Eating carbs last gives lower blood sugar spikes

From IDDT newsletter December 2018

A report in BMJ Open Diabetes Research and Care Sept 2017 shows that in type two diabetes, eating sugar and starch later in the meal halved the blood sugar spike after the meal compared with those who ate the sugar and starch first.

This study was done on 16 people who ate test meals of protein, vegetables, bread and orange juice. Those who were instructed to eat the bread and juice last also had 40% lower post meal glucose levels compared to those who ate all of the meal components in a mixed fashion.

My comment: This is a small study but easily reproducible with yourself and your blood glucose meter. If you do wish to eat sugar and starch best have these last, unless you are treating a hypo.

 

 

Hypoglycaemia: the neglected complication

Adapted from Hypoglycaemia: the neglected complication by Sanay Kalra et al.

Indian J Endocrinol Metab. 2013 Sep-Oct; 17(5): 819-834

Hypoglycaemia is an important complication of glucose lowering therapy in patients with diabetes mellitus. Attempts made at intensive glycaemic control invariably increases the risk of hypoglycaemia. A six fold increase in deaths due to diabetes has been found in patients with severe hypoglycaemia compared to those not experiencing severe hypoglycaemia.

Repeated episodes can lead to hypoglycaemia unawareness. Complications  of hypoglycaemia include stroke, heart attacks, cognitive dysfunction, retinal cell death and loss of vision. Apart from this there are the effects on quality of life regarding sleep, driving, employment, exercise and travel.

To maintain good glycaemic control, minimize the risk of hypoglycaemia and thereby prevent complications, there are steps that need to be taken: recognise risk factors for hypoglycaemia, use appropriate self monitoring of blood sugar, select treatment regimens that have little or no risk of incurring hypoglycaemia and teach health care professionals and patients how to avoid hypoglycaemia.

Although the DCCT showed that complications were reduced when blood sugars were brought under a HbA1C of 7%, other trials have noted a three fold risk of hypoglycaemia when the level is reduced under 6.5%. This tends to negate any improvements in long term complications.

Insulin users are most at risk. Those who have had diabetes for more than 15 years are particularly at risk. The DARTS study showed that the risk of severe hypoglycaemia was 7.1% for type one patients, 7.3% for type two patients and 0.8% for type twos on sulphonylureas. This causes increased cost for their healthcare as hospitalisation for around a week is needed in the average case.

The majority of hypos are due to medications but there are other potential causes such as: pancreatic or islet cell tumours, dietary toxins, alcohol, stress, infections, sepsis, starvation and excessive exercise.

In diabetics not eating enough food was the most common cause. Others were physical exercise, insulin miscalculation, stress, overtreating a high blood sugar, and impaired glycaemic awareness.

Nocturnal hypoglycaemia is seen in half of diabetic children, particularly under the age of 7. Dead in bed syndrome causes 5-6% of all deaths in type one youngsters.  Contributory factors are increased exercise that day or delayed meals.

In type two patients additional causative factors are alcohol ingestion and liver disease and duration of insulin over ten years. As in type ones there tends to be more hypoglycaemic unawareness as the person ages. In type twos  there is a 9 fold increase in deaths in those with hypoglycaemic unawareness.

Severe hypos in elderly patients increase the risk of dementia, functional brain failure and cerebellar ataxia. There are clear signs of neuronal death in specific brain areas at post mortem in these patients and a history of fits make these more extensive.

Hypos in elderly patients promote cardiac ischaemia. Arrhythmias are more likely due to catecholamine release during hypos. Prolonged QT intervals lead to increased heart rate, fibrillation and sudden cardiac death.  Inflammatory cytokines are released during hypos, abnormalities of platelet function and the fibrinolytic system occur.

Hypos can cause double vision, blurred vision and dimness of vision.  Blindness can occur due to retinal cell death.

Recurrent hypos make people feel powerless, anxious and depressed. Acute hypos cause mood swings, irritability, stubbornness and depression.  Quality of life scores are worse in patients with recurrent hypos.

Driving ability is affected by hypos. The affected driver can inadvertently cross lanes and speed and generally drive worse.

Hypos at night may be recognised by sleep disturbance, morning headaches, chronic fatigue and mood changes. In young children fits and bed wetting may occur.

Hypos at work can be awkward, embarrassing and frightening. Hypos are particularly dangerous for those who work at heights, underwater, on railway tracks, oil rigs, coal mines, handling hot metals or heavy machines.

Expert medical advice and planned action counselling can help workers. So can self blood glucose testing, healthy food options in canteens, flexible meal times, arrangements to carry and use emergency glucose/sugar, storage and disposal sites for medications and sharps, and time off for medical appointments. Work time and productivity due to hypos can be reduced and nocturnal hypos can also have a knock on effect the next day.

Hypos in children tend to be increased in summer months when they are more active. In adults, intense prolonged exercise following an episode of recent severe hypoglycaemia can damage skeletal muscle and the liver and can cause severe neurological symptoms.

Travelling long distances, particularly over times zones can cause insomnia, tiredness, stress, reduced appetite, nocturia,  gastric disturbance, muscle aching and headaches. Psychological symptoms include low mood, irritability, apathy, malaise, poor concentration. These deficits in both physical and mental performance can profoundly affect decision making.

The fear of hypos can affect patients more profoundly than the fear of long term complications.  Withholding of insulin can occur. Sometimes patients refuse to start it when they need it and sometimes they miss out their doses.

About 30% of type one patients are affected by hypoglycaemia unawareness and under 10% of type two patients are thus affected. Duration of insulin use is the main common factor.

Educating patients about how to detect, treat and prevent hypoglycaemia must be understandable to the patient and their family.

In 2013 the ADA recommended that insulin users test their blood sugars 6-8 times a day.

Basal insulin needs to be matched to the patients needs. If hypos persist, particularly overnight, switching to pump therapy may help.

Newer diabetic medications, which do not cause low blood sugars such as the gliptans and gliflozins, may be preferable in type two patients who have multiple co-morbidities, are elderly,  who live alone, are at high risk of falls, and who have hypoglycaemia unawareness or who otherwise could not effectively deal with a hypo.

 

 

 

Freestyle libre on NHS prescription at last!

My son has at last been given an NHS prescription for the Freestyle Libre sensors.

These make a big difference in the ease and frequency with which you can test your blood sugars. If you know how to adjust your insulin to meals, activity and sort out your basals, the added readings that you get help you stay in your target zone much more easily.

I bought the device and the sensors   for my son very soon after they launched and have been funding them at £100 every four weeks since. Ouch!

This was worth it for the added peace of mind. The worry of a child never ends and is more so if that child uses insulin, lives alone, is a driver, and is 5 hours drive away.

My son was actually expecting to wait another four months as he was told there was an eighteen month waiting list for the diabetic clinic. He got a short notice cancellation some four months earlier. I know from Emma and other people with type one that getting the device and sensors is a post-code lottery and that although Theresa May thinks everyone who would benefit from them should get them, this is far from practice at present.

I can only hope that there is an increase in funding to help those of  you who need them and that the scripts continue to be NHS funded, particularly when I retire.

Update: The Freestyle Libre System can now be used for drivers say the DVLA.

 

Diet doctor: Type one and women’s videos

A year ago I was interviewed by Diet Doctor and after quite a wait, I’m delighted so say that my video interviews are now available at their site.

The subjects are tips for self management for people living with insulin dependent diabetes  and addressing women’s issues with type one and type two diabetes.

The videos are in the MEMBERSHIP section.

You can access these by joining the site. You can take on a free months trial and decide if you wish to continue or not after that.

 

Katharine.

 

 

 

Scottish Diabetes Survey 2016: are we winning or losing the diabetes struggle?

In Scotland 5.4% of the population is registered as having diabetes. 10.6% have type one and 88.3% have type two. 1.1% have other types such as Maturity Onset Diabetes in the Young.

In type ones 37.3% are overweight and a further 26% are obese. So 36.7% are of normal weight. In type twos 31.6% were overweight and 55.6% were obese. So only 12.8% were normal weight.

The annual HbA1c was done in over 90% of diabetics in both groups. 24.5% of type ones and 58.6% of type twos met the target of less than 58 mmol/mol which is equivalent to 7.5%.

Over 84.9% of both groups had their blood pressure measured that year and 45% of type ones and 32.7% of type twos met the target of less than 130 mmHg systolic.

Cholesterol levels were done in 86.4% of patients and this met the target of less than 5 mmol/l in 69.1% of type ones and 78.4% of type twos.

22.9% of type ones were current smokers compared to 17.2% of type twos.

Eye screening was undertaken in 85.4% of diabetics that year. 59.1% had had their feet checked and the score recorded.

When it comes to end stage disease in type ones, 3.5% had had a heart attack, 2.6% had had coronary revascularisation, 1.4% had end stage renal failure and 1.1% had had a major limb amputation.

In type twos, 9.7% had had a heart attack, 7.5% had had revascularisation, 0.6% had end stage renal failure and 0.7% had had a major amputation.

Overall 10.8 of the diabetic population use insulin pumps.

My comments: It can be seen from the data that screening is  doing very well. We have an average number of people with diabetes and the distribution between types one and two has not changed. Smoking is an issue in only about 20% of diabetics which probably compares favourably with social norms.

We have lost the battle of the bulge. Only 12.8% of type twos are of normal weight. Type ones are more like the “norm” for Scotland with just over a third being of normal weight.

Blood sugar control is very poor particularly in type ones with about three quarters of them with blood sugars over 7.5%. 

When it comes to complications, type twos are much more likely to get cardiac problems whereas type ones are more likely to get renal failure and amputations. 

 

Metformin improves blood sugar and vascular health in type one children

 From Diabetes in Control: Metformin Improves Vascular Health in Children With Type 1 Diabetes
Nov 18, 2017
In individuals with type 1 diabetes (T1DM), cardiovascular disease (CVD) is a major issue and the primary cause of death.

Vascular changes can be detected years before progression to CVD. Targeting blood sugar regulation early in patients at high risk of developing T1DM and in those already diagnosed with T1DM, could potentially help reduce vascular dysfunction risk and even reverse changes already made in vascular function.

Past studies have shown that in adults with T1DM, metformin reduces HbA1c, BMI, and required insulin doses. It has also been suggested that metformin leads to reduced cardiovascular events and better blood sugar regulation in patients with type 2 diabetes. Studies conducted on children with T1DM suggest the same benefits. However, there is currently no research on how metformin affects vascular function in children with T1DM.
A double blind, randomized, placebo-controlled trial was conducted to evaluate the association between metformin and vascular health in children with T1DM over a 12-month period. The study included a total of 90 children from a Women’s and Children’s Hospital in South Australia.  Children were randomly divided into two groups to receive either the metformin intervention or the placebo intervention. Children who weighed 60kg or greater received 1gm of metformin twice daily and those who weighed less than 60kg received 500mg twice daily. Doses were then increased to the complete dose over a period of 2 to 6 weeks.
Follow-up was conducted at 3, 6, and 12 months from the start of the study. Vascular function was obtained at baseline and at every follow-up visit using the brachial artery ultrasound, HbA1C, insulin dose, and BMI were among some of the other outcomes measured.
Results show that vascular function defined by GTN improved over the 12-month period by 3.3% in the metformin intervention group regardless of HbA1c when compared to the placebo group (95% CI 0.3 to 6.3; P=0.03). GTN was found to be the highest in the metformin group at 3 months when compared to placebo. Children in the metformin group also experienced significant improvement (P=0.001) in HbA1c levels at 3 months (8.4%; 95% CI 8.0 to 8.8) (68mmol/mol; 95% CI 64 to 73) when compared to the placebo group (9.3%; 95% CI 9.0 to 9.7). At 12 months, the overall difference between HbA1c improvement between the two groups was lower but remained a significant 1.0% (95% CI 0.4 to 1.5) 10.9mmol/mol (95% CI 4.4 to 16.4), P=0.001. In addition, it was found that children in the metformin group had a decreased insulin dose requirement of 0.2 units/kg/day throughout the 12-month period compared to those in the placebo group (95% CI 0.1 to 0.3, P=0.001).
The following study determined that children with T1DM with above average BMIs and taking metformin saw a significant improvement in vascular smooth muscle function compared to those not taking metformin. The study suggested that in addition to vascular health, metformin also improved HbA1c levels and reduced total daily insulin dose. It was found that improvements in both vascular function and HbA1c were the highest at 3 months. This is most likely due to medication adherence being the highest around 3 months.
Practice Pearls:
In children with above average weight and who were diagnosed with type 1 diabetes, metformin provides a significant improvement in vascular smooth muscle function.
Metformin provides a significant improvement in HbA1c levels in children with type 1 diabetes.
In addition to vascular health and HbA1c benefits, metformin further aids in reducing daily insulin dose in children with type 1 diabetes.
Reference:
Anderson JJA, Couper JJ, Giles LC, et al. Effect of Metformin on vascular function in children with type 1 diabetes: A 12 month randomized controlled trial. 2017. J Clin Endocrinol Metab. 2017; 0: 1-16.

Diabetes Digital Media launch low carb app endorsed by NHS

Adapted from The Times  January 6 2019 by Peter Evans

The better late than never NHS has finally endorsed a phone app that helps diabetics stick to a low carb diet.

Diabetes Digital Media based in Warwick have had their app, The Low Carb Program, accepted by the NHS apps library.  DDM has partnered with Ascensia Diabetes Care to allow patients free use of the app when recommended by GPs.

DDM was founded by Arjun Panesar and Charlotte Summers. Their company is on track to make sales of 1.7 m this year.