D-solve Course part one: learning objectives and overview quiz

Dr Katharine Morrison

This module was written by Dr Katharine Morrison, General Medical Practitioner, Ballochmyle Medical Group Mauchline, Ayrshire, Scotland.

Helping Patients with Diabetes Achieve Normal Blood Sugars with Diet and Insulin

This course is to help those who have diabetes and those who care for them learn more about the ways that normal blood sugars for diabetics can be achieved. The evidence on which the steps are based is presented as internet links whenever possible.  This module can be taken on its own as an introduction to the subject or taken after completion of the course at www.dsolve.com to consolidate learning.

 

Learning Objectives
After completing this module you should have:

  • Knowledge of why normal blood sugars are essential to the prevention of the complications of diabetes.
  • Knowledge of dietary choices that make having normal blood sugars easier.
  • Ability to design an appropriate blood sugar monitoring regime that suits your personal goals.
  • Ability use highly advanced insulin techniques to improve the predictability of insulin response.
  • Ability to match insulin type and dosage and timing to different types of meals.

Medical knowledge is constantly changing. The author has far as it is possible, taken care to ensure that the information given in this module is accurate and up-to-date at the time it was created. However, users are strongly advised to confirm that the information, especially with regard to drug usage, complies with current legislation and standards of practice in your own country. This module can increase your knowledge of the options for managing diabetes but is not a substitute for medical care from a professional who knows you well and can monitor your condition appropriately.

Helping Patients with Diabetes Achieve Normal Blood Sugars with Diet and Insulin

Type one diabetes, obesity and type two diabetes continue to increase in the population and there is real concern at the effects this will have on health care delivery for these patients. The key to success is to prevent the onset of diabetes where this is possible and to reduce complications in those patients with established diabetes. Treating diabetic patients who have developed complications is many more times more expensive than in those without complications.

There are various plans to help reduce the burden of complications, including earlier diagnosis and effective surveillance of diabetes. This module looks in depth at one other aspect: how people with diabetes and their carers can prevent, reduce or reverse diabetic complications through the achievement of normal blood sugars.

The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have firmly established that the better the control of blood sugar, the better the reduction of complications. For insulin users the downside was that better control also resulted in more frequent and more severe hypoglycaemia attacks. For patients with type 1 diabetes, and for the increasing population of patients with type 2 diabetes on insulin, this worry about hypoglycaemia has been a barrier to the introduction of more intensive treatment of diabetes.

Research and experience both old and new prove that the aim of achieving normal blood sugars is no pipe dream. Normal blood sugars without excess hypoglycaemia can be achieved by the use of a restricted carbohydrate diet in conjunction with advanced insulin techniques. Furthermore, added benefits on weight control, blood pressure, triglycerides and high-density lipoproteins (HDL), which are the markers for metabolic syndrome and increased cardiovascular risk, are also improved on a carbohydrate-restricted diet.

Dr Sylvan Lee Weinberg, former President of the American College of Cardiology, former President of the American College of Chest Physicians and editor of the American Journal of Cardiology has written: “The low fat high carbohydrate diet since 1984 may well have played an unintended role in the current epidemics of obesity, lipid abnormalities, type two diabetes and metabolic syndromes. This diet can no longer be defended by appeal to the authority of prestigious medical organisations or by rejecting clinical experience and a growing medical literature suggesting that the much maligned low carbohydrate high protein diet may have a salutary effect on the epidemics in question.” (Weinberg, 2004).

Jacqui Troughton, specialist dietician at Warwick University in England, stated that: “Nutritional advice that has little or no supporting evidence is still being given to people with diabetes. People with diabetes need evidence based information about carbohydrates and to be given the knowledge and skills necessary to adjust their lifestyle, medication or insulin around the choices they wish to make.” (Troughton, Practical Diabetes International 2003).

We have known for many years that blood sugar and lipid markers for cardiovascular disease worsen with high carbohydrate diets and improve on low carbohydrate diets. More recently longer term studies of both diets have shown that diabetics experience measurably worse long term outcomes with the so called “healthy” high carbohydrate/low fat diets compared to no intervention (Problem with Women’s Health Initiative) and improve on a low carbohydrate/high fat/moderate protein diet. (Jorgen Vesti Neilsen).

The extent to which you may wish to achieve control over your blood sugars will vary. It is you the patient, or you the carer, who has to bear the physical and emotional burden of diabetic complications. The choice of how far to restrict carbohydrates, and how tight the glycaemic control should be, is a decision that ethically remains with the patient. By completing this module you will have increased knowledge to help you make so-called “progressive” diabetic complications much less severe and even obsolete. This does not happen all by itself of course and a commitment to lifelong dietary control, insulin mastery and intensive monitoring is necessary.

There has been some progress in the last few years from evidence based guidelines in Sweden, Scotland and in the USA towards acceptance that low carbohydrate eating is acceptable for diabetics. Change has been very slow and many medical practitioners, nurses and dieticians will require considerable retraining before they can offer proper advice to their patients.

The information in this module is only starting to be taught in mainstream diabetic clinics. Doctors and carers supervising patients and people with diabetes need to be aware that carbohydrate restriction is so effective in blood sugar reduction that a considerable reduction in insulin and other medications is often required. A planned and gradual reduction of both carbohydrate and medication is safer for both patients and doctors.

My 22-year-old son has had type 1 diabetes for ten years.  As soon as he was diagnosed I became determined to find out how to protect him from the effects of his illness. I am pleased to say that that his blood sugar control has been near normal since diagnosis due to the dietary and insulin management practices we have learned. Dr Bernstein’s book Diabetes Solution and membership of the associated online forum have greatly influenced my management of diabetes. I no longer have the belief that diabetes need be a relentlessly destructive and “progressive” condition.

 

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Before undertaking the module we have a short multiple choice quiz.  Questions 8 onwards are concerned with insulin use.  You may wish to take this before the module so that you can see how much benefit you gain from the course or leave it till after you complete the course. It is entirely up to you.  The answers are discussed at the end.

  1. Who should determine the dietary and blood sugar goals for a patient?

A The dietician

B The diabetes consultant

C The patient

D The diabetes specialist nurse

E The General Practitioner

  1. What evidence has been reported in dietary trials concerning diabetics?

A Carbohydrate restriction results in less frequent and less severe hypoglycaemia compared with a higher carbohydrate standard diet in insulin users.

B Carbohydrate intake of <130g is dangerous because the brain needs this amount of glucose to function normally.

C Carbohydrate restriction is frequently associated with reduction or elimination of the need for medication.

D Markers for metabolic syndrome improve on a carbohydrate-restricted diet.

E Transient blood sugar spikes after meals do not cause any diabetic complications.

  1. What blood sugar patterns are normal for fit, slim, young non-diabetics?

A A HbA1c of 4.5

B A fasting blood sugar of 6

C A one hour post-meal blood sugar of 8

D A two hour post-meal blood sugar of 10

E A HbA1c of 5.9

  1. Which of these are low glycaemic carbohydrates?

A an apple

B a slice of wholemeal bread

C a baked potato

D an avocado

E a stick of celery

  1. What is true about protein consumption?

A Most people need 1 to 1.2g/kg of their body weight a day.

B It can be covered effectively with a single injection of rapid acting insulin such as humalog, novorapid or aphidra.

C You don’t need to cover it with insulin at all. Just count the carbohydrates.

D It can be covered effectively with a single injection of regular/ soluble insulin such as hypurin or humulin S.

E It stimulates the release of hormones that make you feel full up. 

  1. What sorts of fat have been shown to cause damage to health?

A Saturated animal fat such as butter and cream.

B Margarine.

C Refined vegetable cooking oil

D Cold pressed extra virgin olive oil

E Non hydrogenated lard

  1. Which of these are appropriate meal plans for a diabetic who wants to have normal blood sugars?

A  A breakfast of wholemeal toasted bread, a sliver of margarine and marmalade, freshly squeezed orange juice, coffee with skimmed milk.

B A breakfast of scrambled eggs made with double cream, smoked trout, a tomato and coffee with cream.

C A lunch of roast chicken, avocado, romaine lettuce, parmesan cheese with a vinegar and olive oil dressing and a mineral water.

D A lunch of spaghetti with tomato sauce, fruit salad and a diet coke.

E A dinner of rib eye steak fried in butter, green salad with olive oil dressing and a glass of dry red wine, with cheese to follow.

For insulin users only:

  1. What is correct about insulin injections?

A Use a maximum of 7 units per shot for greater insulin predictability.

B The legs are the least painful place to inject.

C Frio wallets can help keep insulin cool in hot environments.

D You need an insulin pump to get completely normal HbA1cs.

E Regular/soluble insulin in pen form is available in animal and human types.

  1. When calculating what amount of insulin to inject at a particular meal you need to consider which of these factors?

A Recent or intended exercise.

B Your current blood sugar.

C Your current weight.

D Your carbohydrate sensitivity for the time of day.

E The type and amount of food you intend to eat.

  1. What sort of insulins are correct to use in these circumstances?

A Rapid acting humalog or novolog for a correction dose.

B Regular/soluble insulin for a slow-digesting meal.

C Regular/soluble insulin to keep blood sugars steady overnight and during the day.

D Discontinue basal insulin when you are fasting for an operation.

E Insulin that is three months out of date  when this is all you have immediately  available.

  1. When a patient is practising good blood sugar control they will do which of these?

A Aim for a fasting or pre-meal blood sugar of 4-7mmol/l.

B Take a blood sugar two hours after the meal is finished and be happy if it is 10mmol/l or under.

C Undertake meal profiles for commonly eaten meals.

D Take blood sugars at 3 am every few weeks.

E Have several meters and use them interchangeably for more accuracy.

  1. What blood sugar monitoring is necessary for normal sugar control?

A HbA1c once every year at least.

B One hour blood sugar after every meal.

C 3am blood sugar once a week.

D Increased monitoring, e.g. every 2.5 hours during periods of acute dehydrating illnesses such as gastroenteritis.

E Increased monitoring during changes to meal plans or insulin or medication doses.

Answers:

  1. C The patient. They may seek information and advice from the medical profession but the decision is theirs.
  2. A, C and D are true. Your brain on average does need 130g of glucose to function well but this can be made in the liver and you don’t need to eat the equivalent amount of carbohydrate. Transient blood sugar rises after meals are inevitable with high carbohydrate diets and are damaging to the blood vessels. You can expect fewer hypoglycaemic attacks if you are insulin dependent and have adjusted your insulin to your diet. To start with however, large reductions in insulin and often other medication is required when you move to a low carb diet. A beneficial side effect of your efforts to maintain normal blood sugars on a low carb diet is that abdominal fat, lipids and blood pressure usually improve too.
  3. A and C are true. Non diabetics may often have a hbaic of 4.5% and a one hour post meal blood sugar of 8. The other measurements  are all raised for a healthy, fit, slim non diabetic but can be reasonable targets for diabetics to achieve.
  4. D and E are true. Avocado and celery are low glycaemic, an apple is medium and baked potato and wholemeal bread are high.
  5. A, D and E are true. Most people need at least 1g/kg of their body weight a day and many need a lot more. Protein does make you feel full up quicker and for longer than fat or carbohydrate. For insulin users they do need to estimate how much they are eating and cover it with a medium length acting insulin such as Hypurin Neutral or Humulin S. Rapid acting insulins come on too early, peak too early and stop acting too early to be really useful in coverage. If the medium acting injections are not available it is possible to cover protein by either increasing basal insulin or multiple low dose injections of a rapid acting insulin.
  6. B and C cause damage to health. The others don’t. Margarine and refined vegetable and seed oils are high in omega 6 fats which cause inflammation in the body. Inflammation is considered to be a major cause of atherosclerosis and cancers and there is a correlation between the dietary input of these oils and these conditions.
  7. B, C and E are all good. The scrambled egg breakfast, the chicken lunch and the rib eye dinner are all suitable for an insulin user. The toast breakfast and the spaghetti lunch are all pretty high in carbohydrates and therefore harder to cover accurately with insulin.
  8. A, C and E are true. The legs tend to be the most painful place to inject. The buttocks and abdomen are usually less sensitive. You don’t need an insulin pump to get normal blood sugars. Pens are fine but you should be using the 7 unit rule and the correct types of insulin for maximum effectiveness. The other statements about Frio and insulin availability are true. In the USA porcine insulin can be hard to obtain but it can be shipped from the UK.
  9. A, B, D and E are necessary. Your exercise pattern, current blood sugar, type and amount of food you intend to eat and your insulin sensitivity for that time of day all need to be considered. Your weight is a longer term issue and it may have relevance to your insulin sensitivity.
  10. A, B and E are true. Rapid insulins are indeed needed for correction doses and regular/soluble insulins are given for slowly digesting meals. If your insulin is out of date it should still be effective as long as it has been stored correctly. It is better than risking ketoacidosis as you make your way to the emergency pharmacy. Basal insulin is what you need to keep your blood sugars steady by day and night and this should never be discontinued before an operation.
  11. A, B, C and D are true. All the first four behaviours should result in good blood sugar control. It is best however to stick to one meter and keep another for back up rather than use them interchangeably as there is always a degree of variation. At least your variation is consistent with one meter.
  12. A, D and E are true. The annual hbaic is a bare minimum. The increased monitoring during potentially febrile or dehydrating illness is essential to prevent ketoacidosis by appropriate response to the blood sugars you are seeing. The appropriate response may be that you increase insulin and fluids substantially or that you go to hospital immediately.

Checking the blood sugar every week at 3am or after every meal at one hour is only usually necessary during certain conditions eg when planning or during a  pregnancy when diet and insulin are continually being adjusted to get near normal blood sugars.

 

The author wishes to acknowledge the help of the members of Dr Bernstein’s Diabetes Forum, the Nutrition and Metabolism Society and the Insulin Dependent Diabetes Trust.

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