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Regardless of the cause, the effect is the same - initially the pancreas has to release more and more insulin to maintain blood sugars.  

At some point, the pancreas can no longer keep up, insulin levels plateau and then decrease.  When this happens, blood sugars begin to rise.

When blood sugars become mildly abnormal we call this pre-diabetes (5.5 mmol/l to 6.9 mmol/L).  At this point, insulin levels are 2-3 times normal and 50% of pancreatic beta cells are dysfunctional.

With further progression of pancreatic dysfunction, insulin levels begin to fall and blood sugars rise.

Once fasting blood sugars reach 7.0 mmol/L we call this Type II Diabetes and an estimated 80% of pancreatic beta cells are no longer secreting insulin.

Insulin resistance takes place in multiple organ systems: muscle, fat, liver and pancreas.

The sequence and degree of progression in these organs determines the pattern of disease in each person.

The key to reversing Type II Diabetes lies in understanding how each of these 4 organ systems become insulin resistant and what simple actions you can take to reverse the conditions that lead to insulin resistance.

With insulin resistance the effect of stress and the importance of stress cannot be underestimated.  

Both result in increased levels of the stress hormone cortisol and both increase appetite.  Anything that chronically increases cortisol will worsen insulin resistance.

The Wellness Garage 4+2 Diabetes Reversal Strategy is an evidence-based approach that  identifies the key behaviours that can reverse the underlying, tissue specific insulin resistance process.

In combination, changing these behaviours has been shown to improve insulin resistance and decrease or normalize blood sugars while decreasing weight and improving overall health.

If you are on diabetic medications, your dosing may need to be adjusted as you implement these strategies, and in some cases reduced before you start.  For anyone on medications, we recommend consultation and close collaboration with a physician to ensure that you do not have any dangerous low blood sugar events.

​Download the Wellness Garage 4+2 Diabetes Reversal Strategy

​

​ At Wellness Garage - we believe that each of us should take control of our own health.

Easy to say, but what does this mean?

Simply put - our lifestyle behaviours are the most powerful medicine there is.

Building better habits for

• Nutrition
• Exercise
• Sleep
• Stress Tolerance
• Relationships
• Purpose

…is the way to better health.


It is estimated that over 80% of health care costs are related to lifestyle related diseases and 80% of us have at least one modifiable risk factor for chronic disease.

​But diseases and symptoms are only manifestations of more important interactions.

At Wellness Garage we believe in looking beneath the surface, beyond disease and symptoms to understand how the interplay of your behaviours, environment and genetics change the  biological systems that ultimately thrive in good health or fail into disease.

This approach is backed by research that shows that the interaction of behaviours, environment and genetics determine most health outcomes.

While we cannot (yet) change our genes, we can change our environment and behaviours.

But where to start?

There is so much noise and conflicting information out there - fad diets and snake oil.

This is why we founded Wellness Garage:
Create a place where people can get the help they need, from trusted, evidence-based practitioners, to take control of their health. 

At Wellness Garage, the first step to taking control of your health is to do a Precision Health Tune Up (PHTU)

A PHTU is comprehensive look at your health from your behaviours to your key biomarkers.

Our team:

• Physician
• Nutritionist
• Exercise Physiologist
• Health Coach

…will review of your medical history, current health, symptoms, and goals and look at all medically necessary tests.

We also offer the most cutting edge, evidence-based advanced testing options that include:

• Genetics
• Advanced Cardiac Risk Assessment
• Molecular testing
• Hormone testing
• Body Composition
• Gut Health Assessments

As a team we compare your biomarkers to your current behaviours and develop a personalized set of actionable recommendations for you to make the necessary changes to improve your health.

With these recommendations as your action plan, we then can provide you with all the support that you need to make the changes required to reach your health goals.

Over the past year, we have helped hundred's of people take control of their health from:

• Reversing diabetes and pre-diabetes
• Decreasing risk of heart disease
• Lowering cholesterol
• Safely discontinuing medications
• Losing weight + gaining muscle
• Normalizing blood pressure
• Improving symptoms of osteoarthritis
• Resolving inflammation
• Decreasing menopausal symptoms
• Decreasing risk of osteoporosis
• Improving fitness
• Improving sleep
• Learning to meditate

...and many more improvements

The most inspiring realization that we have had since starting is that the human body is much more resilient than any of us can imagine.  Treat it with the right behaviours and health improves, one habit at a time.

Two large prospective studies in the US with almost 120,000 people followed for 15 to 30 years showed that people who ate nuts seven or more times per week had a 20% lower death rate than those who avoided nuts altogether. (NEJM 369;21)

Nut eaters had lower rates of death across most major causes including heart disease, cancer and respiratory disease.

The benefits were similar for both tree nuts and peanuts.

Concerns about weight gain were not substantiated, in fact across both these cohorts, nut eaters gained less weight over time.

The benefits of nuts have been seen in other major trials:

• The Adventist Health Study showed that consuming nuts 5 times per week was associated with 18-44% reductions in mortality across all study groups as compared to eating nuts less than once a week.
• PREDIMED - the famous Mediterranean diet study showed a 39% reduction in deaths for people that ate 3 or more servings of nuts per week

Observational studies and other clinical trials have suggested that eating nuts will decrease coronary artery disease and improve key lipid biomarkers.

Yet more studies have shown improvements in other key biomarkers indicating benefits including:

• Reduced oxidative stress
• Reduced inflammation’
• Less visceral adiposity (reduced waist circumference)
• Reduced weight gain
• Decreased risk of obesity
• Better glycemic control
• Less insulin resistance
• Reduced risk for Type II Diabetes
• Reduced metabolic syndrome
• Improved blood pressure
• Decreased colon cancer
• And fewer gallstones!                   

            

All of these benefits for something that tastes so good.

In my thinking, “you would have to be nuts to avoid nuts!”

​

Research shows that dieting is ineffective for long term weight loss and maintenance of weight.  Most people who lose weight by dieting will regain it after a year. Worse, many regain more weight than they ever lost in the first place.  This pattern of weight loss followed by weight gain has been termed “yo-yo dieting” and has been linked to increased risk of obesity, diabetes and cardiovascular disease.

Contributing to these poor results are the abundance of fad diets, overly restrictive and often lacking in essential nutrients.  Requiring massive will power, these diets may result in weight loss, but since the behaviour required is not sustainable the rebound in weight is swift.  Inevitably, the dieter returns to the poor behaviours that led to the initial weight gain in the first place.

Finally, these restrictive diets can take the pleasure away from eating and lead to lifelong disordered eating.

If you are going to lose weight and keep it off - you have to address the root causes of weight loss and address the lifestyle behaviors that resulted in weight gain.

Rather than restriction, the initial focus of any sustainable and effective approach should be on improving the quality of food in the first place.

Healthy eating is all about eating and enjoying real food - not counting calories, points or tracking macros.

But what is real food?

• Real food is food that comes from a farm rather than a factory.  
• Food from a single ingredient or made from a few ingredients, that you recognize as food.
• Food that your great grandmother would recognize.
• Foods that have not been processed, extracted, concentrated, purified or transformed enzymatically
• Foods that have been grown, not invented by the food-industrial complex.

There is now clear evidence that eating processed foods leads to increased food consumption and weight gain.  Further, when diets do work, they often do so by having people shift from refined, processed, packaged and fast foods to real, whole foods (for more on this here is a previous post).

Along with making the shift to whole food eating, other keys to losing weight for the long term are:

• Exercise and Movement - being active, in any form, helps.  Of course, exercise burns calories, but more importantly, exercise leads to metabolic changes that favor the maintenance of a healthy weight.
• Sleep - lack of sleep is one of the key contributors to obesity, through its combined effect of increased appetite and increased  cortisol, the stress hormone that can lead to weight gain, especially around the middle. Giving yourself an 8 hour window for sleep, building a sleep routine and addressing any worrisome symptoms are the place to start.
• Hydration - often we confuse thirst for hunger.  Maintaining good hydration, decreases appetite and makes you feel better.
• Going 12 hours without food - you can call this by fancy names like intermittent fasting or time restricted eating, but really this one falls in the common sense bucket.  The reason it’s called breakfast is that you are breaking your fast!
• Relaxation - finding ways to relax and recover from the stressors of the day will lower cortisol and help to improve sleep.

All of these behaviours are foundational to excellent health, and any changes in their direction can help.  As we often say to our members: “you may not always be able to choose ‘best’, but ‘better’ is better”.

Small, sustainable changes go a long way!

Finally, understanding your weight loss in context of your history and current health should come first.  It is essential that you work with your physician to understand if there are any other potential causes for your weight gain - especially hormonal, metabolic or inflammatory abnormalities.

At Wellness Garage, we offer a medically directed lifestyle program for weight management.  

All medical visits are covered by MSP, for those with a BMI over 30 or a BMI > 27, with an obesity related diagnosis.

Our program leverages a personalized, multidisciplinary lifestyle behavior change approach - your care team will consist of a physician, nutritionist, exercise professional and health coach who will get to know you from multiple perspectives and work with you to make lifelong habit changes.
​
Learn more about the Wellness Garage Sustainable Weight Management program and to see if you qualify.

​

A very compelling read from a New York Times op/ed, making the point that we have made previously on our blog:  today's chronic diseases have their origin in the evolutionary mismatch between our current environment and behaviors and what our bodies evolved to be.

In this article, we learn how evolution set out to protect us from starvation, infections and injuries leaving us vulnerable to atherosclerosis - the disease process underlying heart disease.

​https://www.nytimes.com/2019/08/06/opinion/evolution-heart-disease.html?action=click&module=Opinion&pgtype=Homepage

At Wellness Garage - we take a precision health approach to atherosclerosis prevention, treatment and reversal, by working with our members through a structured change process: Assess, Change Behaviors, Re-assess and Adjust. 
 
Learn more about what it looks like to do a Precision Health Tune Up and take control of your health.

What are the symptoms?
The main symptoms of OSA are 

• loud snoring,
• fatigue, and 
• daytime sleepiness. 

However, some people have no symptoms or may not recognize that they have symptoms.

Other symptoms may include one or more of the following:

• Restless sleep
• Awakening with choking, gasping, or smothering
• Morning headaches, dry mouth, or sore throat
• Waking up to urinate more than once per night 
• Feeling unrested and groggy in the morning - “brain fog”
• Fatigue, low energy, memory challenges with difficulty concentrating

Perhaps the best way to determine risk is the use of the STOP-BANG questionnaire which uses a series of questions and results of physical measurements to calculate the risk for sleep apnea in adults aged 18 and older.
Snoring – Do you snore loudly (loud enough to be heard through closed doors)?
Tired – Do you often feel tired, fatigued or sleepy during the daytime?
Observed – Has anyone observed you stop breathing or choking/gasping during your sleep?
Pressure – Do you have or are being treated for high blood pressure?
Body mass index (BMI) – Body mass index more than 35kg/m2?
Age – Age older than 50?
Neck circumference – Neck size 17 inches or larger for males or 16 inches or larger for females?
Gender – Male?
​
Positive answers to the above questions are then used to determine risk:
Low risk – Yes to 0 to 2 questions
Intermediate risk – Yes to 3 to 4 questions
High risk – Yes to 5 to 8 questions

• OR yes to 2 or more of 4 STOP questions + male gender
• OR yes to 2 or more of 4 STOP questions + BMI > 35kg/m2
• OR yes to 2 or more of 4 STOP questions + neck circumference ≥ 17 inches for males or ≥ 16 inches for females

How common is it?
In 2017, 6.4% of Canadians self-reported a diagnosis of sleep apnea through the Canadian Health Measures Survey (CHMS) - this was more than double the rate reported in 2009.
In the US, using the broadest criteria is estimated that 20-30% of men and 10-15% of women have sleep apnea.   
In all likelihood, sleep apnea is under-diagnosed - using the STOP-BANG risk tool, the CHMS found that nearly one-third (30%) of Canadian adults were considered to be at intermediate or high risk for sleep apnea - 15% were high risk and 15% were moderate risk.

Rates are increasing along with the rates of obesity.

What are the risk factors?

• Age – sleep apnea is more common as you age
• Obesity - the link between excess weight and sleep apnea is well established. People who are overweight are more likely to have extra tissue in the back of their throat, which can fall down over the airway and block the flow of air into the lungs while they sleep.
• Male sex – men are twice as likely as women to have sleep apnea
• Having a large neck size (greater than 17” in men; 16” in women
• Drugs and/or Alcohol – increases the risk of sleep apnea as you may not awaken to open the airway
• Airway abnormalities - large tonsils, large tongue, deviated septum

What happens if it is left untreated?
The initial consequences of untreated sleep apnea are daytime sleepiness and difficulty concentrating results in increased errors and accidents.  People with severe sleep apnea are two to three times more likely to have a motor vehicle accident - this represents an impact on morbidity and mortality that is similar to the cardiovascular sequelae of OSA.

Over time untreated sleep apnea increase risk for cardiovascular disease, high blood pressure, abnormal heart rhythms, heart attack and stroke.

People with OSA have higher rates Insulin resistance and Type II Diabetes.  This association is partly manifested by the shared risk factor of obesity, but also appears to be independent.  In one study, patients with severe OSA had a 30% higher risk of diabetes even after controlling for age, obesity, pre-existing cardiovascular disease. 
The physiological mechanisms underlying this risk are likely related to the increase in oxidative stress caused by lack of oxygen as well as activation of the sympathetic nervous system (with the insulin resistance effects of adrenaline and cortisol).

For patients with existing metabolic syndrome - OSA is associated with poorer metabolic biomarkers: increased glucose, triglycerides, inflammatory markers, and overall increased cardiovascular risk.

Nonalcoholic fatty liver disease (NAFLD) - given the increased risk of metabolic syndrome with OSA and the shared risk factors between NAFLD and metabolic dysfunction -   OSA appears to contribute to the development and severity of nonalcoholic fatty liver disease (NAFLD), independent of shared risk factors such as obesity.

Mortality - Severe OSA increases the risk of death by 2-3 time independent of other risk factors - interestingly an increased risk of mortality does not appear to be present for untreated mild OSA.  What isn’t completely clear is how treatment of severe OSA affects the risk of mortality.

Diagnosis:
Once suspected due to witnessed apneic episodes, loud snoring, daytime sleepiness, resistant hypertension, or ineffective sleep - the next step is to get a sleep assessment.

The gold standard is the polysomnogram - done overnight in a sleep lab (and requiring a referral from your physician), it measures  breathing effort and airflow, blood oxygen level, heart rate and rhythm, duration of the various stages of sleep, body position, and movement of the arms/legs.

A more accessible alternative not requiring physician referral is a Level III sleep study - using portable devices that can be used at home.

Is it reversible?
This depends primarily on the underlying cause of the sleep apnea - if the primary cause is obesity then weight loss can improve symptoms and lead to a cure.  

Brain damage caused by severe sleep apnea is reversible.  A 2017 neuroimaging study is the first to show that white matter damage caused by severe obstructive sleep apnea can be reversed by continuous positive airway pressure therapy.

There is high quality evidence that in most adults positive airway pressure therapy reduces the frequency of respiratory events during sleep, decreases daytime sleepiness, improves systemic blood pressure (BP), lowers the risk of crashes, improves erectile dysfunction, and improves quality of life across a range of disease severities.

Unfortunately to date there have been no studies that have demonstrated that treatment improves mortality.

What are the treatments?

• Weight loss — Weight loss may be helpful for obese or overweight patients.
• Avoid alcohol and other sedatives — Alcohol can worsen sleepiness, potentially increasing the risk of accidents or injury. People with OSA are often counseled to drink little to no alcohol, even during the daytime. Similarly, people who take anti-anxiety medications or sedatives to sleep should speak with their healthcare provider about the safety of these medications.
• Stop Smoking
• Adjust sleep position — Adjusting sleep position to stay off the back may help improve sleep quality in people with sleep apnea, but this is difficult to maintain and is rarely an adequate solution.
• Continuous positive airway pressure (CPAP) — The most effective treatment for sleep apnea uses air pressure from a mechanical device to keep the upper airway open during sleep. A CPAP device (figure 3) uses an air-tight attachment to the nose, typically a mask, connected to a tube and a blower which generates the pressure [3]. Devices that fit comfortably into the nasal opening, rather than over the nose, are also available. CPAP should be used any time the person sleeps (day or night).  Continued follow up with a healthcare provider helps to ensure that the treatment is effective and comfortable. “The best CPAP device is the one you’re going to use.”
• Dental devices — A dental device, called an oral appliance or mandibular advancement device, can reposition the jaw (mandible), bringing the tongue and soft palate forward as well. This may relieve obstruction in some people [4].  This treatment is excellent for reducing snoring, although the effect on OSA is sometimes more limited [4]. As a result, dental devices are best used for mild cases of OSA when relief of snoring is the main goal. Failure to tolerate and accept CPAP is another indication for dental devices. While dental devices are not as effective as CPAP for OSA, some patients prefer a dental device to CPAP. Side effects of dental devices are generally minor but may include changes to the bite with prolonged use.
• Surgical treatment — Surgery is an alternative therapy for patients who cannot tolerate or do not improve with nonsurgical treatments such as CPAP or oral devices.  The most common surgical procedures for sleep apnea:
  • ​​Nasal surgery: Correction of nasal problems such as a deviated septum.
  • Uvulopalatopharyngoplasty (UPPP): A procedure that removes soft tissue on the back of the throat and palate, increasing the width of the airway at the opening of the throat. UPPP alone has limited success rates (less than 50 percent) and people can relapse
  • ​Mandibular maxillomandibular advancement surgery: Surgery to correct certain facial problems or throat obstructions that contribute to sleep apnea. MMA may have a higher success rate, particularly in people with abnormal jaw (maxilla and mandible) anatomy, but it is the most complicated procedure.

References:
https://www.uptodate.com/contents/sleep-apnea-in-adults-beyond-the-basics?search=sleep%20apnea&topicRef=7683&source=see_link
https://open.alberta.ca/publications/level-i-and-level-iii-sleep-studies
Canadian Thoracic Society Guidelines: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3070752/pdf/crj18025.pdf
American Academy of Sleep Science: http://jcsm.aasm.org/ViewAbstract.aspx?pid=31513

https://www.health.harvard.edu/blog/weight-loss-breathing-devices-still-best-for-treating-obstructive-sleep-apnea-201310026713

https://aasm.org/brain-damage-caused-by-severe-sleep-apnea-is-reversible/

https://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea
STOP-Bang Questionnaire. Property of University Health Network, for further info: www.stopbang.ca modified from Chung F., et al. Anesthesiology. 2008. Vol. 108: 812-821; Chung F., et al. British Journal of Anaesthesia. 2012. Vol. 108:768-75; Chung F., et al. Obesity Surgery. 2013. Vol. 23: 2050-2057; Chung F., et al. Journal of Clinical Sleep Medicine. 2014.

The best feature of my exam room at Wellness Garage the glass "white board" that I inherited and repurposed from the gym that used to occupy our space.

Many times per day, I find myself drawing the same diagram:

or more neatly drawn and shared with our Diabetes Reversal Group:

I have written about Insulin Resistance before:

• Insulin Resistance - a silent killer - what you need to know
• Is Diabetes Reversible - Part I
• Is Diabetes Reversible - Part II
• Is Diabetes Reversible - Part IIII

Insulin resistance is, in my opinion, the single greatest health issue of our time, and is increasing at epidemic rates.

When I review the mental model for insulin resistance with our members here is a quick summary of what I share:

Metabolic health is one of the most important drivers of optimal health.

Weight gain and metabolic health are tightly related: poor metabolic health leads to increased fat which further worsens metabolic health.

Dysfunction in metabolic health manifests as insulin resistance - the process where the pancreas must release higher and higher levels of insulin in order to maintain blood sugars.

Insulin resistance can happen in multiple organ systems: muscle, fat, liver as well as the pancreas itself.

The initial phase of insulin resistance is marked by normal blood sugar levels but increasing insulin levels - the simplest biomarker for this is the TG/HDL ratio which generally increases with hyperinsulinemia.

By the time the fasting blood sugar becomes abnormal - insulin levels are often 2-3 x normal - at the same time approximately 50% of the pancreatic beta cells are no longer functioning. In most people it takes 10 -15 years to reach this point.

This marks the beginning of the second phase of insulin resistance, that of decreasing insulin production from the pancreas, and mildly abnormal blood sugars. We call this pre-diabetes.

Type II Diabetes is diagnosed when fasting blood sugars are greater than 7.0 mmol/L.

At this point, pancreatic beta cell function has been reduced over 80%.

Insulin resistance is a major risk factor for cardiovascular disease, cancer, dementia, liver failure, kidney failure in addition to being the cause of Type II Diabetes.

Risks for insulin resistance include: age, genetics, obesity - especially visceral obesity, sedentary behavior, stress, poor sleep and of course poor nutrition.

I will be blogging more on this in the future as we prepare to digitize our Diabetes Reversal program.

In the meantime, if you have Type II Diabetes, pre-diabetes, metabolic syndrome or insulin resistance (and you live within driving distance of our clinic in White Rock), you may be interested in our Group Diabetes Reversal Program