Fig 3 - uploaded by Michelle Jospe
Content may be subject to copyright.
Source publication
"Hunger training", which aims to teach people to eat only when blood glucose is below a set target, appears promising as a weight loss strategy. As the ability of participants to adhere to the rigorous protocol has been insufficiently described, we sought to determine the feasibility of hunger training, in terms of retention in the study, adherence...
Context in source publication
Context 1
... blood glucose cut-off of 4.7 mmol/L, adhered to the goal of eating only when blood glucose was below this level 66 % of the time, which was below our within- person adherence requirement of 75 % (Table 2). Fur- thermore, four out of the nineteen (21 %) participants in this cohort adhered to protocol A on less than half of their eating occasions (Fig. 3), with one participant only adhering on two eating occasions over the two week period (5 % of all eating ...
Similar publications
Citations
... Like other timed-eating strategies, such as time-restricted eating (33), GGE does not impose specific dietary restrictions. Instead, its primary objective is to optimize energy intake times, ideally when glucose levels are beneath a personalized threshold, akin to morning fasting glucose levels (34). This nuanced approach integrates both the chronobiological insights of when to eat with the metabolic cues of what the body needs. ...
Background
High glycemic variability (GV) is a biomarker of cancer risk, even in the absence of diabetes. The emerging concept of chrononutrition suggests that modifying meal timing can favorably impact metabolic risk factors linked to diet-related chronic disease, including breast cancer. Here, we examined the potential of eating when glucose levels are near personalized fasting thresholds (low-glucose eating, LGE), a novel form of timed-eating, to reduce GV in women without diabetes, who are at risk for postmenopausal breast cancer.
Methods
In this exploratory analysis of our 16-week weight loss randomized controlled trial, we included 17 non-Hispanic, white, postmenopausal women (average age = 60.7 ± 5.8 years, BMI = 34.5 ± 6.1 kg/m², HbA1c = 5.7 ± 0.3%). Participants were those who, as part of the parent study, provided 3–7 days of blinded, continuous glucose monitoring data and image-assisted, timestamped food records at weeks 0 and 16. Pearson’s correlation and multivariate regression were used to assess associations between LGE and GV, controlling for concurrent weight changes.
Results
Increases in LGE were associated with multiple unfavorable measures of GV including reductions in CGM glucose mean, CONGA, LI, J-Index, HBGI, ADDR, and time spent in a severe GV pattern (r = −0.81 to −0.49; ps < 0.044) and with increases in favorable measures of GV including M-value and LBGI (r = 0.59, 0.62; ps < 0.013). These associations remained significant after adjusting for weight changes.
Conclusion
Low-glucose eating is associated with improvements in glycemic variability, independent of concurrent weight reductions, suggesting it may be beneficial for GV-related disease prevention. Further research in a larger, more diverse sample with poor metabolic health is warranted.
Clinical trial registration: ClinicalTrials.gov, NCT03546972.
... Glucose-guided eating (GGE) is a timed eating paradigm that promotes metabolic homeostasis by deterring energy intake when circulating glucose is the primary source of fuel. GGE (historically called "hunger recognition" and "hunger training") has been tested over the past 2 decades in adults without diabetes who often experience overweight or obesity [1][2][3][4][5][6][7][8][9][10]. GGE involves learning to eat only when physically hungry. ...
... People following GGE are trained to monitor perceived hunger and glucose levels and to associate symptoms experienced when glucose levels approximate (morning) fasting levels with being physically hungry. Eating according to GGE includes recognizing the symptoms of physical hunger and having preprandial glucose below a personalized threshold, which is computed as the average of 2 consecutive morning preprandial glucose levels [1,5,7,11]. Eating when glucose is below the GGE threshold requires postprandial glucose to return to a fasted state before initiating a subsequent eating event. ...
... Among people without evidence of T2DM, the threshold to guide decisions about meal timing is computed as the average of preprandial glucose for 2 consecutive mornings after fasting for at least 8 hours [1]. Using this method for computing and implementing GGE thresholds for people with T2DM is potentially complicated by the presence of the DP. ...
Background:
Glucose-guided eating (GGE) improves metabolic markers of chronic disease risk, including insulin resistance, in adults without diabetes. GGE is a timed eating paradigm that relies on experiencing feelings of hunger and having a preprandial glucose level below a personalized threshold computed from 2 consecutive morning fasting glucose levels. The dawn phenomenon (DP), which results in elevated morning preprandial glucose levels, could cause typically derived GGE thresholds to be unacceptable or ineffective among people with type 2 diabetes (T2DM).
Objective:
The aim of this study is to quantify the incidence and day-to-day variability in the magnitude of DP and examine its effect on morning preprandial glucose levels as a preliminary test of the feasibility of GGE in adults with T2DM.
Methods:
Study participants wore a single-blinded Dexcom G6 Pro continuous glucose monitoring (CGM) system for up to 10 days. First and last eating times and any overnight eating were reported using daily surveys over the study duration. DP was expressed as a dichotomous variable at the day level (DP day vs non-DP day) and as a continuous variable reflecting the percent of days DP was experienced on a valid day. A valid day was defined as having no reported overnight eating (between midnight and 6 AM). ∂ Glucose was computed as the difference in nocturnal glucose nadir (between midnight and 6 AM) to morning preprandial glucose levels. ∂ Glucose ≥20 mg/dL constituted a DP day. Using multilevel modeling, we examined the between- and within-person effects of DP on morning preprandial glucose and the effect of evening eating times on DP.
Results:
In total, 21 adults (59% female; 13/21, 62%) with non-insulin-treated T2DM wore a CGM for an average of 10.5 (SD 1.1) days. Twenty out of 21 participants (95%) experienced DP for at least 1 day, with an average of 51% of days (SD 27.2; range 0%-100%). The mean ∂ glucose was 23.7 (SD 13.2) mg/dL. People who experience DP more frequently had a morning preprandial glucose level that was 54.1 (95% CI 17.0-83.9; P<.001) mg/dL higher than those who experienced DP less frequently. For within-person effect, morning preprandial glucose levels were 12.1 (95% CI 6.3-17.8; P=.008) mg/dL higher on a DP day than on a non-DP day. The association between ∂ glucose and preprandial glucose levels was 0.50 (95% CI 0.37-0.60; P<.001). There was no effect of the last eating time on DP.
Conclusions:
DP was experienced by most study participants regardless of last eating times. The magnitude of the within-person effect of DP on morning preprandial glucose levels was meaningful in the context of GGE. Alternative approaches for determining acceptable and effective GGE thresholds for people with T2DM should be explored and evaluated.
... Glucose-guided eating (GGE) is a timed eating paradigm that promotes metabolic homeostasis by deterring energy intake when circulating glucose is the primary source of fuel. GGE (historically called "hunger recognition" and "hunger training") has been tested over the past 2 decades in adults without diabetes who often experience overweight or obesity [1][2][3][4][5][6][7][8][9][10]. GGE involves learning to eat only when physically hungry. ...
... People following GGE are trained to monitor perceived hunger and glucose levels and to associate symptoms experienced when glucose levels approximate (morning) fasting levels with being physically hungry. Eating according to GGE includes recognizing the symptoms of physical hunger and having preprandial glucose below a personalized threshold, which is computed as the average of 2 consecutive morning preprandial glucose levels [1,5,7,11]. Eating when glucose is below the GGE threshold requires postprandial glucose to return to a fasted state before initiating a subsequent eating event. ...
... Among people without evidence of T2DM, the threshold to guide decisions about meal timing is computed as the average of preprandial glucose for 2 consecutive mornings after fasting for at least 8 hours [1]. Using this method for computing and implementing GGE thresholds for people with T2DM is potentially complicated by the presence of the DP. ...
BACKGROUND
Glucose-guided eating (GGE) improves metabolic markers of chronic disease risk, including insulin resistance, in adults without diabetes. GGE is a timed eating paradigm that relies on experiencing feelings of hunger and having a preprandial glucose level below a personalized threshold computed from 2 consecutive morning fasting glucose levels. The dawn phenomenon (DP), which results in elevated morning preprandial glucose levels, could cause typically derived GGE thresholds to be unacceptable or ineffective among people with type 2 diabetes (T2DM).
OBJECTIVE
The aim of this study is to quantify the incidence and day-to-day variability in the magnitude of DP and examine its effect on morning preprandial glucose levels as a preliminary test of the feasibility of GGE in adults with T2DM.
METHODS
Study participants wore a single-blinded Dexcom G6 Pro continuous glucose monitoring (CGM) system for up to 10 days. First and last eating times and any overnight eating were reported using daily surveys over the study duration. DP was expressed as a dichotomous variable at the day level (DP day vs non-DP day) and as a continuous variable reflecting the percent of days DP was experienced on a valid day. A valid day was defined as having no reported overnight eating (between midnight and 6 AM). ∂ Glucose was computed as the difference in nocturnal glucose nadir (between midnight and 6 AM) to morning preprandial glucose levels. ∂ Glucose ≥20 mg/dL constituted a DP day. Using multilevel modeling, we examined the between- and within-person effects of DP on morning preprandial glucose and the effect of evening eating times on DP.
RESULTS
In total, 21 adults (59% female; 13/21, 62%) with non–insulin-treated T2DM wore a CGM for an average of 10.5 (SD 1.1) days. Twenty out of 21 participants (95%) experienced DP for at least 1 day, with an average of 51% of days (SD 27.2; range 0%-100%). The mean ∂ glucose was 23.7 (SD 13.2) mg/dL. People who experience DP more frequently had a morning preprandial glucose level that was 54.1 (95% CI 17.0-83.9; P <.001) mg/dL higher than those who experienced DP less frequently. For within-person effect, morning preprandial glucose levels were 12.1 (95% CI 6.3-17.8; P =.008) mg/dL higher on a DP day than on a non-DP day. The association between ∂ glucose and preprandial glucose levels was 0.50 (95% CI 0.37-0.60; P <.001). There was no effect of the last eating time on DP.
CONCLUSIONS
DP was experienced by most study participants regardless of last eating times. The magnitude of the within-person effect of DP on morning preprandial glucose levels was meaningful in the context of GGE. Alternative approaches for determining acceptable and effective GGE thresholds for people with T2DM should be explored and evaluated.
... Research shows that eating without physiological hunger is a modifiable health risk behavior associated with excessive weight gain and increased metabolic risk [31,32]. Consistent with this research, we have shown that individuals with obesity are over-sensitive to changes in glucose levels [32] and that low-glucose eating patterns (defined by personalized thresholds) can be taught as an effective self-regulation strategy that promotes weight control [33,34]. Glucose-guided eating (GGE; historically referred to as hunger training) is a timed eating intervention that teaches people to differentiate between physiological hunger and the hedonic desire to eat [35]. ...
... The modification of glucose eating patterns by GGE is feasible [33,36] and has resulted in clinically significant, average weight loss of 7.4% in 5 months and improvements in eating behavior (including reductions in hedonic eating) and cancer-related risk biomarkers [34,[36][37][38][39]. GGE has resulted in improvements in whole-body insulin sensitivity by 31% (Matsuda index, 7.1 ± 4.1 to 9.4 ± 5.2) in non-diabetic, lean adults (BMI = 23 ± 4 kg/m 2 ) [38]. Insulin resistance is the most important modifiable risk factor for postmenopausal breast cancer and is caused by obesity and maladaptive eating patterns. ...
Postmenopausal breast cancer is the most common obesity-related cancer death among women in the U.S. Insulin resistance, which worsens in the setting of obesity, is associated with higher breast cancer incidence and mortality. Maladaptive eating patterns driving insulin resistance represent a key modifiable risk factor for breast cancer. Emerging evidence suggests that time-restricted feeding paradigms (TRF) improve cancer-related metabolic risk factors; however, more flexible approaches could be more feasible and effective. In this exploratory, secondary analysis, we identified participants following a low-glucose eating pattern (LGEP), defined as consuming energy when glucose levels are at or below average fasting levels, as an alternative to TRF. Results show that following an LGEP regimen for at least 40% of reported eating events improves insulin resistance (HOMA-IR) and other cancer-related serum biomarkers. The magnitude of serum biomarkers changes observed here has previously been shown to favorably modulate benign breast tissue in women with overweight and obesity who are at risk for postmenopausal breast cancer. By comparison, the observed effects of LGEP were similar to results from previously published TRF studies in similar populations. These preliminary findings support further testing of LGEP as an alternative to TRF and a postmenopausal breast cancer prevention strategy. However, results should be interpreted with caution, given the exploratory nature of analyses.
... Here, we hypothesize that elevated glucose concentrations prior to an eating event (pre-prandial blood glucose; PPBG) indicate EAH. In support of this hypothesis, intervention research using PPBG thresholds measured by glucometers to guide meal initiation in a person's natural environment has proven to be a feasible and effective weight control strategy (Ciampolini et al., 2010;Jospe et al., 2015). This research used PPBG to "train" individuals to recognize symptoms of hunger to guide decisions about meal initiation. ...
... A limitation of this approach was that, in some individuals, fasting glucose concentrations were greater than 85 mg/dl. To address this limitation, later research personalized glucose thresholds by averaging two glucose concentrations measured after consecutive overnight fasts (Jospe et al., 2015). This method of personalizing glucose thresholds was found to be feasible such that study participants achieved their threshold multiple times a day (Jospe et al., 2015) despite being based on longer, overnight fasts. ...
... To address this limitation, later research personalized glucose thresholds by averaging two glucose concentrations measured after consecutive overnight fasts (Jospe et al., 2015). This method of personalizing glucose thresholds was found to be feasible such that study participants achieved their threshold multiple times a day (Jospe et al., 2015) despite being based on longer, overnight fasts. Collectively, this research preliminarily supports the use of PPBG as a biological indicator of EAH. ...
Our ability to understand and intervene on eating in the absence of hunger (EAH) as it occurs in peoples' natural environments is hindered by biased methods that lack ecological validity. One promising indicator of EAH that does not rely on self-report and is easily assessed in free-living individuals is glucose. Here, we hypothesize that elevated pre-prandial blood glucose concentrations (PPBG), which reflect a source of readily-available, short-term energy, are a biological indicator of EAH. This was a 7-day observational study of N = 41, 18–24 year old men and women with BMI < 25 kg/m² (60%) or BMI ≥ 25 kg/m² (40%). We collected data using ecological momentary assessment from people in their natural environments. We defined EAH by self-report (perceived EAH) and by PPBG thresholds using two methods (standardized, PPBG < 85 mg/dl; personalized, PPBG<individual fasting levels). Multilevel modeling was used to analyze the data. N = 963 eating events were reported. There were significantly (p < .05) fewer perceived EAH events (25%) as compared to standardized (62%) and personalized PPBG-defined EAH events (51%). Consistent with published literature, perceived EAH was more likely to occur at a higher PPBG (p < .01), particularly among participants with a BMI ≥ 25 kg/m² (pint < .01). Additionally, discordance between perceived EAH and PPBG-defined EAH, indicating a perception of hunger at an eating event when PPBS was elevated, was less likely among participants with a BMI < 25 kg/m² vs. those with a BMI ≥ 25 kg/m² (pint < .01) as well as at snacks vs. meals (pint < .01). These findings provide preliminary support for using PPBG as a biological indicator of EAH in free-living individuals.
... All research on hunger training to date used fingerpricking as the method to measure blood glucose (Ciampolini & Bianchi, 2006;Jospe, Brown, Roy, & Taylor, 2015;Jospe, Roy, et al., 2017). Whether observed benefits are attributable to the pain of stabbing fingertips, which might have acted as a form of aversion therapy to eating given that the protocol only allows food intake if blood glucose is below a certain level (Ciampolini, Lovell-Smith, & Sifone, 2010;Jospe et al., 2015), is unknown. ...
... All research on hunger training to date used fingerpricking as the method to measure blood glucose (Ciampolini & Bianchi, 2006;Jospe, Brown, Roy, & Taylor, 2015;Jospe, Roy, et al., 2017). Whether observed benefits are attributable to the pain of stabbing fingertips, which might have acted as a form of aversion therapy to eating given that the protocol only allows food intake if blood glucose is below a certain level (Ciampolini, Lovell-Smith, & Sifone, 2010;Jospe et al., 2015), is unknown. We were interested in whether a painless and more convenient form of glucose monitoring would improve adherence and outcomes, while retaining the benefits seen using traditional fingerpricking, before embarking on a full-powered trial. ...
Background
Hunger training teaches people to eat according to their appetite using pre-prandial glucose measurement. Previous hunger training interventions used fingerprick blood glucose, however continuous glucose monitoring (CGM) offers a painless and convenient form of glucose monitoring. The aim of this randomised feasibility trial was to compare hunger training using CGM with fingerprick glucose monitoring in terms of adherence to the protocol, acceptability, weight, body composition, HbA1c, psychosocial variables, and the relationship between adherence measures and weight loss.
Methods
40 adults with obesity were randomised to either fingerpricking or scanning with a CGM and followed identical interventions for 6 months, which included 1 month of only eating when glucose was under their individualised glucose cut-off. For months 2–6 participants relied on their sensations of hunger to guide their eating and filled in a booklet.
Results
90% of the fingerpricking group and 85% of the scanning group completed the study. Those using the scanner measured their glucose an extra 1.9 times per day (95% CI 0.9, 2.8, p < 0.001) compared with those testing by fingerprick. Both groups lost similar amounts of weight over 6 months (on average 4 kg), were satisfied with the hunger training program and wanted to measure their glucose again within the next year. There were no differences between groups in terms of intervention acceptability, weight, body composition, HbA1c, eating behaviours, or psychological health. Frequency of glucose testing and booklet entry both predicted a clinically meaningful amount of weight loss.
Conclusions
Either method of measuring glucose is effective for learning to eat according to hunger using the hunger training program. As scanning with a CGM encouraged better adherence to the protocol without sacrificing outcome results, future interventions should consider using this new technology in hunger training programs.
... [8][9][10] To overcome this barrier, an intervention known as hunger training (HT) uses glucose monitoring as an indicator of hunger to help people gain greater awareness of their appetite signals and eat accordingly. 11 12 A limited body of research has found that HT produces clinically important weight loss, and reduces emotional and external eating [13][14][15] ; however, more research into the efficacy of HT and the ability of participants to adhere to this novel method is needed. ...
Objectives
Hunger training (HT) is an intervention designed to teach people to eat according to their hunger by connecting physical symptoms of appetite with glucose levels. HT is most effective for weight loss, and improving eating behaviours when adherence is high. However, adherence is a challenge that should be explored prior to wider dissemination. The aim of this study was to explore participants’ experience and self-reported adherence and behaviour change related to HT.
Design
A qualitative study, nested within a randomised controlled pilot study of two different methods of monitoring glucose during HT. Semistructured interviews were audio-recorded, transcribed verbatim and analysed thematically using a phenomenological approach.
Setting
Single-centre study with participants recruited from the local area.
Participants
40 participants began the pilot study and 38 participants (52.6% women) remained at 1 month and completed interviews.
Results
Most participants felt they were able to match their hunger to their glucose levels by the end of the intervention. The main adherence barriers were the social pressure to eat, lack of time and lack of flexibility in participants’ meal schedules. Common adherence enablers were having a set routine, social support and accountability. Participants described increased awareness of hungry versus non-hungry eating and better cognition of feelings of hunger and satiety as a result of the intervention, which in turn led to changes of food choice, portion size and adjusted meal timing and frequency.
Conclusions
Findings show that HT is acceptable from a patient perspective, and results can be used to inform the translation of HT programme to healthcare settings.
Trial registration number
ACTRN12618001257257.
... However, training individuals to eat only when hungry on the basis of blood glucose measurements has been tested in only two studies [18,19]. Ciampolini et al. [20] reported significantly greater weight loss (difference of 3.5 kg) over 5 months in participants who were only able to eat when their blood glucose was below a standard cut-off (4.7 mmol/L). ...
... Ciampolini et al. [20] reported significantly greater weight loss (difference of 3.5 kg) over 5 months in participants who were only able to eat when their blood glucose was below a standard cut-off (4.7 mmol/L). As we had concerns regarding the feasibility of participants being able to restrict food intake to only when blood glucose was this low, we undertook a feasibility study, which demonstrated that adherence to the protocol was greater over two weeks if an individualized blood glucose cut-off was used (determined from fasting blood glucose) [19]. In our subsequent randomized controlled trial (RCT), we examined the efficacy of this modified protocol for producing weight loss over 12 months in conjunction with diet and exercise advice [21]. ...
... The hunger training procedure was similar to that used for our feasibility study [19], with modifications to the frequency of monitoring to make it suitable for a longer intervention. For the first fortnight, participants were instructed to measure their capillary blood glucose from a finger prick sample by portable glucometer (Freestyle Optium Glucose Meter, Abbott, Doncaster, Australia) every time they wanted to eat (or drink a caloric beverage). ...
Monitoring blood glucose prior to eating can teach individuals to eat only when truly hungry, but how adherence to ‘hunger training’ influences weight loss and eating behaviour is uncertain. This exploratory, secondary analysis from a larger randomized controlled trial examined five indices of adherence to ‘hunger training’, chosen a priori, to examine which adherence measure best predicted weight loss over 6 months. We subsequently explored how the best measure of adherence influenced eating behavior in terms of intuitive and emotional eating. Retention was 72% (n = 36/50) at 6 months. Frequency of hunger training booklet entry most strongly predicted weight loss, followed by frequency of blood glucose measurements. Participants who completed at least 60 days of booklet entry (of recommended 63 days) lost 6.8 kg (95% CI: 2.6, 11.0; p < 0.001) more weight than those who completed fewer days. They also had significantly higher intuitive eating scores than those who completed 30 days or less of booklet entry; a difference (95% CI) of 0.73 (0.12, 1.35) in body-food choice congruence and 0.79 (0.06, 1.51) for eating for physical rather than emotional reasons. Adherent participants also reported significantly lower scores for emotional eating of −0.70 (−1.13, −0.27). Following hunger training and focusing on simply recording ratings of hunger on a regular basis can produce clinically significant weight loss and clinically relevant improvements in eating behaviour.
... However, monitoring hunger might be challenging for some individuals with overweight if their sensitivity to hunger signals is impaired (11). Blood glucose monitoring may be a feasible biomarker of hunger (12) and effective for weight loss when combined with self-monitoring of hunger symptoms (13). ...
Objective:
To determine the effectiveness of various monitoring strategies on weight loss, body composition, blood markers, exercise, and psychosocial indices in adults with overweight and obesity following a 12-month weight loss program.
Methods:
Two hundred fifty adults with BMI ≥ 27 were randomized to brief, monthly, individual consults, daily self-monitoring of weight, self-monitoring of diet using MyFitnessPal, self-monitoring of hunger, or control over 12 months. All groups received diet and exercise advice, and 171 participants (68.4%) remained at 12 months.
Results:
No significant differences in weight, body composition, blood markers, exercise, or eating behavior were apparent between those in the four monitoring groups and the control condition at 12 months (all P ≥ 0.053). Weight differences between groups ranged from -1.1 kg (-3.8 to 1.6) to 2.2 kg (-1.0 to 5.3). However, brief support and hunger training groups reported significantly lower scores for depression (difference [95% CI]: -3.16 [-5.70 to -0.62] and -3.05 [-5.61 to -0.50], respectively) and anxiety (-1.84, [-3.67 to -0.02]) scores than control participants.
Conclusions:
Although adding a monitoring strategy to diet and exercise advice did not further increase weight loss, no adverse effects on eating behavior were observed, and some monitoring strategies may even benefit mental health.
... We checked the learning by comparing the estimated BG and the BG measured by autoanalyzer [3]. Independent laboratories studied adults and confirmed our results [20] [21]. BG measurements were conceived as a protection from excessive BG lowering [1]. ...
