type 2 medication advice please

Ah xyzzy! As I said above I have the greatest respect and admiraion for those whom some might
refer to by the 2g" and "n" words. They find all sorts of useful information and explain the science behind it , and their discussions sometimes even stimulate my few remaining brain cells into attempting o fiollow the arguments .

I imagine life is very diffficult for such intelligent and logical minds. There must be an expectattion that others , especially professionals will recognise and appreciate their logic. Unfortunately this is seldom the case ,especially in the NHS and it seems , particularly when dealing with diabees-related issues. They are very goood at stonewallig, pretending to be deaf, losing files , and failing to answer.
The PCTs cannot deal with he smallest general enquiry in a rational direct manner , even where it is a general matter and not related to a paricular case. PALS are the same. They ry to resolve issues but are ignored by the front-line staff so it is all just PR.

They have all had many years of practice and are almost perfec in this area.

It is very hard o accept that even when you are oally in the right and making perfect sense you may still be ignored, but so it is. As many posters will testify.

In general, the thinking around safe HbA1C numbers is based on us as a general population of diabetics. Recommendations aren't based on what is right for a person on insulin, another on Glic and others on diet only or metformin. That seems too complex for them, and they're worried that if they tell someone on metformin "it's ok to go to 5.5" they can't say the same to someone on insulin and so are giving different advice on "good" levels to different people. I've heard all the arguments, but remain convinced that for a person on diet only or metformin, as near to non-diabetic as possible must be best. Otherwise, why wouldn't it be better for a non-diabetic to have a higher level? This is all about avoiding risk to me.
One note on the levels you quote though: a normal healthy diabetic would normally be about 4.6; although they can be lower, it's unusual. Also, HbA1C in non-diabetics rises with age (some say about 0.1 per annum above about 60) Aiming for 3.5 is thus unrealistic I think. Anywhere near 5 has got to be good. I'd love to see a dead on 5.0, but won't go mad to get there.
Stick to your guns; tell them you want the met. If the met got you there, taking it away could send you back (they want to ignore the low carb bit you said so let them) and you don't want to yo-yo
Good luck

spaglemon said:

how many years away do you think the nhs are from acknowleding that a low carb diet is an excellent way of controlling blood sugar levels ?

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Again, I think it's the diet only/met versus insulin or similar concern. People can correct me if I'm wrong because I don't use insulin, but I'm betting it's easier to control insulin use on higher carb levels and aiming at 7.5, than insulin use on low carbs aiming for 5.5. The latter scenario would have far more risk of dangerous hypos I would think. Remember, some people aren't as bright as others numerically, and they can't discriminate between the bright and the less than bright ( did I say that in a good PC way?) so the safer option is taken for advice. That doesn't excuse them from not taking a different line with people not at risk of hypos. But that requires advisors to use judgement and discretion - dangerous eh? :lol:

When I went to see the nurse on Monday I took along a printout of a doc Pneu had pointed me at the other day which is basically the health targets used for diabetics in Sweden

http://www.healthcare-bulletin.com/...ascular_Disease__in_Diabetes_Care_-_2011_.pdf

I also printed out the front cover of the Swedish Health care doc "Kost vid Diabetes" which is the one which specifically recommends a low to medium car diet and specifically trashes the NHS starchy carb diet. Interestingly the doc although not recommending ultra low carb diets < 30g / day doesn't condemn them either. It just states people who elect to do ULC should be closely monitored.

Did it so she couldn't accuse me of following some nutty fad.

btw spaglemon I presented my case for more drugs even though she said my BG's were "under excellent control" and very low. She agreed to refer me to a specialist to see if I can drive them lower and in the meantime upped the Metformin, so they're not all bad...

Again, I think it's the diet only/met versus insulin or similar concern. People can correct me if I'm wrong because I don't use insulin, but I'm betting it's easier to control insulin use on higher carb levels and aiming at 7.5, than insulin use on low carbs aiming for 5.5. The latter scenario would have far more risk of dangerous hypos I would think. Remember, some people aren't as bright as others numerically, and they can't discriminate between the bright and the less than bright ( did I say that in a good PC way?) so the safer option is taken for advice. That doesn't excuse them from not taking a different line with people not at risk of hypos. But that requires advisors to use judgement and discretion - dangerous eh? :lol:[/quote]

The dangers of regimentation? Maybe it has reached the stage where it is doing more harm tha good. I know a few Gps who think this is the case..
Treating patients as individuals may well be the better course.
I often thik that in local practices at least the "dumbed down " treatment has to be dunmbed down further so the Gps can distance themselves from patients with diabetes more and more.
My diabees nurse penly boasts of not understanding any metric system , the new HBAic measurement , anything technical and cannot remeber the ames of the ew drugs available for T2.
She is very proud , however , of knowig that there are some.
Some HCPs are also less bright than others also!
Remeber "The Prisoner"? I often feel like shouting I am not a diabetic, I am a free woman " when I attend the REALLY USEFUL " clinics and reviews.

Unbeliever said:

I'm betting it's easier to control insulin use on higher carb levels and aiming at 7.5, than insulin use on low carbs aiming for 5.5.

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Yes that maybe the case but many Type 1's low carb and aim for control in the non diabetic range, say 4 to 5.5. They end up having stand up rows about hypos with their gp's who tell them its dangerous to do so. They do it for the same reason I aim for that range as Type 2 (but without the constant hypo danger), to minimize the risk of diabetic complications and in their cases to minimise how much insulin they need to inject.

GP's and HCP's should support not criticise any diabetic who wants to gain that kind of control so long as that person obviously knows what they're talking about and shows a responsible attitude. It appears that many just want to treat everybody at the lowest common denominator of irresponsibility, if you are Type 1, and stupidity (maybe not the right word), if you are Type 2 because it just makes life easy for them to do so.

Unbeliever said:

Remeber "The Prisoner"? I often feel like shouting I am not a diabetic, I am a free woman " when I attend the REALLY USEFUL " clinics and reviews.

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The Prisoner now you're talking Unbeliver, the original 1960's series is probably the best TV series ever made imho. I watched it as a teenager when it was repeated in the late 70's and again in the 90's was transfixed by every episode.

Regarding Insulin / Carbohydrate and Blood Glucose Control...

This is a difficult one to explain to a non-insulin dependant but I will try!

You basically have three factors that determine the amount of insulin that you need to inject and these variables can interact with each other..

So..

1. Your current blood glucose level - for the most part.. insulin works best when you blood glucose is less than 8 mmol/l. As your blood glucose rises over 8 mmol/l then you need to inject more insulin to get the same result.

2. The Amount of Insulin - again for the most part over a certain amount (which is different for each person) as you inject more insulin you get ever decreasing returns. So for instance 50u is not necessarily twice as effective as 25u.

3. The amount of Carbohydrate - again the final piece of the puzzle.. the more carbohydrate the more insulin.. again this ratio can vary depending on time of day... also you should really also take in to account protein of which the body converts some off at about a ratio of about 2:1 into carbohydrate (glucose)..

So... in relation to what's easier... To be honest I think if you understand your diabetes then there is not much difference between aiming at 5.5 or 7.5.. I could quite happily aim my fasting glucose at either target and probably be within 1/2 mmol/l...

Personally I run tight control and aim for my fasting to be less than 5mmol/l... in the last year I have had zero instances of blood glucose less than 3.5 mmol/l which I consider to be my total bottom line.. I rarely drop below 4 mmol/l perhaps once a week before a meal.. I don't consider this to be an issue.. I can do this because I am blessed with a hypo awareness that kicks in at 3.5 - 3.8 mmol/l.. now some people don't have this and therefore might choose to run higher. But if you have control I don't see why you wouldn't aim to be 'normal'. The body operates in a healthy individual in a tight range of around 3.5 - 5.5 mmol/l I think it does this for a reason therefore I should try to emulate this if I can.

Low carbohydrate diets are useful for type I's as you can identify just as a type II can how different carbohydrates effect your blood glucose and also it's easier to an extent to work out ratio's. It's also like any other person good for losing weight whilst not having to exercise!

Just to add in relation to HCP's!

When I first started to return HbA1c's in the low 5% the nurse at my local diabetes clinic would get very upset.. she couldn't seem to comprehend that I wasn't falling over every 10 mins with hypo's.. I was actually send in to talk to the consultant about it and get my hand slapped for being such a bad diabetic?!

Suffice to say I had a 'discussion' with said consultant who again promptly read me the riot act.. Anyway I stood my ground took his e-mail address and when I got back sent him a spreadsheet with ALL my readings on for the previous six months (around 2,500) showing that from memory I had only 1 reading sub 3.5 mmol/l in that period.. he sent an e-mail back asking some questions about how I achieved the control and if he could share this with his students..

I think what needs to be understood is that most of these people don't have diabetes.. they have differing degrees of theoretical understanding of how diabetes works in the general populas.. you, me, everyone else here has a degree of theoretical understanding but also a practical understanding of what being diabetic is all about... I do not doubt that my consultant understand the medical theory of diabetes in way more depth than I do.. but from a practical point of view he would not have a hope of matching my understanding of my diabetes.. he understands this and luckily is now a resource I can use to check that the things that I am doing are not dangerous or to tap for advice, rather than just dictating 'policy'. The best HCP's are the ones who recognise that the individuals knowledge and understanding is just as important if not more important than theirs.

/engage cynicism
Unless you come across the rare NHS HCP who is willing to listen then you will be pushed down the path of least cost...

Just need to point out that I was quoting Grazer in my post earlier. I am not deliberately atempting to take credit for your observations Grazer. had prob;ems with that post.
First it did not seem to be acceped at all, then I found duplicate posts. was told I had deleted one sucessfully but it was still there , attempted to delee it word by word and eventually ended up not knowing what I had done.
Can't ever read what I have just posted anyway. I always have to come back later to edit when I am able to read my posts.

No problem unbeliever, although I had just instructed my solicitors to start copywright proceedings! :lol:
By the way, I think some may have misunderstood my point. I was simply answering a query and giving my view on WHY HCPs act the way they do. I wasn't agreeing with it! My point is they are scared by low HbA1Cs for the reasons I gave, not that those reasons are valid. I like HbA1Cs to be as low as a whores drawers to use salty seadog language! :lol:

spaglemon said:

carb intake gets too low

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my understanding is that all food stuffs can convert to carbs except dietary fibre. If you don't eat enough carbs the first response is your body converts your fat to carbs, if you have no fat then as a survival trait it will begin to convert protein (i.e. your muscles) to carbs as well.

So as long as you eat something your body should always have something its able to convert and therefore a zero carb diet isn't necessarily a dangerous thing. I say "isn't necessarily a dangerous thing" as no one has actually done a long term study of a zero carb diet which is why the Swede's didn't come out and recommend it in their 2011 study. They didn't discourage an ultra low carb diet <30g either but just said their HCP's should carefully monitor anyone on one so you would guess they think that it may not be overtly dangerous but that's my opinion.

I personally think zero carb or ULC diets are not necessary unless your BG's need you to do one. I think eating as many carbs within strict safe BG levels is a better approach as it allows you to have a wider ranging diet which is likely to be more sustainable long term for many people including me.

i'm now trying to find a balance of carb intake that'll let me continue to lose weight and control my blood sugar levels that i can be comfortable with for the rest of my life



thanks[/quote]
Ain't we all Spaglemon! Good luck!

spaglemon said:

i'm now trying to find a balance of carb intake that'll let me continue to lose weight and control my blood sugar levels that i can be comfortable with for the rest of my life

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yep that's me as well.

the highest spike will vary depending on the food.. generally the closer a carbohydrate is to glucose the quicker it hits the blood stream.. however you can slow carbohydrate absorption by eating meals that are proportionally higher in fat and protein.

Generally with a typical meal the spike is going to be somewhere between 50 and 80 mins.. something like pizza though which is high in carbs and fat might not spike until 120 - 150 mins.. so a bit of trial and error.