VALLEY METABOLIC HEALTH RESOURCE CENTRE
INTRODUCING HEALTH PROFESSIONALS TO
THERAPEUTIC NUTRITION & VALLEY METABOLIC HEALTH
BY MICHAEL MINDRUM, MD, FRCPC
updated February 2020
Our modern food environment with inexpensive, convenient, ultra-processed, and palatable foods have delivered a hefty toll on our metabolic health. We have seen a rampant rise in obesity and type 2 diabetes with 2/3rd of Canadians now obese or overweight and ~1/3rd of Canadians with type 2 diabetes (T2D) or pre-diabetes. 40% of people over the age of 40 have metabolic syndrome which leads to increased risk of heart attacks, strokes, and fatty liver. Nova Scotia and the Annapolis Valley is no exception. (1-3)
Our current health care system is oriented to address complications of metabolic disease (think things like ambulances, clot busting drugs, bypass surgeries, and amputations). We are spending a tremendous amount of money and despite important advances in acute care our collective suffering from the impact of poor metabolic health is rising unabated. We are poorly equipped to properly address and support patients in prevention. There is actionable evidence that lifestyle interventions such as exercise and proper diet can profoundly improve a patients risk of complications. As a society and and a medical system we are ignoring the evidence at our own peril. It is time to reorient our systems of care to properly provide patient’s this support. This is why Valley Metabolic Health was born. We are at our humble beginnings but doing our best to put one foot in front of the other and do what is right for the patient and our community!
While there is no one best diet for all, therapeutic nutrition is any pattern of eating that is tailored to an individual to improve metabolic conditions such as diabetes, PCOS, fatty liver, and obesity. There are different types of therapeutic nutrition each with various degrees of evidence to support their use that include healthy whole food plant based diets, low energy diets, mediterranean diets, and low carbohydrate diets. With time we hope to provide as many dietary streams as possible that suit a patients medical condition along with their own individual preferences and values. Based on the evidence as well as the needs in our community to increase support for patients wanting to engage in a low carbohydrate diet we are focusing efforts on this pattern of eating.
There has been an exciting term that is increasingly used in the medical literature as it relates to therapeutic nutrition: diabetes remission. Diabetes remission has been discussed in several trials. The Look Ahead trial utilized a healthy low fat diet with intensive lifestyle intervention and achieved modest remission rates in Diabetes (4) . The DiRECT trial recently demonstrated significant success with a hypocaloric diet and achieved impressive remission in almost 46% of patients at one year (5). Virta Health is an innovative health company in the States that uses virtual care to support patients in a ketogenic diet which is a very low carbohydrate high fat diet (VLCHF). At one year they demonstrated a 12% weight loss, an A1c reduction from 7.6% to 6.3% while discontinuing sulfonylureas in 100% of patients while reducing or eliminating insulin in 94% of patients. They also showed marked improvement in almost all cardiovascular risk markers (6-8). Despite Virta’s study being a single arm study, the results are stunning.
As an internal medicine physician with a special interest in care of type 2 diabetes I knew that changes in lifestyle were emphasized in the guidelines but through my early clinical experience I never felt optimistic that these types of interventions had a meaningful impact. I was taught that diabetes was a chronic progressive disease that needed more medications over time. This opinion was supported in the literature and confirmed by my clinical experience. That is until I began helping patients with carbohydrate restriction and quickly saw that patients with type 2 diabetes could either be weaned off insulin completely or the amount of insulin be markedly reduced. For many patients they returned not only happy with not needing to take as many medications but that they felt better and more optimistic. So in January of 2019 we took a cohort of around 30 patients and tracked their data over one year and we saw remarkable results (publication pending) which has fuelled our desire to continue to create more opportunities for patients to engage in lifestyle interventions.
For those unfamiliar with carbohydrate restriction, this is a brief introduction. Carbohydrates are composed of sugars and starches. Starches are found in higher quantities in things like bread, pasta, potato, rice, cereal, and processed foods. When they are consumed they are rapidly digested into glucose which places further demand on the pancreas to make more insulin. Many patients with type 2 diabetes have significant insulin resistance which leads to a negative circular problem of progressive hyperinsulinemia and insulin resistance.
A ketogenic diet is very low in carbohydrates, moderate in protein, and higher in healthy dietary fats that provide a balance of whole, real, and satisfying foods. Patients are taught that they do not need to count calories or need to fight hunger. In general, one learns how to consume a nourishing, satisfying diet while keeping carbohydrate intake to less than 20 grams a day. The basic premise to LCHF is that by reducing sugars and starches from the diet we decrease blood sugars after meals, insulin levels decrease, and a metabolic switch in the body occurs—patients begin burning more fat instead of glucose to fuel metabolic processes. Protein intake is maintained at a moderate level to maintain or build muscle mass. Dietary fat can be increased with time as needed for satiety. There is a growing body of research demonstrating the efficacy of LCHF. In response to the evidence we are seeing the guidelines shift toward being inclusive of LCHF for the treatment of T2D (ADA, EASD, UK, and Australia — still waiting Diabetes Canada!).
One of the limitations of therapeutic nutrition is that food is more than just “medicine.” Food is cultural, social, and about celebration, joy, and comfort. Ways of eating that diverge from the highly processed “western pattern diet” take motivation, discipline, planning, and support. The key to success is long term adherence and your role as a supportive non-judgmental provider is one of the key determinant in helping foster a patients success at any type intensive lifestyle intervention.
VALLEY METABOLIC HEALTH
In response to a high-level of interest from people with diabetes in Nova Scotia and the Annapolis Valley we launched the Valley Metabolic program in January of 2018. This was supported by a grant from the Valley Regional Hospital and we enjoyed tremendous success which has fueled our mission to continue efforts at reversing the tide of diabetes in our area.
Valley Metabolic Health integrates the work of providers at the Valley Metabolic Clinic with associated Valley Metabolic Programs in order to create a medically supervised program that utilizes a diet first approach to treat type 2 diabetes or other appropriate metabolic illnesses. We focus on reducing medications when possible, while optimizing other medications to lower risk of diabetes complications.
At this time due to patient need as well as effectiveness we are focusing on variable degrees of carbohydrate restriction. For some patients we will guide on a very low carbohydrate diet or ketogenic diet and at other times will focus on a liberal low carbohydrate diet. In time we also aim to offer very low energy diets and whole food plant based approaches.
Our overarching vision is to catalyze a healthy vital community with vibrant metabolic health for all. While we have a grand vision we are taking “one step at a time” to bring the vision to fruition. In the future we hope to provide multiple dietary streams for therapeutic nutrition in order to best individualize treatment — be it a healthy low fat diet, whole food plant based, meal replacement systems, liberal low carbohydrate did or other approaches that have a body of evidence to support its use. We would like to integrate exercise, psychology, online resources, virtual care, and information technology capacities to support patients.We would love to integrate research, grants, and utilize all tools including pharmacologic therapies to improve the quality of life of the patients we meet. Greater organizational and financial planning will be needed to achieve these targets. Ideally we would like to find a home base with ‘bricks and mortar’ to centralize our efforts and resources – perhaps a lifestyle clinic where the community and patients can come for exercise, cooking classes, community talks, educational resources, clinical support, fun, and good food. If any of this sounds like a dream of yours that you would like to be involved wither support, please contact us.
- Davies, M. J., D’Alessio, D. A., Fradkin, J., Kernan, W. N., Mathieu, C., Mingrone, G., et al. (2018). Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 41(12), 2669–2701. http://doi.org/10.2337/dci18-0033
- American Diabetes Association. (2018). 4. Lifestyle Management: Standards of Medical Care in Diabetes-2018. Diabetes Care, 41(Suppl 1), S38–S50. http://doi.org/10.2337/dc18-S0042337/dci18-0033.
- Gregg, Edward W, Haiying Chen, Lynne E Wagenknecht, Jeanne M Clark, Linda M Delahanty, John Bantle, Henry J Pownall, et al. “Association of an Intensive Lifestyle Intervention With Remission of Type 2 Diabetes.” JAMA 308, no. 23 (December 19, 2012): 2489–8. https://doi.org/10.1001/jama.2012.67929.
- Lean, MEJ, W S Leslie, A C Barnes, N Brosnahan The Lancet Diabetes, and 2019. “Durability of a Primary Care-Led Weight-Management Intervention for Remission of Type 2 Diabetes: 2-Year Results of the DiRECT Open-Label, Cluster-Randomised Trial.” Elsevier, n.d. https://doi.org/10.1016/S2213-8587(19)30068-3.
- Hallberg, S. J., McKenzie, A. L., Williams, P. T., Bhanpuri, N. H., Peters, A. L., Campbell, W. W., et al. (2018). Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Therapy, 9(2), 583-612. http://doi.org/10.1007/s13300-018-0373-9
- Sainsbury, E., Kizirian, N. V., Partridge, S. R., Gill, T., Colagiuri, S., & Gibson, A. A. (2018). Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: A systematic review and meta-analysis. Diabetes Research and Clinical Practice, 139, 239–252. http://doi.org/10.1016/j.diabres.2018.02.026
- Saslow, L. R., Daubenmier, J. J., Moskowitz, J. T., Kim, S., Murphy, E. J., Phinney, S. D., et al. (2017). Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutrition and Diabetes, 7(12), 1. http://doi.org/10.1038/s41387-017-0006-9
- Tay, J., Thompson, C. H., Luscombe-Marsh, N. D., Wycherley, T. P., Noakes, M., Buckley, J. D., et al. (2017). Effects of an energy-restricted low-carbohydrate, high unsaturated fat/low saturated fat diet versus a high-carbohydrate, low-fat diet in type 2 diabetes: A 2-year randomized clinical trial. Diabetes, Obesity and Metabolism, 20(4), 858–871. http://doi.org/10.1111/dom.13164
VALLEY METABOLIC HEALTH
SUITE 250, 21 Roy Avenue, New Minas, Nova Scotia B4N 3R7
OFFICE PHONE: (902) 915-4435
OFFICE FAX: 1(855) 962-2375