Tag: Weight loss

Kris Kresser: Should you skip breakfast to lose weight?

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Does Skipping Breakfast Help with Weight Loss?
on May 9, 2017 by Chris Kresser 

Is breakfast really the most important meal of the day? Researchers have been trying to answer that question for years, particularly as it relates to achieving a healthy weight. Read on to learn what the latest randomized clinical trials are telling us, and whether intermittent fasting is really an effective weight loss strategy.
While intermittent fasting has been lauded for its health benefits, including promoting cellular maintenance and protecting against aging and neurodegenerative diseases, popular wisdom maintains that skipping breakfast is bad for you. Often labeled as the most important meal of the day, breakfast is said to “boost metabolism” and reduce hunger. But is this really true? Mounting evidence suggests that eating three meals a day may not be important for weight loss.

In this article, we’ll explore the evidence for and against eating breakfast with all its nuances, including an ancestral approach, the problems with association studies, a review of the biochemistry of intermittent fasting, and relevant results from randomized controlled trials.
Did our ancestors eat breakfast?

The truth is, it’s hard to know for sure, but it’s thought that most hunter–gatherers ate intermittently depending upon food availability. (2, 3) Loren Cordain, founder of the Paleo diet, writes:
“The most consistent daily eating pattern that is beginning to emerge from the ethnographic literature in hunter–gatherers is that of a large single meal which was consumed in the late afternoon or evening. A midday meal or lunch was rarely or never consumed and a small breakfast (consisting of the remainders of the previous evening meal) was sometimes eaten. Some snacking may have occurred during daily gathering, however the bulk of the daily calories were taken in the late afternoon or evening.” (4)
It appears that the three-meals-a-day paradigm was not adopted until the Agricultural Revolution around 10,000 years ago. Frankly, the fact that we eat three times a day is somewhat arbitrary and seems to be based on when it was most convenient to eat during farm work and harvest. (5)

Most studies regarding breakfast consumption and obesity are association studies. And while there is undeniably an association between a lean body type and breakfast consumption, correlation does not imply causation, and many of these association studies have been inappropriately used to shape recommendations for weight loss.
Because “eat breakfast” is such popular health advice, people who are committed to their health are more likely to eat breakfast. They are also likely to avoid smoking, manage stress, and eat more fruits and vegetables, all things associated with a healthier weight. Breakfast eaters tend to be leaner, but this doesn’t mean that they are lean because they eat breakfast.

Luckily, in the last few years, several research groups have sought to use randomized controlled trials (RCTs) to answer the question “does eating breakfast cause weight loss?” Let’s take a closer look at the studies and what they found.
In one of the first RCTs in 1992, researchers separated 52 moderately obese adult women based on their normal breakfast habit (whether they ate or skipped breakfast regularly) and then randomly assigned half of each category to a breakfast group and half to a no-breakfast group. In their results, they reported a trend suggesting that women who had to make the most substantial changes to their initial eating habits achieved more weight loss. Essentially, habitual breakfast skippers tended to do a bit better when they had to eat breakfast, and habitual breakfast eaters tended to do better when they had to skip breakfast. (10) Unfortunately, when this result was cited by other studies and the media, it was widely misconstrued. First, the researchers only observed a trend for this interaction effect, meaning that it did not reach the level of statistical significance (p < 0.06, for those familiar with statistics). Second, the study was widely reported in the scientific literature as having shown that eating breakfast led to weight loss, even though the authors never concluded anything of the sort. Unfortunately, poor reporting of this study shaped scientific and popular opinion for several decades.
The belief that breakfast is important for weight loss prevailed, despite a few smaller studies that found that skipping breakfast had no effect or even a potential beneficial effect on weight loss.

In 2013, Cornell researchers performed a randomized crossover study in 24 undergraduate students and found that skipping a meal did not result in energy compensation at later meals and that it might even be an effective means to reduce energy intake in some people. (11)

In 2015, researchers in the UK performed a similar study with a week-long intervention in 37 participants and concluded that “there is little evidence from this study for a metabolic-based mechanism to explain lower BMIs in breakfast eaters.” (12) However, these studies were both relatively short-term compared to the 1992 study and didn’t receive as much attention.
In 2014, as part of the Bath Breakfast Project in the UK, 33 obese adults were randomly assigned to a breakfast group or no-breakfast group for six weeks. (13) The breakfast group ate slightly more calories but was also a bit more physically active. The no-breakfast group ate fewer calories over the entire day but was also slightly less active and had slightly more variable glucose levels in the afternoon and evening at the end of the trial. Body mass and fat mass did not differ between the two treatments, and neither did indexes of cardiovascular health. Contrary to the popular notion that breakfast “boosts metabolism,” resting metabolic rate did not differ between the groups. Breakfast also did not provide any significant suppression of energy intake later in the day. It seemed like the evidence was mounting against popular belief.
Finally, in the largest long-term, multisite clinical trial to date, researchers attempted to settle the debate once and for all. They randomized 309 obese adult participants to a breakfast group or no-breakfast group for 16 weeks. They reported in the American Journal of Clinical Nutrition:
“A recommendation to eat or skip breakfast for weight loss was effective at changing self-reported breakfast eating habits, but contrary to widely espoused views this had no discernable effect on weight loss in free-living adults who were attempting to lose weight.” (14)
Over 92 percent of subjects complied with the recommendation they were given, but it had no impact on weight loss. They also separated individuals based on their baseline breakfast habit and found no interaction between initial breakfast habit and success of the intervention. This is directly contrary to the near-significant interaction found by Schlundt and colleagues in 1992 and was a much larger study.

But wait, does a bowl of cereal and toast with jam have the same effect as an egg omelette, greens, and a sweet potato? Food quality matters more than food quantity, right? Yep. When “breakfast” is lumped into one big category, there’s not conclusive evidence for or against it, (15) as we saw in the previous section. But researchers have looked at different types of breakfast and weight loss as well, with some intriguing results.
In 2015, a study in China found that obese teenagers ate less at lunchtime if they had an egg breakfast compared to a bread breakfast. The egg breakfast was reported to increase levels of satiety hormones, keeping them full for longer. The egg breakfast group also had significantly more weight loss. (16) Sounds pretty good to me! Unfortunately, there wasn’t a “no-breakfast” group in this study, so it’s hard to know how the egg breakfast would have compared to intermittent fasting.
Researchers in Missouri performed a randomized trial in 2015 with three different groups. They randomly assigned 57 breakfast-skipping teens to a cereal-based breakfast (13g protein), an “egg-and-beef rich” breakfast (35g protein), or to continue skipping breakfast. They found that the egg-and-beef breakfast led to voluntary reductions in daily food intake and reduced reported daily hunger. It also prevented fat mass gains over the 12-week study. (17)
The truth is, most of the studies above (that found no effect of breakfast) were likely based on a typical high-carbohydrate breakfast, a la the Standard American Diet. It would be very interesting to see the metabolic response to breakfast omission in a group of healthy individuals eating a nutrient-dense, evolutionarily appropriate diet.

What about fasting in relation to exercise for weight loss? In the fed and fasted states, we preferentially oxidize (“burn”) different substrates to produce energy. Could exercising in one state or the other provide benefits for weight loss? In 2012, researchers in London performed a crossover study, monitoring food intake and energy expenditure in 49 participants during one week with breakfast and one week skipping breakfast. They found that total energy intake, energy expenditure, and activity levels did not differ between conditions. (18)
A study in Japan in 2014 used a randomized crossover design with eight male subjects, all of whom were habitual breakfast eaters. The subjects were instructed to eat or skip breakfast, and the researchers measured their energy expenditure during the day. Interestingly, they found that breakfast skipping did not affect energy expenditure, fat oxidation, or the thermic effect of food if you looked at the entire 24-hour period (similar to the previous study), but it did change the rhythm over the course of the day.

When people skipped breakfast, energy expenditure was lower during the morning but higher during the evening and sleep than those who ate breakfast. Breakfast skipping increased fat oxidation and reduced carbohydrate oxidation in the morning relative to breakfast eating and increased carbohydrate oxidation during the evening. (19)
Following up on this study, a crossover study in Korea in 2015 tracked 10 obese male college students. For one week, they ate before their morning workout. The second week, they ate breakfast after their morning workout. Their results? The fasted workout caused the men to burn more body fat, but it also increased levels of the stress hormone cortisol after exercise relative to the fed workout. (20)

While burning body fat is beneficial to weight loss, large rises in cortisol are not. It should be noted that these participants were not adapted to fasted exercise and that “fat-adapted” people might have a smaller cortisol response to fasting.
What do these studies tell us? Well first, the thermic effect of food in the morning, a common argument for why we should eat breakfast and “boost our metabolism,” is a myth. Over the total course of a day, total energy expenditure does not change. They also suggest that morning fasting might be a great time for a fat-burning workout, as long as it’s not too stressful on your body.

When you eat, the hormone insulin is released from your pancreas to the bloodstream and shuttles glucose (carbohydrate) into muscles and other tissues, where it is used for energy production. Excess glucose is converted to fat and stored in the adipose tissue. When you fast, the hormones glucagon and cortisol stimulate the release of these fatty acids from adipose tissue into the bloodstream. The fatty acids are taken up by the muscles and other tissues and broken down (oxidized) to produce cellular energy. In this concerted manner, the body switches from utilizing carbohydrates to fats as its primary fuel and ensures a constant source of energy to the body.
This is all good and rosy, as long as the body can actually make this metabolic switch. In the scientific literature, this is called “metabolic flexibility,” (21) though you may be familiar with it as “fat-adapted.” People who are “fat-adapted” are more accurately “metabolically flexible,” meaning that they can easily switch from oxidizing carbohydrates in the fed state to oxidizing fat in the fasted state, and vice versa.

On the other hand, people who are said to be “carb-adapted” are “metabolically inflexible,” meaning that they are constantly burning carbohydrates and have trouble switching to fat oxidation. These people still release fatty acids from adipose tissue to the bloodstream but have lost the capacity to oxidize fatty acids in the muscle and other tissues. The accumulation of lipids due to reduced fatty acid oxidation has been hypothesized to cause insulin resistance, (21) and a low ratio of fat to carbohydrate oxidation has been identified to be a good predictor of weight gain. (22)
The phenomenon of metabolic inflexibility may explain some of the results of breakfast studies. Most of the participants in these studies were individuals eating an evolutionarily inappropriate Standard American Diet with large amounts of refined carbohydrates three times a day. If, all of a sudden, you instruct these “carb-adapted” people to skip breakfast, you’re asking for a blood glucose crash and insatiable hunger by lunchtime. In reality, most people who want to try intermittent fasting transition do so gradually by slowly increasing the time between meals, allowing the body to adapt and restore metabolic flexibility.
This may explain why prior breakfast habits have an effect in some studies. Researchers at the University of Colorado studying 18 overweight women found that the adverse effects of skipping breakfast were restricted to habitual breakfast eaters. While habitual breakfast eaters who skipped breakfast had increased blood lipids, insulin, and free fatty acid responses at lunchtime, habitual breakfast skippers who skipped breakfast had none of these effects. The authors concluded that meal skipping may have enhanced effects in habitual breakfast eaters due to entrainment of metabolic regulatory systems. (23)
So, skipping breakfast might not cause weight loss in the short term, but if over the long term it allows your body to “reset” and restore metabolic flexibility and insulin sensitivity, you may ultimately see some weight loss benefit. This is especially true if you’re also improving the overall quality of your diet. A low-fat diet reduces your body’s ability to release fatty acids from adipose tissue and oxidize them in the muscle, (24) while a high-fat diet increases the ability to use fat for energy in muscle and thus improves metabolic flexibility. (25, 26)
Summing it up: should you fast, or break-fast?
If you’re overwhelmed by this quantity of research, you’re not alone. Researchers have been struggling to find consensus on this topic for decades. If you glazed over some of it, here are the major takeaways from this article:
Hunter–gatherers probably only ate one large meal later in the day.
You cannot trust association studies. Correlation does not equal causation!
When all breakfast is lumped together, skipping or eating breakfast has no apparent effect on weight loss.
If you separate out different types of breakfasts, a protein-rich, fiber-rich breakfast seems to confer the most benefits.
Eat before or after exercising depending on your health status and goals. Skipping breakfast will optimize fat metabolism during your morning workout, but it may also spike your cortisol levels.
Most of the individuals in these studies were “carb-adapted” individuals eating a Standard American Diet. It would be interesting to see how the results might differ in “fat-adapted,” metabolically flexible individuals eating a nutrient-dense Paleo diet.
And that’s it!

If anything is clear from this consortium of research, it is the need for individualized nutrition. I’ve written several articles and spoken on my podcast previously about why intermittent fasting (IF) may not work for everyone. If IF works for some people (they lose weight) and is detrimental to others (they gain weight), and these people are all lumped together, we’ll see a net zero change in weight.
So how do you know if intermittent fasting is right for you? Try an n=1 experiment: eat or skip breakfast for a period of time, and notice how it affects your weight, mood, productivity, gut function, and other factors. Transition slowly if necessary, by eating your first meal of the day later and later each morning. There are some predictors of success with fasting, but only you can really know if IF works well for you.

BMJ: Why don’t we encourage and register the diabetics who achieve remission?

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weight

Weighing up the benefits of registering those in remission from type two diabetes

Adapted from BMJ Louise McCombie et al 16 Sept 17

Type two diabetes now affects between 5 -10% of the UK population. This is 3.2 million people in the UK. 10% of the NHS budget is spent on treating diabetes and costs are between two and three times that of age matched individuals without diabetes. Life expectancy is six years less for people with type two diabetes.
Remission is attainable for some patients but is rarely achieved or recorded. (My comments: except in the low carbing community) The trend is for diabetes management to focus on reversible underlying disease mechanisms rather than treating symptoms and multisystem pathological consequences.
Lowering blood glucose remains the primary aim of management and drugs are the main method of doing this rather than diet and lifestyle advice. (My comment: because high carb/low fat dietary advice is counterproductive).
It has been found that weight loss of 15kg often produces biochemical remission of type two diabetes, restoring beta cell function. The accumulation of fat in the liver and pancreas impairs organ function to cause type two diabetes but is potentially reversible. If remission is achieved, the person no longer requires diabetes drugs.
The American Diabetes Association describe a partial remission as below the threshold for diabetes diagnosis. This is a hba1c of less than 6.5%/48 mmol/mol and a fasting blood sugar less than 6.9 without diabetes drugs. A full remission is described as the elimination of the criteria for impaired glucose tolerance. This means a hba1c less than 6%/42 and a fasting blood sugar under 5.6 again without the use of diabetes drugs.
A full remission will completely remove the cardiovascular risk associated with diabetes but partial remission removes a great deal of the risk and is still very much worthwhile.
We suggest that whether hba1c or fasting blood sugars are used to detect remission that these are repeated twice at two month intervals. Once in remission, a patient should be tested annually.
No study has yet been done that has reported the outcomes for diabetics in remission, but you would expect their outcomes to be much better than it otherwise would.
If a patient achieves remission, and if the Read code C10P is applied to them, they would still be scheduled for annual reviews and retinal screening programmes but would be considered non-diabetic for matters such as insurance, driving, and employment. But so far, in Scotland, only 0.1% of diabetics have been coded as being in remission.
Perhaps there are coding errors, but the possibility that type two diabetes can be reversed may not be fully understood by both doctors and patients. If patients achieve either a 10% body weight loss or 15kg, then 75-80% of them can expect to go into diabetes remission.
Physical and social environments, emotional states and self- regulatory skills are important factors affecting adherence to a weight management intervention.
It costs around £5,000 for the medical care of a person with type two diabetes but this almost doubles over the age of 65. The patient also has increasing holiday insurance costs. This is around double the usual rate for type twos and more for insulin users. Could knowledge of the advantages of weight loss act as an incentive for patients?

 

Susan Pierce Thompson: How to be happy, thin and free

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the-3-huge-mistakes-report

This March, Susan’s first book, Bright Line Eating: The Science of Living Happy, Thin & Free, arrived in bookstores.

Here’s what she had to say:

Susan, in Bright Line Eating, you argue that the reason so many people struggle with their weight is that the human brain blocks weight loss. How so?

The human brain was designed to keep us stable in a right-sized body. But modern processed foods and the modern pace of life have hijacked various systems in the brain, and the result is that now, in the present-day environment, the brain does indeed block weight loss.

Here’s how: willpower is a finite resource in the brain. And it doesn’t just help us resist temptations or persevere in the face of challenges – it helps us do all kinds of things, like make decisions (e.g., checking email, going shopping), regulate our emotions (e.g., having kids, being in traffic), and regulate our task performance (e.g., working in Excel, giving a presentation).

After a brief period of time doing any of these things, if we start to think it might be a good time to get something to eat, we’re likely to fall into the Willpower Gap.

This is why so many of us order out for pizza or take-out on a Friday night after a long week, irrespective of how sincere we were when we pledged that this time we would stick with our diet until we lost all our excess weight.

In our modern society, the Willpower Gap is waiting for us, nearly always. Most plans of eating implicitly ask you to rely on your willpower to stick with the plan over the long term. The truth about your brain is that that will never work. You need a plan of eating that assumes you have no willpower at all (because, at any given moment, you may not), and works anyway.

To avoid relying on willpower, you suggest people adopt 4 “bright lines” into their eating habits. What are they?

Bright lines are clear, unambiguous boundaries that you don’t cross, no matter what–similar to how a smoker who wants to quit and get healthy throws up a bright line for cigarettes. The four bright lines I recommend are:

  1. No added sugar or artificial sweeteners
  2. No flour of any kind
  3. Eating only at meals–no snacking or grazing
  4. Bounding quantities of food, both to make sure you get enough vegetables, and to make sure you don’t eat too much of everything else.

What’s one thing everyone reading this can do right now to improve their chances of maintaining a healthy weight?

To really bridge the Willpower Gap, start writing down what you’re going to eat for the day in a little journal, ideally right after dinner the night before. Do it religiously until it becomes a habit. The next day, your job is to eat only and exactly that, no matter what. Make sure there’s no sugar or flour in your food plan for the day, and, ideally, stick with three meals a day, because three meals are much more automatizable than five or six.

Within a few weeks these habits will be automatic, and eating the right things, and not the wrong things, will start to be as easy as brushing your teeth.

 

(From original interview by Ron Friedman)

Planning a pregnancy: the importance of getting slim before you get started

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newborn baby

In Europe the World Health Organisation estimate that more than 50% of men and women are overweight or obese and 23% of women are obese.

In a pregnant woman obesity raises her chances of gestational diabetes and pre-eclampsia. She is also more likely to get metabolic syndrome and type two diabetes later in life. The resulting children are more likely to come to harm in utero and at birth and also more likely to become fat children. They are then more likely to develop higher blood pressure and excess weight in early adulthood.

Despite the push to improve the outcome for the babies in utero, lifestyle changes and medical interventions have largely proved unsuccessful.

Women with a BMI over 25 find it more difficult to conceive in the first place and then are more likely to miscarry compared to their slimmer sisters. The miscarriage rate is 1.67. Congenital abnormalities become more common.

The placenta responds to maternal insulin levels. In normal weight women they become 40-50% less sensitive to insulin but this bounces back within days of delivery. Obese women show greater decreases in insulin sensitivity, this affects lipid and amino acid metabolism. African Americans and Southern Asians get these changes at lower body masses than Europeans.

Obese women are more likely to go into labour early. They also may need to be delivered early. They have a higher rate of failed trial of labour, caesarean sections and endometritis and have five times the risk of neonatal injury.

Anaesthetic complications are more common. The Royal College of Obstetrics and Gynaecology recommend that women with a BMI over 40 see an obstetric anaesthetist before going into labour. Epidural failure is more common. The woman may have lower blood pressure and respiratory problems and the baby may have more heart rate decelerations in labour.

Broad spectrum antibiotics are recommended for all caesarean sections. Despite this, overweight women get more post- operative infections. The wounds are also more likely to come apart.

Obese pregnant women are obviously at even more risk.

Babies of obese mothers are usually fatter at birth compared to other babies. Obese mums tend to put on more weight than average during the pregnancy and then find it even harder to lose weight after delivery.

Recent randomised controlled trial  have shown that interventions started after pregnancy have little or no effect. These include increasing the mum’s physical activity and cutting the dietary glycaemic load. These things reduced the weight gained in pregnancy a little but did not affect adverse pregnancy outcomes and the birth of fat babies. Thus there is now a bigger push to intervene before pregnancy.  

Currently between ten and twenty percent of obese women lose weight between pregnancies. This has been found to reduce weight gain in the next pregnancy and also the risk of pre-eclampsia.  Supervised intensive lifestyle interventions can be done, work and are safe, even in breast feeding mothers. Pre-pregnancy classes to get women fit for pregnancy would help improve the outcome for the babies of the future.  The metabolic environment, a mixture of inflammation, insulin resistance, lipotoxicity, and hyperinsulinemia,  can then be optimised prior to conception. After this, it is really too late.

 

Adapted from Obesity and Pregnancy. Patrick M Catalano and Kartik Shankar from Cleveland Ohio and Little Rock Arkansas Universities.  BMJ 18 February 2017 BMJ 2017;356;j1

Weight plateaus are a normal, but frustrating, feature of your weight loss journey

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frustration

 Here are some words of wisdom and encouragement from a health care professional who knows how discouraging weight loss plateaus can be. Don’t let weight stabilisation lead you to jack in your efforts.
When Losing Weight, Warn ‘em!

Diabetes in Control November 8th 2016

I work in obesity medicine. As many of us know, losing weight isn’t the problem for most, but weight regain is.

As the saying goes for many, you can’t be rich enough or thin enough. Many of our patients come in with unrealistic goals regarding their weight loss, and don’t give themselves enough credit for the weight they have lost. Many, for many reasons, regain.
Woman, 58 years of age, class II obesity, prediabetes (A1C 6.0%), HO depression, on antidepressants, weight of 188, BMI 38. Started on metformin and lower carb meal plan.
Warned her early on it’s not just about losing weight, but what’s important is keeping it off. We need plans for both.
Her treatment plan does not end when she loses weight.  Over 6 months she lost 22 pounds. This is a 12% weight loss. BMI 33.5 now.  No further weight loss since the 6-month period, but no weight gain.
Patient frustrated. She has upped her exercise. No longer wants to continue metformin. Encouraged her to continue her meal plan, metformin and bump up her exercise plan. Praised her for her weight loss and not regaining.  And, reminded her this is what we discussed from the start. She remembered and said she’ll stay with the plan.
Lessons Learned:
  • Keeping weight off is a different stage of the weight loss journey.
  • Reminder that losing 3-5% total body weight can improve health outcomes.
  • 5-7% weight loss was shown in the DPP to prevent or delay type 2 diabetes.
  • From the beginning, let patients know there are stages to losing weight. First is to lose, then it’s to keep off the weight lost. Make a plan for both.
  • Regarding weight loss, put more emphasis on the food side.
  • Regarding weight maintenance, put more emphasis on exercise.
  • Remind patient of discussion and encourage patient to embrace the weight loss they have been able to achieve and keep off.

Anonymous

Margaret Coles: Invite this Physiotherapist into your home

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At  www.movingtherapy.co.uk. you can find Margaret Cole’s free educational resource to help your health and well being.

home-physio

Margaret worked as a community physiotherapist and when she retired she decided to put her knowledge and experience to good use. She produced videos covering a lot of different situations that you can face regarding your physical and mental states and has put them on the site. She also gives advice on how to lose weight.   People from all over the world have visited the site since 2011.

NHSinform Scotland and her local authority also promote the site.

 

 

PUBLIC HEALTH COLLABORATION: WHAT TO LOOK OUT FOR WHEN STARTING A LOW CARBOHYDRATE DIET

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PHC-Space-Top

 

FOR EVERYONE

As you start a low carbohydrate diet your kidneys get better at excreting salt thus you will usually find that you lose a lot of water from the tissues of the body.  This can make you instantly slimmer, particularly around the legs, but also can give some cramps in the muscles when you exert yourself.  Be aware of this and add extra salt to your food, and drink plenty of water.  When you are on a low carbohydrate natural foods diet you will be consuming considerably less sodium chloride, which is present in many processed foods including sweet ones.  Bread for instance has a lot of added salt that most people are completely unaware of, therefore feel free to be liberal with the salt cellar.

 

BLOOD PRESSURE

Blood pressure comes down, partly due to less water retention, but also due to lowered natural insulin levels in the body.  As the weight comes down as well, blood pressure tends to drop.  For most people who are not on any antihypertensive drugs they may feel slightly lightheaded from time-to-time.  This can be abolished by adding more salt to the diet.

For people who are on medication to reduce their blood pressure they should have their blood pressure measured by their general practitioner and cut back on medication on embarking on a low carbohydrate diet if their blood pressure is under 140/90.  After a few weeks on a low carbohydrate diet they will be adjusted to a lower level of blood pressure.  Thereafter blood pressure only requires to be checked on several occasions with each extra half stone of fat loss.

It is helpful to buy your own blood pressure monitor as measurements done when you are relaxed at home tend to be more accurate than those undertaken in a surgery.

As many blood pressure medications have more than one use, and different effects on the body, it is worth discussing with your general practitioner which ones would be better to cut out altogether or which ones could be reduced in dose.  This is because certain drugs such as ACE inhibitors and sartans have an extra protective effect on the kidney and this can be important for diabetic patients. They also help improve heart function in cardiac failure.

Beta-blockers are sometimes given to people with atrial fibrillation, or who have had a heart attack, or who suffer from angina, and continuing these may be a priority for some individuals.

BLOOD SUGAR REDUCTIONS

Blood sugar reductions happen rapidly with a low carbohydrate diet.  This is mainly due to the lack of sugar and starch being turned into blood glucose.  This has several effects.

The most pronounced and rapid effect could be on the eyesight.  The lens of the eye adjusts to a particular blood sugar and if the level goes suddenly up, or suddenly down, your vision can become blurry, particularly for reading print.  It is worthwhile avoiding getting new spectacles for about 6 months to give time for the lens of your eye to adjust otherwise you can end up having to get another pair of spectacles at a very short interval and this can be rather expensive.

 

INSULIN and ORAL HYPOGLYCAEMIC DRUG USERS NEED TO TAKE EXTRA PRECAUTIONS

Type 1 diabetics will have been using insulin from the time of diagnosis.  Increasing numbers of Type 2 patients are going on insulin as their pancreas needs more support as time goes on.  A rapid change in pattern of sugar and starch intake can give dangerously low levels of blood sugar unless the insulin dose is proportionately reduced from the outset of the diet.  The amount of reduction will depend on how high your blood sugars run normally, and how strict your low carbohydrate diet is.

For many people who are taking insulin, or sulphonylurea drugs which also have a marked blood sugar reduction effect, starting on a moderately low carb diet of 100g or so a day may cushion the effect somewhat.

Most diabetics will need to cut their insulin quite dramatically, particularly if they go on less than 50g of carbohydrate a day.  It is normal to have to cut insulin by a half or even two thirds in some individuals.

A close eye on blood sugar monitoring needs to be done and we would recommend that, for particularly people who are operating machinery or driving, they start a low carbohydrate diet over a period of holiday when there are other people around who can assist them should they have low blood sugars, and also people to undertake driving on their behalf.

 

Your own general practitioner or hospital endocrinologist is the best person with whom to discuss your planned reduction in insulin or sulphonylurea medications.

Many patients on sulphonylureas are able to stop these drugs completely prior to starting a low carbohydrate diet and thus remove the risk of low blood sugars completely.  People who use insulin however are not able to do this and must have a degree of background insulin to prevent them developing dangerously high blood sugars and ketoacidosis.

  The normal blood sugar ranges between 4 and 7 at most times.  Drivers must not drive unless their blood sugar is at least 5, and they should re-check their blood sugar after every 1-2 hours of driving.  To treat a hypo use 15-20g of glucose and do not drive till blood sugars are completely normal and you have fully recovered.

Setting an alarm to check blood sugars in the middle of the night, and taking blood sugars at 2½ hourly intervals through the day is advised in the first few days for insulin users.

The normal correction dose is one unit of rapid acting insulin for every 2.5 units of blood sugar elevation. This can be helpful to know if you have cut down your insulin doses a bit too much.

Aiming for blood sugars between 6 and 8 mmol can be a safe strategy in the first 2 weeks after starting a low carbohydrate diet.  Thereafter the blood sugars can be tightened up when insulin requirements are more predictable.  To prevent blood sugars going up and down unpredictably it is best to stick to 3 main meals a day and avoid snacking.

EDUCATIONAL COURSES

For insulin users and people on sulphonylureas it is best to fully understand the implications of a low carbohydrate diet and know how to control your blood sugars and insulin as well as having a good grasp of carb counting prior to undertaking a low carbohydrate diet.  There are many educational resources on the web to do this.  Some of these resources are Dr Bernstein’s Diabetes University on you tube, diabetes.co.uk website and Low Carbohydrate Course which is web based, and diabetesdietblog.com which has two written courses.

LONG TERM

Although it can be daunting to think about the initial difficulties that can occur with a low carbohydrate diet, the long term benefits of improved blood sugars, weight, blood pressure and lipids make the outlook for pre-diabetics, the overweight and people suffering from diabetes much brighter indeed.  It is worth educating yourself about your condition and how to effectively use a low carbohydrate diet to change your health destiny.  The extra planning that you need to do for meals, more frequent shopping for fresh ingredients and often increased expense are worth the long term health benefits.

ALCOHOL

Alcohol can be a pleasant part of life.  Many alcoholic drinks are high in sugar, such as beer and sweet wines, and also cocktails.  These need to be eliminated for success in a low carbohydrate diet.  Spirits such as whisky, gin and vodka have less impact on the blood sugar, and dry red and white wines are also suitable.

For insulin users, and particularly Type 1 insulin users however, alcohol can tip them into unexpected hypoglycaemia if they are consuming more than 1-2 units of alcohol without a corresponding increase in dietary carbohydrate.  This is because alcohol limits the ability of the liver to manufacture glucose, and also blood sugars tend to run much more towards the normal range, around 4.6, when diabetes undergoes an apparent reversal on a low carbohydrate diet.

EXERCISE

Exercise is a very beneficial and pleasant adjunct to a low carbohydrate diet for increased mood and health.  For insulin users and those on medication such as sulphonylureas, adding exercise into the regime early on in the stages of a low carbohydrate diet add an increasing layer of complexity to blood sugar management.  We therefore recommend that unaccustomed exercise is avoided for the first 2 weeks until blood sugar stability is achieved.

 

Dr Katharine Morrison

 

 

Public Health Collaboration: Free booklets

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LA2-vx06-konsthallen-skulpturThis is the link to the Public Health Collaboration site where you can download for free or order print versions, at a modest cost, of illustrated health booklets that will help you:

 

know what to eat for a wide variety of good health outcomes

plan your meals

count your carbohydrates

lose fat

https://www.PHCuk.org/booklets/

 

Hopefully you will end up somewhere between the extremes of our sisters up there!

Bariatric surgery better than diets for sustained weight loss

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Bariatric surgery has been shown to be the most effective treatment for substantial and sustained weight loss with a significant reduction in obesity related conditions and long term mortality according to the National Confidential Enquiry into Patient Outcome and Death 2014. Bariatric surgery operations are likely to become more popular as a result.

Bariatric surgery is particularly helpful for diabetics because it can greatly improve blood sugar control and even induce complete remission of type two diabetes. NICE recommends that those with a body mass index over 30 who have had diabetes for under ten years are considered for the operation. Asians may be considered at even lower BMIs.  Simple observation will demonstrate that there are many more people eligible for these operations than can currently be dealt with on the NHS. Indeed currently just under a third of patients pay for the operations themselves.

There are various types of surgery. Some reduce the area of the stomach like the laparoscopic adjustable band,  and some reduce absorption of nutrients like the sleeve gastrectomy. Some are a mixture of the two like the Roux-en-Y gastric band which is the commonest procedure that also produces the greatest weight loss.

Excess weight loss can be as high as 58% with patients’ weight levelling off after two years. Weight gain can recur and this can be due to not following the diet or a surgical failure than needs adjustment.

Once referred to a bariatric clinic the advantages and disadvantages of the various types of surgery is discussed. Psychological support and dietetic support is given. I recall that a bariatric surgeon told me that people referred to his clinic had very marked self- esteem issues and often defaulted from the clinic.

The short term problems after surgery include wound infections, vomiting, intolerance to pureed meals, problems swallowing and leaks at the staple lines for some operations.

Long term patients will need to continue to restrict calories and take multivitamins.  Acid suppression therapy is often required and patients should avoid non- steroidal anti-inflammatories. Gall stones may occur and may require surgical removal.  Hair loss may occur but is temporary.

After a Roux-en-Y operation calories are restricted to less than a thousand a day.  Patients have to take a protein rich diet so they do not become deficient. Iron supplement are particularly needed by women. Most people require vitamin B12 injections every 3 to 6 months. B vitamins, calcium and vitamin D, and the fat soluble vitamins A, D, E and K may be needed.  Annual checks of full blood count, electrolytes, liver function, glucose, iron, ferritin, vitamin D, B 12, calcium, parathyroid hormone, thiamine, folate and selenium are required.

The good news for diabetic  is that blood sugars often improve a great deal and for many  return to normal. Thus insulin and drug requirements will lessen or even stop.  Blood pressure, lipid problems and obstructive sleep- apnea also improve or resolve.

Women may find that they are able to conceive after bariatric surgery but this is discouraged for about 18 months after surgery because of the rapid weight loss and nutritional deficiencies that are common at this time. There is more risk of pre-term and small for age births in women post- surgery.

It can be seen that should the number of surgeries be increased to anything like what is required to deal with the obesity/diabetes epidemic, that resources for long term follow up of these patients will also need to be improved. Support for General Practitioners  will be needed, particularly as there is not sufficient structured follow up, particularly for those who have had operations out with the NHS and even abroad.

Based on article by Vamshi P Jagadesham and Marion Sloan from Sheffield in British Journal of General Practice August 2014.

You only need one arrow: Dr Unwin proves it again

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Dr David Unwin has completed another study in his practice patients showing that a low carb diet greatly reduces fatty liver, weight and blood sugar. The knock on effects on the prescribing budget, secondary care referrals and complications can only be a good thing for the struggling NHS. His practice alone, compared to those in his area, is making savings when it comes to diabetes care.  Currently 66-70% of the adult UK population is overweight or obese, 20-30% have non alcoholic fatty liver disease and 10% have diabetes. The low carbing community remains mystified as to how such a rational, safe and effective treatment option is still side-lined by most diabetology clinics, NICE, and Diabetes UK.

Dr Unwin estimates that between £15,000-£30,000 a year has been knocked off his prescribing budget for a single practice in which the low carb diet was routinely offered to patients. While the drug spend continues to rise in adjacent practices, his budget has not risen in the last three years. His patients are now officially thinner than in neighbouring practices and below the national average. In two years the average blood sugar has come down 10% and is now below the national average of 61.5 mmol/mol.

Here is the abstract which we are proud to present ahead of publication in Diabesity in Practice in September 15.

  • Unwin DJ1, Cuthertson DJ2, Feinman R3, Sprung VS2 (2015) A pilot study to explore the role of a low-carbohydrate intervention to improve GGT levels and HbA1c. Diabesity in Practice 4 [in press]

     1Norwood Surgery, Norwood Ave, Southport. 2Department of Obesity and Endocrinology, Institute of Ageing & Chronic Disease, University of Liverpool, UK. 3Professor of biochemistry and medical researcher at State University of New York Health Science Center at Brooklyn, USA.

    Working title: Raised GGT levels, Diabetes and NAFLD: Is dietary carbohydrate a link?  Primary care pilot of a low carbohydrate diet

    Abnormal liver function tests are often attributed to excessive alcohol consumption and/or medication without further investigation. However they may be secondary to non-alcoholic fatty liver disease (NAFLD). Considering the increased cardiovascular and metabolic risk of NAFLD, identification and effective risk factor management of these patients is critical. NAFLD is now prevalent in 20-30% of adults in the Western World

    Background Excess dietary glucose leads progressively to hepatocyte triglyceride accumulation (non-alcoholic fatty liver disease-NAFLD), insulin resistance and T2DM. Considering the increased cardiovascular risks of NAFLD and T2DM, effective risk-factor management of these patients is critical. Weight loss can improve abnormal liver biochemistry, the histological progression of NAFLD, and diabetic control. However, the most effective diet remains controversial.

    Aim We implemented a low-carbohydrate (CHO) diet in a primary health setting, assessing the effect on serum GGT, HbA1c levels (as proxies for suspected NAFLD and diabetic control), and weight.

    Design  69 patients with a mean  GGT of 77 iu/L (NR 0-50) and an average BMI of 34.4Kg/m2 were recruited opportunistically and advised on reducing total glucose intake (including starch), while increasing intake of  natural fats, vegetables and protein.

    Method Baseline blood samples were assessed for GGT levels, lipid profile, and HbA1c. Anthropometrics were assessed and repeated at monthly intervals. The patients were provided monthly support by their general practitioner or practice nurse, either individually or as a group.

    Results After an average of 13 months on a low-CHO diet there was a 46% mean reduction in GGT of 29.9 iu/L (95% CI= -43.7, -16.2; P<0.001), accompanied by average reductions in weight [-8.8Kg (95% CI= -10.0, -7.5; P<0.001)],and HbA1c [10.0mmol/mol (95% CI= -13.9, -6.2; P<0.001)].

    Conclusions We provide evidence that low-carbohydrate, dietary management of patients with T2DM and/or suspected NAFLD in primary care is feasible and improves abnormal liver biochemistry and other cardio-metabolic risk factors. This raises the question as to whether dietary carbohydrate plays a role in the etiology of diabetes and NAFLD, as well as obesity