Dr Sheri Colberg: exercise for diabetics Q and A

May 14, 2023Apr 26, 2023 kaitiscotland3 Comments

Diabetes in Control Nov 6, 2021

Author: Sheri R. Colberg, PhD, FACSM

Q: Can you speak to the ability or inability to “cure” T2D? Does it have to do with the loss of the pancreatic beta cells?

A: Yes, it has generally been shown that new-onset type 2 diabetes is easier to “reverse,” meaning that blood glucose levels can be so well managed that it appears diabetes has been cured. Over time, a loss of some insulin-making capacity occurs in people with long-standing T2D, particularly if it has not been well-managed, related both to the impairment of pancreatic β-cell function and the decrease in β-cell mass. (PMID: 27615139)

Q: Isn’t insulin resistance now found to be in T1DM as well?

A: Yes, anyone can develop insulin resistance, and it occurs in at least a third of people with type 1 diabetes as well, although it is not always associated with excess weight gain or overweight. Since people with T1D lack insulin due to the body’s own immune system killing off the pancreatic β-cells, greater resistance increases the total doses of insulin needed (whether injected, pumped, or inhaled). Thus, they have developed characteristics of both types and have “double diabetes.” (PMID: 34530819)

Q: Under lifestyle goals, would you include stress management?

A: Stress management was not assessed in the large multi-center clinical trials on type 2 diabetes prevention, but mental stress can certainly raise blood glucose levels due to the greater release of glucose-raising hormones like cortisol and adrenaline. It certainly would be beneficial to address better ways to manage mental stress as part of lifestyle goals for optimal blood glucose outcomes. (PMID: 29760788)

Q: As each person has their own limitations, how important is it to get a physician clearance and exercise guidelines before working with the client?

A: It really depends on the person’s circumstances. How intense will the planned activities be? Is the person currently sedentary? Has he/she been getting annual checkups to monitor blood glucose management and to check the status of any complications? Does he/she have diabetes-related or other health complications that could be worsened by physical activity? The lower the intensity, the more active an individual has been, and the lower the risk for cardiovascular complications, the less likely medical clearance is absolutely necessary.

The latest ACSM Consensus Statement on activity and T2D will be released in early 2022 in Medicine & Science in Sports & Exercise and states, “For most individuals planning to participate in a low- to moderate-intensity physical activity like brisk walking, no pre-exercise medical evaluation is needed unless symptoms of cardiovascular disease or microvascular complications are present. In adults who are currently sedentary, medical clearance is recommended prior to participation in moderate- to high-intensity physical activity.”

Q: Can flexibility training be used for warmups, or do you recommend it only after the workout?

A: While it is possible to do flexibility training at any point during a workout, joints tend to have a greater range of motion after blood flow to those areas has been increased with a light or short aerobic warmup. It may be prudent to do a quick aerobic warmup, some stretching, the full workout, and then more extensive stretching afterwards for optimal results.

Q: Was there any particular protocol for strength training? sets, reps, periodization? What is considered “intense” resistance work? Would fatigue based off of several sets of moderate intensity be recommended then?

A: That is a tough question, and it depends on who you ask. I have seen a lot of debate over the optimal strength training protocol during the many years I have been in the exercise/fitness world. If people are just starting out with resistance training, they will gain from doing even a minimal amount of training.

Starting out with 1-3 sets of 8 to 10 main exercises that work all of the large muscles groups at a light to moderate intensity is considered appropriate for most older or sedentary adults, many of whom have joint limitations or health issues. Moderate intensity is considered 50%-69% of 1-RM (1 repetition maximum) and vigorous is 70%-85% of 1-RM. Both intensity (fewer reps at a higher intensity) and the number of sets (3-5) or days of training (starting at 2, progressing to 3 nonconsecutive days) can increase over 2 to 3 months. Periodization is usually not undertaken by older adults, but may be appropriate for younger, fitter ones.

Q: Do you have any insight or are aware of any studies that involve high intensity (%1-RM) resistance training and T2DM? Or any studies that compare resistance training volume (Sets x Reps x Load)?

A: Some older studies have determined that glycemic management is improved by supervised high-intensity resistance training in people with type 2 diabetes (PMID 12351469). Others have also found that home-based (and, therefore, unsupervised) resistance training results in a lesser impact on blood glucose levels, likely due to reductions in adherence and exercise training volume and intensity (PMID 15616225).

Q: I’m still confused about glucose response to acute exercise. Which is better if you want to bring down your BG right now? Can you speak to the possibility of increased blood sugars with intense aerobic exercise?

A: Most light-to moderate-intensity aerobic exercise will lower blood glucose levels, assuming that some insulin is present in the body. (People who are very insulin deficient may have a rise in blood glucose from doing any activity.) Any activity that gets up into the intense/vigorous range, even if only during occasional intervals, has the potential to raise blood glucose due to a greater release of glucose-raising hormones during the activity. This is particularly true if the activity is short and intense. In individuals with any type of diabetes, declines in blood glucose during high-intensity interval exercise are smaller than those observed during aerobic exercise.

That said, if someone wants to lower blood glucose right now with exercise, it also depends on the timing of exercise. Doing something light to moderate for at least 10 to 30 minutes is the best bet, particularly after a meal when insulin levels are generally higher. Avoid doing intense aerobic or heavy resistance training as those may have the opposite effect. For early morning exercise, any intensity can potentially raise blood glucose due to higher levels of insulin resistance then and lower circulating levels of insulin in the body.

Q: I had an endocrinologist say that long runs or walks are better, and another one said to do a bit of weights.

A: Which activities someone chooses to do should depend on the goal of the training. Is it increased fitness, lowering blood glucose levels acutely, or gaining strength and improving overall blood glucose management? Long, slow aerobic training does have the benefit of increasing cardiorespiratory fitness and lowering blood glucose levels (in most cases). Resistance training, on the other hand, increases muscular strength and endurance and helps people gain and preserve muscle mass, which is where most carbohydrates are stored in the body. It may not, however, lower blood glucose levels, at least not acutely.

Both have their place in a weekly training regimen. Insulin resistance is lowered for 2 to 72 hours following a bout of aerobic training. Resistance training has more of a long-term impact on insulin action by enhancing carbohydrate storage capacity. The best advice is to do some aerobic training at least every other day and some resistance training at least 2, and preferably 3, nonconsecutive days per week. These activities can be done on the same days or different ones.

Jovina cooks: Chinese steak and peppers

May 11, 2023 kaitiscotland3 Comments

Chinese Steak and Peppers by Jovina Coughlin

Ingredients

1 tablespoon plus 1/4 cup water
¼ teaspoon baking soda
1 pound tender steak{beef tenderloin tails, ribeye, or flank steak} trimmed, cut into 1-inch squares
3 tablespoons soy sauce, divided
3 tablespoons dry sherry or Chinese rice wine, divided
up to 3 teaspoons cornstarch, divided
up to 2 ½ teaspoons packed light brown sugar, divided
1 tablespoon oyster sauce
2 teaspoons rice vinegar
2 teaspoons toasted sesame oil
1/2 teaspoon coarsely ground pepper
3 tablespoons plus 1 teaspoon peanut oil, divided
1 red bell pepper, stemmed, seeded, and cut into 1-inch squares
1 green bell pepper, stemmed, seeded, and cut into 1-inch squares
6 scallions, white parts sliced thin on a bias, green parts cut into 2-inch pieces
3 garlic cloves, minced
1 tablespoon grated fresh ginger

Directions

Combine 1 tablespoon water and baking soda in a medium bowl. Add beef and toss to coat. Let sit at room temperature for 5 minutes.

Whisk 1 tablespoon soy sauce, 1 tablespoon sherry, 1½ teaspoons cornstarch, and ½ teaspoon sugar together in a small bowl. Add soy sauce mixture to beef, stir to coat, and let sit at room temperature for 15 to 30 minutes.

Stir-fry Sauce
Whisk remaining ¼ cup water, remaining 2 tablespoons soy sauce, remaining 2 tablespoons sherry, remaining 1½ teaspoons cornstarch, remaining 2 teaspoons sugar, 1 tablespoon oyster sauce, 2 teaspoons vinegar, 2 teaspoons sesame oil, and ½ teaspoon pepper together in the second bowl.

Heat 2 teaspoons peanut oil in a 12-inch nonstick skillet over high heat until just smoking. Add half of the beef in a single layer. Cook without stirring for 1 minute. Continue to cook, stirring occasionally, until spotty brown on both sides, about 1 minute longer. Transfer to a bowl. Repeat with remaining beef and 2 teaspoon oil.

Return skillet to high heat, add 2 teaspoons peanut oil, and heat until beginning to smoke. Add bell peppers and scallion greens and cook, stirring occasionally, until vegetables are spotty brown and crisp-tender, about 4 minutes. Transfer vegetables to bowl with beef.

Return now-empty skillet to medium-high heat and add the remaining 4 teaspoons vegetable oil, scallion whites, garlic, and ginger. Cook, stirring frequently until lightly browned, about 2 minutes. Return beef and vegetables to skillet and stir to combine. Whisk sauce to recombine. Add to skillet and cook, stirring constantly, until sauce has thickened, about 30 seconds.

Glucosamine supplements related to lower cancer mortality

May 8, 2023Apr 22, 2023 kaitiscotland2 Comments

*Photo by Nataliya Vaitkevich on Pexels.com*

Adapted from Medscape 5 Dec 2022 by Vinod Rane BS Pharm

Glucosamine, popularly used for osteoarthritis, has previously been found to have anti-inflammatory properties and regular use has now been shown to reduce cancers overall and particularly kidney, lung and rectal cancer.

This was a large prospective study that included 453,645 participants aged 38 to 73 who did not have cancer at the start of the study.

19.4% were taking glucosamine regularly and 80.6% were not. The patients were followed up for a median of 12 years.

Cancer was reduced in cancer overall 0.95, kidney cancer 0.68, lung cancer 0.84 and rectal cancer 0.76.

The study did not include the dose, form and duration of supplement use and there could be a risk that the people who took glucosamine also followed other healthier behaviours than those who didn’t.

My comment: I have been taking glucosamine for 23 years now and it has been a great benefit to my joints. I can see that confounding could be a problem. Non smokers greatly reduce lung cancer, vitamin D users are less likely to get rectal cancer, and slim people are less likely to get kidney cancer.

Zhou J et al Associaton between glucosamine use and cancer mortality. A large prospective cohort study. Front Nutr. 2022;9:947818.

Covid infection as good as two vaccinations in prevention of future attacks

May 2, 2023Apr 22, 2023 kaitiscotland4 Comments

*Photo by Maksim Goncharenok on Pexels.com*

BMJ 18 March 2023

The Lancet has published research concerning the effect of clinical Covid 19 infection protection against further infections.

Looking at 65 research studies, the conclusion is that alpha, beta and delta variants strongly protected against future infection. There was 78% protection at 40 weeks post covid. The Omicron variant however was less protective, immunity only being 36% at 40 weeks.

Any infective agent however was highly likely to protect against hospital admission or death. The effectiveness was 90% at 40 weeks.

This was considered as useful has having had two mRNA vaccines.

Good news for those who have had Covid infection.

Public Health Collaboration Edinburgh

Apr 26, 2023Mar 26, 2023 kaitiscotland7 Comments

I attended the PHQ conference in Edinburgh on 17 March 23. This was the first such meeting in Scotland and it was well organised, interesting and well attended.

Moira Newiss is on your far left of the photo in her navy dress and black boots. Moira organised the meeting and also spoke about her experience of having post viral fatigue twice in her life. This led her to explore the functioning of the mitochondria in our cells. She found that the mitochondria don’t function normally and become depleted in chronic fatigue syndrome and fibromyalgia but that primitive pathways in the cell using ketones for fuel are still active. She started a ketogenic diet and recovered completely from her chronic fatigue syndrome. She now runs for a hobby.

Dr David Unwin is standing next to her and is wearing a bow tie and suit. He is now 65 years of age and has been promoting low carb diets in his practice for the last ten years with great results. He is having so much fun that he doesn’t want to retire!

He found that in many cases type two diabetics can reverse their condition completely by the adoption of a low carb or ketogenic diet. Statistical analysis showed that the people most likely to reverse their condition had had been diagnosed in the previous 18 months. There is thus a great window of opportunity for advice and coaching to be provided to these patients at the earliest opportunity after diagnosis.

Results after 18 months are more variable, with a great improvement in diabetes seen, but sometimes not to the extent that complete remission occurs. Some medication support is often still necessary. Insulin may be able to be substantially reduced or stopped but some alternative medication may still be required.

Monitoring of patients blood sugars will still be required for both groups lifelong in case high blood sugars return. This can be due to secondary beta cell failure and may require tightening up of the diet, the addition of medication and sometimes insulin. If higher blood sugars and weight loss is reported, pancreatic cancer requires consideration and this is detected by urgent MRI scans. Sometimes a patient has been wrongly diagnosed as type two when they are really type one. In all cases they will need to see their GP for diagnosis.

Dr Iain Campbell is standing next to Dr Unwin and is wearing a waistcoat and white shirt. Iain told us about his struggles with bipolar disorder. There certainly could be a creative advantage to this illness, as Iain spent his young day in a rock band and even now is a successful composer. He has now settled into fatherhood and medicine and since starting a ketogenic diet has been mentally stable. My comment: Dr Christopher Palmer in the USA has also researched this phenomenon and there is a blog article on this site about him. Iain works at the university of Edinburgh, and has done preliminary studies in other patients who have bipolar disorder and has found that anxiety, depression, mood swings and impulsiveness all improve with a ketogenic diet. Further research is planned.

Dr Rachel Bain, on your far right, is a psychiatrist and works with Ally Houston, who is standing beside her, to promote coaching for mental health patients in the low carb diet. The site is metpsy.com.

Rachel explained that the gut and brain are very intimately connected and share the same neurotransmitters. The gut microbiotica are affected by what we eat. This affects our mood. If leaky gut occurs inflammatory substances can gain access to our blood vessels and cross the blood /brain barrier to cause neuro-inflammation. This is one cause of degenerative brain conditions such as Alzheimer’s disease and Parkinson’s disease. The foods most likely to disrupt the junctions between the gut cells are sugar, starch, gluten and alcohol. She and Ally as well as other team members treat people who have Attention Deficit Disorder, Obsessive Compulsive Disorder, Binge Eating Disorder, Bipolar Disorder and Schizophrenia. They don’t aim for a person to stop their medication so much as to gain control of their lives.

Ally Houston used to be a physicist but is now a chef and low carb coach. Comment: Ally also appears in a previous blog post on the site. He explained what coaching was and wasn’t. It isn’t telling someone what to do. It is exploring with the person how their life works now and how they can introduce positive changes around eating sugar, starch, vegetable oils, exercise, stress reduction and sleep.

The services at met.psy.com are out with the NHS and there is a fee for the services, but it is very reasonably priced.

PHQ are expecting videos of the conference to be available on You Tube now or very shortly.

Total mortality rates are improved when type two diabetics follow a low carb diet

Apr 20, 2023Mar 25, 2023 kaitiscotland3 Comments

*Photo by Jess Bailey Designs on Pexels.com*

Adapted from Diabetes in Control March 24 2023

Mortality Reduced With Adherence to Low-Carb Diet in Type 2 Diabetes

Mar 24, 2023

Lower mortality seen with increases in total, vegetable, and healthy low-carbohydrate diet score

By Elana Gotkine HealthDay Reporter

FRIDAY, March 24, 2023 (HealthDay News) — For individuals with incident type 2 diabetes (T2D), a greater adherence to low-carbohydrate diet (LCD) patterns is associated with lower mortality, according to a study published online Feb. 14 in Diabetes Care.

Yang Hu, Ph.D., from the Harvard T.H. Chan School of Public Health in Boston, and colleagues calculated an overall total LCD score (TLCDS) among participants with incident diabetes identified in the Nurses’ Health Study and Health Professionals Follow-up Study. Vegetable (VLCDS), animal (ALCDS), healthy (HLCDS), and unhealthy LCDS (ULCDS) were also derived.

The researchers documented 4,595 deaths, of which 1,389 cases were attributable to cardiovascular disease (CVD) and 881 to cancer among 10,101 incident T2D cases, contributing 139,407 person-years of follow-up. Per each 10-point increment of postdiagnosis LCDS, the pooled multivariable-adjusted hazard ratios for total mortality were 0.87, 0.76, and 0.78 for TLCDS, VLCDS, and HLCDS, respectively. Significantly lower CVD and cancer mortality was seen in association with VLCDS and HLCDS. From the prediagnosis to postdiagnosis period, each 10-point increase in TLCDS, VLCDS, and HLCDS correlated with 12, 25, and 25 percent lower total mortality, respectively. For ALCDS and ULCDS, no significant associations were seen.

“Our findings provide support for the current recommendations of carbohydrate restrictions for T2D management and highlight the importance of the quality and food sources of macronutrients when assessing the health benefits of LCD,” the authors write.

Age Related Macular Degeneration could probably be prevented by avoiding processed food

Apr 14, 2023Mar 9, 2023 kaitiscotland8 Comments

*Photo by Tima Miroshnichenko on Pexels.com*

Adapted from The Displacing Foods Age Related Macular Degeneration by Chris A Knobbe. Medical Hypotheses 109 2017 184-198

Chris A Knobbe from the University of Texas has studied factors that are thought to be important in the causation of Age Related Macular Degeneration. (AMD).

AMD is the leading cause of irreversible blindness in developing nations. In 2020 some 196 million people were affected worldwide. And Dr Knobbe thinks this is almost always down to dietary factors, in particular the consumption of processed food such as sugar, vegetable oils, refined white flour and trans fats.

Historically, between 1851 and 1930, AMD was a rarity. It rose modestly in the 1930s but became an epidemic in the UK and USA by 1975.

By 2009 63% of the American diet consisted of processed sugars, starch and oils. My comment: Dr Google now puts this at 73% “hyper-processed foods”.

By looking at the food intake and AMD in 25 nations, it was seen that as the traditional diets were replaced with processed foods, the incidence of new onset AMD correspondingly rose.

If sugar intake is moderate but polyunsaturated fat ingestion is rare, AMD does not rise.

It would therefore appear that processed and nutrient deficient foods are toxic to the retina.

AMD could probably be entirely preventable through reverting back to ancestral dietary patterns, should that be feasible, or eliminating processed foods that have become ubiquitous. Avoidance of these foods is likely to be extremely important for people who have been diagnosed with early or moderate AMD.

My comment: I was recently at a Hospice ladies lunch group and was sitting at a table with six other women who were about 10-20 years older than myself. Five of them were currently getting eye injections for AMD. Diets that are considered the healthiest by Dr Google are the Mediterranean, Japanese, South Korean and French. None included processed foods.

You will eat 150 fewer calories a day if you get a good sleep at night

Apr 8, 2023Mar 9, 2023 kaitiscotland2 Comments

Adapted from Medscape Get More Sleep, Lose More Weight: A Randomised Trial by F. Perry Wilson MD MSCE.

Feb 7 2022

A study in JAMA Internal Medicine has shown that you can lose more weight just by lying in bed, having a good sleep. Because, if you sleep poorly, you will eat more the next day.

The whole thing becomes a vicious circle. Sleep loss leads to poor impulse control, and a preference for hypercaloric food. Long term stress can even increase eating disorders such as emotional eating.

Sleep loss increases Ghrelin and decreases Leptin which increases the appetite. Stress increases the Hypothalamus and Pituitary hormones and this increases Cortisol which attempts to dampen these down. Weight increases due to more calories being ingested and insulin resistance increases. Adiponectin decreases and you store more of your calories as fat. Your risk for obesity and diabetes increases.

My comment: When I worked as a Police Surgeon and GP I was often working all day, then a lot of the night, then all day. At 5 am when I often got home from a call out, I would crave toast, butter and Marmite. I have this about once a year now that I’m retired and when I wake through the night I may have a cup of tea, but I don’t feel like eating anything at all.

Dr Esra Tasali from the University of Chicago randomised 80 people, all of whom were overweight and getting less than 6.5 hours of sleep a night, to get personalised sleep recommendations to boost their sleep time or routine study visits where nothing was advised.

The suggestions were to decrease ambient light, create a bedtime routine, limit phone and TV use in bed, decrease caffeine intake and increasing daytime exercise. Each person was given a goal bedtime and wake up time schedule.

After two weeks, wrist monitors indicated that the intervention group was sleeping an extra 1.5 hours a night, which is approximately one full sleep cycle. This was maintained over the next two week monitoring period.

The calorie intake and output in the subjects was also measured by using doubly labelled water. Don’t ask me how this works!

They found that the extra sleep randomised group consumed 150 fewer calories a day. There was no increase in energy expenditure. On average they lost a pound in weight over the study period. They also reported being more alert, having a better mood and having more energy through the day.

Another tip I’ve heard elsewhere to improve sleep is to get outside in the morning for a bit of light exposure and exercise, even if it is winter or raining.

Men are noticeably less fertile from age 45 onwards

Apr 2, 2023Mar 9, 2023 kaitiscotland5 Comments

Adapted from Medscape The Male Biological Clock- How to Tell the Time by Mark Trolice MD

Most women know that their fertility declines from the age of 30 onwards. From then on it will become more difficult to become pregnant and there will be an increase in the rate of miscarriage and in infants with chromosomal abnormalities. Yet, due to our modern lifestyles, the availability of contraception and the economic situation, first births in women aged 35 to 39 has increased six fold. To give an increased chance of conception women are increasingly freezing their eggs in their late twenties and early thirties.

Men are also becoming fathers for the first time at later ages. Over the last 40 years this has increased by 3.5 years.

Men over 45 years need five times longer to achieve a pregnancy than men under 25 after their female partner’s age is adjusted for. Sperm counts start to decline from the age of 41 and sperm motility decreases. Chromosomal abnormalities in sperm also increase.

At all ages, being overweight, alcohol consumption, cigarette and e cigarette smoking, can lead to impaired semen production.

The first treatment will be to correct lifestyle factors and then consider ovulation induction and intrauterine insemination. Men over 45 have lower pregnancy rates and higher miscarriage rates with Intrauterine Insemination Treatment.

During IVF cycles injecting the sperm into the egg can improve fertilization rates but in men over 45 there is still reduced fertilization rates and decreased embryo development to the blastocyst stage.

The offspring of older men have higher rates of stillbirth, low birth weight, preterm birth and birth defects. Men older than 40 to 45 have twice the risk of having an autistic child and three times the rate of schizophrenia.

A consideration is that men consider sperm freezing at younger ages, similar to what women do. Another way to tackle the problem is pre-implantation genetic testing of embryos from older men.

Insulin as a murder weapon: the case of Colin Norris

Mar 27, 2023Mar 8, 2023 kaitiscotland2 Comments

Adapted from Journal of Forensic and Legal Medicine Feb 2023 Insulin murder and the case of Colin Norris by Alan Wayne Jones University of Linkoping, Sweden.

Although insulin is an essential medicine and a life saving drug, it has been used in many poisonings. These can be accidental, suicidal or to deliberately cause harm. An insulin overdose causes severe low blood sugars, and if untreated can lead to coma, irreversible brain damage and death.

Normally, in non- diabetic individuals, the beta cells in the pancreas secrete the same amounts of insulin and C peptide into the portal venous system. In the liver, the insulin is broken down faster than the C peptide, so normally there is more C peptide in the general circulation than insulin. When there is more insulin in the system than C peptide, that is a very strong indicator that insulin from a non- pancreatic source has been administered.

Sophisticated biochemical measuring systems can identify insulin analogues. This provided part of the evidence that convicted Colin Norris, a nurse, of injecting insulin into five of his patients, four of whom died as a result.

Clinical symptoms of low blood sugars occur when the blood sugars drop below 2.5 (UK) or 45 (USA), although the exact threshold can vary between individuals. If this is prolonged for up to 6 hours or more then the brain damage can be irreversible and death can occur. The hormonal response to correct low blood sugars also prolongs the QT interval in the heart electrical pacing mechanism leading to an increase in cardiac arrhythmias and sudden death.

Proof of insulin poisoning requires positive identification of the causative agent in plasma or serum samples taken from the victim before the low blood sugar is corrected.

The first proven case of murder by insulin occurred in the mid 1950s and forensic evidence was obtained from analysing tissue samples from around injection marks on the victim’s buttocks.

During an investigation into suspicious deaths caused by insulin, the entire case scenario and totality of the evidence must be carefully considered. Tissue samples around any injection marks need to be kept for later analysis of insulin and C peptide levels.

In a Leeds hospital, in September 2002, a Mrs Hall was recovering from a hip joint operation and seemed to be making good progress. In the early hours she was found unresponsive. A bedside test showed that her blood sugar was only 1.5. Although intravenous dextrose was given, she never regained consciousness and later died. She did not have diabetes. Assays showed that the insulin level was far higher than the C peptide level indicating that pharmaceutical insulin had been injected. It was believed that she may have been mistakenly injected with insulin which was kept for patients in an unlocked fridge.

Nurse Colin Norris became the prime suspect. As part of the investigation a retrospective review of other unexpected deaths and incidents which could have been due to insulin administration were found. Four incidents had occurred in the previous year when Colin Norris was on duty. Three earlier deaths had been attributed to natural causes at the time and there was no toxicological evidence that any of them had been injected with insulin. Colin Norris maintained his innocence throughout the investigation.

In October 2005 Colin Norris was charged with murdering four patients and attempting to murder a fifth by the injection of insulin. The trial started at Newcastle Crown Court in October 2007. In March 2008 he was found guilty and was sentenced to life imprisonment. He was described by the judge as a “thoroughly evil and dangerous man…arrogant and manipulative….with a real dislike of elderly patients. There cannot be any suggestion that you were motivated to hasten their ends to spare them suffering”.

After the first appeal against Norris’s conviction failed in 2009, clinical evidence emerged that spontaneous attacks of hypoglycaemia in elderly and frail patients are not as rare as the jury had been led to believe. Indeed, a literature review showed that 2-10% of elderly frail patients, who can be malnourished, with co-morbidities such as sepsis, liver disease, or kidney failure are vulnerable to attacks of hypoglycaemia.

Other weaknesses in the case were:

The insulin vials on the ward were not subject to any inventory.

No insulin or needles were found near Mrs Hall.

The fingertip blood sample showing low blood sugar was not verified with a venous blood sample.

The very high insulin level was found on an NHS assay machine, not a more accurate forensic one. Rigour in following chain of custody procedures were not done. A confirmatory sample had also not been done.

The low blood sugar had been corrected before the low C peptide versus high insulin was found.

Spontaneous hypos can indeed occur in the elderly and frail.

Another hypoglycaemia related death had occurred at the hospital but it had not been mentioned as Norris had not been on duty. Thus the police were suspected of cherry picking cases to incriminate Norris.

Toxicological evidence of hypoglycaemia was only found for Mrs Hall. Death certificates for the other suspected hypoglycaemia deaths had been attributed to old age and other natural causes.

The cause of death of Mrs Hall was brain damage due to insulin induced hypoglycaemia but it was not known if the pathologist had looked for any insulin secreting tumours.

One of the senior police officers had been involved in the Dr Harold Shipman case two years previously and he may have been primed to find another serial killer in the health profession.

The Criminal Case Review Committee, which is the official authority in the UK charged with looking into miscarriages of justice, have examined the evidence and recommended that the court of appeal have a fresh look at the case.

My comment: It will be interesting to find out what happens and what their reasoning regarding this case will be. Meanwhile, look after yourself, look after your diabetes, keep up a healthy lifestyle and keep out of hospital!