The best diet for optimal blood sugar control & health
Author: kaitiscotland
I am a Scottish doctor who is working to improve the outcomes for people who have diabetes using a low carb diet, and advanced insulin techniques when necessary. Professionally I provide expert witness reports in the clinical forensic and family medicine areas and I also provide complementary therapies. I enjoy cooking, cinema, reading, travel and cats.
Adapted from BMJ 18 June 2022: Type 2 diabetes: summary of updated NICE guidance
When type 2 patients eventually get their diabetes checks, they can expect a few changes to management if their practices are keeping up with NICE guidelines.
Instead of looking at the 10 year risk for cardiovascular disease, type 2 diabetics over the age of 40 will be assessed for lifetime risk. This is usually a pathway to the initiation of statins, if they are not already being taken. If the cardiovascular risk is raised you will also be considered for an SGLT inhibitor.
If you have chronic heart failure or have already been diagnosed with atherosclerosis you will be considered for an SGLT2 inhibitor. These give a proven cardiovascular benefit.
SGLT2 inhibitors work well with Metformin if a glucose lowering drug is needed.
Modifiable risk factors for diabetic ketoacidosis should be assessed before prescribing SGLT2 inhibitors.
Such factors are: Alcohol limit above 14 units a week, use of illegal drugs, use of other medicines, concurrent illness, injury or planned surgery, very low carbohydrate or ketogenic diet.
To reduce the chances of your developing type two diabetes, it is best to keep your belly measurement to less than half of your height. You don’t need a tape measure. A bit of string will do.
NICE say that BMI may still be useful to define overweight and obesity, although it does have considerable limitations in muscular people and in old age. As it is not a direct measure of belly fat which is the driver for diabetes, hypertension and cardiovascular disease it must be interpreted cautiously.
In people of south Asian, Chinese, other Asian, Middle Eastern, black African or African-Caribbean backgrounds NICE are now stating that a BMI of 23 can be considered as overweight and 27.5 can be considered as obese.
These parameters may be important when treatments are being limited by BMI category.
Adapted from Medscape May 25 2022. Why is long term weight loss so difficult? It’s biology, not willpower! by Donna Ryan MD.
When people lose weight changes occur in food regulation hormones and subjective hunger increases. This drives an increase in food intake. The hormones that make you feel full after a meal reduce and the ones that make you hungry increase. Reduced energy expenditure also occurs and this also drives weight regain.
Even when both diet and exercise strategies are applied, regain of more than half of the lost weight occurs by 2 years and 80% of lost weight is regained by 5 years.
People who defy these norms report that they do very high levels of physical exercise, eat low calorie and low- fat diets, have very high degrees of eating restraint, and have low levels of disinhibition. They also tend to weigh themselves several times a week. So, they work really, really hard at it, and can never let up.
The medications that reduce weight work if they are taken for long enough, but on discontinuation, weight gain returns.
This question is a lot trickier health wise than you think. There has been new research on a variety of beverages that show various harms and benefits.
Coffee
A study from Cambridge suggests that coffee in itself is not a dangerous drink but that thermal damage to the oesophagus is the problem that can result in a higher risk of oesophageal cancer.
In the UK we drink 98 million cups of coffee each day. There are 67 million adults and children in the UK at present to put this into context.
Tea
Green tea is known to confer some health benefits and a recent prospective study has shown benefit for black tea drinkers too. Half a million UK participants in the Biobank cohort were assessed. There is a moderately reduced all-cause mortality reduction in those who have two or more black teas a day. There also was a reduction in mortality from cardiovascular disease, ischaemic heart disease and stroke. There was no effect on cancer mortality or respiratory disease. Surprisingly given the coffee study, there seemed to be no effect from the temperature of the drink or the addition of milk or sugar.
It is thought that substances in the tea improve endothelial function and this is the cause of the effect.
Pre-meal whey protein drink
A small whey protein pre-meal drink taken 10 minutes before meals, significantly reduces mean blood glucose concentration and for diabetic subjects, the amount of time they spend in normal blood sugar ranges.
A placebo RCT was done on 18 people who had type two diabetes who had never been treated with insulin. They were given a 100ml drink containing 15.8g of protein to be taken ten minutes before breakfast, lunch and dinner.
The protein drinkers significantly reduced the prevalence of hyperglycaemia over the day, increased the amount of time in the normal blood sugar range by around 2 hours extra a day, and reduced the 24 hour glucose concentrations. There was no effect on night time blood sugar levels. The acceptability levels of this were high at 98%.
The researchers at Newcastle University say that the protein seems to slow down the speed of gastric emptying and stimulating hormones that reduce the spike in blood sugars.
Alcohol containing drinks
Alcohol is a major preventable risk factor for cancer. About 4-5% of cancers are alcohol related. A new study suggests that reducing alcohol intake reduces the risk of getting an alcohol related cancer in a Korean study.
Those who drink three or more alcohol containing drinks a day are at particular risk of cancer. The heavier drinkers at the outset have the most to gain by cutting down. Some cancers are much more likely from alcohol than others. More than 45 % of mouth and throat cancers are drink related, 25% of laryngeal cancers, 12% of female breast cancers, 11% of colorectal cancers, 10.5% of liver cancers and 7.7% of oesophageal cancers.
Health screenings in Korea were done in 2009 and 2011. The average age was 53 years and they were followed up for just over six years. Over that time, new cancers were seen in 7.7 per thousand of the 4.5 million people screened.
Those who increased their alcohol consumption had a higher increase in cancers. Those who lowered their alcohol intake lowered their risk. The risks were dose related.
Fruit juice, fizzy pop and diet soda
Drinks sweetened with sugar but not natural juices or artificially sweetened drinks were related to a higher risk of inflammatory bowel disease in people who drank more than one a day, in a study of more than 120,000 people.
66% of the people did not drink any sugar sweetened beverages a day but those who consumed more than one such drink a day had a higher BMI and consumed higher amounts of total energy and sugar.
The participants were followed up over ten years. There was a significant increased risk for Crohn’s disease but not for Ulcerative Colitis in the sugary drink consumers. Diet drinks or natural fruit or vegetable drinks had no effect.
All the subjects were over the age of 40 so the effect on the younger population was not studied. Dr Hasan Zaki said that this would be of interest to study because children consume a lot of sugary drinks and the incidence of inflammatory bowel disease in children increased by a third between 2007 and 2016.
My comment: I was pleased to see the beneficial effects of black tea because I drink about 4 pints of it a day. I do like a glass or two of wine with my dinner, but maybe I should cut this down and have a tomato juice or just plain water instead? The pre-meal protein drink looks interesting. I would expect that it would reduce the amount of food consumed at each meal as it should blunt the person’s appetite. I wonder what the longer term effects on weight would be?
Adapted from Diabetes in Control Sept 18 2021: Effects of earlier dinner times on glycaemic control by Andy Dao, Pharm D candidate, University of South Florida.
Growing up you may have heard from your family that eating close to bedtime isn’t a good idea. Eating later has indeed been shown to cause weight gain and metabolic dysfunction. Type 2 diabetes develops 10% more commonly in those who work shifts for instance. It is though that hormonal disruption of the circadian rhythm is the problem.
A recent study looked at how blood sugars were affected by eating earlier than 6pm or after 9pm over the whole 24 hour day. Adults over 20 wore blood sugar monitors over three days in this experiment. They were assigned to have their last meal of the day by 6pm or after 9pm. They had to eat or drink nothing but water after this meal. They were given identical meals three times a day. How they felt, what exercise they took and how well they slept were all assessed.
12 subjects completed the tests. Each group were of comparable height, weight and BMI.
There were significant reductions in blood sugar levels in the early diners in mean blood sugars throughout the whole day, night and early morning. Post prandial levels were also better in the evening for the early diners compared to the late diners but not for breakfast and lunch post prandial levels which were the same regardless of the evening mealtime.
The early diners did report more hunger and capacity to eat in the evenings than the later diners. There was no difference in sleep or physical activity.
So, if you do eat earlier, you can expect improved blood sugars all day long, and perhaps less likelihood of getting diabetes. The downside is more evening hunger. This study was done in healthy non-diabetic people and it would be interesting to see what the results in diabetic subjects would show.
Comment: Sitting down at 5 to 5.30 pm just wouldn’t work well for me, yet this is what we did in my childhood, and we didn’t eat snacks in front of the television after this. In my own house we have dinner at 7.30pm. This however is because I didn’t usually get home before 6.30 pm or even 7pm for many years so an earlier mealtime was not possible for me. I also tend to watch television from 8 pm for about 40 minutes or so before bath and bed. I couldn’t abide eating after 9pm as a regular thing, yet this is very common in Italy. I do think that I would be reaching for the oatcakes and cheese or more if I was in front of the television having eaten at 6pm.
Adapted from Medscape News by Megan Brooks July 13 2022
Transmission of anxiety appears to be sex specific. It spreads from mothers to daughters and from fathers to sons, new research shows.
Dr Barbara Pavlova from Nova Scotia says that findings suggest that anxiety is a learned behaviour from parents. Therefore, perhaps it is preventable. Effective treatment of anxiety in young adults, prior to parenthood, could make a difference to children too.
Anxiety disorders are known to run in families. Both genes and environment are thought to be at play.
If a mother for instance has an anxiety disorder, the chance of a daughter developing it, by an average age of 11 years old, is 2.85 times normal, but this is not the case for her son, who would have a normal risk.
Of 398 children studied 27% had been diagnosed with some sort of anxiety disorder including generalised anxiety disorder, social anxiety disorder, separation anxiety disorder or a specific phobia.
The rates increased with the age of the child from 14% in the under 9s to 52% in the over 14s. There was a similar rate of anxiety in both boys and girls. Rates were lower if one parent had the disorder and higher if two parents had the disorder. Dr Pavlova thinks that a child will tend to model themselves on their same sex parent.
Anxiety disorders are the most common psychiatric disorder and emerge earlier than mood disorders.
My comment: I was interested to see this information. My mother had GAD, generalised anxiety disorder, and I have had a specific phobia since I was about 9 (Spiders!). If I was going to get something I suspect that a common specific phobia is a lot less disruptive to life than GAD. The good news is that I’m not a pilot on a jet plane!
Adapted from Medscape August 31 2022 Would you like to live to a ripe old age? George D Lundberg MD
Do
Choose ancestors who did not die of natural causes in young adulthood or middle age (oophs…too late!)
Maintain a body mass index within the healthy range using a variety of tools
Maintain blood pressure within a normal range with or without medications
Maintain a low resting heart rate
Do eat whole grains including bran
Consume above ground leafy vegetables, some root vegetables, tree nuts, peanuts and berries
Ingest supplemental fibre such as psyllium husks
Ingest supplemental magnesium and possibly vitamins K2, C and D
Enjoy eating animal and vegetable fats including milk, cheese, meat, poultry, seafood, and eggs in moderation.
Eat two full meals a day
Do drink alcohol after 5pm
Sleep 6-8 hours a night
Walk up and downstairs and use handrails if necessary
Continue to be active physically, mentally, socially and sexually
Study and enjoy birds, bees, trees, plants, flowers and wildlife
Value your family life and participate actively while encouraging individuals to live their own lives
Read great books, fiction or non fiction a little every day
Actively engage in person or electronically with younger people
Stay informed about current world affairs and care about what you can change
Be passionate about culture such as performing and visual arts and sport
Recognise the value of spirituality and religion and feel free to live otherwise if you choose
Do your best to earn and retain as much money as needed to control your environment into old age
Take charge of your own health
Listen to your body
Maintain a long term relationship with a reliable and conservative primary care physician and certain specialists that fit the needs of older people.
Promote good vision in any way you can
Use hearing aids if you need them to retain brain function
See your dentist every 6 to 12 months and practice good oral hygiene. There is a strong correlation between the number of original teeth and length of life
Keep up to date with vaccinations
Maintain a safe distance and use mask if you may be around infective people
Take as few medications as necessary
Have as few diagnostic tests and surgical procedures as possible especially on the back and the knees
Use acupuncture and massage appropriately
Apply moisturising skin lotion especially after sun exposure
Use saline mist often to prevent nosebleeds
Walk at least 2 miles every day
If you can, swim every day
Practice yoga particularly the standing side bend, prone baby cobra, forward plank and windshield-wiper
Eat a protein rich diet and deliberately weight train or lift heavy objects to reduce sarcopenia
stand on one foot to improve balance
Use wearable exercise monitors if you find them useful
If you retire from work do some part time or volunteer jobs
Have something productive and fulfilling to do each day
Don’t
Inhale tobacco smoke
Consume sugar or sugar in anything in home cooked or restaurant meals, in soft drinks, fruit juices, pastries, desserts or processed foods
Use street drugs
Use natural or synthetic opioids except for short term relief of severe pain or the relief of pain from advanced cancer: then use all you need
Use sleep medication
Drink more than moderately or binge drink
Drive a vehicle after drinking or taking certain psychoactive drugs
Keep firearms in your home or workplace
Fret about things in your personal life or world affairs that you cannot change
Completely retire and have nothing useful to do
My comments: Dr Lundberg has a pretty long list of sensible suggestions. To these I would add, get some daily sunshine if you can and enjoy your pets. Have things to look forward to. Keep in touch with your friends and make contact with old ones who you value but don’t see often. Learn new things. What other suggestions do you have?
A longitudinal study of women from Oakland California has been following 19 thousand of their offspring since the early 1960s.
So far 68 people have been diagnosed with colorectal cancer.
Risk factors include: obesity in the mother, weight gain during pregnancy, and a high birthweight. This suggests that uterine life has something to do with why this cancer develops. This could explain why there has been a relatively recent increase in colorectal cancer in younger aged adults. Unfortunately there is little you can do yourself about these factors.
Adapted from BMJ: Hiding unhealthy heart outcomes in a low fat diet trial: The Women’s health initiative randomised controlled dietary modification trial finds that post menopausal women with established coronary heart disease were at increased risk of an adverse outcome if they consumed a low fat “heart healthy” diet. by Timothy David Noakes. Open Heart. 2021.
The WHI trial was designed to test with the US Department of Agriculture’s 1977 Dietary Guidelines for Americans protects against coronary heart disease (CHD) and other chronic diseases.
The only significant finding was that post menopausal women with CHD randomised to a low fat diet in 1993 were at a 26% greater risk of developing additional CHD events compared to women eating the control diet. In 2017 an additional 5 years of follow up data was published. It found that the risk for this group of women had increased to 47-61%.
The authors sought to explain why this was but author Tim Noakes has looked at the evidence and his opinion is that the women who had consumed 13 years of a low fat/high carbohydrate diet had inadvertently succumbed to the features of insulin resistance. Their risk of type 2 diabetes went up almost eleven fold and metabolic syndrome went up six fold.
Dr Noakes advises that according to the principle of “do no harm” the practice of putting women on low carb diets if they are diagnosed with cardiovascular disease is certainly not evidence based and probably not ethical.
The WHI is one of the most expensive long term dietary intervention trials ever undertaken. It started in 1993. Although the advice was given to cut dietary fat, particularly saturated fat in 1977, the policy had never actually been tested regarding its effects on weight, CHD, cancer and type two diabetes.
The idea was to replace the calories from saturated fat with increased carbohydrates from grains, fruits and vegetables. The effect of this was to lower blood cholesterol concentrations. The trial did not seek to replace saturated fat with polyunsaturated fat as studies of this had been published in 2013 and 2016.
Nutritionists led the first year 18 group sessions followed by individual follow up every 3 months. Feedback was given so as to encourage low fat intake.
A low fat diet was not found to improve rates of breast cancer, colorectal cancer, and only resulted in 0.4 kg weight loss over the first 8 years of the trial. The more women adhered to the low fat diet, the more weight they gained. The women who ate high fat, lower carb diets, the more weight they lost.
Blood sugar started to deteriorate in the first year of the trial for the low fat diet group. Post menopausal women who went on statins were at a 49% increased risk of developing type two diabetes. A prior meta-analysis had found that there was a 9% chance of developing type two diabetes with statin use.
The 2017 report analysed women in subgroups: No CHD or hypertension. Hypertension only. and pre-existing CHD. The idea was to see who may benefit or lose the most from the low fat intervention.
Women with hypertension only had neither benefit or harm from the low fat diet. Women who had no pre-existing hypertension or CHD had a small reduction in CHD risk but this was off set by a higher risk of stroke.
Regarding another study, the ERA trial, women who were on HRT who reported that they ate the most saturated fat over the trial time of three years, found that their coronary atheroma did not progress. In fact there was a modest regression in coronary artery narrowing. Both those who ate the most polyunsaturated fat, and those who ate the highest amount of carbohyrate and therefore the lowest amount of total fat showed worsening of their coronary atheroma.
Statin use was similar in both groups who were randomised to each diet, low fat versus usual. Indeed more than 40 percent of the women in each group were on statins.
Only post menopausal women who do not have CHD or hypertension are safe to eat the low fat diet, the others can expect some negative effects.
The Women’s health study (WHS) was established between 1992 and 1995 at Harvard Medical School to look into the effects of aspirin and vitamin E on the risks of developing CHD or cancer in women who started off with neither condition.
The study showed no benefit for either treatment.
A 21 year follow up programme of over 2,800 of these women evaluated more than 50 different clinical, lipid, inflammatory and metabolic factors.
Results showed that the development of Type two diabetes, and not high cholesterol levels were important factors in the development of CHD. Hypertension gives a 4.58 fold increase in CHD. Obesity gives a 4.33 fold risk. These factors as well as type two diabetes and metabolic syndrome were more predictive of CVD than smoking.
A Lipoprotein Resistance Score was developed looking at various factors particularly VLDL and HDL and a high level produced a 6.4 fold risk of cardiovascular disease. This is worsened in insulin resistance. LDL scores only gave a 1.38 fold risk of CVD by comparison.
The Progression of Early Subclinical Atherosclerosis Study looked at HbA1c in people who did not have type two diabetes. The higher the HbA1c, the higher the risk of CVD and the risk even started below HbA1c levels of 5.5%.
Women who had low HDL levels was associated with a higher breast cancer incidence and all cause mortality after breast cancer as well as an increased risk of cancer specific and all cause mortality.
The Recovered Minnesota Coronary Experiment (RMCE) study found that people randomised to eat more polyunsaturated fat in place of saturated fat were at a 22% higher risk of death with each 0.78 mmol/L reduction in blood cholesterol. This effect was worse in the over 65s.
The Recovered Sydney Diet Heart Study (RSDHS) showed that replacement of dietary saturated fat with linoleic acid was also associated with raised all cause mortality with increased deaths from cardiovascular disease and coronary heart disease.
Lawrence ( Lawrence GD Perspective: the saturated fat- unsaturated oil dilemma: relations of dietary fatty acids and serum cholesterol, atherosclerosis, inflammation, cancer and all cause mortality. Adv Nutr. 2021; 12: 647-56) concluded: PUVAs are unstable to chemical oxidation and their oxidation products are harmful in a variety of ways. They can initiate inflammation that can have dire health consequences. If saturated fats are replaced by carbohydrates in the diet there would be no significant improvement in serum cholesterol and it can result in a more atherogenic lipoprotein profile. …It appears that saturated fats are less harmful than the common alternatives.
This set of findings from four different studies effectively ends the debate about which diet should be eaten to lower the risk of CVD, especially in those with insulin resistance.
Two diets shown to prevent the clinical features of IR leading to type two diabetes are the restricted low calorie diet developed by Lim et al (Lim et al. Reversal of type two diabetes; normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetalogica 2011;54:2506-14.) and the ad libitum low carbohydrate higher healthy fat ketogenic diet.(Hite AH et al. In the face of contradictory evidence: report of the dietary guidelines for Americans Committee. Nutrition 2010;26:915-24.)
It is the ethical responsibility of those who manage those with cardiovascular disease or diabetes or other insulin resistance that they should NOT prescribe the never proven and now disproven low fat “heart healthy” DGA diet.
There have been large reductions in myocardial infarction, cardiac death, and all cause mortality over the last fifteen years in Denmark for type two diabetics. For instance, the cumulative seven year risk of myocardial infarction reduced from6.9% to 28%. These reductions occurred over a period of time when there has been a lot more emphasis on using drugs to reduce cardiovascular risk. (Diabetes Care 2021)
In Sweden blood was tested to see how much dairy products were being consumed. Those who consumed the most dairy fat had 25% less risk of myocardial infarction compared to the lowest risk.
As many dietary guidelines recommend limiting dairy products in order to limit saturated fat intake, perhaps they should take note.
An article in the American Journal of Clinical Nutrition suggests that if the carbohydrate – insulin model of obesity is correct, then instead of calorie control diets and exercise to reduce obesity, focus should be put on low carbohydrate diets.
In young adults sleep deprivation has been found to cause fat accumulation in the belly for the first time.
Naima Covassin from the Mayo Clinic Rochester Minnesota studied 12 healthy slim young people aged between 19 and 39. The poor souls were randomised to two weeks of just 4 hours sleep a night or 9 hours sleep followed by a three day recovery period. During this time the subjects were kept in hospital and factors such as calorie intake and energy output were measured.
Over the two weeks of sleep deprivation, the subjects put on an average of a pound or half a kilogram and all of it on the belly.
This was because they consumed an extra 308 calories a day compared to the 9 hours a night group.
Despite stopping the study after two weeks and then during recovery sleeping more, eating fewer calories and their total weight coming down, their bellies continued to get bigger, by an average of 3 cm by day 21 of the study.
This could be why shift workers are so prone to gaining fat around the belly.
The continued rise in belly fat could have been missed if body weight, BMI and overall body fat percentage were the only factors measured.
Dr Harold Bays who is an endocrinologist and president of the Louisville Metabolic and Atherosclerosis Research Centre says “Sleep disruption results in fat dysfunction and this may result in increased cardiovascular risk factors and unhealthy body composition including an increase in visceral fat.”
Diabetes Diet 