Essentials in Metabolic Health

1. Nutrition science and non-science

• Levels of evidence,  epidemiological observational studies
• Association data, food frequency questionnaires, healthy user bias
• Interpretation of the data, especially absolute vs relative risk
• The influence of vested interests
• Declaring conflicts of interest
• Communication of the data
• The role of the media
• Fraudulent science and mis/disinformation
  • the Diet-Heart Hypothesis
  • red meat and disease (cancer, heart disease, type 2 diabetes)

2. Metabolic dysfunction and type 2 diabetes

Definition of good metabolic health

• Aetiology of metabolic dysfunction and type 2 diabetes
• insulin resistance – the carb-insulin model of disease
• the role of dietary consumables including sugar, refined carbohydrates, seed oils, UPFs, and alcohol
• the role of exercise
• genetics vs environment

Diagnosis of metabolic dysfunction and type 2 diabetes 

• physical measures – girth:height, BMI
• fasting blood sugar tests – glucose, GTT, HbA1c, insulin
• fasting blood lipid tests – triglycerides, HDL, TG:HDL, LDL Subfraction Analysis
• LFTs
• BP
• US liver
• CAC score, CT coronary angiogram

3. Management options for type 2 diabetes; complications of type 2 diabetes

Lifestyle options, including an introduction into remission

• • LCHF
  • Very low calorie/energy diets (VLCD/VLED)

Medical options:

• medications – insulin, oral hypoglycaemics
• appetite suppressants
• statins

Surgical options

• the role of bariatric surgery
• complications of bariatric surgery

Complications of type 2 diabetes

• micro-vascular
• macro-vascular

4. How to prevent and reverse metabolic dysfunction

Prevention of metabolic dysfunction and type 2 diabetes

• dietary
• exercise
• stress
• sleep
• sun exposure (vitamin D)
• other

Reversal of metabolic dysfunction

• dietary
• exercise
• other
• Remission of type 2 diabetes
• Definition
• Evidence
• Long term sustainability and safety
• Benefits, including improvement in complications

5. Implementing Therapeutic Carbohydrate Reduction (TCR)

• approaches (eg LCHF, low carb, keto)
• what to expect:
  • keto flu, sugar withdrawals
  • timelines
  • milestones – short/long term
  • long term expectations
  • habits of people who succeed
• de-prescribing
• the role of CGM
• the role of carb tracking apps
• the role of intermittent fasting
• potential uses for TCR therapies

6. Nutrition and systemic disease part 1

Metabolic Dysfunction Associated Fatty Liver Disease (MAFLD)

• stages of MAFLD
• pathophysiology of MAFLD
• MAFLD as the hepatic manifestation of metabolic syndrome
• clinical considerations and investigations including elastography
• MHO and TOFI
• The reversibility of MAFLD
• dietary approaches to MAFLD – almost anything is better than a low fat diet
• weight loss – important, but not strictly necessary
• changes to upcoming guidelines

Cardiovascular disease

• biochemistry and pathophysiology of cholesterol and lipoproteins
• the role of dietary fats and bile acid
  • the safety of saturated fats
  • the concern regarding poly-unsaturated fats (eg seed oils and margarines) and ultra-processed foods
• markers of cardio-vascular disease and their improvement with LCHF

7. Nutrition and systemic disease part 2

Cancer

• understand the concept of cancer as a metabolic disease
• the use of therapeutic ketogenic diets as an adjunct to standard cancer treatment protocols
• how to implement a therapeutic ketogenic diet as an adjunct to cancer therapy
• how to implement fasting at different stages of cancer therapy
• what is a Press-Pulse treatment? 
• what is the Glucose Ketone Index and when to use this? 
• How to manage weight loss in the setting of chemotherapy and fasting
• the role of nutrition in cancer survivorship 

Abnormal Uterine Bleeding (AUB)

• the menstrual cycle can be considered a vital sign
• normal pathophysiology of the menstrual cycle
• definition of AUB
• hyperinsulinemia underlies many gynaecological conditions e.g. PCOS, endometriosis, uterine fibroids & polyps
• the uterus responds to cardiovascular disease endothelial inflammation, like other end organs
• the role of nutrients in management of AUB (vit D, A, omega 3, fats)
• the role of gluten in pathophysiology of endometriosis

8. Nutrition and systemic disease part 3

Gut health

• TCR and how it may assist Gastroesophageal Reflux Disease 
• TCR and ‘Irritable Bowel Syndrome’ 
• managing diarrhoea and constipation on TCR diets 
• what to do if a patient has had a cholecystectomy?
• how to manage suspected fat malabsorption
• the use of TCR as an adjunct to standard therapies for Inflammatory Bowel Disease

Mental health

• to re-look at mental health disorders as metabolic disorders
• to emphasise dietary and lifestyle measures as important adjuncts to psychopharmacotherapy
• to create awareness for working with an experienced low carb clinician with deprescribing medications

9. How to engage patients with metabolic dysfunction and effect meaningful change

• how to establish readiness for change
• the role of stigma
• avoidance of shaming
• Use of self compassion
• Helpful ways to approach mindset

10. Individualising Therapeutic Carbohydrate Reduction

Nutritional needs at different stages of life

• pregnancy
• infancy
• childhood
• adolescents – disordered eating risk
• post-menopausal
• elderly
• other

Dietary preferences

• omnivore 
• pescatarian
• vegetarian 
• vegan 
• carnivore
• other

Patients with specific medical conditions

• chronic renal failure
• menstrual cycle disruption