treating metabolic syndrome, type 2 diabetes, and obesity with … · 2020-03-04 · treating...

Treating metabolic syndrome, type 2 diabetes, and obesity with therapeutic carbohydrate restriction

2

MODULE 1: Background and definitions

MODULE 2: Physiological and metabolic effects of carbohydrate-restricted diets

MODULE 3: Initiating the intervention

MODULE 4: Administering TCR

MODULE 5: Follow-up care

1.1 Introduction: Outline of course

Therapeutic Carbohydrate Restriction CME

3



35%+

30 - 34.9%

25 - 29.9%

20 - 24.9%

15 - 19.9%

10 - 14.9%

0 - 9.9%

Obesity rates increase over the last 3 decades

Therapeutic Carbohydrate Restriction CME 41.1.1 Background and general principles

Obesity 2017Obesity 1990

31.9%

22.6%25.1%

37.3%

25.7%

Historical uses of TCR

51.1.2 History

https://archive.org/details/diabeticcookeryr00oppeiala


https://archive.org/details/diabeticcookeryr00oppeiala

EASD and ADA Guidelines

61.1.2 History Therapeutic Carbohydrate Restriction CME

ADA Guidelines Statement

71.1.2 History

“Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences (Evert et al., 2019).”


Time

Blo

od s

ugar

Fasting blood sugar

Carbohydrate

Nutrients and their impact on blood glucose

81.2 Nutrition physiology and adequacyTherapeutic Carbohydrate Restriction CME


91.2 Nutrition physiology and adequacy

Protein

Time

Blo

od s

ugar

Fasting blood sugar

Carbohydrate




Fat

Protein

Carbohydrate

Time

Blo

od s

ugar

Fasting blood sugar


111.2.1 Protein

Recommended protein intake:

RDA

Therapeutic carbohydrate restriction

0.8 g of protein per kg reference body weight

1.2 - 1.7 g of protein per kg reference body weight


100 grams of protein


3 eggs 60 g (2 oz) cheese

30 g

150 g (5 oz) salmon

30g

140 g (5 oz) chicken

40 g+ + = 100

Breakfast Lunch Dinner


Olive oil

Salmon

Whole fats are a mixture of fatty acids

131.2.2 Fat and saturated fat

Beef


141.2.2 Fat and saturated fat

Why is saturated fat allowed on a carbohydrate-restricted diet?

Absolute grams of fat may not increase on TCR.

(Hite et al., 2010)

Higher dietary saturated fat does not always increase serum saturated fat.

(Volek et al., 2009)

Within the context of TCR, it is unclear what effect saturated fats have on health.

(Forouhi, Krauss, Taubes & Willett, 2018)


151.2.3 Micronutrients Therapeutic Carbohydrate Restriction CME

TCR includes a variety of whole foods

The liver stores glucose as glycogen

glycogenolysis

glucose

Getting energy without dietary carbohydrates: glycogenolysis

161.2.4 Carbohydrate Therapeutic Carbohydrate Restriction CME

Getting energy without dietary carbohydrates: gluconeogenesis


Active skeletal muscle

gluconeogenesis

glucose

Burn fatfor fuel

ketones

body fat

dietary fat

Getting energy without dietary carbohydrates: ketones from fatty acids


Glycemic index and glycemic load

191.2.5 Glycemic index and glycemic loadTherapeutic Carbohydrate Restriction CME

Above-ground vegetables: high fiber, low starch

201.2.6 Fiber Therapeutic Carbohydrate Restriction CME

Net carbs per 100 grams of vegetable

211.2.7 Total vs. net carbohydrateTherapeutic Carbohydrate Restriction CME

221.3.1 Defining TCR Therapeutic Carbohydrate Restriction CME

Moderate LiberalUnder 20 grams of net carbs per day

This meal has 6 grams of net carbs.

Under 50 grams of net carbs per day


Under 100 grams of net carbs per day


Ketogenic

231.3.2 Calories

“Calories still count, but we don’t have to count them.”


Personal 53 years old, female

Low-fat, moderate-carbohydrate diet, focusing on low-glycemic-index foods

Patient believes fat has definitely been proven to cause heart disease and cancer.

• GLP-1 agonist (exenatide)• Insulin• Metformin• SGLT-2 inhibitor (empagliflozin)

Health history

Clinical

Diet history

Medications

Tests

Social/other

Type 2 diabetes

Ultrasound

HbA1c Creatinine ALT 86 U/L9.3%

(12.2 mmol/L)1.6 mg/dL

(141.5 µmol/L)

Evidence of fatty liver

5’2” (157 cm)

186 lbs (84 kg)

146/90 mmHg

Height

Lab Value Lab Value Lab Value

Weight

Blood pressure

241.4 Module 1 case studies

Module 1, Patient 1



How do you respond to her concern that eating fat

definitively causes heart disease and cancer?

Q1:



Module 1, Patient 2

Personal

Health history

Diet history

34 years old, female

Metabolic Syndrome

Vegetarian


Can she successfully start TCR as a vegetarian and

still achieve adequate nutrition goals?

Q1:

271.4 Module 1 case studiesTherapeutic Carbohydrate Restriction CME

What is her target daily protein range and how do you

explain the difference between plant and animal proteins?

Q2:



29Therapeutic Carbohydrate Restriction CME

Shift from “glucocentric” to “adipocentric”

302.1 Glucose, insulin, and ketones Therapeutic Carbohydrate Restriction CME

“Glucocentric” Fuel = glucose

“Adipocentric”Fuel = fatty acids & ketones

Foods that digest down into glucose

312.1.1 GlucoseTherapeutic Carbohydrate Restriction CME

Fat

Insulin

Insulin prevents fat from leaving cell

322.1.2 InsulinTherapeutic Carbohydrate Restriction CME

ketones

body fat

dietary fat

Beta-hydroxybutyrate (BHB)

Acetoacetate

Acetone

332.1.3 KetonesTherapeutic Carbohydrate Restriction CME

Blood ketones in mmol/L

Op

tim

al f

uel f

low

for

bra

in a

nd m

uscl

es

0 0.5 1.0 1.5 2.0 2.5 3.0

Nutritionalketosis begins

Optimalketonezone

342.2.1 Nutritional ketosisTherapeutic Carbohydrate Restriction CME

352.2.1 Nutritional ketosisTherapeutic Carbohydrate Restriction CME


Op

tim

al f

uel f

low

for

bra

in a

nd m

uscl

es

0 0.5 1.0 1.5 2.0 2.5 3.0 5.0 10+


Optimalketonezone

Post-exerciseketosis

Starvationketosis

Ketoacidosis

Adapted from: Phinney & Volek

May occur with SGLT-2 inhibitors, combined with TCR.

Patient has normal blood glucose levels.

Patient has metabolic acidosis.

Patient is typically symptomatic: fatigue, confusion, dehydration, and more.

Requires immediate treatment.

Euglycemic ketoacidosis

362.2.2 KetoacidosisTherapeutic Carbohydrate Restriction CME

≥ Systolic 130 mmHg

≥ Diastolic 85 mmHg

Receiving treatment for hypertensionBlood pressure

≥ 150 mg/dL (1.7 mmol/L)

Receiving treatment for elevated triglyceridesTriglycerides

< 40 mg/dL in men (1.0 mmol/L)

< 50 mg/dL in women (1.3 mmol/L)

Receiving treatment for low HDL-cholesterolHDL-cholesterol

≥ 100 mg/dL (5.6 mmol/L)

Receiving treatment for type 2 diabetesFasting

glucose level

> 40 inches for men (102 cm)

> 35 inches for women (89 cm)

Waist circumference

372.3.1 Definition of metabolic syndromeTherapeutic Carbohydrate Restriction CME

Metabolic syndrome is defined by the presence of 3 of the 5 criteria:

Central nervous system: Increased sympathetic nervous system activity

Blood vessels: Proliferation of smooth muscle Diminished release of nitric oxide from the endotheliumIncreased secretion of endothelin-1, a potent vasoconstrictor

Kidneys: Increased sodium retention

382.3.2 HypertensionTherapeutic Carbohydrate Restriction CME

How does insulin increase blood pressure?

392.3.2 HypertensionTherapeutic Carbohydrate Restriction CME

402.3.3 DyslipidemiaTherapeutic Carbohydrate Restriction CME

Summary of different measures of cholesterol

Name

LDL-C

LDL-P

ApoB

Description

Low-density lipoprotein cholesterol Total concentration of cholesterol contained in LDL particles

Low-density lipoprotein particles Total number of LDL particles in circulation

Apolipoprotein B-100 Serves as a proxy measure for all potentially atherogenic lipid particles, including LDL, IDL, and VLDL

Unit

mg/dL

nmol/L

mg/dL


Increased triglycerides

Decreased HDL

Increased atherogenic, small LDL particles

Hyperinsulinemia is associated with changes in serum lipids:

Fasting blood sugar ≥ 100 mg/dL (5.6 mmol/L)

HbA1c > 5.7% (6.3 mmol/L)

Impaired glucose tolerance or prediabetes

432.3.4 Hyperglycemia and type 2 diabetesTherapeutic Carbohydrate Restriction CME

The insidious cycleWeight gain and insulin

resistance actually form a closed circle of cause and effect,

leading to diabetes and all its complications.

Weight gain in a person with family history and predisposing genes to diabetes mellitus type 2

Increased need for glucose

β-cells in the pancreas secrete more insulin

Insulin resistancedevelpos in the liver, muscles and fat

Even more insulin is secreted

β-cells become exhausted

Diabetes mellitus type 2

Hypertension


Insulin resistance


Adapted from: King & Blom, 2017

Insulin resistance

Fasting blood glucose

Time:YearsDecreasing post-mealglucose control

Loss of !-cell mass

Pre-diabetes Diabetes

Insulin production

High insulin keeps glucose low — until insulin production fails

Food Item

Basmati rice 69 150 10.1

9.1

7.5

6.6

4.0

1.3

5.7

2.3

3.0

0.2

0

150

150

180

80

80

120

120

30

80

60

96

64

39

60

51

62

39

74

15

0

French friesbaked

Spaghetti whiteboiled

Sweet cornboiled

Frozen peas,boiled

Banana

Apple

Wholemealsmall slice

Broccoli

Eggs

Potato, white,boiled

Glycaemicindex

Servesize g

How does each food affect blood glucose compared with one 4g teaspoon of table sugar?


All carbohydrate foods are not the same

Adapted from: Unwin, Haslam & Livesey, 2016

Other foods in the very low glycemic range would be chicken, oily fish, almonds, mushrooms, cheese


Open-label, 2-year, non-randomized study of TCR (n= 262) showed, compared to control:

Elimination of all diabetes medications (except metformin) for most participants

Reduced: HbA1c, fasting glucose, fasting insulin, body weight, blood pressure, triglycerides

See: Athinarayanan et al., 2019

492.3.5 Obesity and abdominal obesityTherapeutic Carbohydrate Restriction CME

Why people might be less hungry during TCR:

Ketosis (Gibson et al., 2015; Paoli et al., 2015)

Protein & fiber-filled foods (Blundell & Stubbs, 1999; Veldhorst et al., 2008) Satiety

without stimulating brain food-reward centers (Alonso-Alonso et al., 2015)

Subcutaneous fat

502.3.5 Obesity and abdominal obesityTherapeutic Carbohydrate Restriction CME

Visceral fat linked to metabolic impairment

Visceral fat


Case study: Patient 3

Personal

Health history

Social/other

Female

Obesity (BMI 43)

BHB level, post-exercise, home test: 4.5 mmol/L


Does a BHB level this high suggest she may be

at risk for ketoacidosis? Q1:



Op

tim

al f

uel f

low

for

bra

in a

nd m

uscl

es

0 0.5 1.0 1.5 2.0 2.5 3.0 5.0 10+


Optimalketonezone

Post-exerciseketosis

Starvationketosis

Ketoacidosis

Personal 62 years old, male

• Aspirin, 81 mg daily• Lisinopril, 10 mg daily•Metformin, 1000 mg twice daily

Health history

Clinical

Medications

Type 2 diabetes; coronary artery disease; stent placed 18 months prior

HbA1c LDL

HDL

TG 265 mg/dL(3 mmol/L)

7.2%(8.9 mmol/L)

165 mg/dL(4.3 mmol/L)

31. mg/dL(0.8 mmol/L)

5’10” (178 cm)

234 lbs (106 kg)

126/72 mmHg

Height


Weight

Blood pressure




Given his history of coronary disease and elevated

LDL is he a good candidate for TCR?

Why or why not?

Q1:


How would you address his elevated LDL? Q2:


Would you check an advanced or nuclear magnetic

resonance (NMR) lipid profile?

How would you expect his lipid panel to change

with statin therapy and TCR initiation?

Q3:

593.1.1 Exclusion criteriaTherapeutic Carbohydrate Restriction CME

Advanced renal insufficiency not on hemodialysis

Therapeutic carbohydrate restriction is not appropriate for patients with:



Pyruvate carboxylase deficiency

Carnitine palmitoyltransferase (CPT) deficiency

Short-chain, medium-chain or long-chain acyl dehydrogenase deficiency (SCAD,MCAD or LCAD)





Hyperchylomicronemia






Hyperchylomicronemia

Acute, decompensated medical condition





633.1.2 Need for cautionTherapeutic Carbohydrate Restriction CME

Type 2 diabetes

Hypertension

Type 1 diabetes

Gallbladder removal

Decreased kidney function

Kidney stones

Gout

Pregnancy & breastfeeding

Conditions that require caution:

643.2 Baseline assessmentsTherapeutic Carbohydrate Restriction CME

Height

Weight

Lean body mass / body fat %

Blood pressure

Baseline measurements

653.2.1 Recommended lab testsTherapeutic Carbohydrate Restriction CME

Fasting insulin*

µIU/mL or mIU/L pmol/L Reference

High Johnson, Duick, Chui & Aldasouqi, 2010

McAuley et al., 2001

Johnson, Duick, Chui & Aldasouqi, 2010

Moderate

Low

≥ 25 ≥ 174

> 83 >12

≤ 8

Risk for insulin resistance

Homeostatic model assessment for insulin resistance (HOMA-IR)**

Score Risk for insulin resistance Reference

< 1.6 Low Shashaj & Luciano, 2015

HOMA-IR score = fasting insulin (mIU/L) x fasting glucose (mg/dL) / 405 (Matthews et al., 1985)

* These definitions have not been standardized. These are “working” ranges until more studies are done to standardize values for predicting insulin resistance. Following the trend in an individual patient over time is likely more helpful than an absolute value when monitoring patients on therapeutic carbohydrate restriction.

** A calculator for HOMA-IR can be found at: mdcalc.com/homa-ir-homeostatic-model-assessment-insulin-resistance

663.2.1 Recommended lab testsTherapeutic Carbohydrate Restriction CME

Baseline fasting labs

CMP: liver, kidney, electrolytes, glucose CBC

HbA1c

Lipids (NMR or advanced analysis if possible)

Insulin (with glucose, can calculate HOMA-IR)

For select individuals: Uric acid, TSH

Improved blood pressure control

Improved overall lipid profile

Improved glucose control

Diabetes & blood pressure medication reduction

Weight loss, especially reduced waist circumference

Potential benefits of therapeutic carbohydrate restriction

673.3 Pre-diet evaluation and counseling Therapeutic Carbohydrate Restriction CME

683.4 Module 3 case studies Therapeutic Carbohydrate Restriction CME



Low-fat, high-carbohydrate diet

15 minutes of walking per day

• Lisinopril, 10 mg daily

• Metformin, 500 mg twice daily

Health history

Clinical

Diet history

Medications

Tests

Social/other

Metabolic syndrome; gallstones; cholecystectomy 4 years prior

Ultrasound

HbA1c LDL TG 210 mg/dL(2.37 mmol/L)

6.3%(7.5 mmol/L)


FBG HDL ALT 78 U/L118 mg/dL(6.6 mmol/L)



5’2” (155 cm)

172 lbs (78 kg)

38 inches (96.5 cm)

142/88 mmHg

Height


Weight

Waist circumference

Blood pressure


Case study: Patient 5 (cont.)

Current diet

Oatmeal with raisins, brown sugar, and fruit7:00 am

9:30 am

12:00 pm

3:00 pm

7:00 pm

8:30 pm

Protein bar

Turkey sandwich with chips and diet soda

Apple, orange, or grapes

Chicken with rice, potatoes, or broccoli; pasta with marinara sauce; occasionally pizza

Usually ice cream, popcorn, or fruit salad

Walks 15 minutes on lunch break, with no other regular exercise.


Is she a good candidate for TCR? Why or why not?Q1:


What are your initial dietary recommendations for her?Q2:


Are there special considerations for her initiation?Q3:


What baseline assessments would you check

and follow?

Q4:




Insulin

Health history

Medications

DepressionSocial/other

Type 1 diabetes; frequent hypoglycemia; 3 hospital admissions for DKA

HbA1c FBG10.2%(13.6 mmol/L)


Lab Value Lab Value


Is he a good candidate for TCR? Why or why not? Q1:

MODULE 4: Administering therapeutic carbohydrate restriction


774.1 Supporting behavior changeTherapeutic Carbohydrate Restriction CME

Discuss current diet, diet history, and health goals

Address concerns about carbohydrate restriction

Create a personalized dietary plan

Provide ongoing support

Assess patient’s knowledge about carbohydrate restriction

Support your patient’s dietary changes

784.1 Supporting behavior changeTherapeutic Carbohydrate Restriction CME

Sample menu

Recipes

Meal-planning tips

Replacement options for favorite foods

Shopping list

Patient education resources for therapeutic carbohydrate restriction

794.2 Patient educationTherapeutic Carbohydrate Restriction CME

Therapeutic carbohydrate restriction: Easy as 1-2-3!

Limit carbohydrates.

Aim for adequate protein.

Adjust fat as needed for fullness and flavor.

1

2

3


Foods to choose for TCR


Foods to avoid on any diet

824.2.1 CarbohydrateTherapeutic Carbohydrate Restriction CME

Limit carbohydrate foods


Above ground

Below ground


High-fiber, low-glycemic berries

854.2.2 ProteinTherapeutic Carbohydrate Restriction CME

Aim for 75 -100 g of protein (or more) per day

3 eggs 60 g (2 oz) cheese

30 g150 g (5 oz) salmon

30g 140 g (5 oz) chicken

40 g

Breakfast Lunch Dinner

What does 25 grams of protein look like?

Quinoa

Amount Calories Protein

Peanut butter

Black beans

Edamame

Beef

25 g3 cups (700 ml)

6.25 tablespoons (92 ml)

1 ⅔ cups (378 ml)

1 ⅓ cup (307 ml)

3 ounces (85 grams)

25 g

25 g

25 g

25 g210

251

385

587

666

864.2.2 ProteinTherapeutic Carbohydrate Restriction CME

Biological value of protein sources

874.2.3 FatTherapeutic Carbohydrate Restriction CME

Adjust the amount of fat as needed

Butter 0

Coconut oil 0 Heavy cream 3

Cold cuts 2

Olive oil 0

Olives 3

Eggs 1 Avocado 2

Cheese 2

884.2.4 BeveragesTherapeutic Carbohydrate Restriction CME

Choose alcohol wisely

“Getting started” tips for patients

Two-steps to a TCR kitchen:

Toss or give away foods not on TCR list.

Use list to restockthe kitchen.

Keep cooking simple:

Find substitutes for favorite foods.

Make “deliberate” leftovers.

Plan no-cook meals.

Repeat quick & easy favorite meals.

Eat when you’re hungry; stop when you’re full.

1

2

894.2.6 “Getting started” tips for patientsTherapeutic Carbohydrate Restriction CME

904.3.1 Diabetes medicationsTherapeutic Carbohydrate Restriction CME

Initial adjustments for diabetes medications

Insulin

If post-prandial glucose is <200 mg/dL (11 mmol/L), stop short-acting insulin.

Reduce long-acting insulin by 33-50%.

Stop mixed insulin; transition to long-acting insulin only.

A history of diabetic ketoacidosis (DKA)

A history of hospitalizations for severe hyperglycemia

Think “possible latent autoimmune diabetes of adults (LADA)” if a patient has:



Initial adjustments for diabetes medications

InsulinIf post-prandial glucose is <200 mg/dL (11 mmol/L), stop short-acting insulin.

Reduce long-acting insulin by 33-50%.

Sulfonylureas Stop sulfonylureas, unless fasting glucose is > 200 mg/dL (11 mmol/L).

Stop mixed insulin; transition to long-acting insulin only.

Metformin

DPP-4 inhibitors and GLP-1 agonists

May safely be continued.

May be continued until glucose levels are well controlled.

SGLT-2 inhibitors

Stop all SGLT-2 inhibitors before TCR is initiated.

SGLT-2 inhibitors + TCR = increased risk of DKA.

Educate patients about symptoms of low BP

Have patients monitor BP at home & communicate results to healthcare team

If BP is consistently < 110/70, consider stopping or reducing meds

If patient develops symptomatic hypotension, stop or reduce meds to relieve symptoms

Initial adjustments for anti-hypertensive medication

934.3.2 Anti-hypertensive medicationTherapeutic Carbohydrate Restriction CME

Electrolyte imbalance

Side effects related to diuresis and natriuresis and how to treat

4-7 grams of sodium/day (2-3 teaspoons or 10-15 mL of salt)

Constipation magnesium oxide 400 mg per day or supplemental fiber

Muscle cramps

400 mg/day magnesium citrate or magnesium oxide

If GI side effects, use magnesium glycinate or transdermal

944.4 Side effects, adverse outcomes, and treatmentTherapeutic Carbohydrate Restriction CME

954.4 Side effects, adverse outcomes, and treatmentTherapeutic Carbohydrate Restriction CME

400 mg/day magnesium citrate or magnesium oxideIf GI side effects, use magnesium glycinate or transdermal

4 -7 grams of sodium (2-3 teaspoons or 10-15 mL of salt)

Muscle cramps

Stop TCR.

Continue TCR with reduced saturated fat and increased monounsaturated fat intake.

Start a statin or other lipid-lowering drug.

Make no changes; follow coronary calcium scores and carotid intima-media thickness test (CIMT) for signs of progressive athersclerotic disease.

Continue TCR with a modestly higher carbohydrate intake.

Potential responses to LDL increase

964.4.4 LDL increaseTherapeutic Carbohydrate Restriction CME

974.5 Other lifestyle considerationsTherapeutic Carbohydrate Restriction CME

Continue ongoing program, with 25% reduction of duration and intensity

Do not start new program until TCR is established

Exercise should not increase frequency or amount of eating

Reinforce that activity is its own reward!

Exercise and initiation of TCR


• Atorvastatin, 20 mg daily• Canagliflozin, 300 mg daily • Insulin glargine, long-acting, 30 units daily• Insulin aspart, dosed before meal • Metformin, 1000 mg twice daily

Health history

Clinical

Medications

Type 2 diabetes; orthopedic surgeries


8.2 %(10.5 mmol/L)


FBG HDL

ALT 88 U/L

Creatinine 1.4 mg/dL

(123.8 µmol/L)178 mg/dL

(9.9 mmol/L)32 mg/dL

(0.84 mmol/L)

5’10” (178 cm)

288 lbs (130 kg)

43 inches (109 cm)

144/88 mmHg

Height


Weight

Waist circumference

Blood pressure




Is he a good candidate for TCR?

Why or why not?

Q1:


Are there any special considerations when

starting him on TCR, especially regarding his

kidney function and medications?

Q2:


After the first week of TCR with a goal net

carbohydrate intake of less than 20 grams per day, he

complains of being lightheaded, fatigued, and having

muscle cramps. What are your main considerations,

what tests, if any, would you order, and what are your

main interventions?

Q3:


Increase hydration

Drink pickle juice or bone broth

Add magnesium 200 - 400 mg daily

Increase sodium: Add salt to eggs and veggies

“Keto flu” intervention


When would you suggest he get

his next lab draw?

Q4:


• Atorvastatin, 40 mg daily• Glipizide xl, 2.5 mg daily • Liraglutide, 1.2 mg daily• Lisinopril, 10 mg daily• Metformin, 100 mg twice daily

Health history

Clinical

Medications

Type 2 diabetes; diabetic nephropathy; calcium oxalate kidney stones

HbA1c LDL Potassium 4.1 mEq/L8.2% (10.5 mmol/L)


Creatine HDL1.8 mg/dL

(159.2 µmol/L)31 mg/dL

(0.81 mmol/L)

Uric acid

GFR

TG

Sodium 138 mEq/L

45 mL/min/1.73m²

Calcium9.2 mg/dL

(11.1 mmol/L)5.6 mg/dL


(2.56 mmol/L)

124/76 mmHg


Blood pressure




Is he a good candidate for TCR?

Why or why not?

Q1:


Are there any special considerations for

starting him on TCR?

Q2:


Working on improving athletic performance

Started TCR 3 months ago; lost 15 lbs (6.8 kg)

Health history

Clinical

Diet history

Social/other

none

5’4” (162 cm)

120/70 mmHg

125 lbs (57 kg)140 lbs (63 kg)

5.9% (6.8 mmol/L)

126 mg/dL (3.3 mmol/L)



5.3% (5.9 mmol/L)



52 mg/L (0.58 mmol/L)

Height

Lab

Weight

HbA1c

LDL

HDL

TG

Baseline Current

Blood pressure




Given her LDL elevation, can she continue

with TCR? Why or why not?

Q1:


• Atorvastatin 40 mg daily

• Empagliflozin 10 mg daily

• Metformin, 1000 twice daily

• Blood sugar average, fasting, home test: 110 mg/dL (6.1 mmol/L)

• Blood sugar average, postprandial, home test: 150 mg/dL (8.3 mmol/L)

• BHB level, home test: 11 mmol/L

Health history

Diet history

Medications

Social/other

Type 2 diabetes

Started TCR six weeks ago




How do you respond to this information?Q1:

Weight | weekly or monthly, not daily

Body fat percentage, lean body mass, waist circumference

Blood pressure | Self-check daily & communicate changes to provider

Blood glucose | Self-check daily & communicate changes to provider

Follow-up measurements

1125.1.1 Metrics to followTherapeutic Carbohydrate Restriction CME


Follow-up labsFasting glucose

Ketones

HbA1c

Fasting lipids

Transaminases

Fasting insulin/HOMA-IR

Self-check daily if on diabetes meds; weekly otherwise

Self-check daily if on diabetes meds; weekly otherwise

Recheck at 12 weeks, then every 3-12 months


Recheck at 12 weeks, then annually


TSH Check only if symptoms of hypothyroidism are present

Elevated fasting glucose (100 - 125 mg/dL or 5.6 - 6.9 mmol/L)

Normal HbA1c

Normal preprandial and postprandial glucose levels

“Dawn effect”



100 mg/dL (5.6 mmol/L) or lowerNormal

Prediabetes

Diabetes

100 to 125 mg/dL (5.6 to 6.9 mmol/L)

126 mg/dL (7.0 mmol/L) or higher

140 mg/dL (7.8 mmol/L) or lower

141 to 199 mg/dL (7.8 to 11.0 mmol/L)

200 mg/dL (11.1 mmol/L) or higher

Fasting blood sugar 2-3 hours after eating

For perspective, review weight loss from the start.

Identify other health metrics that have improved.

Look for “non-scale victories.”

Identify time frame of “stall.”

When weight loss seems to stall:

1165.1.3 Troubleshooting weight lossTherapeutic Carbohydrate Restriction CME


Snacking

Troubleshooting weight loss

1

Prioritize protein!

Average of 1.2 - 1.7 g/kg of “reference body weight”

Usually equates to about 70 - 120 grams of protein per day

Patients should try to evenly distribute protein among meals

For example:

Three meals/day = 25 - 35 grams of protein/meal

Two meals/day = 45 - 50 grams of protein/meal



Snacking


1

Protein2

Carb and calorie “creep”Focus on whole foods; avoid “keto” treats; eliminate “MCT coffee”

3


Snacking


1

Protein2

Issues not related to diet4


Activity, sleep, stress, medications, other medical issues

3

Snacking


1

Protein

Unrealistic goals

2

Issues not related to diet4

5


Activity, sleep, stress, medications, other medical issues

3


1225.2.1 Long-term maintenanceTherapeutic Carbohydrate Restriction CME

Use individualized approach

What happens to targeted biomarkers?

What is the patient’s relationship to carbohydrate foods?

What is the patient’s physiological carbohydrate tolerance?

What, if any, dietary restrictions are needed to maintain health?

For long-term maintenance

1235.2.2 ReimbursementTherapeutic Carbohydrate Restriction CME

Medicare reimbursement for patients with BMI > 30

One face-to-face visit every week for the first month

One visit every other week for months 2 through 6

One visit per month in months 7 through 12

Intensive behavioral therapy for obesity:

Reimbursement codes:

15 minutes of one-on-one counselingCPT G0447

G0473 Groups of 2-10 people.

1245.2.3 Reversal and remissionTherapeutic Carbohydrate Restriction CME

1255.2.3 Reversal and remissionTherapeutic Carbohydrate Restriction CME

Type 2 diabetes outcome Criteria and cut-offs used

HbA1c below 6.5% (7.8 mmol/L; 47.4 mmol/mol) without any diabetes medication, except metformin

Two HbA1c measurements 5.7 - 6.5% (6.5 - 7.8 mmol/L; 38.8 - 47.4 mmol/mol) Over the course of 1 year No medications

Two HbA1c measurements below 5.7% (6.5 mmol/L; 38.8 mmol/mol) Over the course of 1 year No medications

Reversal

Partial remission

Complete remission




Health history

Clinical

Medications

Type 2 diabetes; orthopedic surgeries


8.2 %(10.5 mmol/L)


FBG HDL

ALT 88 U/L

Creatinine 1.4 mg/dL

(123.8 µmol/L)178 mg/dL


(0.84 mmol/L)

5’10” (178 cm)

288 lbs (130 kg)

43 inches (109 cm)

144/88 mmHg

Height


Weight

Waist circumference

Blood pressure



• Atorvastatin, 20 mg daily• Metformin, 500 mg twice daily

Clinical

Medications

288 lbs (130 kg)

8.2 % (10.5 mmol/L)



210 mg/dL (2.37 mmol/L)

88 U/L

5.4, 5.5% (6.0, 6.2 mmol/L)



87 mg/dL (0.98 mmol/L

28 U/L

43 inches (109 cm)

144/88 mmHg

215 lbs (97.7 kg)

36 inches (91 cm)

118/76 mmHg

Baseline

Baseline

Current

Current

Lab

Weight

Waist circumference

Blood pressure

HbA1c

LDL

HDL

TG

ALT


Case study: Patient 7 follow-up


Does he meet criteria for reversal or remission of his diabetes?

Q1:


Type 2 diabetes outcome Criteria and cut-offs used

HbA1c below 6.5% (7.8 mmol/L; 47.4 mmol/mol) without any diabetes medication, except metformin

Two HbA1c measurements 5.7 - 6.5% (6.5 - 7.8 mmol/L; 38.8 - 47.4 mmol/mol) Over the course of 1 year No medications

Two HbA1c measurements below 5.7% (6.5 mmol/L; 38.8 mmol/mol) Over the course of 1 year No medications

Reversal

Partial remission

Complete remission


Would you stop his metformin at this time?Q2:




Low-fat, high-carbohydrate diet

15 minutes of walking per day

• Lisinopril, 10 mg daily

• Metformin, 500 mg twice daily

Health history

Clinical

Diet history

Medications

Tests

Social/other


Ultrasound


6.3%(7.5 mmol/L)


FBG HDL ALT 78 U/L118 mg/dL(6.6 mmol/L)



5’2” (155 cm)

172 lbs (78 kg)

38 inches (96.5 cm)

142/88 mmHg

Height


Weight

Waist circumference

Blood pressure




TCR for 6 months; initially lost 24 lbs (11 kg); has started to regain weight

• Coffee with butter and MCT oil twice per day

• Snacking on keto treats once or twice per day

• Drinking 1-2 glasses of wine 3 nights per week

Health history

Diet history

Social/other


• Lisinopril, 10 mg daily• Metformin, 500 mg twice daily • Metformin, 500 mg twice daily

Clinical

Medications

172 lbs (78 kg)

6.3% (7.5 mmol/L)



210 mg/dL (2.37 mmol/L)

78 U/L

5.5% (6.2 mmol/L)

106 mg/dL (2.78 mmol/L)



30 U/L

38 inches (96.5 cm)

142/88 mmHg

153 lbs (69.5 kg)

33 inches (84 cm)

127/66 mmHg

Baseline Current

Lab

Weight

Waist circumference

Blood pressure

HbA1c

LDL

HDL

TG

ALT

118 mg/dL (6.6 mmol/L) 97 mg/dL (5.4 mmol/L)FBG




Does she meet the criteria for a weight loss stall?Q1:


What do you think are the three most likely factors contributing to her recent weight gain?

Q2:


What do you think about her weight goal of 120 pounds (54 kg)?

Q3:

5.4 Summary





MODULE 4: Administering TCR


Please see supplemental course materials for: • clinician resources • patient resources • complete list of references included in this course • additional information on therapeutic

carbohydrate restriction

treating metabolic syndrome, type 2 diabetes, and obesity with … · 2020-03-04 · treating...

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