D-solve part three:how to do a low carb diet

How do I go about planning a restricted carb diet?

This case study is also applicable to insulin users. They also have to adjust their insulin regime to avoid hypoglycaemia.

Sandra is a 58-year-old with type 2 diabetes who has been on a diet-only regime for five years. Her HbA1c is 6.7% (49.7mmol). She has overlapping toes in one foot and is concerned that these could cause ulcers in the future. She could have an operation to straighten the bones in the feet, but the orthopaedic surgeon is reluctant to operate on her feet as she has no ulcers at present and she is diabetic. He would be willing to operate if her blood sugars were normal. How should she achieve this?

1. She should start a food diary.

Having a record of what she is actually eating can help her monitor the foods she may need to eliminate, reduce or replace to help her achieve normal blood sugars.

The correct answer is YES. It is a good idea.

2. She should check her blood sugars pre-meal, fasting, one hour after eating, two hours after eating and the occasional one at 3am.

This level of monitoring is quite detailed but need only be done intermittently in most patients with type 2 diabetes. As a baseline it will help her establish such things as whether she has a pronounced dawn phenomenon, and whether her basal insulin is adequate and whether her insulin response to meals is adequate. As she learns to “eat to meter” she will see improvements. Sometimes these improvements are not enough and additional exercise or medications, or even adding insulin is needed.

The correct answer is YES. She needs to know what her blood sugar pattern is.

 

3. She should start resistance training exercise.

Resistance training exercise is particularly helpful for patients with type 2 diabetes because it helps to build muscle mass and also reduces insulin resistance. The insulin that the pancreas can make itself is therefore more effective in reducing blood sugars. Walking can help use up calories and aid weight loss and improve mood. Other benefits to exercise regimes include companionship, reduction in osteoporosis, and improved flexibility and coordination.

Exercise need not be always undertaken in a gym. Offering to walk a dog, dancing, undertaking a sport and simply using cars or public transport less and walking more can all add up to greater health benefits.

Exercise in 10 minute segments can build up to the same effects on fitness as a single longer session.  People in one study needed to do 38 minutes of exercise a day to stay weight neutral. Interval training has been found to be the best exercise method for weight loss in women. High Intensity Interval Training has muscle sparing effects when a weight loss diet is also being undertaken at the same time.

When weight training is undertaken it is best to leave 2 or 3 days before that particular muscle group is worked again. This gives time for the muscle to recover from the exertion so that it can repair itself and become bigger and stronger.  Cardiac, stretching, relaxation, meditation, balance and coordination exercises or sports participation  can be done in the days in between the muscle training workouts.

4. Start metformin right away.

The American Diabetes Association state “It is recommended that metformin is started at the time of diagnosis along with lifestyle modification. Metformin is usually well-tolerated, especially if the dose is increased gradually to the effective dose. Patients should be started on a low dose, such as 500mg once or twice daily with dinner and breakfast. If gastrointestinal side-effects have not occurred the dose can be increased to 850mg with breakfast and 1,000mg with dinner. There are only modest improvements in glucose control with further dose increases up to  3g daily. The expected reduction in HbA1c is approximately 1.5%.”

The advantages of metformin include the lack of weight gain and a lower cost. The major disadvantages are the high incidence of gastrointestinal side-effects such as bloating, diarrhoea and wind and the rare potential for lactic acidosis. Lactic acidosis is more likely in patients with severe renal impairment.

Vitamin B12 deficiency may occur with metformin. This is reversible when it is stopped or alternatively B12 injections can be given.

Preliminary evidence from the United Kingdom Prospective Diabetes Study (UKPDS, 1998) indicates that metformin may have a beneficial effect on cardiovascular disease outcomes. In the UK current guidance is to defer metformin therapy till three months of a restricted carbohydrate and calorie diet and exercise is undertaken.

The correct answer is YES. She would benefit from the addition of metformin. If adverse side effects occur the long acting version could be tried or the drug stopped.

5. Advise her to eat at least ten ounces of lean protein-containing foods a day.

To obtain the minimum protein requirements of 1mg/kg of protein a day, an easy calculation is to take the ideal body weight in kilograms of the person and divide it by 6. This gives the total amount, in ounces, of meat, poultry, fish, or eggs that should be consumed over the day.

For this woman an ideal weight of 60kg is reasonable, making her minimum protein requirement ten ounces a day. One egg is about one ounce; cheese is often half the protein by weight for another approximate calculation. Most people recognise how big a quarter pound burger is and can estimate the sizes of protein in their meals visually.

People with advanced kidney disease are usually advised to limit their protein intakes to 0.8mg/kg per day. This intervention may increase just before dialysis is needed.

Replacement of dietary carbohydrate with protein is associated with lower rates of ischaemic heart disease (Hu et al, 1999).

People who are body building, undergoing growth spurts or who are simply not satisfied with this amount and get hungry between meals would benefit from more protein in their meals.

The correct answer is YES. This is the minimum amount she should eat and she may benefit from more.

6. She should avoid deep fried items, processed foods, foods cooked in refined vegetable oils and trans fats.

These fats are usually high in hydrogenated omega 6 oils. High amounts of these are thought to lead to increased inflammation in the body and the production of free radicals which cause damage to tissue cells. There are epidemiological studies relating these to increased rates of diabetes, heart disease and cancers.

For instance, Israel has one of the highest dietary polyunsaturated/ saturated fat ratios in the world. Israelis eat 8% more omega 6 polyunsaturated fatty acids than is eaten in the US and 12% more than in most European countries and yet there is a very high prevalence of cardiovascular diseases, hypertension, type 2 diabetes and obesity. These conditions are all associated with hyperinsulinaemia and insulin resistance. There is also an increased cancer incidence and mortality rate.

On the other hand more suitable fats, which do not seem to have adverse effects on the body, include cold-pressed monounsaturates, such as extra virgin olive oils and naturally saturated fats such as butter and coconut oil.

The idea that saturated fats cause heart disease is completely wrong, but the statement has appeared in published articles so many times over the last three or more decades that it is very difficult to convince people otherwise unless they are willing to take the time to read and learn what produced the anti-saturated fat agenda (Enig et al, 1993)

It is important to understand that trans fats and saturated fats are completely different from one another and actually have opposite effects on health. The food industry’s latest gimmick it to imply that both are bad and should be avoided. This is a dangerous deception given that fats in fresh meats and dairy foods are important nutritionally. They lower the most significant factors for heart disease including blood pressure, lipoprotein a and homocysteine. They raise protective HDL and they reduce the risk for inflammatory disorders such as asthma and arthritis. The only fats we need to be truly worried about are the oils that are made into margarine and shortening and used for deep frying. These are added fats; they are not part of any natural food and they are the only fats linked to any disease (Anderson KM who reported on the long term Framingham Study).

Healthy fats are omega 3 fats, which are found in fatty fish, flaxseed and walnuts. They have additional benefits – people who eat more of them have fewer episodes of cardiac arrhythmia and possibly sudden cardiac death.

Other healthy fats are naturally saturated fats, such as butter and coconut oil.

Yam D, Eliraz A, Berry EM. Diet and Disease-the Israeli paradox: possible dangers of a high omega-6 polyunsaturated fatty acid diet. Isr J Med Sci. 1996 Nov;32(11):1134-43 URL http://www.ncbi.nlm.nih.gov/pubmed/8960090?ordinalpos=7&tool=

EntrezSystem2.Pentrez.Pubmed.P

Shapira N. Israeli ”cancer shift” over heart disease mortality my be led by greater risk in women with high intake of n-6 fatty acids. Eur

J Cancer Prev. 2007 Oct:16(5):486-94. URL http:// www.ncbi.nlm.nih.gov/pubmed/17923822?ordinalpos=1&tool=

EntrezSystem2.Pentrez.Pubmed.P

http://www.tfx.org.uk/page31.html

30 minute interview with fat specialist Mary Enig PhD

http://vimeo.com/41052434

EDITORIALS:
J. Thomas Bigger, Jr and Tarek El-Sherif
Polyunsaturated Fatty Acids and Cardiovascular Events: A Fish Tale
Circulation, Feb 2001; 103: 623 – 625.

http://circ.ahajournals.org/content/103/5/623.full?%2520.

The answer is YES. Trans fats and artificial fats should be avoided.

7. She should consider undertaking a structured educational course to help her understand and plan the best blood sugar targets for her personal needs.

NICE recommendations state that self-monitoring of glucose should be taught if the need and purpose are clear and agreed with the patient (NICE, 2002).

Diabetes UK state: Diabetes is a life-long condition, which can have a profound impact on lifestyle, relationships, work, income, health, well being and life expectancy. Following a strict regime of medical treatment and self-care activities is critical for the length of survival of people with diabetes, since tight control of blood glucose reduces the risk of complications such as blindness, amputations, strokes and kidney failure. Self-management is key to good diabetes care and structured and ongoing patient education should be at the heart of any service.

Several meta-analyses, however, have shown no significant improvement in blood glucose control for patients with type 2 diabetes. The reason for this is perhaps that patients did not understand what action they could take when they found their blood sugars to be out with their target range.

When dietary guidelines are in place which give permission to limit the amount and type of carbohydrate intake, it becomes much easier to control blood sugar levels, particularly post prandially.

There is considerable variation in the extent to which diabetic patients limit carbohydrate consumption. At the strict end of the scale is the 20-50g of carbohydrate advocated by Dr Richard Bernstein for example; 50-90g of carbohydrate is a typical amount consumed by many followers of Dr Robert Atkins, Dr Arthur Agatson and Drs Mary and Michael Eades; 90-120g is advocated by Dr Lois Jovanovich.

There are also various blood sugar targets that have been proposed for different groups of people by different organisations. For instance, these targets are much stricter for a pregnant woman with type 1 diabetes than for an elderly patient with type 2 diabetes. Ultimately, the patient needs to read around the issues and make a decision about how strictly they wish to control their blood sugars.

A reasonable programme for patients with type 2 diabetes can be found at:

http://www.everydayupsanddowns.co.uk/p/newly-diagnosed-read-jennifers-advice.html

Targets are:

Fasting and before meals: <6mmol/l

One hour after meals: <8mmol/l

Two hours after meals: <6.5mmol/l

• Other targets for different groups can be found at: dsolve.com and in the books, Think Like a Pancreas by Gary Schiener ISBN-13: 978-1569244364

and Pumping Insulin by John Walsh and Ruth Roberts (Chapter 18 is devoted to pregnancy). ISBN-13: 978-1884804861

Beta cell destruction begins at blood sugar levels >5.6 mmol/l (Gastaldelli, 2004). Damage to beta cells is a duration and concentration exposure phenomenon rather than a threshold effect (Gleason et al, 2000). People whose fasting blood sugar is between 6.1 and 6.9 have already lost on average of 40% of their insulin-producing beta cells. People with diagnosed glucose intolerance or established type 2 diabetes who wish to avoid further loss should try to keep their sugars under 7.8 at all times, including after meals (Butler, 2003).

• Improving overall glucose control especially in the early course of diabetes can slow or prevent complications, preserve beta cell function and improve low term glycaemic control. Walter Willet “Eat Drink and be Healthy.” 2005). ISBN-13: 978-0743266420

Improved diabetic care also reduces long-term healthcare costs. The ill-effects of complications include personal misery and loss of employment for both the patients themselves, and family members who may have to adopt a full-time carer’s role. These factors need to be considered when rationing of testing strips for patients with type 2 diabetes is being debated.

I wrote in reply to an article by Professor Andrew Farmer that said that self monitoring blood sugars were a waste of money for type twos:

http://www.bmj.com/content/336/7654/1177

“Self testing but not self managing”

With respect to the commentary by Waldron-Lynch and Dinneen,1 self testing is clearly not going to benefit people with type 2 diabetes unless they know what to do when their blood sugars are out of their target range.

Treatment options for those with type 2 diabetes are limited. If they do not use injected insulin, they need to rely on their endogenous insulin to deal with the sugar they make from their meals.

The more carbohydrates their meal contains, the higher the glucose load their body has to deal with. As they have lost their first phaseinsulin response and often have limited ability to make insulin “to order,” they need to limit the amount of carbohydrate they eat to ensure adequate blood sugar levels after meals.

Some diabetic people prefer the certainty of normal blood sugars by restricting their meals to quantities of items that they know their pancreas can cope with. How do they know if they need to cut back on dietary carbohydrate the next time they have that meal? They test of course.

Unfortunately, carbohydrate counting and carbohydrate restriction are still not taught at mainstream diabetic clinics. This has little to do with science and much to do with politics. Fortunately there are online forums and publications that can help those diabetic patients who are not willing to play Russian Roulette with complications: www.dsolve.com

It costs nine times more to treat patients with diabetes who have complications compared with those who don’t. The diabetic patients who choose to master their blood sugar control and who need test strips to do it should be supported. They get a personal benefit and the NHS gets a long term financial benefit.

Katharine Morrison

1. Waldron-Lynch F, Dinneen D. Commentary on ‘‘Selfmonitoring

of blood glucose did not improve glycaemic

control in patients with type 2 diabetes not treated

with insulin.’’ Evid Based Med 2008;13:7. Comment on

Farmer A, Wade A, Goyder E, et al. Impact of self

monitoring of blood glucose in the management of

patients with non-insulin treated diabetes: open parallel

group randomised trial. BMJ 2007;335:132

ebm8521 Module 11 Evidence-Based Medicine 10/6/08 15:07:31

 

Dr Richard Bernstein”Diabetes Solution”  ISBN-13: 978-0316167161

Dr Mary Vernon and Jaqueline Eberstein’s« Atkins Diabetes Revolution“ISBN-13: 978-0060726966

• Dr Arthur Agatson « South Beach Diet »ISBN-13: 978-0755311309
• Drs Mary and Micheal Eades “Protein Power” ISBN-13: 978-0722539613

This is a 2013 study which showed some improvement in type two diabetes when educational interventions were used with blood sugar monitoring in type twos.

http://www.ncbi.nlm.nih.gov/pubmed/23735724

The correct answer is YES. Understanding blood sugar targets and getting help to reach them is at the core of good diabetes control.

8. In hospital she should eat from the diabetic menu section.

Most diabetic menus are based on low-fat, high-carbohydrate foods with limited sucrose. Bread and other grains, potatoes, rice, fruit and vegetables are the major part of most meals and snacks. The problem for diabetics is that if they stick to this diet it will make blood sugar control extremely difficult even if insulin is used to cover the carbohydrate.

Patients with type 2 diabetes, may be able to make enough endogenous insulin to cover generous amounts of low glycaemic carbohydrates, such as non-starchy vegetables, protein and fat, but it is unlikely that they will be able to prevent high post-prandial blood sugars with even modest amounts of sugar or starchy foods.

Patients with type 2 diabetes have limited storage of insulin available for immediate release and have to make the insulin to cover a meal as they eat. Patients with type 1 diabetes also lack this phase one insulin-release ability. If the content of the meals can be kept so that less demand is made on the pancreatic beta cells that remain, high blood sugars can be prevented.

High blood sugars are responsible for the macrovascular and microvascular complications of diabetes, but also kill off pancreatic beta cells. Even if basal insulin is needed for patients with type 2 diabetes, they may manage without prandial insulin injections on a low carbohydrate diet without compromising their future health or endogenous insulin-making ability.

High carbohydrate, low fat food choices also make patients more likely to over-eat at the next meal or snack due to increased hunger. On the other hand high fat, low carbohydrate, high protein meals improve satiety (Ludwig et al, 1999).

On admission to hospital for any elective procedure, diabetic patients need to be very firm with the staff that they are entitled to choose from the entire menu provided and decide for themselves what portion sizes are suitable for their dietary needs.

NICE (2004) guidelines for patients with type 1 diabetes state: “Use the personal expertise of the individual with type one diabetes: integrate that expertise into ward based glucose monitoring and insulin delivery through the nursing care plan and use it as a major determinant of food choice.”

www.nice.org.uk/page.aspx?o=CG015adultsquickrefguide

The cost of hospital food in England varies from £1.60 to £2.40 per day. No wonder it doesn’t  satisfy patients.  At the same time wastage is high. This report discusses some of the problems and possible solutions.

http://www.bapen.org.uk/professionals/publications-and-resources/bapen-reports/hospital-food-as-treatment

The correct answer is NO. Stick to your usual restricted carb, adequate protein and healthy fat diet in hospital. You will probably need to have relatives bring in food for you to achieve this.

9. She should consider other drug treatments if her blood sugars do not reach optimal targets.

Although low carbohydrate diets will usually rapidly reduce blood sugars and more gradually reduce weight, insulin resistance, and blood pressure, as well as normalising the lipid profile, there are still going to be times when the results fall short of what could be achieved with further drug therapy.

Metformin is the first choice of add-on drug after diet, exercise and appropriate weight loss are tackled. This drug is not suitable for those with severe renal impairment due to the potential for lactic acidosis. Metformin dosage may be limited by gastrointestinal side-effects, but this can be helped in some people by switching to the long-acting preparation. Metformin may cause deficiency of vitamin B12 due to metformin impairing its absorption.  This can be treated with B12 injections or the metformin can be reduced in dose or stopped.

Sulphonureas and meglitanides are a popular choice as the next add-on drugs, but because they stimulate beta cells to produce more insulin they have the unfortunate long-term effect of exhausting insulin production in remaining beta cells. In the: A Diabetes Outcome Progression Trial (ADOPT) the time to 50% failure of glucose control was 33 months with glyburide, 45 months with metformin and was estimated at 60 months for rosiglitazone.

There is also epidemiological evidence of higher cardiac mortality in patients treated with sulphonureas. This may be due to the effect of sulphonureas increasing insulin levels, which adversely affect the endothelium. Weight gain and increased hypoglycaemia may also occur.

In practice hypoglycaemia occurs only in 2 per cent of patients per year. The frail elderly, those on multiple medications, and those who have frequent hospital attendances are more likely to be affected.

http://archinte.jamanetwork.com/article.aspx?articleid=623652

A Glitazone may therefore be preferable to a sulphonurea. Rosiglitazone was withdrawn worldwide and is still not available in Europe. It seemed to cause adverse cardiac events. Very recently it has been decided that the cardiac events were not related to the drug and it is now available in the USA.  Pioglitazone  has never had a problem with cardioprotective data.  But both drugs share side-effects such as increased fluid retention, heart failure and osteoporosis.

The Gliptans, such as  Sitagliptan and Linagliptan are more recently introduced drugs.

Both are taken once a day.

Gliptans workin part by increasing the amount of insulin produced by your body, which then controls the level of sugar in your blood. They also reduce the amount of a substance called glucagon being produced by your pancreas. Glucagon causes your liver to produce more sugar, so by reducing the amount of glucagon in your body, this also helps to reduce the levels of sugar in your blood.

Gliptans can be given alone or alongside other antidiabetic medicines. The main side effect can be hypoglycaemia but this is more common when sulphonylureas are being used as well.

Byetta, twice a day, and Victoza once a day, are also relatively new injectable treatments for diabetes. They increase insulin secretion, suppress glucagon secretion and slow gastric emptying. They help reduce weight by appetite suppression. In my experience Victoza also known as Liraglutide is superior in this respect to Byetta which is also known as Exanatide.  Nausea is the main limiting  side effect of both. Neither drugs should be used in pregnancy. Liraglutide has been used in type one patients in short term studies and it has been found to reduce weight and improved glycaemic control from 6.5% to 6.1% in a group of 14 highly motivated insulin pump users. Use of this drug in this way is still “off label”but it may be considered if a type one patient has a serious weight problem and is suffering from significant insulin resistance. This phenomenon is also known as “double diabetes”.

The Endocrine Society
Source reference: Varanasi A, et al “Liraglutide as additional treatment in type 1 diabetes”ENDO 2011; Abstract OR07-5.

Acarbose is sometimes added. This product reduces the absorption of dietary carbohydrate to a limited extent. A very high incidence of adverse gastrointestinal effects greatly limit its usefulness in practice.

Insulin should be considered at the outset if a patient has very high blood sugars or has symptoms of hyperglycaemia. Gerald Reaven demonstrated in the 1970s that early insulin treatment could prevent the death of beta cells (Reaven, 1986) Two weeks’ treatment with insulin to the extent of normalising blood sugars caused enough regeneration of beta cells that it took a further two years for the treated group’s HbA1c to rise to the same extent as the untreated group.

Basal insulins can be given for most patients with type 2 diabetes to start with, and the meal profile testing that is recommended will reveal whether additional prandial insulin is required.

Mixed insulins may be given for convenience in certain patients who prefer this. For the most flexibility over dietary choice and times, however, many patients with type 2 diabetes may prefer to have basal and bolus insulins entirely separate and have an insulin regime similar to an intensive insulin regime that is usually prescribed for patients with type 1 diabetes.

The correct answer is YES. The right diet can do a lot for diabetes but other treatments are often required too.

10. What other drugs may be offered to diabetic patients?

Medications to reduce blood pressure and reduce kidney damage:

ACE inhibitors

ACE inhibitors are useful in patients with type 2 diabetes for blood pressure control. They are also used in heart failure and prevention of cardiovascular events. They can cause a chronic cough which usually disappears when another class of drug or a Sartan are used instead. ACE inhibitors can also cause allergic reactions which can occur even when people have used them for years.  Kidney damage can occur if non steroidal anti inflammatory drugs or diuretics, particularly in moderate to higher dose, are used at the same time. ACE inhibitors are best avoided if the person has known reno-vascular disease. The group of patients who are most likely to be affected also may have peripheral arterial disease or ischaemic heart disease. ACE inhibitors should not be given in pregnancy.

Sartans also known as angiotensin II receptor antagonists are similar in many ways to ACE inhibitors but they do not cause the cough or the same number of allergic reactions.  They also should not be given in pregnancy.

Other medications to reduce blood pressure:

Beta blockers, Diuretics and  Calcium Channel Blockers, are commonly used to enhance blood pressure reduction. There are many different add on drugs to choose from and the doctor chooses drugs that tend to help other conditions from which the patient is suffering, also known as co-morbidities, do not exacerbate other things that are wrong with the patient and have a side effect profile that the patient can live with.

Calcium Channel Blockers often cause facial flushing which often subides over time and ankle swelling which usually does not subside over time. These drugs are not recommended in pregnancy.

Beta blockers can worsen asthma. They slow the heart rate and so may not beneficial if you are sporty or athletic. The beta blocker Labetalol is recommended in pregnancy for women who are hypertensive.

Diuretics can make you pass urine more. The drug Furosemide is particularly effective in this regard. The timing of the dose may be of considerable importance for those who are driving or travelling by public transport. Diuretics may be particularly helpful if you have ankle swelling.

Aspirin used to be recommended for all adult type two diabetics and type ones over the age of 40 or who had developed complications. It is used as an anti platelet agent and thus reduces the clotting effect when a wound occurs or when a plaque bursts in the coronary blood vessels. The problem is that the main side effect is gastro-intestinal bleeding. Over the years recommendations about whether it is useful or not in primary prevention of heart attacks, thrombotic strokes and bowel cancer have varied. Currently the advice is that diabetics should not take it unless they already have established ischaemic heart disease or a transient ischaemic attack or a stroke because the gastro-intestinal bleeding effects cause more harm than good in simple primary prevention.

Statins are often advised for those who have a higher risk for developing atherosclerotic disease. This includes those with a poor family history, diabetics over the age of 40 or who already have complications of diabetes or anyone whose ten year risk is over 20%.

When it comes to treating younger diabetic patients, those who have a hbaic over 9%, low HDL and high triglyceride concentrations, or hypertension are at higher than usual risk of cardiovascular disease and thus may benefit from statin treatment.

Hypothyroidism can give falsely raised blood lipid readings so it may be worth excluding this before statins are given. Heavy drinkers are at risk of liver disease from statins.  Since diabetics are always getting blood tests of one kind or another it is prudent to ask for a thyroid and liver check before starting statins is considered. After 3 months NICE recommends further lipid, liver and creatine kinase checks. (BNF 2013).

Statins do have long term side effects such as increasing insulin resistance, producing cataracts, tendon damage and memory loss. They are teratogenic and should not be used if a pregnancy is being considered or if adequate contraception is not being used. Muscle pain affects about one in 10 people and a severe life threatening muscle disease called rhabdomyolsis can occur.

Statins do not improve total mortality for women and if within 20 years of the expected time of death probably do not offer much added value for men. Possible exceptions may be those who have had a transient ischaemic attack or a stroke who may benefit from the anti-fibrinogen effect.

This site can help you figure out what your heart attack risk may be and what changes may most benefit you.  There is nothing you can do about your genes but there are other modifiable factors.

In this course I advocate a change in lifestyle factors which together with proper monitoring and treatment of diabetes can transform the expectancy of diabetes from that of inevitable complications to that of eradicating the metabolic and glucose damaging effects of diabetes. In time, you can expect to see reversal of some of the complications of diabetes and arrestment of others.

In my opinion it would not be appropriate for a diabetic who has had normal blood sugars since onset of the condition who has no complications and who is very likely never to get them or who has rendered themselves metabolically normal, what I term the “super-diabetic,” to be treated along the same pathways as those who are “average” or “poorly controlled” diabetics. Avoidance of potentially damaging drugs when they are not required is sensible.

Although statins reduce cholesterol, their main effect may be more to do with their anti-inflammatory and anti-fibrinolytic effect.

Orlistat is now the only licenced drug in the UK for weight loss. It works by preventing dietary fat from being absorbed by the intestine. It is a safe drug to use and is available over the counter at 60mg one with each meal. Prescribed, the dose can be increased to 120mg up to three times a day with each meal. It’s main side effect is diarrhea, which can be explosive in nature. Orlistat is usually used alongside a LOW FAT diet to achieve weight loss. I point this out because it would certainly not do well with the high fat, moderate protein, low carbohydrate that I recommend for diabetics in this course.

Medications for painful neuropathy are commonly used for people with complicated diabetes.

Duloxetine is often used first line because it does not produce sedation while most of the other drugs do, at least to some extent. The dose can vary from 30mg to 120mg.

Amitryptiline is given in doses of 10mg to 50mg  or higher at night. This tricyclic anti depressant drug improves pain and is particularly good for giving a long night’s sleep. It’s main limiting effect is a hangover effect in the morning which can be off set to some extent by taking it earlier in the evening.

Gabapentin and Pregabalin are anti convulsants which help chronic pain. Drowsiness and dizziness are the main limiting side effects. These can be minimised by starting the drugs at low dosage and increasing gradually.

Opiate analgesics such as Tramadol, Dihydrocodiene, Oxycodone, Morphine and Fentanyl may be used as adjuncts for unremitting pain.  When nerves are healing, as they do when normal blood sugars are obtained for the first time in many years, it is common to experience a worsening of pain before the pain reduces.

Anti Reflux Medications:

The combination of eating highly refined carbohydrates and being overweight often causes acid reflux.  Alginate antacids, Ranitidine and Omeprazole or Lansoprazole are commonly prescribed.

Many sufferers get complete and almost immediate remission when they start to follow a wheat free, low carbohydrate diet. Eczema of the face also tends to remit too. (Wheat Belly by Dr William Davis)

Smoking cessation drugs:

It is a rare diabetic who has not been told multiple times that smoking greatly aggravates the complications of diabetes. There is now a wide range of nicotine replacement therapies, e-cigarettes, and specific drugs to address addiction and craving. Champix  is one of the most successful. This drug is increased in dose over a two-week period before the last cigarette is taken. It has often a profound effect on mood and an counselling and family support  is recommended before taking it.

Answer: Many other types of drugs may be offered. Many of the indications for these drugs such as hypertension, cardiovascular disease, and nerve damage can be prevented by getting control of blood sugars, normalising weight, and getting and keeping fit. Smoking and poorly controlled diabetes are two particularly bad combinations as both accelerate tissue aging, cardiovascular disease and certain cancers.