Dietician's advice at odds with everything I've read

[Bertyboy]

So, I've just had an interesting first appointment with the dietician at the diabetic clinic. For background, I was diagnosed 6 weeks ago with diabetes. The DSN couldn't say which, but as BG was 26+ and Ketones were 1.1 she said they would treat it as if it were type 1.
The dietician found my blood results, and thankfully GAD and c-peptide came back negative so she suggested maybe coming off the insulin in favour of dietary remedy (as it was probably type 2, which I suspected from the outset), but she consulted a nurse who said no, stick with the insulin for now (2x14 Levemir plus 6 Novorapid per meal).
She asked me how I was getting on. I pointed out my relatively stable fasting BG numbers in the 4-7 range, that I was feeling much better, that I had lost a little weight and that I had removed any sugar from my diet and eating meals that had no simple carbs with some complex carbs.
She seemed very surprised and asked why I had changed to this policy. I just pointed out that, in the absence of any other dietary advice from the NHS, I was going off what I read here, that it would make control easier.
Her take on it was that it screwed up the diagnosis if I was changing my dietary habits, that it was dangerous whilst I was still taking fixed bolus (if no carbs then no Novorapid), and that I would end up replacing my energy source with less healthy dietary fats, and that it may cause ketosis, which would exacerbate complications. She's not suggesting to carb count or modify insulin injections, but to reintroduce more normal ratios of pasta, rice and bread, but smaller portions of everything, especially saturated fats. She's also suggesting to test the post-meal (+2hr) BG levels to ensure that the rise is no more than 3 mmol/l.
Her point was that if it's type 1, reducing carbs makes no difference anyway and if it's type 2, everything will need to be reduced, including sat fats.
To be honest, all this makes sense. So why is there such an emphasis on low-carbohydrate diets on these forums as a way of controlling diabetes?
I feel a bit conflicted now.

 

[Bluetit1802]

To be honest, all this makes sense. So why is there such an emphasis on low-carbohydrate diets on these forums as a way of controlling diabetes?
I feel a bit conflicted now.

The dietician was advising you how to manage your diet whilst taking fixed doses of insulin. To avoid hypos and hypers it is necessary to have insulin and carbs balanced. Low carb diets are more appropriate to non-insulin users and insulin users that carb count and can adjust their insulin units accordingly.

 

[Bertyboy]

The dietician was advising you how to manage your diet whilst taking fixed doses of insulin. To avoid hypos and hypers it is necessary to have insulin and carbs balanced. Low carb diets are more appropriate to non-insulin users and insulin users that carb count and can adjust their insulin units accordingly.

Which would explain why she was interested in trying to treat it as type 2, without insulin (which would suit me just fine!). But she was even suggesting that for type 2 diabetes, low carb is not really that necessary, that it is better to have a standard balanced diet with less of everything. Which is the usual "everything in moderation is good for you", not a specific restriction.

 

[Resurgam]

Basically she's telling you to be a good boy take your medicine and don't try to be clever.
She is also confusing lipolysis (fat burning) with keto-acidosis, high glucose high ketones, which doesn't cause complications so much as diabetic coma and death.With your blood glucose levels keto-acidosis seems very unlikely, in my self opinionated judgement at least.
If you are type one it gives you a lot more freedom to eat carbs, but you would then be dictated to having to cover the amounts of insulin you have been prescribed by eating foods with little nutritional value which could cause you to put on weight.
As a type two, I eat fewer carbs and all the problems of diabetes just go away. What carbs I do eat are all very tasty ones, and pasta and grains don't get much of a look in, nor potatoes. I have to confess to developing a really light and fluffy Yorkshire pudding option for High Days and holidays in order to have them with gravy from the meat, made with mushrooms. but the flavour!!!
As long as I have normal results I will remain unmedicated and low carb.

 

[Resurgam]

The standard balanced diet as prescribed for me all my adult life is how I got to needing to lose an entire person's weight in fat on a carefully supervised cholesterol lowering diet - which did nothing to lower my cholesterol.

 

[Bluetit1802]

You may have read many times on here that all carbohydrate converts to glucose once inside the system. All carbohydrate. That means wholemeal as well. All that glucose swimming about in the blood stream needs insulin to push it out of the blood stream and into the cells to be used as energy. The more carbs we eat, the more glucose there will be and the more insulin will be required to clear the glucose. People that inject insulin can, if they wish, inject more insulin to cover any extra carbs they eat. People that rely on their own natural insulin cannot do this. They are restricted because either their pancreas is failing and no longer produces enough natural insulin to cope with the carbs, or because they are insulin resistant. Most T2s are insulin resistant (as are some T1s), which means when they eat carbs and these carbs turn to glucose, their own natural insulin cannot push the glucose into the cells because the cells reject the insulin and thereby the glucose. Hence they end up with high blood glucose levels and high circulating insulin.

 

[Bertyboy]

You may have read many times on here that all carbohydrate converts to glucose once inside the system. All carbohydrate. That means wholemeal as well. All that glucose swimming about in the blood stream needs insulin to push it out of the blood stream and into the cells to be used as energy. The more carbs we eat, the more glucose there will be and the more insulin will be required to clear the glucose. People that inject insulin can, if they wish, inject more insulin to cover any extra carbs they eat. People that rely on their own natural insulin cannot do this. They are restricted because either their pancreas is failing and no longer produces enough natural insulin to cope with the carbs, or because they are insulin resistant. Most T2s are insulin resistant (as are some T1s), which means when they eat carbs and these carbs turn to glucose, their own natural insulin cannot push the glucose into the cells because the cells reject the insulin and thereby the glucose. Hence they end up with high blood glucose levels and high circulating insulin.

So, what I don't understand about this is, if the tissue cells are resistant to insulin, why is injecting insulin effective in bringing my blood glucose levels down? Or is injected insulin different to the stuff from our own pancreas?

 

[Jaylee]

So, what I don't understand about this is, if the tissue cells are resistant to insulin, why is injecting insulin effective in bringing my blood glucose levels down? Or is injected insulin different to the stuff from our own pancreas?

Hi,

This vid may help explain...? Just wait till it gets to the part on insulin resistance?

Sorry if it makes you feel like your back a school in a darkened science room!

 

[Bluetit1802]

So, what I don't understand about this is, if the tissue cells are resistant to insulin, why is injecting insulin effective in bringing my blood glucose levels down? Or is injected insulin different to the stuff from our own pancreas?

The more insulin resistant we are, the more insulin we need to "clear" the glucose.The less insulin resistant we are, the less insulin is required to do the same job. When the cells reject the insulin, the pancreas produces more insulin, then more, then more, until enough has been produced to clear the glucose. This can take a shortish time or a very long time, depending on the severity of the insulin resistance.

In your case in particular, your nurse thinks you are most likely T2 and therefore producing insulin of your own in addition to any you inject, so you have all that extra insulin to clear your glucose.

 

[bulkbiker]

So, what I don't understand about this is, if the tissue cells are resistant to insulin, why is injecting insulin effective in bringing my blood glucose levels down? Or is injected insulin different to the stuff from our own pancreas?

Therein lies the problem with diagnosis. If you are Type 2 you will lower your blood sugars by injecting insulin because it is an extra boost that temporarily overcomes your bodies insulin resistance. If you are a Type 1 and still honeymooning then your body could still be producing some insulin but the extra you are adding will also cause your blood sugars to go down. Its only when your body stops producing your own insulin completely that you can be sure you are Type 1. There are other tests that can give an indication (GAD and C-peptide) but as a diet controlled Type 2 I am no expert on them so will let far more knowledgeable folks explain them.

 

[Bertyboy]

Thanks for info and the video link. So....*if* I have type 2 diabetes, what is it that can be reversed by diet - is it the underproduction of insulin by the pancreas, the overproduction of glucose by the liver or the reduction of resistance of tissue cells? And is there a specific recommend dietary change that works towards that.
I'm quite buoyed by the fact it is probably not Type 1 (the GP who diagnosed me and referred me to the diabetes clinic was quite matter-of-fact about it being type 1), because, well, who wants to keep testing and injecting?
So, I'll do as the professional dietician advises, and re-introduce more carbs and go for small portion sizes, and see if the numbers stay low.

 

[ringi]

I see no issue with you reducing your carbs provided you test your BG often and know what to do if you get a Hypo. As soon as you start to get BG readings at a level that puts you at risk of a hypo talk to your GP about reducing the insulin dose.

But try to keep your carb intake consistent at each meal, also note I am NOT saying zero carbs, just a reduction in carbs.

 

[ringi]

So....*if* I have type 2 diabetes, what is it that can be reversed by diet - is it the underproduction of insulin by the pancreas, the overproduction of glucose by the liver or the reduction of resistance of tissue cells?

All three, it starts with insulin resistance of the tissue, then increased fat on the liver, then the pancreas can no longer cope with the ever-increasing demands being made off it. Google "diabetes twin cycle Professor Roy Taylor" and watch the film of one of his talks to get an understanding of what scientists think about going on with Type2.

It is also possible to have a high level of insulin resistance and be Type1......

 

[catapillar]

BG was 26+ and Ketones were 1.1 she said they would treat it as if it were type 1.

It's very unusual for a type 2 diabetic to be diagnosed with ketones. The presence of ketones on diagnosis points towards type 1.

The dietician found my blood results, and thankfully GAD and c-peptide came back negative so

I'm not sure why you are thankful a cpeptide test came back negative? No cpeptide means you aren't producing any insulin, at all. Which would be unusual for a newly diagnosed adult type 1 diabetic because they would be expected to be honeymooning. It would be very unusual for a type 2 diabetic who would be expected to have higher than normal cpeptide because type 2 is hyperinsulimia. So no cpeptide points to type 1. What exactly do you mean by a negative result on your cpeptide test?

25% of type 1 diabetics are GAD negative. A negative GAD test doesn't mean you aren't type 1.

(2x14 Levemir plus 6 Novorapid per meal).

So that's a total daily dose of 46 units? And you're staying over 4? That's a fairly standard dose, it doesn't suggest insulin resistance. Nor does it suggest you'll be fine without insulin and without testing and injecting. You are obviously needing those injections to keep blood sugars in check.

 

[dbr10]

Which would explain why she was interested in trying to treat it as type 2, without insulin (which would suit me just fine!). But she was even suggesting that for type 2 diabetes, low carb is not really that necessary, that it is better to have a standard balanced diet with less of everything. Which is the usual "everything in moderation is good for you", not a specific restriction.

Does that make sense to you?

 

[Pinkorchid]

Thanks for info and the video link. So....*if* I have type 2 diabetes, what is it that can be reversed by diet - is it the underproduction of insulin by the pancreas, the overproduction of glucose by the liver or the reduction of resistance of tissue cells? And is there a specific recommend dietary change that works towards that.
I'm quite buoyed by the fact it is probably not Type 1 (the GP who diagnosed me and referred me to the diabetes clinic was quite matter-of-fact about it being type 1), because, well, who wants to keep testing and injecting?
So, I'll do as the professional dietician advises, and re-introduce more carbs and go for small portion sizes, and see if the numbers stay low.

Well you can only try it and see how you go that's all any of us can do it is trial and error to find what suits us. I often go for smaller portions of carbs like bread and potatoes than I used to have before diabetes but do not have them every day

 

[Jaylee]

So that's a total daily dose of 46 units? And you're staying over 4? That's a fairly standard dose, it doesn't suggest insulin resistance. Nor does it suggest you'll be fine without insulin and without testing and injecting. You are obviously needing those injections to keep blood sugars in check.

To be fair to @catapillar , she's right. I had similar when put on MDI. Though, I personally had to reduce my basal of Lantus.
(Too many serious fasting/non bolus onboard hypos.) & get my head round carb counting for the bolus...

She asked me how I was getting on. I pointed out my relatively stable fasting BG numbers in the 4-7 range, that I was feeling much better, that I had lost a little weight and that I had removed any sugar from my diet and eating meals that had no simple carbs with some complex carbs.
She seemed very surprised and asked why I had changed to this policy. I just pointed out that, in the absence of any other dietary advice from the NHS, I was going off what I read here, that it would make control easier.
Her take on it was that it screwed up the diagnosis.

I'm only an "expert" on me with this one @Bertyboy .

If the above (in the quote) works for you? Then why "fix it?" Living with insulin always needs a revamp or a tweak..
But that comes with further understanding your needs of yourself.. (Not a "one size fits all.")

It's all about getting a "bespoke" regime that works just for you...?!

You've been diagnosed a few weeks? I'm confident you'll get there...

 

[Resurgam]

As you are on insulin and planning to stay on it, if you drive a car you should have notified your insurer and the driving license people.
There are rules about driving and testing your blood glucose levels you need to comply with.

 

[Bertyboy]

All three, it starts with insulin resistance of the tissue, then increased fat on the liver, then the pancreas can no longer cope with the ever-increasing demands being made off it. Google "diabetes twin cycle Professor Roy Taylor" and watch the film of one of his talks to get an understanding of what scientists think about going on with Type2.

It is also possible to have a high level of insulin resistance and be Type1......

Oh, ok. This gets more complicated than I thought, then.

 

[Bertyboy]

I see no issue with you reducing your carbs provided you test your BG often and know what to do if you get a Hypo. As soon as you start to get BG readings at a level that puts you at risk of a hypo talk to your GP about reducing the insulin dose.

But try to keep your carb intake consistent at each meal, also note I am NOT saying zero carbs, just a reduction in carbs.

I mentioned to the dietician that I had one mild hypo already (it was a meal on a long haul flight that turned out to be more a small snack, but I'd already bolused). I had started the Bertie course to understand carb counting, but she seemed to think I should avoid that until I've had my first appointment with the diabetic consultant.