An Interview with Mona Morstein, ND, DHANP
Mona Morstein, ND, DHANP, is the author of the highly-praised book Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type 1 and Type 2 Diabetes (Chelsea Green Publishing, 2017). She is also the founder of the Low Carb Diabetes Association, a nonprofit organization dedicated to educating people about integrative therapies for diabetes. Morstein has been a naturopathic physician for three decades, and has a private practice, Arizona Integrative Medical Solutions, in Tempe, Arizona.
Every day, our bodies are charged with the task of transforming each morsel of food we swallow into energy. People with good metabolic health efficiently metabolize fats, proteins, and carbohydrates without issue. They effortlessly maintain an optimal weight, a balanced mood, and vibrant energy. But not everyone is so blessed.
Family history and genetics, environmental exposures, a processed-food diet, a lack of exercise and especially weight gain and obesity, are a few reasons why cellular and blood-sugar metabolism can become compromised.
In this interview with Element Senior Writer Sarah Cook, ND, metabolic health authority Mona Morstein, ND, DHANP, shares her clinical insights on blood-sugar metabolism—including her Eight Essentials® of Metabolic Health, and how she helps patients achieve them.
SARAH COOK: How can clinicians identify patients who need metabolic support?
MONA MORSTEIN: The fact of the matter is that right now, one out of every three people in the United States has either elevated blood sugar or conditions that are diagnosed when their blood sugar rises to clinical relevance. That amounts to 110 million Americans. Depending on where you live in the country, 30 percent to 70 percent of the people are overweight or obese and at risk for elevated blood sugar.
These statistics tell us that a considerable number of patients in a general family practice—at least one in every three—will benefit from metabolic and blood-sugar support. Being overweight or obese is one clinical clue that a person needs metabolic support, especially if the weight is focused around the middle. Abdominal visceral fat releases inflammatory cytokines and other chemical mediators that interfere with the ability of glucose to enter cells—driving insulin resistance.
Other signs that a person might need support for healthy blood-sugar regulation include poor wound healing, recurrent fungal infections (like athlete’s foot or vaginal yeast infections), fatigue, or a sedentary lifestyle.
Metabolic support can be indicated for people of any ethnicity, but should particularly be considered for Hispanics, Native Americans, Pacific Islanders and people with a family history of conditions associated with metabolic or glucose regulation.
Let’s also keep in mind that children need to maintain healthy blood sugar as much as adults. There has been an alarming tenfold increase in childhood and adolescent obesity over the last four decades. We need to keep metabolic health top of mind in our pediatric population as well.
COOK: Which lab tests are most helpful for evaluating a person’s metabolic health?
MORSTEIN: Before jumping to lab tests, I want to emphasize how vital it is for clinicians to have patients do diet diaries and glucose graphs. My patients are very well trained to bring this documentation to follow-up visits. I have patients use a glucose meter to measure their blood sugar 90 minutes after each meal (and before meals if they are injecting insulin at meals). These are the first investigatory tools, and are invaluable for monitoring blood-sugar patterns.
When it comes to lab tests, we want to do the standard comprehensive metabolic panel (CMP), complete blood count (CBC), lipids, and hemoglobin A1C (HbA1C). But there are also a few other labs to consider.
Ferritin is important to add. This is not part of the regular CBC, so you need to add ferritin to the lab form. Elevated ferritin can be the first sign that a person is accumulating fat in the liver. If this is the case, ferritin is acting as an acute-phase reactant to an irritated liver. When you see elevated ferritin, the next step is to do an abdominal ultrasound. It’s essential to evaluate the health of the liver because this will influence what the patient should or should not be eating or drinking (such as needing to avoid alcohol).
Insulin levels are also helpful to know. Sometimes I do a test with patients when their fasting glucose is less than 126 mg/dl, where we take a fasting glucose and insulin level, have the patient eat a high-carbohydrate and high-glycemic meal, and retest blood glucose and insulin 90 minutes to two hours later. This method often reveals a need for blood-sugar support that we wouldn’t detect by testing fasting glucose and insulin levels alone. Note that if a person is injecting insulin, the only way to gauge what the pancreas can produce is to test c-peptide.
Testing high-sensitivity C-reactive protein (hs-CRP), fibrinogen, and homocysteine give us insight into cardiovascular health and how much inflammation is in the body. It’s good to check thyroid function and sex hormones as well. Women who need support for blood-sugar regulation often experience decreases in estrogen and increases in testosterone. Men experience the opposite, with decreased levels of testosterone. If men are taking statin medications, testosterone can be even more depressed.
Some clinicians like to test for food sensitivities, but I’m cautious to jump to this too quickly. The diet I recommend for blood sugar and metabolic support is already restrictive and eliminates many food allergens. I order food-sensitivity testing in some cases, but don’t routinely order it for patients whom I suspect need metabolic support.
If the patient has an autoimmune type of dysregulation of glucose and has been eating gluten regularly, test for transglutaminase IgA antibody, deaminated gliadin IgA, endomysial antibody IgA (all reflexed to IgG if total IgA is low).
COOK: How do you prioritize your recommendations and avoid overwhelming the patient?
MORSTEIN: Patients are easily overwhelmed. I’ve seen colleagues lose patients after the first visit merely by recommending at the last minute that the patient go on a low-carb diet. The key to gaining trust and commitment from your patients is being organized and methodical in your delivery of information.
I set up my first office visit to be the intake, physical exam, and lab test orders. I send patients home after the first visit with a FEATURE Lab Tests to Evaluate Metabolic Health diet diary and glucose graph. This visit is strictly for information gathering. I do not give any recommendations until the second visit.
The second visit is designed to review the diet diary, glucose graph, and lab tests. This is also when I take the time to go step by step through the recommendations. This is not a short visit. I have an eight-page handout to review all of my suggestions. But I don’t just hand them the packet. I go through each page and educate the patient on each point.
In the eight pages of recommendations, we discuss what I have coined The Eight Essentials® of metabolic health. The concept of The Eight Essentials® is covered in my book Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type 1 and Type 2 Diabetes, which is promoted by the Low Carb Diabetes Association. The Eight Essentials® include a low-carb diet, exercise, sleep, stress management, gut health, environmental detoxification, supplements, and medications.
As we go through each of these concepts, I get agreements and commitments from the patient. They don’t need to do everything at once. The low carb diet is paramount. On top of that, maybe they agree to drink more water, go for a walk after dinner, and avoid fragrances. These are the items I list on their final plan.
It might seem repetitive or like drudgery to go through the same eight pages of recommendations with every patient. But every job has aspects that are tedious. Following an organized and step-by step approach is the best way to ensure compliance from our patients. It’s the best way to achieve better outcomes and sincerely help our patients attain metabolic health. That’s why I’ve chosen this career, and why I never lose my excitement for the day-to-day work.
COOK: You mentioned the low-carb diet. Is that what you recommend for everyone to support blood-sugar regulation?
MORSTEIN: There was an article published recently in the Nutrition Journal by 26 of some of the leading physicians and researchers on the low-carb diet. The authors presented 12 points of evidence that unequivocally support a low-carb diet for blood-sugar regulation and metabolic health.
The way I explain it to my patients is that their cells have lost the metabolic capacity to process carbohydrates. A patient who is 10 pounds overweight and in relatively good health doesn’t need to restrict carbohydrates as much as a patient who is 100 pounds overweight and in poor metabolic health. Still, a low-carb diet is something I implement with all of my patients who need support for blood-sugar regulation.
The goal is generally 20 to 40 grams per day of total carbohydrate intake. But I’m not an extremist. I don’t want patients eating only steak, hamburgers, and bacon. I want them eating vegetables throughout the day, and maybe a few berries as carbohydrates.
If a person’s metabolic situation is more extreme, we also need to count protein intake. Fats are a free-for-all because they don’t break down into glucose at all. I don’t have patients count calories, but I do ask them to track their macronutrient intake on an app, like MyFitnessPal or Carb Manager.
One key to our patients’ success is recommending alternatives to replace foods we remove from their diet. I provide as many as 20 different recipes to patients. I teach them how to make muffins and pancakes with nut flours, and pizza crust with cauliflower. They’re excited when they see a new world of possibilities open to them.
COOK: What are some of the nuances of implementing a low-carb diet?
MORSTEIN: Even though I recommend a low-carb diet as the best way to support blood-sugar regulation, there is no single best way to do it. I modify the diet to individual preferences. We can do a low-carb diet that is an omnivore diet, an ovo-lacto vegetarian diet, a vegan diet, or (for more strict regulation) a ketogenic diet.
It’s possible to follow a low-carb diet in either a healthy or unhealthy way, so I emphasize high-quality, nutrient-dense, whole foods. I want my patients to eat a variety. Protein sources can include meats, fish, eggs, dairy, nuts, and seeds. Protein powders are fine for people who enjoy smoothies. Fats should be high quality, like pasture-raised butter, extra-virgin olive oil, flaxseed oil, and coconut oil. Carbohydrates should come from a variety of vegetables, low-sugar fruits, and berries.
Portion control is another aspect of the diet. People who need extra metabolic support often have lost the signals in the brain to tell them they’re full. Their tendency to overeat is not because of a lack of willpower, but because of changes in the brain. The low-carb diet supports healthy appetite control in as little as one week. It’s a win-win, making the diet more natural, more pleasant, and more rewarding.
If people feel like they need to snack, I recommend things like cheese sticks, organic meat sticks, or ketogenic protein bars. But most patients should not snack. I teach them to eat breakfast, lunch, and dinner at about five-hour intervals. Allowing breaks between meals supports blood sugar regulation and digestive health.
Finally, there’s intermittent fasting. This gives the body an extended break from eating, and has been shown to have a wide range of metabolic benefits. The simplest way to do this is by fasting for at least 12 hours between dinner and breakfast. Some patients are willing to extend that fast to 14 or 16 hours. Another option is to eat significantly fewer calories than usual for two days out of each week or five days out of each month. The timing of when we eat works synergistically with the low-carb diet to support metabolic balance.
COOK: Are there any concerns about a low-carb diet lacking specific nutrients?
MORSTEIN: If the low-carb diet is done in the way I just described (with a wide variety of whole foods), there are not a lot of concerns about specific nutrients. However, there is evidence that a low-carb diet can adversely affect the gut microbiome. Without grains or beans as a source of fiber, the gut microbiota lacks an important source of fuel.
To ensure adequate fiber intake and to support a healthy microbiome, I recommend all patients take a fiber powder. I might also recommend a probiotic supplement and to regularly eat fermented vegetables.
Digestive health is essential to broader metabolic health, so it’s vital that we support the diversity of the gut microbiome with supplementation and a varied diet.
COOK: Are there other reasons why you would consider supplementation for metabolic support?
MORSTEIN: Supplementation serves so many purposes. One important purpose is to replete and optimize nutrients. Magnesium, zinc, chromium, and omega-3 fatty acids are all needed for insulin sensitivity and glucose metabolism. Studies show that people with elevated blood sugar often have deficiencies in one or more of these nutrients. And even the healthiest diets can’t guarantee delivery of all of the necessary vitamins and minerals every day.
Some supplements support antioxidant status. This is a critical part of supporting metabolic health because many of the complications of glucose imbalance result from oxidative damage to the cells and tissues of the body.
Other reasons to use supplements depend on the patient. Many patients who need metabolic support also need support for other systems of the body. Supplements can be used to support digestion, detoxification, cardiovascular health, immune function, hormone balance, mood, sleep, and more.
COOK: What are the top five supplements you recommend for blood sugar support and metabolic health?
MORSTEIN: My top five supplements are:
• A multivitamin and mineral
• Fish oil
• Fiber
• A combination product for blood-sugar support
• Any other supplement that is specific to the individual
The multiple vitamin and mineral supplement should be a product that is recommended on the label to be taken at six tablets or capsules a day. The fish oil also needs to be taken in a high amount, starting at 1,000 mg of eicosapentaenoic acid (EPA) and 750 mg docosahexaenoic acid (DHA) per day. The fiber powder can be taken in an amount of 1 to 2 tablespoons a day.
When I couldn’t find a single product that met my qualifications to support healthy blood sugar levels and insulin metabolism, I formulated one with Priority One. The product is called Diamend, and provides zinc, chromium, and vanadium in amounts that support healthy insulin production and utilization. It also contains Gymnema sylvestre, which is one of the best herbs to support insulin sensitivity and reduce carbohydrate or sugar cravings. Berberine, n-acetyl cysteine (NAC), R-alpha lipoic acid (R-ALA), and turmeric are included to support insulin function and liver health, while green tea extract, bilberry, and benfotiamine provide additional antioxidant support.
Aside from those four products, I only recommend additional supplements as needed. We don’t want our patients to be overwhelmed by too many pills. This amount keeps it manageable and sustainable.
COOK: If I gave you two minutes to sum up your recommendations for practitioners when it comes to supporting metabolic health in their patients, what would you say?
MORSTEIN: I cannot overemphasize how important it is to organize your office visits so as to not overwhelm the patient. Reserve the first visit for data collection. Allow plenty of time (and charge what you need) on the second visit to review recommendations. Use helpful handouts and explain things carefully.
If the day-to-day tasks and reviewing the same recommendations become tedious, focus on the big picture. You are bringing new information to people who have never heard it before. It’s like when you drive down the road and see someone standing on the sidewalk smoking and you think, “People still smoke?” Well, they do. And people still drink soda and eat fast food. Some people have never heard of a low-carb diet.
When you open people’s eyes to a world they never knew before, they are so appreciative. They start to lose weight, they have more energy, they see their blood sugars come into balance, and they are happy. We are guiding our patients on a journey toward health and away from metabolic complications. It’s as exciting to me now as it was 30 years ago. That is what our work is all about.
The Eight Essentials® for Healthy Blood Sugar
Blood-sugar regulation and metabolic health depend on a multitude of factors. Dr. Morstein’s metabolic health protocol is so unique that it’s trademarked: “The Eight Essentials®.” Here are the key points for each of the eight categories.
1. LOW-CARB DIET. Any person with elevated blood sugar or insulin resistance has lost the biochemical capacity to metabolize carbohydrates properly. To support glucose regulation, it’s imperative to reduce carbohydrates in the diet. Eating 20 to 40 grams of carbohydrates per day is highly effective for enhancing weight loss, supporting glucose control, balancing lipid levels, and returning lab values to a healthy range. A low-carb diet is a powerful tool to support insulin responses at the cellular level and promote good appetite control.
2. EXERCISE. Both aerobic and resistance exercise are a vital lifestyle habit. Thirty minutes of aerobic exercise per day can markedly support cardiovascular health. And resistance exercise builds muscle cells—the primary cells that burn glucose.
3. SLEEP. The National Health and Nutrition Examination Study (NHANES) showed that getting less than five hours of sleep a night raised the risk of becoming obese. Good sleep can help the hormones leptin and ghrelin stay in a healthy balance, resulting in better control over appetite and food cravings.
4. STRESS MANAGEMENT. Stress that’s not well managed can lead to overproduction of cortisol and epinephrine, which contributes to problems with glucose regulation. Uncontrolled stress can also lead to problematic eating and lifestyle habits. The following stress-management tools can help patients feel calm, content, and in control each day. » Prayer or meditation » Gratitude journaling » Creative endeavors like painting, writing, sewing, or knitting » Hobbies » Getting into nature by gardening, hiking, or engaging in other outdoor activities » Volunteer work » Laughter (even forced laughter reduces stress)
5. SUPPORTING THE GUT AND MICROBIOME. Gastrointestinal health influences the health of the whole body. Scientists are learning that certain microorganisms may influence insulin function, liver health, body weight, and healthy inflammatory balance. A low-carb diet is not innately healthy for the gut (it removes grain and bean fibers), so adding a fiber powder into the diet supports the proliferation of beneficial gut bacteria.
6. ENVIRONMENTAL DETOXIFICATION. Research shows that exposure to pesticides, herbicides, and other chemical contaminants may interfere with the cellular response to insulin. Environmental exposure may be one of the leading causes of metabolic abnormalities throughout the world today. Ensuring that patients avoid chemicals such as fragrances, lawn chemicals, and plastic food-storage containers is vitally important.
7. SUPPLEMENTATION. Dietary supplements play a considerable role in supporting blood-sugar regulation and metabolic health. In particular, supplements can:
» Address nutrient deficiencies
» Enhance nutrient intake
» Support glucose regulation
» Support insulin function
» Support mood
» Support healthy lipid balance
» Support a healthy inflammatory response
8. MEDICATIONS. The last of The Eight Essentials® is medications. They’re not indicated in all cases, but should be considered as part of the overall approach to blood-glucose regulation and metabolic health.