advised we avoid all breads, milk, beer sweets and
potatoes
• Pamphlet = first ‘diet book’
William Osler - “The Principles ad Practice of Medicine “
• Obesity treatment diet predominantly featured meat and
eggs, was low in reined carbohydrates
• 1882 monograph “obesity and it’s treatment” states fatty
foods crucial in reducing obesity as they promote satiation
LCHF (Low Carb High Fat)
“Low carb, Moderate protein and Enough Fat to Satiate”
LCHF
1. Decreased carbohydrate load (net = total – fibre)
2. Decreased frequency of carb intake
“Decreased degree and duration of insulin exposure”
1. Dec. hunger
2. Dec. fat storage
Outcome = improved insulin resistance
Treating Obesity 2 Compartment
Model
Outcomes
Can help patients loose weight and in most cases REVERSE diabetes
A Look at the Evidence
Sceptics
1. You do not need carbs
There are no essential carbohydrates
2. This is not a high protein diet
3. Saturated fat is not the enemy
4. This IS maintainable
5. This is not expensive
Note: annual out of pocket expense for DM not
on insulin = $1725
Ketosis Ketoacidosis
Nutritional Ketosis
Ketone body production in response to low carbohydrate intake,
and higher fat consumption.
Insulin regulated
Ketoacidosis
Abnormal quantities of ketones produced
Unregulated biochemical situation
Body not producing enough insulin to regulate creation of ketone
bodies.
A Good Place to Start
Real Food
vs.
Fake Food
Real Food
UK Public Health Collaboration
Physicians
1 cardiologist
1 psychiatrist,
7 general practitioners
Clinical psychologist
Dietician
Epidemiologist
PHUK
1. Eating Fat Does Not Make You Fat
2. Saturated Fat Does Not Cause Heart Disease
3. Processed Foods Labelled “Low Fat”, “Lite”, “Low
Cholesterol”…should be avoided.
4. Limit Starchy and Refined Carbohydrates to Prevent and
Reverse Type 2 Diabetes
5. Optimum Sugar Consumption for Health is ZERO
PHUK
6. Industrial Vegetable Oils Should be Avoided
7. Stop Counting Calories
8. You Cannot Outrun a Bad Diet
9. Snacking Will Make You Fat
10. Evidence Based Nutrition Should be Incorporated in to
Education Curricula for All Healthcare Professionals
Case: Ms. X
Eating “Healthy”, walking 3.5km every day
Initially lost weight, but has plateaued, feels hungry all
the time
Abandoned her “diet” x last 2 weeks and weight is piling
on!
Case: Ms. X
Breakfast (0730h)
• 1 slice multigrain bread, 120 cal, 20g carb (net 17g)
• 1 tbsp light PB, 80 cal, 6 (net 5g)
• 1/2 banana, 60 cal, 16 g carb (net 8)
Snack (1000h)
• 1/2C 0% strawberry greek yogurt, 95cal, 15g carb (net 14g)
• 1/4C organic granola, 100cal, 20g carb (net 17g)
Lunch (1230)h
• 1 wholewheat wrap, 180cal, 28g carb (net 25g)
• 3 oz. canned tuna, 90 cal, 0 carb (!!)
• 1 tbsp light miracle whip, 30 cal, 3g carb (3g
net)
• Lettuce, tomatoes...
• 1C grapes, 70 cal, 16g carb (15g net)
Snack (1600h)
• 1 medium apple, 90 cal, 25g carb (20g net)
• 12 almonds, 84 cal, 4g carb (2.5g net)
Case: Ms. X
Supper (1900)
1/2C quinoa, 110 cal, 20g carb (25g net)
Grilled chicken (140g), 230 cal, 0g carb
1/2 Lg pepper, 20 cal, 4g carb (1.4g net)
Snack (2200)
100 cal snack pack, 18g carb (17g net)
Case: Ms. X
Total Calories: 1477
Total carbs (net): 200g, 176 g net carb
Longest fasting period: 9.5hr overnight, 3hr
during day
Results (Case Studies from PEI)
QUOTES
Diabetes Charter for Canada. Diabetes on Prince Edward Island. June 2016.
www.diabetes.ca/charter
Metabolic Syndrome and Chronic Disease. Vol 34. No 1. Feb 2014. Public
Health Agency of Canada
Metabolic Syndrome Canada. Metabolicsyndromecanada.ca
“The Obesity Code”. Dr. J. Fung.
Dietdoctor.com
Public Health Collaboration U.K. www.NationalObesityForum.org.uk
Relationship of Insulin Resistance and Related Metabolic Variables to Coronary
Artery Disease: A Mathematical Analysis. American Diabetes Association. 2009.