RCGP: Adapting diabetes medication for a low carb diet

Adapted from RCGP July 19 Adapting diabetes medication for low carbohydrate management of type two diabetes by C Murdoch et al.

This topic has been well covered in our book but has been reviewed in this article. 

Type two diabetes can be reversed by a low carb diet. Changes in medication need to keep pace with lowered blood sugar levels that result. A low carb diet can range from under 30g to 130g of carb a day.  Blood pressure medication also often needs to be reduced or stopped as lower blood pressure results from a reduction in insulin resistance.

Sulphonylureas, meglitinides and insulin all reduce blood sugar and if not reduced appropriately can result in hypoglycaemia.  It is reasonable to cut the dose of these by 50% when a low carb diet is started. Once the diet is stabilised the levels can be increased if this is necessary. If a patient has very high blood sugars eg HbA1C of 10% or more then a reduction of 30% can be considered initially. As more weight is lost or more carb is cut from the diet, further reductions can then be made. Some patients will be able to stop insulin and oral hypoglycaemics entirely as progress is made.

Some patients have latent autoimmune diabetes and although they can reduce their doses, their insulin must be maintained at some level. These patients can often be identified because they developed type two diabetes when they were thin.

Some patients who may need to stay on some insulin have had type two diabetes for many years and have ceased to make any pancreatic insulin. (Secondary beta cell failure).  My comment:  Users of sulphonylureas eg Gliclazide over five years are prone to this problem.

It is important to provide plenty of blood glucose testing strips to patients over the transition so they can let you know if they are experiencing hypos.

GPs can refer to endocrinologists for advice over patients who are giving concern.

Flozins also known as SGLT2 inhibitors increase the risk of ketoacidosis in patients who have significant pancreatic insufficiency.  The ketoacidosis is hard to recognise because the blood sugar is often normal or only very slightly raised. The person just feels ill and may vomit. My comment: in my experience this effect is difficult to predict but usually occurs in the first week or two of treatment. Low carb diets of below 30g-50g of carb a day also produce dietary ketones so can muddy the waters even more. Therefore is someone is on a flozin and starts a low carb diet it is best to suspend the flozin. They may not require it after a while on a low carb diet in any event.

Commonly used drugs that do not give any risk of hypoglycaemia include Metformin, Glutides, Glitazones, Gliptins and Acarbose.

About a quarter of people on metformin get diarrhea and need to go on the long acting version or stop it altogether.  Because acarbose is meant to help block starch and this is eliminated on a low carb diet, this drug can be stopped.  Glutides, Glitazones, Gliptins can be stopped when blood sugars are at a satisfactory level.  My comment: The target blood sugar will vary from patient to patient. You can see more about this in my PHC talk on you tube or in our book.

 

 

 

#LowCarb Vegetarianism and other adventures

meat-free alternatives Maybe it’s the Extinction Rebellion folks gluing their hands to pavements, disrupting flights and parking their uncooperative crusty* posteriors on roads throughout central London.

Or it could be the underlying anxiety about eating meat that has always bothered me since I took it up again after more than 20 years of vegetarianism. But lately I have drastically cut down on the amount of it I’m eating and embraced the substitutes.

Vegetarianism and particularly veganism aren’t natural fits with a low-carb diet, the one I follow because I believe it’s the best one for helping people with type 1 and type 2 diabetes manage their blood sugar levels. Heck, the good Doctor Morrison and I even wrote a book about it!

Quorn slices

But the meat substitutes have come much further than the last time I ate them. Quorn makes decent fake ham slices. Cauldron sausages and marinated tofu work for me too—all of them low carb, though not as low-carb as the real thing. Even the Diet Doctor—the best source of everything you need to know about a low-carb diet in general—recognises that many people do want to follow a low-carb diet that they can square with their conscience and the website offers low carb vegetarian and even vegan plans these days.

While I question some of the health claims people make for a plant-based diet (and I’m picky about the word being used to mean ‘veganism’—I’ve always based the bulk of my diet around vegetables), poor Mama Earth’s resources will run out far too quickly if meat consumption continues at its current levels.

As I have no children, I can tick that big box on the green credentials list but the other two are eating a plant-based diet and not flying anywhere. As someone who’s not that fussed about travel, the latter might be easily achieved too. That just leaves me with what I choose to eat. As I don’t do absolutes any more, opting to be a vegetarian with limited dairy most of the time is what appeals.

Low-carb vegetarian recipes

How about you? Have you changed your diet because of environmental concern s or do you plan to? We do have veggie options on our website if you are looking for low-carb meat-free recipes. They include low-carb curried cauliflower cheese, aubergine and pepper parmigiana, baba ghanoush, Tofu with teriyaki sauce and crustless spinach and feta quiche.

*As Boris Johnson called them. Maybe he was attempting ‘wit’ as a distraction from the chaos he is in midst of creating in the UK.

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.

 

 

 

Matthew’s Friends: a lifeline for epileptic patients

The charity Matthew’s Friends was set up by Emma Williams whose son Matthew got a great improvement in his epilepsy which did not respond to drugs but did respond to a ketogenic diet.

The charity aims to promote the ketogenic dietary option as an adjunct or alterative to drugs in children or adults whose epilepsy control is sub optimal. The hassle of following the diet often becomes much more preferable to facing a daily struggle with unpredictable and dangerous fits.

The website, Matthew’s Friends#KetoKitchen You Tube channel gives free ketogenic recipes, demonstrations and tutorials, which can be a great help to those embarking on ketogenic or low carb diets, including many diabetics. 

Professor Helen Cross from Great Ormond Street Hospital writes: Epilepsy affects 1% of all children, and in 25% of cases  there are continued fits despite considerable effort with medication. This can affect physical and mental ability, learning and behaviour. This not only affects the child but their family. The ketogenic diet has been used for almost one hundred years to treat epilepsy. There are different versions of the diet. The long chain triglyceride diet, the more liberal medium chain triglyceride diet, the modified Atkins and Low Glycaemic index diet. The best diet for an individual will be developed with the help of qualified and trained ketogenic dieticians in conjunction with the family. Such help is essential. In 60% of people who are resistant to anti-epileptic drugs, they respond, at least  to some extent to a ketogenic diet.

A three month trial of the ketogenic diet is advised to see if there is a response or not.In many cases, the response is so marked that medication can be stopped entirely. Obviously, direct clinical supervision is mandatory.

Matthew’s Friends can advise parents or people who would like to improve their epilepsy and provide contacts and materials to get started on an appropriate ketogenic diet. They are always grateful for donations to further their work.

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.

 

Public Health Collaboration Conference 2018: Achieving your optimal blood sugar target

Videos of the lectures given at the Public Health Collaboration conference 2018 which was held in May over the royal wedding weekend have now been released on You Tube.

You can see my talk, Achieving your optimal blood sugar target, as well as others, on the link below. There are a wide variety of lifestyle topics discussed. Happy viewing.

 

https://www.youtube.com/results?search_query=public+health+collaboration+conference+2018

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

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.