Health Promotion: Using the Concepts of Insulin and

Glucagon to Let Food Be Our MedicineWelcome

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Pharmacy Practice Innovative Webinar Series Sponsored by:

The Canadian Pharmacists Association is pleased to be partnering with RxA to highlight a local pharmacist who is doing an exceptional job at providing a financially sustainable initiative and service that improves medication safety, health outcomes and disease prevention for Canadians.

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Today’s Speaker – Melissa Hozack• BSc Pharm from University of Alberta 2001

• Ideal Protein Certified Coach May 2013-Present

• Recognized as one of Pharmasave National’s Visionary Pharmacists 2014

• Recipient of the Canadian Commitment to Care and Service Award in Health Promotion 2015

• Ideal Protein’s Coach of the Month (4000+ clinics) January 2016

• Featured in Pharmacy Practice+ and Pharmacy Business Magazines for work in Health Promotion with Ideal Protein

• Recipient of the Pharmasave Western Business and Innovation Excellence Award 2015

• Recipient of the University of Alberta’s Outstanding Pharmacy Alumnus Award October 2016

• I was the very first client in our Ideal Protein Clinic and I have lost 125lbs and maintained it now for over 2 years!

Disclosure(s)

• Disclosure: Redcliff Pharmasave is an Independent Authorized Center for the Ideal Protein Weight Loss Method, but Melissa does not work for Ideal Protein. Redcliff Pharmasave uses the product and protocol as described and coach dieters to lose weight and promote over all health.

• Disclosure: This learning activity has been sponsored by Pfizer for CPhA’s Pharmacy Practice webinar

Learning Objectives

After participating in this activity, the participant will be able to:

• Understand the “Unbalanced” Nutritional Approach in Addressing Metabolic Syndrome and Weight Loss

• Be familiar with the roles of insulin and glucagon in the body• Review the key points concerning ketosis• Be familiar with the pharmacological implications with Low

Calorie Ketogenic diets

Health Promotion

Melissa – before Melissa – After losing 100lbs

Homeostasis

• Homeostasis is the natural tendency towards a relatively stable equilibrium between interdependent elements

• Homeostasis is controlled by 2 systems:

• – The Autonomic Nervous System

• – Hormones

Homeostasis

• In order to adapt and survive, our body must maintain its physicochemical parameters as stable and relatively constant

• Examples of such parameters:

– Body temperature

– Blood pressure

– Glycaemia

– Mineral salts concentrations

– Hydration

Why is this important when addressing diet and weight loss?

• Insulin and glucagon are the master hormones to maintain homeostasis. The ratio of Insulin to Glucagon is very important. Let’s look at the roles of Insulin and Glucagon in the body.

Insulin• Lowers elevated blood sugar

• Shifts metabolism into storage mode (Weight gain)

• Converts glucose and protein to fat

• Converts dietary fat to storage

• Removes fat from blood and cells; transports it into fat cells

• Increases the body’s cholesterol production

• Encourages fluid retention by the kidneys

• Stimulates arterial muscle cells growth

• Stimulates the use of glucose as energy

Glucagon• Raises low blood sugar

• Shifts metabolism into fat burning mode

• Converts protein and fat to glucose

• Converts dietary fats to ketones and sends them to the tissues for energy

• Releases fat into bloodstream for use by tissues as energy

• Decreases the body’s production of cholesterol

• Encourages excess fluid release by the kidneys

• Stimulates a smooth regression of arterial muscle cells

• Stimulates the use of fat as energy

What is the problem?

And what is behind the epidemic of obesity and metabolic syndrome in our patients?

Hyperinsulinemia and insulin resistance due to...

Types of Sugars• Examples include:

• Table sugar

• Brown sugar

• Corn syrup

• Honey

• Maple syrup

• Molasses

• Jams, jellies

• Fruit drinks

• Soft drinks

• Candy

Simple Carbohydrates

Contains 1-2 sugar molecules

Quickest source of energy, very rapidly digested.

Complex Carbohydrates–chains of sugars

• Examples include:

-Green vegetables

-Whole grains and foods that contain them such as oatmeal, pasta, and whole-grain breads

-Starchy vegetables such as potatoes, sweet potatoes, corn, and pumpkin

-Beans, lentils, and peas

Often contains starch, are rich in fibre, often high in vitamins and minerals

Influence of Food on Insulin & Glucagon

All carbohydrates, with the exception of fiber, increase insulin production because they eventually become sugar (glucose) in vivo –sometimes quickly (simple carbs), sometimes more slowly (complex carbs).

And remember, insulin stores sugar as fat… and so, increased insulin levels then also lead to the epidemic of obesity and metabolic syndrome.

Carbohydrates can prevent fat burn

• Any carbohydrates in the diet (even healthy options like an organic apple or piece of whole wheat bread) will prevent or inhibit weight loss because the body will chronologically burn sugar/carbohydrates before it will burn fat.

• In most low calorie diets, many times the dieter ends up losing muscle and other lean tissue because they have consumed ‘healthy’ carbohydrates and inadequate amounts of protein. This is because of the insulin produced and remember, insulin blocks fat burn and actually switches the metabolism into fat storage.

Carbohydrates can prevent fat burnIf the patient still requires extra energy for day to day activities because they have cut the calories lower than their basal metabolic rate (BMR), the next energy source is amino acids found in muscle. This means the body will choose muscle to burn before fat burn (insulin is blocking fat burn from happening).

Unfortunately if, or more commonly, when that dieter regains the weight later on, they regain only fat, making them more unhealthy than when they started.

Note: Muscles are the engines that burn the calories, so we start to see patients losing muscle and slowing their BMR, making it harder to lose weight the next time or maintain their new weight.

What happens when Sugar

Is taken out of the diet?

Ketosis

• Ketosis simply means the body is producing ketonicbodies from free fatty acids (this can happen from the breakdown of stored fat, or from fats that are eaten in the diet).

• A certain degree of ketosis will occur in any diet where fat is lost and carbohydrate stores are depleted.

Ketosis - continued

Ketosis may occur nightly during the 2nd half of the sleep cycle, particularly if glycogen stores are low, resulting in a better quality, more rested feeling sleep. Our patients note that sleep generally improves when they take out carbohydrates in the diet.

Most cells in the body actually prefer the ketonic bodies for energy, then Gluconeogenesis can happen via the liver and kidneys for the tiny amount of glucose that may be required (brain, parts of the adrenal glands and the RBCs), hence good function of both liver and kidney is necessary for the biochemistry to happen.

Types of Ketosis and Acetoacetic Acid Levels

• Normal Ketosis – occurs during second half of sleep cycle) [AAA] < 0.6 mmol/L

• Nutritional Ketosis: occurs during carbohydrate restriction phases of a low calorie ketogenic diet.

[AAA] 0.6 to ~3.0 mmol/L

• ‘Medicinal’ Ketosis: patients are placed on a eucaloric ketogenic dietand may be given oral B-hydroxybutyrate as a supplement. [AAA] 0.6 – up to ~5 mmol/L

• Epilepsy: since the 1920’s in childhood epilepsy

• Ketoacidosis: This is a life-threatening medical emergency. [AAA] > 15 mmol/L and blood glucose > 16.7 mmol/L

Treatment: I.V. insulin drip + electrolytes and glucose.

• Do Type II Diabetics go into ketoacidosis? No, because they have some insulin and glucose in their systems so the body can convert excess ketonic bodies back into acetyl-CoA

Ketoacidosis

• In Type I Diabetics whose insulin therapy is insufficient

• In patients with severe liver dysfunction

• In patients with severe kidney dysfunction

The life-threatening state of ketoacidosis, which many people are worried about when they hear the term ‘ketosis’, can only occur:

Note: In a low calorie, adequate protein diet such as the IPWLM, we require the liver and kidneys to function at optimal levels to perform the biochemistry needed to eliminate/neutralize the acidic ketone bodies that otherwise accumulate and could cause ketoacidosis. This is not an issue with the correct function (we can help to determine this with bloodwork on GFR and LFT’s).

“

”

Let food be thy medicine and medicine be thy food.

Hippocrates 400BC

So how can we as pharmacists and technicians take what we know about insulin and glucagon and put that into practice? How can we promote health instead of dispensing medications only to extend the inevitable decline? How can we help manage our patient’s health by using food as their medicine?

Health Promotion in Community PharmacyIn my pharmacy, I utilize the Ideal Protein Weight Loss Method. With this protocol, we focus on having the patient in ketosis and losing weight by eliminating almost all of the simple and complex carbohydrates.

This encourages fat burn to happen, but at the same time, spares muscle and other lean tissue with the diet supplying a minimal daily requirement of protein (it is NOT a high protein diet). This addresses insulin resistance, it is not just about losing the weight.

We start to see the reversal of metabolic syndrome as patients progress through the protocol.

Health Promotion - Continued

As a clinical pharmacist, I have focused 100% of my time towards this protocol for the past 3.5 years and have seen over 600 patients lose over 25,000lbs (about -42lbs per dieter).

I am using the Alberta Pharmacy Services framework to perform care plans regarding obesity, metabolic syndrome components and other inflammatory conditions. The best part is I am seeing great results from my involvement in almost all areas. (BP, diabetes, cholesterol, PCOS, inflammation, asthma, all are seeing reduced need for medications or being deprescribed altogether).

Health Promotion - continued

I check Netcare for prescriptions at other pharmacies, send patients for bloodwork, and then can review results online. I keep in touch with physicians and other health care professionals by fax or phone and keep them up to date on our patient’s progress when necessary.

Our patients come to see myself or my coaches weekly for weigh ins, daily food journal review which includes blood pressure numbers, blood glucose self testing, sleep length and quality, as well as exercise type and duration.

Health Promotion

I also check weight, height, use our body fat composition analysis machine, body measurements, then review how the dieter is feeling overall and a variety of other things, individual to each client.

If I am not available, I have other pharmacists on duty that are familiar with the program and are available during or after any appointment. We offer them vaccinations, injections, and regular medication reviews with their appointments as well.

Some Pharmacological Implications with Low Calorie Ketogenic Diets

Because the rate of weight loss is more rapid than other diets, (male dieters lose 3lbs/week and females lose 2lbs/week), so medications dosed on a mg/kg basis will have to be addressed regularly.

Note: we communicate to the MD about the patient being on protocol, and any changes to medications should always be discussed, evaluated, and managed with the patient’s physician. Good communication between providers is essential.

Some Pharmacological Implications with Low Calorie Ketogenic DietsWarfarin Therapy: dieters have 4 cups of non-starchy vegetables daily & salads. Vit K levels may greatly increase, negatively impacting the INRs. Patients would be instructed to choose the same 5-6 vegetables and keep salads consistent. Check weekly PTs (includes the INR) until stable. Adjust warfarin dose PRN

Insulin doses will be reduced as early as the first week on the IPWLM as well as reducing sulfonylureas and GLP-1 agonists.

Some Pharmacological Implications with Low Calorie Ketogenic Diets

In patients on diuretics or combo drugs (ARBs + HCTZ or ACE-I + HCTZ), watch for signs of hypotension (dizziness, fatigue, orthostatic HTN, or ‘brain fog’). D/C diuretic or switch to plain ARB or ACE-I if necessary (remember hyperinsulinemia makes you retain Na).

SGLT-2 Inhibitors-Because of warning of ketoacidosis associated in low calorie diets (any diet), D/C these as soon as [BG] improves (usually into week 2)

Note: Any medication changes to be discussed and evaluated with the physician, communication is essential.

How To Promote Health

We focus on the education of the patient, regular support via texts, phone calls, coaching emails, and a private facebook sharing group where dieters have the support of others going through this journey.

By reviewing food journals and providing phase one Ideal Protein recipes, we see great patient outcomes. There is no counting of carbohydrates or calories, you simply follow what is on the medically designed protocol. Not everyone uses the Ideal Protein weight loss method, but you can put some of the principles into place using information about insulin/glucagon and how they work in the body.

And, we always have a pharmacist on duty for the medical support required to help patients reach their health outcome goals!

What kind of food should we be eating?

What should you avoid?

OverviewDecrease

sugar in the patient’s

diet

Decreases insulin

production

Burn Fat

Decreases metabolic syndrome conditions

Reduce or Eliminate

Medications

Become more active

Conclusion

-A better understanding of the “Unbalanced” Nutritional Approach in Addressing Metabolic Syndrome and Weight Loss

-Reviewed the roles of insulin and glucagon in the body

-Reviewed the key points concerning ketosis and the different states we are looking at in community pharmacy

-Familiarity with some of the pharmacological implications with Low Calorie Ketogenic diets

References

• Ideal Protein Scientific Support Materials and Training – Dr. Tran Tien Chanh Co-founder and Medical Consultant for Ideal Protein and Olivier Benloulou, President and Chief Executive Officer of Ideal Protein, Michael Ciell, RPh

• The Relationship between Insulin and Glucagon in the Pathogenesis of Metabolic Syndrome - written by Michael Ciell, RPh, Chief Science Advisor, and Director of the Scientific support center with Ideal Protein.

• Aspirus: The Effect of a Very Low Carbohydrate Diet on Residual Dyslipidemia in Statin Treated Overweight Patients By: Timothy Logemann, MD; David K. Murdock, MD; Kelly O’Heron, RD & Adam Hoffmann

• Results: Results: 1) 36 patients completed at least 12 weeks of the diet with a 90% compliance rate. 2) Weight decreased from 255.3±40.5 to 219.5±34.5 lbs (p<0.001). 3) Waist size decreased from 49.2±4.8 to 43.6±4.4 inches (p<0.001). 4) Total Cholesterol decreased from 185.1±44.3 to 153.6±41.7 mg/dl (p<0.001) 5) Non-high density lipoprotein cholesterol decreased from 139.3±39.3 to 104.8±38.7 mg/dl (p<0.001). 6) Triglycerides dropped significantly from 213.8±105.9 to 90.1±36.6 mg/dl (p<0.001).

• Conclusion: The IPWLM has a powerful effect on lipid abnormalities and can significantly improve the residual dyslipidemia in statin treated patients. Further investigation and long term results of the role of a very low carbohydrate diet on treating residual dyslipidemias is indicated.

• Aspirus: Effect of the Ideal Protein Weight Loss Method on Weight Loss and Metabolic Parameters By: Timothy Logemann, MD; David K. Murdock, MD, MS; Kelly O’Heron, RD & Adam Hoffmann

• Results: 1) 233 patients completed at least 12 weeks of the diet with 86% compliance. 2) Average weekly weight loss was about 3.5 lbs for males and 2.5 lbs for females. 3) Mean weight decreased from 228.4±47.8 to 195.0±41.8 lbs (p<0.001).

• Conclusion: The IPWLM results in rapid weight loss and marked improvement in metabolic parameters in a short period of time. Further investigation of the IPWLM on individual and population health and long term results is indicated.

Questions

For more Information, Check out

Redcliff Pharmasave on Facebook and Twitter

Melissa Hozack on linkedinmhozack@gmail.com

www.Redcliffweightloss.com

Thank you!

This presentation will be available online at http://www.pharmacists.ca/index.cfm/education-practice-resources/professional-development/pharmacy-practice-webinars/

Thank you to Pfizer for sponsoring this Pharmacy Practice webinar series.