On Monday, my blog looked at why nuts were generally such a good food for diabetics. And part of their attraction is that they are a food rich in protein and fat and low in carbohydrate. These nutritional qualities mean that nuts will liberate sugar in a tempered fashion into the blood stream (they have a low glycaemic index), which is ideal for diabetics who have limited capacity to regulate blood sugar levels.
What sorts of foods a diabetic eats is obviously important for optimising blood sugar control, but so is when food is eaten. Generally, I advocate a ‘little and often’ approach, which usually means breakfast, lunch and dinner, maybe with one or two healthy snacks between meals. For most individuals regular eating can help quell the appetite and naturally control the amount that is eaten at actual meal times. For any given type of meal, smaller volumes will be less disruptive to blood sugar levels than larger meals. Plus, when the appetite has not been allowed to run riot, healthier food choices are usually easier to make. In particular, it tends to make eschewing generally sugar-disruptive foods like bread, potatoes, rice and pasta much easier.
This week, however, saw the publication of a study which suggests that regular eating has another major boon for diabetics. Researchers from Newcastle University in the UK tested what is known as the ‘second meal effect’ [1]. Briefly put, the second meal effect is the effect a meal has on the blood sugar control of a meal eaten subsequently. What they did is test the blood sugar response to a set lunch in two settings in different days. On one day, the lunch was eaten preceded by breakfast some hours before. On another day, no breakfast was given and the same set meal was given.
The results of this study showed that having breakfast appeared to reduce rises in blood sugar levels post-lunch by 95 per cent.
Because the lunch was set in terms of type and size, this means that the presence of breakfast is exerting a strong and potentially important effect on blood sugar balance after a subsequent meal. This has profound significance I think, for diabetics.
But does it have potential ramifications for non-diabetics, too?
Well, I’m not aware of any specific science here, but my experience in practice leads me to believe that regular eating may have specific benefit for non-diabetic individuals. My observations concern people who have food cravings in the afternoon and/or tend to find themselves overeating at night. Generally speaking, I find these issues can often be significantly improved if not completely eliminated by establishing a half-decent breakfast if it wasn’t in place already.
So, how might this work? Well, one mechanism here relates to blood sugar balance. Recently I wrote about carbohydrate cravings (particularly in the afternoon) and their link with episodes of low blood sugar. Well, if breakfast causes less of a blood sugar spike after lunch, it might help to prevent the low blood sugar that can follow it later in the afternoon.
But this effect may also last into the evening. Because more stable levels of sugar throughout the afternoon and maybe into the early evening could also impact positively on eating behaviour in the evening. If this were true, then it might be that eating breakfast might have a positive domino effect on blood sugar levels (and appetite) right through the day.
With regard to what to eat for breakfast I strongly recommend what some regard as standard morning fare such as usually highly sugar disrupting and generally nutritionally inadequate toast/breakfast cereal combo. One good alternative is Bircher muesli ” a usually homemade blend of oats, plain yoghurt, fruit, nuts and/or seeds. For some more generally decent breakfast ideas, see here.
References:
1. Jovanovic A, et al. The Second-Meal Phenomenon in Type 2 Diabetes Diabetes Care 2009;32:1199-1201
Good to see some discussion and research go beyond just ‘what’ we should eat. Consumers are bombarded with various advice (often conflicting) over what to eat, but receive relatively little information on the when and how (to much scoffing on the move, not enough chewing and giving time for proper digestion) is best to eat, which I feel is also very important.
So well done on pointing out this research. Hopefully it will lead to more studies being done is this area.
It is a little bit contradictory to link to a post of a blogger who supports and practices intermittent fasting and to recommend eating 5 small meals a day, for non-diabetic people. People who have problems in the afternoon should definitely check their processed carb intake, as Dr. Briffa says. For almost a year now I gave up bread, pasta, rice, potatoes, porridge for breakfast and also dairy deserts, fruit yoghurts (with the odd birthday party slice of cake) and I can definitely go much longer without food. I am even thinking of doing some short term fasting, longer than from breakfast to dinner that I have already done.
So, still conflicting information, this time regarding when to eat.
Dr. Briffa,
Long time reader, and a huge appreciator of what you do. I’m curious as to whether there is actually benefit here, or if they have simply shifted the same sugar/insulin fluctuations to earlier in the day.
Let me explain. If blood sugar is lower after lunch when breakfast was eaten, wouldn’t it be lower after dinner when lunch was eaten? Does this mean that to minimize blood sugar after breakfast, we should wake up in the middle of the night to eat a meal? I think it’s questionable to suggest that adding meals to prevent spikes in blood sugar is better than allowing the body to begin steadily releasing FFA’s for sustainable energy.
At some point during the day, there is going to be an insulin spike after eating (if carbs are involved). This article seems to simply recommend that we have that spike at breakfast, to avoid the spike at lunch. Have we really gained anything by moving that spoke to earlier in the day? I also notice that they say the “rise” in blood sugar is minimized, but is overal blood sugar less? I imagine that eating this way would lessen blood sugar spikes, but would increase overall blood sugar throughout the day, thus increasing total daily insulin production and therefore hindering sustained released of FFA’s.
I’d be very interested in your thoughts on this. Thanks and I look forward to more of your consistently informative posts!
-Bryce
I was really hoping I’d receive a little feedback on this, as it’s still an issue I’ve been putting a lot of thought into.
-Bryce
Bryce,
My understanding is that approximately 50% of insulin is released in response to carbs and 50% in response to glucose.
At first glance one might assme that a diabetic should be seeking to optimize insulin release to control blood glucose levels. In fact, I believe, the goal should be to reduce insulin levels as much as possible whilst maintaining optimal blood sugar levels. This means limiting carbohydrate intake and possibly protein intake to some extent as well – inevitably this means an increase in fat intake. The objective is to increase insulin sensitivity and to switch to fat burning as the principle source of energy. Perhaps crab and protein intake has to be more closely matched to exercsie level, with restriction reflecting the degree of insulin resistance. proxy measures for this might include trigliceride and HDL levels, waist measurement, weight, and maybe other markers for metabolic syndrome .
Inulsin is need to store nutrients after eating. Smaller meals should inhibit weight gain and facilitate weight loss. Itend to find that the more I eat the hungrier I feel and vice versa. Intermittent fasting may also improve insulin sesnitivity and weight loss. I guess waht most people are seeking to do is lose body fat and maintian or even gain muscle and/or strength. I ahve seen it suggested that some proteins like casein also stimulate excessive insulin production. So maybe this is where a paleo type type comes in handy for some.
Base you diet around meat, veg nut and eggs and you won’t go far wrong in my opinion. But I guess it a question of fine tuning, and what works for you.
Paul.
Typo – meant to say 50% carbs and 50% protein (amino acids).
Paul.
Bryce
You might be right about the moving of the spike.
However, if you follow Paul’s dietary suggestions/Paleo diet (e.g. meat, veg, nuts, eggs) then there will not be much of a spike in sugar after meals anyway. High protein foods are more satisfying, generally. So eating a protein rich diet and eating relatively regularly (e.g. not skipping breakfast) can help stop the appetite running out of control. A well-controlled appetite makes it easier for individuals to forgo starchy carbs at lunch (and other meals), which will help prevent blood sugar spikes.
There is almost certainly some merit in intermittent fasting. But if someone eats a paleo-style diet on a regular basis, blood sugar and insulin levels will tend to be nicely under control, as Paul suggests (with no need to get up at night, either).
John, If the bodies requirement for energy is around 2000 cals per day is that like saying the bodies cells require energy broadly at a rate of 100 cals/ hour? Cells have little capacity to buffer energy and so require our bodily systems to meet their constant need.
We could consume two meals of 1000 cals each with a sizeable interval between, but is this expecting a lot of our bodily systems to cope?
Presumably skipping meals adds to the load upon the body to cope. Would not five meals each of 400 cals each place substantially less of a loading upon the bodily systems that ‘sink’ the post prandrial rise in blood sugar to glycogen to be stored for frequent and cyclical retrieval from the liver and muscles?
Bryce, my name links to an expression of view that may constitute food for thought.
Glad to see all of your thoughts on this.
As for me, I eat a pretty strict paleo diet, though circumstances prevent me from eating only grassfed meats and etc. Still, despite the occasional weekend cheat, I eschew any refined carbohydrate, any wheat, almost all legumes, and most dairy (I eat butter and heavy cream but have milk sparingly).
I’ve found that as I eat less and less carbohydrate and more and more fat (animal fat and olive/avocado/nut fats), I’m simply not hungry enough most days to eat 3 squares. I usually eat my first meal at around 11-11:30, have dinner at around 6-7, and occasionally I have a piece of fruit or some nuts in between. I simply tend not to wake up hungry, and I think an important part of being truly paleo is trusting your body and not eating when you’re not hungry, nor drinking when your not thirsty.
I rarely get thirsty (especially since I don’t eat dry carbs that suck up lots of moisture), and my hunger has become far more controllable since I’ve gotten away from refined foods and begun to incorporate a ~24 hour fast once a week. Even during the fasts, I only get hungry once or twice, and my energy levels skyrocket as FFA’s release more freely from my adipose. As you eat a Paleo diet more consistently, hunger becomes so much less of a concern, because insulin levels plummet.
I think people place a lot of stock in eating frequent small meals, but hunter gatherers didn’t and don’t really eat that way. They have large filling meals when they’re hungry, and insulin responses, as Dr. Briffa said, aren’t as much of a concern when your macronutrients aren’t misproportioned. I think frequent small meals are only necessary if you’re eating a “heart healthy” diet of cheerios and whole grains and etc. If you’re not, then I think eating when you’re hungry, until you’re full is the way to do it, because it’s the way Grok would have.
Thanks so much for all of your input!
-Bryce
Hello Bryce, the general favour some people have with the paleo diet is something that interests me but is something I have not yet studied to the potential it deserves. We are in agreement to a point. I would light upon certain aspects of the modern western diet as unhelpful and detrimental to health and would also agree that rolling back the diet to a point back along the time line may be beneficial.
When we talk of a paleo diet we light upon a single perception of what a diet may have been in the past. In actuality, paleo is referencing the diets of peoples who lived subsistence lifestyles in a diversity of habitats. Present day peoples living subsistence lifestyles exhibit considerable dietary variation between them and of course this is a factor of natural variation in habitat. We should the think the same was true of our ancestors prior to the adoption of agriculture and industrialisation. The ‘typing’ diets (1,2,3) are founded upon this notion. By contrast, the agrarian, indusrtrial, urbanised habitat is becoming universal amongst developed nations, it is largely standard and uniform, and entirely man-made. It is no wonder we are running into problems.
Retreating to a perception of a diet of times past may well bestow benefits but I am not sure that lighting upon a single period for inspiration is a fully enlightened approach.
I have this vague and underdeveloped idea of the principle of moments as applied to evolution and dietary development.
Consider if you will a beam balance and imagine the iconic building from Canary Wharf on the rhs of the beam. Consider all of human evolutionary history, including progenitor species, going back to the very origins of life counterbalancing on the LHS, then consider which parts of that time line are NOT important. Bacteria will be furthest back on that timeline and would remain singular for a huge wedge of time. Our gut is populated by 500sp of bacteria whose numbers exceed our cells by factor of ten to one. I cast it into the discussion that it is impossible to discard any part of the timeline as life, particulary the higher order complexity in question, carries the legacy of evolution from all of time.
I concede it is asking a lot to consider 4bn years of history while trying to select a meal from the works canteen but at the other extreme I would postulate that it is naiive to think we can light upon a perception of an optimal diet by clearing all of time from our balance and replacing it with a singular point load from somewhere in the paleo period. Nature exhibits a pluralism that defies a singular, mechanistic, or Newtonian interpretation, and I was interested to see Prince Charles say much the same in his delivery to the Richard Dimbleby lecture broadcast on BBC 1 last night.
The difficulty with my idea of applying the principle of moments is refining and deciding which periods during the emergence of mammals, mammals into primates, and primates into humans carry importance in the dietary sense and deciding how much weight should be attributed to pertinent periods. Probably there is something to be learned from looking at origins and transition during 4 – 6my of transitions rather than just a couple of hundred thousand.
Neil Shubin, ‘Your Inner Fish’, is an interesting and entertaining read which while not about diet, does illustrate how far evolotionary precedent can be carried forward. For all the complexity inherent within nature, it also serves as an illustration of the outward simplicity and predictability.
Bryce, my link will take you to an expansion of this. At 3000 words it would not be polite for me to post it here.
‘Typing’ books of which I am aware
(i1) Dr John Briffa, The True You Diet
(2) Dr Peter J D’Adam, Eat Right For Your Type
(3) Paul Chek, Eat, Move and be Healthy.
Mankind has to become enlightened as to what it means to be human, and quick. We face health challenges, economic challenges, sustainability challenges, and the prospects of climate change. Somewhere within them is a link, and likely the link has to do with the primacy of energy.
Consistent through HRH speech last night was the theme that mechanical thinking permitted creation of wealth but did so at the expense of the earths natural capital. Double entry book-keeping with knobs on, I suppose, in that every transaction has a reaction. We’re in a mess because to date and for the last 20,000 years we’ve completely ignored one half of the binary accounts.
Chris,
I think we’re largely in agreement, and I’ll look into some of the things you’ve referenced. I don’t necessarily think of my brand of the Paleo diet as an optimal blend of nutrients and etc that will yield the best result, nor of a particular snapshot in our evolutionary history in which I feel we thrived. I look at my diet more as a list of things I know have NO place in the vast majority of that evolutionary history (high fructose corn syrup, partially hydrogenated soybean oil, and white bread are good examples).
Many pre-agricultural societies had VASTLY different macronutrient ratio intakes, and thrived, but they all have in common a lack of refined sugar, processed vegetable oils, refined grains, and along with that, a lack of almost any heart disease, cancer, or diabetes. We can wax philosophical all day, and I do enjoy this, but at the end of the day it isn’t hard to identify a few things that are killing western society, nor is it that hard to stop doing those things.
-bryce
Can someone tell me what FFA stands for and its role. Thanks, Mark
free fatty acids
Dawn Phenomenon
http://www.diabetes-support.org.uk/joomla/dawn-phenomenon
more:
http://loraldiabetes.blogspot.com/2009/02/i-ate-nothing-why-are-my-bgs-high.html
My insulin resistance is such that I top out at about 15g carbs at breakfast but can do 30 – 50g by evening. Many diabetics have an even steeper slope.
The dietician approved bowl of museli with low fat milk and a glass of orange juice was a disaster for me, shooting my BG high then low and leaving it swinging all day as I tried to (over) compensate.
These days I usually eat fish (or meat) and salad which keeps me going with level BG for several hours.
More breakfast ideas
http://loraldiabetes.blogspot.com/2006/10/breakfasts.html
I suspect this way of eating may be a good plan for nondiabetics also, helping to keep them that way
Trinkwasser you have some excellent views and links.
After persisting with the practice of buying semi-skimmed milk for a number of years we have discarded with that practice. That excellent book, ‘The True You Diet’ by the site host, Dr Briffa does bring the validity of the low fat paradigm into question. Likewise did the recent Mente review.
Subject to what is included in your salad that likely constitutes carbohydrate and protein in broadly equal measure, but not especially generous in either, and a good source of plant fibre. The fibre will help reduce the glycaemic load through buffering the rate of digestion. Barry Sears, in more than one from his ‘Zone’ books, explains how the balanced consumption of protein at each meal can mitigate the undesirable aspect of a high insulinemic response by balancing insulin with the less often mentioned hormone ‘glugagon’. Sears suggest there is merit in these two hormones working in balance. An excessive dependency upon the denser carb sources, especially the refined ones, has the potential to knock out this balance. (It runs in families, apparently)
The cyclical nature of day and night must surely be imprinted in our physiology. Returning to work rolling big wheels and starting work at 0000 – 0300 is helpful for my bank balance but challenges my resolve to keep BG stable. Is that a case of ‘Every Little Helps’ of ‘Every Little Hurts’? ( – I’m hauling reefers fro a major supermarket.)
Do you have any tips for shift-workers, John? Anybody?
Yes the insulin/glucagon balance is one of my bugbears, my liver has a tendency to either dump far too much glucose in the morning, or withhold it in the afternoon. The bloodstream only contains around 5g glucose at any one time
http://www.proteinpower.com/drmike/sugar-and-sweeteners/a-spoonful-of-sugar/
so it doesn’t take much of an imbalance to double (or halve) your BG.
Glucose internally generated from protein comes in at a relatively slow rate which doesn’t generate the insulin spikes, and keeping carbs down to a borderline ketotic level means I mostly burn fats for fuel: this keeps my energy levels even which the high carb diet never managed. The salad also contains olives for fat, and as well as the fibre it provides various micronutrients, all of which helps reduce the variation in glucose, insulin and glucagon levels.
Mark Sisson is a must-read
http://www.marksdailyapple.com/primal-blueprint-101/
When I was a trucker I used to exist on bacon sarnies during the day, with snacks of chocolate and nuts, but I always made sure I either cooked a decent meal or ate in a decent restaurant in the evening. Unfortunately I also made sure it contained plenty of healthy carbs. 🙁
My days tended to start between 6 and 9 so I had the variation but without the shift pattern. If I could go back and do it again I might well keep the bacon sarnies for the protein and fat but dilute them with salad, and ensure a similar balance in my evening meals, basically swap out the carbs for more of everything else.
I’m still tinkering with the balance between protein and fats at different times of day but so far my BG is almost level, my BP has come down and my lipids are normalised (I do seem to need a statin though, my LDL goes unacceptably high without it), and I have more and more consistent energy without the need for constant snacking. I believe this is achievable for most people though almost never on the Heart Healthy diet, which blatantly isn’t, but it takes some experimenting to discover your own best practice. This is definitely an area where those “cranks on the internet” are way ahead of Conventional Wisdom.