Category: Living with diabetes

FreeStyle Glucose Monitoring – an Update

Emma10 Comments

freestyle libre on the Diabetes DietHashtag love the NHS—and the NHS in Scotland if we’re going to be specific.

Off I trotted to the diabetic clinic on Thursday armed with my best persuasion skills. Oh pleasy-weasy dear doctor, may I have a FreeStyle Libre flash glucose monitoring system? One of my arguments was going to be—Hey, you won’t be paying for it for too long. Did you see the recent research that tells me I can expect to knock eighteen years off my life expectation?!*

In the end, my polished debate wasn’t needed. Just as well as I couldn’t sell hot-water bottles to the Inuit. Or ice-cold beer to Australian sun-bathers for that matter. I brought the subject up. The doctor queried the number of blood tests I do per day and voila. I’m on a list. I’ll need to go to an education event and after that, a letter wings its way to my GP recommending she prescribes the sensors.

Sensors

Flash glucose monitoring for those of you who aren’t familiar with it is where you wear a sensor on your body (usually your upper arm) and you can take a reading from it using a monitor. It differs from blood testing in that it’s super quick and easy. You don’t need to prick your finger and you can check endlessly and the sensor works through your clothing.

Those of us who tend towards obsessive compulsive disorder—it’s hard not to when you’ve got diabetes—might baulk at that, but I am looking forward to monitoring what happens to me during exercise. And when I’m eating.

The device doesn’t come with an alarm—i.e. a warning when your blood sugar goes too far up or down, or it changes rapidly but there is software for that. The cat lover in me is delighted the manufacturers chose to call the software MiaoMiao, and this sends readings to your phone every five minutes, and will warn you of spikes.

Hello Big Brother!

You can even connect it to others’ devices, so they can monitor you too. I’ll skip that as it feels too Big Brother-y to me. Most type 1s hate other people telling them when they are hypo. Imagine how much worse this would be!

Incidentally, all this new diabetes-related tech has had a knock-on effect on the hospital I go to. Thursday’s clinic was running one hour late because it was so busy. The doctor told me he can’t get the GP support (where a GP handles some of the patients to gain experience in diabetes care), thanks partly to the fast development of new tech.

Our GPs are under so much pressure, it’s too difficult for them to keep up with all the tech that type 1s use these days—pumps, continuous glucose monitoring, flash glucose monitoring, software and more. My appointments have been spaced eight months apart for the last few years and that’s likely to change to a year from now on.

But in the meantime, I have my new toy and a whole heap of questions for Google. Can you wear it in the steam room? How much is MiaoMiao? How many actual blood tests do I still need to do to calibrate the thing?

Thanks again NHS Scotland. I look forward to reporting back.

 

*Whatevs. I debated discussing the research here and decided it wasn’t useful. Doom-laden stuff is such a turn-off isn’t it? 

My Favourite Health & Fitness Freebies

Emma4 Comments

free sign on the Diabetes DietA continuous glucose monitoring system, the MiniMed 670G self-adjusting insulin pump, a personal trainer AND an unlimited food budget so I can buy organic, ethically sourced food all the time…

And, whoops—you interrupted me there in the middle of a reverie relating to the things I’d have to help me manage my diabetes if money were no object. The top of the range monitoring and pump therapy tech is obvious while the food and exercise one less so—but activity and an excellent low-carb diet can help you manage your blood glucose levels.

Stable blood glucose levels don’t guarantee you riches or the partner of your dreams, but a person who doesn’t ride the blood sugar roller coaster is far more energetic, and free to pursue what they want unhindered by the hell of mood swings.

In the meantime, what can we fiscally challenged diabetics do so we can fix our blood glucose levels to the best of our abilities? Here are suggestions for freebies that can help you manage your condition…

YouTube—otherwise known as the exercise channel in our house. Online, you’ll find tens of thousands of exercise uploads—from yoga to Pilates, barre classes, HIIT workouts and weight-lifting. You could spend several years working your way through them and not do the same workout twice. If you find gyms off-putting or their membership fees too expensive, YouTube’s perfect. Look for workouts that don’t need equipment either.

Start with walking workouts (Lesley Sansome’s Walk at Home channel is great). Fitness Blender’s videos are explained well, and the exercises done at a speed you can keep up with. Jessica Smith TV does a huge variety of workouts that offer different fitness benefits, and Heart and Soul Fitness does the same.

MyFitnessPal—there are studies that claim food tracking helps you maintain your weight. Food logs are useful for we diabetics too as they allow us to work out how much insulin we need for meals we eat regularly. MyFitnessPal has a huge database, but you can also add your own recipes and the site will give you a full nutritional breakdown of each.

MySugr – a free app for logging blood sugar results and additional information such as insulin does, exercise, weight, blood pressure and more. The app is useful, but if you don’t log for a day or so you will struggle to remember all the information you need to input for a complete picture of what is going on.

The internet—thanks to the world-wide web, there’s a wealth of information at our fingertips. As a teenager and twenty-something with diabetes, I only knew one or two others with the condition, and we didn’t meet up regularly to swap notes. Now there are forums, websites, charities, blogs, recipes and more online where we can find out more about the ol’ defunct pancreas problem.

A word to the wise… We all know the internet allows unprecedented freedom of speech, which is mostly for the good. But it’s also a place where information spreads unchecked. Blogs—and I include this one too—offer opinions and personal experience, which do not always equate to fact and recommendations suitable for you. Still, the Diet Doctor, Diabetes.co.uk, radiabetes.com and diabetesdaily.com offer gems. (I  apologise if I missed your great site out—limited room here.)

NHS 70 logo on the Diabetes DietAnd finally…drum roll… the NHS! Here in the UK, we folks with type 1 diabetes get free healthcare and prescriptions. I mump and moan occasionally about wanting the latest tech, but I’ve had diabetes for more than 30 years and in that time, I’ve never paid for medications, appointments or equipment. Our fabulous healthcare system has existed 70 years now. It’s shaky on its feet sometimes, but you can’t argue with the wonderful principles at its core—free healthcare for all, based on clinical need.

What are your favourite diabetes freebies? And what websites or blogs do you like?

Treating hypos post sugar tax

kaitiscotland5 Comments

Lucozade just isn’t what it used to be. With the sugar tax affecting the diabetics favourite emergency beverage the Independent Diabetes Trust have compiled a list of substitutes that you may wish to use.

For shear portability and cuteness Emma and I are great fans of Jelly Babies but you may have your own.

 

5-7 Dextrosol

4-5 Glucotabs

60 mls Glucojuice (one bottle)

150-200mls pure fruit juice

3-4 heaped teaspoons of sugar dissolved in water

4-5 Jelly Babies

The Good Ol’ Days of Diabetes

Emma4 Comments

Ah, the good ol’ days of diabetes – glass syringes, peeing on sticks and rigid eating times.

cover of Artists Town by Emma BairdWe veterans remember them fondly and with the odd head shake in disbelief. Did it really used to be like that? by ‘eck, we have come far… Recently, I wrote a book, Artists Town, which features. a type 1 protagonist. My book is set in the early 1990s and life for we pancreatically-challenged has changed substantially since then.

My own diagnosis came in the 80s. Here’s what used to happen then. See if you remember any of this stuff, and newbies read it and gasp.

  1. Glass syringes. Yup! The environmentally-friendly option too, given the waste your average type 1 inadvertently produces these days.
  2. Urine, not blood testing. It was a lot less painful; a lot less accurate too.
  3. Dextrosol. Standard treatment for hypos were these chalky, horribly-flavoured, expensive sweets. After a while they turned rock hard too. When Lucozade tablets appeared on the market, I was in HEAVEN.
  4. Exchanges. Long ago, doctors and nurses taught us carbohydrate counting. One exchange was roughly 10g of carbohydrates and you were given an amount for every meal and snack. To make it simple, one tbsp. of cooked rice or potatoes equalled an exchange, as did a slice of bread or an apple.
  5. NO SUGAR. It astounds me that at some point post my diagnosis, advice for diabetics included ‘eat anything you want and cover it with insulin’. As a wee girl, doctors said no cakes, no biscuits, no sweet, ice-cream and watch out for sugar in ketchup. Nine-year-old me burst into tears.
  6. Tab – the only no-sugar fizzy drink on the market. It tasted of grapefruit. The no-sugar market exploded in the mid to late 80s.
  7. The all-knowing doctors. In the 80s, doctors were still viewed as all-knowing, authoritative figures and you didn’t question them when they told you why you were having so many highs/lows. They were the experts. Your day to day experience of living with diabetes counted for naught.
  8. Fruit salad. Young me got offered a lot of fruit salad for dessert – the world’s worst pudding when it comes to taste, and not that great for your blood sugar levels anyway. I haven’t eaten the stuff in decades.
  9. Terrible chocolate and carob bars. Boots had a line of chocolate they advertised as suitable for diabetics. It was a) not very nice and b) little better than the real stuff for blood sugar control. And as for carob bars… carob is one of those acquired tastes, and I never got it.
  10. Two (count ’em) injections a day. This is the one that will astound the newbies, what with today’s regimes of multi-daily injections or pump therapy. I took one long-acting and one-medium acting insulin, mixed together twice a day. This meant meal times had to be the same and stuck to every single day. While flexibility is nice, sometimes I think there are advantages to rigidity. “Sorry, I need to go. If I don’t eat now, I’ll collapse” – a great excuse to get out of anything.
  11. Thrift. My mum and I used to cut up my blood testing sticks to make them last longer, possible then because you measured your blood sugar level by comparing the colour the pad on the stick turned to a chart on the tube. We cut them lengthways, a fiddly but effective job.

Artists Town is now available for pre-order on Amazon.com and Amazon.co.uk Please note – this book contains adult content and strong language. 

RCGP: What doctors need to know about types one and two diabetes in young people

kaitiscotland2 Comments

The Royal College of General Practitioners have recently released an educational programme for UK doctors which they have very kindly allowed me to link to our website.

I recorded this over a year ago and I think the college held off production until their type two diabetes low carb course was also released for doctors.

This means that the RCGP joins the American Association of Clinical Endocrinologists as supporters of low carbing  for both type one and two diabetes.  Surely the other clinical associations and Royal Colleges will follow in due course?

The screencast includes information on diagnosis, emergency situations, blood sugar and dietary management and contraception.

“I have also separately produced an educational screencast on Diabetes in adults (type 1), children and young people (type 1&2) for the Royal College of General Practitioners in my role as an RCGP Clinical Adviser”

http://elearning.rcgp.org.uk/mod/page/view.php?id=8368

 

Most of the public are blissfully unaware of serious diabetes complications

kaitiscotland2 Comments

A survey by Walnut Unlimited asked 1,000 UK people, what can the effects of having diabetes be?

None of them were aware of the pregnancy related consequences of diabetes.

2% knew about stroke, 4% about kidney damage, and 6% about heart disease.  Similarly low numbers knew that diabetes is related to a shorter life span.  A quarter of those surveyed however did know that amputation and sight loss were complications of diabetes.

Diabetes affects more individuals in the UK than any other serious health condition such as dementia or cancer. 3.7 million people in the UK have diabetes. There are 8,700 diabetes related amputations and 1,600 cases of visual impairment every year.

Diabetic complications can be minimised or avoided by early diagnosis, education and support.

BMJ: Diabetic foot

kaitiscotland2 Comments

foot-57128_960_720

Summarised from BMJ Clinical Update Diabetic Foot by Mishra et al Mumbai and London 18 Nov 17

Foot disease troubles 6% of people who have diabetes and includes infection, ulceration or destruction of tissues of the foot. It can affect both social life and work. Up to 1.5% of diabetic people will end up with an amputation. Good foot care, screening and early treatment of ulceration is hoped to prevent a foot problem developing into a need for amputation. This article gives an update on the prevention and initial management of the diabetic foot that can be expected from primary care.

A combination of poor blood sugar control, foot neglect, lack of appropriate footwear, insufficient patient education and failure to find and treat pre-ulcerative lesions cause increasing foot damage and worsens the outlook.  Nerve and blood vessel damage make damage more likely to go unnoticed and more difficult to heal.

A careful examination of the feet by the patient or carer every day is a good idea. A careful examination by health professionals also detects problems early. Fungal infections, cracks and skin fissures, deformed nails, macerated web spaces, callouses, and deformities such as hammer toes, claw toes, and pes cavus increase the risk of ulceration.  Cold feet can suggest poor blood supply and warm feet can be an indicator of infection.

Monofilaments are often used to detect neuropathy at annual assessments. Pain after walking a certain distance and pain at rest suggest peripheral arterial disease.

Assessments every three to six months is needed for medium risk feet and every one or two months for high risk feet.

As neuropathy is difficult to reverse once established, prevention is key. Optimal glycaemic control is extremely important. Smoking cessation, maintaining a normal weight and continued exercise help the circulatory system.  Patients also know how to check their feet and who to get help from if they find problems. New shoes should be worn in gradually to prevent blisters.

Health care professionals need to send urgent cases to a specialised diabetic foot centre if at all possible. Such cases would include foot ulceration with fever or any signs of sepsis, ulceration with limb ischaemia, gangrene,  or suspected deep seated soft tissue or bone infection.

Ulcers are best washed in clean water or saline with a moist gauze dressing.  Anti-microbial agents can be cytotoxic  and can affect wound healing. Weight bearing on the area needs to be avoided. Tissue will be taken for bacterial culture and antibiotics prescribed due to local policies.

Referral within a day or two is needed for rest pain, an uncomplicated ulcer or an acute Charcot foot. (suspected fracture due to neuropathy).

Patients with rest pain and intermittent claudication need vascular referral.

Here are the top tips for patients:

Inspect your feet daily including between the toes and if you can’t do it yourself get someone else to do so

wash your feet in warm but not hot water daily and dry carefully especially between the toes

use oil or cream on dry feet but not between the toes

cut nails straight across and if necessary go to a podiatrist for this

Don’t do home treatments for corns and callouses

Check your shoes for objects or rough areas inside them and wear socks with them

avoid walking barefoot

get your feet examined regularly by a health care professional

notify the appropriate health care professional if you develop a blister, cut, scratch or sore on your feet

Public Health Collaboration Conference 2018: a great success for Lifestyle Medicine

kaitiscotland2 Comments

I was delighted to attend and speak at the third PHC conference in London this year.  We met at the Royal College of General Practitioners in London on the sweltering weekend of the Royal Wedding. Apart from superb international speakers we were treated to low carb, high protein food, such as one would typically eat on a ketogenic diet. Instead of picking at our dinners as we often have to do with mass catering  we could eat the whole lot. Great!

Dr Peter Brukner from Australia started off the weekend with a review of what was happening in the low carb world. There are more and more reports coming out describing the advantages of ketogenic and low carb diets to different groups of people but the establishment are fighting back viciously as can be seen by the attack on Professor Tim Noakes in South Africa.  Indeed if his defence lawyers and expert witnesses had not worked for free he would be bankrupt.  This is a terrible way to wage war on doctors who are acting in the best interests of their patients.

Dr Aseem Malhotra also described bullying tactics that had been used against him when he was a junior doctor and first becoming publicly engaged in the low carb debate. I have been subjected to this as well.  Professor Iain Broom showed that the proof that low carb diets are superior to low fat diets goes back 40 years.

Dr Zoe Harcombe gave us an explanation of how the calories in- calories out idea just doesn’t add up. The well known formulas about how many calories you need to avoid to lose weight don’t work in practice because of the complex compensatory mechanisms we have to avoid death from starvation.  How you put this over to patients and give them useful strategies for weight loss and blood sugar control was explored by Dr Trudi Deakin.

Food addiction is a real issue, at least it is for the majority of the audience in attendance, who answered the sort of questions usually posed by psychiatrists when they are evaluating drug addiction.  Unlike drugs, food can’t entirely be avoided but ketogenic diets are one tool that can be used to break  unhealthy food dependence. This worked for presenter Dr Jen Unwin who at one point had a really big thing for Caramac bars.  I haven’t seen these in years but they did have a unique taste.

Dr David Unwin showed clearly that fatty liver is easily treatable with a low carb diet.

Dr Joanne McCormick describes how her fortnightly patient group meetings are making change accessible for her patients and how many GPs in the audience could broach the subject in a ten minute consultation.

The website Diabetes.co.uk will shortly be starting up a type one educational programme online that all are welcome to join. I discussed the issue of what blood sugar targets are suitable for different people and how they can achieve this with dietary and insulin adjustment.

Dr David Cavan spoke about reversing diabetes in patients in Bermuda. Although Bermuda looks idyllic the reality is that good quality food is about five times as expensive in the UK as it is all shipped in. Many inhabitants work their socks off but barely cover their costs and cheap sugared drinks and buns are their staple diet. Despite these setbacks he managed to persuade a lot of diabetic patients to ditch the carbs and this had favourable results even after the educational programme had stopped.

A cardiologist Dr Scott Murray described the effects of metabolic syndrome on the heart and really why sticking stents in diseased arteries is too little, too late. He is convinced dietary change is needed to reverse and prevent heart disease. This is the first time I have been told that certain types of heart failure and atrial fibrillation are direct effects of metabolic syndrome on the heart.

The importance of exercise for physical and mental well being was not neglected and we had Dr Zoe Williams describing the great benefits that even the minimum recommended exercise can produce.

Dr Simon Tobin and Tom Williams spoke enthusiastically about Parkrun. This is a free event that runs every Saturday morning in parks all over the world. You can choose to walk, jog or run the course.

Claire McDonnell-Liu is the mother of two children who have greatly benefited from a ketogenic diet. The conditions are urticaria and epilepsy.  Although NHS dieticians do help families with childhood epilepsy who want to use a ketogenic diet, they can’t do it unless drugs have failed, as this is NICE guidance. I wonder how many children would benefit in fit reduction without side effects of drugs if this guidance was changed?

This was a fabulous conference with a positive enthusiastic vibrancy. Thanks to Sam Feltham for organising this event especially since he has become a new dad as well.

The Public Health Collaboration are putting all the talks on You Tube.

I was interviewed about diabetes and women’s health issues for Diabetes.co.uk and Diet Doctor and these interviews and many others will be available for you all to see to improve your lives with diabetes.

 

 

 

Why I bought my son a Freestyle Libre

kaitiscotland3 Comments

The Freestyle Libre blood sugar monitoring system has been out for about a year now. It consists of a sensor that you put in your upper arm and a reader, a bit like a mobile phone, that tells you the blood sugar, whether the trend is rising or falling, and what your blood sugar pattern has been like over the last eight hours.

I haven’t met anyone who has tried it who didn’t prefer it to finger pricks. About the only situation that it is no good for is driving. You need to have proof of your blood sugar on a regular meter should your ability to drive while under the influence of injected insulin comes under scrutiny.

The NHS is a big organisation and no doubt funding for this will vary from area to area, but in Scotland at least, there is no prospect of my son getting one on the NHS.

The main people who will be able to get the device are pregnant women and those women who are planning a pregnancy. Since these women ideally have to get their Hbaic down to 6% or under to ensure a healthy baby, then you can see why they have the greatest need. You are looking at two patients in one and complications that can affect a child lifelong.

The other groups that are eligible are those with very frequent admissions for diabetic ketoacidosis or severe hypoglycaemia. By this is meant three times in a single year. Both these complications of diabetes can result in sudden death or brain damage and often in young people.

Those people whose HbA1cs are over 8.5% or who test their blood sugars more than six times a day will also be considered. Since most people attending hospital diabetic clinics will have blood sugars over this threshold it is a big group.  Perhaps diabetic athletes will also be considered.

The group that won’t be given the device and sensors on the NHS are the ones who are already making great efforts to reduce complications by eating low carb diets, exercising consistently and monitoring frequently.  Using the Freestyle libre should help this group adjust their insulin and food more finely, in particular avoiding hypos, since their blood sugars are wiggling around normal much of the time anyway.  As they are already at much lower risk for complications they are saving the NHS a great deal of money just by being so committed to their task, yet something that would make the job easier is denied them because they are not “bad enough”.

So, I’ve just bought my son one. So far he is thrilled with it. The sensors are £45 (VAT exempt) a fortnight and the initial outlay is £137 (VAT exempt) including two sensors.

There are two great advantages as far as I’m concerned. Peace of mind. And Christmas and Birthday presents for the foreseeable future are sorted.

 

 

 

 

 

Sulphonylureas increase cardiac deaths but are still recommended for use after Metformin in type two diabetics in Scotland

kaitiscotland1 Comment

 

heart attackFrom Diabetes in Control May 2017. Cheapest treatment associated with increased risks of cardiovascular events and death.
After the cardiovascular issues with rosiglitazone, cardiovascular safety trials had to be conducted for all new anti-hyperglycemic agents. However, approval for older medications was based simply on evidence of a reduction in glucose parameters; cardiovascular safety was not a concern back then. But, data from the UKPDS trial shows that metformin reduces CV events, so, it was never in doubt. The ORIGIN trial has shown no increased harm with early initiation of insulin. However, some questions linger regarding the cardiovascular safety profile of sulfonylureas.

Data exist on the weight gain and risk of hypoglycemia associated with sulfonylureas, but the associated cardiovascular events have not been well-quantified. Sulfonylureas are used commonly across the world and are very effective in lowering HbA1C, but often the effect wears off, as shown in the ADOPT study.
Recent randomized trials have compared the newer antidiabetic agents to treatments involving sulfonylureas, drugs associated with increased cardiovascular risks and mortality in some observational studies with conflicting results. They reviewed the methodology of these observational studies by searching MEDLINE from inception to December 2015 for all studies of the association between sulfonylureas and cardiovascular events or mortality.
Sulfonylureas were associated with an increased risk of cardiovascular events and mortality in five of these studies (relative risks 1.16–1.55). Overall, the 19 studies resulted in 36 relative risks as some studies assessed multiple outcomes or comparators. Of the 36 analyses, metformin was the comparator in 27 (75%) and death was the outcome in 24 (67%). The relative risk was higher by 13% when the comparator was metformin, by 20% when death was the outcome, and by 7% when the studies had design-related biases.
The lowest predicted relative risk was for studies with no major bias, comparator other than metformin, and cardiovascular outcome (1.06 [95% CI 0.92–1.23]), whereas the highest was for studies with bias, metformin comparator, and mortality outcome.
In summary, sulfonylureas were associated with an increased risk of cardiovascular events and mortality in the majority of studies with no major design-related biases. Among studies with important biases, the association varied significantly with respect to the comparator, the outcome, and the type of bias. With the introduction of new antidiabetic drugs, the use of appropriate design and analytical tools will provide their more accurate cardiovascular safety assessment in the real-world setting.
So this study reviewed over 19 trials looking at sulfonylureas, specifically studying cardiovascular events and mortality. The problem with some studies is that they don’t take into account the duration of diabetes et cetera; so, they may end up comparing sicker patients with those who aren’t as sick. This group looked at potential biases such as exposure misclassification, time-lag bias, and selection bias, and, of the 19 studies, 6 did not have any of these biases. Of those 6 studies, 5 showed that sulfonylureas were associated with an increased risk of cardiovascular events and mortality, with relative risks ranging from 1.16 to 1.55.
It is not possible to tease out what the cause of the increase in events is based on this type of analysis. Is it hypoglycemia? Is it a direct drug effect? However, regardless of the mechanism, the consistent finding of increased cardiovascular risk may have an impact on selection of agents for our patients. Newer agents have been shown not to increase events, and recently some have even shown reduction in events. So, perhaps our algorithm of selecting medications for our patients may have to change to focus on the cardiovascular effects first and then the glycemic benefits because, in the end, our goal is preventing cardiovascular events from happening in our patients with diabetes.
Practice Pearls:
Sulfonylureas are associated with increased risks of cardiovascular events and death.
Sulfonylureas also associated with hypoglycemia events.
Data exist on the weight gain and risk of hypoglycemia associated with sulfonylureas.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-853.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)07019-6/fulltext
The ORIGIN Trial Investigators. Basal Insulin and Cardiovascular and Other Outcomes in Dysglycemia. N Engl J Med. 2012;367(4):319-328. http://www.nejm.org/doi/full/10.1056/NEJMoa1203858
Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies. Diabetes Care 2017 May; 40(5): 706-714. http://care.diabetesjournals.org/content/40/5/706
Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies. Diabetes Care. 2017 May;40(5):706-714. doi: 10.2337/dc16-1943. https://www.ncbi.nlm.nih.gov/pubmed/28428321

My comments: The health issues of sulphonylureas have been known about for at least a decade or two, but because they are cheap and effective in blood sugar lowering they continue to be promoted as the next drug to use after Metformin for type twos.  The Scottish Government have produced a paper which I reviewed a few weeks ago. It is their “new” strategy to deal with diabetes. Mainly, they wanted to limit the expenditure on the newer gliptans eg Linagliptan, Sitagliptan, the flozins eg Empagliflozin  and the injectibles such as Victoza and Byetta. These are a lot more expensive than metformin and gliclazide. They propose that lifestyle measures are first line. This means promoting exercise and “Healthy Eating” first. Yes, this means  a high carb, low fat diet, with lots of starch, limited sugar, salt, and whatever fat you eat should be the good monounsaturated type and also the inflammatory vegetable oil/margarines.  As we know this actually increases obesity for most people and worsens diabetes control. You then get put on metformin and then before you get put on drugs that actually lower your weight, blood sugar and blood pressure and cardiovascular risk, you get put on a sulphonylurea which wears out your pancreas, makes you fatter, makes you more prone to hypos and increases your cardiovascular risk. In my view sulphonylureas should be AFTER the newer drugs and given as a choice if someone does not want to use insulin.  I put in my comments regarding diet to the editorial board but they have done nothing saying that the remit of the paper was really about drugs, not diet. Yet, without the right diet, diabetes management is doomed to failure.