Eat to your meter and Controlled Carb Regimes

[xyzzy]

I thought I would show existing members where I get a lot of my information from regarding the recommendations I make to new members and the other ideas I advocate.

A simple statement first though so that there can be no misunderstandings

All dietary recommendations I make are for correctly diagnosed T2's who have some amount of pancreatic function (insulin production capability) left. Different dietary regimes may well be better for T1's, LADA and T2's who have little or no pancreatic function left. In these cases it is very likely that controlling by diet (any diet) is unrealistic and is fully accepted by myself.

On Controlled Carbohydrate Regimes

As my posts have said many times I try to follow the guidelines of the Swedish Health Service from a modern 2011 document called "Kost Vid Diabetes". This is the Swedish Health Authorities official policy document for recommended diets for diabetics. Phoenix posted a link to it the other day but here it is again through a Swedish to English translator

http://translate.google.co.uk/trans...=/search?q=Kost+Vid+Diabetes&hl=en&prmd=imvns

When I make new member posts then to me I am recommending what one of the worlds leading health care systems says. It is not just something I think or others with similar views to me think but the recommendation of a modern Western European countries health system. Some would say more modern than the NHS.

The document does not recommend just one diet but several. One it specifically does recommend and I chose to promote is a "moderately reduced carbohydrate" diet. Here are the extracts that I find most useful. Apologies for the bad English as its gone through a Swedish to English translator. I recommend this moderate one as its applicable for the food stuffs that are easily available in the UK and to be upfront it worked and continues to work for me.

The bold is mine and I use it to emphasise why I recommend in my newly diagnosed posts why carbohydrates should be reduced.

The bold underline is again my doing and to me IS the key statement.

In recent years, moderate carbohydrate diet scientifically studied and in increasing quantities. Several studies have examined the effect of a moderate carbohydrate reduction even in diabetic patients.

The diet consists of meat, fish, shellfish, eggs, vegetables, legumes and vegetable proteins and fats from olive oil and butter. The diet includes less sugar, bread, cereals, potatoes, root vegetables and rice than a traditional diabetes diet.

Several international guidelines for the dietary management of people with diabetes recommend today a diet that is broadly similar moderate carbohydrate diet, especially in overweight and decreased sensitivity to insulin.

...

With a diet low in carbohydrate content, it is easier to avoid rises in blood sugar after meals.

...

Moderate carbohydrate diet may be helpful in diabetes. The diet has a positive impact on long-term blood sugar (A1C) and weight and improves blood lipids (ie, increases HDL cholesterol in patients with low HDL cholesterol).

Moving on to VLC (very low carbohydrate diets). In my posts I will mention VLC in a neutral fashion so something along the lines of "while not actively encouraged neither are they discouraged. All that is recommended is that a diabetic who elects to go on one should be closely monitored by their HCP's"

This is excatly what the Swedish recommendation is. The document points out no long term studies have yet to be concluded that prove VLC is harmful. The document gives examples of a VLC diet and implicitly assumes that some people will elect to choose such a diet as my bold underline shows. It summarises VLC by saying.

It is still unclear whether the extreme low-carbohydrate diet can be good for diabetes, because there is no scientific basis for assessing long-term effects and long term risks. If a person chooses to try extreme low carbohydrate diet it is important that health care can provide information on how this type of diet is composed and monitor health of the person and what diet is for effect.

So I hope you can see that my attitude to VLC is no different from the current Swedish Health care systems which is what I have stated in my posts.

Finally some will undoubtedly query "What does moderate carbohydrate" actually mean in real terms. The document actually states as Phoenix pointed out a 30% total daily carbohydrate intake. Lets compare that to the UK. From the British Nutritional Foundation. Again my bold underline

Current advice is that we should get half our energy needs from carbohydrates, with at least one third of our daily intake of food being starchy carbohydrates.
According to the British Nutrition Foundation, the average adult's daily diet meets this target with women getting 47.7 per cent of their daily energy from carbs (203g) and men 48.5 per cent (275g).

Well I don't know about others on just a Diet + Metformin regime but 33% starchy carbs, 275 grams / day would give me a long slow and painful death.

Finally on diet I and others make a specific recommendation on grams of carbohydrate per day. This obviously different from just recommending a reduced 30% regime so where does my recommendation of 120 - 150 grams come from. Again this isn't something I have picked out of thin air. It comes from the 2012 document "Standards of Medical Care in Diabetes—2012" drawn up by the American Diabetes Association. You can read the ADA's latest recommendations here

http://care.diabetesjournals.org/content/35/Supplement_1/S11.full#sec-171

Here's the exact extract referring to grams / day

It should be noted that the RDA for digestible carbohydrate is 130 g/day and is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested protein or fat.

So while not being an explicit Swedish recommendation it is an American one. What it is saying is that at 130g / day enough energy is available without having to go into ketosis as you would on some VLC diets.

So to sum up on diet I really do think my advise is both safe and very importantly up to date.

I would like to see other forum members opinions on this and if there is any disagreement to rationally and calmly state why. I think any disagreement should be written at a similar language / jargon level I have tried to use rather than baffle everyone with complex science.

On Eat to you meter

I very much agree with the prevailing sentiment on the forum that all T2's should be encouraged to test. They should be provided with testing equipment and strips by prescription on the NHS for as long as it is seen that they are paying attention to what their meter is telling them.

A very general statement on what I interpret "Eat to your meter to mean"

A person is eating to their meter if after two hours after eating their blood sugar levels have returned below 8.5.

This is nothing more than the NICE guidelines currently state. If you read my new member posts I will say exactly the above and then go onto say but "some of us think that's a bit out of date and aim for 7.8".

This statement of 7.8 is not taken from thin air. It is the level recommended by the IDF (International Diabetes Federation) after the an AACE (American College of Endocrinology) study. The recommendation dates back to 2007 and has been adopted by a number of countries.

Their published recommendations state:
. .a large number of highly robust cross-sectional and prospective epidemiologic studies have clearly implicated a close association between postchallenge or postprandial hyperglycemia and cardiovascular risk. These studies encompass diverse populations and disparate geographic regions, from Honolulu to Chicago to Islington to Paris. A recent analysis of 25,000 patients in Diabetes Epidemiology:Collaborative Analysis of Diagnostic Criteria in Europe (DECODE)Study supports the concept of an important link between postchallenge glycemia and macrovascular risk. Furthermore, Hanefeld et al showed that moderate postprandial hyperglycemia (148 to 199 mg/dL) not only is more indicative of atherosclerosis than fasting plasma glucose levels but also may exert direct detrimental effects on endothelium. . . .

In subjects without diabetes, blood glucose levels typically peak approximately 1 hour after the start of a meal and return to preprandial levels within 2 to 3 hours; 2-hour postprandial blood glucose levels rarely exceed 140 mg/dL.

Therefore, the consensus panel recommends a treatment-targeted 2-hour postprandial blood glucose level of 140 mg/dL to facilitate tighter control of glycemia without increasing the risk of hypoglycemia.

In plain English my bold underlining in the above quote means

The two hour target reading after eating should be less than 7.8mmol/l in UK units

So again all I would contend is that I am advocating the latest international recommendations made back in 2007. It's not because I am some "levels fanatic" as some would portray me. It's ironic that the NHS initially took the 8.5 recommendation from the IDF but haven't thought to adopt the updated value.

To be as uncontentious as possible I believe it is acceptable for either the 8.5 or 7.8 recommendation to be used so long as either of those values is being recommended for the vast majority of times a patient eats. Yes everyone should be allowed to have treats etc, a good night out but for normal day to day life those are the levels that people should stick to and they should be actively encouraged by the NHS.

Again I would like to see other forum members opinions on this and if there is any disagreement to rationally and calmly state why.

Combining the two together

Based on the above two sections I would have no problem stating the following to a correctly diagnosed T2 with some pancreatic function.

I would recommend that as an option you may want to consider to try a restricted carbohydrate diet of roughly 130g / day and then based on your 2 hour after meal meter readings adjust up or down your carbohydrate intake until you can consistently achieve readings below 8.5

As a supplemental statement I would add

If you want to adopt a carbohydrate restricted regime but do not wish to reduce your carbohydrates much below 130g / day then return to your doctor and ask to be placed on drugs that will allow you to consistently achieve 2 hour after meal meter readings of less than 8.5

Yet again I would like to see other forum members opinions on this and if there is any disagreement to rationally and calmly state why.

On the failing NHS

I have an interpretation about the current NHS diabetic care system based on mine and my families dealings with it. So far I am less than impressed, in fact I have been appalled. Reading other peoples comments on this forum has shown me I am not alone and that treatment is at best a post code lottery and in some cases has been positively life threatening. I do not doubt some people get what they consider good treatment but my subjective view is there are by no means enough good outcomes to outweigh my belief that the system fails far too many people. I will repeat what I see a damning statistic.

70% of diabetics have HBA1c's greater than 7.5%

What more evidence of failure do people want?

My belief as why the system is failing is very much the same as another experienced poster on the forum. It is a cultural thing, an attitude of "It can't be done the public wont accept it" and "That 8.5 target is too tough and people don't like tough choices so let's water down the message (or increasingly up the 8.5)"

To me this is just complete self defeatist claptrap. Going back to my Swedish examples. A while back the Swedish government made a choice to promote not only a moderately reduced carbohydrate diet for diabetics but are actively pushing a low carb high fat (LCHF) regime for all their people as a means of preventing the progression of obesity and T2D. Obviously they push the right fats so dangerous fats are out.

Their approach in my mind is comendable and is no different from the anti-smoking campaign that has been fought out over years in lots of other countries. I'll just provide one example. Here is a link to a recent widely read supplement that comes from a Swedish newpaper.

http://translate.google.com/translate?hl=en&sl=sv&tl=en&u=http://www.kostdoktorn.se/

This shows the promotion of 100 LCHF recipes and is an example of how the Swedish media are also aiding that countries healthy life style push.

So in that kind of context I see the UK government, media and yes the NHS who should be shouting this kind of message to be failing.

So one more time do other forum members see the fundamental cause of poor diabetic care to be our failing systems like me?

I would hope the responses to this will address it from the health care perspective and not just tie everything up in big business conspiracy theory stuff. I can see that there may be self interests that stop our system from changing but my point is if other countries can and do push the "we can do it" message why don't we.

If you got to the bottom of this thanks for taking the time to read it!

 

[the_anticarb]

Interesting that you say 7.8 mmol is thought to be a better post prandial limit, as this is the figure given to pregnant diabetics by our dear NHS /NICE guidance, although you have to be 7.8 mmol one hour after eating, not 2, when pregnant.

 

[Grazer]

Interesting that you say 7.8 mmol is thought to be a better post prandial limit, as this is the figure given to pregnant diabetics by our dear NHS /NICE guidance, although you have to be 7.8 mmol one hour after eating, not 2, when pregnant.

I guess it's no coincidence that a non-diabetic (on average) wouldn't exceed 7.8 mmols even after an oral glucose tolerance test,; that's the MAX they go to. So why would we think it's ok to go higher than the body is designed to go? Which I suppose is why a pregnant woman would be advised not to exceed normal limits - but also why i agree we shouldn't if we can manage not to.

 

[xyzzy]

Agree Grazer. That 7.8 limit is chosen for the reasons that for the average person its when problems can start. Consequently and simplistically I look at it in the way you suggest which is it's the level that 100% (all) of the non diabetic population achieve. As they are non diabetic its therefore the safe level or they would exhibit diabetic symptoms and not be safe.

 

[CarbsRok]

Different dietary regimes may well be better for T1's, LADA and T2's who have little or no pancreatic function left. In these cases it is very likely that controlling by diet (any diet) is unrealistic and is fully accepted by myself.

Hi xyzzy,
can I pick you up on this point please?
No matter what type of diabetes a person has they have to be carb aware. I have type 1 diabetes and have always been carb aware and everything that goes into my mouth has to be accounted for. I have done this since the age of 4 1/2. So infact being on insulin actually makes it vitaly important to control what is eaten. This includes fats and protien as these also affect the way food is absorbed.(Eratic blood sugars)
So yes us type 1's do control by diet as well as insulin

Regards
CR

 

[smidge]

Hey all!

Interesting that you say 7.8 mmol is thought to be a better post prandial limit, as this is the figure given to pregnant diabetics by our dear NHS /NICE guidance, although you have to be 7.8 mmol one hour after eating, not 2, when pregnant.

That's why I think they tell Type 1's to aim for too high a level. If it's good enough for Type 1 pregnant women, why not the rest of us? As far as i know, they don't differentiate between Types 1 and 2 when it comes to setting targets for pregnant women, so why do they set Type 1 targets higher for those that are not pregnant? Surely the risk of hypos is there equally for pregnant and non pregnant diabetic insulin users - or am I missing something? They also give pregnant women a lower fasting target (3.6ish I think?) and yet if a non pregnant insulin user talks about levels of below 4, they are liable to get a lecture on hypos. It really confuses me. How can those levels be safe for pregnant women and not for the rest of us?

To be honest, it's something of an academic argument for me, because keeping my post-prandial levels below 7.8 at 2 hours is hard going and getting them there within 1 hour is very unlikely to happen :lol:

Smidge

 

[xyzzy]

Different dietary regimes may well be better for T1's, LADA and T2's who have little or no pancreatic function left. In these cases it is very likely that controlling by diet (any diet) is unrealistic and is fully accepted by myself.

Hi xyzzy,
can I pick you up on this point please?
No matter what type of diabetes a person has they have to be carb aware. I have type 1 diabetes and have always been carb aware and everything that goes into my mouth has to be accounted for. I have done this since the age of 4 1/2. So infact being on insulin actually makes it vitaly important to control what is eaten. This includes fats and protien as these also affect the way food is absorbed.(Eratic blood sugars)
So yes us type 1's do control by diet as well as insulin

Regards
CR

Yes no problem CR and I agree with what you say entirely.

The trouble is as a T2 who IS recommending the Swedish and American stuff I should restrict my advice to fellow T2's or I'll get in trouble with the "powers that be"

That's all I'm attempting to do by my limitation. While what the Swedes state is for all diabetics I wouldn't be at all comfortable saying that to anyone who wasn't a correctly diagnosed T2.

 

[Defren]

Xyzzy - All I am going to say is THANK YOU! Thank you for giving us who are newly diagnosed, those of us who have been diagnosed longer but have been given the wrong information, the chance to put things right. You are not the only one who does this, there are a couple of others, and I appreciate ALL who have helped me, teaching me by lowering carbs that is how to lower BG's. I for one am deeply grateful for all the help I have been given here.

 

[xyzzy]

Hey all!

Interesting that you say 7.8 mmol is thought to be a better post prandial limit, as this is the figure given to pregnant diabetics by our dear NHS /NICE guidance, although you have to be 7.8 mmol one hour after eating, not 2, when pregnant.

That's why I think they tell Type 1's to aim for too high a level. If it's good enough for Type 1 pregnant women, why not the rest of us? As far as i know, they don't differentiate between Types 1 and 2 when it comes to setting targets for pregnant women, so why do they set Type 1 targets higher for those that are not pregnant? Surely the risk of hypos is there equally for pregnant and non pregnant diabetic insulin users - or am I missing something? They also give pregnant women a lower fasting target (3.6ish I think?) and yet if a non pregnant insulin user talks about levels of below 4, they are liable to get a lecture on hypos. It really confuses me. How can those levels be safe for pregnant women and not for the rest of us?

To be honest, it's something of an academic argument for me, because keeping my post-prandial levels below 7.8 at 2 hours is hard going and getting them there within 1 hour is very unlikely to happen :lol:

Smidge

Hello Smidge glad to see you're back. :wave:

My attitude is a plain vanilla "T2" one which is if you can aim and achieve safe non diabetic levels through diet and maybe minimum meds if you want then you should try and be given the information to allow you to do that at diagnosis. As part of that information pack then some combination of what the Swedes /Americans recommend for carbs combined with a real and meaningful "eat to your meter" ethos to me seems obvious. It allows a great number of newly diagnosed T2's to get back to essentially non diabetic readings without loads of meds (and costs to the NHS). Many on the forum have done exactly that.

Some people will of course never take their T2 condition seriously but a lot don't take it seriously because they haven't been told its serious and challenged to see its serious. They are also never told that Swedish / American carb level + testing route is open to them to help them.

I fully admit that for a 1.5 LADA like yourself tight control may be harder to achieve because your insulin production is erratic but I bet you try your best because you have been informed about levels and carbs and other stuff by this site. Without at all wishing to sound uncaring as you're a lovely LADY just because the levels are hard doesn't make them wrong as I'm sure you'd recognise.

 

[smidge]

Hey Xyzzy!

I fully admit that for a 1.5 LADA like yourself tight control may be harder to achieve because your insulin production is erratic but I bet you try your best because you have been informed about levels and carbs and other stuff by this site. Without at all wishing to sound uncaring as you're a lovely LADY just because the levels are hard doesn't make them wrong as I'm sure you'd recognise.

:lol: :lol:

No, I think you're exactly right! I think everyone should aim for as low a level as they can safetly do. I aim to get my levels low at the 2hour mark. Sometimes I manage and sometimes I don't, but that's no reason to stop trying. Aiming low means I occasionally drop a bit below 4, but it's easy to correct when that happens - one jelly baby does the trick when you're my size :roll: The trouble is, some of the medical profession are terrified of hypos and so tell insulin users to keep levels relatively high to make sure they never fall below 4. My point is, though, that they instruct pregnant insulin-using women to keep their levels low - they actually tell them to aim for fasting levels between the mid 3s and mid 4s. So why is it OK for pregnant women to aim for fasting levels that low, but not the rest of us? If mid 3s to mid 4s fasting levels are deemed safe for pregnant women, then they must surely be OK for the rest of us to aim for wouldn't you think? I don't think I've explained that very well, so i'll shut up - I know what I mean :lol:

Good post by the way!

Smidge

 

[Glados]

I really appreciate your posts and the fact that you back up your reasoning with links to studies. You seem to have the right ideas to me...

BUT, I don't just take your views on board without doing any other research. I use my own experiences, my meter and my own ability to READ, in order to formulate my personal approach to controlling my diabetes. I apply the same filter to ANY advice I get on here (or from my nurse/doctor). I'd advise others to do the same.

At present I don't feel the need to debate any of the points you've made but if I thought you were seriously misleading people I'd say so, with evidence as to why.

Thanks for clarifying your position.

 

[xyzzy]

BUT, I don't just take your views on board without doing any other research. I use my own experiences, my meter and my own ability to READ, in order to formulate my personal approach to controlling my diabetes.

I should hope so too as that's exactly what I do. It's that very "one size fits all" approach that I fight against so vehemently.

There is a difference between recommending a sensible course of action for someone to start out with as newly diagnosed and what those people then learn is best for them and end up doing.

Look at me I freely admit my average grams per day is around 60 to 75ish so roughly half that 130g ADA figure and I take all those "herbs" and supplements along with my Metformin. Others will say their averages are lower than mine and some others say they are higher. So long as they keep within "safe" (7.8 or 8.5) I have no issue whatsoever. To be honest even if someone exceeds "safe" day in day out and takes the risks as long as they don't start saying that equates to "eat to your meter" as well then I also have no problem.

As you say Glados its all a personal choice you arrive at with your meter once you've been given a chance as a newly diagnosed person to make the right kind of choices to begin with. I do worry for people who can't afford a meter which is why I would personally recommend those people to aim at around that 130g level as that seems on the latest research to be a level that should give reasonable level control in most people.

The key thing to me at diagnosis is to include all choices that work and at the moment this country does not recommend one key dietary choice that has had spectacularly successful results in other country's and research trials which is why I advocate it on this forum.

 

[xyzzy]

I see the "Low carb and putting on weight" thread has returned but in a locked state http://www.diabetes.co.uk/diabetes-forum/viewtopic.php?f=18&t=27702&start=75

I agree that the later posts went off topic so perhaps anyone who wishes to continue to calmly and rationally debate those later posts could post on this thread as the topics on this thread are what I was on about.

 

[Paul1976]

Everything aside after my depression fuelled outbursts,I just want to say thankyou xyzzy for the above post and for writing in laymans terms and with clear points that i understand with no confusion,it might not seem much to some,but for me and any future members who have a communication difficulty-A topic such as this,being written the way it has been done,makes a LOT of difference to us!
I know I can't take back what I've said and for any anger and upset I've caused and I know I need help for my current mental health issues but once again,I'm sorry

 

[xyzzy]

Not a problem Paul take care and good luck on Thursday? with the specialist.

I realise you must be really stressed out which is why I never replied. Just one word of advise please stick to one forum or the other I really don't mind which. I specifically have never read the ABC forum anyway and will never post on it or in the "other" places. I did get told by other forum members who offered me their support what was going on but it doesn't bother me.

I have had to face far more stress and aggravation than that over the years in my normal working life so I'm entirely use to it and know its best just to ignore it.

This is the forum that counts and is the one I'll continue pushing my message on.

Take care Paul and think no more about it I'm not. Concentrate on getting well. :wave:

 

[Defren]

Everything aside after my depression fuelled outbursts,I just want to say thankyou xyzzy for the above post and for writing in laymans terms and with clear points that i understand with no confusion,it might not seem much to some,but for me and any future members who have a communication difficulty-A topic such as this,being written the way it has been done,makes a LOT of difference to us!
I know I can't take back what I've said and for any anger and upset I've caused and I know I need help for my current mental health issues but once again,I'm sorry

Paul, we would not be human if we didn't get upset and angry sometimes. I have been in a bad place the last day or two, and feel a little stressed and very tired. I know that I can usually get my point across in a civil way, but then sometimes I read something, and find I have steam coming out of my ears. By 'blowing your top' you have possibly released a stress valve that needed to be released. I'm sure no one here holds grudges, we all have tough times. I was furious at low carbers being called militia and said so. Do I regret that? Hell, no I don't. I don't force my opinions on others, and would fly off the handle again, if I read the same thing. Chin up!

 

[Paul1976]

Thankyou for that!! I would like to stick around on here,think it might be to late though as I Pm'd Benedict and Pneu during all this and asked for them to remove my profile and I fear that I won't be able to get a message to stop that happening in time but I'll try anyway!
All the best
Paul

 

[xyzzy]

Thankyou for that!! I would like to stick around on here,think it might be to late though as I Pm'd Benedict and Pneu during all this and asked for them to remove my profile and I fear that I won't be able to get a message to stop that happening in time but I'll try anyway!
All the best
Paul

Sorry Paul I had to go out hence the delay. I hope you do stay and I'm sure the Admins will keep your account open.

 

[xyzzy]

Xyzzy - All I am going to say is THANK YOU! Thank you for giving us who are newly diagnosed, those of us who have been diagnosed longer but have been given the wrong information, the chance to put things right. You are not the only one who does this, there are a couple of others, and I appreciate ALL who have helped me, teaching me by lowering carbs that is how to lower BG's. I for one am deeply grateful for all the help I have been given here.

Sorry Defren I saw this yesterday and then got diverted by something else. I REALLY appreciate what you've said thank you!

 

[borofergie]

The diet consists of meat, fish, shellfish, eggs, vegetables, legumes and vegetable proteins and fats from olive oil and butter. The diet includes less sugar, bread, cereals, potatoes, root vegetables and rice than a traditional diabetes diet.

This is brilliant, the best two sentence description of a decent low-carb diet that I've ever read.

With a diet low in carbohydrate content, it is easier to avoid rises in blood sugar after meals.

Moderate carbohydrate diet may be helpful in diabetes. The diet has a positive impact on long-term blood sugar (A1C) and weight and improves blood lipids (ie, increases HDL cholesterol in patients with low HDL cholesterol).

I wish that the NHS would recognise this. Of course it depends what they mean by a moderate carbohydrate diet. If, as you suggest below, they mean 30% of energy from carbs, then I'm not sure how significat that improvement would be:
@2500kcal 30% = 750kcal = 187g of carb a day.

That's pretty high, even by Grazer's standards (but of course much better than the 45-65% that the NHS recommend).

My own personal opinion is that even 130g is on the high side (it's about 30% higher than the minimum amount of carbohydrate that you'd need to fuel your brain without resorting to some level of ketosis). However, I am pragmatic and I realise that for some newly diagnosed diabetics 130g represents a huge impovement over the default "balanced" diet that they are used to. If you stick with the 130g level you need to make it explicitly clear that many T2s will not be able to achieve good control at that level, and my have to find a more appropriate level by eating and testing. (Equally others will be able to iterate themselves upwards).

If it were my decision, I'd go for <<100g, but then I'm a Bernstein kinda guy, that attacked my diabetes by going sub 30g and working my way up (eventually to about 70g, which I think is the maximum that I can tolerate with exercise).

For comparison with the Swedish study, 130g is about 20% of a 2500kcal diet or 25% of a 2000kcal diet.