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I've was diagnosed a diabetic in 2015 although I see that my morning blood sugar back when I first started tracking it in 2002 was higher than it is today. Since diabetes was common in my family, it thought it would be wise to start measuring it early but I really had no idea about it. I've learned since that diabetes runs in families because diets run in families and often for generations. Diabetes is the condition of having Glycated Hemoglobin (aka HbA1c: hemoglobin A1c) of ≥6.5% and the Canadian Diabetes Association Guidelines define HbA1c for diabetes:

<5.5 % Normal
5.5% - 5.9 % At risk
6.0% - 6.4 % Prediabetes
≥6.5 % Diabetes

However, elevated blood sugar (serum glucose) is only one part of Metabolic Syndrome and the International Diabetes Federation 2006 consensus worldwide definition of metabolic syndrome is:

Central obesity (defined as BMI is >30 kg/m² or a ethnicity-specific waist circumference)

AND any two of the following:

Raised triglycerides: > 150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality
Reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females, or specific treatment for this lipid abnormality
Raised blood pressure (BP): systolic BP > 130 or diastolic BP >85 mm Hg, or treatment of previously diagnosed hypertension
Raised fasting plasma glucose (FPG): >100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes

Dr Sarah Hallberg’s Ted talk first got me seriously thinking about reversing diabetes in 2018. Dr Hallberg runs a diabetes reversal clinic at Indiana University Health - Arnett through Virta Health. As I learned more about metabolic metabolic health, I realized that this wasn't all that hard to do and for a variety of reasons, the health system is geared towards chronic disease treatment rather than prevention.

DISCLAIMER: My background is engineering and what I have written here is from my personal interest in staying healthy. If you disagree with any of it, let know what you feel is inaccurate and include some references so I can make corrections. This is a work in progress so check back often for updates as I continue to learn. CONSULT WITH YOUR DOCTOR BEFORE MAKING DIET AND LIFESTYLE CHANGES.

There are two kinds of diabetes: Type 1 and Type 2. Type I Diabetes (aka Diabetes Mellitus Type 1, DM1, T1D) is an autoimmune disease but Type II Diabetes (aka Diabetes Mellitus Type 2, DM2, T2D) is more of a lifestyle disease that can be controlled with diet and exercise. Insulin Resistance is the body's inability to properly utilize insulin and the main cause of Type 2 Diabetes. Pre-Diabetes is a condition where your blood sugar is higher than the normal range but below the diabetic range and requires increasingly greater amounts of insulin for control. Obesity can be a side effect of insulin resistance and, to add insult to injury, obesity adversely affects Type 2 Diabetes because it increases insulin resistance. Not sure if you're insulin resistant? Your body has a couple of obvious signs of this condition: skin tags and dark skin creases (Acanthosis Nigricans).

People are often considered to be genetically predisposed to Type 2 Diabetes and health professionals want to know if Diabetes runs in your family. Since a majority of the North American population has Diabetes or Pre-Diabetes, I would argue that Type 2 Diabetes is normal response to an unhealthy, carbohydrate-rich diet prevalent in developed countries. I think that people who can tolerate a high carbohydrate diet without developing insulin-resistance are the exception rather than the rule. Dr Robert Lustig of UCSF suggests that Type 2 Diabetes should be more accurately labeled as Processed Food Disease.

In contrast to conventional medical advice, many doctors (including Dr Sarah Hallberg, Dr Jason Fung, Dr Paul Mason) believe that Type 2 Diabetes is a reversible condition that CAN be cured with a low carb diet and Dr Fung is a proponent of therapeutic intermittent fasting. Unlike caloric reduction, intermittent fasting doesn't reduce the basal metabolic rate. A ketogenic diet is compatible with low carbohydrate consumption and works well with fasting. Dr Fung says that it isn't easy to regularly fast, presumably because extended periods of hunger can be somewhat uncomfortable, although he says that it is easier to fast while on a ketogenic diet. Hunger typically comes in waves due to the hormone Ghrelin and peaks during accustomed eating times and will dissipate until the next meal time. If you're going to try fasting, make sure that your body has become accustomed to a low-carb diet.

Being Type II diabetic now, I've been reading up on leading a healthy lifestyle and I've learned a few things. In no particular order:

Understanding the role of pancreatic hormones (insulin and glucagon) is crucial in achieving overall health.
Exercise has great health benefits but isn't very effective in rapid weight-loss.
A healthy diet and lifestyle result in longevity, of which a healthy weight is a characteristic.
No-one becomes overweight overnight and the weight you've gained over the years should be shed slowly.
Your body is extremely good at energy conservation. If you lose weight too quickly, your body will reduce its metabolic rate and make weight loss even more difficult.
The body's mechanism for reducing the basal metabolic rate in order to conserve energy is the Famine Response.
Snacking between meals keeps insulin at a continuously high level and inhibits the body's ability to burn fat.
Snacking on low-glycemic index foods can still affect blood sugar and weight if consumed in excess. Don't eat if you're not hungry!
Gut health is extremely important and you need to keep your microbiome healthy and well nourished.
A good attitude is important. It is better to have positive thoughts that you are becoming healthier or more attractive than to to have negative thoughts about having a deadline for losing weight.
Muscle is a denser tissue than fat so it is possible to become heavier even though you're becoming leaner, especially if you also engage in weight-training.

References

The human body converts ingested carbohydrates to GLUCOSE, which is a simple sugar molecule used as energy in the bloodstream. There are there are two types of sugars: simple sugars (monosaccharides) and compound sugars (disaccharides). Oligosaccharides are short-chain carbohydrates containing 3-9 monosaccharide units. Polysaccharides are long chains of monosaccharides are often longer than 10 monosaccharide units and can either occur naturally or be manufactured for use as food additives.

Monosaccharides

Fructose: occurs naturally in fruits, some root vegetables, cane sugar and honey and is the sweetest of the sugars. It is known as fruit sugar and is one of the components of sucrose. It is used as a high-fructose syrup, which is manufactured from hydrolyzed corn starch that has been processed to yield corn syrup, with enzymes then added to convert part of the glucose into fructose. Agave Syrup is another high-fructose sweetener commonly added to foods.
Galactose: is generally found as the other half of lactose (milk sugar) and is less sweet than glucose. Interestingly, galactose is a component of the antigens found on the surface of red blood cells that determine your blood t ype.
Glucose: occurs naturally in fruits and plant juices and is the primary product of photosynthesis but can also be manufactured from starch by enzymatic hydrolysis. It was originally found in grapes and dextrose (manufactured from corn starch) is similar in structure.

Disaccharides

Lactose: (galactose + glucose) occurs naturally milk. It is broken down into its constituent parts by the enzyme lactase during digestion. Children have this enzyme but some adults no longer form it and they are unable to digest lactose. The ability of adults to produce lactase is known as lactase persistence and people who are lactose-intolerant can consume some dairy products (eg, some yogurts and cheeses) because the fermentation process converts lactose into lactic acid. Bacteria in the microbiome may also help to digest lactose.
Maltose: (glucose + glucose) is formed during the germination of certain grains (eg. barley), which is converted into malt, the source of the sugar's name. Maltose is less sweet than glucose, fructose or sucrose. It is formed in the body during the digestion of starch by the enzyme amylase and is itself broken down during digestion by the enzyme maltase
Sucrose: (fructose + glucose) is found in the stems of sugarcane and roots of sugar beet. It also occurs naturally in some fruits and roots (like carrots) alongside fructose and glucose. The range of sweetness depends upon the proportions of sugars found in these foods. Sucrase enzymes split sucrose into its constituent parts during digestion.

Oligosaccharides

Maltodextrin is a food additive that can be 3 to 17 monosaccharide units derived from starch. Its sweetness depends on the length of polymerization with shorter chains having higher sweetness and solubility.

Polysaccharides

Storage Polysaccharides

Starch
Glycogen (sometimes known as animal starch)

Structural Polysaccharides

Arabinoxylan
Cellulose
Chitin
Pectin

High Fructose Sweeteners

While fructose is commonly found in fruits, fruit contains small amounts and it is bound to dietary fibre. Food manufacturers like to use sweeteners containing high quantities of fructose (like High Fructose Corn Syrup) because it is sweeter than other sugars and cheaper to produce, which makes it a great processed food additive for manufacturers. Corn starch is readily converted to glucose with enzymes and this glucose is then processed into fructose. The danger to human health is that, while glucose can be metabolized throughout the body, fructose can only be metabolized in the liver into glycogen and triglycerides. The liver has a limited capacity to store glycogen and excess amounts result in fatty liver disease, which is commonly associated with metabolic syndrome (diabetes, hypertension, obesity, and dyslipidemia).

Excess levels of the following foodstuffs metabolized in the same way in the liver, overload mitochondria in tissues, and cause metabolic syndrome:

Transfats
Branched Chain Amino Acids (eg, protein powder, corn-feed beef, chicken, & fish)
Ethanol
Fructose

Process food manufacturers love to add fructose because it's cheap and sweet. FRUCTOSE FOOD ADDITIVES ARE TOXIC!

References

While all of the organs in the body work together, some organs have important roles in energy usage and storage.

Pancreas

The pancreas produces several hormones in specific cell areas known as pancreatic islets (islets of Langerhans). Glucagon is produced in alpha cells and Insulin is is produced in beta cells. Glucagon and insulin directly affect blood sugar and work opposite to each other. Insulin performs an anabolic function (synthesizing larger more complex modules from simpler ones, ie storing fat) where it stores glucose into adipose tissue while glucagon performs a catabolic function (breaking down of complex modules into smaller simpler ones, ie, burning fat) where it draws lipids out of adipose tissue and where they are ultimately converted them into ketones. Interestingly, insulin affects the entire body because pretty much every cell has an insulin receptor. Glucagon has no effect on muscle tissue.

Generally, high serum glucose levels cause the pancreas to secrete more insulin, which then signals other tissues like muscle and adipose tissue) to remove it. Low serum glucose levels cause the pancreas to secrete more glucagon, which signals adipose tissue to release lipids.

Muscle Tissue

One of the effects of diabetes is that muscle tissue has trouble getting glucose delivered across its cell membranes. Insulin can be considered a key that helps glucose to unlock the boundary and cross that membrane into the muscle cell. Glycolysis is the process that allows cells to convert glucose to ATP for cellular fuel.

Adipose Tissue

Fat in our bodies is stored in fat cells (Adipocyte) and the number of fat cells in adults is generally constant over their lifetimes. The number is set during childhood and adolescence, although obesity can cause the number of adipocytes to increase and fasting can cause the number to decrease. As your body digests food, excess glucose is stored as glycogen in the liver and skeletal muscle tissue but neither has a high glycogen storage capacity.

High glucose levels cause an increase in insulin (the fat storage hormone) and a decrease in glucagon (the fat burning hormone), which triggers Lipogenesis to then store triglycerides in fat cells . Insulin causes causes excess glucose to be stored in adipose tissue through lyposis. Acetyl-CoA is produced by the breakdown of both carbohydrates and lipids, which is then used to manufacture and store fat in both adipose tissue and the liver through Lipogenesis.

Low glucose levels cause an increase in glucagon and a decrease in insulin, which triggers the release of lipids from adipose tissue. As a result, the liver will manufacture ketones from those lipids through ketosis. The ketones in turn have an additional beneficial metabolic effect on adipose tissue in that it causes white fat to behave more like brown fat. The body uses the mitochondria in brown fat to generate heat and ketones cause the fat tissue to "waste" its stored energy as heat. Normally, mitochondria are "coupled" in that they only use as much fuel (glucose or ketones) as is necessary to manufacture ATP. Ketones tend to cause adipose tissue mitochondria to be "uncoupled" so that that they instead generate heat. Something to think about if your hands and feet are always cold.

Liver

The liver performs many tasks in managing energy usage in the body. The liver manufactures glycogen through Glycogenesis when IGR is high, which is used as a glucose energy reserve. When IGR is low, the liver uses Gluconeogenesis to manufacture glucose sourced from adipose tissue to maintain a minimum serum glucose level and it also uses the lipids in adipose tissue to manufacture ketones, which is the body's alternative fuel. While most tissues can use either glucose or ketones as fuel, only erythrocytes (red blood cells) must rely on glucose for fuel because they lack mitochondria and this conserves the oxygen they carry.

The body also excretes ketones through respiration (high ketone levels can result in "ketone breath") and urine, which adds another aspect to weight loss.

Insulin to Glucagon Ratio

The Insulin to Glucagon Ratio (IGR) determines whether the metabolism has a anabolic or catabolic tendency. The biochemical effects of insulin and glucagon are often antagonistic.

Process	Insulin Dominates (High IGR)	Glucagon Dominates (Low IGR)
Glycogenesis	Increased	Inhibited
Gluconeogenesis	Inhibited	Increased
Glycolysis	Increased	[no effect]
Glycogenolysis	Inhibited	Increased
Ketogenesis	Inhibited	Increased
Lipogenesis	Increased	Inhibited
Protein Synthesis	Decreased protein degradation	Increased amino acid uptake by liver; Decreased amino acids in plasma

Effects of Insulin and Glucagon on body tissues

Metabolic State	Muscle Tissue	Adipose Tissue	Liver
Anabolic High IGR	Glycogenesis Protein Synthesis	Lipogenesis	Lipogenesis Glycogenesis
Catabolic Low IGR	[no effect]	Lipolysis Brown Adipose Tissue Activation	Glycogenolysis Gluconeogenesis Lypolysis Ketogenesis

More information:

Having a healthy weight is a characteristic of a healthy lifestyle and should not be a goal in itself. Obviously, everyone knows that they should be doing things that are good for you and not doing things that are bad for you. One way to tell what things are good or bad is to look to groups who tend to have particularly long lifespans and a couple of them are people living in Japan (particularly Okinawa) and the Mediterranean (particularly Sardinia and Calabria in Italy and Icaria, Greece). Dan Buettner identified regions of exceptional human longevity in his article "The Secrets of a Long Life", which was the November 2005 cover story of National Geographic magazine. He found 5 locations (Blue Zones) with high incidences of centenarians:

Sardinia, Italy
The islands of Okinawa, Japan
Loma Linda, California, USA
Nicoya Peninsula, Costa Rica
Icaria, Greece

However, many Blue Zone areas have poor record-keeping and there may be an incentive for some people to report themselves to be older than actual. See The World's Oldest People Might Not Be As Old As We Think

Common characteristics of the older members (90+ years) of these areas include (See How to live to be 100+ - Dan Buettner):

Move naturally: use human power as much as possible, have physical activities you enjoy and don't be a couch potato.
Not smoking or smoking infrequently.
Have the right outlook
- Slow down & minimize stress in your life.
- Always have a sense of purpose in your life
Eat wisely
- Drink moderately: having red wine with dinner is good.
- Have a mainly plant-based diet with a high consumption of legumes.
- Avoid overeating: stop eating when you reach 80% full.
Connect
- Always put loved ones first.
- Belong to a faith-based community.
- Find the right tribe (healthy social circle) to run with. Unhealthy friends tend to result in unhealthy lifestyles.

More information:

Foods can be characterized with a Glycemic Index (GI), which is a scale that represents the rise in blood glucose 2 hours after the ingestion of a food. The Glycemic Index scale is from 0 to 100, where 100 is defined to be the effect of ingesting pure glucose. Any food that does not cause a rise in blood glucose will have a Glycemic Index of zero. A food's Glycemic Response is the food's effect on blood glucose levels over time, starting from the moment the food is consumed.

Sarah Hallberg (Medical Director of the Medically Supervised Weight Loss Program at IU Health Arnett) has the following Rules for Eating, which are consistent with the importance of glycemic response in Blue Zones diets:

If it says "light", "low-fat" or "fat-free", it must stay in the grocery store.
EAT FOOD.
Don't eat anything you don't like.
Eat when you are hungry. Don't eat when you are not.
NO GPS - No grains, potatoes, or sugar.

Ketogenic Diets are by definition low-carb and many people report excellent results with weight loss and improved blood sugar control with it. The only part of the body that absolutely requires glucose are erythrocytes (red blood cells) due to their lack of mitochondria. While weight loss and reduced insulin resistance are great benefits of a ketogenic diet, there can also some minor side effects such as "keto flu" (headaches, muscle cramps, brain fog, etc). Because insulin causes the body to retain water, lower insulin levels result in greater fluid excretion along with some electrolytes (ie, sodium). The loss of electrolytes causes keto flu symptoms and is remedied the consumption of salt. Ketogenic diets reportedly tend to absorb excess body proteins such as excess skin from weight loss and skin tags. The Adkins Diet is one type of low-carb diet and was popular at one of my workplaces several years ago. Although most people who tried it loved the resulting weight loss, no-one was able to stay on it for periods much longer than 6 months. I think the boss really liked it because it gave him the excuse to eat fried chicken all the time.

Dr Paul Mason states that a ketone meter is an excellent tool for finding the optimum level of carbohydrate restriction. His clinic regularly tests for ketone, which is the result of fat metabolism. He reports that higher ketone levels (0.4 mmol/L & higher) act as an appetite suppressant, which is obviously helpful in aiding weight loss by reducing your caloric intake. If you're a diabetic, you're probably already monitoring your blood glucose. Using your glucometer's ketone measuring capability, it is extremely useful to see the effect of various foods on your fat metabolism by keeping a food log correlated with blood ketone. If you don't have a glucometer, you can also measure ketones in your urine although less accurately. You can often get a free glucometer capable of reading ketones (like a FreeStyle Precision Neo and Libre) from your doctor or pharmacy with a coupon from Abbott Laboratories.

Glucose-Ketone Index (GKI) is a means of estimating your level of ketosis and is a unitless number based on mmol/L.
GKI = (serum glucose, mmol/L) / (serum ketone, mmol/L)

If you're using mg/dL for blood sugar, divide your reading by 18.016 to convert to mmol/L. Having any ketone measurement result above zero suggests to me that you have a low IGR, which will also tends to result in lower serum glucose levels. It's not that hard to reach 0.5 mmol/L of ketones without fasting so you would only need a blood sugar measurement of 4.5 mmol/L be in a low ketosis level, which can be maintained through gluconeogenesis on a low-carb diet. Normally, gluconeogenesis will maintain glucose at a level of 70-80 mg/dL (3.9-4.4 mmol/L) in a long-term fasted state using mainly lactate (eg, from muscles). A normal fasting blood glucose level falls within the range of 3.9 to 5.6 mmol/L although the normal lower limit is 3.3 to 3.9 mmol/L.

Symptoms of hypoglycemia don't usually appear until glucose levels have dropped to the range of 2.8 to 3.0 mmol/L (50 to 54 mg/dL). If you are experiencing any hypoglycemic symptoms (eg, nausea, lethargy, impaired mental functioning, irritability, headache, shaking, twitching, weakness in arm and leg muscles, pale complexion, sweating), eat some sugar (and stop fasting). If your blood sugar continues to drop, you risk confusion and unsteadiness and eventually the loss of consciousness when glucose levels fall below 2.2 mmol/L (40 mg/dL). Be aware that persistent exposure to hypoglycemia can potentially result in hypoglycemic unawareness and you may not notice any hypoglycemic symptoms but this appears to be rare for Type 2 Diabetics NOT being treated with insulin (ie, only with diet, exercise, or insulin-sensitizing medicine).

Nutritional Ketosis will typically result in ketone levels in the 0.5-5 mmol/L (with fasting glucose levels) compared to 15-25 mmol/L ketone levels (blood sugar typically over 13.8 mmol/L / 250 mg/dL) and for Diabetic Ketoacidosis.

The following table summarizes various ketosis states:

GKI	Ketosis Level	Description
>9	Not in Ketosis	Not in Fat-Burning Mode
6 - 9	Low	Weight loss
3 - 6	Moderate	Metabolic Syndrome Treatment
<3	High	Epilepsy & Cancer Treatment

More information:

The health of the microbes living in our gut is crucial to our health and well-being. The various areas of the body are populated with their own specific communities of microorganisms (microbiome). Two types of foods that influence human gut flora are:

Prebiotics - foods that are digested by bacteria in the colon, such as Resistant Starch and Dietary Fiber
Probiotics - foods that contain beneficial bacteria that are intended to improve the glut flora.

The effect of consuming probiotics is inconclusive about populating the gut. While the specific effects of the microbiome are not well known, having a healthy and diverse microbiome is desirable. Junk foods (highly processed, loaded with empty calories) should be avoided and eating foods with a high proportion of prebioitics will help keep the gut microbiome well nourished. Even though science writer Ed Jong is an expert in microbiomes and is familiar with probiotics, he eats yogurt because he likes the flavour and not because he expects any improvement in his own microbiome. Dr Paul Mason suggests that high amounts of dietary fiber are not necessarily conducive to weight loss or gut health.

The consumption of antibiotics (both therapeutic and dietary) should be done with care. Indiscriminate antibiotic use can be potentially be considered as "carpet bombing" the gut's microbiota and wiping out a large populations of both beneficial and harmful bacteria.

Lectins are carbohydrate-binding proteins and people can have a sensitivity to them that ranges from not at all to very. Lectins have been implicated in a variety of health issues including autoimmune diseases such as Inflammatory Bowel Disease and Type 1 Diabetes. Lectins can be factor in obesity due to their ability to bind to Leptin (a hunger-regulating hormone) and to stimulate insulin receptors in fat tissue. Lectin-rich foods (eg tomatoes, can stimulate histamine production in the stomach, thereby exacerbating acid-reflux (heartburn). Maybe the roasted peanuts (high-fat, low GI) that I like as a snack may not be an ideal diabetic snack.

Related to gut health is the notion to purge toxins from the body with a "cleanse". No-one that recommends a particular kind of cleanse ever states what toxins the cleanse will be removing nor are there any clinical studies to back up the recommendation. The body's natural toxin cleansing organ is the liver and it performs this task extremely well. Eating whole foods and avoiding processed foods minimizes the ingestion of toxins.

Another important consideration somewhat related to diabetes is Arteriosclerosis or hardening of the arteries. Atherosclerosis is a specific type of arteriosclerosis that involves a restriction in the flow area of the arteries resulting from a build-up of plaque (fatty deposits) on the arterial walls. This flow restriction can result in circulatory issues and severe cases can result in bypass surgery. While arteriosclerosis has a variety of causes, some of which are genetic and some are lifestyle-related. Lifestyle-related causes include:

Various forms of tobacco (and possibly similar non-tobacco) consumption.
Obesity, diabetes/insulin resistance.
High triglycerides & low HDL Cholesterol (as a result of insulin resistance)

The prevention of Arteriosclerosis is similar to the control of Type 2 Diabetes: not smoking and maintaining healthy weight. Maintaining a healthy weight requires a healthy diet and staying physically active.

I mention Arteriosclerosis because there has been some controversy about eating a low fat (and especially low cholesterol) diet in order to control [blood] serum cholesterol and triglycerides. There are 2 kinds of serum cholesterol: HDL (High-Density Lipoprotein: “good” cholesterol) and LDL (Low-Density Lipoprotein: “bad” cholesterol). While the American Heart Association maintains that LDL Cholesterol (LDL-C) causes plaque to form on arterial walls, this has been shown to false and people actually live longer with high LDL cholesterol levels. HDL Cholesterol (HDL-C) helps to scavenge some of the LDL from the bloodstream and carry it to the liver for excretion. Excess glucose (primarily from carbohydrates) in the body are converted into triglycerides and stored in fat cells throughout the body. The combination of low levels of HDL Cholesterol and high levels of Triglycerides have been linked to heart disease and the simplest way to control both is to maintain a low and steady baseline level of insulin.

While there are many kinds of dietary fat, they can simply categorized as either being saturated or unsaturated. Saturated meaning that the available molecular positions are occupied by hydrogen atoms and saturated fats are typically solids (as opposed to liquids) at room temperatures. Mono-unsaturated fats contain a single carbon double bond whereas poly-unsaturated fats contain two or more carbon double bonds. The length of the carbon chain in a fat affects how it is absorbed and metabolized. See Saturated Fat.

Fats (and oils) are composed of three fatty acid molecules combined with a glycerol (aka glycerin) molecule . Fatty acids are long, straight chain carboxylic acids and glycerol is an organic compound containing multiple hydroxyl groups. Omega-3 fatty acids are a particular kind of polyunsaturated (fat molecules that have more than one unsaturated carbon bond in the molecule) fatty acid that is important for normal metabolism and that the body is not able to manufacture. While Omega-3 fatty acids can be obtained from plant-based sources (such as seeds and nuts), fish (such as salmon, mackerel, tuna, herring, and sardines) are an especially rich source. The best forms of vegetable cooking oils are the ones that have a lower levels of Omega-6 fatty acids such as olive oil, avocado oil, coconut oil, and red palm oil. Good refined vegetable oil alternatives are canola oil and palm kernel oil. Although demonized by the Diet-Heart Hypothesis, animal fats (butter, lard, tallow, etc) are more stable at high temperature (because they're saturated) and are actually the healthier and tastier alternative. See Revision History: McDonald’s Broke My Heart.

The liver manufactures the majority (about 80%) of the cholesterol in your body with the remaining 20% coming from the food you eat. As a result, it is difficult to control LDL cholesterol levels purely by controlling saturated fat intake. A low-carb diet tends to increase LDL-C levels but research has shown that people with higher LDL-C levels tend to live longer and those with lower LDL-C levels tend to have more Cardiovascular Disease (CVD - including heart attack, angina (chest pain), and stroke). LDL-C is part of the immune system and works with macrophages (white blood cells) to kill infection. A Mayo Clinic Study (published in 2019-11) found that LDL-C was protective against death when people were diseased and, following a heart attack, people were 24% LESS likely to die with HIGH cholesterol.

Russian scientists in 1908 developed the Lipid/Cholesterol Hypothesis based on research involving feeding saturated fats to herbivores. Ancel Keys used the Lipid Hypothesis to develop the Diet-Heart Hypothesis (ultra low fat diet with avoidance of saturated fats) and cherry-picked data in his Seven Countries Study to support his hypothesis. The Diet-Heart Hypothesis is a key part of Canada's Food Guide and the US Food Pyramid, which also promote the Mediterranean Diet, which was first publicized by Ancel Keys. The 1968-73 Minnesota Coronary Experiment confirmed that a low saturated fat diet did in fact reduce serum cholesterol and showed a direct correlation between lower cholesterol and increased mortality. See also Revisionist History: The Basement Tapes.

Statins (eg, atorvastatin [Lipitor], fluvastatin [Lescol XL], lovastatin [Altoprev], pitavastatin [Livalo], pravastatin [Pravachol], rosuvastatin [Crestor, Ezallor] and simvastatin [Zocor, FloLipid], etc) are regularly prescribed to lower LDL cholesterol levels but are minimally effective in improving lifespan (statistically only a few days). The side-effects of Statins are significant and can include insulin resistance (diabetes), Coenzyme Q10 deficiency, cancer, low testosterone/erectile dysfunction, liver disease, kidney disease, muscle atrophy, cataracts, mitochondrial dysfunction, dementia, etc. For those on a low-carb diet, statins also appear to reduce ketone body production. The adverse effects of taking statins appear to outweigh the trivial extension in lifespan and appear to be most beneficial those who maintain an unhealthy diet and lifestyle.

Coronary Artery Calcium score (CAC) is a much better indicator of arteriosclerosis than traditional risk factors. The lower the score, the better and it is possible to have a CAC score of zero. Statins do not appear to have any effect on CAC progression. The prevention of CAC is not well understood but there has been research linking gut bacteria to plaques.

There are 7 types of LDL cholesterol (LDL-1, LD-2, LDL-3, ... LDL-7). Pattern A LDL cholesterol consists of Types 1 & 2 (LDL-1, LDL-2), which are benign and the good forms of LDL cholesterol while Pattern B consists of the remaining Types 3-7, which are the bad forms. The main risk from high levels of LDL cholesterol is that glycation of the Pattern A LDL from high levels of blood sugar which converts cholesterol to the Pattern B LDL. High levels of Pattern B cholesterol are the ones that form the plaques in Atherosclerosis. Increasing blood glucose levels tends to increase LDL glycation so this is another excellent reason to keep blood glucose in control. Glycated LDL molecules (Pattern B) become more damaged when they are oxidized and they are more prone to oxidation in the presence of oxidized (rancid) Omega-6 fatty acids.

While Lipids are frequently tested in Laboratory Blood Work, doctors generally do not request the advanced lipid particle size test (Lipid Electrophoresis: a lipid subfraction test) that identifies the LDL type proportions (ie, Pattern A & B). A good way to estimate whether you have Pattern A or Pattern B is through the Triglyceride and HDL tests. LifeLabs indicates a target range of <1.71 mmol/L of Triglycerides and >1.29 mmol/L of HDL Cholesterol in their Lipid Tests.

Lipid Test	High Likelihood of Primarily Pattern A LDL-C	High Likelihood of Primarily Pattern B LDL-C
Triglycerides Target: <1.71 mmol/L	<0.5 mmol/L <9.0 mg/dL	>2.0 mmol/L >36 mg/dL
HDL Cholesterol Target: >1.29 mmol/L	>1.5 mmol/L >27 mg/dL	<0.4 mmol/L <7.2 mg/dL
Triglyceride/ HDL-C Ratio Calculation	<0.8 mmol/mmol <1.8 mg/mg	>1.8 mmol/mmol >4 mg/mg

Eggs can be good source of Omega-3 fatty acids if the chickens are fed an enriched diet. While eggs contain both unsaturated and saturated fats, the saturated fats in eggs tend to have a high HDL to LDL ratio. Even so, for many years the American Heart Association recommended the consumption of egg per day (or a total of 7/week) as a safe limit for healthy people, while a somewhat lower consumption (up to a total of 4/week) has been recommended for diabetics, but they have now dropped these recommendations. Since eggs have a glycemic index of zero, egg consumption (without the customary accompanying toast/potatoes) reduce blood sugar levels, which would in turn reduce the risk of cardiovascular disease. If you're already on a low-glycemic-index-carb/high-fat diet and your blood sugar is under control, it would appear that egg consumption would actually be beneficial part of your diet.

Trans Fats are generally vegetable oils that have been partially hydrogenated but some animal fats (eg, beef fat & dairy fat) also contain small amounts of trans fats. Saturated fats are fully hydrogenated. Hydrogenation make vegetable oils more stable and rancid-resistant. Trans Fats have adverse effects on human health and their consumption should be avoided or at least minimized. Trans Fats are bad because they simultaneously raise LDL and lower HDL cholesterol and they contribute to insulin resistance and create inflammation.

Glucose Pathology

Glycated Proteins (Advanced Glycation End-products - AGEs) have a multiple of nasty effects in the body in addition to damaging LDL cholesterol from healthy Pattern A to CVD-causing Pattern B. Related to Cadiovascular Disease is peripheral artery disease (blockage in arteries leading to the limbs) and carotid artery disease (blockage in arteries leading to the brain). High blood glucose is responsible for also causing:

Retinopathy - damage to blood vessels in the retina
Nephropathy - damages to the tiny filtering units of the kidney
Neuropathy - damage to nerves, often causing a loss of sensation in the feet and toes
Microvascular Disease - damage to capillaries
Pancreatic beta cell dysfunction and necrosis
Osteoarthritis - damage to cartilage
Fibromyalgia - widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues
Cancer - links between obesity and cancer.
Premature Aging - premature cellular senescence in human skin fibroblast and higher degree of collagen cross-links
Gout - crystals resulting from high uric acid levels and glucose
Polycystic ovarian syndrome & benign prostatic hyperplasia (prostate enlargement)

Researchers have found a link between Alzheimer's Disease and insulin resistance and some have gone as far as identifying Alzheimer's Disease as Type 3 Diabetes. See Dementia.

Insulin Pathology

People being treated for Type 2 Diabetes with insulin injections often require increasingly higher doses of insulin to combat insulin resistance. While high blood sugar is damaging to tissues, high levels of insulin are also damaging to some tissues.

Hypertension - high blood pressure
Baldness - early-onset androgenetic alopecia in both men and women
Low testosterone (Male Hypogonadism)
Kidney Stones (Nephrolithiasis)
Leptin Resistance - inability to sense when caloric needs are satisfied, leading to overeating
mTOR activation - amplifies aging effects, contributes to the initiation and development of tumors

More information:

It is obvious that, if you don't eat, you'll lose weight but this is easier said than done. Many people have not had success by restricting calories because the glucose-adapted body responds to a reduced calorie intake by reducing its basal metabolic rate through the Starvation (Famine) Response. Fasting is voluntary form of starvation, which has been commonly practiced throughout history. Intermittent Fasting is often done today for therapeutic reasons - often to treat or prevent Metabolic Syndrome but there are other benefits as well. Intermittent fasting shifts the body from using glucose as its main source of fuel to ketones and ketone usage tends to maintain or increase the basal metabolic rate (eg, though the uncoupling of adipose tissue mitochonria) while also suppressing appetite, likely because fasting affects the timing of caloric consumption rather than the amount.

The key to avoiding Metabolic Syndrome is keeping insulin levels low and constant. Because insulin is produced by the pancreas in response to serum glucose, the obvious thing to do is restrict carbohydrate intake. Excess dietary carbohydrates are stored in the liver and muscle tissue as glycogen and, since these tissues have a limited storage capacity, the remaining are then stored in adipose (fat) tissue. It normally takes a few hours of fasting to deplete the body's glycogen stores and, as this happens, insulin levels will fall and glucagon levels will rise. With a low Insulin to Glucagon Ratio (IGR), ketone levels will increase and the body will be in fat-burning mode. This reality means that are essentially two metabolic states: FED (high IGR) and FASTED (low IGR). A low carb diet tends to keep glycogen stores low, which in turn allows the body to return to a fasted state much quicker.

Rapamycin is a macrolide first isolated in 1972 and was initially found to inhibit fungal activity. In the early 1990s, several researchers (including Dr David Sabatini) found a biological process that is sensitive to Rapamycin, which was eventually named Target of Rapamycin (TOR) and the process specific to mammals was named Mammalian Target of Rapamycin (mTOR). mTOR is a protein kinase that regulates cellular pathways (including cell, organ, and body growth) in mammals and has many inputs and outputs - basically any process that consumes or produces large amounts of energy/nutrients. One of the inputs is metabolic state (fed or fasted) and some of the outputs are Autophagy (recycling of proteins) and Mitophagy (recycling of mitochondria). The human body contains an mTOR (mechanistic Target Of Rapamycin) gene. Being in fasted state inhibits mTOR with the beneficial effect of increased lifespan and decreased tumor growth. Increased mTOR activity has been implicated in central nervous system disorders (eg, Autism, Alzheimer's Disease, Parkinson's Disease). Although there are no tests for autophagy, autophagy is the mechanism that enables the body to absorb excess skin tissue so that extreme weight loss does not result in flabby loose skin.

Dr. Valter Longo's research found that prolonged fasting can remove damaged cells and regenerate new cells. Research on the Little Women of Loja, Ecuador found that their growth hormone-receptor deficiency (IGF-1) gave them a long lifespan and low risk of cancer and diabetes. Research into starved organisms found that amino acids activate the TOR pathway related to IGF-1 and glucose activates the PKA pathway to accelerate aging. A normal diet causes IGF-1 and PKA genes to stall stem cell production. Fasting causes old and dysfunctional cells to be recycled through autophagy and refeeding activates stem cell growth, thereby causing a rejuvenating effect.

Dr Longo developed the Fasting Mimicking Diet (FMD) to treat a variety of diseases, including cancer, neurodegenerative, autoimmune, and metabolic. Both amino acids (from proteins) and glucose (from carbohydrates) have pathways to activate mTOR. The FMD effectively causes the body to function in a fasted state with minimal nutritional restrictions (800-1100 calories/day) by reducing the body's glucose levels while increasing its ketone levels. The FMD restricts calories for 5 days of a month with reduced carbohydrates & proteins and increased plant-based fats. According to Dr Longo, people can go as long as 60 days without food so 5 days is doable without much difficulty. However, Virta Health's Dr. Stephen Phinney cautions against zero-calorie fasts that are longer than 48 hours due to re-feeding syndrome and the risk of permanent metabolic rate reduction.

It appears that the closest thing to drinking from the fountain of youth is to inhibit mTOR activity via regular intermittent caloric restriction. There are several ways to inhibit mTOR activity, including:

Long Fasts: Water-only
- 2-day fast every month
- 2-week fast twice a year
Intermittent Fasting
- Alternate Day Fasts: eat 0-600 calories/day
- 5-2 fasts: eat normally for 5 days and then 0-600 calories/day for 2 days
- Daily Time-Restricted Fasting: consume normal amount of food within 4-8 hours/day
Fasting Mimicking Diet - low carb & protein diet 5 days/month

For most of my life, I believed the common wisdom that breakfast was the most important meal of the day, which is inconsistent with intermittent fasting and completely untrue. This notion was invented by General Foods in 1944 in order to sell more Grape Nuts cereal. Similarly, Sunkist (formerly, California Fruit Growers Exchange) hired marketer Albert Lasker to influence North Americans to consume more oranges, which is how orange juice became a breakfast staple. See How Breakfast Became a Thing and Meet the man who influenced your entire breakfast this morning.

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Modern government health departments generally have advice about what to eat and the recommendations are similar and easy to follow. However, much of their advice is based on epidemetigolical research (food surveys) rather than randomized control trials (RCTs) and influenced by food industry sponsors and animal activists.

Basically, their dietary recommendations are:

Eat plenty of colorful fruits and vegetables.
Eat plenty of nuts, seeds, and legumes (low glycemic indexes and lots of dietary fibre).
Grain-based foods should contain the whole grain with a minimum of refining/processing.
Eat more foods that contain unsaturated and polyunsaturated fats.
Eat less foods that contain saturated fats.
Minimize the consumption of red meat. Consume fish, poultry, beans or nuts instead.
Avoid highly processed foods.
Avoid foods containing trans fats.
Drink water whenever you're thirsty. If you're craving a snack, drink some water instead because might be mistaking a hunger for thirst.
Don't drink your calories (soda, fruit juices, etc). Artificially sweetened drinks have an adverse effect on health.

There are significant benefits to having a low-carb, high-fat diet. LCHF diets recommended by experts (such as Dr Ben Bikman, Dr Sarah Hallberg, Dr Paul Mason) contradict government dietary recommendations to maintain healthy, lean body mass. There also appears to no upper limit to the amount of dietary protein and the improvement in lean body mass is enhanced with resistance training. This is my understanding of a good high fat, low carb diet:

Minimize the consumption of carbohydrates (approximately < 50g/day) and ensure that those carbohydrates have a low glycemic index.
Consume more protein (1.5-2 g/kg of body weight per day) and NO LESS than 1.3 g/kg of body weight.
Consume the balance of your daily caloric requirements from high-quality, minimally-processed fats.
Consume more Omega-3 fats and less Omega-6 fats.
Avoid foods that a metabolized in the liver, especially those that contain added sugar (sucrose & fructose).
Avoid foods manufactured from industrial processes.
Consume more protein as you get older.
Saturated and mono-unsaturated fats (including those from red meats) are good to consume. Avoid poly-unsaturated fats - especially vegetable/seed oils high in linoleic acid.
Eat when you're hungry, don't eat when you're not. No need to count calories because fat consumption tends to be self-regulating in total daily caloric intake.
Avoid snacking between meals (unless you're hungry) to allow blood sugar to fall low enough for ketosis (fat burning) to occur.

Some sites for healthy diet recipes:

Canada's Food Guide Recipes
Canadian Living Magazine's Recipes (one of my wife's favourites)
Diet Doctor: Low-Carb Recipes

More information about Blue Zone diets:

Long periods of exercise is not necessary to lose weight and to keep a low weight. I would argue that it is counterproductive in the long run because it would be extremely difficult to maintain an time-consuming exercise routine over a lifetime. Centenarians in the Blue Zones instead stay physically active with activities that are low intensity such as walking and gardening. They don't rely on labor-saving devices in their daily routines. However, research has shown that there are significant benefits to short periods of high-intensity (where your heart rate is at least 80% of its maximum) exercise.

No matter what your daily routine is, it is important to always keep moving:

For Christmas, my daughter gave me a Fossil (Android) smart watch, which integrates with the Google Fit app. I've come to appreciate the feedback that the watch gives me about my activity level. I now try to increase activity (though still nowhere close to any level of high intensity) because of the continuous activity tracking.

Since our goal in losing weight is to shrink fat cells, we need to get the lipids out of the fat cells, which will in turn reduce the size of the fat cells. Insulin is the switch that determines fat burning or storing: it is impossible to burn fat when insulin is high and it is impossible to gain fat when insulin is low.

Dry Jason Fung makes the case for using intermittent fasting as means burning fat. The idea is to first consume the body's glycogen which then reduces the insulin level. Since insulin and glycogen are low, the body will then start converting triglycerides in the fat cells back into ketones and glucose. This requires you to fast (ie, not eat), which can be problematic for diabetics whose blood sugar can fall too low. Dr Fung suggests that there are benefits to alternate day fasting where cut your food intake on the fasting day to 500 calories. He regularly has 23 hour fasts - that is, he only eats once a day at supper. It appears that it is not beneficial to continuously graze all day but instead to allow your blood sugar levels to fall between meals so as to draw upon your glycogen stores. Especially if you're diabetic, make sure that you only undertake fasting with the supervisor of your doctor.

Similarly, it would be useful to engage in physical activities that also increase your caloric consumption. The body tends to use a greater percentage of fat with lower levels of endurance exercise intensity and the shift toward carbohydrate consumption increases with exercise intensity. Training tends to increase the body's fat metabolism which in turn improves the body's ability to conserve carbohydrates (carbohydrate sparing). Low to moderate intensity endurance exercise doesn't require your body to first draw down its glycogen stores. While low-intensity exercise favours fat metabolism, blood glucose is still impacted and the effect also temporarily increases insulin sensitivity after exercise. However, with training, your body becomes more efficient with glycogen storage so increasing amounts of physical activity could require increasing time for glycogen depletion.

Exercise opens another pathway in the cell to allow glucose. Increased physical activity causes an improvement in metabolic health by increasing insulin sensitivity while a sedentary lifestyle causes insulin resistance.

Cities often have Active Transportation programs (like Fort Erie's FEAT Committee) to encourage healthy lifestyles. Take advantage of your town's recreational trails and bike routes whenever you can but, with North America's car-oriented suburban environments, walking and cycling for errands may often be impractical. In parking lots, parking far from the entrance has the added benefit of reducing door dings and other parking lot mishaps. Take the stairs whenever you can.

Strength training tends to increase muscle mass and and additional muscle tissue increases the body's basal metabolic rate. Additional benefits of strength training include increased bone mineral density and increased connective tissue strength.

Even though our energy consumption during sleep can be much lower than while we're awake, getting adequate and quality sleep is important for overall health. Not getting enough enough quality sleep can lead to weight gain. Many people regard sleep as an inconvenience: they can sleep when they're dead. However, sleep is not a wasted time and this part of a daily routine has important biological functions, some of which we don't understand very well.

Many people suffer from Obstructive Sleep Apnea, which is condition where breathing stops during sleep with a resulting interruption in sleep. Snoring is a symptom of sleep apnea and is a result of obstruction in the airway. Talk to your doctor if you always feel tired after a sleeping and especially if you snore. Treatments often involve CPAP (Continuous Positive Airway Pressure) machines that blow air into your nose while you're sleeping.

Some people have had success with chin strap devices that hold the mouth closed during sleep to encourage breathing through the nose.

Philip Randle described the Randle Cycle (aka Randle Effect) in 1963 as an explanation of how the human physiology determines glucose or fat metabolism, which determined by the body being in either a fasted or fed state. When in insulin levels are low, the body is in a fasted state and conversely, when insulin levels are high, the body is in a fed state. When the body is in fed state, the mitochondria favour glucose metabolism and inhibits fat metabolism. When the body is in a fasted state, the body favours fat metabolism and inhibits glucose metabolism.

I became aware of the effect of the Randle Cycle after I stopped taking Dapagliflozin (Forxiga/Farxiga). After being off of Forxiga for two weeks, I noticed that the Dawn Phenomenon became more pronounced and took longer to wear off. Others on a fat-adapted (eg, ketogenic) diet have also reported a similar situation and some describe it as psysiological insulin resistance. This occurs because the liver responds to waking hormonal changes and "dumps" glucose into the bloodstream, which significantly boosts serum glucose. Dr Ben Bikman (see Diet Doctor Podcast #35 @ 13:04) states he believes this situation is "acute glucose intolerance" rather than insulin resistance because psysiologially the body has extremely low insulin levels and will readily respond to an influx of insulin. With this glucose intolerance (aka carbohydrate intolerance), hyperinsulinemia is NOT present and the pancreas does not appear to be responding to the endogenous glucose produced by the liver. This has also been described as "Adaptive Glucose Sparing" because, although the liver raises serum glucose from the Dawn Phenomenon, tissues have been adapted to using ketones and no-longer require as much glucose for fuel. This cause the body to clear glucose in a much longer period than a someone who is not fat-adapted. The body readily switches back to glucose metabolism within a day or two of consuming carbohydrates. It appears that high morning glucose on a low-carb diet is normal and healthy but I'm not sure how this impacts the HbA1c. I found that physical exertion readily consumes this excess glucose so a brisk morning walk is a great way to start the day.

References

Having a FreeStyle Libre Continous Glucose Monitor (CGM) has been extremely helpful to get immediate feedback with glucose control. The biggest issue I've had with it has been keeping the sensor (white disc on the back of your arm) in place. I've learned that proper skin cleaning is important along with sensor positioning. Even so, the sensor can loosen from sweat and this can just easily happen lounging around a pool at a resort in Costa Rica as it could from a day of intensive work in hot weather. Even though the sensor seems secure, it can easily be pulled off with your tee-shirt.

This has happened once too many times so I've been using an overlay of Tegaderm to prevent catching on shirt sleeves as well as Skin-Prep to get the Tegaderm and sensor to stick better. This seems to work reasonably well unless I experience a lot of perspiration.

With my blood sugar now staying primarily in the healthy range (3.9-6.9 mM) and steady, it has become easy to defer breakfast as the Dawn Phenomenon typically takes until early afternoon to wear off. As a result, I've been deferring breakfast until mid afternoon or until late afternoon / early evening (one meal a day). Without eating, my blood tends to gradually fall into the low 4 range by late afternoon.I monitor my blood glucose with my FreeStyle Libre to help me determine the best time to eat. Since gluconeogenesis is demand-driven, I expect that the Dawn Phenomenon may possibly diminish over time with decreasing hepatic insulin resistance. As my focus is to become insulin sensitive and this can only be done by minimizing insulin levels, I am going to continue with time-restricted, LCHF diet and see where it takes me.

To minimize the Dawn Effect, it appears that not consuming food and having low-intensity exercise (eg, walking) after supper are helpful. It also appears that having higher-intensity exercise (compared with walking) in the morning does not quickly drive down serum glucose but seems to have somewhat of an opposite effect - at least initially. This may be because the high-intensity exercise demands glucose from gluconeogenesis. Riding my bike seems to be the best at driving down serum glucose but it usually takes 15-20 minutes before I start to see downward movement. There is also typically an slight increase in glucose before a decrease.

Milestones

Date	Milestone
2015-10	Diagnosed diabetic, prescribed Metformin and Januvia.
2017-10	Prescribed Janumet XR to replace Metformin and Januvia.
2018	Prescribed Dapagliflozin (Forxiga/Farxiga).
2019	Janumet adjusted with lower metformin content.
2019-11-02	Started using FreeStyle Libre glucometer.
2019-11-11	Stopped taking Janumet (Metformin & Januvia).
2019-11-20	Blood sugar trending higher, sometimes deferring breakfast until noon as per blood glucose.
2019-12-02	On vacation, stopped taking Rosuvustatin.
2019-12-12	Starting regularly deferring breakfast until noon or later (2 or 1 meal/day).
2020-01-11	Stopped taking ‎Forxiga. Now only taking Telmisartin (Micardis) and ASA 81 mg daily.
2020-01-28	Stopped taking Telmisartin.
2020-06-06	Stopped taking 81mg ASA.

If you're overweight and trying to work towards a healthier weight, please recognize that being overweight is a chronic condition that requires a doctor's supervision. Since obesity is closely related to Type 2 Diabetes, seek the help of your local diabetes clinic where you can get advice from a diabetic nurse and a dietitian. Be aware that many health care professionals are wedded to the (low fat) diet-heart hypothesis. See Weight Loss.

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