T2 or NAFLD? ...or, a funny thing happened on the way to the surgery

[Chris24Main]

As for food advice - I'm really not trying to give anyone advice, and definitely not advice on food.

For me, I grew up all over the place, on the one hand that meant there was only real food - most places I lived in had no shops. However, I would probably drink up to 5 bottles of Coke a day as it was the only safe form of "water"... and dehydration was the problem.

Then, in my adult life, I've never been able to stomach any sugary drink, but I've always gravitated to noodles, pasta, rice and tortillas - and felt that because they don't involve deep frying - they were healthy.
I could eat a whole packet of grapes (all the dietary knowledge I had was limited essentially to - grapes are better than raisins, because of all the extra water, you are getting fewer calories per gram). Sheesh.

I'm just dumbfounded at how ignorant I was - and I was really paying attention. I can remember the advent of Margerine, and all the lard suddenly disappearing, but I don't remember ever being told that "starches and sugars are fattening" - but maybe that was simply that I grew up in expatriate communities where everyone was blotto all the time...

As I read more deeply, I can see that as more and more sugar has been added to "food" - you have first of all a kind of democratisation - a granting of the wonderful properties of sugar out of the upper classes to the masses, followed by an ever-growing demand, followed by more and more clever marketing as competition for market share overtakes a spirit of altruism... but the effect of this all hides the true nature of sugar.

Many will remember a time that non-sugar sweeteners were discredited and some banned as being carcinogenic. All the research that led to this was funded by the sugar industry (quite openly and deliberately) and if sugar was allowed to be subject to the same tests (it was not, and sugar has had a kind of protected status that is remarkable), well - per the forum rules, I can't finish that statement.

But - I'm really not trying to lay on anything negative - One of my best friend's daughters, who I've known since she was a month old, could well be joining Coca-Cola - and I couldn't be happier for her, it's a great company that's done some amazing work...

...but it was easier to remove the wine and cocaine from coke than the sugar.

Much of the language around "whole foods" and "whole grains" and fibre, really amounts to evidence that refined starch is quicker to absorb. There has never, ever been any evidence that the fibre, or the husk, or the "bits of the plant that otherwise get refined out" are inherently beneficial, only in comparison... yet we (I used to) take that for granted as a known thing - it never has been, but this is all about the stories we tell ourselves.

 

[Chris24Main]

I suppose, just for reference - I don't actually agree that "high-carb low-fat" is a con - it can be a perfectly healthy way to live.. and genetics play a part, but you are somewhat at the mercy of insulin - in order for this to actually be healthy, you must be eating very little..

if you understand the tyranny of the medical phrase "adipose tissue will hypertrophy under the influence of elevated insulin and sufficient energy"

this means - option 1 - high carb can be fine, but only if you are taking in less than sufficient energy. That is difficult for lots of people, mainly because high carb drives hunger.
or - option 2 - if you keep your insulin low, it's difficult to put on weight.

What I definitely agree on, is that bits of the story are presented in ways that make it more difficult to see the wood from the trees, and that too much effort is put into option 1, but I do think that option 2 is becoming gradually more visible.

 

[Outlier]

This is all really good food for thought - please keep at it, @Chris24Main.

 

[MrsA2]

For me the alarm signals are the oh so rapid rises in diagnosis of T2 and prediabetes. Millions and millions in just a generation or 2. Unheard of in the whole history of human evolution (runs away quickly expecting barage of those better informed that me )
I do hope the answers are found in the Tofis (aka the normal weight t 2s) or the lean mass hyper responders and all the other phenotypes that can aid the research.
Which is why I keep reading, even if not fully understanding ...

 

[Chris24Main]

Oh - I think your bang on the money there - from diabetesatlas.org;

At a glance	2000	2011	2021	2030	2045
Diabetes estimates (20-79 y)
People with diabetes, in 1,000s	151,000.0	366,000.0	536,600.0	642,800.0	783,700.0
Age-adjusted comparative prevalence of diabetes, %	4.6	8.5	9.8	10.8	11.2

That's worldwide, and it's some scary numbers...
I don't recall the source, but one of the very first interview videos I watched - the headline statement was along the lines of "look, if we don't do something different, in a couple of generations there simply won't be enough well people to look after all the sick ones".

And honestly I can't remember if it was generations, or decades, so I've gone with the less sensational.

But - I do feel a part of what we need to do here is understand and inform; it isn't enough that a subset of all diagnosed diabetes patients reverse their diabetes, somehow we have to turn this tide around.

and how do you inform without preaching? well ultimately it will happen anyway, the human race is pretty resilient like that, but the more people there are with positive stories, the easier it will be.

 

[RachelG.]

Hmm okay, there's a lot here! I'll respond to a few things:

Many will remember a time that non-sugar sweeteners were discredited and some banned as being carcinogenic. All the research that led to this was funded by the sugar industry (quite openly and deliberately) and if sugar was allowed to be subject to the same tests (it was not, and sugar has had a kind of protected status that is remarkable), well - per the forum rules, I can't finish that statement.

It's not just the sugar industry that is exploring adverse health links with artificial sweeteners, although the cancer link doesn't seem strong from what I have read. There's a correlation between sweetener consumption and heart problems explored by this paper from the French Health Ministry (seems pretty legit in terms of funding) https://www.bmj.com/content/378/bmj-2022-071204

Also, research is emerging on the possible negative effect of artificial sweeteners on the gut microbiome which has a huge effect on overall health. There are many studies but take a look here for example - https://pmc.ncbi.nlm.nih.gov/articles/PMC10144565/

Finally, this article is mostly stressing the need for more comprehensive research but it's possible that artificial sweeteners consumed by pregnant women may cross into the placenta and make the child more prone to metabolic issues - https://www.bmj.com/content/383/bmj-2023-075293

So for me, there's enough worrying evidence to avoid artificial sweeteners until we know more. In any event, I think from a common sense point of view that training your body to think it needs sweet food is more likely to create problems with sugar than avoid them. But then I've never had a sweet tooth and I know people who do and find it very hard to avoid sweet things so for them, small amounts of the less contraindicated artificial sweeteners are probably a sensible choice. Obviously sugar is worse, but for me that analogy is a bit like comparing smoking cigarettes with vaping - the former is worse but the latter is not healthy.

Much of the language around "whole foods" and "whole grains" and fibre, really amounts to evidence that refined starch is quicker to absorb. There has never, ever been any evidence that the fibre, or the husk, or the "bits of the plant that otherwise get refined out" are inherently beneficial, only in comparison... yet we (I used to) take that for granted as a known thing - it never has been, but this is all about the stories we tell ourselves.

There's quite strong evidence that high fibre protects against several types of cancer, see here - https://pmc.ncbi.nlm.nih.gov/articles/PMC10255454/

"The quality of evidence for the outcome of the included meta-analysis was evaluated by the criteria in the WCRF/AICR expert report, involving a total of 11 cancers. The results of grading showed that the protective effect of dietary fiber on gastric cancer was convincing evidence. The protective effect of dietary fiber on rectal, colon, breast, endometrial, pancreatic, colorectal adenoma, and prostate cancers was probable evidence, on ovarian and renal cell cancers was suggestive evidence, while on esophageal cancers was inconclusive evidence."

Increasing gut motility is probably one reason why it plays a role. But in any event, you can consume a good amount of fibre on a low carb diet so there isn't a conflict here.

 

[RachelG.]

I suppose, just for reference - I don't actually agree that "high-carb low-fat" is a con - it can be a perfectly healthy way to live.. and genetics play a part, but you are somewhat at the mercy of insulin - in order for this to actually be healthy, you must be eating very little..

if you understand the tyranny of the medical phrase "adipose tissue will hypertrophy under the influence of elevated insulin and sufficient energy"

this means - option 1 - high carb can be fine, but only if you are taking in less than sufficient energy. That is difficult for lots of people, mainly because high carb drives hunger.
or - option 2 - if you keep your insulin low, it's difficult to put on weight.

What I definitely agree on, is that bits of the story are presented in ways that make it more difficult to see the wood from the trees, and that too much effort is put into option 1, but I do think that option 2 is becoming gradually more visible.

Hmm this is an interesting idea! Isn't the main problem with option 1 that over time, the person would become underweight though? Which *is* bad for a number of bodily processes.

 

[MrsA2]

Finally, this article is mostly stressing the need for more comprehensive research but it's possible that artificial sweeteners consumed by pregnant women may cross into the placenta and make the child more prone to metabolic issues - https://www.bmj.com/content/383/bmj-2023-075293

That's interesting. I read somewhere that there's a school of thought that what the mother eats while baby in utero can predispose to T2. I wonder if its the same article/research?
It would, if one considers the advent of diet drinks and soda, seem to fit with the explosion of t2 diagnosis

 

[Chris24Main]

First article about the impact on gut biota;

This is really interesting timing, the very last episode of Ben Bikman's metabolic classroom was talking about the effect of oxalates - the "thing" in some leafy greens such as spinach and kale, that is technically an "anti-nutrient" - meaning it will bind to nutrients (calcium, iron, other electrolytes) making them both unavailable to the body, and also directly becoming toxic in the process. Oxalate binding to Calcium in the blood for example becoming the starting point for Kidney stones.

So - a single example - spinach. We think of spinach as being a good source of iron. I was eating a packet of spinach leaves a day this time last year, so I'm very much in the scope of this... But it isn't - the iron that is in the plant, is in the kind of iron ion that is only available to plants - not to animals, so we cannot absorb it, and further, it contains these oxalates, that will sponge up iron from the blood, so the net effect of eating spinach can be to reduce the bio-availability of iron.

The actual effect is more complex - your gut biota can contain bacteria that can absorb this stuff, and the way you prepare the spinach and with what also makes a difference (though grabbing handfuls from the plastic bag as I did is probably the worst way to eat spinach, natch). Oxalates that pass through and out of the digestive system are not toxic in the way that oxalates that pass into the blood stream are, so it isn't quite like saying "spinach is toxic".

But it does lead into an interesting line of thought... all of the discussion them becomes, what is the "least worst" way of eating these leafy greens (this isn't all leafy greens, by the way, my favourite, Rocket, still seems to be on the nice list...) - what is the downside of just not eating them in the first place..

And the answer seems only to be that (if you are getting nourishment enough elsewhere) that your gut biome may become less adapted to these leafy greens. Now - that isn't nothing... the products of some bacteria consuming some of this material produces directly beneficial molecules - it really is the case that we contain a lot of bacteria that we exist in a state of symbiosis with. I haven't seen anything to directly conflict with that, and fully 1/4 of us, in terms of the number of cells, is bacteria, so it's something we ignore at our peril... but to me anyway, it leads you down a path of thinking "yes, I should eat some of the least toxic leafy greens and fermented carbs in the form of sauerkraut and Kimchi - but I should think about that as feeding and helping my gut biome, not me.."

The report seems balanced and very thorough in its examination of the impacts on the gut biome.. but it's striking, reading through the detail, what affects what... it's all about various carbs and sugars and how they interact with the bacteria.. the effect of too much sugar on the lower intestine.. all good... and then near the bottom you get:

"The consumption of unhealthy diets that are high in saturated fat and refined sugar and a lack of physical activity has been associated with dysbiosis of the gut microbiota, leading to inadequate glycemic control"

Wait, what - ? all the detail discusses sugars and suddenly you are invoking "unhealthy diets high in saturated fat" - I had to read back again, and no.. none of the detail of the report mentions anything about the effect of any kind of fats on the gut biome, but the conclusion immediately talks about saturated fat first.

 

[Chris24Main]

The second report - very clearly a nutritional epidemiology study. Right, so first off, we need to be clear what nutritional epidemiology is. It's essentially making connections between things based on maths. You don't need to explain why a thing may be occurring, only point to a statistical likelihood.

I'm fundamentally turned off by all nutritional epidemiology, because you can design a study to say what you want. Most of us are not equipped to be able to say whether the result is meaningful, because there are all sorts of mathematical tools that can be used to say "because, this, I can say that these results are meaningful".

That's about as far as I go.
And - I mean that more broadly, there are reports that somewhat align with things I believe and some that don't - I'm not sure I buy into any of it - explain to me why you think this thing is happening, and have people try to disprove it - then I'll pay attention.


I caught part of an interview with a dental health expert on the "diary of a CEO" channel on YouTube - she was claiming that improvements in gum health could lead to better general health outcomes, including heart disease, blood glucose control, and even erectile dysfunction. That of course was the clickbait, and might motivate many of us on the "Y chromosome side of the fence" to brush our teeth more often...

But - simply cutting sugar out of your diet leads to all the things, including better gum health - on the very simple basis that you have less sugar in your mouth less often. (I can attest to this directly - my last dental appointment was astonishing; my dentist was literally lost for words on how there could have been such improvement since my last visit)
Cause and effect - if you just rely on the statistics, it's equally likely that brushing your teeth will lead to improved heart health. Mechanistically, it's nonsense.

 

[Chris24Main]

Hmm this is an interesting idea! Isn't the main problem with option 1 that over time, the person would become underweight though? Which *is* bad for a number of bodily processes.

I would certainly agree with your conclusion, yet this was accepted for some time in various medical treatments - it was better to starve patients than allow the disease to take over. This does makes some sense absent insulin before the 1920s, but there has been controversy ever since about whether lowering Carbs or lowering Calories is the better approach.

All I'm saying is that there isn't a one-size fits all approach. For some, reducing calories can work. But - if you understand that phrase - you need to reduce calories a lot.

That said, understanding the same phrase also means that you need to reduce insulin a lot (compared to "normal") and you get into a philosophical discussion about whether as a species we are better off (or have evolved to flourish) with a generally low insulin level, or insufficient energy. I know where I would put my money.

 

[Chris24Main]

Third article about sweeteners passing through the placental barrier and

"The challenge of developing intake recommendations with the available research"

So - that's really interesting - do we not also think that sugar passes through to the developing baby? - why is it that in every population that has introduced higher levels of sugar in the diet, we see a generational shift in the uptake of sugars.. is there anything special that concerns non-sugar sweeteners that doesn't also concern sugar? - if we are concerned, shouldn't we be more concerned about sugar?

.. to that end... what is the recommended intake level of sugar?

Going back to that pivotal congressional hearing of 1977 - which lead to the reduction of fats in favour of carbs. It also recommended a reduction in sugar intake to 40% of what it was then.

Doing some quick googling.. the average sugar consumption in the US at the time was 50gm per day, so by that reckoning (rough now) 20 grams of sugar is "safe" per day.

The current level of sugar consumption in the US is around 70gm per person per day.

The difference is that sugar also gives us that big, big dopamine hit, and that we collectively have this enormous blind spot in terms of thinking of it as a naturally safe food, rather than a powerful drug (which is was for hundreds of years).

But - the relative consumption of saturated fat has largely fallen according to those 1977 guidelines...

 

[Chris24Main]

So I found myself over the weekend trying to figure out the electron transport chain. This is, if you like, the essential mechanism that we burn fuel with using oxygen that we breathe. So it's pretty important.. but I'm watching this video, a Harvard University production no less, and it's an animation showing the surface of the lining of the mitochondria - absolutely fascinating - there are protein structures sitting in this membrane - spinning like a kind of water mill. The details are almost irrelevant, the whole thing is so complicated - but in a deeply satisfying way. Anyway - I'm going to need many many more viewings to be able to say anything coherent about any of it; for sure I don't want to sound like I have any real clue..

it was more a general sense of, "man, I'm pretty deep down this rabbit hole now, surely this has to be close to bottom"..

 

[Melgar]

Fascinating, would you mind sharing that link @Chris24Main. I’m curious.

 

[Chris24Main]

here you go (what did we do before YouTube history...?)

Again - I really don't offer this as anything anyone needs to hold in mind or feel that it's important, but as my understanding of metabolism increases, I become more aware that I need to have a basic idea of what a mitochondria is. Turns out you can imagine them sort of like batteries - they hold chemicals either side of a porous boundary with a voltage between either side - just like batteries.

 

[Melgar]

Thanks @Chris24Main .

 

[Melgar]

The graphics are amazing. It did go over my head, but still fascinating.

 

[RachelG.]

Hi guys, I have some comment responding to catch up on at some point and and defo watch that video @Chris24Main - just really busy atm

I wanted to pop in and say I have changed my gp surgery and got through the gatekeeping admin to get an in person gp appointment tomorrow. What I want out of it is either a referral to an endocrinologist, c-peptide and/or GAD antibodies test or a reason that makes sense to me as to why they aren't doing any of those things.

To recap, (sorry for repetition across threads) I am 40, always been normal or underweight, always been very active and have always eaten a good, whole foods based diet - albeit with carbs but mostly wholemeal ones. My great aunt had diabetes and my aunt had gestational and is now prediabetic, both of them are also normal weight. I also seem to have regular ish hypos (below 4mmol/l) on the cgm at night, (I am not sleeping on the cgm). I am concerned the NHS has decided I'm Type 2 without proper investigation.

I'll be taking a copy of the Newcastle Study with me with the part highlighted where they had to exclude 4 out of 24 of the normal weight 'Type 2 diabetics' as they did not in fact have type 2 diabetes. I also found a diagnosis guide for gps from a different health trust. Does anyone have any other recommendations of things to bring along to strengthen my case that I need further tests?

 

[Chris24Main]

Just the general advice - I mean you're doing this anyway - think through what you want to cover or achieve (may not be the same things) and write them down - take that in with you, and make sure you refer to it.

and - good luck. It isn't easy, but also try to see things from the GP side, make it as easy as possible to work with you...
Hope it goes well..

 

[Melgar]

Hi guys, I have some comment responding to catch up on at some point and and defo watch that video @Chris24Main - just really busy atm

I wanted to pop in and say I have changed my gp surgery and got through the gatekeeping admin to get an in person gp appointment tomorrow. What I want out of it is either a referral to an endocrinologist, c-peptide and/or GAD antibodies test or a reason that makes sense to me as to why they aren't doing any of those things.

To recap, (sorry for repetition across threads) I am 40, always been normal or underweight, always been very active and have always eaten a good, whole foods based diet - albeit with carbs but mostly wholemeal ones. My great aunt had diabetes and my aunt had gestational and is now prediabetic, both of them are also normal weight. I also seem to have regular ish hypos (below 4mmol/l) on the cgm at night, (I am not sleeping on the cgm). I am concerned the NHS has decided I'm Type 2 without proper investigation.

I'll be taking a copy of the Newcastle Study with me with the part highlighted where they had to exclude 4 out of 24 of the normal weight 'Type 2 diabetics' as they did not in fact have type 2 diabetes. I also found a diagnosis guide for gps from a different health trust. Does anyone have any other recommendations of things to bring along to strengthen my case that I need further tests?

Hi there @RachelG. When one falls outside the typical T2 profile, without trying to over simplify it: over weight; high levels of surplus circulating insulin due to insulin resistance, evidenced by raised levels of c-peptides; a sedentary lifestyle; high triglycerides, a poor diet, or diet high in carbs alongside high fats; metabolic syndrome, things becomes less clear, a certain degree of mistrust seeps into your thinking. You start questioning the diagnosis and by extension your trust in your GP. Most of what we read involves classic T2 contributing factors, as already mentioned. I’ve been banging my head with this since I was first diagnosed. It’s led to frustration and to be honest anger.

I will digress slightly as you mentioned hypos. I would mention your low blood sugar episodes, but know this (I always believe in being informed before I see my GP) Hypos, unless you are on blood lowering meds, those that are listed as causing hypos, are not really part of the T2 landscape. My own blood sugars are very unstable. My night time blood sugars CGM graph can flat Line at 7mmol/ls or my graph can look like the Himalayan mountain range, I can hypo for an hour at 3mmol/ls and then rise to 8mmol/ls just because my liver dumps, but my liver does not dump in time and I can go even lower. I get hypo symptoms.

What Iwill say about cgm generated graphs that show low blood sugars is this - cgms can be less accurate once outside the ‘normal range’. By that I mean if your CGM is saying you are at 3.5 and your alarm goes off you are can be likely around 4 - 4.5. Check and confirm your blood sugars with a finger prick. In general, Your blood sugars dropping to the mid 3’s is nothing to worry about unless you are on insulin or one of the listed drugs that can cause hypos. In fact, people without diabetes can and do regularly drop into the 3’s.

After a heavy carb/sugary meal people sometimes get a reactive low. Simply put your pancreas either over produces insulin causing a brief low sugar episode, usually your liver will adjust relatively quickly, or sometimes low blood sugars can be the result of late food dumping, but this is not common, insulin is released to absorb the sugars in your small intestines. Now, if you drink alcohol, Alcohol can and does cause low blood sugars, in particular alcohol with sugary mixers.

As to your question, sorry, it took a while to get there, in general unless your blood sugars are in the high blood sugar range GPs don’t seem to be that willing to write out lab rec forms for c-peptide tests or lab recs for the tests for the four types of autoantibodies that can be generated during an autoimmune attack on your pancreas. Frustrating I know. Some members are able to persuade their GP’s to authorize the tests. They are lucky. Others go private. I am actually going to go private for my C-Peptide test. Your Dr will likely want to visit your dietary choices. This is well worth looking at. Low carbing has been very successful for a lot of members. The issues for lean diabetics is the weight loss that may accompany low carb diets. I certainly did not wish to lose any weight as I’m thin already. I tried the low carb diet for 9 months, it barely dented my blood sugars. I lost weight I could ill afford to lose, but that was my situation. Everyone is different. Also Fasting has shown a degree of success for some members, @Chris24Main can talk more about fasting.

The Type 2 category is very broad, too broad in my opinion, but really that is just my opinion. There are reasons why lean diabetics get frustrated and the means to lower blood sugars can be challenging. Idont have the stats on how many lean diabetics are misdiagnosed and are actually T1’s. And to add another spoke in the wheel, you don’t have to be lean to be T1, you can be over weight and be T1 but misdiagnosed as T 2. They may have a harder time convincing the Drs that their blood sugars are not behaving as they should despite the meds.

I wish you luck, please keep us posted. I am always interested in lean diabetes. Sorry I ended up writing a lot. And my apologies to @Chris24Main for going off piste.