The role of nutrition

THE ROLE OF NUTRITION IN THE MANAGEMENT AND PREVENTION OF DIABETES AND INSULIN RESISTANCE

The information you have just read does offer a rather gloomy picture for our health. Still to this day, the conventional wisdom is that type-2 diabetes cannot be reversed and that once you have it, you have it for life. It is certainly true that type-1 diabetes is irreversible, but can absolutely be effectively improved by the right approach to diet. Type-2, on the other hand, is a different story. In spite of the less optimistic conventional stance, there is a vast evidence base to show that changes in diet and lifestyle can offer massive improvements in individual’s symptoms and in clinical markers of the disease. There are huge numbers of documented cases of individuals reversing their condition, but I couldn’t possibly say that it is a guarantee, that it will definitely be the case for you.

What I will say with absolute certainty is that, if you implement these changes, you will get huge benefits to your condition. Of this I assure you.

In type-2 diabetes, there can be several manifestations of the condition. Some individuals will just be in a state where they are insulin resistant, in that their cells just aren’t responsive to insulin signalling. This is the early stages, the precarious border between pre-diabetes and full-blown type-2 diabetes. Others, on the other hand, as we have seen above – mostly those that have had the condition for some time – will get dysfunction of the pancreas, where it no longer makes sufficient insulin (in response to the consistently elevated level that starts the condition off). It is my personal belief that individuals in the first category, those where severe insulin resistance is their main pathological factor, or those who have just moved into full-blown type-2, are the ones who are the most likely to see reversal of the condition.

But it is certain that everyone will benefit to some degree when they make the right dietary changes. It is completely logical and really a no-brainer. I do also believe that providing you don’t have any complications associated with your type-2 diabetes (which must be dealt with by the relevant drugs from your doctor, without question), then the dietary changes and strategies I suggest, providing you stick to them for life, will be the most suitable long-term intervention for you.

LEARN TO REACH FOR LOW-GLYCAEMIC FOODS

Learning the glycaemic value of foods will be one of the key tools that will help you to shape your diet for life and will soon become second nature to you.

It can be a little complex if you really delve deep, but you will soon start to see a pattern forming and before long it will be easy to know what foods are what and, trust me, you will end up making your choices and putting together meals almost on autopilot.

There are several terms that are frequently used in the health and diet worlds that have the word glycaemic in them, and all are important. The first one – and one that is probably familiar to most people – is the glycaemic index (GI). This is a measure of how quickly blood sugar levels go up after eating a certain food. It is basically a measure of how the carbohydrates in a certain food will affect your blood sugar. It gives you this value in comparison to the rate at which pure glucose would send blood sugar up. This is a fairly useful starting point as it gives you an indication as to which foods are most likely to be problematic for you. But, it doesn’t give you the full picture.

A further extension of this is something called the glycaemic load (GL). This measurement takes the glycaemic index, then combines that with the actual amount of usable carbohydrate that is in a portion of the given food. A food could have a very high-GI carbohydrate in it, but a portion of that food may actually have very little usable total carbohydrate in it, thus having a low glycaemic load. That’s not as complicated as it sounds. Let’s use watermelon as an example. The carbohydrates in watermelon have a glycaemic index of 72 (wow! Pure glucose is 100) which is an incredibly high value. However, a reasonable 100g portion of watermelon only has 5g of carbohydrate in it. That seems like less of a gargantuan number, doesn’t it? So the calculation is: carbohydrate content in grams, multiplied by GI score, divided by 100. So, for watermelon: 5 x 72 / 100 = a GL score of 3.6. A food with a GL score of 20 is considered high.

FOOD	GLYCAEMIC INDEX	SERVING SIZE	GLYCAEMIC LOAD
Sweet foods
Honey	87	2 tbsp	17.9
Table sugar	68	2 tsp	7
Jam	51	2 tbsp	10.1
Cereal & Bread
Corn flakes	92	28g	21.1
Rice Krispies	82	33g	23
Special K	69	31g	14.5
Porridge	58	117g	6.4
French bread	95	64g (1 slice)	29.5
White loaf	70	25g (1 slice)	8.4
Wholemeal loaf	70	28g (1 slice)	7.7
Pumpernickel bread	41	26g (1 slice)	4.5
Drinks (soft)
Orange juice	57	250ml	14.25
Cranberry juice	68	250ml	24.5
Apple juice	41	250ml	11.9
Cola	63	370ml (can)	25.2
Legumes
Baked beans	48	253g	18.2
Chickpeas	31	240g	13.3
Kidney beans	27	256g	7
Lentils (green)	29	198g	7
Soy beans	20	172g	1.4
Peanuts	13	146g	1.6
Vegetables
Potato	104	213g	36.4
Parsnip	97	78g	11.6
Carrot	92	15g	1
Beetroot	64	246g	9.6
Sweet potato	51	136g	16.8
Peas	48	72g	3.4
Fruit
Watermelon	72	152g	7.2
Pineapple	66	155g	11.9
Apples	39	138g  (1 medium)	6.2
Banana	51	118g	12.2
Plums	24	66g	1.7
Grapes	43	92g	6.5
Pears	33	166g	6.9
Peaches	28	98g	2.2
The chart, left, is obviously not even close to an exhaustive list. If it was, I would create a book of a size that would make Tolkien feel inadequate, and it would be so dull it would anaesthetise the most hardened of insomniacs! These books do exist – and please be my guest and grab one – but you really don’t need it. This table is simply to illustrate my big key points: choose foods that are in their whole state (brown over white, minimally processed); make sure they have plenty of fibre (pumpernickel bread or lentils, for example); and you will be choosing foods that by default have a very low glycaemic impact indeed. Follow this trend, along with the correct food-combining techniques, and you will have it nailed for life. A little note about proteins such as meat and fish… luckily these sit at a big fat zero, so go nuts and make them the stars of the show.

OK, I know this may seem a bit like gobbledegook. Why does any of this matter? Well, these values basically tell you how the food that you eat is going to affect your blood sugar. Remember how we become less sensitive to insulin and what sets the stage for all of this? When we completely bombard our bodies with sugar on an ongoing basis, our insulin receptors start to gradually get less sensitive to insulin signalling and cells soon are unable to take up glucose to anywhere near the same extent that they were previously able to. The good news is that our bodies can bounce back very quickly when we give them an environment that allows it. So, if you are suffering from insulin resistance, pre-diabetes or full-blown type-2 diabetes, the sooner you stop the bombardment of sugar, the better. Foods with lower GL values don’t bombard the blood with sugar, instead, they drip-feed it in smaller amounts. Smaller amounts of sugar, added to the bloodstream in small, manageable increments. Levels that don’t require huge surges of insulin in order to deal with their sugar flood.

There are a few reasons why these types of foods will have more of a drip-feeding effect. Many tend to be of a more complex chemical structure, meaning that their available sugars are bound up in complex chemical bonds and require greater digestive effort to liberate them. Others require specific metabolic processes once absorbed, to liberate their energy. The important point is that these are the foods that you should be reaching for more. Why? Well, insulin resistance, given the chance, can bounce back pretty quickly. If you bring the glycaemic impact of your whole diet down, then in time insulin receptors will start to believe what insulin is telling them again and become far more receptive to its influence. Over time your body will handle insulin properly, produce less of it and manage blood sugar more effectively. It takes time and it takes discipline, but it is achievable.

CARB RESTRICTION AND GETTING CARB SMART

So you should now have some familiarity with the glycaemic values of specific carbohydrate-rich foods. The next step is carb reduction and being carb smart. Don’t panic, I’m not saying that you need to start doing the Atkins diet, but looking at your overall carbohydrate intake is of massive importance here, both for managing insulin resistance and diabetes and also for the complications that are associated with these conditions.

In general, in the Western world, our intake of carbohydrates has gone a little insane. We are consuming more of these foods than during any other period of history or our evolution. The pattern has changed to an alarming degree. This is due to a series of events that took place about 50 years ago, in the form of a very ill-informed public health campaign sparked in essence by just one man. His name was Ancel Keys.

Keys was an American physiologist with a strong interest in nutrition. He had been part of many dietary projects with the US government, including the development of the K-ration, a nutrient-dense bar that was given to American troops in the field to provide daily sustenance in a small portable unit. Keys had a theory that cardiovascular disease was caused by saturated fat and a nation’s heart disease statistics would be a direct reflection of the amount of saturated fat that the population ate. So, he set about to prove it. To do this, he devised a study into the dietary habits of 22 countries. Each population’s intake of saturated fat was compared against cardiovascular disease rates to search for the connection. Once the study was finished, the findings were published and, boy, did they prove the saturated fat and heart disease hypothesis perfectly. Case dismissed… or was it? The only problem was that the data published was from only seven of the 22 countries. Hang on a second! Seven? What happened to the rest? Well, if the data from all 22 countries had been published, Keys’s theory would have completely fallen apart. The data showed absolutely no connection at all between saturated fat intake and heart disease. But, Keys was an ambitious chap, and also had a lot of investors and backers who were certainly… keen… to see a specific result. So, data was selected that showed what Keys wanted to show. He used the data only from countries where a connection between saturated fats and heart disease could be found, that supported his beloved ideas, and completely threw out all the rest!

This outright fraud should have been massive news and a scandal, but no. Keys became a national hero and in no time at all was on the front cover of Time magazine.

Next, he was beginning to advise on government public health policy. When this happened, the US government soon developed a public health campaign that warned the American public to drastically reduce their intake of saturated fats and replace them with low-fat starchy foods such as bread, potatoes and the like. These were low-fat so must be ‘heart-healthy’, right? Whoops! This message almost instantly shot across the Atlantic and became policy in the UK.

What happened next was the biggest public health cock-up of them all, and boy there have been a few! You can literally chart this on a graph when you look at disease patterns in populations from institutions such as the World Health Organisation. We took on this message and our diets changed. Massively. It was breakfast cereal and margarine all round before you could say ‘death diet’. As we moved increasingly towards the low-fat high-starch diet, our waistlines began to expand.

I am in my late 30s and I can remember being a child in the late 1970s and 1980s. Seeing someone overweight was really quite unusual. It wasn’t unheard of, but it wasn’t that often that you’d see someone that was struggling with their weight. But it was beginning to change. And people were starting to notice things changing. Diet clubs and the battle against the bulge began to sneak in, and it has been an absolute public health apocalypse. As the changes started taking hold, obesity, heart disease, metabolic syndrome and type-2 diabetes soared. They went from a relatively small problem to epidemic proportions in a few generations.

Bearing in mind that we have been evolving for millions of years, a change that severe can only be the result of an environmental impact upon our physiology. It must be something we are doing or that we have changed, that is causing this. Our intake of starch and the wrong types of fats (I’m saving that nugget for a little later) went through the roof. This caused our blood sugar to go bananas, overloading our insulin system and unleashing metabolic chaos.

Constantly high blood sugar, coupled with poor fatty acid balance, meant that we were synthesising fats and storing them around our collective midsections at a rate of knots. Our insulin sensitivity went south and, at the same time, cardiovascular disease became the single biggest killer in the developed world.

This unnatural increase in carbohydrate intake, particularly intake of refined carbohydrates, has been killing us in our millions. You may not be directly aware of the amount of these foods that you are eating. But look at this picture and think if it sounds familiar. How many people would start the day with a bowl of cereal and maybe a slice or two of toast? Then at lunch time, it’s not too extreme a statement to say that, for most, a weekday lunch would be a sandwich. An evening meal may be pasta, rice, potatoes or a slice of bread to mop up the juices on the plate. Between meals there may be crisps or a cereal bar, a biscuit or a fruit smoothie. These are everyday patterns. When I work with clients and look at their food diaries, I see it consistently.

The sad thing is that we have been told for so long that these are healthy eating patterns and we believe we are doing the right thing. This is what truly saddens me most of all. I see so many people who truly want to make the right changes, but based on the poor public health information they have been given in the past, have been inadvertently destroying their health! When you look at it though, the amount of starchy foods and fast-release carbohydrates in our daily diets are getting to be at an extreme level.

So what should we do? Well, I would certainly encourage everyone to consider reducing their overall intake of starchy foods such as bread, pasta, rice and potatoes. When you do want to include some of these types of foods – and there are indeed recipes in this book that use these types of ingredients (I want to lead you in the right direction slowly and comfortably rather than just force you into a massive dietary overhaul in one go) – then you need to be carb smart. This means choosing the best sources. So, you want some rice? Go for brown. Throw the white variety out of your kitchen cupboard. You want a bit of bread? Have multigrain. These versions of the staple carbs in our diet are much more complex in their structures, take longer to digest and release their energy (and affect blood sugar) more gradually.

 

 

 

“If we continue on the same trend, 10% of the world’s population, around 592 million, will have diabetes by the year 2035.”

INTERNATIONAL DIABETES FEDERATION

But, the key message and the thing I would really encourage you to do, is to reduce your overall consumption of these foods right across the board. Instead of nasty sugared breakfast cereals, opt for scrambled eggs or a frittata. If you absolutely must have a cereal-based breakfast, then porridge would be the best option, with a few nuts (for protein) on top.

Main meals should be centred around lean proteins, as many vegetables as you can possibly shoehorn in and generous helpings of good fats, such as olive oil, avocados and nuts. Before you think this is a carb-free diet, I want to point out that vegetables are… carbohydrates. They are just carbohydrates that have a very low GL score so they give you a nice slow, sustained energy release, rather than simply napalming your bloodstream with a flood of sugar. These are the smartest carbs of them all and the ones that we should be filling up with as much as possible.

A little note about fruit: it is considered the perfect food by many and is seen as the ultimate healthy snack option. Well, I’m kind of 50:50 on this one. I think for people that don’t have any blood sugar issues and are very active, fruit is great. But, for those of you that are suffering from blood sugar issues, I would be super cautious. I’d advise avoiding all the sweet juicy types and, if you really must have some, then apples and berries are going to be your best bet, as they have the lowest GL value.

MEAL COMPOSITION

After you have got to grips with choosing low glycaemic foods and being carb smart, one of the best weapons you can have in your armoury on a daily basis is to be aware of meal composition. The way in which you combine foods can have a huge impact on blood sugar levels, insulin response and insulin sensitivity.

So, if the first part of the picture is choosing foods with the lowest GL values and keeping a curb on carbohydrate-dense foods, then the next part is how you eat them. The combination that foods are eaten in can affect their glycaemic impact. If you recall, some foods, such as proteins, take a very long time to digest and stay in the stomach for much longer than other foodstuffs.

So, rule number one in every meal is: look to see where your protein is coming from. The protein in the meal will slow down the digestion and release of usable sugars from the meal considerably. The proteins require more digestive effort within the stomach, as hydrochloric acid does its thing to break the bonds. As we saw, very little in the way of carbohydrate digestion takes place in the stomach. So, a meal with a good protein content is going to leave the stomach much more slowly than would a simple carbohydrate meal. This basically releases the sugars from the meal into the bloodstream in a much more slow, sensible and sustained fashion.

To take this process a step further, and bring down the glycaemic impact of a meal even more, bring in a good source of fat with each meal. I’m not talking a pound of lard, but healthy fat sources such as olive and flax oil dressings, nut butters, avocados… Fat slows gastric emptying, so this effect of drip-feeding blood sugar is enhanced even further.

Now, don’t panic about fat. As we have seen above, the evidence that links fat and heart disease is complete nonsense and many studies since have backed this up further. Fats are an absolute vital nutrient for almost every body system. Cut them out of your diet at your peril.

Fats are essential for the manufacture of hormones, vitamin D synthesis, transporting fat-soluble nutrients, regulating the structure and function of cell membranes, regulating the inflammatory response and many other metabolic functions.

Low-fat diets fail at keeping us healthy and anybody that has tried them long term will attest to that. Adding a good source of fat with each meal will have unforeseen benefits. Not only will it keep you feeling fuller and lower the glycaemic response of the meal, but it will also help you to absorb the fat-soluble nutrients in the food as well as ensure that you get adequate intake of the vital essential fatty acids your body need each day. Fat. Get it in and don’t be scared of it!

So, in practice, this is how we could put meals together. As I have mentioned previously, the ideal meal composition would be protein, vegetables and fat. So an example of this would be a salmon salad with a bit of feta cheese and a nice olive oil dressing. It could be a baked chicken breast with steamed greens, roasted carrots and a sauce made with soft cheese and dill, or even a good Sunday roast, minus the roasties… OK, maybe a couple. Breakfast could be a frittata. If you wanted to have a cereal for breakfast, don’t do it every day and, as I have said, go for an unsweetened oat-based cereal such as porridge or a clean (sugar-free) muesli. But, make sure you have protein and fat with it. This is an easy one. Sprinkling it with nuts and seeds gives you a good protein boost, plus a good lashing of important fats. Chicken with vegetable stir-fry and seedy quinoa. You get the picture, I am sure. The beautiful thing is that eating this way is a doddle and a joy, too. No weird exotic additions to your diet, merely being conscious of what is on your plate.

FATTY ACID COMPOSITION OF THE DIET

I have touched on the fact that fats are of drastic importance when it comes to our health. Our relationship with fat has gone dreadfully wrong and we are paying the price. Big time!

The problem we are facing started with the publication of Keys’s very watered down study of 22 countries; remember, he only used the data from seven because their numbers proved his theory but, when all 22 were observed, the connection between fat and heart disease was non-existent.

This farce caused an international public health campaign that drummed it into us that we need to avoid saturated fat like the plague and instead opt for more ‘heart-healthy’ options such as sunflower oil, vegetable oil, corn oil, soy oil…

 

 

 

“Rarely, type-2 diabetes develops without any readily identifiable predisposing factor. But in the great majority of cases, it is brought on by lifestyle activities… most importantly dietary choices.”

DR DAVID PERLMUTTER

Why would this be a problem? Well, these types of oils are made up almost completely of omega 6 fatty acids. There are two essential fatty acids our bodies need to get from the diet and are vital to health. These are omega 3 and omega 6. So if they are important for health, what’s the problem? Well, omega 6 is only needed in tiny amounts. When taken in these amounts it plays some very important roles in our body. Once we get past this level, this once beneficial compound becomes incredibly problematic.

Dietary fatty acids play many roles. One of their biggest is as metabolic building blocks for the production of an important group of communication compounds called prostaglandins.

Essential fatty acids are incorporated into our cell membranes and are liberated by an enzyme called phospholipase for use in daily metabolic processes, such as the formation of prostaglandins. These prostaglandins regulate several important responses in the body, including the inflammatory response. There are three types of prostaglandin: Series 1, Series 2, and Series 3. Series 1 is mildly anti-inflammatory, Series 2 is powerfully pro-inflammatory (ie it switches on and exacerbates inflammation), and Series 3 is powerfully anti-inflammatory.

Omega 6, when consumed at a level above our daily needs, gets converted into something called arachidonic acid. In turn, this is then converted into Series 2 prostaglandins, the powerfully pro-inflammatory variety. On average here in the UK, we are consuming 23 times more omega 6 than we need per day! The end result of this is that we are essentially force-feeding metabolic pathways that manufacture prostaglandins and our bodies’ expression of the pro-inflammatory Series 2 goes into overdrive.

It’s pretty logical what’s going to happen here. This leads to a state of subclinical (ie not immediately obvious, such as your big toe swelling up), chronic (ongoing long-term) inflammation. In its most obvious manifestation, this can exacerbate inflammatory conditions such as arthritis and eczema.

But probably of more sinister consequence are the small, subtle changes that it makes within body tissues. Continual inflammation within tissues can lead to damage to them, such as that found in cardiovascular disease, when the blood vessel walls become damaged by inflammation and plaques then form. Inflammatory changes in tissues have also been linked to the changes that occur in the instigation of cancer.

The other thing this can do is affect cell receptor function. The fatty acid content of our cell membranes has a massive effect upon the cell and its functioning, and also upon the functioning of trans-membrane and membrane-bound structures. What one cellular structure is of great importance to us here? The insulin receptor. Our fatty acid intake will affect the performance of this, so we need to make sure it is correct.

So, on the flip side, the other big dietary fatty acid, one you have probably heard a great deal about: omega 3 fatty acids. These amazing fatty acids are almost an antidote to the above. There are three main types of omega 3 fatty acid: ALA, EPA and DHA. As has been outlined, the essential fatty acids are the metabolic precursors to prostaglandins. EPA and DHA are actually metabolised to form Series 3 prostaglandins (EPA more so). These are the ones that are the most potently anti-inflammatory and an increase in their production can influence inflammatory events very quickly indeed. Consuming good quantities of omega 3 fatty acids encourages our body to produce more of the anti-inflammatory prostaglandins.

The benefits of omega 3 on heart health are well documented and have been studied widely for at least 20 years. However, in recent years we have found that omega 3 intake benefits other aspects of the metabolic disease storm that we are weathering. Increased omega 3 intake is associated with improved insulin production, utilisation and sensitivity. A study of 126 adults in rural British Columbia, Canada found that increased omega 3 intake was negatively associated with insulin resistance . This is a population-based observation study and only shows associations rather than cause and effect, but some experimental studies have offered compelling support. A small experimental study conducted by Tsitouras et al in 2008 found that individuals who ate 720g of fatty fish per week, and took 15ml of sardine oil daily, had greater insulin sensitivity after eight weeks than those who ate a control diet . There are many more of these small experimental studies and population-based studies around.

While more research is needed, it certainly looks like a pattern is emerging and, when viewed from a logical, physiological point of view, it makes sense. At the end of the day, the massive health benefits associated with increased omega 3 fatty acids across the board means that even if this observation proves to not hold true, there will be no harm to our health, only benefit.

So, as is becoming obvious, our fatty acid intake does become a bit of a balancing act. As you can see, omega 3 fatty acids are a pretty important part of the picture, while too much omega 6 can cause a problem. So it is vital to get the balance right. With the current trends arising from research, the recommendation now is to aim for a 2:1 ratio in favour of omega 3. That basically means that you need to be eating twice as much omega 3 than omega 6 in order to maximise the potential benefits, and counteract any negative effects of omega 6.

Thankfully this is pretty easy in practice. The first step is to avoid most vegetable oils like the plague. These are the apparently ‘heart-healthy’ oils such as sunflower oil, corn oil or generic vegetable oil. These are basically pure omega 6 and will send your levels rocketing up very fast.

In place of these oils there are two cooking oils to choose from. In most of my cooking I use olive oil. The dominant fatty acid in olive oil is something called oleic acid which comes into a third category: omega 9. Omega 9 fatty acids have zero influence on omega balance, so don’t particularly present a problem at all.

The other oil I use to prepare food is coconut oil. This is best for high-temperature cooking as it is completely heat stable. Also the fatty acids found in there, medium chain triglycerides, are rapidly broken down and used as an energy source, so their impact on post-prandial lipaemia (elevation of blood fats after a meal) is minimal.

The next step in aiming for omega balance is to drastically cut back on processed foods. This is good advice for a million and one reasons but, in terms of omega balance, many processed foods use untold amounts of vegetable oils. They are cheap as chips and, for decades, food manufacturers have been under pressure to reduce saturated fat in foods, so have moved over to cheap vegetable oils as an alternative. Most ready meals, pre-made sauces and so on will have a lot of omega 6 in them. Get back to basics, like we do in the recipes in this book and get into cooking your food from scratch as much as you can.

The second part of the picture is to up the omega 3. The first and most obvious place to start is by eating oily fish around three times per week. Then you could consider taking supplements as well. I personally take an omega 3 supplement that contains 750mg of EPA and 250mg of DHA twice daily. (If you are taking medications such as warfarin, or if you have recently had a heparin injection, please check with your doctor first before using high-dose fish oil supplements as there is potential for interaction here.)