Issues with Clinical Guidelines for Treatment of TYPE 1 Diabetes

[Neemo]

This thread is primarily a critical analysis, proposition of an alternative set of dietary guidelines and subsequent discussion concerning current clinical guidelines for the management of Type 1 Diabetes, in particular Dietary advice and Insulin Regimes, and whether these guidelines are fit for purpose.

----------------------------------------------------------------------------------------------------------------------------------
Q. What are clinical guidelines?
A. Clinical guidelines recommend how healthcare professionals should care for people with specific conditions.

Q. Who comes up with Clinical Guidelines?
A. The National Institute of Clinical Excellence (NICE) - an executive non-departmental public body of the Department of Health in the United Kingdom
https://en.wikipedia.org/wiki/National_Institute_for_Health_and_Care_Excellence

Q. So do Healthcare Professionals devise their patient treatment plans based on these recommendations?
A: In essence, yes. These guidelines and recommendations make up the foundation for clinical guidelines at regional and local levels.
----------------------------------------------------------------------------------------------------------------------------------
OK, let’s take a look at 3 different Regional NHS trusts, specifically their Clinical Guidelines for Diabetes Management:

Note we will only focus on Dietary advice, as I do not want to deviate too much from this post’s topic – however there are other issues which are apparent and warrant further discussions/analysis; future thread if there is an appetite for it.

Enfield (Reviewed October 2014, Next Review set for October 2015)
http://www.beh-mht.nhs.uk/Downloads/Our services/ECS/Diabetes/Enfield Diabetes Clinical Guidelines V6 .pdf

Mersey (Reviewed in early 2014, Next review 2016)
http://www.panmerseyapc.nhs.uk/guidelines/documents/G5.pdf

Herefordshire (most current guidelines they have published are from 2012, so we will assume these still apply)
http://www.hertschs.nhs.uk/Library/Adult_Services/Diabetes/Diabetes Clinical Guidelines-V21.0 27.07.10.updated Jun2012pdf.pdf
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Firstly, looking at Mersey’s guidelines, it’s very interesting/disconcerting that, to quote 2nd page>Introduction>Important notes;

” Pragmatically, much management of Type 1 & Type 2 has been harmonised using the more up to date Type 2 guidance CG87 http://www.nice.org.uk/CG87 (the Type 1 guidance is over 5 years old and dated and to be reviewed by NICE)”

I assert that Diabetes research/knowledge is still in its infancy (scientifically speaking). In the age of the CERN Particle accelerator and Mapping of the human genome, is it really the case that NICE have not revised/updated/improved TYPE 1 guidelines in five yrs!! Additionally, I will be writing to the author of these guidelines to understand precisely what is meant in regards to “much management of Type 1 & Type 2 has been harmonised using the more up to date Type 2 guidance”. TYPE 1 and TYPE 2 Diabetes are FUNDAMENTALLY different and should NOT be conflated in this manner. The causes, Patient lifestyle, patient treatments etc are distinct.

Below, I have compiled the dietary recommendations found within the clinical guidelines for the 3 trusts mentioned, with relevant comments;


The UKs biggest Diabetes Charity (Diabetes UK) also advocates a diet rich in starchy carbohydrates..(Disappointing) here is there latest publication regarding their position on consumption of carbohydrates for diabetics; this was I response to a number of queries they received concerning this topic (So much to critique regarding this publication, and the so called peer reviewed study cited, but I don’t have the energy to write analysis at the mo :{. I will say that it’s a MAJOR COPOUT to say there isn’t enough data to support the theory that carbohydrates increase risk factors in diabetics , the second link below mentions the fact that a number of corporate sponsors for Diabetes UK are food companies, hmmm ;

https://www.diabetes.org.uk/About_u...tion-of-carbohydrate-in-people-with-diabetes/

As an aside, here is an excellent article by a Dr regarding Diabetes UK Carb advice issue: http://www.drbriffa.com/2012/03/05/...y-advice-diabetes-uk-dishes-out-to-diabetics/

Really excellent documentary regarding carbohydrates and the societal impact/consequences/corporate greed, really recommend it, available on NETFLIX;

http://www.imdb.com/title/tt2381335/ fed up: An examination of America's obesity epidemic and the food industry's role in aggravating it.

continued...

 

[Neemo]

----------------------------------------------------------------------------------------------------------------------------------
Analysis

The current dietary guidelines are incredibly flawed, the myth that we need lots of starchy carbs to maintain good blood glucose, as the NHS trust of Enfield advocates above, is inherently flawed advice.

The image below illustrates the GI profile of different types of carbs, basically this shows how quickly and the length the energy in that food is released;



This demonstrates how High GI Starchy carbs affect blood sugars in a normal person; these swings are bigger in diabetics as Synthetic Insulin can’t replicate the body’s efficiency (the above chart is in mg/dl, for reference 90 mg/dl is 5mmol)

The Low GI carbs have a very flat profile, and are excellent for diabetics.

Fibrous veggies have an even flatter profile, so an excellent choice.

The main 2 issues with the high starchy carb diet, is as follows;

1. Insulin is a highly anabolic hormone; the starchy carbs require much more insulin, therefore the more insulin you use the more fat you will store, and consequently more insulin resistant you become (adipose(fat cells) increase resistance) – Insulin concentration also has a strong correlation to Cardiovascular illness.

2. Your Blood sugars will spike with regularity; even if you’ve mastered DAFNE and are a carb counting guru, and you calculate insulin doses effectively for these Starchy Carb meals, the CUMALITIVE effect of the blood sugars spiking causes micro/macro vascular damage (don’t want to go too sciency, but any excess sugar spills out into cells and causes damage; essentially this spillage is a toxin in your blood – this spiking is NOT natural, for NON diabetics, Beta Cell Insulin and Amylin are exceptionally efficient at keeping blood glucose profile very flat, for example below is a non-diabetics Glucose profile over 24 hrs with 3 starchy carb meals;


There are more adverse effects I could go into, but I hope the above illustrate the bad effects this type of diet has on your body.

----------------------------------------------------------------------------------------------------------------------------------
My Dietary recommendations/rationale and benfits

1 .Avoid Starchy carbs, Instead opt for Low GI carbs (if you’re unsure of food GI, you can google) in moderate portions.

Benefits: MUCH better BS readings, less Insulin, no wild swings and therefore much better health – and you will be able to manage/lose weight MUCH more effectively as there is less insulin in you body and Low GI foods are VERY slow release, unlikely to get stored as fat.

2. Try to include veg with meals; vegetables are highly nutritious, filling and have little effect on BS.

Benefits: Will keep you full up, keep weight down as Veg are not calorie dense and provide your body with essential nutrients to supercharge your cells and keep your body healthy; anti-oxidants etc.

3. Incorporate some mono-saturated fats 5 times a week; pistachios, almonds. Additionally they are an excellent snack if you get a hunger pang.

Benefits: Excellent source of GOOD fats , are extremely filling, Lower (LDL) bad cholesterol and increase good cholesterol (HDL)

4.Add lean meats to majority of meals; Chicken breast, Lean cuts of lamb, beef (keep red meat to moderate levels)

Benefits; extremely filling and excellent source of protein.

These are the primary recommendations I would make, I would also highly recommend incorporating some kind of exercise into your day; resistance training with weights is incredibly effective at making your body more Insulin sensitive and improving cardiovascular health.

Tip: where possible, go for a walk within 30 minutes of eating. I typically walk 2 miles after lunch, this reduces my insulin requirement by up to 70% (brisk walking) for that particular meal. So I can take 3 units instead of 8 for a large lunchtime meal.

LOADS more to go into, like adverse effects of ketogenic diet/atkins diet, HBA1C targets etc. But that’s for another day.

Closing

A forum member put forward the argument that diabetes control should be about achieving a middle ground, and we should shouldn’t aim for an extreme; I;e the best control possible. I completely disagree and believe this to be a false economy, better to make changes and put the work in now as opposed to having premature complications. GLUCOSE CONTROL IS DIRECTLY PROPORTIONATE TO THE RATE/ONSET OF COMPLICATIONS (for majority of complications)

Yes people are averse to change , I work within a change management function and I can testify to this; even when your offering them a better more efficient solution they would rather continue doing what they have done for years, its through demonstrating the benefits they will see that you (most of the time ) get the buy in/adoption.

Everyone’s circumstances; culture, age, health etc are different; however I’m a firm believer that everyone can make positive changes whether small, or big.

Its always good to quote stats, but I feel a lot of stats get thrown around without a link to an authoritative study, and often time I feel as though stats get “enhanced”/ or completely changed when someone is quoting a study they read last year.. human memory is fickle; better to re-find that stat, make sure its correct and post a link when you’re making a point, adds credibility to your points.

A study on HBA1C distribution across the US for Diabetics, interesting findings. Im aiming to stay in the <6 mark, I’ll have plenty of company;

 

[Daibell]

I'm not going to comment in detail on your points but many of us would agree overall. What most of us have realised since becoming diabetic and doing our research is that the national bodies involved are not really interested in what actual diabetics in practice find works and doesn't work. They look to 'experts' for guidance. Many of these 'experts' are professors in university departments often funded by pharmas or food companies. These people all have their own agendas and no-one wants to break ranks. Their opinions will change but slowly over years. It's a very sad state of affairs and many of us regularly complain to DUK, the NHS etc but it has very little effect. So, do try what you can to change the status quo but don't expect miracles! Meanwhile this forum does a good job in informing newbies with what we believe from experience works.

 

[ButtterflyLady]

Thanks for taking the time to write your extensive posts above. In the other thread, you said:

"The thing is, when they come up with these clinical guidelines they utilise data models stats and percentages and then extrapolate generic guidelines for a whole group."

I would like to know what you think is wrong with using "data models stats and percentages" to inform guidelines. What alternative is there that will be as reliable?

 

[Neemo]

I'm not going to comment in detail on your points but many of us would agree overall. What most of us have realised since becoming diabetic and doing our research is that the national bodies involved are not really interested in what actual diabetics in practice find works and doesn't work. They look to 'experts' for guidance. Many of these 'experts' are professors in university departments often funded by pharmas or food companies. These people all have their own agendas and no-one wants to break ranks. Their opinions will change but slowly over years. It's a very sad state of affairs and many of us regularly complain to DUK, the NHS etc but it has very little effect. So, do try what you can to change the status quo but don't expect miracles! Meanwhile this forum does a good job in informing newbies with what we believe from experience works.

Yep, I agree. I defo think that a large proportion of this forums members are clued up.

The newbies can definitely benefit from this info, as several users have commented on being advised to eat starch carb meals and we're expiring fluxes.

I think there's also pertinent info that could be useful to veterans aswell; I think one of issues in this day and age is that there is too much conflicting ' evidence' and lots of variables to consider.

 

[ButtterflyLady]

Yep, I agree. I defo think that a large proportion of this forums members are clued up.

The newbies can definitely benefit from this info, as several users have commented on being advised to eat starch carb meals and we're expiring fluxes.

I think there's also pertinent info that could be useful to veterans aswell; I think one of issues in this day and age is that there is too much conflicting ' evidence' and lots of variables to consider.

That's why it is helpful to learn the skills to weigh different pieces of evidence against each other. Large scale studies are generally more reliable than small ones. Human trials better than animal studies. High impact journals better than low impact journals, etc.

 

[TooMuchGlucose]

I admit I only read the Mersey guidlines, as it was the shortest but will look at the others. I found some things very disturbing.

First of all there is this "Type 1 patients should be supplied with and instructed in use of urine ketone testing strips (some T1DM patients now use blood ketone monitoring)." Whilst they do mention blood testing strips, urine strips belong in the past there is a reason they were discontinued years ago for glucose testing they are not as reliable.

"Important Notes (1) Pioglitazone appears to be associated with an increased risk of bladder cancer which should be taken into consideration when choosing this drug. It should not be used in un-investigated macroscopic haematuria and should be used with care in those at increased risk of bladder cancer. Patients should be monitored at 3-6 months and regularly thereafter (see EMA guidance, July 2011). (2) Gliptins may be associated with increased pancreatitis risk you must warn about pancreatitis risk, relevant symptoms and appropriate action. (3) SGLT2 inhibitors are very new and are associated with increased risk of urinary and genital infections. "

This is also worrying, again noted that it's important but patients should be told what the risks are for all of these drugs as in the long run it could actually save money, as the patient would have a better awareness of what their problem likely is.

"We typically use a short-acting analog (e.g. Apidra 15 minutes before breakfast, lunch & evening meal, together with a long-acting insulin analog (e.g. Lantus) at bedtime. NPH insulin (e.g. Humulin I) is less expensive than Lantus & Levemir but may cause more nocturnal hypoglycaemia."

This was incredibly worrying, nocturnal hypoglycaemia is no joke, worst case scenario this could potentially lead to someone's death because they were prescribed this. It should against guidelines to prescribe this at all.

My final point again is to do with hypoglycaemia:

"Glucose (e.g. 4 dextrosol or half a glass of lucozade) is the best treatment for hypo, but a glass (150 ml) of fresh orange juice, sugary (3 sugars) tea is ok. A rapidly absorbable sugary solution is available (GLUCOGEL). This may be used in semiconscious patients (who can still protect airway) if parenteral treatment and emergency help is not available (not in unconscious patients).
If short-acting carbohydrate (as above) is used then it should be followed up by more complex carbohydrate (such as a sandwich) to prevent further hypoglycaemia.
Strive for a BM  8.0 mM before discharging the patient from clinical supervision."

Half a glass of lucozade is very general, and could lead to great fluctuations in sugar levels, is it supposed to be 150ml? I find that would actually be too much. Then the statement of having a sandwich afterwards this would send sugars through the roof. I also don't think tea should be on the list, what the diabetic is supposed to wait around for five minutes until the tea cools?

 

[Neemo]

Thanks for taking the time to write your extensive posts above. In the other thread, you said:

"The thing is, when they come up with these clinical guidelines they utilise data models stats and percentages and then extrapolate generic guidelines for a whole group."

I would like to know what you think is wrong with using "data models stats and percentages" to inform guidelines. What alternative is there that will be as reliable?

The latter part of this excerpt gives the context; "very generic guidelines for an entire group". There needs to explicit guidelines that are more specialised, e.g. Broken down into age ranges, duration of diabetes, Body composition etc.

I am an Analyst by profession; context, relevance and accuracy is vital in providing insights and guiding consequent strategic guidance/decisions.

In short; more granularity, context and tailoring needs to be derived from the data - as opposed to generic guidelines for all diabetics; Type 1 or 2.

 

[tim2000s]

I'll admit I haven't read all these, but generally the issue with guidelines is that most experienced people find them wrong or inadequate.

Personally, I think what they should contain is pointers to better management once the triage is done, and these really are the triage. Where do you get that? Well engaging the diabetes community isn't a bad place to start.

With regard to the original post, there's an issue with stating " Your blood glucose level will spike". Only if you aren't timing and intensively managing. I can eat a 170g bag of fruit pastilles without spiking, as long as I manage it. That's the hard bit, and the bit that again, really can't come from a non-diabetic hcp.

Whilst mentioning Amylin is an interesting one, in the UK it is redundant as artificial Amylin isn't available due to hypo fears. When eating a low carb diet it would help immensely.

As an analyst, you should also be aware that the cost of providing explicit breakdowns and advice is exponential and more importantly, requires resource that is simply not there. While I don't disagree that it would help initially, one of the difficulties with diabetes is individual physiology which drives different people different ways. I'm not sure of a good answer for that.

 

[ButtterflyLady]

The latter part of this excerpt gives the context; "very generic guidelines for an entire group". There needs to explicit guidelines that are more specialised, e.g. Broken down into age ranges, duration of diabetes, Body composition etc.

I am an Analyst by profession; context, relevance and accuracy is vital in providing insights and guiding consequent strategic guidance/decisions.

In short; more granularity, context and tailoring needs to be derived from the data - as opposed to generic guidelines for all diabetics; Type 1 or 2.

I'm an analyst by profession too... and I already know how to suck eggs My main issue with more detailed guidelines is the same as tim2000's: the cost benefit ratio of that work needs to justify doing it. Guidelines should not be too prescriptive: they are meant to be used as a foundation, a platform, and the HCP then tailors them to individual patient need. This seems to provide greater accuracy at a reasonable cost, and more acceptance of the guidelines by HCPs.

 

[Neemo]

I'm an analyst by profession too... and I already know how to suck eggs My main issue with more detailed guidelines is the same as tim2000's: the cost benefit ratio of that work needs to justify doing it. Guidelines should not be too prescriptive: they are meant to be used as a foundation, a platform, and the HCP then tailors them to individual patient need. This seems to provide greater accuracy at a reasonable cost, and more acceptance of the guidelines by HCPs.

....

I'm not advocating a mega expensive study; and yes, I'm very well acquainted with 'cost-benefit' consideration. But please look at the publically available figures for current diabetes management spending and forecasts..I'd say it's a little short sited to be so dismissive when the rate/cost of complications due to diabetes is becoming unsustainable through a tax funded National Health Service.

The explicit point I'm trying to make is that, the current guidlines, OR the way they are being interpreted and implemented, needs to be reviewed and improved. And whos to say more rigidity in these guidelines would not result in a positive outcome.

I'm sorry, but some of the rhetoric in your pody sounds very simular to NHS Middle Management Bureaucracy..

 

[ButtterflyLady]

I'm not advocating a mega expensive study; and yes, I'm very well acquainted with 'cost-benefit' consideration. But please look at the publically available figures for current diabetes management spending and forecasts..I'd say it's a little short sited to be so dismissive when the rate/cost of complications due to diabetes is becoming unsustainable through a tax funded National Health Service.

The explicit point I'm trying to make is that, the current guidlines, OR the way they are being interpreted and implemented, needs to be reviewed and improved. And whos to say more rigidity in these guidelines would not result in a positive outcome.

I'm sorry, but some of the rhetoric in your pody sounds very simular to NHS Middle Management Bureaucracy..

One person's "analysis" is another person's "rhetoric". I would be more interested in engaging with your arguments if you adopted a more mature, professional and respectful tone. My mention of teaching people how to suck eggs was a subtle hint that your tone was condescending. You failed to get the hint.

 

[Neemo]

Your subtle hint was actually very insulting to me. I'm not trying to condescend anybody..u seem to have taken affront to the fact that I am OPINIONATED and rebutted your assertions and responses with well reasoned arguments.

The fact is, nearly every single post youve made on my threads has had a cynical, disrespectful tone, at times passive-agressive *I know it's the Internet, but that's the impression I was getting :/). You have not added a single positive: pure negativity. Look back at your posts if you don't remember.

If you don't engage amicably, why do you expect positive reciprocity; I'm utterly bewildered.

You purposely hijacked this thread with a question you had from an issue with another thread..

Please let people reap the benefits of the info in this post; even you can't dispute there is some excellent info in here for individuals who may not be as learned as yourself. Thanks!!

 

[ButtterflyLady]

Your subtle hint was actually very insulting to me. I'm not trying to condescend anybody..u seem to have taken affront to the fact that I am OPINIONATED and rebutted your assertions and responses with well reasoned arguments.

The fact is, nearly every single post youve made on my threads has had a cynical, disrespectful tone, at times passive-agressive *I know it's the Internet, but that's the impression I was getting :/). You have not added a single positive: pure negativity. Look back at your posts if you don't remember.

If you don't engage amicably, why do you expect positive reciprocity; I'm utterly bewildered.

You purposely hijacked this thread with a question you had from an issue with another thread..

Please let people reap the benefits of the info in this post; even you can't dispute there is some excellent info in here for individuals who may not be as learned as yourself. Thanks!!

There was nothing disrespectful about my posts. You made threads inviting debate, you got it. You describe your assertions as arguments, and my assertions as assertions. How about a bit of evenhandedness? I don't find your assertions/arguments convincing and I'm allowed to ask questions and make comments. If you think my posts breach the site rules, you are free to report them. Making a personal attack on me is not the solution; reasoned, respectful debate is.

I won't engage further unless you are respectful.

 

[RuthW]

With regard to the original post, there's an issue with stating " Your blood glucose level will spike". Only if you aren't timing and intensively managing. I can eat a 170g bag of fruit pastilles without spiking, as long as I manage it.

I agree with this and I therefore disagree with your very strongly stated views on carbohydrates. Your need for/use of carbs correlates more tightly with your level of physical activity, than with whether you are diabetic or not. It is true that many diabetics should be on a lower carbohydrate diet, given the amount of exercise they take. But it would be better advice to increase their output of energy rather than decreasing their diet.

And lots of walking without resistance training in the long term decreases muscle mass, which in turn raises insulin resistance, which in turn wrecks your ability to control blood sugar, which in turn......and so on.

So, no, afraid I'm not with you on this one. Your analysis leaves out a good understanding of the most essential factor in control, IMO.

 

[Neemo]

I agree with this and I therefore disagree with your very strongly stated views on carbohydrates. Your need for/use of carbs correlates more tightly with your level of physical activity, than with whether you are diabetic or not. It is true that many diabetics should be on a lower carbohydrate diet, given the amount of exercise they take. But it would be better advice to increase their output of energy rather than decreasing their diet.

And lots of walking without resistance training in the long term decreases muscle mass, which in turn raises insulin resistance, which in turn wrecks your ability to control blood sugar, which in turn......and so on.

So, no, afraid I'm not with you on this one. Your analysis leaves out a good understanding of the most essential factor in control, IMO.

Yep, some valid considerations . But I think there are a lot of caveats to your assertions.

Firstly, judging by your previous post, you're a gym-bunny; you are into weight lifting
So am I, I've lifted weights for years and can testify to the profound effect this kind of regime has on insulin sensitivity and obviously increase in muscle mass etc. BUT most people are averse to weight training, women particularly are afraid that weights will bulk them up. In the thread I mentioned resistance training before walking, but didn't want to put too much emphasis on it as I knew it would fall on deaf ears.

BUT if you read the post back you will see that the post explicitly/primarily concerns the issue with dietary guidelines/advice, not exercise, hence there was no detailed analyis on the exercise aspect, although it definitely is an important aspect so I made sure I mentioned it - U mention that "it would be better to advise an increase in activity, well what's wrong with advising both, as I did in the original post..

Regarding diet, I'm mainly advocating a shift towards lower GI foods and foods that have a higher satiety, not a calorie reduction as you mentioned above. As I articulate in the post, the lower GI carbs have a slower energy release and are superior in respect to maintaining flatter glucose profile(fact), less fat storage, require less insulin. It's important to note carbs are digested very differently, this is important to note when comparing high GI potato based meal vs Low GI Oatmeal for example. If your body can't utilise the energy in that High GI Potato, it will get stored as fat(High GI means that the carbohydrates, simple in the case of potatoes, become glucose in the blood stream very quickly-opposite true for low GI)

I completely disagree with the statement that walking will diminish muscle mass without 'resistance training and consequently will lead to fat gain and insulin resistance',. Please provide your evidence.

I stopped all resistance training 2 years ago when I incurred a back injury, instead I walked 6-7 miles a day (briskly) I had excellent control and maintained a very lean muscular physique (no I wasn't as big as when I was weight lifting, lost my hypertrophic bulk) but at 5ft 8 90 kg, I had visible abdominals and gained size in my calves.

Reality is walking is an excellent exercise, and as I emphasised in my post walking 'briskly' in particular will reduce weight increase insulin sensitivity, lower cortisol, burn calories, promote cardiovascular health etc etc. plenty of studies to back this up.

Regarding the Fruit pastille statement you agreed with; I don't want to go into too lengthy a breakdown......., but this misrepresents my original point about 'spikes' (i.e. striving for smaller deviations, as opposed to greater fluxes which starchy carbs cause for diabetics) and is a dangerous precedent to set; i;e advocating that any food can be consumed without a spike if insulin regieme is managed.

Quick example; A diabetic and a non diabetic both consume 10 original crispy creme donuts;

Diabetic; has to bolus for entire carb content. Has to anticipate spike, which has a very steep profile. so there is bound to be a spike (now the other poster's interpretation of a spike i.e up to 11 is not a spike - That's fine, that's the standard advice I was given at 10 yrs old. If you had read my post you would see that I strive to keep my glucose as 'Normal' as possible to a normal persons. Through Low GI, calorie choices my blood glucose doesn't go above 8, even 10, 30, 60 minutes aftet meal. All excess sugar is a toxin and as I mentioned excess sugar damage is cumulative.
I have always had HBA1C less than 6.5 in my earlier years, I was congratulated by drs/nurses. However there were still plenty of occasions I had blood sugars above 10, so as a very high level indicator the 'gold standard' hba1c is good, but doesn't tell the full story.

Issues; Nothing to mitigate huge glucose ingestion; non diabetics beta cells produce amylin, which mitigate effects profoundly. Additionally bolus profiles are not comparable to beta cell Insulin, apples and oranges.




Non Diabetic; Beta cell Insulin in synergy with Amylin (glucose homeostatis) effectively manage this huge Glucose ingestion. Amylin basically slows down the digestion/prevents spikes, not going to into too much detail, but amylin has a number of primary secondary functions. Consequently the BS of a healthy non diabetic will typically not deviate above 8 mmol at the extreme.

 

[tim2000s]

Yep, some valid considerations . But I think there are a lot of caveats to your assertions.

Firstly, judging by your previous post, you're a gym-bunny; you are into weight lifting
So am I, I've lifted weights for years and can testify to the profound effect this kind of regime has on insulin sensitivity and obviously increase in muscle mass etc. BUT most people are averse to weight training, women particularly are afraid that weights will bulk them up. In the thread I mentioned resistance training before walking, but didn't want to put too much emphasis on it as I knew it would fall on deaf ears.

BUT if you read the post back you will see that the post explicitly/primarily concerns the issue with dietary guidelines/advice, not exercise, hence there was no detailed analyis on the exercise aspect, although it definitely is an important aspect so I made sure I mentioned it - U mention that "it would be better to advise an increase in activity, well what's wrong with advising both, as I did in the original post..

Regarding diet, I'm mainly advocating a shift towards lower GI foods and foods that have a higher satiety, not a calorie reduction as you mentioned above. As I articulate in the post, the lower GI carbs have a slower energy release and are superior in respect to maintaining flatter glucose profile(fact), less fat storage, require less insulin. It's important to note carbs are digested very differently, this is important to note when comparing high GI potato based meal vs Low GI Oatmeal for example. If your body can't utilise the energy in that High GI Potato, it will get stored as fat(High GI means that the carbohydrates, simple in the case of potatoes, become glucose in the blood stream very quickly-opposite true for low GI)

I completely disagree with the statement that walking will diminish muscle mass without 'resistance training and consequently will lead to fat gain and insulin resistance',. Please provide your evidence.

I stopped all resistance training 2 years ago when I incurred a back injury, instead I walked 6-7 miles a day (briskly) I had excellent control and maintained a very lean muscular physique (no I wasn't as big as when I was weight lifting, lost my hypertrophic bulk) but at 5ft 8 90 kg, I had visible abdominals and gained size in my calves.

Reality is walking is an excellent exercise, and as I emphasised in my post walking 'briskly' in particular will reduce weight increase insulin sensitivity, lower cortisol, burn calories, promote cardiovascular health etc etc. plenty of studies to back this up.

Regarding the Fruit pastille statement you agreed with; I don't want to go into too lengthy a breakdown......., but this misrepresents my original point about 'spikes' (i.e. striving for smaller deviations, as opposed to greater fluxes which starchy carbs cause for diabetics) and is a dangerous precedent to set; i;e advocating that any food can be consumed without a spike if insulin regieme is managed.

Quick example; A diabetic and a non diabetic both consume 10 original crispy creme donuts;

Diabetic; has to bolus for entire carb content. Has to anticipate spike, which has a very steep profile. so there is bound to be a spike (now the other poster's interpretation of a spike i.e up to 11 is not a spike.


Non Diabetic; [/B]Beta cell Insulin in synergy with Amylin (glucose homeostatis) effectively manage this huge Glucose ingestion. Amylin basically slows down the digestion/prevents spikes, not going to into too much detail, but amylin has a number of primary secondary functions. Consequently the BS of a healthy non diabetic will typically not deviate above 8 mmol at the extreme.

I'm afraid I still disagree with this, as the example is highly derived and in a non-diabetic is likely to incur a significant spike (I've seen evidence which is posted somewhere in the forum or a very clearly non-diabetic spiking on a 500ml bottle of lucozade). It is the recovery time that makes the difference.

It is very much possible to eat many foods with a very high GI without spiking (remaining below 8mmol/l) but it isn't easy. The point I was trying to make is that making a sweeping generalisation that spikes can't be avoided in day to day eating of "a normal diet" just wasn't true.

There is, however, a lot of very good evidence that eating these types of foods as with a diabetic or non-diabetic is not good due to the insulin reaction and consequences of that.

I come back to the point that the way to manage diabetes is not well taught beyond the triage stage, even with DAFNE, which also ignores all the other factors associated with insulin responses and glucagon. So while your recommendations, which are valid, go so far, they don't really go far enough.

The question is, at what point do you introduce a newbie to the complexities of their body and digestive system/energy metabolism?

 

[RuthW]

I suggest you read Diabetic Athlete's Handbook for a whole lot of case studies of people who cope very well with high carb diets - extremely high carb diets. And yes, most people are physically lazy. Sure, that's true. But if they have no self control about exercise, why do you think they will have self control about food?

For me, the key thing that is missing in diabetes treatment guidelines is exercise. Seriously, I think we should be "prescribed" free fitness passes, etc.they do that now for people with mental health problems. Why not for us?

I think there are many ways of dealing with diabetes. In fact, I think you and I use much the same methods BUT I wouldn't turn my own methods into a set of guidelines.

Oh, and yes, you are right, cardio alone does not reduce muscle mass, except when you are in calorie deficit. So I should have said a lot of walking without resistance training *when you are on a reducing diet.* (That pattern is probably the cause of most 'yo-yo' dieting in women.)

 

[Neemo]

@tim2000s, I respect your opinion and perspective, but it would lend a lot of credibility to your arguments if you provided a link/visual of the research - My krispy kreme analogy was contrived, but I strongly felt the same about the 170g of Fruit pastille argument.

Regarding the lucozade point, I question the veracity if this point, as you havent provided a link...maybe the individual you were referring to was insulin resistant or obese. I will try to locate some facts.l regarding non diabetic spike, better still, I have Dr Gallen's email address, he was my endocrinologist when I was younger; he advised Sir Steve Redgrave on training Insulin regieme when he developed type 1 diabetes prior to his olympic victory. (will keep you posted)
http://www.runsweet.com

My brother has frequently been a guinea pig/lab rat for my experiments; previously on one of his cheat days; where he consumed a lot of cheat foods; cake, coke, pizza - I tested his BS prior to, and then at 4-15 minute intervals to see the spikes: highest it got to was 6.9mmol after 45 mins - he consumed a massive amount of carbs/calories . I am happy to make a video of us both (me bolusing novaprapid 15 mins prior) consuming a 380 ml lucozade and then testing every 10 minutes to compare.... (although my GP better not find out; test strips are expensive) obviously a continuos monitoring would be superior, but don't have access to this.

Agree with the diabetes not being taught effectively beyond triage statement. My recommendations were not meant to be comprehensive/authoritative. Diabetes is extremely complex and there are numerous variables. However I stand by the LOW GI approach - not sure why your so averse to this - as opposed to what local trusts, GPS are advising, I.e; High GI/processed carbs, this will both impact your control (vs Low carb, natural carb sources) and make you fat (ignore BMI, how many Type 1s are lean, in good condition and not overweight - I'm leaner now (approximately 12%bf, then on a starchy diet - I still trained hard on this diet, but my body fat was extremely stubborn.

Change should be progressive and better accomplished in small steps, equally habits are difficult to break but physiologists have proven a habit can be changed within a number of weeks. Some people are stubborn and obstinate, though. human nature.

Totally agree there is a massive issue with food choices (supermarkets /corporations) causing the health of the whole planet to suffer by promoting nasty processed food.

Regarding, the last point with respect to newbies: the earlier these good practices and habits are instilled the better. They don't have to be inundated with the science behind it all, just guided regarding better food choices (low GI) rather then current starchy carb with every meal advice given to all (new or old) diabetics. If you see the guidlines/advice that NHS Enfield trust(original post) gives to diabetics with regards to diet, it's very poor, e.g "starchy carbs should be included with every meal, they help achieve good Blook glucose readings" - not good advice.

 

[Neemo]

Agree with the majority of your post.

Diabetic Athletes handbook, I will definitely give this a read, don't know if your familiar with runsweet website I've linked in above response to tim.

Agree, that athletes can manage well on a high carb diet, but athletes are very very unique, metabolically ..(by athlete I mean someone who undertakes a significant I can't amount of exercise, not a competitive athlete as such.

Sir Steve Redgrave Olympics type 1 prep is detailed in the run sweet website; amazing that even with the adversity of diabetes, he managed to maintain the crazy carb requirements/training, and then went in to win a Gold Medal! !!