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.