Author: Dr. Christina De Avila, ND CDE

Metabolic health, especially as it relates to blood sugar regulation, is a fundamental pillar of health. It directly impacts our energy levels, mood, weight, immune function, nervous system, hormones, and even our sleep quality. Based on the Diabetes in Canada report published in 2020, 29% of Canadians live with diabetes or prediabetes and 7.0% live with high blood glucose.¹ These are alarming statistics as this comes with increased risk of heart attack, blindness, kidney failure, nerve damage, and amputation.

Are we missing the mark when it comes to preventative screening?

Doctors generally diagnose diabetes by measuring fasting blood glucose and HbA1C, however, normal values for these two parameters does not mean optimal metabolic health. Additional investigations should include the main hormone involved in blood sugar regulation, insulin. ‘Considerations for both tests [HbA1C and fasting insulin] combined identifies highly increased risk for future Type 2 Diabetes in the great majority of white individuals, even those with apparently normal HbA1C’.² Assessment of insulin, fasting and/or with a glucose challenge, allows for the detection of insulin resistance which precedes the development of type 2 diabetes by 10-15 years.³ Imagine how many people could avoid developing diabetes if they had 10 years to work on it!

What is insulin resistance?

Insulin resistance is a state of impaired biological response to insulin of target tissues, specifically fat, liver, and muscle. At its simplest, this means insulin is less effective at getting glucose out of the blood and into cells. It can present as a wide spectrum of metabolic consequences including:

• Obesity
• Cardiovascular disease
• Metabolic fatty liver disease (previously known as non-alcoholic fatty liver disease)
• Polycystic ovarian syndrome (PCOS)

Type 2 Diabetes can be considered the end state of insulin resistance, the point at which blood sugar levels rise and fall within diagnostic criteria as outlined below⁴:

• Fasting plasma glucose greater than or equal to 7.0mmol/L or
• HbA1C greater than or equal to 6.5%
• Random plasma glucose greater than or equal to 11.1mmol/L

What causes insulin resistance?

Insulin resistance is multifactorial and often results due to the presence of blood sugar dysregulation, mitochondrial dysfunction, and inflammation. Nutritional and lifestyle practices are main contributors including:

• High simple carbohydrate intake (e.g., bread, rice, sugar, juice)
• Low physical activity
• Weight gain especially around the midsection
• Poor sleep quality (and the presence of obstructive sleep apnea)

Nonetheless, it is important to remember biological processes are never so straightforward and the development of insulin resistance is no different. Additional considerations include:

• Prolonged use medications such as proton pump inhibitors (PPIs) and statin therapy
• Compromised methylation (MTHFR)
• Bile acid metabolism
• Microbiome and dysbiosis (small intestinal bacterial overgrowth)
• Low grade chronic infections

What can you do to support your metabolic health?

Commit and stay consistent with the fundamentals including:

• Eat your fruits and vegetables! They are rich in vitamins, minerals, fibre and most importantly polyphenols which have been shown to increase Akkermansia muciniphila which reduces risk of obesity, inflammation, and insulin resistance.
• Move your body. When it comes to insulin sensitivity, muscle mass is key and general recommendation encourages at least two sessions of strength/resistance training a week for adults.
• Sleep. Matthew Walker, PhD highlights that ‘Inadequate sleep—even moderate reductions for just one week—disrupts blood sugar levels so profoundly that you would be classified as pre-diabetic.’⁵

For everything else, work with a naturopathic doctor or practitioner that will support you in going beyond what is ‘normal’ and takes a proactive and functional approach to metabolic health.

1. Diabetes in Canada: Backgrounder. Ottawa: Diabetes Canada; 2020
2. Meigs JB et al. Simultaneous Consideration of HbA1c and Insulin Resistance Improves Risk Assessment in White Individuals at Increased Risk for Future Type 2 Diabetes. Diabetes Care (48), 2020.
3. Freeman & Pennings. Insulin Resistance. PMID: 29939616
4. Diabetes Canada – Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome
5. Matthew Walker, PhD. Why We Sleep: Unlocking the Power of Sleep and Dreams. Scribner, 2017.

 

Glucose management generally focuses on what we eat. However, when we eat is now recognized to be significant as well. With around-the-clock accessibility of highly palatable foods (i.e., processed and refined products, pop), excessive exposure to artificial blue-light from
screens, and increased demands to squeeze as much as possible into the 24-hour day, we have weakened our connection to nature and disrupted our internal clock. ‘The lack of alignment with the circadian clock has been reported to influence food intake, glucose metabolism, weight regulation and obesity’ (Henry et al., 2020). This is important to consider given that diabetes mellitus continues to be a leading chronic disease worldwide and dietary interventions remain a cornerstone in diabetes prevention and management.

Beyond calories and macronutrient breakdown, the field of chrononutrition looks at the relationship between circadian rhythms and food intake and how meal timing affects metabolism (Adafer et al., 2020). Eating patterns have shifted with the majority of calories being consumed later in the evening. This sets the stage for metabolic dysfunction since the hormones involved in glucose metabolism, such as insulin produced by the pancreas, typically peak during day-light hours. A cohort study investigating the relationship between late-night-dinner and glycemic control in people with type 2 diabetes found that consuming dinner after 8pm is a risk factor for poor glycemic control (Sakai, 2018).

Figure: Chrononutrition plays a role in regulating circadian rhythms that influence metabolic health and risk of diabetes mellitus (Henry et al., 2020).

Time-restricted eating (TRE) focuses on the time during which food is consumed, usually within a 4-12 hour period, resulting in a state of fasting over a 12-20 hour period. Within the eating window, individuals are to eat without any restriction on the quality or quantity of food intake, however reduced caloric consumption by 20% on average is observed, without an alteration of macronutrient distribution (Adafer et al., 2020). Based on the systematic review of TRE on human health, benefits include:

• Weight loss (specifically reduction in body fat)
• Decreased fasting glucose and insulin resistance
• Reduced cardiovascular risk (triglycerides, total cholesterol, systolic and diastolic blood pressure)
• Improved sleep quality and quantity
• Increased energy, alertness, and focus

TRE is a simple and cost-effective lifestyle practice to harness your circadian rhythm so you can align with your hormones, optimize metabolic health, and improve glucose management. Check out Satchin Panda’s myCircadianClock for feedback on your eating, sleeping, and activity patterns and remember…

1. First morning sunlight exposure. Light/dark cues are important to maintain the relationship between circadian systems and energy homeostasis (Oike et al., 2014).
2. Time-restricted eating. Consuming meals within an 8 to 10-hour eating window supports metabolic health and blood sugar regulation.
3. Minimize blue light at night. Blue light exposure can impact the production of melatonin, our sleep hormone, contributing to sleep disturbances and increased oxidative stress.
4. Avoid eating 2-3 hours before bedtime. This promotes initiation and maintenance of sleep and fasting overnight which is associated with lower systemic inflammation reducing the risk of metabolic diseases.

 

References:

Adafer R et al. Food Timing, Circadian Rhythm and Chrononutrition: A Systematic Review of Time-Restricted Eating’s Effects on Human Health. Nutrients. 2020 Dec; 12(12): 3770.

Henry, C.J., Kaur, B. & Quek, R.Y.C. Chrononutrition in the management of diabetes. Nutr. Diabetes 10, 6 (2020). https://doi.org/10.1038/s41387-020-0109-6

Oike, H., Oishi, K. & Kobori, M. Nutrients, Clock Genes, and Chrononutrition. Curr Nutr Rep 3, 204–212 (2014). https://doi.org/10.1007/s13668-014-0082-6

Sakai, R. et al. Late-night-dinner is associated with poor glycemic control in people with type 2 diabetes: The KAMOGAWA-DM cohort study. Endocr. J. 65, 395–402 (2018).

 

FACT: 50-60% of type 2 diabetes may be preventable by eliminating modifiable risk factors such as physical inactivity, low vegetable and fruit consumption, and tobacco smoking.  (Public Health Ontario)

The technology we have all come to take for granted in our day-to-day life has recently found a new application: harnessing the power of personalized data-driven medicine to improve our health!

Behaviour change works best when it is informed by the best expert of what is good for you – your body. We are all able to tune into what our body is telling us, but today’s technology allows us to eliminate the guesswork. We now have at our fingertips precise information on our resting heart rate, heart rate variability, energy expenditure, and sleep quantity and quality. Using this information empowers individuals to tailor nutrition and lifestyle for maximum benefit.

Frontiers in Endocrinology published a study with results showing a positive association with the use of apps supporting changes in lifestyle and glucose monitoring, for both individuals living with type 1 and type 2 diabetes (Kebede and Pischke, 2019).

So, whether you are someone who has a strong family history of metabolic disease looking to adopt preventative healthy lifestyle habits or are currently engaged in diabetes management, here are three technology tools to support awareness, inform health promoting behaviour change, and optimize blood glucose control.

Nutrition Tracker:

Options: myfitnesspal, Cronometer, Lose It, Carb Manager

Diabetes is defined as a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine. This is why the amount and type of food we consume on a daily basis is a fundamental determinant of health and blood sugar regulation.

By looking beyond calories in and calories out, we gain deeper insights when focusing on the breakdown of key nutritional elements including macronutrients (carbohydrates, protein, and fats), micronutrients (e.g., iron, calcium, magnesium), and fibre intake. This in turn will allow any gaps to be identified and determine which meals, based on blood glucose readings, may be negatively effecting blood sugar metabolism.

Traditional Self-Monitoring Blood Glucose (SMBG) or Continuous Glucose Monitors (CGMs):

Options: Dexcom, Freestyle Libre, One Touch, Contour Next Ez

At any given point in time, our body is undergoing homeostatic processes to maintain a stable internal environment. When it comes to blood sugar regulation, this translates to the release of insulin from the beta cells of the pancreas to support the removal of sugar out of the bloodstream and into the cells for energy production or storage.

Compared to traditional glucometers that provide a snapshot, CGMs provide in real-time dynamic information which provides insight to current blood glucose status, predictive and overall trends, and total time spent in range. Monitoring blood glucose provides feedback on how nutrition, exercise, and even sleep impacts blood sugar and is most effective when combined with educational programs that guide people living with diabetes on healthy behaviour changes in response to blood glucose levels (Diabetes Canada Guidelines, 2019). These tools provide information but we must interpret and act on that data appropriately.

Fitness/Sleep Wearables:

Options: FitBit, Apple Watch, Whoop, Oura

Wearable technology has grown tremendously within the last few years and provides a vast amount of information including resting heart rate, calories burnt during a workout, sleep quality and quantity that can be tracked over time.

Wearables nudge us to stand up and move when we have been sitting around for too long, celebrate milestones with a little ‘HOORAY!’ when we achieve 10,000 steps, and also allow you to share your data with friends, which is one of the most powerful evidence-based behaviour change techniques!

Technology, Behaviour Change, and Preventing Type 2 Diabetes

When it comes to creating change in the incidence and prevalence of metabolic conditions such as type 2 diabetes, these three tools are powerful to support effective behaviour change in addressing modifiable risk factors. We cannot change what we do not know and the first step is cultivating awareness, understanding where we are, and the steps we need to take to support our health and wellbeing. As James Clear, author of Atomic Habits, said “if you get one percent better each day for one year, you’ll end up thirty-seven times better by the time you’re done”.