There are currently around 3.9 million people in the UK living with Diabetes and 90% of these have ‘Type 2’ Diabetes. Although the number of people suffering from Diabetes is predicted to grow to 5 million by 2025, there is also a growing awareness that the treatment and reversal of many chronic conditions, such as Diabetes, may not lie in the field of prescriptive medicine, but in the hands of our own lifestyle and dietary choices.
Indeed, the impact that a non-pharmaceutical approach, concentrating on lifestyle and diet, has on reducing the prevalence of many chronic conditions such as Diabetes and Alzheimer’s disease continues to grow in stature.
Our blog this week is provided by Dr David Morris – a freelance General Practitioner in the NHS – who looks at three dietary examples of how insulin resistance and Diabetes are clear examples of conditions that can be prevented and potentially reversed through a functional approach to treatment concentrating on diet and lifestyle.
Following on from my blog post detailing the absolute primary importance of addressing insulin resistance in the management of diabetes and pre-diabetes there are simple non-pharmaceutically based approaches that can radically address this.
These have been conclusively shown to have the potential to reverse diabetes and all of its metabolically damaging effects.
Unsurprisingly these are not ‘rocket science’ – they are the right dietary approaches, the right form of exercise, stress reduction and to support this appropriate supplements.
In this post I will talk about the importance of diet and in future posts I will discuss exercise, stress reduction and supplements.
Dietary Approaches to Reversing Insulin Resistance
It is astonishing to me how ‘wrong –headed’ a lot of current dietary advice is – there is no doubt that commercial interests and pseudo-scientific dogma have corrupted much of the official guidelines around diet.
However it is important to avoid becoming too dogmatic and there is no ‘one size fits all’ approach to diet – recent research has shown us that there can be very considerable variations in post-eating blood sugar response to identical meals in different people.
This appears to be determined by genetics, gut microbiome and other factors1. I also believe that a good guiding principle is to eat the best diet that you can enjoy not the best that you can endure! (In this context I wholeheartedly recommend Charles Eistenstein’s “The Yoga of Eating” as an excellent approach to food and diet in general.)
These caveats aside, there is good evidence that the following dietary approaches are likely to be beneficial in the majority of people with diabetes or pre-diabetes and they are definitely a good starting point, these are:
1. Lowering your carbohydrate intake.
3. Avoid artificial sweeteners.
Lowering Carbohydrate Intake
Before discussing low carbohydrate dieting it is worth reminding ourselves that:
- There are “essential amino acids” – without them in your diet you will eventually die as your body cannot make them.
- Similarly there are “essential fatty acids” – the building blocks of fats.
- Your body requires glucose to function BUT YOU DO NOT NEED CARBOHYDRATE TO MAKE GLUCOSE – your body can easily manufacture glucose from fat or protein that you ingest.
This means there are NO essential carbohydrates required for life. There is a commonly held belief that you need carbohydrates as your brain needs glucose to function but this is wrong on two counts.
Firstly, just because your brain will preferentially burn glucose for fuel when it is available does not mean that it cannot metabolise other substrates when there is limited glucose – ketones in fact are a better source of energy for the brain especially with regards to dementia risk. It is worth pointing out that when we have alcohol on board the body preferentially metabolises alcohol for energy but we don’t claim that alcohol is essential for energy production!
Secondly, the body is quite capable of producing enough glucose de novo (i.e. gluconeogenesis) to supply the needs of the brain, especially if you are metabolically well adapted to burning fat not sugar.
So what is the rationale for lowering carbohydrate intake to reduce insulin resistance? It’s really quite simple.
Logic tells us that the macronutrient balance of a meal will determine the amount of insulin released:
- Carbohydrate stimulates insulin release.
- Fat has no significant impact on insulin release.
- Protein stimulates insulin (although less than carbohydrate) but also stimulates glucagon release which counteracts this.
Measuring insulin and sugar levels after eating confirms this impact with higher carbohydrate meals consistently producing higher peaks in glucose and then insulin response – usually followed by a sharp fall with a hypoglycaemic response. Hence the common experience of sudden hunger around 10:30 to 11:00 am having eaten a cereal based breakfast first thing.
Many studies have demonstrated that low carbohydrate diets have better outcomes in comparison to low fat diets, consistently reducing glucose levels more, reducing insulin levels by up to 50% more and creating greater weight loss, in particular fat loss2.
The other advantage of low carbohydrate diets is that they are less likely to make you feel hungry and therefore compliance is easier – hunger as we all know is the fatal breaker of the firmest resolutions!3
Defining Low Carbohydrate Diet
There are scenarios where trying to achieve a very low carbohydrate intake and primarily metabolising fat and ketones is very important – for example some forms of epilepsy, some cases of dementia and also in cancer treatment. There is compelling evidence that it is a healthy diet for many people BUT you do not necessarily need to go to this length to see beneficial impacts from lowering carbohydrate.
Our current carbohydrate intake, which is pushing up to around 65% of energy intake is so high compared to our ancestral diet that even reducing to the level of around 45%, that was the approximate intake four decades ago, is likely to be of some benefit. It is in the last 40 years that we have seen the exponential rise in diabetes and obesity.
The commonly accepted definitions are –
Very low-carbohydrate ketogenic diet (VLCKD):
- Carbohydrate, 20–50 g/day or <10% of the 2000 kcal/day diet.
- Derived from levels of carbohydrate required to induce ketosis in most people.
- The Atkins diet is an example of this.
- Carbohydrate Moderate-Carbohydrate Diet
- Carbohydrate 26%–45%
Simple steps to achieving Low Carbohydrate Intake –
- Cut down the ‘white stuff’ – remember starchy carbohydrates are just concentrated sugar so minimise bread, pasta and rice. New potatoes and oats are okay in moderation.
- Cut out the sugar – that means cakes and biscuits are out (sorry!) They will trigger cravings too.
- All green veg/salads are fine – eat as much as you can. So that you still eat a good big meal try substituting veg such as broccoli, courgettes or green beans for your mash, pasta or rice. One good rule of thumb for vegetables is that those vegetables that you eat the part above the ground will have significantly lower carbohydrate (and higher healthful nutrients) than those that you eat the part below the ground.
- Be careful with fruit – all berries are great and can be eaten freely, apples and pears too, but not tropical fruits like bananas, oranges, grapes, mangoes. Remember that bears eat lots of fruit in the autumn because the high fructose content makes them fat for hibernation. In particular you should avoid fruit juices and dried fruit.
There are additional advantages to adopting this approach to your diet – reducing wheat based products in practice is often of benefit in many people, regardless of whether they reduce total carbohydrate intake. This is because of the high proportion of people that have various intolerances to wheat. It also essentially removes a large amount of the processed food options which is clearly helpful!
What should you replace the carbohydrate with?
Unless you wish to ultimately starve and fade away to nothing then reducing the carbohydrate proportion of your diet requires you to either increase the proportion of your diet coming from fat or from protein.
Regardless of whether we eat a predominantly plant based or animal based diet, the proportion of energy coming from protein tends to hover around the 20-25% mark. Higher levels of protein intake start to lead to the production of higher levels of glucose which we are of course trying to avoid.
Additionally, high levels of protein intake in the absence of fat ultimately leads to craving for fat and essentially starvation. Hunter gatherers that could only access lean meat such as deer or rabbits (which are very low fat) would make great efforts to access fatty foods, brought in often from coastal areas, e.g. in the form candle fish. There was even the term “rabbit starvation” coined for this situation.
This leads us to the simple equation that cutting down carbohydrates will lead to a proportionally higher intake of fat i.e. a Low Carb High Fat Diet (LCHF) – and no we do not need to be concerned that the much demonised fat is unhealthy providing we avoid trans-fats and processed plant oils.
A final carbohydrate tip
The timing of your carbohydrate intake in your meal also has an impact – eating fat and protein first and carbohydrates last leads to a lower rise in glucose and insulin levels4.
It takes most people 8-10 hours for their body to burn the sugar stored as glycogen.
It is not until you have used up your glycogen that your body starts to burn fat and insulin levels fall allowing the spiral of insulin resistance to be switched off – it appears that the vast majority of people hormonally switch from “fed” state to “fasted” state by 12 hours.
This fits with the theory of thrifty genes which states that fluctuations in food intake are required for optimal metabolic function. Many studies have shown that even after only a two-week intermittent fasting regime that insulin resistance falls and alongside this fat breakdown increases.
Please note that you will not see the same benefits from fasting if you continue to eat badly when you do eat – your body needs to be programmed to burn fat through eating lower carbohydrates to really maximise the benefit!
How to fast
There are a number of variations including –
- Alternate day fasting – this can in fact include an evening meal each day but on the fasting day this means you have gone nearly 24 hours since your last meal
- 5:2 diet – restricted calories (usually 600) on 2 days per week
- Shortened food window – this involves eating your meals over a shortened time period each day
In simple terms, by far the simplest way to fast is to delay or skip breakfast – if you can delay eating for at least 12 hours since the last meal the day before then your body is already primed to start metabolising fat.
Of course to contribute to this you should not eat your last meal of the day late into the evening – i.e. aim to eat your last meal at least 3 hours before sleeping – AND breaking your fast with the ubiquitous bowl of cereal will send you right back into metabolising carbohydrate and a raised insulin state!
Aiming for the 16:8 method (16 hours of not eating, 8 hours of eating during a day) is a great option as it is effective, becomes easy to do and does not require counting calories.
What about “breakfast being the most important meal of the day?”
This is a very commonly perpetuated myth and it is often claimed that people who skip breakfast often end up eating more in the rest of the day.
A scientific review in 2013 in the American Journal of clinical nutrition found that very few good studies had even looked at the role of breakfast and that overall there was no good evidence that skipping breakfast increased weight gain. In fact the common belief that skipping breakfast leads to eating more calories in the whole day proved to be absolutely wrong and the opposite was true.5
The other benefits of fasting –
Promotion of Human Growth Hormone (HGH) Secretion – I have so far kept things simple only mentioning insulin and briefly glucagen but there are a number of other hormones that promote reduction in blood sugar and one of these is HGH. HGH not only lowers blood sugar but promotes muscle growth and ‘revs’ up your metabolism – because of this it plays a vital role in general fitness and longevity.
Normalisation of Appetite -There is another hormone called Ghrelin which basically drives your appetite – fasting lowers ghrelin allowing your appetite to stabilise. We often presume that long term fasting is impossible because hunger will override but in fact people have been known to successfully fast from food for well over 300 days.
Promotion of Brain-Derived Neurotrophic factor (BDNF) – BDNF activates brain stem cells to convert into new neurons and triggers numerous other chemicals that promote neural health. This protects your brain cells from changes associated with Alzheimer’s and Parkinson’s disease.
Fasting has a profound impact on BDNF – for example alternate-day fasting (restricting your meal on fasting days to about 600 calories) can boost BDNF by anywhere from 50 to 400 percent, depending on the brain region.
One further point, fasting and low carbohydrate intake clearly work best together. If your body is constantly set up to burn carbohydrate then it will want “topping up with fuel” every few hours. If it is set to burn fat then it will naturally be able to go much longer. Think of a fuel tanker to understand this; if the fuel tanker does not top up its own engine’s tank then, despite carrying thousands of litres of fuel, it will grind to a halt. Overweight or otherwise, we all carry far, far more energy in storage as fat than we do as carbohydrate so moving into a fat burning state allows us access to a far greater energy reserve.
Avoid Artificial Sweeteners
It all seems so “logical”, we are all evolutionarily wired to like sweetness – sweet taste indicates sugar which means easy calories and so our hunter gatherer ancestors would enjoy honey as quick source of energy compared to hunting for food – and the modern diet is way, way too high in sugar.
So to combat this, step in artificial sweeteners with the sweet taste we crave but NO sugar and no calories.
Job done – lower calories, less obesity, less diabetes etcetera etcetera.
So many of my patients proudly declare that they only use sweeteners, indeed my local supermarket has removed most of the sugared versions of squash self-righteously claiming that they only stock the artificial sweetened versions as they are healthier…..if only!
The food industry would dearly love you to believe the above is true – in particular if you have diabetes artificial sweeteners should be a panacea but there are two overwhelming reasons why this is not the case:
- They are potentially TOXIC to your health
- They actually INCREASE your risk of developing diabetes.
Artificial Sweeteners and Toxicity
This could easily be the subject of a full blog post, and indeed has be the subject of whole books and numerous pages of the internet. Needless to say both the regulatory bodies and the industry body relentlessly state they there is no evidence of harm from artificial sweeteners, but I would like to direct you to two points regarding this.
Firstly Safety studies are contradictory – so check who the safety studies! This has been nicely proven with a review of 164 scientific studies by Dr Walton, a Professor of Psychiatry. He concluded that –
“Of the 90 non-industry-sponsored (independent) studies – 83 (92%) identified one or more problems with aspartame. Of the 74 aspartame industry-sponsored studies – all 74 (100%) claimed that no problems were found with aspartame.”6
Secondly, consider biological plausibility.
If you take a substance in to your body:
- That will release very high levels of a potential neuroexcitoxin (e.g. phenylalanine in high doses from Aspartame)
- OR is metabolised to form formaldehyde from methanol (e.g. Aspartame – in which, unlike overripe fruit, the methanol is not tightly bound to pectin so it is readily absorbed),
- OR indeed if this substance is closely related to insecticides and bio-accumulates in your fat tissue for your lifetime (e.g. Sucralose)
Do you really need “safety” studies to question the wisdom of taking such substances into your body??
Artificial Sweeteners and Diabetes Risk
Regardless of toxicity issues the fundamental question to ask is whether artificial sweeteners actually reduce diabetes risk and the answer it turns out is the opposite!
In a large study of 66,000 women over 14 years comparing sugar sweetened drinks with artificially sweetened drink, artificially sweetened drinks increased the risk of diabetes just as much as sugar and the rise in insulin and subsequent resistance was the same.7
There are numerous reasons why this is the case and recent research is indicating that, at least in part, this happens because artificially sweeteners adversely affect our gut bacteria. (Our understanding of the role of the gut “microbiome” is really in its infancy but it is increasingly apparent how great a role it plays in health and disease.)
It has been shown that sucralose triggers glucose intolerance in mice by altering the function and composition of the gut microbiota. The metabolic changes can be reversed using antibiotics or indeed can be passed on by faecal transplant. Similar changes have been seen in healthy human subjects.8
We All Like Sweetness so What Should We Do?
In an ideal world we would simply alter our palate and reduce our sugar intake without any recourse to sweeteners.
It is true to say that with time our palate does adapt to less sweetness BUT the craving for sweet has very powerful evolutionally roots. The Nucleus Ambiguousus -part of the pleasure centre in the brain – will light up like fairy lights with a sugar fix. In fact it reacts more intensely to sugar than with a cocaine fix!
The story around a lost tribe of aborigines, the Pintupi Nine, 9 illustrates this very nicely,
they were discovered by related aboriginal tribes in 1984 and had been continuing a hunter gatherer lifestyle with absolutely no contact with the modern world until then.
Despite being offered a lifestyle with readily available water, food and shelter it seemed that they considered returning into the outback until they were offered sugar -as their elder reported:
“I tasted the sugar, we didn’t know what it was, but it was so sweet. I tasted the sugar and it tasted so sweet – like the Kulun Kulun flower. My mother tasted it and it was so sweet. It was good.”
So water, food, shelter and all the other modern comforts were not necessarily enough but sugar cracked it!!
There are some natural alternatives to artificial sweeteners that I believe can be useful and that appear to all extents and purposes to be safe. Ideally these should be used as part of developing an all-round better diet and overall reduction in sweetness.
These are stevia, monk fruit (which is not yet legally available in the European Union area) and erythritol. Erythritol is similar to mannitol and the more commonly used xylitol BUT does not have any metabolic effect on the bowel as it is absorbed and passed in urine unchanged. Consequently it does not have any laxative issues and does not appear to have any negative impact on the gut microbiome.
Dr Morris qualified as a doctor in 1994 and spent six years in hospital medicine – mostly in general adult medicine, but also in paediatrics and Accident and Emergency.
In 2000 David moved into family general practice and was a GP partner for many years. During this time he was also extensively involved in commissioning health care services.
Dr Morris has significant training and experience in complementary therapies such as acupuncture and homeopathy, and ran a primary care based pain clinic for over a decade using acupuncture therapies.
With many thanks to David for this article, over the next couple of months he will be providing further blogs concentrating on specific dietary and lifestyle changes that can be made to help manage insulin resistance; including exercise, stress management and supplementation.
If you have any questions regarding the health topics that have been raised, then please do get in touch with me (Amanda) via phone (01684 310099) or e-mail (firstname.lastname@example.org)
Amanda Williams and The Cytoplan Editorial Team; Clare Daley and Joseph Forsyth
- CELL Volume 163, Issue 5, p1079–1094, 19 November 2015 Personalized Nutrition by Prediction of Glycaemic Responses David Zeevi et al.
- Carbohydrate Restriction has a More Favourable Impact on the Metabolic Syndrome than a Low Fat Diet Volek et al.
- A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidaemia: a randomized, controlled trial. Yancy WS Jr et al.
- Food order has a significant impact on postprandial glucose and insulin levels. Louis J. Aronne et al.
- Belief beyond the evidence: using the proposed effect of breakfast on obesity to show 2 practices that distort scientific evidence. Andrew W Brown et al
- Consumption of artificially and sugar-sweetened beverages and incident type 2 diabetes in the Etude Epidémiologique auprès des femmes de la Mutuelle Générale de l’Education Nationale–European Prospective Investigation into Cancer and Nutrition cohort . Guy Fagherazzi et al.
- Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Jotham Suez et al. Nature. 2014 Oct 9;514(7521):181-6. doi: 10.1038/nature13793