What would you like to drink?

Photo by Chevanon Photography on Pexels.com

This question is a lot trickier health wise than you think. There has been new research on a variety of beverages that show various harms and benefits.


A study from Cambridge suggests that coffee in itself is not a dangerous drink but that thermal damage to the oesophagus is the problem that can result in a higher risk of oesophageal cancer.

In the UK we drink 98 million cups of coffee each day. There are 67 million adults and children in the UK at present to put this into context.


Green tea is known to confer some health benefits and a recent prospective study has shown benefit for black tea drinkers too. Half a million UK participants in the Biobank cohort were assessed. There is a moderately reduced all-cause mortality reduction in those who have two or more black teas a day. There also was a reduction in mortality from cardiovascular disease, ischaemic heart disease and stroke. There was no effect on cancer mortality or respiratory disease. Surprisingly given the coffee study, there seemed to be no effect from the temperature of the drink or the addition of milk or sugar.

It is thought that substances in the tea improve endothelial function and this is the cause of the effect.

Pre-meal whey protein drink

A small whey protein pre-meal drink taken 10 minutes before meals, significantly reduces mean blood glucose concentration and for diabetic subjects, the amount of time they spend in normal blood sugar ranges.

A placebo RCT was done on 18 people who had type two diabetes who had never been treated with insulin. They were given a 100ml drink containing 15.8g of protein to be taken ten minutes before breakfast, lunch and dinner.

The protein drinkers significantly reduced the prevalence of hyperglycaemia over the day, increased the amount of time in the normal blood sugar range by around 2 hours extra a day, and reduced the 24 hour glucose concentrations. There was no effect on night time blood sugar levels. The acceptability levels of this were high at 98%.

The researchers at Newcastle University say that the protein seems to slow down the speed of gastric emptying and stimulating hormones that reduce the spike in blood sugars.

Alcohol containing drinks

Alcohol is a major preventable risk factor for cancer. About 4-5% of cancers are alcohol related. A new study suggests that reducing alcohol intake reduces the risk of getting an alcohol related cancer in a Korean study.

Those who drink three or more alcohol containing drinks a day are at particular risk of cancer. The heavier drinkers at the outset have the most to gain by cutting down. Some cancers are much more likely from alcohol than others. More than 45 % of mouth and throat cancers are drink related, 25% of laryngeal cancers, 12% of female breast cancers, 11% of colorectal cancers, 10.5% of liver cancers and 7.7% of oesophageal cancers.

Health screenings in Korea were done in 2009 and 2011. The average age was 53 years and they were followed up for just over six years. Over that time, new cancers were seen in 7.7 per thousand of the 4.5 million people screened.

Those who increased their alcohol consumption had a higher increase in cancers. Those who lowered their alcohol intake lowered their risk. The risks were dose related.

Fruit juice, fizzy pop and diet soda

Drinks sweetened with sugar but not natural juices or artificially sweetened drinks were related to a higher risk of inflammatory bowel disease in people who drank more than one a day, in a study of more than 120,000 people.

66% of the people did not drink any sugar sweetened beverages a day but those who consumed more than one such drink a day had a higher BMI and consumed higher amounts of total energy and sugar.

The participants were followed up over ten years. There was a significant increased risk for Crohn’s disease but not for Ulcerative Colitis in the sugary drink consumers. Diet drinks or natural fruit or vegetable drinks had no effect.

All the subjects were over the age of 40 so the effect on the younger population was not studied. Dr Hasan Zaki said that this would be of interest to study because children consume a lot of sugary drinks and the incidence of inflammatory bowel disease in children increased by a third between 2007 and 2016.

My comment: I was pleased to see the beneficial effects of black tea because I drink about 4 pints of it a day. I do like a glass or two of wine with my dinner, but maybe I should cut this down and have a tomato juice or just plain water instead? The pre-meal protein drink looks interesting. I would expect that it would reduce the amount of food consumed at each meal as it should blunt the person’s appetite. I wonder what the longer term effects on weight would be?

The FreeStyle Libre—a two-week report

a sensor and reader on a post on the Diabetes DietYou find me, un-sensored and sad… Yes, I’ve completed two weeks on the FreeStyle Libre sensor and reader system, and now I’m back to finger pricks, at least temporarily.

At my last diabetes clinic appointment, my consultant* agreed that I’m a candidate for flash glucose monitoring (which is different from blood glucose testing, but more on that later) and sent me off with a 14-day sensor while I wait for bureaucracy to kick in.

So, what’s flash glucose monitoring like? For the uninitiated, the system comprises a sensor you wear on the back of your arm and a reader that can be used any time. Type 1 diabetes tends to encourage obsessive compulsive behaviour, and the FreeStyle Libre system facilitates that, though it’s no bad thing.

Where flash glucose monitoring differs from blood testing is that the sensor reads levels from interstitial fluid, so it lags about four and a half minutes behind blood glucose readings. If you drive, the DVLA requires you to do blood tests, rather than scans beforehand to avoid the risk of hypos while driving.

Parents love them because they can check children with type 1 diabetes while they sleep, able to work out if they are risk of a hypo, and they are also routinely prescribed for pregnant women who have diabetes as frequent testing makes it easier to maintain the tight control you need while growing a baby.

The accompanying app can be downloaded by others, who can gain access to your information if you give them permission. Again, something that is useful for parents although such scrutiny would have horrified the teenage diabetic me.

Here’s what I found:

Frequency of testing

After a day or so of overcoming the hesitation—I can’t do another test, I just did one an hour ago… Oh. Yes, I can—I averaged 11 scans a day, and about two blood tests usually at the same time to check accuracy and a few times because I was hypo.

Ease of testing

Easy-peasy-lemon-squeezy! You can use the reader through clothing, it only takes a few seconds. It’s much easier than pulling out a meter, sticks and finger-pricker—especially when you’re out and about.

Accuracy of readings

I had the odd bit of disparity—usually if my blood sugar was low, as the sensor lags behind blood glucose readings. However, most of the blood tests I did at the same time varied only by 0.1 o 0.2 mmol, and I did get hypo readings that registered at the same time.

Sensor adhesion

No issues there. That thing stuck to me for the two weeks. I didn’t do any swimming in that time, so I can’t attest to how well it works in that setting. Nor did I try it out in the sauna/steam room as threatened—though one suggestion a fellow user came up with was using cling film to bind it onto your arm. The reader lasted on the battery charge for the full two weeks too.

Most useful bits

There are lots of things that sell flash glucose monitoring to me—ease and frequency of testing two of them—but there are other super-useful components. One is the pattern tool. You can see where you have the most glucose variability and when you tend to have hypos. In the two-week period, I had (ahem) 17 low glucose events, most of them between 11am and 5pm and that corresponded with the time of day I have most glucose variability.

I’ve never been good at logging my blood tests. It just feels too much like hard work. I know you can download from your meter, but the checks I made on the flash glucose monitor gave me a clear idea of what happens. And, more importantly, some ideas of how to fix it.

The excess hypos may have been because of the half-marathon, which happened not long after I started my 14-day sensor and because I’ve been eating more carbs. As we say in the Diabetes Diet, more carbs mean more insulin. Bigger amounts of insulin mean bigger mistakes. A salutary reminder, then, that it’s back on the low-carb for me.

Thanks too, to Steven Morrison—my blog and book co-author’s son—who emailed me in detail about his own experiences using the FreeStyle Libre. He’s a convert too, and the cling-film tip came from him.

So when does my prescription come in? I’m now on a list for a short course at the hospital and once I’ve taken part in that, the organisers write to my doctor recommending she add sensors to my list of prescribed diabetes medications and gear. Fingers crossed, it doesn’t take too long.


* #LovetheNHS

Genteel claim first painless lancet device that takes accurate blood sugars from different sites

Genteel palm pic.pngThe USA company Genteel have developed a new lancet device that is reported to be painless and can be used successfully for blood sampling in a variety of sites.  It is only available in the USA but can be shipped from there.  It does cost $129 plus lancets and postage so it does not come cheap. The manufacturers explained how the new device has a role in diabetes management….

The common belief, presently held by many endocrinologists, is that test blood, drawn from the fingertips, gives a more current and accurate indication of blood glucose than blood drawn from alternate sites, such as the forearm, shoulder and stomach. Unfortunately, for many with diabetes, the fingertip areas are those most laden with pain nerves, causing the lancing process to be the most sensitive and uncomfortable as well as leaving the finger tips bruised, calloused and with reduced tactile sensation.

Fortunately, Genteel researchers have found four new test sites that appear to give the same response time and accuracy as finger tips, now affording the option of relief to these most common testing sites. These two sites are located on the fleshy area of the palms, on a line between where the thumb joins the palm and the center of the wrist (thenar), and fleshy area along a line connecting where the pinky joins the palm to the wrist (hypothenar).

To verify this assertion, the following tests were done at Genteel’s test facility. Test subjects fell into three categories: non-diabetic, pre-diabetic, and under-control diabetic. Tests consisted of simultaneously taking blood samples from alternate sites, such as the forearm, fingertips and from the thenar/hypothenar areas. The tests began at (t=0) after a prolonged period (at least 2 hours, and mostly after arising from a night’s sleep). This was considered the static blood glucose level, or baseline. Before first blood drawn all subjects sat for 15 minutes in a room at a temperature of between 68 and 73°F. At the start time (t=0), each test subject consumed the standard 15-gram load of fast-acting glucose. Thereafter, at 5-minute intervals, blood glucose levels were simultaneously measured in these same three test areas: alternate site, finger tips, and either the thenar or hypthenar areas. After testing at 5-minute intervals for 1 hour, test intervals were increased to 10 minutes, for another hour, or until blood glucose levels returned to at, or near, baseline levels, whichever came first.

Four Charts Using Typical Data, Out of the 24 Subjects Tested
Figure 1.1: Measuring Rate of Change Between Calf/Knee (Alternate Site), Finger Tip, Thenar and Hypothenar Eminence of Palm – #17

Figure 1.2: Measuring Rate of Change Between Calf/Knee (Alternate Site), Finger Tip, Thenar and Hypothenar Eminence of Palm – #31

Figure 1.3: Measuring Rate of Change Between Calf/Knee (Alternate Site), Finger Tip, Thenar and Hypothenar Eminence of Palm – #23

Figure 1.4: Measuring Rate of Change Between Calf/Knee (Alternate Site), Finger Tip, Thenar and Hypothenar Eminence of Palm – #27

Figure 1.5: Measuring Rate of Change Between Calf/Knee (Alternate Site), Finger Tip, Thenar and Hypothenar Eminence of Palm – DG

Blood glucose levels on the thenar and hypothenar areas of both hands consistency matched those on the finger tips well within meter accuracy. Both areas had matching bell shaped curves reaching approximately (within meter accuracy) the same growth rates and peak levels at the same times. The alternate site not only lagged behind both the thenar and hypothenar areas by about 22 minutes, but only reached about 70% the rise from the static level to peak values.

Genteel’s test lab results indicate that the thenar and hypothenar areas are viable alternatives to finger sticks because they have less pain nerve density. However, blood does not rise easily or readily to the surface in these areas without using specific technology currently present in Genteel’s lancing instrument, and applied over the lancing site. With this technology, comfortable and extremely accurate blood draw is readily available, allowing finger tips to heal and regain sensation.

All who now wish to test from these new sites should check with their doctor to be certain there are no special metabolic considerations that would preclude you from testing on these new areas.

Literature and laboratory research are continuing on the subject. If you would like to be informed of the latest results, go to support@mygenteel.com, provide your email and add the note, “Palm Research Results.”

Potatoes may give you gestational diabetes: but eat lots of them and base your meals around starch say Diabetes UK


Potato-rich diet ‘may increase pregnancy diabetes risk’

  • Eating potatoes or chips on most days of the week may increase a woman’s risk of diabetes during pregnancy, say US researchers.

This is probably because starch in spuds can trigger a sharp rise in blood sugar levels, they say.

Their study in the BMJ tracked more than 21,000 pregnancies.

But UK experts say proof is lacking and lots of people need to eat more starchy foods for fibre, as well as fresh fruit and veg.

The BMJ study linked high potato consumption to a higher diabetes risk.

Swapping a couple of servings a week for other vegetables should counter this, say the authors.

UK dietary advice says starchy foods (carbohydrates) such as potatoes should make up about a third of the food people eat.

There is no official limit on how much carbohydrate people should consume each week.

Starchy carbs

Foods that contain carbohydrates affect blood sugar.

Some – high Glycaemic Index (GI) foods – release the sugar quickly into the bloodstream.

Others – low GI foods – release them more steadily.

Research suggests eating a low GI diet can help manage diabetes.

Pregnancy puts extra demands on the body, and some women develop diabetes at this time.

Gestational diabetes, as it is called, usually goes away after the birth but can pose long-term health risks for the mother and baby.

The BMJ study set out investigate what might make some women more prone to pregnancy diabetes.

The study followed nurses who became pregnant between 1991 and 2001. None of them had any chronic diseases before pregnancy.

What is gestational diabetes mellitus?


  • It is a condition where there is too much glucose (sugar) in the blood
  • About three in every 100 pregnancies are affected in the UK
  • Symptoms include a dry mouth, tiredness and urinating frequently
  • Gestational diabetes can be controlled with diet and exercise, but some women will need medication to keep their blood glucose levels under control
  • If not managed properly, it could lead to premature birth or miscarriage

Every four years, the women were asked to provide information on how often potatoes featured in their diets, and any cases of gestational diabetes were noted.

Over the 10-year period, there were 21,693 pregnancies and 854 of these were affected by gestational diabetes.

The study took into account other risk factors, such as:

  • age
  • a family history of diabetes
  • overall diet
  • physical activity
  • obesity

It found a 27% increased risk of diabetes during pregnancy in the nurses who typically ate two to four 100g (3.5oz) servings of boiled, mashed, baked potatoes or chips a week.

In those who ate more than five portions of potatoes or chips a week, the risk went up by 50%.

The researchers estimate that if women swap their potatoes for vegetables or whole grains at least twice a week, they would lower their diabetes risk by 9-12%.

Cuilin Zhang, lead study author, from the National Institutes of Health in Maryland, US, said the findings were important.

“Gestational diabetes can mean women develop pre-eclampsia during pregnancy and hypertension,” she said.

“This can adversely affect the foetus, and in the long term the mother may be at high risk of type-2 diabetes.”

But UK experts stressed there was not enough evidence to warn women off eating lots of potatoes.

Simple swaps that can lower GI

Switch baked or mashed potato for sweet potato or boiled new potatoes

  • Instead of white and wholemeal bread, choose granary, pumpernickel or rye bread
  • Swap frozen microwaveable French fries for pasta or noodles
  • Try porridge, natural muesli or wholegrain breakfast cereals

Dr Emily Burns, of Diabetes UK, said: “This study does not prove that eating potatoes before pregnancy will increase a woman’s risk developing gestational diabetes, but it does highlight a potential association between the two.

“However, as the researchers acknowledge, these results need to be investigated in a controlled trial setting before we can know more.

“What we do know is that women can significantly reduce their risk of developing gestational diabetes by managing their weight through eating a healthy, balanced diet and keeping active.”

Dr Louis Levy, head of nutrition science at Public Health England, said: “As the authors acknowledge, it is not possible to show cause and effect from this study.

“The evidence tells us that we need to eat more starchy foods, such as potatoes, bread, pasta and rice, as well as fruit and vegetables to increase fibre consumption and protect bowel health.

“Our advice remains the same: base meals around a variety of starchy foods, including potatoes with the skin on, and choose wholegrain varieties where possible.”

This is an article published today  BBC News


Gestational diabetes – NHS Choices


BMJ – British Medical Journal


Diabetes UK



When you are a food addict, what can you do to re-claim your body?

Susan Pierce Thompson PhD is a neuroscientist who used to be pretty hefty in her teens and twenties till she went on a 12 step programme along the lines of alcoholics anonymous but dealing with the issue of food addiction.  She has stayed very slim for the last 12 years and reckons she knows what keeps us from losing weight and keeping it off long term. Indeed she teaches about this subject at university and has recently started online classes with team support to help the food addicts get “happy, thin and free”. She calls her programme Bright Line Eating.

The basics of this is that the “everything in moderation” mantra does not work with the seriously addicted food addict. Flour, sugar and anything that even tastes sweet gets the heave-ho permanently. Could you do this? Of course you could, if you want to get thin and stay thin. But Susan recognises that breaking your intentions happens and that the most important thing is to resume your plan immediately rather than beat yourself up about it, or use a minor deviation as an excuse to binge with a vow to start on Monday again.

Rats as well as humans seem to fall into three groups. The ones who seem able to resist temptation without a problem, the ones who can resist it for a while but then will give in, particularly if under some sort of stress, and the highly addicted who just can’t leave sugar, sweet stuff, refined flour products and white potatoes in all their forms alone. Susan says that modern foods and patterns of eating have hijacked the brain and sap willpower, induce cravings and set up feelings of hunger. Indeed she has found that rats rate sugar water as more pleasurable than cocaine even when they had been made into serious cocaine addicts by researchers.

The taste of anything sweet seems to be a problem. Saccharine, and all artificial sweeteners have the ability to induce cravings, even stevia. Although fat and salt make food more palatable, and humans eat more of it when laced with butter, cream, olive oil and salt for instance, they don’t set up the same addiction circuits. It is the flour/sugar items such as chocolate, ice cream and pizza that are the top addictive foods for most westernised humans, with potatoes and potato products coming in fourth.

When you get a craving for something, parts of your brain are being affected by chemicals that you have no control over. Cravings and hunger are controlled by the hypothalamus. This is your body’s thermostat that controls all sorts of complex processes through the release of hormones.

Your willpower centre is in the anterior cingulate cortex and behaviour is controlled here. The problem is that behaviour gets more difficult to control if you have to withstand temptation for just 15 minutes. It gets even harder to control behaviour when the blood sugar is low or you are already tired, have already had your temptation tested, are feeling emotional or have been focussing on tasks. Susan calls this the “willpower gap”. You know what you are meant to do but you just can’t seem to help yourself from doing something else. Like opening that packet of biscuits.

Your brainstem is where leptin is active. Your brainstem is the most primitive part of the brain and the most basic functions that keep you alive such as breathing reside here.  The trouble is that insulin resistance leads to leptin resistance, and although your brain stem may be flooded with leptin, telling you that you are full, the leptin resistance means that the message doesn’t get through, and your brain stem thinks you are starving. Mindless eating ensues just as mindless breathing continues.

A major step in resolving this impasse is that insulin levels need to be lowered. And what raises insulin the most? Yes, sugar and starch.  This is why a low carb diet, as we describe in our book, can help you lose weight and get your appetite under control. It is all down to physiology.

Susan goes a bit further than we do, however, in that all sweet stuff, with the exception of sweet fruit, is banned. Also all flour products are completely banned. This is because those people who have very serious food issues are more susceptible to dopamine, the reward hormone.

Dopamine is active in the nucleus accumbens. It goes up in response not only to food stimuli but also to sex stimuli for example. Indeed Susan describes sugar as the pornography equivalent of sex. I have to agree with her here.

In large magazine shops you often see rows of women’s magazines on one side and men’s magazines on the other.  The men’s magazines seem to be mainly all about becoming more competent in something eg music, muscle building, computer know-how, with some soft pornography thrown in. Women’s magazines have “how to be more nurturing” magazines with pets, home decorating and crafts taking about a quarter of the space. The rest seems evenly split between “how to make lovely food” often featuring beautifully iced sponge cakes with lashings of cream on the one hand, and “how to get thin from not eating beautifully ices sponge cakes with lashings of cream on them”. I’ve often thought of food articles and particularly photographs as being porn for women.

So, back to dopamine. What a great hormone. You have lots of it and you feel like you rule the world. The downside is that your reward feeling gets worn down by the never ending waves of  dopamine and you tend to need a bigger fix for the same wonderful feelings over time. Also if dopamine becomes depleted you can feel pretty unhappy and also can need another fix to bring it up.  This is a reason why Zyban, the anti-smoking drug can induce suicidal depression.

Zyban, also known as varenicicline,  makes the craving for cigarettes stop by blocking dopamine. When you smoke, you don’t get the hit. Instead you think, “This fag is lousy, why the hell am I smoking it?” This makes it somewhat easier to break the smoking habit. The downside is that you can feel lousy about everything. And sometimes the effect is unpredictably tragic.

Despite the common belief  that we are in control of our behaviour rather than our brain chemicals, Susan is so convinced of the chemical superiority over willpower, that she builds methods of how to resist the hijack into her diet plan.

Dr Thompson knows that a chemically affected brain really has the belief that the body is starving and that flour and sugar are even more powerfully addictive than heroin or cocaine for about a third of the population. She knows you can’t reason with your brain stem. Instead it reasons with you.

That little voice says, “I deserve that”. “It’s only one time”. “It’s only a little bit.”  As more and more exceptions to our dietary plan creep in, we watch ourselves breaking rules, and the belief that we are incapable and lacking in some way, especially compared to thin people, reduces our feelings of competency. Our self-esteem goes down the plug hole. As I have said before, a prominent bariatric surgeon told me that the drop out rate with bariatric patients was particularly high because of the very low self- esteem that this group of people have.

Susan says that very clear boundaries are necessary to get back on track. A lot of planning, daily preparation, long term habit change and support is necessary to overcome addictive eating. Emergency action plans and support are needed for the inevitable breaks in willpower.  But, she says that dopamine receptors recover in time and that as insulin resistance disappears, the insatiable hunger goes with it. She says that reliance on willpower is the single biggest mistake dieters make. Instead you need a whole system to deal with false hunger, addiction and social pressures to eat flour and sugar.

Restorative behaviours such as meditation are important. So is getting out in nature. Anything other than food that boosts your willpower battery is good. Exercise is not part of the plan for most people because it can be a step too far when good eating habits are in the process of being embedded. She thinks exercise can be too much a sap on a person’s willpower unless it is already an entrenched habit.

The path to being slim and healthy is not easy so a different way of looking at the problem is welcome. In particular simple calorie measuring is no good for some people if sugar and flour are part of the calories. Also low carbing may not be extreme enough for some people and cutting out all sweeteners and sugar rather than keeping to small amounts of sugar and starch may be necessary.

Based on an online webinar by Susan Pierce Thompson PhD. October 14 2015.

What’s new for type one diabetics?

NICE have released their new guidelines for type one adults. This paper was given some prominence in September’s BMJ as well as other papers that could be of interest to diabetics, their carers and health professionals.

In many respects the adult guidelines are similar to the children’s guidelines. Structured education gets support as does advice to aim for a hba1c of 6.5% (48) or lower provided hypos can be minimised. Of course this is virtually impossible if a high carb diet is followed but is much easier if the low carb dietary advice and precision meal to insulin matching as we describe in our book is done.

Levemir twice a day is the recommended basal insulin for all new patients and Lantus is advised only for those who refuse to use a twice daily bolus or perhaps need assistance from others for injection. We know that Lantus has some gaps in coverage as a 24 hour insulin and that it is less stable in heat and light than Levemir. It also stings on injection. Levemir also gives fewer hypos. Of course if someone is happy with Lantus, they can stay on it.

Life expectancy for type ones is currently 13 years less than for people without the condition. Fewer than 30% of adults achieve a hba1c of 7.5% or less.

Although the Cochrane collaboration noted a small degree of success with a low glycaemic diet strategy for type twos, this was not seen in the research that NICE looked at for type ones and therefore they don’t recommend low glycaemic as a dietary strategy.

Blood sugar targets are suggested to be ideally 5-7 first thing in the morning, 4-7 before meals and 5-9 at least 90 minutes after meals. Adults are advised that 4-10 blood sugar tests may be required each day. Before each meal and before bedtime are minimum testing times.

NICE want type ones to stick to their finger tips for blood sugar testing. This is the most accurate as hypos can be missed if other parts of the upper limb are used.

It is recommended that hypos are evaluated at least annually by a scoring system. The idea is to seek out those people for whom these are a problem and then fix it. NICE say this should not involve simply raising blood sugar targets. The obvious thing is to match insulin to meals, activity and basal needs more closely. If structured education around this appears to fail then the person should be considered for pump therapy and real time glucose monitoring.

Meal insulin boluses are recommended before meals. After meals is a strategy that works for toddlers but adults are expected to be able to adjust their insulin to meals and that means that they must be able to carb count.

So what can we expect from the implementation of these guidelines? There is still no clarity over diet and exactly how patients will get near normal blood sugars just by carb counting without actually restricting the amount they consume isn’t explained. There certainly will be a lot more adults who could be considered for pumps. But these are relatively expensive and require a lot of training. Setting strict blood sugar targets and hoping that technology will solve the problem has been going on for decades now. Why should it work now? NICE admits it hasn’t worked so far with more than 70% of type one adults having wildly high blood sugars. I would have been very interested to know what percentage of adults with diabetes achieved the target blood sugars of 6.5% or 48.

NICE do admit that to implement their proposals the medical workforce will need to be sufficiently trained to deliver the structured education and to help individual diabetics with their problems.

Forthcoming Drug Recommendations for Type 2 Diabetics from NICE

NICE have some drug recommendations to make for diabetics in their forthcoming guidelines later this year. It can be seen that NICE are heavily influenced by drug costs. So what could these new guidelines mean for you?

The blood pressure recommendations have scarcely changed but the use of Repaglinide first or second line for blood sugar control is a change from previously. Blood sugar targets have tightened up a bit and structured education is expected for insulin users. Cheaper, older insulins are favoured. Blood sugar testing is being rationed considerably. Aspirin is out of favour but drugs for erectile dysfunction are in. Erythromycin is being adopted for the very difficult to manage problem of gastroparesis.

The medications you will need to take to improve your life with diabetes will depend on many factors. Primarily, what do you want a medication to do for you?

The answer to this will depend on how well you are managing lifestyle changes, how long you have had the condition, the presence of any complications, and how tight you want glycaemic control, blood pressure and lipids to be. The targets need to be individualised to you, and this can be done by becoming more informed about your condition and discussing it with other health care providers and people with diabetes. We discuss these factors in our book, the Diabetes Diet, and I will be updating you on some of the new recommendations in further articles.

This article covers the changes to blood pressure medications, glycaemic targets and drugs to control blood sugar, self-monitoring of blood sugar, insulin initiation and the management of complications.

Blood pressure

For diabetics the BP target is 140/80 if there are no blood vessel complications such as kidney, eye or cerebrovascular disorders. If these are present the target is 130/80. BP lowering can improve peripheral neuropathy as well as stroke, MI, blindness and renal failure. 25% of those with type 2 diabetes develop nephropathy within 20 years of diagnosis.

Because ACE inhibitors and sartans reduce progression to renal disease better than other classes of anti-hypertensive agent they should be used first in diabetics unless they are a woman who could get pregnant as this class of drug is teratogenic. First line for women in this situation is a Calcium channel blocker CCB instead.

For Afro-Caribbean use ACE + diuretic or ACE + Calcium channel blocker. This is because this group respond less well to ACEs and sartans so should have add on drugs right from the start.

For those who can’t tolerate an ACE use a sartan unless there is renal deterioration or hyperkalaemia.

If BP is still not controlled add a CCB or thiazide diuretic.

If still not controlled use any of an alpha blocker e.g. Doxasozin or a beta blocker e.g. Bisoprolol or potassium sparing diuretic e.g. Spironolactone.

If someone has already had a heart attack or heart failure they will probably be on a beta blocker anyway. Carvedilol was superior to metoprolol in metabolic terms for renal protection in one study.

Use spironolactone with caution if someone is already on a sartan or ACE because they all can raise potassium.

Glycaemic control


All-cause mortality rises as hbaic rises and decreases as hbaic reduces. The risk of microvascular complications increase over hba1c of 6.5% (48 mmol/mol) or 7% (53) for macrovascular complications. Fasting blood glucose levels influence MI but not stroke or angina.  Amputation rates rise over the age of 60 for any given hbaic. Therefore it can be seen that to improve life expectancy and the quality of life that in general the tighter the blood sugar control the better.  At the same time doctors are asked to adopt an individualised approach to blood sugar targets and consider life expectancy, personal preferences, co-morbidities, risks of polypharmacy and they should consider stopping ineffective drugs.


NICE felt they could not comment on hba1c under 6% because only one study they looked at achieved this. Hba1cs in the 4s or 5s are not uncommon in low carbing diabetics however so don’t let this put you off your stride. NICE do say that if adults reach a lower blood sugar target than they were expecting and are not having hypoglycaemia the doctor should encourage them to maintain it.

They suggest:

6.5% for non-drug using diabetics or on drugs that don’t cause hypos e.g. metformin, pioglitazone, gliptins, victoza.

7% for the rest e.g. repaglinide, sulphonylureas, insulin.

7.5% intensify treatment, but individual circumstances e.g. life expectancy, co-morbidities, hypos need to be taken into account.

Drug step-laddering:

The first step for most diabetics is to offer metformin as the initial drug treatment.  But don’t give or stop metformin if the kidney test, the egfr is below 30 and use with caution if under 45. Regular metformin can give diarrhoea and if this is a problem the long acting version can be used.

If there is symptomatic hyperglycaemia, such as thirst and weight loss consider a sulphonylurea or insulin first. Other drugs may be considered once the blood sugars have stabilised. .

Next they suggest Repaglinide on its own or with metformin. Repaglinide is not licenced with other drugs. For people who could not tolerate metformin and repaglinide are the most cost effective treatment option.

If repaglinide was not suitable or is not achieving the desired blood sugar target any of pioglitazone, a sulphonylurea or a gliptin can be used.  The choice can be tailored to the patient.

Sulphonylureas had the most hypos and gliptins the least. Metformin had the best weight loss. Sulphonylurea and Pioglitazone had the most weight gain. NICE prefer doctors to use the lowest cost gliptin because they are relatively expensive.

Reducing hypoglycaemia should be a particular aim for those on insulin or a sulphonylurea. As blood sugar monitoring is necessary for these drugs, this factor can increase the cost considerably over and above the costs of the medication.

Consider GLP1 mimetic i.e. Byetta or Victoza if the BMI is over 35.  Only continue it if hba1c goes down by 1% and weight goes down by 3% over six months.

Insulin is considered to be the “last option”. There is currently research being carried out on the effects of early use of insulin in type two diabetes and this may change practice in the future.

Only offer insulin + Victoza in specialist care setting.

Insulin initiation

When starting insulin use support from an appropriately trained health professional and give:

Structured education

Telephone support

Frequent self monitoring

Dose titration to target

Dietary understanding

Hypoglycaemia management

Management of acute rises in blood sugar

Continue metformin

The usual first choice insulin is NPH insulin at bedtime or twice daily.

The more expensive Lantus or Levemir may be considered if a carer would be able to cut to once daily injections or if hypoglycaemia is a problem or otherwise the patient would need twice daily NPH and oral drugs or they can’t use the NPH device.

If hbaic is 9% (75) consider twice daily pre-mixed bi-phasic insulin.

Blood sugar testing

NICE recommends that self- monitoring of blood sugars is to be avoided unless a person is on insulin, has symptomatic hypoglycaemia, or oral medication that causes hypos or driving or operating machinery, pregnant or trying for a baby.  It may be worth considering if a patient is on oral or intravenous steroids.

Doctors or nurses should reassess the need for self monitoring annually to see if it remains worthwhile.

Self monitoring produced only a 0.22% reduction in hbaic. It was considered by NICE to be not helpful for most people with type two diabetes though more hypos were detected with it.


Anti-platelet therapy for cardiovascular protection

There is no overall benefit to taking aspirin or clopidogrel in type 2 diabetes unless they already have cardiovascular disease.

Managing complications

Autonomic neuropathy symptoms are: gastroparesis, diarrhoea, faecal incontinence, erectile dysfunction, bladder disturbance, orthostatic hypotension, gustatory and other sweating disorders, dry feet and ankle oedema.

Treatments for gastroparesis are metoclopramide, domperidone and erythromycin.

Refer to a specialist if severe or persistent vomiting occurs or the diagnosis is in doubt.

Nocturnal diarrhoea may indicate autonomic neuropathy.

Tricyclics are often given for neuropathic pain but can increase postural hypotension.

Erectile dysfunction

Offer men the chance to speak about this at their annual review. Offer Viagra, Cialis and similar and refer if these don’t work.

Eye damage

Diabetic eye damage is the single largest cause of blindness before old age.

Refer to the emergency ophthalmologist if:

Sudden loss of vision

Rubeus’s Iridis

Pre-retinal or vitreous haemorrhage

Retinal detachment

Send for rapid review if there is new vessel formation.

So what do you think of the new NICE recommendations?  Do you think these changes will affect your medications?

You only need one arrow: Dr Unwin proves it again

Dr David Unwin has completed another study in his practice patients showing that a low carb diet greatly reduces fatty liver, weight and blood sugar. The knock on effects on the prescribing budget, secondary care referrals and complications can only be a good thing for the struggling NHS. His practice alone, compared to those in his area, is making savings when it comes to diabetes care.  Currently 66-70% of the adult UK population is overweight or obese, 20-30% have non alcoholic fatty liver disease and 10% have diabetes. The low carbing community remains mystified as to how such a rational, safe and effective treatment option is still side-lined by most diabetology clinics, NICE, and Diabetes UK.

Dr Unwin estimates that between £15,000-£30,000 a year has been knocked off his prescribing budget for a single practice in which the low carb diet was routinely offered to patients. While the drug spend continues to rise in adjacent practices, his budget has not risen in the last three years. His patients are now officially thinner than in neighbouring practices and below the national average. In two years the average blood sugar has come down 10% and is now below the national average of 61.5 mmol/mol.

Here is the abstract which we are proud to present ahead of publication in Diabesity in Practice in September 15.

  • Unwin DJ1, Cuthertson DJ2, Feinman R3, Sprung VS2 (2015) A pilot study to explore the role of a low-carbohydrate intervention to improve GGT levels and HbA1c. Diabesity in Practice 4 [in press]

     1Norwood Surgery, Norwood Ave, Southport. 2Department of Obesity and Endocrinology, Institute of Ageing & Chronic Disease, University of Liverpool, UK. 3Professor of biochemistry and medical researcher at State University of New York Health Science Center at Brooklyn, USA.

    Working title: Raised GGT levels, Diabetes and NAFLD: Is dietary carbohydrate a link?  Primary care pilot of a low carbohydrate diet

    Abnormal liver function tests are often attributed to excessive alcohol consumption and/or medication without further investigation. However they may be secondary to non-alcoholic fatty liver disease (NAFLD). Considering the increased cardiovascular and metabolic risk of NAFLD, identification and effective risk factor management of these patients is critical. NAFLD is now prevalent in 20-30% of adults in the Western World

    Background Excess dietary glucose leads progressively to hepatocyte triglyceride accumulation (non-alcoholic fatty liver disease-NAFLD), insulin resistance and T2DM. Considering the increased cardiovascular risks of NAFLD and T2DM, effective risk-factor management of these patients is critical. Weight loss can improve abnormal liver biochemistry, the histological progression of NAFLD, and diabetic control. However, the most effective diet remains controversial.

    Aim We implemented a low-carbohydrate (CHO) diet in a primary health setting, assessing the effect on serum GGT, HbA1c levels (as proxies for suspected NAFLD and diabetic control), and weight.

    Design  69 patients with a mean  GGT of 77 iu/L (NR 0-50) and an average BMI of 34.4Kg/m2 were recruited opportunistically and advised on reducing total glucose intake (including starch), while increasing intake of  natural fats, vegetables and protein.

    Method Baseline blood samples were assessed for GGT levels, lipid profile, and HbA1c. Anthropometrics were assessed and repeated at monthly intervals. The patients were provided monthly support by their general practitioner or practice nurse, either individually or as a group.

    Results After an average of 13 months on a low-CHO diet there was a 46% mean reduction in GGT of 29.9 iu/L (95% CI= -43.7, -16.2; P<0.001), accompanied by average reductions in weight [-8.8Kg (95% CI= -10.0, -7.5; P<0.001)],and HbA1c [10.0mmol/mol (95% CI= -13.9, -6.2; P<0.001)].

    Conclusions We provide evidence that low-carbohydrate, dietary management of patients with T2DM and/or suspected NAFLD in primary care is feasible and improves abnormal liver biochemistry and other cardio-metabolic risk factors. This raises the question as to whether dietary carbohydrate plays a role in the etiology of diabetes and NAFLD, as well as obesity

Logging Your Results

Screenshot 2015-04-10 12.44.22I treated myself to an app recently to record my blood test results. Historically, this hasn’t been a strength of mine (ahem!). When I was first diagnosed with diabetes in 1982 (way, way before the internet folks, imagine…) blood testing wasn’t common, and when it did come in, you were issued with log books to write down your results.

I’m sure I was not the only teenager who sat in the diabetic clinic’s waiting room, filling in weeks of blood test results using different-coloured pens to give my made-up results added authenticity.

Continue reading “Logging Your Results”

Dr Unwin’s winning formula for fitness and health

Dr Unwin
Proof that you can eat low-carb AND run…

Hello, I am David Unwin, another GP interested in the low-carb approach to helping my patients with type two diabetes.

My work formed the basis of an article published in the March 2014 edition of Practical Diabetes. ‘Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice’.

I am not a diabetic, but have been on the diet for about two years now. I started it as a gesture of support for my patients but find I am more alert and need less sleep on it. Surprisingly it seems to help me run faster too! I recently finished a 10 K road run in less than 46 minutes, my best time for years.

Since writing the article in March, my practice has been given a small grant which means we have now helped 37 people with type two diabetes. Interestingly, the results are very similar to our original cohort including improvements to cholesterol, despite a diet higher in fat which makes one wonder…


Diabetics have long been exhorted to give up sugar and encouraged to take in complex carbohydrate in the form of the starch found in bread and pasta (especially if ‘wholemeal’). In fact, bread should be seen as concentrated sugar which explains why it has a higher glycaemic index than table sugar itself.

As there are no essential nutrients in starchy foods and diabetics struggle to deal with the glycaemic load they bring, we question why they need form a major part of their diet at all.

The recent increase in screening in general practice along with epidemic of ‘central obesity’ is revealing large numbers of pre-diabetics and diabetics (diabesity). At a time when there are questions about drug safety, which diet is best is of particular importance.

Many patients are already experimenting with the ‘low carb’ approach as it is so widely advocated on the internet. We wanted to see how effective and well tolerated it was.

A series of 19 type 2 diabetics and pre-diabetics volunteered to go on a low carbohydrate diet backed up with ten-minute one to one sessions with a GP or practice nurse, and regular group education.

After seven months only one had dropped out, of the rest all had significant weight loss (average 8.63 Kg) and the average HbA1c was down from 50.68 to 39.9 mmol/mol (6.7% to 5.7%).

Despite the higher fat intake on this diet the cholesterol dropped and liver function improved for nearly all participants.

We conclude this approach is easy to implement, brings rapid weight loss and improvement in HbA1c using a diet that the great majority of patients find easy to live with.

You can find the full article at Practical Diabetes.